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Aortic occlusion with bilateral iliac artery stenoses

Posted on May 7, 2019 by CPC Exam Medical Coding Updates

The vascular surgeon used an "aortic occlusion Endologix AFX graft deployment (main body, right iliac limb and left iliac limb/unibody bifurcated graft) to "navigate through the occlusions" in the terminal aorta.
He also performed a right iliac angioplasty and left iliac angioplasty with stent placement; I know I can charge for both of these.
Can this type of graft deployment be charged for the occlusion in the terminal aorta? if so, what CPT code should be used… there was no aneurysm.
I have contacted the manufacturer to inquire about this type of graft, but their response is to send me a list of "potential" CPT codes, none of which are pertinent in this case.
Thank you!
-Kim

Medical Billing and Coding Forum

need b/l iliac stenting help

Posted on April 26, 2019 by CPC Exam Medical Coding Updates

Conclusion

This 53-year-old female has a known left common iliac artery occlusion status post failed attempt with an antegrade approach from the left femoral was brought in today for attempt from the left brachial. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 8:26 AM and monitoring period Ended 10:16 AM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery and the left brachial artery. A long destination sheath was inserted from the left brachial artery into the distal aorta at the bifurcation. The 6 French sheath from the right femoral artery was also a long sheath that was advanced to the distal aorta. .
Finding:
1: Repeat angiogram did show the occlusion in the left common iliac artery. There is barely any knob.
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Intervention:
With a support of an angled 4 French glide catheter, allowing zip wire was able to cross the occlusion all the way to the common femoral artery. The glide catheter was advanced over it. The wire was removed and angiogram so the catheter showed that we were all intraluminal. A V 18 wire was then used and advanced into the left superficial femoral artery. The catheter was then removed. The occlusion was dilated with a 5 x 80 mm balloon. As the occlusion was proximal, I decided to perform kissing stenting as I could not ensure that the stent placement in the origin of the common iliac artery would not impinge on the origin of the right common iliac artery. Since the occlusion is long I covered the distal occlusion with a 8 x 60 mm epic self-expanding stent. Following that simultaneous 8 x 27 mm express of the balloon-expandable stents were placed in the origin of bilateral common iliac artery in a kissing fashion with excellent result and no residual stenosis
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Impression:
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100% occlusion of the origin of the left common iliac artery. I placed a 8 x 80 mm epic self-expanding stent in the common iliac artery. The origin of bilateral common iliac arteries were covered with an 8 x 27 mm express LD balloon expandable stents in a kissing fashion
Plan: Continue medical treatment with dual antiplatelet therapy and aggressive risk factor control

thanks in advance
am I only coding 37221-50 or should I add 37223-lft also?

Medical Billing and Coding Forum

Coil Embolization and Two Iliac balloons – Please help!

Posted on February 1, 2019 by CPC Exam Medical Coding Updates

Any help is much appreciated. I came up with the following:

37220-78-RT
+37222-RT
37244-80-RT

PROCEDURES PERFORMED:
1. Right lower extremity angiography.
2. Balloon inflation of the right external iliac artery with an Armada 4 mm x 40 mm balloon, balloon inflation of the right common iliac artery with an Armada 7 mm x 40 mm balloon, coiling of the right inferior epigastric artery with Interlock 2×3 mm, 2×4 mm and 3×6 mm coils.

INDICATIONS FOR PROCEDURE: Patient is a 34-year-old Caucasian female that presented earlier today for an outpatient atrial septal defect closure via right and left femoral venous access. Post procedure, she had a right groin hematoma and complained of extensive pain. She was hypotensive and continued to be unstable, so the patient was brought back to the Cath Lab emergently for lower extremity angiography.

FLUOROSCOPY TIME: 17.5 minutes.

RADIATION EXPOSURE: 578 milligray.

CONTRAST: 100 mL of Omnipaque.

PROCEDURE IN DETAIL: The patient was brought to the Cardiac Cath Lab in an emergent fashion. The bilateral groins were prepped and draped in the usual sterile fashion. The skin overlying the left common femoral artery was anesthetized with 1% lidocaine. A Cook needle was used to access the left common femoral artery under direct ultrasound visual guidance and a 6-French short sheath was placed. At that time, a Contra catheter was advanced over a J-tipped wire and used to engage the right common iliac artery. The J-tipped wire was then advanced down into the right common femoral artery. The Contra catheter was removed and a 4-French Glidecath was advanced over the wire into the right external iliac artery. At that time, selective right lower extremity angiography was performed with hand injection of contrast. We noted that there was extensive extravasation of contrast from the inferior epigastric artery on the right. The Glidecath was removed over a wire and then the 6F short sheath was exchanged out for a 6F Destination sheath which was placed in the right common iliac artery. An Armada 4 mm x 40 mm balloon was advanced over the J-tipped wire into the proximal portion of the right external iliac artery. That balloon was inflated to 2 atmospheres for 5 minutes. We then performed another angiogram and noted that there was still extravasation, so it was inflated for another 5 minutes. We then performed another angiogram and noted that there was extravasation from the same vessel from branches coming from the internal iliac artery as well, so that balloon was removed and an Armada 7 mm x 40 mm balloon was placed in the distal right common iliac artery just proximal to the bifurcation. Balloon occlusion was performed for 10 minutes and we repeated angiography and noted that there was still extravasation. Another balloon inflation was performed at 6 atmospheres for 10 minutes and we were still unable to control the bleeding despite already giving protamine and having multiple balloon inflations.

At that time, I asked Dr. _______ for assistance and he joined the procedure to help with coil embolization of the bleeding artery. The balloon was removed and a 6-French IMA guide catheter was advanced through the 6-French Destination sheath. The IMA guide was directed towards the ostium of the inferior epigastric artery and then a BMW wire was advanced up the inferior epigastric artery. We then placed a microcatheter over the BMW guidewire up into the inferior epigastric artery and removed the BMW wire. At that point, we were able to deploy 2 coils in the more superior aspect of the inferior epigastric artery, distal to where the bleeding was noted, and then pulled the microcatheter down and place 1 more coil proximal to the bleeding site in the inferior epigastric artery. A repeat angiogram was performed and we noted that we had achieved hemostasis of the inferior epigastric artery with the coils. The microcatheter was removed and the multipurpose guide catheter was removed. We again repeated right lower extremity angiography through the Destination sheath and noted that the common iliac, internal iliac, external iliac, femoral, and profunda arteries were all patent, although severely vasospastic, and there was no longer any signs of extravasation from the inferior epigastric artery. At that time, the Destination sheath was removed from the left groin over a wire and a 6 French short sheath was placed. An angiogram was performed noting that the left femoral artery was acceptable for a closure device. The 6-French Angio-Seal was deployed successfully.

FINDINGS:
1. Right lower extremity angiography.
2. Severe vasospasm in all the lower extremity arteries.
3. Widely patent right common iliac, right external iliac, and right internal iliac arteries.
4. Extravasation of contrast from the right inferior epigastric artery near the takeoff from the common femoral artery.
5. Post procedure there was no longer any extravasation noted from the inferior epigastric artery.

ASSESSMENT AND PLAN:
1. Extravasation of contrast from the right inferior epigastric artery.
2. Successful coiling of the right inferior epigastric artery with 3 Interlock coils both proximal and distal to the site of extravasation.
3. We will admit the patient to the CCU and monitor closely. The patient received 2 units of PRBCs during the procedure. We will wean the phenylephrine drip off as soon as possible.

I administered moderate sedation throughout this 118-minute procedure. An independent trained observer pushed medication at my direction and monitored the patient’s level of consciousness and physiologic status throughout.

Medical Billing and Coding Forum