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Tag Archives: /selective

Selective Debridement Crosswalk

Posted on by
Hello,

I work for a wound care company that provides services in many different settings. I am looking to map Selective Debridement CPT (97597) to ICD-10 PCS Codes. When referencing the book, it wants me to distinguish between Excisional and Non-Excisional. I know that most Sharps debridements, Subcutaneous, Muscle, & Bone are excisional. I cannot find clarification on a Selective Sharps Debridement and would appreciate if anybody can give me information on what they code for in this scenario in their practice. Thanks in Advance!

Medical Billing and Coding Forum

Can anyone help here? – Selective Iliacs

Posted on by
I’m getting 36247-LT, 36246-RT and 75716 but I’m questioning adding 36248 because he selectively engages the external iliac on the left as well.

Also, a different physician (who is not in our practice) did the angioplasty during the same surgical session. Co-surgeons mod? Is what my doc did even billable? Doesn’t cath placement bundle with intervention?

DESCRIPTION OF PROCEDURE: Risks and benefit of the procedure were explained to the patient and the patient was placed in the supine position on the Cath Lab table. He was draped in a sterile fashion and access of the right femoral artery was achieved under ultrasound guidance using a micropuncture kit. A 6-French sheath was inserted into the right femoral artery under ultrasound guidance. This was followed by insertion of a crossover catheter. A Glidewire was advanced into the crossover catheter to cross into the left common iliac. The Glidewire was selecting the internal iliac. The crossover catheter was advanced gently. This was followed by insertion of the J-tip wire into the superficial femoral artery and advancing the crossover catheter over it until the wire was far enough into the superficial femoral artery. This was followed by removal of the crossover catheter and advancing of a long sheath. The 45 cm Terumo sheath was advanced into the external iliac artery. On the left side, After the sheath was advanced into the left external iliac artery a selective angiography of the left lower extremity was performed. Multiple views were obtained to delineate the severity of stenosis in the left superficial femoral artery. A runoff was performed to the level of the foot on the left side. This was followed by attempts to cross the superficial femoral artery using a BMW wire. Multiple attempts were done; however, the BMW wire was not possible to cross into the lesion. An angiography revealed that the BMW wire is stuck in the lesion. Multiple attempts to remove the BMW wire was not successful. After more attempts, the distal end of the wire, which was attached to the stiff end of the wire broke off and the wire was lodged into the lesion. A Quick-Cross 0.035 sheath was or microcatheter was advanced over a Pilot 200 wire. The Pilot 200 wire was advanced beyond the lesion and the microcatheter was advanced over the BMW portion of the wire. A surgical backup was called regarding the fact that the superficial femoral artery flow was impaired. The Pilot 200 wire was beyond the lesion; however, it was not free enough to confirm that it is intraluminal therefore the Quick-Cross catheter was removed along with the Pilot 200 wire by Dr. Burke. This was followed by confirming that the BMW portion of the wire was removed with a Quick-Cross catheter. A confirmation was obtained and a Quick-Cross catheter removal was successfully done along with a portion of the BMW wire. A NanoCross catheter was advanced along with an angled Glidewire. This was successfully able to cross the lesion in the SFA. This was followed by advancing a 4 x 40 balloon, which was inflated 2 times in the lesion. This was followed by advancing a 6 x 100 _____ drug-coated balloon. The balloon was inflated once for 3 minutes with slow deflation. Angiography after removal of the balloon and wire showed no dissection that is flow limiting and no perforation.

The sheath was withdrawn into the external iliac artery on the right and this was followed by advancing a short 6-French sheath. A selective angiography of the right lower extremity was performed through the 6-French sheath down to the foot level.

FINDINGS OF THE STUDY: There was evidence of a 30% lesion in the external iliac artery on the left. The superficial femoral artery on the left had evidence of 80-90% mid SFA stenosis. The _____ artery was normal. There was evidence of 3-vessel runoffs was evidence of 40% proximal anterior tibial artery stenosis, 50% proximal peroneal stenosis.

On the right side, there was evidence of 30% external iliac stenosis.

Superficial femoral artery had evidence of 50-70% stenosis in the midportion with significant calcification. There was evidence of 40% stenosis in the popliteal artery. There was evidence of 3-vessel runoff down to the level of the foot.

CONCLUSION:
1. Severe disease in the SFA on the left. Moderate to severe disease in the SFA in the right.
2. Successful angioplasty of the left superficial femoral artery performed by

COMPLICATIONS: BMW wire fractured with a successful recovery of the fractured portion.

Medical Billing and Coding Forum

Selective cath bil subclavian arteries, bil upper extremity venograms…

Posted on by
How would you code the following case? Our codes are the following:
36255-50, 36100-59-LT, 76937, 75822

We are unsure if ultrasound guidance can be coded in this case. Also, with the RUE venogram performed through IV access site, there’s no catheter placement code for this, right? Additionally, the reason we are choosing 36100 is for the LUE vein branch that was punctured for the LUE venogram. We are also unsure if the LT modifier is used on 36100.

Pre-operative diagnosis:
1. End stage renal disease on dialysis with multiple failed accesses

Post-operative diagnosis:
1. same

Procedure:
1. BL UE venogram with US guidance
2. BL UE angiogram with selective catheterization of subclavian arteries
3. Arch aortogram
4. R transfemoral artery access

Complications: none

Specimens: none

Procedure in detail:
In the angio suite the BL upper extremities were prepped and draped in the usual sterile fashion. BL groins were prepared and drapped in the usual sterile fashion. Direct US guidance was used to obtain access to the R common femoral artery with micropuncture needle, wire, and sheath. Wire and catheter were used to shoot an arch aortogram. Great vessels patent. Both R and L subclavian arteries were selectively catheterized. Angiography revealed patent vessels with sluggish flow in BL UE’s, likely cardiogenic in nature. RUE IV was used to perform venogram, which showed diffuse sclerosis of the cephalic, basilic, and brachial veins with poor caliber. Axillary veno open but somewhat small. LUE vein branch punctured with micropuncture needle, wire, and sheeth with US guidance. Venogram shows old occluded graft, patency of axillary vein. 5 Fr sheath pulled from groin. Pressure held. No hematoma.

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

93451 or 93456 (with 93568). Does selective imaging imply the coronary angiography?

Posted on by
75-year-old patient with worsening shortness of breath and chest pain. Via a right brachial access, the catheter is advanced to the left coronary artery with selective imaging of the left anterior descending and left circumflex arteries. The catheter is then placed in the right coronary artery. The right coronary artery is normal. The left ventricle could not be entered due to the presence of a mechanical valve replacement. A flow directed catheter is then advanced into the right ventricle, right atrium and pulmonary artery, with wedge pressure performed. Contrast is selectively injected in the main pulmonary artery with angiography performed. The catheter is removed and pressure held for hemostasis.

Does the term selective imaging imply the coronary angiography?

93451, with 93568?

OR

93456, with 93568?

Thank you!

Medical Billing and Coding Forum

LHC /selective angiography HELP!

Posted on by
Would I code 36245 and 75710 in addition to 93459 and 93567 in this example? Any thoughts/explantions would be appreciated!

PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Left ventricular angiography.
3. Aortic root angiography.
4. Right and left coronary angiography.
5. Saphenous vein graft angiography x3.
6. Left internal mammary angiography.
7. Left subclavian angiography.
8. Abdominal aortogram with selective left common iliac angiogram
and monitored anesthesia care for 1 hour.

CLINICAL DATA:
69-year-old female with severe peripheral vascular disease,
kyphoscoliosis, post Harrington rod procedure who has severe coronary
artery disease, abnormal stress test performed recently demonstrating
multiple reversible perfusion defects and depressed ejection fraction.
Procedure was performed from the right groin using modified Seldinger
technique. There was severe disease in the right common iliac artery.
We utilized a 25-cm 6-French sheath, because of tortuosity, 6-French
diagnostic catheters were utilized.

HEMODYNAMIC DATA:
The patient is in sinus rhythm with a heart rate of 60 to 70 throughout
the procedure. The arterial pressure 180/60 and 104 mean. LV pressure
of 180 with an LVEDP of 12 to 14, there was a 20 mm gradient on pullback
across the right common iliac lesion in the proximal, but not ostial
portion of the common iliac artery on the right side.

Left ventricular angiography was performed in a single RAO projection.
Left ventricle is well opacified with dye, it is moderately dilated.
There is severe hypokinesis of the inferior basal segment. There is
severe hypokinesis in the anterior lateral wall, apical wall motion
is relatively well preserved. The mid inferior wall is hyperkinetic.
Angiographic ejection fraction is estimated in the 35% range. There
was no mitral regurgitation.

Her aortic root angiogram, aortic root angiogram was performed in a steep
LAO projection. The aortic root is aneurysmal and moderately dilated,
appears to be at least 5 cm. There was moderate/2+ aortic insufficiency.
There are buttons for 3 saphenous vein grafts. All saphenous vein
grafts appeared to be closed. Saphenous vein graft, which appears to
have gone to an intermediate or diagonal branch has multiple stents
in it. No flow is noted through these. There is no evidence of dissection.

CORONARY ANGIOGRAPHY:
Coronary angiography is performed in multiple projections.

A. The right coronary artery appears to have been a dominant vessel.
It is totally occluded in its proximal portion. Right after a large
right ventricular marginal branch arises. There are intercoronary collaterals
to the distal right coronary artery; however, we cannot visualize the
PDA or posterior lateral branches. There were also intracoronary collaterals
from the left circumflex.
B. The left main coronary artery is a moderate type vessel arising from
the left cusp. There appears to be mild ostial left main lesion approximately
20%, which is nonobstructive to flow. The left main ends in a bifurcation.
C. The circumflex is a large, but nondominant vessel. There is mild
atherosclerotic plaque in the proximal circumflex. It gives rise to
a series of small high lateral branches before giving rise to the groove
branch. It is tortuous in this segment. There appears to be severe
disease in the AV groove branch. As the circumflex continues, it bifurcates
into medium posterior and marginal branches. There is a saphenous vein
graft, which is inserted right at this bifurcation. The vein graft
is closed. There appears to have been a lesion here. There was brisk
flow. No significant obstructive disease is noted. The circumflex
provides a profuse collateral flow to the distal right coronary artery
and also to the diagonal system of the left anterior descending artery.
D. The left anterior descending artery has flush total occlusion at
its ostium. No significant antegrade flow was noted.

Saphenous vein graft angiography is performed x3. Vein graft to the
RCA closed. Vein graft to the circ marginal closed. Stented vein graft
to an intermediate or diagonal branches closed with no flow.

Left subclavian angiogram is performed. The left subclavian is patent.
There was severe calcific disease noted. The left internal mammary,
we cannot see the ostium of it, but the vessel appears to be free of
significant obstructive disease, inserts in end-to-side manner in the
mid to distal third of the LAD. The distal insertion sites widely patent
with brisk TIMI-3 flow into the LAD.

Abdominal aortogram is performed in a single AP projection. The exam
is somewhat limited due to hardware from previous spinal surgery. The
celiac axis is patent. Superior mesenteric and inferior mesenteric
arteries are patent. There are profuse abundant pelvic collaterals
noted. There is severe obstructive disease in the right iliac artery
indeed we had problem crossing this and required a Wooley wire and a
long sheath to complete cardiac catheterization. There was an 80% obstruction
in the proximal right common iliac artery. Unable to evaluate the left
common iliac artery, because of hardware. The left renal artery has
a lesion of approximately 40% to 50% at its ostium. The right renal
artery is patent. However, again because of hardware and anatomy unable
to judge whether there is any significant disease.

IMPRESSIONS:
1. Dilated cardiomyopathy ejection fraction 35% with multiple wall
motion abnormalities.
2. Moderate aortic insufficiency.
3. Ascending aortic aneurysm.
4. Severe coronary artery disease including a totally occluded LAD
and right coronary arteries. There is mild disease in the ostial left
main, with a patent circumflex.
5. Total occlusion of 3 saphenous vein grafts.
6. Patent LIMA graft to LAD.
7. Peripheral vascular disease with a high-grade lesion in the right
common iliac artery with mild disease in the left renal artery.
8. Diffuse, but nonobstructive disease in the distal abdominal aorta.

COMMENTS:
This patient has dilated cardiomyopathy. The right coronary artery and
graft are totally occluded. The patient has abundant coronary collaterals,
which appears to be a poor candidate for redo coronary bypass grafting
operation. She may benefit from revascularization of the right iliac
artery. At this point in time, maximal medical therapy will be instituted.
The patient needs aggressive treatment of her dyslipidemia.

Medical Billing and Coding Forum