apogoreski
New
I work for a Vascular Vein office that performs procedure in an access center located in their office. Sometimes (maybe 3 x per year) we have situations where they bring a patient in with the intent of placing an SFA stent but cannot complete/do this d/t occuled arteries. My doctor wants to know which would be appropriate in this instance-- billing the SFA stent procedure with a 53 modifier (showing that it was incomplete/aborted due to the patient's well being) OR billing the catheter & access with a 22 modifier (showing that it was more difficult than normal). The difficulty, amount of materials used, etc that goes into the attempt is much more than just a simple access, cath & aortogram so we know that billing more than just that is justifiable. We're just wondering which way to go, which is correct. If anyone has any documentation on this also that would be GREAT, we're looking to avoid getting the "opinions/interpretations" and more of a concrete "ruling" on this. He said that if we can find something saying that it's basically up to my (the coders) discretion that's fine but he would like something in stone saying that. He is also willing to contact whoever would be "governing" on this if anyone has any ideas on who that would be (NOT payer specific). Here is an example operative note so you can see what we're dealing with.
Thank you in advance!
PREOPERATIVE DIAGNOSIS: Disabling claudication left lower extremity.
POSTOPERATIVE DIAGNOSIS: Disabling claudication left lower extremity.
PROCEDURE PERFORMED:
1. Aortogram.
2. Left lower extremity arteriogram.
3. Failed crossing of a chronic total occlusion of the left superficial femoral artery with multiple attempts, multiple catheters, and multiple wires.
HISTORY:
This is a 49-year-old male with disabling claudication of the left lower extremity and the need for improvement of quality of life. The patient failed conservative therapy. He has stopped smoking and has modified as many risk factors as he can.
FINDINGS OF OPERATION:
The aorta is widely patent. The common iliac arteries are widely patent. The external iliac artery is widely patent. The common femoral artery is widely patent.
The left profunda femoris is widely patent. The left superficial femoral artery is patent proximally. The superficial femoral artery occludes at its abductor canal and it is occluded for approximately 20 cm with reconstitution via large collateral. The remainder of the runoff is intact with three-vessel runoff to the foot.
Upon placing a sheath in the left superficial femoral artery, an attempt with a total of four different wires of different sizes, diameters and gram tip weight, as well as different directional catheters, we were unable to get out of the subintimal space and back into intraluminal space. The procedure was terminated to prevent the patient from experiencing problems or harm from further dissection of the superficial femoral artery with an inability to recannulate the lumen.
OPERATIVE PROCEDURE:
After the benefits, the risks and the nature of the procedure were discussed with the patient, consent was obtained. The patient was taken to the interventional suite. Sedation was given. The patient was prepped and draped in a sterile fashion. Access to the right common femoral artery was undertaken. A needle wire sheath flush catheter was positioned at the renal arteries. Angiography was undertaken. A crossover technique was used. The catheter was placed in the left common femoral artery and a left lower extremity arteriogram was performed. At this time, a 6-French sheath was placed in the left superficial femoral artery. Heparin was given and allowed to circulate. Next, multiple support catheters and multiple wires of 018 floppy tip, 018 30-gram tip, 035, as well as 014 wires were used to traverse this occlusion. A catheter was able to be placed in the subintimal space, but intraluminal access beyond the occlusion was unable to be obtained despite multiple techniques, multiple catheters, and a prolonged x-ray time. Again, the procedure was terminated as not to harm the patient. The product was removed, the sheath was pulled, and pressure was held.
Thank you in advance!
PREOPERATIVE DIAGNOSIS: Disabling claudication left lower extremity.
POSTOPERATIVE DIAGNOSIS: Disabling claudication left lower extremity.
PROCEDURE PERFORMED:
1. Aortogram.
2. Left lower extremity arteriogram.
3. Failed crossing of a chronic total occlusion of the left superficial femoral artery with multiple attempts, multiple catheters, and multiple wires.
HISTORY:
This is a 49-year-old male with disabling claudication of the left lower extremity and the need for improvement of quality of life. The patient failed conservative therapy. He has stopped smoking and has modified as many risk factors as he can.
FINDINGS OF OPERATION:
The aorta is widely patent. The common iliac arteries are widely patent. The external iliac artery is widely patent. The common femoral artery is widely patent.
The left profunda femoris is widely patent. The left superficial femoral artery is patent proximally. The superficial femoral artery occludes at its abductor canal and it is occluded for approximately 20 cm with reconstitution via large collateral. The remainder of the runoff is intact with three-vessel runoff to the foot.
Upon placing a sheath in the left superficial femoral artery, an attempt with a total of four different wires of different sizes, diameters and gram tip weight, as well as different directional catheters, we were unable to get out of the subintimal space and back into intraluminal space. The procedure was terminated to prevent the patient from experiencing problems or harm from further dissection of the superficial femoral artery with an inability to recannulate the lumen.
OPERATIVE PROCEDURE:
After the benefits, the risks and the nature of the procedure were discussed with the patient, consent was obtained. The patient was taken to the interventional suite. Sedation was given. The patient was prepped and draped in a sterile fashion. Access to the right common femoral artery was undertaken. A needle wire sheath flush catheter was positioned at the renal arteries. Angiography was undertaken. A crossover technique was used. The catheter was placed in the left common femoral artery and a left lower extremity arteriogram was performed. At this time, a 6-French sheath was placed in the left superficial femoral artery. Heparin was given and allowed to circulate. Next, multiple support catheters and multiple wires of 018 floppy tip, 018 30-gram tip, 035, as well as 014 wires were used to traverse this occlusion. A catheter was able to be placed in the subintimal space, but intraluminal access beyond the occlusion was unable to be obtained despite multiple techniques, multiple catheters, and a prolonged x-ray time. Again, the procedure was terminated as not to harm the patient. The product was removed, the sheath was pulled, and pressure was held.