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During a PTCA, a bare metal stent is inserted in the mid posterior descending artery and a drug eluting stent is inserted in the right coronary artery. The question is are these two vessels considered one vessel and coded to 92980 only or are these considered 2 vessels and coded to 92980 and 92981?
The PDA arises from the right coronary artery 95% of the time (5% of the time from the LC). If intervention is performed in the RC and a branch of the RC (the PDA), only one intervention is coded to the highest level, (in this case a DES,G0290 for the hospital and 92980 for the MD). Dr.z
Thank you in advance for reviewing. This patient presented with atheroembolic problems to the lower extremities and kidneys. Op report states that an IVUS exam of the thoracic and abdominal aorta was done and multiple lesions throughout the thoracic and abdominal aorta were found. My question is what code to use when the surgeon places two 20 & 5.5 cm AneuRx aortic cuffs in the infrarenal segment of the aorta. He also placed three 23 & 3.3 Excluder cuffs in the distal thoracic aorta. I coded the Excluder cuffs with 33881.
The codes for thoracic aorta and abdominal aortic stent graft placements require the medical necessity of aneurysm, psuedoaneurysm, arteriovenous malformation or trauma. This does not appear to be the case here, with apparent ulcerated plaques being covered by the stent grafts. I would code these as I would placement of a stent graft for stenosis, and that is as a regular old stent placement with 37205, 37206, 75960, 75960-59 and 36200. I would code two stent placements for the separate treatments with stents for the above diaphragm and below diaphragm disease. Dr.z
Hi Dr. Z, 2 mg TPA was infused for 10 minutes for "provacative testing" for a lower gastrointestinal bleed that was finally embolized. I would not assign 37202 for this infusion, because for one thing, I don't see it as therapeutic. What do you think? Thanks.
I would not code for this infusion over 10 minutes, other than the catheter placement, imaging and the drug charge (for the hospital). The infusion of a thrombolytic agent (37201) is for thrombolysis of clot to open up an occluded vessel for reperfusion of the distal vessels and must be for a prolonged period of time (which 10 minutes does not qualify anyways). I agree with your concept that 37202 is also not appropriate as this code is for a therapeutic infusion (again, for a prolonged period of time) of a non-thrombolytic agent (which this is a thrombolytic agent). I would just consider this part of the diagnostic visceral angiographic procedure). Dr.z
Regarding CPT Code 61635: Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed.
Please recommend coding of the following cerebral intervention procedure. Is all selective catheterization & diagnostic imaging inclusive for the entire procedure when reporting code 61635 or is there additional coding that may be reported?
PROCEDURE: Diagnostic cerebral angiogram and stenting of the intracranial left vertebral artery.
PREOPERATIVE DIAGNOSIS: Posterior fossa stroke.
POSTOPERATIVE DIAGNOSIS: Posterior fossa stroke.
VESSELS CATHETERIZED:
1. Left vertebral artery.
2. Left common carotid artery.
3. Right common carotid artery.
4. Right subclavian artery.
5. Right vertebral artery.
VESSELS IMAGED:
1. Frontal and lateral posterior fossa angiogram through left vertebral artery injection.
2. Frontal and lateral left common carotid bifurcation angiogram through left common carotid artery injection.
3. Frontal and lateral full cerebral angiogram through left common carotid artery injection.
4. Frontal and lateral right common carotid bifurcation angiogram through right common carotid artery injection.
5. Frontal and lateral full cerebral angiogram through right common carotid artery injection.
6. Frontal angiogram of the right subclavian artery through right subclavian artery injection.
7. Frontal and lateral posterior fossa angiogram through right vertebral artery injection.
PROCEDURE AND DETAILS: The patient was placed on the angiography table in the usual supine position. The right groin was prepped and draped in the usual sterile fashion. After giving the patient 10ccs of 1% Lidocaine in the right groin, access to the right common femoral artery was obtained using a micropuncture system. After serial dilatation, a 6 french long sheath was advanced over a guidewire and hooked to heparinized saline flush. Through the sheath, a 5 french JB1 diagnostic catheter was advanced and selectively placed in the left vertebral artery without difficulty. With the catheter in this position, frontal and lateral posterior fossa angiogram was obtained. The catheter was then selectively placed in the left common carotid artery without difficulty. With the catheter in this position, frontal and lateral left common carotid bifurcation angiogram was obtained. The image intensifier was moved cephalad, full cerebral angiogram was obtained. The catheter was then selectively placed in the right common carotid artery without difficulty. With the catheter in this position, frontal and lateral right common carotid bifurcation angiogram was obtained. The image intensifier was moved cephalad, full cerebral angiogram was obtained. The catheter was then selectively placed in the right subclavian artery without difficulty. With the catheter in this position, frontal angiogram of the right subclavian artery was obtained. The catheter was then selectively placed in the right vertebral artery without difficulty. With the catheter in this position, frontal and lateral posterior fossa angiogram was obtained. The catheter was removed. The sheath was removed and adequate hemostasis was obtained by using Starclose device. There were no immediate complications.
SUPERVISION AND INTERPRETATION: The posterior fossa angiogram obtained through left vertebral artery injection demonstrates total occlusion of the pericranial left vertebral artery. There is no flow to the posterior fossa. The frontal and lateral left common carotid bifurcation angiogram obtained through left common carotid artery injection demonstrates no evidence of significant stenosis. Minimal posterior plaque is present at the proximal left internal carotid artery. The full cerebral angiogram obtained through left common carotid artery injection demonstrates no evidence of significant abnormality. There is opacification of the top of the basilar artery and both posterior cerebral arteries, as well as the anterior cerebral artery, through posterior communicating artery. The frontal and lateral right common carotid bifurcation angiogram obtained through right common carotid artery injection demonstrates minimal posterior plaque at the proximal right internal carotid artery. There is no evidence of significant focal stenosis. The full cerebral angiogram obtained through right common carotid artery injection demonstrates no evidence of significant vascular stenosis. There is no evidence of significant filling of the posterior circulation from this injection. The frontal angiogram of the right subclavian artery obtained through right subclavian artery injection demonstrates normal vessels. There is minimal, less than 50% stenosis at the ostium of the right vertebral artery. The posterior fossa angiogram obtained through right vertebral artery injection demonstrates the right vertebral artery to be congenitally small, ending predominantly in PICA. The intracranial right vertebral artery, distal to the origin of the right PICA, is congenitally small and barely opacifying the basilar artery in antegrade fashion.
THERAPEUTIC INTERVENTION: A 6 french long sheath was inserted into the left common femoral artery, and a 5 french short sheath placed in the left common femoral vein. Through the 6 french long sheath a diagnostic catheter was selectively placed in the left vertebral artery. A roadmap was obtained. The diagnostic catheter was exchanged over a Neuroexchange wire to a 6 french Envoy catheter with its tip in the distal pericranial left vertebral artery. The guiding catheter was secured to the skin and hooked to heparinized saline flush. Through the guiding catheter, a roadmap was obtained. A microcatheter (Echelon 014) was advanced over microwire (Transcend .014). The microcatheter was selectively placed at the pericranial left vertebral artery, the microwire was removed. The microcatheter was flushed. Frontal and lateral angiogram was obtained through the microcatheter. This demonstrated total occlusion of the left vertebral artery. The microcatheter was flushed. A (Transcend .014) microwire was advanced through the microcatheter and navigated through the total occlusion of the intracranial left vertebral artery, up to the expected position of the basilar artery and then to the expected location of the right posterior cerebral artery. The microcatheter was advanced over the microwire up to the mid basilar artery. The microwire was removed. The microcatheter was flushed and gentle injection of contrast through the microcatheter was performed confirming its intraarterial position. The microcatheter was flushed and an exchange length 014 wire was advanced through the microcatheter and selectively positioned in the right posterior cerebral artery. The microcatheter was removed. A balloon catheter (Gateway 2 x 9mm) was advanced through the microwire and angioplasty of the pericranial left vertebral artery was performed, up to the expected origin of the posterior-inferior cerebellar artery. The balloon was deflated and follow up angiogram through the guiding catheter was performed demonstrating improvement of the antegrade with critical stenosis at the distal pericranial left vertebral artery, just proximal to the posterior-inferior cerebellar artery, which is responsible for occlusion of this vessel. However the residual stenosis was critical and there were multiple filling defects inside the pericranial left vertebral artery present, consistent with a clot. At this time, the balloon catheter was removed. A new balloon catheter (Gateway 3 x 15mm) was advanced over an exchange length 014 wire, up to the pericranial left vertebral artery. The balloon was inflated up to nominal pressure, then deflated. A followup angiogram was obtained through the guiding catheter demonstrating further improvement of the flow, but persistent, approximately 75-80% stenoses, despite inflation of the balloon up to nominal pressure. Multiple filling defects, consistent with clot formation are still present in the pericranial left vertebral artery. At this time a half dose of cardiac dose of Repro was injected through the guiding catheter. The guiding catheter was removed and a balloon-mounted stent (Xience 3 x 12mm) was advanced over an exchange length 014 wire. The stent was placed at the pericranial left vertebral artery, at the site of the significant residual stenosis, by gradual inflation of the balloon. The balloon catheter was removed. A followup angiogram through the guiding catheter, while the microwire was still in place, demonstrated significant improvement of the flow, without evidence of residual stenosis at the intracranial left vertebral artery. There is antegrade flow to the basilar artery and its branches. There has been interval decrease in size of the filling defect, which was suggestive of clot formation. The microcatheter was removed. The guiding catheter was removed. The three sheaths were sutured in place (6 french long sheath in the right common femoral artery, 6 french long sheath in the left common femoral artery, and the 5 french short sheath in the left common femoral vein). There were no immediate complications.
IMPRESSION:
1. Patient is status post successful stenting of totally occluded left pericranial vertebral artery, with perfect angiographic result. There were no immediate complications.
2. Congenitally small intracranial right vertebral artery, with possible critical stenosis at the right vertebrobasilar junction.
In this case, the stent was placed in the intracranial vertebral artery, thus, code 61635 applies for non-Medicare. The angioplasty is included in the stent placement. The catheter placement and all imaging of this vertebral artery (before, during and after, cervical and cerebral vertebral) is included the stent placement code. The right vertebral arteriogram (75685) and the right and left cervical (75680) and cerebral (75671) carotid arteriograms are reported along with these catheter placements (36217, 36218, 36215-59). If this were a Medicare patient, your facility/physician must be part of a class B IDE study and instead of 61635, code 37799 should be submitted and the critical stenosis should be documented as atherosclerotic in nature. I would not code the subclavian angiogram on the right unless it were medically necessary and not just imaging for guidance to place the catheter into the right vertebral. G0269 is for the closure device placement. Dr.z
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