medical coding books, medical coding conferences, medical coding education

Case-of-the-Month Example

A completely new feature of ZHealth Online, our Case-of-the Month will highlight a specific interventional radiology and cardiology coding case that we believe will be particularly valuable to interventional radiology and coding professionals.

Here is the Case-of-the-Month for June 2005

CLINICAL HISTORY: Superior mesenteric artery stenosis with mesenteric ischemia.

PROCEDURE PERFORMED:
Via right femoral approach:

Selective superior mesenteric artery catheterization and angiogram.
Percutaneous transluminal angioplasty of superior mesenteric artery with 5 x 20 Slalom balloon.
Intravascular stent placement of superior mesenteric artery with 6 x 15 Genesis stent and 6 x 12 Genesis stent, overlapping.

INDICATIONS FOR PROCEDURE: This is a 76-year-old female with mesenteric insufficiency documented on diagnostic angiography perform 10 days ago. She presents for superior mesenteric artery angioplasty and stent.

DESCRIPTION OF PROCEDURE: The patient was taken to the angiography suite and placed on the table in the supine position. The patient was positioned, prepped and draped with the Betadine solution in the usual sterile fashion. 1% Xylocaine was used to anesthetize the right inguinal crease. I accessed the right common femoral artery percutaneously with a micropuncture kit and sized this up to an 0.035 system. SOS Omni II catheter was advanced. This was reformed and used to cannulate the superior mesenteric artery origin with the image intensifier in the 90-degree left anterior oblique projection. I performed a hand injection of the superior mesenteric artery to confirm the catheter was in the appropriate vessel and to obtain preoperative mapping. I changed out my 0.035 wire for an 0.018 SV5 wire and then changed out the SOS Omni II catheter for a 6-French LIMA guide catheter. I first placed a 6-French sheath in the right groin over the guide wire and then advanced the 6-French guide LIMA up to the level of the origin of the superior mesenteric artery. Five-thousand units of heparin was administered. I then threaded a 5 x 20 Slalom balloon and performed dilatation of the superior mesenteric artery origin. Based on the size of the 5 x 20 balloon compared to the size of the native vessel, I chose a 6 x 15 Genesis stent. I dilated the 6 x 15 Genesis stent to nine atmospheres, which was complete expansion. I deflated the balloon and then performed completion angiogram, demonstrating what appeared to be a residual filling defect just distal to the distal margin of the stent. I chose to place a 6 x 12 Genesis stent overlapping with the 6 x 15 up to cover this residual defect. After having done so, I performed one final completion angiogram and this demonstrated no residual problems, no residual defects. The patient received protamine sulfate. I then removed the catheter over a guide wire. After protamine sulfate had circulated, I removed the sheath and applied pressure until hemostasis was adequate. The patient tolerated this procedure well and returned to the outpatient discharge unit in stable condition.

CASE CODES

36245 – 1st order selective arterial catheter placement below the diaphragm
37205 – Transcatheter stent, percutaneous, initial vessel
75960 – Transcatheter intro intravascular, percutaneous or open, each vessel, S&I

CASE CODES DISCUSSION

Diagnostic angiography of the superior mesenteric artery was performed, but it is not coded separately as:

The patient had a recent diagnostic study that lead to the intervention being performed and
The physician stated that the imaging performed in this session was for mapping purposes.

If there is a recent diagnostic study available, unless there is a clinical reason to repeat it, an additional diagnostic study should not be coded and/or charged. Following is an excerpt from the NATIONAL CORRECT CODING POLICY MANUAL FOR PART B MEDICARE CARRIERS, Version 10.3, Chapter 9:

“If a diagnostic angiogram was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. “

Angioplasty was performed prior to and after the stent was deployed. This procedure is not coded separately as:

The stent placement appeared the planned definitive treatment - see the Indication for the Procedure statement in the report.
There was no documented post angioplasty angiography and documentation of suboptimal results. To code angioplasty separate from stent placement in the same lesion there must be documentation that the angioplasty did not produce the desired result, so a stent was utilized. A sub-optimal or failed PTA is defined as a technically successful dilation judged by the physician to be suboptimal or failed due to the presence of unfavorable lesion morphology such as:

An inadequate angiographic and/or hemodynamic result as defined by a 30% or greater residual stenosis after PTA, lesion recoil, or intimal flaps.

Flow-limiting dissections post-PTA.

A 5-mm Hg or greater mean trans-stenotic pressure gradient post - PTA.

Acute occlusion of the vessel after PTA.

(See Dr. Z’s Medical Coding Series, Interventional Radiology Coding Reference, 2005 Edition, page 149 and SIR Interventional Radiology Coding User’s Guide 2005, page 107).

By definition, the stent CPT codes are per “each vessel.” Two stents were placed, but since they were in the same vessel only one stent placement procedure may be coded and billed.

The catheter was placed in the initial branch of the mesenteric artery off of the aorta. This is a 1st order catheter placement and it is below the diaphragm so code 36245 is the appropriate code.