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Here is your ZHealth Coding Newsletter
for July 2006
Coding
Question:
This physician
performed angioplasty and stent placement involving a
right femoral popliteal vein bypass graft. Is it
correct to code one open stent placement (37207,75960)
and two angioplasties (35456,35459,75962,and 75964) for
the procedure described herein? Are 36247 and
36248 the correct catheterization codes? The
puncture of the graft and distal anastomosis is
confusing me.
Incision was made over the previous
vein graft and the vein graft was exposed. It was
punctured with a 4 French Micropuncture needle and I
then exchanged this for a 6 French sheath. We then
did an injection which showed a patent vein graft.
There was a tight calcified distal anastomotic stenosis
calcification in the popliteal artery with a 90%
stenosis and a tibioperoneal trunk stenosis which was
very tight, about 90%. I was able to traverse
these with a Miracle Brothers 3 wire. We then used
a 3x6 mm cutting balloon to angioplasty these three
sites. There was improved angiographic appearance
but I still was not satisfied with it. We then
exchanged catheters. We attempted to get a wire
down a posterior tibial which would have given a pulse
in the foot and an anterior tibial, but we were unable
to transverse these. There was pretty extensive
collateral runoff and the graft was patent so therefore
it was elected to treat the immediate distal outflow
problems. We exchanged for a 4x2 mm balloon and
angioplastied the distal anastomosis, the right distal
popliteal lesion and the right tibioperoneal trunk
lesion. I was satisfied with the appearance of the
distal two lesions but there was a slight dissection at
the anastomosis in the popliteal just distal to the
suture line. There was no proximal runoff.
Another inflation was tried for about 2 minutes but was
still not satisfied so we deployed two 6x22 mm wall
stents across this region and then dilated the wall
stent with a 4 mm balloon. There was a much
improved angiographic appearance. We then removed
the stent and closed the vein with 5-0 Prolene
sutures..
Dr. Z's
Answer:
I would consider
the proximal and distal anastamosis of the graft and the
entire graft in-between to be one vessel for coding
purposes. The native distal popliteal artery
stenosis appears to be distinct and separate and should
be allowed as a separate vessel to code. I am
uncertain as to the exact location of the tibio-peroneal
trunk lesion. If it were immediately adjacent to the
distal popliteal, I might consider it part of a bridging
lesion and not additionally code. If it were mid
to distal, separate and distinct, then I would code for
this lesion as well. The MD states he got a good
result with the two distal lesions but the proximal
lesion he was not satisfied with. Unfortunately,
most local policies require documentation of 30% or
greater residual stenosis, 5mm or greater residual
gradient, a flow-limiting dissection or an acute
occlusion be documented to meet medical necessity for
billing both an angioplasty and a stent. In this
case he only states he wasn't satisfied because of a
"slight dissection". This doesn't meet criteria to
bill both so I would code as you have, with two open
angioplasties and one open stent. The catheter placement
code in this case would be coded based on the graft as
the non-selective 36140, the popliteal as a first order
and the furthest you got, and the tibio-peroneal trunk
as a second order vessel. Due to bundling, I would code
36246 only for the catheter placement as that is the
furthest that a catheter is documented.
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2006
ZHealth Coding
Conferences
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radiology and cardiology coding conferences in 2006:
Sept 12-15
at the Gaylord Opryland in Nashville,
TN
Nov 7-10 at
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NV
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