Here is your ZHealth Coding
Newsletter for July 2007
Can
you correctly code the case presented in the question
below?
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Coding
Question:
I have a case that seems complicated to code and cannot
find info in the vascular book we purchased to address
it. Please advise: Pre-op dx: non-healing lt great toe
amputation site; hx of lt common fem to peroneal
bypass performed 3 months ago; high
grade velocity detected by duplex in distal portion of
the vein graft. Pt currently on dialysis Procedure:
antegrade punc of LLE graft w/ LLE angiography; PTA of
distal anastomosis between vein graft and peroneal
artery; PTA of vein graft in more prox. segment; coil
embolization of a lg. mid thigh branch of saphenous vein
bypass Lt thigh prepped with antegrade direct puncture
of saph vein and sheath placed. Selective LLE
angiography performed. Prox portion of vein graft
patent. At mid thigh of the saph vein bypass creating a
functioning AV fistula. In fact-more flow going through
the fistula than distally within the graft. Further
imaging of distal vein graft revealed a small vein that
became diminutive as it entered the calf w/ high grade
stenosis at this level. Peroneal artery not visualized
distally due to some sort of near occlusive high grade
stenosis involving the distal anastomosis. The peroneal
artery was visualized as it was reconstituted by other
collaterals. The two distal stenoses within the vein
graft were easily crossed with a guidewire and the wire
was placed into the distal peroneal artery. A catheter
was then passed into the artery. Angiogram confirmed we
were in the true lumen of the peroneal artery. Distally
the artery appeared free of disease. A 2x2 cutting
balloon was then used to perform angioplasty along the
vein graft at these anastomotic sites. Resulted in
improvement of flow through the graft at this level but
greater than 30% residual stenosis at the most distal
aspect of the vein. After the plasty it became clear
that the vein had become stenotic and there was not an
anastomotic problem. Used a 2.5x8 balloon to plasty
across the distal portion of the vein into the peroneal
artery. Stenosis improved to less than 30%. Brought
glide cath back prox to the segment and did angiogram at
the level of the distal thigh. Revealed long stenosis of
the vein graft prox to the genu as the known fistula.
Angioplasty of distal segment of vein graft at thigh
level done. Significant improvement. Selectively
catheterized the side branch of the vein with a glide
catheter. Angiogram confirmed placement but there was a
small amount of extravasation of contrast at this level
due to guide wire injury. Follow up angio reveal no
active extravasation so they proceeded with coil
embolization of the side branch. After this there was
excellent antegrade flow down the vein graft. Follow up
imaging of the segment of vein graft at the distal thigh
level revealed stenosis though less than 30% residual.
No further intervention.
The question is this: Here are my thoughts:
36247-Lt-59, 36012-Lt, 75710-59-Lt, 35476, 75978, 37204,
75894, and 75898. Do you treat these plasties as
venoplasties in the saph. Vein or angioplasties as they
are artificially replacing an artery? What about cath
placement? I am thinking 36247 for the peroneal artery and 36012
for the saph vein side branch. With the direct punc to
the saph vein and angiogram, does that qualify for
75820 or 75710 as there are both vein
and artery findings.
Dr Z’s Answer:
In
this example, the patient's own saphenous vein was
utilized in a non-reversed (or in-situ) method to act as
a conduit to transport arterial blood around a
completely occluded native SFA and popliteal arteries.
So, any work done on this vessel is considered arterial
in nature and iscoded with arterial codes. Occasionally,
these grafts have branches to the deep venous system
that are not clipped at surgery, resulting in these AV
fistulae that divert blood from getting to the lower
leg. The access directly into a vessel is 36140. This
changes to 36245 once you exit the vessel punctured and
it enters the peroneal artery. That is the furthest I
see the selection for the catheter. The branch that is
selected off the saphenous vein is another first order
selection, and as you cannot use 36248 for additional
2nd or 3rd order selection here (as it is another first
order selection) use 36245 for this branch selection.
The imaging of the lower extremity is arterial imaging,
75710-59. The angioplasty is billed as a fem-pop
angioplasty (including all angioplasty in the graft
including any anastomoses) so 35474 and 75962. The
embolization is coded for the coil placement and
follow-up imaging with 37204, 75984 and
75898.
Join Us in Nashville, TN at the
next ZHealth Coding Seminar
The
next ZHealth Coding Seminar will be held in Nashville,
TN, Sept 11-14, at the Gaylord
Opryland Resort & Convention Center. If you
haven’t had a chance to attend one
of our Interventional Radiology & Cardiology Coding
programs yet this year, you can make your
reservation(s) now. We’ll also be in Las Vegas at the Wynn
in November and in Scottsdale, AZ at the FireSky
Resort & Spa next February (2008). Read
what participants had to say about our last coding
seminar.
Now Shipping: ZHealth’s 2007
Cardiovascular Coding book:
ZHealth’s third
coding reference of 2007 is now shipping, and it’s our
initial Diagnostic
& Interventional Cardiovascular Coding
Reference. We believe that as a
clinician, medical coder, medical biller, consultant or
other professional involved in the coding and billing of
complex procedures, you’ll
find this just as valuable as our other two coding books
for 2007. Check out the Table of Contents and a sample chapter of this brand new 500+
page book, and order
yours today.
Web Seminar CD’s Now Available : A Great
Addition to Your Coding Reference Library
ZHealth
held its first Web Seminar June 5th :
Understanding
Dialysis Access Coding From Insertion to
Maintenance, and we now plan to offer a series of
interventional radiology, cardiology, and vascular
surgery coding seminars on the web beginning this
September. More information will be coming soon. If you
missed the first one, you
can purchase the course (and the outline) on CD –
and still earn CEU’s. Find out more.
And
remember that ZHealth
Online members receive a 10% discount off all
seminar registrations and publications.
Talk
to you next month!
ZHealth
Publishing
