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Sample Coding Question and Answer

Question: I am fairly new with peripheral coding and would like your help on this one. This is my first time to use your service. A 6 French pigtail catheter was placed into the distal abdominal aorta and aortography with abdominal aortoiliac angiography and selective left lower extremity angiography with runoff was performed. Right lower extremity selective angiography was then performed thru the introducer sheath. A 6 French IMA diagnostic catheter was used to engage the left common iliac artery and a 0.035 inch by 150 cm angled glide wire was used to navigate the distal left profundus artery. The sheath was then exchanged for a 7by 45 pinnacle destination sheath which was placed to the left external iliac artery. Further angiographic views were then taken selectively through the sheath. Following this, we proceeded with revascularization of the left SFA which was chronically occluded from its proximal location just past the profundus bifurcation to just prior to the adductor canal. Several wires were used including a 5 French angled tapered glide catheter, a 0.035 angled glide wire, a 0.035 straight stiff glide wire, a 0.018 v18 control wire, a 4 French nontapered angled glide catheter, and a 4 French straight glide catheter. During the attempted crossing of this long chronic total occlusion, the pinnacle destination sheath became lax. We ultimately were able to advance a 0.035 stiff straight glide wire past the occlusion and into the distal posterior tibial artery. We then exchanged the 7 by 45 sheath for a 7 French by 45 cm arrowflex sheath. Following this, we brought a 3 mm by 8 cm optipro balloon distally and exchanged out the glide wire for a 0.018 v18 control wire. Following this, we navigated a 2 mm by 10 cm savvy balloon into the distal SFA at the adductor canal at the margin of the distal cap and performed multiple serial inflations from distal to proximal. Following this, we used a 4 mm by 10 cm savvy balloon and performed also multiple sequential inflations from distal to proximally. Then we deployed a 7 by 80 mm aurora stent in the distal margin. We followed this with a 7 by 80 mm aurora stent with overlap of the distal stent and then post-dilated both stents with a 5 mm by 10 cm savvy balloon with multiple inflations distal to proximal. Next, we deployed a 7 by 40mm aurora stent just proximal to the second stent. Next, we used an 8 by 80mm aurora stent just proximal to the previously deployed stent. We post dilated with a 5 by 10 savvy balloon with several inflations. Finally, we deployed an 8 by 60mm aurora stent at the most proximal location in the SFA but distal to the profundus bifurcation and post-dilated with a 6mm by 10cm savvy balloon. Following this, we deployed a 9mm by 20cm aurora stent in the mid left external iliac artery and post-dilated with 7mm by 2cm slalom balloon. Coded as: 36246 cath place, 35473 PTA lt iliac, 7596226,35474 PTA lt SFA, 7596226,37205 stent lt iliac, 7596026, 37205 x5 stents lft SFA, 7596026, 756302659 abd aort w/iliofem runoff 757162659 bilateral extremities is this anywhere near correct? Thank you in advance for your help!

Answer: Good to have you aboard ZHealth Online. Interventional is a tough area so don't get frustrated at first. First of all, we need an interpretation to code radiology S&I codes. As I don't hear anything specific as a finding of the aorta, I would not code a separate aortogram and separate runoff. I would use code 75716 for bilateral lower extremity angiography, unless the MD amends the documentation to support some finding in the aorta, even if it is normal. In that case I would code 75630 because the separate aorta and separate lower extremity after catheter movement is not definite (did he really go selective in the left iliac with a pigtail?). The subsequent selective angio of the left leg would be considered a guiding shot for the intervention in the occluded SFA. No code for this. The recanalization and preliminary dilation of the SFA with small 3 and 4 mm balloons would not be coded separately as a stent placement will be coded as the intended procedure. We do not code pre-dilations when the stent was planned. A long segment occlusion such as this will not stay open with balloons only and as the balloons were undersized as a preliminary portion of the stent placements I would not code the angioplasty. The stent placements in the SFA are coded as one stent placement, only, since stenting is coded "per vessel" treated, not per stenosis or stent deployed. 37205 and 75960 for this. The post-dilating is part of the complete stent deployment and is not separately coded. This is the same with the iliac. Only the iliac stent placement is coded as an additional vessel treated with codes 37206 and 75960-59. The catheter placement is third order in the contralateral SFA and is coded with 36247. So, at the end of the day I would use codes 75616-59 (59 required as a true diagnostic study at the time of an intervention requires -59 modifier due to CCI edits), 37205, 37206, 75960, 75960-59 and 36247. There are a lot of rules that must be followed to obtain correct maximum reimbursement but also stay in compliance.

Book References

Dr Z’s 2005 IR Coding Reference p. 148 Instruction 4
Dr Z’s 2005 IR Coding Reference p. 149 Instruction 17 & 18
Dr Z’s 2005 IR Coding Reference p. 89-91 Abdominal Aortography and Run-off
SIR 2005 p. 53 NCCI Edits for DX-TX RS&I Codes
SIR 2005 p 118 Codes 37205-37208
SIR 2005 p. 191-2 Examples A11 & A12
SIR 2004 p. 198 Example V19

Vessel References

External Iliac Artery
Superficial Femoral Artery