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: December 2008

CASE

PROCEDURE: Peripheral angiogram and angioplasty

INDICATIONS:  The patient is a 72-year-old female presenting to the emergency room with a cold left leg referred for peripheral angiogram and revascularization for limb salvage.

PROCEDURE IN DETAIL:  After informed written consent was obtained, the patient was prepped and draped in usual sterile fashion. The right groin was anesthetized with 2% Xylocaine.  Using modified Seldinger technique a 6-French sheath was inserted over guidewire into the right common femoral artery.  A contra flush catheter was advanced into the abdominal aorta, where an abdominal aortogram was performed.

Next, the contra flush was advanced up and over the bifurcation of the left external iliac artery and angiogram was performed from the level of the left external iliac, down to the left foot.  The catheters were removed from the body.  An angiogram was performed of the right leg via the existing 6-French sheath with runoff to the right foot.  This completed the bilateral runoff.  The culprit lesion was identified as total occlusion of the left common femoral artery.  Next, the 6-French sheath was exchanged for a 7-French Pinnacle destination sheath which was advanced up and over the bifurcation into the left external iliac artery.  Next a Silver Hawk LX catheter was advanced into the area of occlusion and several passes were made with removal of both thrombus as well as atheroma from the left common femoral and proximal superficial femoral arteries.  The angiograms revealed some residual thrombus.  A slow infusion of thrombolytics was performed over 5 minutes at the level of the common femoral.  Next a thrombcat thrombectomy catheter was advanced into the area of the common femoral artery and proximal superficial femoral artery where several passes were performed, removing thrombus from the common femoral and superficial femoral artery.  The images after the intervention at the left common femoral and proximal superficial femoral revealed distal embolization of clot into the posterior tibial artery.  A Choice PT guidewire was parked in the posterior tibial artery.  Next thrombectomy using the thrombcat catheter was performed at the posterior tibial artery with modest improvement. After this, a hockey-stick guiding catheter was advanced to the level of the left popliteal and guiding angiogram was performed.  The posterior tibial artery was then ballooned at low pressure to macerate the clot using a 3.0 x 30 mm Voyager balloon which markedly improved antegrade flow.  Additional thrombolytics were infused for a few minutes at the level of the posterior tibial artery.  The final angiograms revealed patent posterior tibial and anterior tibial artery with diminished peroneal flow.  The predominant flow into the foot was that of the anterior tibial with lesser flow via the posterior tibial which was patent into the foot.  Next all devices were removed and the Pinnacle destination was pulled back to the right groin and a 6-French Angio-Seal device was deployed in the right groin with good hemostasis.  The patient tolerated the procedure well and left the catheterization lab in stable condition.

ANGIOGRAPHY:
ABDOMINAL AORTOGRAM:  The abdominal aorta was irregular, with moderate calcifications distally but no evidence of aneurysm or dissection.  The bilateral renal arteries were widely patent as were the mesenteric arteries including the celiac, SMA, and IMA.
LEFT LEG:  The left common external and internal iliac arteries were widely patent.  The left common femoral artery was totally occluded with large thrombus burden.  The profunda and superficial femoral artery were free of significant disease.  The popliteal as well is free of significant disease.  The infrapopliteal runoff was only visualized in the proximal segment on initial images with patent peroneal, posterior tibial and anterior tibial arteries.  No significant flow was noted into the foot.
RIGHT LEG:  The right common external and internal iliac arteries were widely patent.  The right common femoral artery was free of significant disease.  The right profunda and superficial femoral arteries were widely patent and free of significant disease.  The popliteal was free of significant disease.  The infrapopliteal runoff was well preserved with the anterior tibial, posterior tibial and peroneal arteries being widely patent proximally with predominant runoff into the foot being via the posterior tibial with later filling of the anterior tibial and peroneal.
PERCUTANEOUS INTERVENTION:  Status post thrombectomy, thrombolysis and atherectomy of the left common femoral artery.  There is 0% residual stenosis within the treated segment with excellent antegrade flow in the common femoral, superficial femoral arteries.  The patent infrapopliteal runoff, as mentioned above, was predominantly via the anterior tibial and posterior tibial at the termination of the case.

COMPLICATIONS:  None.

IMPRESSION:

1. Total left common femoral artery occlusion.
2. Successful thrombolysis, thrombectomy and atherectomy of the left common femoral artery.
3. Successful thrombectomy and angioplasty of the left posterior tibial artery.
4. Normal right lower extremity arterial circulation.

CASE CODES

35493 – Transluminal peripheral atherectomy, percutaneous; femoral-popliteal
36247 – Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family
37184 – Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel
37185 – Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure)
75625 – Aortography, abdominal, by serialography, radiological supervision and interpretation
75716 – Angiography, extremity, bilateral, radiological supervision and interpretation
75992 – Transluminal atherectomy, peripheral artery, radiological supervision and interpretation
G0269 – Placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure (e.g. angioseal plug, vascular plug)

CASE CODE DISCUSSION

The patient presented with new symptoms, so the diagnostic angiography is reported separately.  There was separate imaging of the abdominal aorta (75625) and bilateral lower extremities (75716).  The extremity imaging was done one leg at a time via catheter placement in each extremity.  The selective catheter placement in the left leg is not coded until the intervention further down the leg is completed.

When selecting codes for the interventional procedures performed it is important to read the entire report before assigning any codes.  The key item to the correct assignment of the interventional codes is that the occlusion was from thrombus and all procedures were in support of removing the thrombus.

The first intervention performed was an atherectomy of the left common femoral and proximal superficial femoral arteries. Atheroma was documented as having been removed.  One femoral-popliteal atherectomy (35493 & 75992) is reported as there is one area of occlusion treated that bridges the two arteries.

Following the atherectomy there was still thrombus present.  Five minutes of thrombolytic infusion was performed followed by mechanical thrombectomy in the common femoral artery.  Intra-procedural thrombolytic therapy performed with mechanical thrombectomy is included in the thrombectomy procedure (37184).  This infusion of thrombolytics a few minutes before, during or after thrombectomy is considered intra-procedural.  This is a primary thrombectomy as all procedures performed were related to the thrombus.  One initial vessel arterial mechanical thrombectomy is reported for the thrombectomy of the common femoral and proximal superficial femoral artery as it is one area of thrombus.

Follow-up imaging (no code) shows that the clot has migrated to the posterior tibial artery.  A second arterial mechanical thrombectomy procedure is performed.  The posterior tibial is an additional vessel in the same vascular family as the common femoral artery (37185). 

Follow-up angiography (no code) was performed from the popliteal artery.  This was followed by angioplasty of the posterior tibial artery.  If you review the angiography results, it states that the posterior tibial is patent during the diagnostic imaging.  The angioplasty was not related to atheroma, but to thrombus.  Therefore, it is part of the thrombectomy procedure.  The additional infusion of thrombolytics is also included in the thrombectomy procedure.

Lastly, the selective catheter placement code can be assigned.  The most distal vessel the catheter was placed in was the posterior tibial artery.  This is a third order selective catheter placement below the diaphragm (36247).  All other catheter placements are in route to this final destination and are included in the distal placement.

The placement of the Angio-Seal device is reported with G0269.

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

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