Rita Bartholomew
Guru
Our Patient Accounts Department is trying to get this claim paid by Anthem Medicare (they already paid the vascular surgeon) but are being told there are codes that are not Medicare-approved, but can't tell them which ones. I coded 75710, 37184, 37225, 37229, 37221. Which ones are wrong?
NAME OF PROCEDURE:
1. Angiogram of the left lower extremity.
2. Percutaneous thrombectomy of the left lower extremity (popliteal artery).
3. Rotational atherectomy and angioplasty of the left popliteal artery.
4. Rotational atherectomy and angioplasty of the left anterior tibial artery.
5. Stent, right external iliac artery (8 mm x 60 mm).
SURGEON: Xxxxxxx X Xxxxx, M.D.
ANESTHESIA: Local with moderate sedation.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CLINICAL HISTORY: This 87-year-old man is approximately 6 months status post prior rotational atherectomy and angioplasty of the left lower extremity which was successful. He had been ambulating 1 to 2 miles per day until the last 1 week, at which point he was able to only go feet before experiencing claudication. Although he had an ultrasound approximately 3 months ago reporting wide patency of the popliteal artery, duplex demonstrates total occlusion of the popliteal artery. He comes for imaging with possible revascularization and intention to treat. Due to his advanced age, lytic therapy dripped over night is likely contraindicated, although I have told him that there is a possibility of percutaneous thrombectomy with lytic therapy. He has renal insufficiency, and so dye was minimized.
OPERATIVE FINDINGS: Images of the left lower extremity were obtained only. Retrograde approach from the contralateral side was used.
RADIOLOGIC FINDINGS: The left external iliac artery was widely patent. Left superficial femoral and profunda femoris arteries were widely patent. The above the knee popliteal artery, behind the knee popliteal artery, and below the knee popliteal arteries and common tibial peroneal trunk were all totally occluded. The patient reconstituted an anterior tibial artery approximately 1 cm from its origin and this artery was the dominant runoff to the left foot. The posterior tibial artery and peroneal arteries were also noted to reconstitute, although these arteries became totally occluded in the mid leg.
I was able to successfully cross the popliteal artery and common TP trunk into the peroneal artery, and then was able to treat the totally occluded popliteal artery with lytic therapy using a Possis Expedior device. After thrombectomy, several areas of critical stenosis were noted in the popliteal artery. Some dissection was noted in the distal popliteal artery. Persistent total occlusion of the proximal 1 cm of anterior tibial artery was also noted. I was then able to treat the popliteal artery and common TP trunk with rotational atherectomy and angioplasty using a CSI 2 mm device. Low speed only was used in the common TP trunk. Next, I was able to cross the area of chronic total occlusion into the left anterior tibial artery, and the left anterior tibial artery was treated with a CSI device at 1.25 mm and this was followed by a 3 mm angioplasty balloon and this gave an excellent result with complete flow through the anterior tibial artery. I then examined the posterior tibial artery again. It was noted to totally occlude in the mid to distal third of the calf and did not reconstitute in the foot. I imaged the right external iliac artery in order to place a closure device, and the right external iliac artery had significant tortuosity and narrowing, which would normally preclude the device, and I treated this artery with a stent in order to straighten the artery and eliminate the areas of stenosis. A closure device was then used successfully.
OPERATIVE REPORT: The patient was taken to the cardiac catheterization laboratory where he was placed on the table in the dorsal recumbent position. After excellent moderate sedation, the skin of the groin areas was prepared and draped in the standard sterile surgical fashion. I called a time-out for correct patient and procedure identification per Xxxxxxxxxx Hospital protocol. I then used local anesthesia and accessed the right common femoral artery in a retrograde direction. An omni flush catheter was advanced into the abdominal aorta and pulled down to the aortic bifurcation. This was then used to selectively catheterize the left common iliac artery and images of the left lower extremity were then obtained. I then was able to successfully catheterize the left superficial femoral artery and additional images of the left lower extremity were then obtained. I placed a stiff wire into the left superficial femoral artery and advanced an Ansel 0 sheath, 7 mm in diameter, up and over the aortic bifurcation and at the left superficial femoral artery proximally. A total of 70 mg per kilogram of unfractionated heparin was administered IV. I next used a CXI catheter in conjunction with a Treasure 12 wire, and was able to selectively catheterize the left peroneal artery. With the CXI catheter in the left peroneal artery, images of the left peroneal artery verified correct positioning. I then passed a 0.035 wire into the left peroneal artery. Over the 0.035 wire, I passed an Expedior Possis device. A power pulse TPA method was used to lyse first the proximal four-fifths of the thrombus in the popliteal artery and into the proximal common TP trunk. This was allowed to sit for 15 minutes, and then was aspirated using the Possis device. Imaging demonstrated patency of the entire system with some persistent thrombus versus dissection in the distal popliteal artery and into the common TP trunk. It also demonstrated persistent thrombus of the proximal anterior tibial artery. An additional power pulse TPA injection was then performed. After an additional 15 minutes, completion arteriogram showed persistence of the chronic appearing dissection plane here. Persistence of the total occlusion of the anterior tibial artery was also noted. I then used a CXI catheter in conjunction with several wires, and eventually was able to selectively catheterize the anterior tibial artery through the area of total occlusion. This was noted to be exceptionally difficult. A CSI atherectomy device, 2 mm in diameter, was first used to treat the popliteal artery at low, medium and high speeds. This was kept at low to medium speeds into the peroneal artery. A 5 mm angioplasty balloon was then used to dilate the popliteal artery and this had a good result. A CSI 1.25 mm device was used to treat the anterior tibial artery proximally at low and medium speeds. A 3 mm x 4 cm angioplasty balloon was then used to treat the proximal anterior tibial artery. Completion arteriogram showed wide patency of the anterior tibial artery. I then performed additional image of the left lower extremity to see if the posterior tibial artery could be salvaged, but determined it could not.
The sheath was then pulled back into the right external iliac artery and images of the right external iliac artery were obtained. This demonstrated a diffusely diseased and extremely tortuous artery which would preclude placement of a closure device. I deployed a self-expanding stent within the left external iliac artery with dimensions as noted above. This straightened out the artery significantly and removed several areas of critical narrowing. The Mynx closure device was then placed. There were no complications. A dry sterile dressing was applied. There were no complications and Mr. Xxxxx tolerated the procedure well. Sponge and needle counts following the case were correct x2.
NAME OF PROCEDURE:
1. Angiogram of the left lower extremity.
2. Percutaneous thrombectomy of the left lower extremity (popliteal artery).
3. Rotational atherectomy and angioplasty of the left popliteal artery.
4. Rotational atherectomy and angioplasty of the left anterior tibial artery.
5. Stent, right external iliac artery (8 mm x 60 mm).
SURGEON: Xxxxxxx X Xxxxx, M.D.
ANESTHESIA: Local with moderate sedation.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CLINICAL HISTORY: This 87-year-old man is approximately 6 months status post prior rotational atherectomy and angioplasty of the left lower extremity which was successful. He had been ambulating 1 to 2 miles per day until the last 1 week, at which point he was able to only go feet before experiencing claudication. Although he had an ultrasound approximately 3 months ago reporting wide patency of the popliteal artery, duplex demonstrates total occlusion of the popliteal artery. He comes for imaging with possible revascularization and intention to treat. Due to his advanced age, lytic therapy dripped over night is likely contraindicated, although I have told him that there is a possibility of percutaneous thrombectomy with lytic therapy. He has renal insufficiency, and so dye was minimized.
OPERATIVE FINDINGS: Images of the left lower extremity were obtained only. Retrograde approach from the contralateral side was used.
RADIOLOGIC FINDINGS: The left external iliac artery was widely patent. Left superficial femoral and profunda femoris arteries were widely patent. The above the knee popliteal artery, behind the knee popliteal artery, and below the knee popliteal arteries and common tibial peroneal trunk were all totally occluded. The patient reconstituted an anterior tibial artery approximately 1 cm from its origin and this artery was the dominant runoff to the left foot. The posterior tibial artery and peroneal arteries were also noted to reconstitute, although these arteries became totally occluded in the mid leg.
I was able to successfully cross the popliteal artery and common TP trunk into the peroneal artery, and then was able to treat the totally occluded popliteal artery with lytic therapy using a Possis Expedior device. After thrombectomy, several areas of critical stenosis were noted in the popliteal artery. Some dissection was noted in the distal popliteal artery. Persistent total occlusion of the proximal 1 cm of anterior tibial artery was also noted. I was then able to treat the popliteal artery and common TP trunk with rotational atherectomy and angioplasty using a CSI 2 mm device. Low speed only was used in the common TP trunk. Next, I was able to cross the area of chronic total occlusion into the left anterior tibial artery, and the left anterior tibial artery was treated with a CSI device at 1.25 mm and this was followed by a 3 mm angioplasty balloon and this gave an excellent result with complete flow through the anterior tibial artery. I then examined the posterior tibial artery again. It was noted to totally occlude in the mid to distal third of the calf and did not reconstitute in the foot. I imaged the right external iliac artery in order to place a closure device, and the right external iliac artery had significant tortuosity and narrowing, which would normally preclude the device, and I treated this artery with a stent in order to straighten the artery and eliminate the areas of stenosis. A closure device was then used successfully.
OPERATIVE REPORT: The patient was taken to the cardiac catheterization laboratory where he was placed on the table in the dorsal recumbent position. After excellent moderate sedation, the skin of the groin areas was prepared and draped in the standard sterile surgical fashion. I called a time-out for correct patient and procedure identification per Xxxxxxxxxx Hospital protocol. I then used local anesthesia and accessed the right common femoral artery in a retrograde direction. An omni flush catheter was advanced into the abdominal aorta and pulled down to the aortic bifurcation. This was then used to selectively catheterize the left common iliac artery and images of the left lower extremity were then obtained. I then was able to successfully catheterize the left superficial femoral artery and additional images of the left lower extremity were then obtained. I placed a stiff wire into the left superficial femoral artery and advanced an Ansel 0 sheath, 7 mm in diameter, up and over the aortic bifurcation and at the left superficial femoral artery proximally. A total of 70 mg per kilogram of unfractionated heparin was administered IV. I next used a CXI catheter in conjunction with a Treasure 12 wire, and was able to selectively catheterize the left peroneal artery. With the CXI catheter in the left peroneal artery, images of the left peroneal artery verified correct positioning. I then passed a 0.035 wire into the left peroneal artery. Over the 0.035 wire, I passed an Expedior Possis device. A power pulse TPA method was used to lyse first the proximal four-fifths of the thrombus in the popliteal artery and into the proximal common TP trunk. This was allowed to sit for 15 minutes, and then was aspirated using the Possis device. Imaging demonstrated patency of the entire system with some persistent thrombus versus dissection in the distal popliteal artery and into the common TP trunk. It also demonstrated persistent thrombus of the proximal anterior tibial artery. An additional power pulse TPA injection was then performed. After an additional 15 minutes, completion arteriogram showed persistence of the chronic appearing dissection plane here. Persistence of the total occlusion of the anterior tibial artery was also noted. I then used a CXI catheter in conjunction with several wires, and eventually was able to selectively catheterize the anterior tibial artery through the area of total occlusion. This was noted to be exceptionally difficult. A CSI atherectomy device, 2 mm in diameter, was first used to treat the popliteal artery at low, medium and high speeds. This was kept at low to medium speeds into the peroneal artery. A 5 mm angioplasty balloon was then used to dilate the popliteal artery and this had a good result. A CSI 1.25 mm device was used to treat the anterior tibial artery proximally at low and medium speeds. A 3 mm x 4 cm angioplasty balloon was then used to treat the proximal anterior tibial artery. Completion arteriogram showed wide patency of the anterior tibial artery. I then performed additional image of the left lower extremity to see if the posterior tibial artery could be salvaged, but determined it could not.
The sheath was then pulled back into the right external iliac artery and images of the right external iliac artery were obtained. This demonstrated a diffusely diseased and extremely tortuous artery which would preclude placement of a closure device. I deployed a self-expanding stent within the left external iliac artery with dimensions as noted above. This straightened out the artery significantly and removed several areas of critical narrowing. The Mynx closure device was then placed. There were no complications. A dry sterile dressing was applied. There were no complications and Mr. Xxxxx tolerated the procedure well. Sponge and needle counts following the case were correct x2.