Case-of-the-Month Archives

Each month ZHealth Publishing will identify a particularly complex and/or relevant interventional radiology or cardiology coding case to profile and analyze for ZHealth Online members:

Case-of-the-Month: November 2008

PROCEDURE PERFORMED

1. Introduction of catheter in the contralateral lower extremity.
2. Abdominal aortogram.
3. Bilateral lower extremity runoff.
4. Additional left leg angiogram.
5. Angioplasty of the left superficial femoral artery using a 5 x 120 mm balloon.
6. Placement of a self-expanding stent into the superficial femoral artery using a 7 x 150 mm stent and a 7 x 100 mm stent.
7. Atherectomy of the left popliteal artery using a SilverHawk device
8. Adjunctive angioplasty of proximal popliteal artery using 4 x 60 mm balloon.

INDICATION FOR PROCEDURE:

Patient who presents wit left foot numbness and left leg ischemia.

PROCEDURE:

The patient was brought to the angiography suite and placed in the supine position.  Both groins were prepped and draped in a sterile manner.  1% Lidocaine was used over the right common femoral artery.  The right common femoral artery was accessed with a 10 gauge needle.  Upon obtaining arterial blood, a guidewire was then placed and a 5-French sheath was subsequently placed.  An 0.035 Glidewire was placed into the perirenal aorta and identified.  5 French VCF catheter was placed through the sheath into the perirenal aorta. Angiography of the abdominal aorta was performed.  Following, the VCF catheter was pulled down to the aortic bifurcation.  Bilateral lower extremity runoff to the toes was performed. 

The main aorta was free of disease, so were the common external and internal iliac vessels.  Both common femoral arteries were free of disease.  The right superficial femoral artery was totally occluded from the origin all the way down to the popliteal artery.  There was also reconstruction of the popliteal artery at the level of the abductor canal, and there was excellent flow in the popliteal artery below and behind the knee and excellent flow down into the trifurcation.  On the left side, the left superficial femoral artery had disease from the knee to proximal area all the way down to the distal area.  There was an area of about 99% stenosis and some areas of occlusion may be in mid-aspect of the superficial femoral artery.  There was reconstitution of the distal superficial femoral artery just below the adductor canal before the abductor canal, and then there was a complete occlusion of the popliteal artery above, behind and below the knee where reconstitution of the distal popliteal artery with a 3-vessel runoff down the leg.

The aortic bifurcation was crossed with a VCF catheter and an 0.035 Glidewire was placed down into the left superficial femoral artery.  A 4-French glide catheter wire was placed down into the superficial femoral artery.  The flexible 0.035 Glidewire was then removed and a stiff Glidewire was then placed through this catheter. The catheter was then removed and a 5-French sheath was then switched to a 7-French destination catheter that was 45 in terms of length.  This was placed down to the level of the left common femoral artery.  At this time, an angled catheter was placed over the stiff wire down into the superficial femoral artery.  The patient was given 5,000 units of heparin and kept heparinized throughout the operation.  The Glidewire was removed.  A guiding angiogram was then performed of the left lower extremity.  An 0.014 wire was placed through the angled glide catheter and used to cross all the lesions down into the below-knee popliteal diameter trifurcation.   The angled glide catheter was then advanced toward the 0.014 wire down to the level of the below-knee popliteal.  Additional angiogram was performed which showed excellent position of the wire.  The glide catheter was removed.  Angioplasty of the severely diseased superficial femoral artery was performed using a 5 x 120 mm balloon.  It was performed through the length of the lesion.  It was performed twice to cover the entire SFA. 

An angioplasty was performed to get a SilverHawk device down to the popliteal artery.  Atherectomy was performed of the popliteal artery.  After 4 passes along 4 quadrants were done, the SilverHawk device was removed.  There was a significant amount of clot present.  Follow up angioplasty showed excellent results.  Due to the severe disease that was present in the superficial femoral artery and distal areas of limited flow, the left superficial femoral artery was stented using self-expanding stents, 7 x 150 and 7 x 100 for the entire SFA.  Followup angiography showed slow flow through the stent and showed reocclusion at the level of the popliteal artery.  Angioplasty of the proximal artery and distal SFA with a 4.0mm x 60 mm balloon was performed.  Followup angiography still showed limited flow and the patient had increasing pain in the left leg. 

At this time it was thought that due to the major lesions that most likely the patient had a selective thrombosis of the popliteal artery.  Thrombolysis of the area was initiated.  This required switching of the 7-French destination catheter to an 8-French sheath and then an Unifuse catheter was placed at the level of the lesions to perform thrombolytic therapy.  The catheter was secured in place and thrombolytic Retavase at 0.5 units per hour was attached to the catheter.  A 20 cm length Unifuse catheter had been placed. 

Patient was then transferred to the bed to be transferred to the ICU.  Upon doing this the patient continued to have increased pain in the left foot and was having trouble with multifunction of the left foot.  Patient was then placed back on the table and further angiographic studies showed continued thrombosis.  It was then decided at this time that patient would need a thrombectomy bypass around these lesions.  As a result, the procedure was terminated and informed consent was obtained from the patient’s family for open femoral to below-knee bypass graft with thrombectomy of the distal circulation.

IMPRESSION:

1. Occlusion of left popliteal artery.
2. Occlusion of left superficial femoral artery with multiple areas of severe stenosis.
3. Occlusion of right superficial femoral artery.

CASE CODES

36247 – Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family
75625 – Aortography, abdominal, by serialography, radiological supervision and interpretation
75716-59 – Angiography, extremity, bilateral, radiological supervision and interpretation
35474 – Transluminal balloon angioplasty, percutaneous; femoral-popliteal
75962 – Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation
35493 – Transluminal peripheral atherectomy, percutaneous; femoral-popliteal
75992 – Transluminal atherectomy, peripheral artery, radiological supervision and interpretation
37205 – Transcatheter placement of an intravascular stent(s), (except coronary, carotid, and vertebral vessel), percutaneous; initial vessel
75960 – Transcatheter introduction of intravascular stent(s) (except coronary, carotid, and vertebral vessel), percutaneous and/or open, radiological supervision and interpretation, each vessel
37201 – Transcatheter therapy, infusion for thrombolysis other than coronary
75896 – Transcatheter therapy, infusion, any method (eg, thrombolysis other than coronary), radiological supervision and interpretation
75898 – Follow-up angiography through existing catheter during thrombolysis

CASE CODE DISCUSSION

The patient did not have diagnostic angiography or a CTA prior to presenting for this exam, so the diagnostic angiography is reported separately.  The abdominal aortography and bilateral lower extremity runoff angiography procedures were performed via two different catheter placements, above the renal arteries and at the bifurcation.  Therefore the two exams are reported separately with codes 75625 and 75716.  Due to Correct Coding Initiative (CCI) edits, code 75716 must be appended with modifier -59 to indicate it is not a repeat diagnostic angiogram.  Code selection for the catheter placement cannot be performed until the entire study is completed.

The findings of the diagnostic angiography are given and then the interventional procedures are begun.  The additional imaging of the left leg is part of the intervention (guiding angiography) and is not reported separately.  After manipulation of catheters and guidewires angioplasty of the superficial femoral artery was performed with an adequately sized balloon to expect a successful procedure.  This is reported with codes 35474 and 75962.  It is one angioplasty as all dilations were performed in the same vessel.

An angioplasty was performed to get the SilverHawk catheter into the popliteal artery.  This angioplasty is included in the subsequent atherectomy procedure as it was in support of the atherectomy.  Atherectomy of the popliteal artery was performed.  The four quadrants and four passes are considered one atherectomy as they are all in the same vessel.  The atherectomy is reported with codes 35493 and 75992.

The angioplasty post atherectomy is considered in support of the atherectomy as an adjunctive procedure and is not reported separately.

The subsequent stent placement in the superficial femoral artery can be reported separately as it is placed because of the significant disease still evident in the artery as documented by the flow limited dissection.  The stent placement is reported with codes 37205 and 75960.  One stent procedure is reported as both stents were placed in the same vessel and interventions are coded once per vessel intervened on.  The follow-up angiography after stent placement and subsequent post-stent deployment angioplasty of the superficial femoral artery are included in the stent placement.

The interventions were successful, however thrombosis of the vascular system started so it was decided to perform thrombolysis to remove the clot.  Catheter directed continuous  thrombolysis was begun.  There was placement of the catheter with imaging guidance and infusion of Retavase, so thrombolysis may be reported with codes 37201 and 75896.
The patient continued to exhibit acute symptoms and the thrombolysis was discontinued after follow-up imaging (75898).   

Lastly the catheter placement code is assigned.  The procedure was started through the right femoral artery with the most distal catheter placement being the contralateral popliteal artery.  This catheter placement is a third order or higher selective catheter placement below the diaphragm.  The common iliac defines the vascular family and it is the first order in the family.  The external iliac is the second order.  The superficial femoral artery and any distal arteries are third order or higher arteries which include all lesser orders in that vascular family.  Only code 36247 is reported to describe all catheter placements performed.

CPT codes Copyright © 2008 American Medical Association. All Rights Reserved.

Read the current Case-of-the-Month