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Tag Archives: Angioplasty

Lower extremity and balloon angioplasty of RT common femoral

Posted on by
Can someone give some guidance from PCI to lower extremity angiography .. may have my PCI code incorrect but definitely missing more…help please!

Codes:
93458-26,59
76937-26
92928-LC
???

PRECATHETERIZATION DIAGNOSIS:
CAD.

POSTCATHETERIZATION DIAGNOSIS:
CAD. Right groin hematoma. No active bleeding at cath site in the right common femoral artery.

PROCEDURE PERFORMED:
Left heart catheterization, left ventriculography, selective coronary angiography via the right transfemoral approach.
US vascular access. Balloon angioplasty of the OM branch. Right common iliac and right common femoral
angiography. Balloon angioplasty of the right common femoral artery for bleeding.

CLINICAL FEATURES:
70 year old black female with DM, dyslipidemia underwent stenting of OM on 2-22-18 with a 2.25 x 16 mm Synergy
stent. Her Lexiscan on 9-20-18 suggested distal anterior wall stress ischemia. She underwent renal transplantation
years ago.
In view of of an abnormal myocardial perfusion stress test and known coronary artery disease having had
coronary stenting on 2/22/18, recommend cardiac catheterization to assess coronary status and to undertake
appropriate treatment.
The patient understands the nature, purpose, alternatives, benefits and risks of cardiac catheterization and
possible PCI, including but not limited to the effects of conscious sedation, myocardial infarction, emergency
cardiac surgery, bleeding, CVA, renal failure, compromised circulation in the extremities, and rarely fatal
complications and the patient offers an intelligent consent.

PROCEDURE:
After an informed consent was obtained, the procedure was undertaken via the right transfemoral approach. The right
groin was infiltrated with xylocaine and the right common femoral artery was entered and a sheath was placed in the
artery. Micropuncture technique was used with US vascular access. Left ventriculography and left coronary
arteriography were done using a JL 4 cm Judkins catheter. Right coronary arteriography was done using a 4 cm right
Judkins catheter.
Having noted instent restenosis in the OM branch, intervention was undertaken using a 3.75 cm EBU guiding
catheter, a Runthrough wire and balloon dilation was done using a 2.0 x 12 Emerge balloon catheter followed by
dilation with a 2.5 x 12 NC Quantum balloon and followed by 2.5 x 6 mm AngioSculpt scoring balloon with multiple
dilations. Having noted a satisfactory result, a AngioSeal was deployed. Sheath angiography was done at the
beginning of the procedure and it indicated no abnormality and the sheath insertion site was in the common femoral
artery. Care was taken to use an exchange wire because she had renal transplant on the right side. An AngioSeal
was deployed.
In the recovery room, it was noticed that she had a hematoma in the right groin. Manual pressure was appliedfor 20
minkute. During observation, she developed a vasovagal episode with hypotension which gradually improved.
To exclude significant bleeding, angiography was undertaken from the contralateral side.The left groin was infiltrated
with xylocaine and with US aid and using micropuncture technique, the left common femoral artery was entered. Using
Omnifush catheter and angled glide wire, the catheter was advanced into the left common iliac artery and contrast
injection was done. Subsequently angiography by hand injection of the iliac arteries and the right common femoral
artery was done. No evidence extravasation was noted. The right inferior epigastric artery was somewhat irregular but
no dissection or perforation was noted.
Balloon dilation of the right common femoral artery was done using a 6 x 60 mm Abbot’s Armada balloon which was
inflated for 3 minutes, just to tamponade any possible oozing that is not readily visible. The patient tolerated the
inflation well. Post dilation angiography was done. No evidence of perforation noted. No extravasation noted.The
patient was hemodynamically stable.

INTERPRETATION:
1. Hemodynamics: Please consult the hemodynamics data.
2. Left ventriculogram: Normal contractility with estimated EF at 60% The presence of a stent noted.
3. Coronary cine arteriogram:
A. Left main coronary artery: Stented vessel patent.
B. Left anterior descending artery: Free of significant disease.
C.Circumflex coronary artery: In-stent restenosis of the OM branch (90%) noted.
D. Right coronary artery:Free of significant disease.
4. Result of intervention:
The 90% instent restenosis in the OM branch was subjected to balloon angioplasty and AngioScult scoring balloon
angioplasty with a satisfactory result with minor residual narrowing. Since the branch is small, it was not deemed
prudent to deploy another stent in the vessel, crowding a small artery.
5. Angiography of the right pelvic arteries.
A. The right iliac arteries are patent. Evidence of kidney transplant noted.
B. The right common femoral artery was patent without obvious evidence of bleeding.Irregularity of the inferior
epigastric artery without perforation or dissection noted.
6. Balloon angioplasty of the right common femoral artery:
Balloon dilation was done to seal any possible oozing from the arterial puncture site.

FINAL DIAGNOSIS:
Normal LV function and in-stent restenosis in the OM branch with successful balloon angioplasty. She had right groin
hematoma and angiography showed normal right sided iliac arteries and femoral artery with no definite bleeding.
Balloon angioplasty of the right common femoral artery was done to seal any possible oozing which was not readily
apparent.

Medical Billing and Coding Forum

Balloon Angioplasty peroneal artery and balloon angio of tibioperoneal trunk.

Posted on by
The provider is asking for number of codes that are bundled but can be unbundled with mods. Any help is appreciated. The provider wants: 36247, 37229, 37252, 75625, 75726. 75774.

Using micropuncture kit the right femoral artery was cannulated and 5 french sheath was placed in the right femoral artery. We then advanced an omni flush catheter to the level of L4 Distal abdominal aortic angiography was completed. After this, we advanced a Bentson wire into the SFA and the omni Flush was then selectively engaged in the SFA. Angiography was then completed. We then performed an angiography of the left lower extremity. After finding significant amount of stenosis in the tibioperoneal trunk and the peroneal artery being completely occluded, we proceeded with the intervention of artery. We advanced a CXI cath and stiff angled glide cath into the peroneal and we were able to enter in thh true lumen distally. After that, we advanced the CXI cath into the dital peroneal vessel. We then exchanged out in favor of Viper wire and performed artherectomy of the tibioperoneal trunk. After this, we swapped out in favor of an 0.018 Treasure 12 wire and performed balloon angioplasy with a 2.5 x 30 cm balloon of the peroneal artery. We performed balloon angioplasy in the this vessel. Afterh that, we advanced a 4.0 x 30 balloon and performed balloon angioplasty in the TP trunk and then we performed IVUS of the tibioperoneal trunk.

Thank you for taking a look.

bb

Medical Billing and Coding Forum

Endarterectomy with patch angioplasty, selective cath, stent placement — pls review

Posted on by
Hello – We would love someone to review our codes and provide feedback. Also, specifically, it’s our understanding that we code for both access sites, hence the use of 36140-XS-RT. Yes/No – Circumstantial? We are specifically being asked why we want to use this code.

These are the codes we want to use for this inpatient Medicare pt.
35371-RT
37221-RT
36140-XS-RT
75625

Many thanks. Kristi

Pre-op Diagnosis:
1. Atherosclerotic PVD with intermittent claudication RLE [I70.219]
2. CKD
3. HTN

Post-op Diagnosis: same

Procedure(s):
1. Right common femoral endarterectomy with bovine pericardial patch
angioplasty
2. Aortogram via L CFA approach
3. Selective catheterization of R EIA
4. R EIA PTA, stent placement, 8 x 60mm

Anesthesia: General

Estimated Blood Loss: 200 mL

CONTRAST: 50 cc

Drain: none

Total IV Fluids: see anesthesia log

Specimens:
ID Type Source Tests Collected by Time Destination
A : RIGHT FEMORAL PLAQUE Tissue Plaque SURGICAL PATHOLOGY

Implants:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No.
Used
PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X W.8 CM PERIPHERAL
STERILE – SN/A Patch PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X
W.8 CM PERIPHERAL STERILE N/A SYNOVIS MICRO COMPANIES ALLIANCE INC – A
BAXTER HEALTHCARE CORP CO SP18B02-1270178 Right 1
mynx N/A CARDINAL HEALTH INC F1805704 Left 1

Complications: none

Findings: R EIA occlusion with bulky calcified plaque extending into R
CFA. S/p endarterectomy. Unable to cross EIA lesion from retrograde
approach therefore L CFA access was obtained and lesion was crossed from
an antegrade approach. Self-expanding 8 x 60mm stent was placed was good
result. Palpable pedal pulses upon completion.

Disposition: awakened from anesthesia, extubated and taken to the recovery
room in a stable condition, having suffered no apparent untoward event.

Condition: doing well without problems

Technique:
After informed consent was obtained the patient was taken to the operating
room. Placed in the supine position. General endotracheal anesthesia was
administered. The abdomen and bilateral groins were prepped and draped
usual sterile fashion.

We began by making an incision in the inguinal
right area right groin midline between a cyst in the pubic tubercle in
vertical fashion. We dissected through the skin subcutaneous tissue
Scarpa’s fascia until we encountered the femoral sheath. Any veins that
were seen were tied off and suture ligated. Then got into the femoral
sheath identified our inguinal ligament and then our right common femoral
artery. It was noted to be calcified with some posterior plaque and some
inflammation noted. We dissected systemic fashion inferiorly identifying a
few branches and putting small Vesseloops around. We then identified the
SFA and profunda. Placed vessel loops around them. We then continued our
dissection more proximally we had to divide part of the inguinal ligament
to get more proximal control.

At this point, we began our endarterectomy
we heparinized the patient and obtained ACTs every 30 min to remain
therapeutic. Once the patient was therapeutic we got control with vessel
loops and then performed an arteriotomy with an 11 blade and extended it
with Potts scissors. The common femoral artery had noted hemorrhagic
calcified plaque. We then perform an endarterectomy between the median
intima with a Freer elevator and piecemeal off the plaque in the common
femoral artery. We then made our endpoint at the distal common femoral
artery. There was noted to be calcified posterior plaque on the proximal
aspect of our endarterectomy site with a chronic occlusion.

We attempted
to access through the open endarterectomy vessel the right external iliac
artery with a Glidewire 035 as well as a 5 French sheath. When we
advanced the wire and there was mild resistance proximally we advance into
what we thought was the abdominal aorta we then performed an angiogram
which demonstrated a dissection plane at this point we then stopped access
from this area. We removed the sheath and the wire and then gain access on
the opposite groin. At this point we then gain access to the left groin
under palpation using Seldinger technique.

We accessed the left common
femoral artery and then we upgraded to a 5 French sheath. We then
advanced a Glidewire and a VCF catheter and performed a angiogram with
minimal contrast. This demonstrated extensive infrarenal calcification in
bilateral patent common iliac arteries. The left hypogastric appeared to
be occluded. The left external iliac had multilevel disease but nothing
hemodynamically significant. The right common iliac artery appeared to be
patent the external had a flush occlusion about 1 cm after the takeoff.
The left hypogastric artery appeared to be patent with an ostial lesion.
There was extensive pelvic collaterals and reconstitution at the femoral
head of the common femoral artery. At this point we then upgraded to a 6
French up-Andover sheath and advanced it over the bifurcation into the
right common iliac artery. We then used a support Seeker catheter within
and a stiff 035 glidewire and was able to go through the chronic occlusion
of the left external iliac artery into our endarterectomy site in the
right common femoral artery. We then switched snared the Glidewire
through the right common femoral artery endarterectomy site. At this point
we then placed a 6 French sheath through the Glidewire in the right groin
and then we used a 8 x 60 mustang balloon used to measure the length of
our occlusion. At this point we then decided to use a 8 x 60 self
expanding stent. We deployed the stent in standard fashion at the takeoff
of the hypogastric artery with the endpoint proximal to the femoral head.
We then post dilated with a 8 x 60 mustang balloon. Postop angiogram
demonstrated good apposition of the stent with no hemodynamic significant
stenosis noted. We then at that point, performed a patch angioplasty with
a pericardial patch with 6 0 Prolene in standard fashion. Before
completing the patch angioplasty we forward flushed and backflushed the
common femoral artery. Before completing the full angioplasty, we left
the wire in place and then performed a angiogram which demonstrated
patency of the right common iliac artery as well as external iliac artery
and common femoral artery with no hemodynamic significant stenosis. The
right groin shot demonstrated patency of the profundus as well as the SFA.

At that point we then finished our patch angioplasty and endarterectomy
site. Everything was noted to be hemostatic and mildly oozy. We reversed
the patient with protamine. We dried out any bleeding points with Bovie
electrocautery and clips. We then closed the right groin in layers of
Vicryl multiple. We closed that the subdermal with 3 0 Vicryl pop offs
and the skin with 4 O Monocryl subcuticular stitches. Sterile dressing was
then applied.

On the left groin we downsized to a 6 French sheath over the
wire under fluoroscopic guidance. We then used a 6 French Mynx closure
device and closed the left common femoral artery at the access site. In
standard fashion. Sterile dressing was then applied. At completion of the
procedure the patient had a palpable right pedal pulses. Patient tolerated
the procedure well was extubated transferred to the PACU in stable
condition.

Medical Billing and Coding Forum

Balloon angioplasty without stent for coarctation of aorta-HELP CODING

Posted on by
Hi all,

Does anyone know what CPT code to report for a balloon angioplasty without a stent for repair of coarctation of the aorta?

Op report reads:

Initial pressures and saturations were obtained as detailed on the accompanying diagram. Pulmonary artery pressures were 13 mmHg. There was a slight gradient from the single ventricle into the ascending aorta. There was a gradient of 16 mmHg from the ascending aorta to the descending aorta. An angiogram was performed in the transverse arch in the region of pressure change. This demonstrated a region of discrete narrowing slightly distal to the left subclavian artery. The transverse arch proximal to the left subclavian measured 13 mm. The aorta at the diaphragm measured 12 mm. The narrowest region measured 7.5 mm. Balloon angioplasty was initially performed with a Tyshak 12 mm x 3 cm balloon to a maximal pressure of 4 atm. This was slightly above the nominal pressure, and the maximal diameter of the balloon was 13 mm compared to a residual waist in the balloon measuring 11 mm. There was a residual gradient of approximately 10 mmHg. An angiogram
demonstrated no evidence of complication. It was elected to repeat angioplasty with a 12 mm high pressure Z-Med balloon to a maximal pressure of 8 atm. There was no residual waist in the balloon. Repeat pressure measurements showed a residual gradient of only 2 mmHg. A repeat angiogram demonstrated no evidence of complication and an increase in the narrowest region to 10 mm. The jugular venous catheter was then manipulated with slight difficulty into the innominate vein. An angiogram here demonstrated a small collateral from the left side of the innominate vein with runoff posteriorly into paravertebral vessels. This collateral did not appear to enter the pulmonary veins or atrium. It was therefore elected not to occlude this vessel at this time.

Medical Billing and Coding Forum

AV angioplasty help

Posted on by
Hi,
It seems the more I read about vascular coding the more confused I become when it comes to ANY dialysis circuit interventions. Physician wants to bill 36832 (Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)) but I don’t see it. I don’t see where he is doing any revision; only angioplasty.

I think the correct codes for the intervention would be 36901, and 36907 but I wanted to be sure.

Op report reads:

After informed consent was obtained patient was taken the operating room and prepped and draped in usual sterile manner. The cephalic vein was marked on the skin with ultrasound guidance and a longitudinal incision was made overlying the cephalic vein down to the anastomosis with the radial artery. The subcutaneous tissue was divided with the cautery and the cephalic vein was dissected circumferentially using sharp dissection. A skin flap approximately 3-4 mm in thickness was made and the subcutaneous tissue closed with running 3-0 Vicryl deep to the vein. A micropuncture set was used to access the fistula and a antegrade fashion and a fistulogram was performed with the findings as noted above. A 0.018 Roadrunner guidewire was advanced through the fistula and retrograde up the radial artery past the stenosis. The stenosis was balloon to 8 atm with a 3 mm angioplasty balloon. No residual stenosis was noted the proximal vein up to the innominate vein was interrogated and no significant stenosis identified. The sheath was removed and hemostasis controlled with a figure-of-eight suture. The wound was irrigated and an additional subcutaneous layer was used to approximate the tissues over the vein followed by a running subcuticular 4-0 Monocryl. A sterile dressing was placed over the incision and the patient returned to the recovery room in stable condition. Plan is to admit overnight for dialysis in the morning and then discharged home.

Medical Billing and Coding Forum

Angioplasty 37248

Posted on by
I’ve got 37248, 75827, 75820, but need IVUS (37242) but that’s needs a primary procedure.

PROCEDURES:
1. Ultrasound-guided percutaneous access of L basilic and brachial veins
2. LUE venography
3. L Innominate vein angioplasty
4. LUE venous Intavascular ultrasoun
5. Completion angiography
6. Supervision and interpretation of the above

DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine on the operating table, had anesthesia induced with no complications. Under ultrasound guidance the L basilic vein was accessed. This was somewhat difficult because there was obstruction and or scarring of this vein upon entrance. With a micropuncture sheath in place a venogram was performed. This showed a diminutive basilic vein which occludes in the upper arm. The axillary vein did not appear normal as there were multiple collaterals seen in the axilla. As there was no connection between the basilic vein and the axillary vein I decided to puncture high in the arm. I was able to puncture what appeared to be the exillary vein and place a 6F sheath. 3000 units of heparin were given. I was able to navigate with a KMP catheter and angled gluidewire into the subclavian , innominate and R atrium. Angiography of this segment revealed a venous aneurysm off of a colateral to the subclavian vein. No thrombus apparent. The subclavian vein appear patent. The innominate vein appeared patent but with flow changes consistent with possible obstruction.
*
We then used ICU to evaluate the central segment. It appeared on IVUS that the innominate was narrow and flattened. No thrombus. We dilated this segment with a 12x40mm PTA. Brisk flow was notice post dilation. We attemted to acces the axillary vein retrograde but this was unsuccessful due to apparent occlusion.

608207569_09_07_17

Medical Billing and Coding Forum

Unsucsessful Angioplasty

Posted on by
PROCEDURE: Left heart catheterization, selective coronary angiography, bypass graft angiography with complex percutaneous intervention attempt of the vein graft to the diagonal.
.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old insulin-dependent diabetic, hypertension, dyslipidemia, CAD, previous CABG, previous PCI, presenting with progressive symptoms of chest pain and angina. With high pretest probability despite maximal medical therapy, he is referred for angiography.
.
CONSENT: Informed consent was obtained. The patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure.
.
DESCRIPTION OF PROCEDURE: The right groin was prepped in the usual sterile fashion and 2% lidocaine was infused subcutaneously until adequate anesthesia was obtained. Right common femoral artery was accessed using modified Seldinger technique. A 6 French 11 cm sheath was placed without complication. Diagnostic 6-French JL4 and JR4 catheters as well as an IMA catheter was used for coronary angiography, left heart catheterization and bypass graft angiography. At the conclusion of the procedure, manual compression was used for arterial hemostasis.
.
FINDINGS:
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 16 mmHg. There was no transaortic gradient on pullback.
.
CORONARY ANGIOGRAPHY:
LEFT MAIN: Had a patent stent with mild disease leading into an LAD that was totally occluded. LEFT ANTERIOR DESCENDING: The distal LAD was seen fed from a patent IMA graft with mild diffuse disease. There was a small second diagonal visualized with mild diffuse disease. The first diagonal was seen imaged from a patent vein graft that was severely diseased at the anastomosis. The distal aspect of the diagonal had mild diffuse disease. LEFT CIRCUMFLEX: Had patent stent seen in the proximal portion. There was mild disease leading into a patent stent in the first marginal. There was a lower-lying second marginal that had mild diffuse disease. RIGHT CORONARY ARTERY: Totally occluded proximally. The distal vessel was fed by a patent vein graft. It was a dominant vessel with a prominent-sized RPDA system with mild diffuse disease. However, leading into the RPDA system, there was a 90% proximal and ostial stenosis. This was visualized through the vein graft to the RCA.
.
The vein graft to the circumflex system was known to be occluded and not injected. The vein graft to the diagonal had moderate disease with evidence of a stent at the anastomosis that had 99% in-stent restenosis with only TIMI 2 flow. The vein graft to the RCA was patent with only mild disease. The LIMA to LAD was selectively injected, was patent with mild disease.
.
SUMMARY: Severe multivessel coronary artery disease with patent stents seen in the LAD and left circumflex system. There were 3/4 patent bypass grafts. However, the bypass graft to the diagonal had high-grade in-stent restenosis at the anastomosis. Severe native RPL disease.
.
Based on the patient’s clinical presentation and angiographic findings, it was elected to proceed with angioplasty of the vein graft to the diagonal.
.
INTERVENTION: Angiomax was used for effective anticoagulation and a JR4 guide was used to intubate the vein graft to the diagonal. Initially, a Runthrough wire was attempted; however, it would not traverse the lesion, and therefore a Pilot wire was able to traverse the lesion and was placed distally. Multiple attempts to pass balloons, either a 2.0 as well as a 1.5 balloon, were unsuccessful, and a Godzilla guide liner was then applied and was able to deep seat within the vein graft to allow initial placement of a 1.5 Apex balloon. This was expanded to 10 atmospheres. However, a subsequent balloon was not able to traverse the high-grade lesion. TIMI flow was reestablished, a TIMI 3 flow. However, with inability to pass a balloon, the procedure was abandoned. There was residual 99% stenosis.
.
SUMMARY: Unsuccessful balloon angioplasty of the vein graft to the diagonal.
.
In light of the complexities with the above-stated procedure, the intervention to the RPL lesion via the vein graft to the RCA will be deferred and achieved in a staged fashion. Due to complexities with hemostasis at the access site, manual compression will be applied, and the patient will be admitted for observation.
.
So my question is do I use a Modifier on the angioplasty 92937? Never had this happen before Thank you Nancy

Medical Billing and Coding

LUE intravascular U/S & Angioplasty LUE AV graft venous anastomosis

Posted on by
I think I’m short &/or incorrect on my codes. Please! I really use some help because it’s been awhile for vascular. I’m putting this under Cardiovascular.

35476
37252
36005
75978/75820

PROCEDURES:
1. Left upper extremity intravascular ultrasound.
2. Cutting balloon angioplasty of the left upper extremity AV graft
venous anastomosis.

DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was taken to the
operating room, placed in supine position on the operating table.
Anesthesia was local with sedation. The left upper extremity was
prepped and draped in the usual sterile fashion. Because of the
patient’s severe allergy to contrast, no contrast was given and we
used intravascular ultrasound to navigate as our guide to perform
upper extremity venogram. The AV graft was accessed under ultrasound
guidance with a micropuncture needle. Micropuncture wire was advanced
into the AV graft and exchanged for a 0.035 guidewire. A short 6-
French dialysis access sheath was placed. At that point, using
fluoroscopy, an angled Glidewire and a Kumpe catheter navigated
through the distal venous anastomotic obstruction and placed the wire
into the left innominate vein. We then exchanged for a 0.018
guidewire and placed the intravascular ultrasound. The intravascular
ultrasound was taken to the central veins. There was no evidence of
any significant stenosis based on intravascular ultrasound from the
innominate vein back to the proximal axillary vein. We did notice a
high-grade stenosis at the distal anastomosis of the Acuseal graft to
the axillary vein. The location of the anastomotic stenosis was
marked on the screen. We then used a 7 mm x 4 cm AngioSculpt cutting
balloon for angioplasty of the stenotic portion. There was an obvious
waist on the balloon upon initial inflation. We did 2 inflations at
this site. We then placed a 7 x 2 standard angioplasty balloon to
iron out the site. Upon completion, we then replaced the IVUS
catheter and the anastomotic stenosis was essentially resolved. There
was excellent flow through the distal anastomosis into the central
veins.

With that completed, we then removed our catheter and wires and with
the sheath and held pressure until hemostasis was achieved. The
patient tolerated the procedure well. There were no complications.
The patient was sent to the recovery room in stable condition. He can
resume dialysis on his usual schedule.

Medical Billing and Coding