Ask Dr. Z

Right external iliac artery injury with arterial bleeding

"Emergent intraoperative vascular surgery consult. Ultrasound-guided retrograde access right common femoral artery. Intra-arterial angioplasty balloon inflation for temporary control arterial bleeding. Diagnostic right iliac and lower extremity angiogram. I-CAST covered stent repair of right external iliac artery injury. StarClose hemostasis right common femoral artery." Are codes 37244, 37236-51XE, and 36140-51XE appropriate for this?

Angioplasty of the Iliac with the Sheath

Can we bill code 37220 for an angioplasty of the iliac artery with the sheath? I don't think so, but I just wanted to double-check because the CPT description does not use the word "balloon".

Stent graft repair

1. Stent graft repair of lt common iliac artery aneurysm to preserve lt hypogastric artery utilizing an Endurant bifurcated graft with snorkeling of the lt hypogastric artery and stenting of the lt hypogastric artery using iCAST stents. 2. Ballon angioplasty of lt external iliac artery for residual stenosis. Endurant graft inserted from lt fem and positioned in the lt limb of the previously deployed endograft. Graft deployed so contralateral gate landed 1.5 cm above takeoff of lt hypogastric. The ipsilateral limb of graft was deployed in the lt external iliac artery. Proceeded to snorkeling of the lt hypogastric. Advanced an iCAST stent into contralateral limb of graft, directing it into lt hypogastric. The initial stent was deployed in the contralateral gate and extending into the origin of lt hypogastric. We advanced a 2nd iCAST stent into lt hypogastric. Allowed for 2 cm of overlap with the initially deployed iCAST stent. 2nd stent extended into lt hypogastric and landed prior to the takeoff of the 1st order sub branches of lt hypogastric.

Occluded EVAR graft

"Access via left CFA. Glidewire was negotiated into left external and common iliac artery stent occlusion. AngioJet percutaneous thrombectomy catheter was serially advanced through the long iliac occlusion rmoving 180 mL defibrinated thrombus. Retrograde angio revealed severe in-stent stenosis. Angioplasty of left CIA and EIA was performed; there were residual stenoses, so a 17 French AFX Endologix sheath was advanced into the AAA Afx graft. An Afx iliac ext cuff endograft was deployed at the flow divider of the previous placed Afx bifurcated endograft. Baloon angioplasty post-stenting noted resolution of proximal CIA stenosis, but residual mid-ext iliac artery stenosis remained. A second iliac balloon-expandable Omni link stent was deployed. Next a left fem arteriotomy was created and critically stenosed profunda was endarterectomized." Would this be reported with codes 37184, 37221, 37223, and 35372? Or are we to look toward an endograft extension limb even though the stent was placed for graft occlusion (rather than an endoleak)? AAA repair was 4 months earlier. 

Endovenotomy

Please advise on the proper codes for this procedure. "Operation performed: Open exploration, left common femoral vein, femoral profunda, femoris vein with endovenectomy of femoral vein. Construction of arteriovenous fistula between the left SFA and femoral vein with reversed anterior accessory saphenous vein. Bilateral lower extremity venogram and inferior vena cavogram. Open angioplasty of the left common femoral vein, external and common iliac veins, and inferior vena cava. Double-barrel stent placement of the para renal inferior vena cava with Palmaz open stent placement from the left and percutaneous stent placement from the right." So far I'm thinking I will need to use an unlisted code for the endovenectomy. I'm not sure about the AVF since there was no bypass performed. Any advise and help would be greatly appreciated.

Common Femoral Endarterectomy

Provider performed left common femoral endarterectomy with patch angioplasty, then a right external iliac balloon angioplasty. Can I report the iliac angioplasty, or is it included?

Vascular Surgery Bundled Component

My physician used bovine pericardial patch for a profundaplasty all the way up to the iliac. He calls this a patch angioplasty. I typically think of a balloon being used for an angioplasty. Would I use the repair codes for "other than vein" for this procedure (i.e., 35286, bovine pericardial patch)? Also, since the entire region from the profunda up to the iliac was repaired, do I report only one CPT code? At the same session he also performed endarterectomy of the same region and then went on to place stents in the iliac. Can I code all three procedures? Patch angioplasty, endarterectomy, and stent? This procedure was performed for severe atherosclerosis and stenosis in one extremity.

AFX Stent Graft for Aortic Stenosis

Please code the following procedure done for aortic stenosis: "Stent graft repair of the patient's abdominal aorta and common iliac arteries and then address residual disease in the external iliac arteries. We utilized the AFX stent graft system. We then used two 8 x 40 mm Armada balloons to perform kissing balloon angioplasty of the aorto-iliac bifurcation, as well as the right and left common iliac arteries. There was still some concern about a possible stenosis or dissection in the distal right common iliac artery and proximal right external iliac artery. IVUS revealed an area of dissection or residual thrombus in the distal right common iliac artery beyond the right limb of the endograft. There was also an area of dissection seen in the proximal to midportion of the right external iliac artery. We placed a covered stent across the distal right common iliac artery immediately above the takeoff of the right hypogastric artery. To cover the area of dissection in the right external iliac artery, we used an Absolute stent."

Bridging Aortoiliac Disease Treated with Stent

PROCEDURE: R/L CATH, COROS, NO LV; AORTOGRAM. PTA WITH STENT OF THE DISTAL AORTA AND RIGHT ILIAC ARTERY. INDICATION: SOB, RIGHT LEG PAIN, AND PAD. Taken from op report: "Decision to intervene on the total right ostial iliac occlusion and the distal aorta with balloon angioplasty first, after deployed stent. Balloons were used to predilate and inflated/deployed stent at the level of the bifurcation not to preclude or occlude the access to the left illiac ostium. The distal aorta was also predilated with the above balloons, and there were excellent angiographic results." I am enclined to code for PTA/stent to right iliac, 37221 (stent placement, w/wo angioplasty illiac artery, and PTA to aorta). I did not read anywhere on report that he stented the aorta. I'm not sure what to code. I came up with 35472 (percutaneous angioplasty, aortic). Please help.

Poor MD Documentation

In reviewing charges for a procedure, I came across a case coded 75625, 75716, 37228. The operative report states selective right leg angio and PTA to anterior tibial. Procedure portion states, "LCFA accessed and wire into aorta with use of Omniflush catheter to access left iliac. Omiflush catheter exchanged for 65 cm sheath. Selective angiogram with multiple views performed. PTA to anterior tibial performed." The physician's report is finalized with an impression, which dictates findings of an abdominal aortagram and findings of only the right side extremity and angioplasty. Due to the difference in charges and report I viewed the x-ray films. These show Omniflush catheter just below renals and abdominal aortagram imaging; next I see bilateral lower extremity imaging from bifurcation to toes. The selective right angio and PTA imaging. I queried physician to verify clarify op report and filming. I suggested including catheter position in their report to assist in proper coding. Physician says will not dictate maneuvers not performed. How can this be coded 75710, 37228?

37220 vs. Nothing for Angioplasty of Iliac to Place Carotid Stent

For the following case, are the angioplasties performed in the iliofemoral billable, or would they be considered bundled into the carotid stent with filter procedure (37215)? "The patient has extensive lower extremity vascular disease. The right femoral artery cannot be accessed percutaneously, and left side is therefore accessed. Severe occlusive disease is present in the iliofemoral segment. Angioplasty was required with a 6 mm balloon of the external iliac and common femoral on the left, allowing placement of 6 French sheath. A 6 mm balloon was dilated to 12 atmosphere pressure of the left external iliac and proximal-mid common femoral. Stenting was not performed. The physician went on to selectively catheterize bilateral common carotids, and left subclavian retrograde for grams, and eventually placed a right carotid artery stent with filter."

Angioplasty of Iliofemoral Venous Bypass

"Aortogram performed (75625) and LLE angiography performed (75710). Patient has iliofemoral venous bypass graft. Stenosis found at distal margin of venous bypass at junction of superficial femoral artery. This was angioplastied. Thrombus was found at blind ending portion at the anastomosis between the iliac limb and bypass vein graft and was treated with AngioJet." How would you code the angioplasty and thrombectomy? Would this be considered arterial or venous?

34812 with 34803

When billing code 34803, would I also report code 34812 if that is done? In our Encoder pro software it says that code 34812 is included in code 34803. "34803 - INCLUDES: Balloon angioplasty/stent deployment within the target treatment zone; introduction, manipulation, placement, and deployment of the device; open exposure of femoral or iliac artery/subsequent closure (34812)." Not sure if I should be billing code 34812 with a -59 (-XS) modifier or just not using it at all.

External Iliac Angioplasty Performed to Stop Bleeding, NOT for Stenosis

One of our cardiologists was assisting another surgeon, and our cardiologist performed an angioplasty in the external iliac to stop bleeding below the iliac so the surgeon could perform repairs. Since the angioplasty was done for bleeding and not disease, I don't think code 37220 would apply. I'm thinking of using code 37799 (unlisted procedure, vascular surgery), but I would appreciate your opinion on this one.

Contralateral SFA with Ipsilateral Iliac Stent

For the following example, is code 36247 billable for the selection of the right SFA because it was more distal than where the intervention was performed? Also, is it acceptable to bill for the retraction of the catheter into the left CFA with subsequent run-off (36140)?  "Access via left groin, catheter placed into aorta for dx aortogram (75625). Catheter advanced to the right SFA for selective RLE run-off and catheter retracted to ipsilateral left common femoral artery for LLE run-off (75716). Access then warranted on the right side for kissing angioplasty and stenting of the common iliacs (37221-RT & -LT)."

Balloon Angioplasty Sciatic Artery for Pseudoaneurysm/AV Fistula

Could you please assist with the correct procedure code? I am unsure of which code is most appropriate (37799 or 37220). "5 French Cobra Glidecath was advanced through the sheath into the distal aorta and advanced over a Glidewire to the contralateral left internal iliac artery. Digital subtraction arteriography was performed over the pelvis and upper thigh. Cobra catheter was exchanged over a guidewire for a 12 mm diameter by 4 cm long angioplasty balloon, which required exchange of a 5 French angiographic sheath, a 4 a 7 French Balkan cross-over sheath, into the contralateral persistent sciatic artery. The antiplastic balloon was inflated across the arteriovenous fistula in the distal persistent sciatic artery, and digital subtraction arteriography of the popliteal and lower leg region was performed to the level of the hindfoot. The balloon was deflated and exchanged over a guidewire for a 5 French Davis catheter, which was advanced into the pseudoaneurysm arising from a persistent sciatic artery, and digital subtraction arteriography was performed."

35883

Patient with common femoral thromboendarterectomy with patch graft performed above the fem-pop bypass. The artery was severely degraded and fell apart during patch angioplasty necessitating the need to go higher in the iliac requiring conversion to ilio-fem bypass. An 8 mm Gore-Tex graft was brought to the table. It was beveled and attached to the iliac with the distal end extending into the bypass graft and sliding nicely together. Would I code for both the endarterectomy and, say, a revision of the graft? Codes 35371 and 35883? Or 35876 alone?

Angioplasty of Superior Gluteal Artery

For the following case, would you code additionally for the superior gluteal artery angioplasty? If so, what code would you use? "Thrombectomy (37184) is perfomed of the superior gluteal artery and the main trunk of the internal iliac artery. Following thrombectomy, there is residual thrombus at the origins of both anterior and posterior division branches, in addition to superior gluteal stenosis and weblike origin stenosis of the internal iliac artery. 4 mm angioplasty was performed of the entire thrombectomized segment, including the two stenoses. The internal iliac artery is stented (37221). Additional thrombectomy was performed of the superior gluteal artery followed by additional angioplasty. tPA is infused along with additional angioplasty. No significant change. Follow-up angio is performed again, and an acceptable result was obtained with good flow."

Endarterectomy vs. Stent Placement

I cannot locate information for coding femoral endarterectomy and stent placement. "Operative Note: After completion of the endovascular stent graft, the external iliac, profunda femoris, and SFA were clamped and the sheath removed. A longitudinal incision was created in the common femoral artery, and extensive plaquing was noted, necessitating endarterectomy of distal external iliac, common femoral, and profunda femoris origin. Additionally, a stent was placed in the proximal superficial femoral artery to tack down the plaque at this level. This was performed, and then a patch angioplasty was used to close the arteriotomy." Would it be appropriate to code for the endarterectomy (35371) or the stent (37226), as I don't feel you can code for both procedures since they are within the same vessel.

Embolization and Angioplasty

I have a case were a chemoembolization was performed in the hepatic arteries and an angioplasty was performed on the left external iliac artery. The angioplasty was not planned; stenosis was found when trying to cannulize the artery for the embolization. The problem is that I have to use codes 37243 and 37220 for two different vascular families, and due to the fact a diagnostic angiography was performed on the external iliac I have catheter placements for both areas of treatment, so codes 36247 and 36248 x 3 for the hepatic embolization and 36249 for the diagnostic angio in the external iliac. Due to code 37220, codes 36247 and 36246 both require a -59 modifier, but code 36247 overrides 36246. How do we address that so that both catheter placements are paid?

Snorkel Stent CIA for 2013

Can you help with coding for the Snorkel repair in 2013?

"DX: infrarenal abdominal aortic aneurysm. 2. L & R common iliac artery aneurysm 1. Percutaneous endovascular repair of the abdominal aortic aneurysm as well as the common iliac artery aneurysms using the Endologix AFX graft (main graft 22 mm x 120 mm x 16 mm in diameter for both limbs with suprarenal extension measuring 28 mm x 75 mm and a second suprarenal extension placed for proximal endoleak measuring 28 mm x 75 mm. 2. Left limb extension 16 mm x 75 mm and right limb extension 20 mm x 120 mm. 3. Snorkel repair of left hypogastric artery using an 8 mm x 15-mm Gore Viabahn covered stent...The left hypogastric artery was then selectively cannulated using a crossover sheath followed by deployment of an 8-mm x 15-mm Gore Viabahn covered stent in this area and a left-sided limb extension was then placed measuring 16 mm x 75 mm. On the right side, a right-sided limb extension was then done using a 20 mm x 120 mm in length covered stent sealing above the right hypogastric artery. Balloon angioplasty was then perfo..."

Endovenectomy with Patch Angioplasty

"Procedures performed: Bilateral groin cutdown with common femoral vein exposure. Extensive left  common femoral vein endovenectomy followed by patch angioplasty. Focal right common femoral vein endovenectomy with primary closure. Kissing stents from IVC into the iliac system... Left groin venotomy was made and extended. An extensive amount of scarring was saline(?) as typical of chronic thromboses with recanalization and anatomy was seen. Extensive endarterectomy of the common femoral into the profunda and also the femoral vein and distal external iliac vein was performed. A bovine pericardial patch angioplasty with 6-0 prolene running suture was performed." We were unsure if open thrombectomy code 34421 would be appropriate in this case without findings or removal of thrombus. Is the reference to the scarring typical of chronic thromboses sufficient? We were unable to locate a venous equivalent to an endarterectomy. Your guidance is greatly appreciated.

Additional Angioplasty Code for Profunda

Based on the report below, my question is as follows: Is an additional angioplasty code used for the "profundus" since it branches off the common femoral? If so, which code? I used codes 37221 (EIA stent), 37224 (fem/pop PTA), 75710-2659 (iliac imaging), and 75774-2659 (SFA imaging).

Access from right. Cross-over to left iliac via omniflush and glide wire. Angiography showed occluded external iliac artery just after internal takeoff. Glide wire passed into SFA. Catheter advanced to SFA, and angio showed patent SFA. Then 0.018 wire placed in SFA and another wire in profunda. Angioplasty was done in SFA, profunda, and left iliac with thrombectomy through the 7 French sheath. This restored flow. A stent was placed in iliac to cover left iliac dissection with slight extravasation at end of procedure treated with reversal of anticoagulation.

Right Hypogastric Artery Embolization

When a right hypogastric artery embolization is performed along with a stent and angioplasty in the right external iliac artery, may we also code the catheter placement for the embolization? Or is it included in the external iliac intervention?

Unsuccessful Recanalization of the SFA with Crosser Catheter

My question on the case that follows is regarding the unsuccessful recanalization of the SFA with a Crosser catheter. The physician was able to pass the Crosser catheter through the occlusion of the SFA, but was not able to proceed with any other interventions due to not be in the true lumen. Based on the documentation in the operative note below, would code 37225 be reportable?

Operative report: PROCEDURES PERFORMED: 1. Abdominal aortogram. 2. Right lower extremity distal runoff, third order catheter placement. 3. Percutaneous transluminal angioplasty and stent placement, right external iliac artery. 4. Crosser atherectomy, right superficial femoral and popliteal artery. INDICATIONS: Woman who presented to the office with ischemic rest pain of the right lower extremity. Physical examination as well as noninvasive studies confirmed the atherosclerotic etiology, and she is, therefore, undergoing angiography with hope for intervention and limb salvage. PROCEDURE: The patient is taken to the Special Procedures Suite and placed in the supine position. After adequate sedation is achieved, both groins are prepped and draped in a sterile fashion. 1% lidocaine is infiltrated in the soft tissues overlying the left common femoral impulse, and access to the left common femoral artery is obtained with ultrasound guidance. Ultrasound is placed in a sterile sleeve. Ultrasound is utilized secondary to lack of appropriate landmarks to avoid vascular injury. Under direct visualization, the common femoral artery is identified. Image is recorded for the permanent record. The artery is noted to be pulsatile and homogeneous indicating patency. Micropuncture needle is inserted into the anterior wall with direct ultrasound visualization. Microwire followed by micro sheath, J-wire followed by 5 French sheath and 5 French pigtail catheter are then inserted. Pigtail catheter is positioned at the level of T12, and AP projection of the abdominal aorta is obtained. Pigtail catheter is repositioned to above the bifurcation, and an LAO projection of the pelvis is obtained. Previously placed stents in the common iliac arteries are identified, and both are patent. Occlusion of the right external iliac artery is identified with reconstitution of the common femoral. 5000 units of heparin is given and using a combination of VS-1 rim, and the pigtail catheter and a stiff angled Glidewire the aortic bifurcation is crossed. Initially the VS-1 is successful. The Glidewire and VS-1 catheter are then negotiated across the external iliac and into the common femoral artery. Hand injection of contrast demonstrates patency of the common femoral and intraluminal placement. The catheter is then advanced into the profunda femoris, and the 5 French sheath is exchanged for a 7 French Balkan sheath. Balkan sheath is positioned in the mid common iliac on the right, and a 6 x 10 Rival balloon is used to angioplasty the external iliac artery. Follow-up angiography demonstrates it is patent. There is a significant intimal flap; however, this does allow advancing the Balkan in so that the tip is now in the common femoral. Additional heparin is given. The S6 crosser with an angled Usher catheter is then positioned at the small cul-de-sac, and Crosser catheter is used to advance down to the popliteal. Ultimately, however, we were not able to re-enter the true lumen in the mid popliteal, and further attempts at treating the SFA were abandoned. The Crosser catheter and Usher catheter were then removed. There was an exchange for a 0.035 Magic torque wire, and a Life Star 7 x 80 stent was deployed across the external posted with a 6 mm balloon. Follow-up angiography demonstrated the iliac system is now widely patent flowing into a common femoral and profunda femoris, which were widely patent. The sheath was then pulled into the external iliac on the left side, oblique view obtained, and subsequently the sheath was exchanged for a 7 French 11 cm sheath. ACT was checked, which was noted to be 200, and the sheath was later then pulled and pressure held. There were no immediate complications. INTERPRETATION: Initial views of the abdominal aorta demonstrate diffuse atherosclerotic changes. However, there are no hemodynamically significant stenoses. The aortic bifurcation is diseased but patent. There are bilateral common iliac artery stents. They do not extend up into the aorta. They are both patent. The right external iliac artery appears occluded. Internal iliac artery is patent. There is reconstitution of the common femoral and profunda femoris. Superficial femoral artery is a flush occlusion. The popliteal is reconstituted in its midportion at the level of the femoral condyles, and there appears to be single vessel runoff to the foot. Following angioplasty there is a flow-limiting dissection in the external iliac. This was later treated effectively with a Life Star stent and postdilated to 6 mm. Attempts at crossing the SFA using a crosser atherectomy catheter were successful at achieving the catheter and negotiating down into the popliteal; however, we could not re-enter the true lumen and, therefore, no further interventions were performed at this time. SUMMARY: 1. Successful recanalization of the iliac system. 2. Unsuccessful recanalization of the SFA.

Stenting of the Lower Extremity Veins

I need help with a procedure for stenting of the lower extremity veins. The portion of the procedure I am in need of assistance with is included below.  Questions: 1) Can I charge for two stent placements in bilateral common iliac veins (37205, 37206, 75960, 75960-59), even though the right side was not stenosed? It seems to me the reason for the bilateral stent placements was done for the stenosis in the IVC. Or should I just charge for one stent for the left iliac stenosis? 2) Before stenting a balloon expanded, I don't think I should charge for angioplasty, as it is stated it was just for confirming the stenoses? Is this a correct assumption?

After wires were advanced into the iliac vein into the inferior vena cava a venography through the side arm of the sheath in the groin was carried out through the left side. Demonstrating a high-grade 80% stenosis of the left common iliac vein and distal inferior vena cava. Venography was then carried out through the side arm of the sheath in the right groin demonstrating a patent external iliac and common iliac artery, about 80% stenosis of the distal inferior vena cava as it joins the right common iliac vein with eccentric stenosis. A balloon was placed across the left common iliac vein. A waist confirmed the stenosis and a balloon was placed across the right common iliac vein and expanded confirming a waist in this area. The stents were then placed across both common iliac veins, extending into the distal inferior vena cava, 24 x 70 mm Wallstent on the left and 20 x 55 mm Wallstent on the right. These were postdilated with 18 x 40 mm XXL balloons in a kissing balloon technique. Completion venography shows good flow throughout the left external iliac, common iliac, and inferior vena cava. Venography through the right groin sheath showed good flow to the right external iliac and common iliac vein and into the inferior vena cava.

Supra-inguinal Atherectomy Case

How would you recommend coding this case?

PROCEDURES: 1. Abdominal aortography. 2. Bilateral lower extremity runoff. 3. Access to the right and left common femoral arteries. 4. Successful percutaneous transluminal angioplasty and stenting of a left external iliac 70% stenosis to less than 10% with a 6 x 30 Zilver self-expanding stent. 5. Successful atherectomy, percutaneous transluminal angioplasty and stenting of a right 100% common iliac, external iliac and proximal common femoral artery with a 1.7 laser, 6 x 80 Zilver, 7 x 80 Zilver and a 7 x 40 Zilver self-expanding stent. DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the cardiac catheterization laboratory. Using approximately 10 mL of 1% lidocaine, the left groin was anesthetized and 5 French sheath placed in the left common femoral artery. I then placed an Omni Flush catheter to the level of the distal aorta and performed abdominal aortography, then pulled the catheter down to the level of the iliac bifurcation and performed bilateral lower extremity runoff. FINDINGS: Aortic pressure 156/72. ABDOMINAL AORTOGRAPHY: Normal bilateral renals. Diffusely diseased distal aorta, approximately 40% stenosis. BILATERAL EXTREMITY RUNOFF: The right lower extremity: The distal common iliac approximately 70% stenosed. The ostium of the internal iliac with approximately 80% stenosis. The proximal external iliac to the proximal common femoral artery is occluded. Widely patent profunda and SFA. Three-vessel runoff to the foot. Left lower extremity: The left common iliac approximately 70% stenosed. Internal iliac is patent. External iliac is widely patent. Common femoral artery and profunda are widely patent. SFA is widely patent with three-vessel runoff to the foot. INTERVENTION: We then placed a 5 French 55 cm Raabe sheath to the level of the right common iliac and then used a Prowater wire with the support of an 0.018 Quick-Cross and crossed the 100% CTO at the distal common iliac, external iliac to the common femoral artery. Then performed selective angiography at the level of the right SFA to confirm placement. Then performed intravascular ultrasound of the right common iliac, external iliac and common femoral artery showing homogenous/heterogenous plaque. Reference vessel approximately 4.5 mm and then used a 1.7 laser at 50/40 and 60/60 resulting in approximately 80% residual. I then placed a 6 x 80 and a 7 x 80 Zilver self-expanding stent to the level of the internal iliac. There was an obvious dissection proximally. I then tried to place a 7 x 40 stent across the proximal aspect but stenting could not pass it. After multiple attempts even posted the stents with a 6 x 100 Cook LP balloon. There was an obvious dissection proximal to the stent. Therefore, accessed the right common femoral artery and placed a 6 French sheath. Then through this 6-French sheath placed the 7 x 40 Zilver self-expanding stent in the right common iliac and then performed post-balloon inflation with a 6 x 100 balloon resulting in approximately 30% residual throughout; however, there was still the sheath in the right groin still obstructing flow. Therefore, performed PTA two more times in the distal external iliac stents with a 5 x 20 balloon. We then turned our attention to the left common iliac 70% stenosis and performed stenting with a 6 x 30 Zilver self-expanding stent resulting in less than 30% residual. ASSESSMENT AND PLAN: 1. Successful percutaneous transluminal angioplasty and stenting of a right common iliac, external iliac and common femoral artery 100% stenosis to less than 30% with a 1.7 laser, 6 x 80 Zilver self-expanding stent, 7 x 80 Zilver self-expanding stent, a 7 x 40 Zilver self-expanding stent resulting in approximately less than 30% residual. 2. Successful stenting of the left common iliac 70% stenosis to less than 30% with a 6 x 30 Zilver self-expanding stent.

37220 via Two Punctures

I have a right common iliac angioplasty. I want to use code 37720 for the angioplasty. But the physician used two different access point. One in the right common femoral and the other in the right brachial, both access sites were used to insert ballons for what looks like a kissing technique. Would I code the brachial catheterization separately, or is that included in code 37720?

Dear Dr.Z A very good morning Could you please answer my coding question, where I am feeling difficult. PROCEDURES PERFORMED 1. Peripheral angiogram of the right extremity with selective engagement of the catheter in the right superficial femoral artery. 2. PTA of the right anterior tibial lesion. 3. Infusion catheter placement in the right anterior tibial artery due to thrombus at the end of the procedure. INDICATIONS: 1. Nonhealing ulcer on the right lower extremity in the right over the ankle. 2. Severe claudication symptoms in the right lower extremity. 3. Severe peripheral vascular disease by CT angio of the lower extremity arteries. PROCEDUER DETAILS: A-5 French sheathe was introduced into left common femoral artery under local anaesthesia using Seldinger technique. After inserting a 5-French sheath I took a J-wire with 5-French catheter. Then, I brought to the catheter and wire over the iliac bifurcation in a retrograde fashion to the superficial femoral artery and placed the catheter there and took pictures of the right lower extremity. The angiographic results revealed the right distal superficial femoral artery shows disease. The right popliteal artery shows about 60% to 70% lesion. The right anterior tibial artery shows total occlusion in the mid portion with reconstitution above the right ankle. The right tibioperoneal trunk shows mild disease. The right posterior tibial artery shows mild disease. The right peroneal artery shows mild disease in the proximal mid segment with distal portion showing totally occluded and reconstitutes right above the foot. I used a 6 French 45 cm length destination sheath brought over the iliac bifurcation placed in the right common femoral artery. Then I used a 20 cm exchange length J wire and placed in the SFA. I brought the glide catheter and took the J wire out. Then, I used an Angiomax bolus drips as per weight-based protocol and creatinine clearance protocol. This is a Quick-Cross catheter. I took the guide catheter out and replaced the Quick-Cross catheter. Then I used a 0.014 guidewire, which is a length prowater wire. Then I used the wire and crossed the lesion in the anterior tibial artery and placed all the way at the end. Then, I used a balloon to inflate across the lesion. The balloon is 3.0x150 sleek balloon and inflated anterior tibial artery at about 10 atmospheres of pressure. Then I used a 5-French sheath tempo echo catheter, took the wire out and took good pictures. It showed there a good flow in the anterior tibial artery with a focal 95% stenosis in the mid portion. Then I went back with the Asahi Prowater wire used a 4.0x150 mm balloon and tried to dilate the entire tibial artery, especially across the lesion at about 6 to 7 atmospheres of pressures. Then I got good flow with good flow all the way to the foot but considering the severe calcification throughout the artery, to get better result, I went with 3.0 mm balloon again and dilated. After that last flow in the anterior tibial artery. Also I see the flow to the posterior tibial artery and the peroneal artery got slow and finally the flow became very faint in the distal portions of the posterior tibial artery, as well as the peroneal artey, which was not intervended at all, and never had a write placed in the artery. Then I realized that there was some thrombotic situation, likely from the Angiomax issues. Either not being given enough or the Angiomax given was not enough anticoagulation. We re-bloused the Angiomax at that point. Then I tried to reverse the leak over the wire balloon and tried to dilate many times, giving intra-arterial nitroglycerin and verapamil. Still the flow was less with thrombus. The flow is was scant. Then I used Activase intra –arterial with catheter placed in the anterior tibial artery area. Then I used a 10 mg IV bolus given initially and then I started infusion. I then inserted an ev3 infusion catheter. The catheter placed in the anterior tibial artery extending into the popliteal artery. At that time I left the catheter in the popliteal artery and left the catheter in place and gave another 2 mg IV push of Activase and started a drip. This lasted for 6 hours with plan to bring him back for repeat angiogram and possible PTA. The patient tolerated the procedure, hemodynamically, stable without any issue from respiratory or cardiac point of view. Also, another procedure was performed, which was PTA of the popliteal artery. There is a 70% lesion in the popliteal artery. I used a 4.0 balloon to do the PTA of the popliteal lesion at about 8 atmospheres of pressure. The balloon extended from the proximal ED into the popliteal artery. CONCLUSIONS: 1. 70% lesion in the right popliteal artery 2. Total occlusion of the anterior tibial artery in the mid portion. 3. Thromboembolism of the infrapopliteal arteries during intervention leading to poor flow into the foot, requiring Activase bolus and infusion using the infusion catheter. The infusion catheter is ev3 infusion catheter. 4. At the end of the procedure, the patient is to have posterior tibial Dopplerable and anterior tibial Dopplerable pulses. Recommendations: 1. Continue the infusion with Activase for 6 hrs. 2. Repeat angiogram after 6 hrs of Activase infusion. My coding is 37228, 37224, 75710-26, 59 & 36247(Infusion catheter placement not for Angiogram). Repeated procedure on same day: INDICATIONS: 1. Thromboembolic phenomenon in the infrapopliteal arteries to PTA of the right popliteal lesion, as well as the totally occluded anterior tibial artery. 2. Status post Activase infusion over 6 hours to see how the thrombus burden in the infrapopliteal arteries and the right lower extremity, and possible intervention. HISTORY: This is a 73 year old white male with a history of significant peripheral artery disease, with nonhealing ulcer on the right lower extremity above the ankle. He was found to have significant infrapopliteal disease. The patient had a PTA of the popliteal artery lesion, as well as intervention of the anterior tibial artery of the right lower extremity during which the patient developed thromboembolic phenomenon leading to a good flow in the infrapopliteal arteries with poor circulation to the foot. An infusion catheter was placed and infusion of the Activase was done over 6 hours. The Patient was brought for a repeat angiogram an possible PTA. Again, a 6 French destination, placed in the right superficial femoral artery beginning proximal portion on the right side. The infusion catheter was already in place which was in the popliteal artery extremity, anterior tibial artery. Then we cleaned this in a sterile fashion and changed the gloves, took an angiogram of the right lower extremity. RESULTS: 1. Angiogram of the right lower extremity showed the popliteal artery lesion was less than 30% 2. Anterior tibial artery flow was again not seen well. 3. Peroneal artery also showed good flow with distal reconstitution after occlusion in the distal portion. The distal portion of the reconstitution was right above the foot. Then I gave him 4000 units of IV heparin. Then, we used the same catheter. Through the same infusion catheter I inserted a Benston wire and placed in the anterior tibial artery all the way to the foot. Then, I used an angioplasty with a balloon which is 4.0x100 balloons. After PTCA the flow is slightly improved but not greatly. Considering his recent complication of thromboembolic problem in the lower extremities, we compromised with results and had partially successful results regarding opening the anterior tibial artery. The posterior tibial artery and peroneal artery were left as they were in the beginning. No complications. My Coding is: 37228-76 & 75710-26,76 I appreciate your help. Thanks & Regards Ronald

37201

Could you please advise on changing overnight thrombolytic catheters? Pt had popliteal vein accessed for thrombolytic yesterday 37201,36140,75986-26 for thrombus in the femoral vein, IVC and iliac veins. The next day dr removes EKOS cath for new brite tip sheath and leg and venal caval gram were performed. 75898-26, do I charge for the cath change also? 35900? PTA was perfromed of the external, common iliac, and common femoral. So that would be just one venous angioplasty of 35476-75978-26? Would the defining difference be whether they kept the thrombolytic going to be able to charge for cath change? Thank you so much for your help!

venous thrombecotmy and thrombolysis 37187

Would appreciate assistance on the following: The patient had extensive DVT in bilateral iliac, femoral, and popliteal veins as well as the IVC. Three infusion catheters were placed (one in each lower extremity and one in the IVC). The next day, followup angios were performed through each of the catheters. Based on findings of extensive residual filling defects, mechanical thrombectomy (Angiojet) was performed in both lower extremities. Additional venograms continued to show extensive residual clots, so an angioplasty balloon was used to macerate the clots. We understand that we would code only 75898 1x for the followup angios. However, since additional intervention was performed in both extremities, are we able to code for catheter placement for the mechanical thrombectomy? Would 36005 with a modifer 52 be appropriate? Also, use of an angioplasty balloon to macerate the clots is included in 37187 and not coded separately as 35476, correct? Thank you.

37221-50

Hello Dr. Z, I have a question about diagnostic angiography performed with stent placement in bilateral iliac artery. I think it is ok to bill 75630 with modify 59 for diagnostic angiography, but I was told not to. Please advice, thank you. By the way, can we bill 37220 with modify 50 for bilateral in this case? Arteriogram confirmed that the puncture was in the common femoral artery and a Bentson wire was uneventfully advanced up into the abdominal aorta. An Omni Flush catheter were then advanced and a angiogram was performed. Findings showed the proximal common iliac artery stenosis which was near occlusive with a patent hypogastric artery and external iliac artery. The left side and had normal flow with no flow-limiting stenoses in the common iliac, external iliac artery, or internal iliac arteries. Next we proceeded to gain access on the right side. Using a micropuncture set, the common femoral artery was punctured and a Bentson wire was advanced up to the near occlusion. A glide catheter was then placed over the wire and this was advanced to the stenosis. A glide wire was then advanced through the glide catheter and this traversed the near occlusion into the abdominal aorta and the glide catheter was then advanced over this into the abdominal aorta. The Glidewire was exchanged for an Amplatz wire and the glide catheter was removed. We then proceeded to place an 8 x 58 mm Omnilink stent on the right side, which was a balloon-expandable stent, and a 9 x 38 mm balloon expandable Omnilink stent on the left side. This was advanced into the abdominal aorta with about a 1 cm overlap and these were inflated simultaneously in a kissing fashion. A repeat angiogram was shot at the conclusion of this which showed still some waist in the right common iliac artery. Thus a decision was made to perform an angioplasty at this level with a 9 x 20 mm EverCross balloon. At the conclusion of this, another angiogram was shot which showed resolution of the stenosis and no flow-limiting areas within both stents. The entire iliac system was patent.

Migrated stent redeployment

We have an unusual case and I am hoping you can advise what is the best way to bill for the procedure. Thank you. Patient had a previously placed subclavian stent. It was found on CTA that the stent migrated to the bifurcation of the aorta and lt common iliac. The physician went in and snared the stent and repositioned it in the left common iliac artery. He has also dictated a complete lower extremity angiogram. Since he did not remove the stent would you use an unlisted code? I don't think there is medical necessity to bill for the angiogram even though it shows Lt SFA stenosis needing angioplasty at a later date. Thank you.

Treatment of ostial stenosis of common iliac and external iliac stenosis

Hi Dr Z/Dr Dunn, I have a question regarding the coding of an anigoplasy & stent placement of an ostial stenosis of the common iliac artery in addition to angioplasty & stent placement of external iliac arterty stenosis. My question is, how would the Ostial common iliac stenosis intervention be code-a aortic stent Or a common iliac stent 37221? I don't see a code for an aortic stent so presumably one could code 37221 & 37224(ext iliac stenosis) thank you.

ECMO

This is the first time I’m seeing a case done like this…have you seen this before and/or do you know how it’s being coded?  The only ECMO code that I’m aware of is 36822…not sure how to code for the graft part.
Thanks!

PREOPERATIVE DIAGNOSES:
1.  Ischemia of right lower extremity secondary to ECMO catheter.
2.  Need for new ECMO access.

POSTOPERATIVE DIAGNOSES:
1.  Ischemia of right lower extremity secondary to ECMO catheter.
2.  Need for new ECMO access.

OPERATION PERFORMED:
1.  Left groin cutdown, left common femoral artery exposure.
2.  Creation of conduit for ECMO ( 8-mm PTFE graft pulled through a 10-mm Dacron graft to left common femoral artery).
3.  Insertion of ECMO cannula arterial to left PTFE conduit.
4.  Right groin cutdown with right common femoral artery repair with bovine pericardial patch, decannulation of ECMO.
5.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm2, left groin.
6.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm in the right groin.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 100 cc.

DRAIN PLACED:  Bilateral groin VAC.

IV FLUIDS:  400 mL of crystalloid, 2 units of packed red blood cells, 2 units of FFP, 1 unit of platelets.

CONDITION:  Critical.

COMPLICATIONS:  None immediate.

INDICATIONS:  an 18 years old female, who has been an ICU patient.  Her initial diagnosis was infectious mononucleosis, it was complicated by respiratory failure as well as cardiac myopathy as well as liver failure and the necrotizing pancreatitis.  The patient had right ECMO catheter placed for about 2 weeks.  Patient initially had intermittent signals in her right lower extremity, but appears that in past over the span of past 24 hours, the ischemia of the right lower extremity has got worse with mottling of right lower extremity.  Patient did not have great volumes on the right lower extremity.  Therefore, decision was made to proceed with this procedure for decannulation of the ECMO from the right side to improve the perfusion of the right leg and therefore help possible viability of right leg and to get access to the left leg for ECMO.  Patient was a very high-risk procedure.  I explained clearly the multiple risk of the procedure including risk of death.  The patient's parents wished to proceed with the operation.

OPERATION:  After the informed consent obtained, the patient was brought to the operating room, placed in supine position.  General anesthesia was induced by anesthesiologist.  Patient's bilateral lower extremity was prepped and draped in standard sterile surgical fashion.  Anatomical landmarks were marked in the left groin including anterior superior iliac spine and pubic tubercle.  Vertical cutdown was performed in the left groin.  Skin was incised with a scalpel, soft tissue with the Bovie cautery.  There was massive tissue edema with infiltration with vitreous fluid.  Femoral artery was identified, common femoral, superficial femoral, profunda femoral artery were identified.  Vessel loops were placed across these vessels.
Next, a 6-mm arteriotomy was created into the common femoral artery.  An 8-mm PTFE graft was then sewed end-to-side to this arteriotomy with the help of a running 5-0 Prolene in a 4-quadrant fashion.  After the anastomosis was completed, proximal and distal clamps were released, forward flush, backward flush performed.  Anastomosis appeared intact.  This PTFE graft was tunneled inside a 10-mm Dacron graft.  Both of these grafts were then tunneled underneath the skin area and then brought through a separate stab wound distally.  The PTFE graft was then connected to the ECMO arterial cannula.  Arterial cannula was then connected and appeared to have good blood flow through the arterial catheter.  At this point in time, distal stab incision was closed with the help of interrupted nylon in a vertical mattress fashion.  Wound VAC therapy was placed in the left upper groin because of the bulging nature of the wound.  On the right side, a groin cutdown was performed.  Skin was incised with the scalpel and subcutaneous tissue with the Bovie cautery.  The muscles appeared dark in the right thigh area and they were not responsive to Bovie cautery at all.  The right groin arterial catheter was removed.  Fogarty was passed proximally and distally in the common femoral artery as well as in the superficial profunda femoral artery.  There appeared to be no clot.  There were no thrombus.  There was good inflow and there was good back bleeding through both SFA and profunda.  All these arteries were flushed with half saline in an olive-tip.  Next, a bovine pericardial patch was used for performing the femoral patch angioplasty of the common femoral artery with the help of 5-0 Prolene, just before completion of anastomosis, forward flush, backward flush were performed with anastomosis appeared intact.  Anastomosis was completed and the flow was released.  There were palpable pulses in the superficial femoral artery and profunda femoris artery; however, we were not able to obtain Doppler signal in the foot.  However, at this point in time, the patient has been hemodynamically unstable, and we were in the OR for more than an hour.  Since the muscles of the right lower extremity were not contractile, I made a decision not to perform further revascularization of right lower extremity because of the concern that the leg may not be viable at all and the fact that the patient may not tolerate any more surgery at this point in time.  We placed the VAC therapy in the right groin where plan is to follow the right leg for next 24 to 48 hours.  Even after restoration of the blood supply  if her legs remain mottled for next 24 to 48 hours, she may need a high amputation possible above knee amputation, possible  amputation hip disarticulation level.  Wound VACs were placed and the patient was transferred back to Intensive Care Unit in critical condition.

Exploration of vessel

Hi Dr. Zielske and Dr. Dunn, I need some assistance with coding a femoral vein venotomy and foreign body removal. This is a condensed portion of the procedure: During an IVUS procedure of the IVC and lower extremity veins stenosis was found in the left common iliac vein. Angioplasty was done on this vein. Balloon ruptured and upon removal the balloon remained in the left common femoral vein and became detached from the catheter. An incision was made over the left groin and a left femoral vein exploration was carried out. The femoral vein was identified and a venotomy performed. The ruptured balloon was then extracted under direct vision from the left femoral vein and the venotomy was repaired with 4-0 Prolene until hemostasis was achieved. I have searched my CPT book and have come up with 35226 for repair of a blood vessel or 37799 for an unlisted vascular procedure. Is there a better way to code this? As always, thanks for your assistance. Pam Johnson

ECMO

This is the first time I’m seeing a case done like this…have you seen this before and/or do you know how it’s being coded?  The only ECMO code that I’m aware of is 36822…not sure how to code for the graft part.
Thanks!

PREOPERATIVE DIAGNOSES:
1.  Ischemia of right lower extremity secondary to ECMO catheter.
2.  Need for new ECMO access.

POSTOPERATIVE DIAGNOSES:
1.  Ischemia of right lower extremity secondary to ECMO catheter.
2.  Need for new ECMO access.

OPERATION PERFORMED:
1.  Left groin cutdown, left common femoral artery exposure.
2.  Creation of conduit for ECMO ( 8-mm PTFE graft pulled through a 10-mm Dacron graft to left common femoral artery).
3.  Insertion of ECMO cannula arterial to left PTFE conduit.
4.  Right groin cutdown with right common femoral artery repair with bovine pericardial patch, decannulation of ECMO.
5.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm2, left groin.
6.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm in the right groin.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 100 cc.

DRAIN PLACED:  Bilateral groin VAC.

IV FLUIDS:  400 mL of crystalloid, 2 units of packed red blood cells, 2 units of FFP, 1 unit of platelets.

CONDITION:  Critical.

COMPLICATIONS:  None immediate.

INDICATIONS:  an 18 years old female, who has been an ICU patient.  Her initial diagnosis was infectious mononucleosis, it was complicated by respiratory failure as well as cardiac myopathy as well as liver failure and the necrotizing pancreatitis.  The patient had right ECMO catheter placed for about 2 weeks.  Patient initially had intermittent signals in her right lower extremity, but appears that in past over the span of past 24 hours, the ischemia of the right lower extremity has got worse with mottling of right lower extremity.  Patient did not have great volumes on the right lower extremity.  Therefore, decision was made to proceed with this procedure for decannulation of the ECMO from the right side to improve the perfusion of the right leg and therefore help possible viability of right leg and to get access to the left leg for ECMO.  Patient was a very high-risk procedure.  I explained clearly the multiple risk of the procedure including risk of death.  The patient's parents wished to proceed with the operation.

OPERATION:  After the informed consent obtained, the patient was brought to the operating room, placed in supine position.  General anesthesia was induced by anesthesiologist.  Patient's bilateral lower extremity was prepped and draped in standard sterile surgical fashion.  Anatomical landmarks were marked in the left groin including anterior superior iliac spine and pubic tubercle.  Vertical cutdown was performed in the left groin.  Skin was incised with a scalpel, soft tissue with the Bovie cautery.  There was massive tissue edema with infiltration with vitreous fluid.  Femoral artery was identified, common femoral, superficial femoral, profunda femoral artery were identified.  Vessel loops were placed across these vessels.

Next, a 6-mm arteriotomy was created into the common femoral artery.  An 8-mm PTFE graft was then sewed end-to-side to this arteriotomy with the help of a running 5-0 Prolene in a 4-quadrant fashion.  After the anastomosis was completed, proximal and distal clamps were released, forward flush, backward flush performed.  Anastomosis appeared intact.  This PTFE graft was tunneled inside a 10-mm Dacron graft.  Both of these grafts were then tunneled underneath the skin area and then brought through a separate stab wound distally.  The PTFE graft was then connected to the ECMO arterial cannula.  Arterial cannula was then connected and appeared to have good blood flow through the arterial catheter.  At this point in time, distal stab incision was closed with the help of interrupted nylon in a vertical mattress fashion.  Wound VAC therapy was placed in the left upper groin because of the bulging nature of the wound.  On the right side, a groin cutdown was performed.  Skin was incised with the scalpel and subcutaneous tissue with the Bovie cautery.  The muscles appeared dark in the right thigh area and they were not responsive to Bovie cautery at all.  The right groin arterial catheter was removed.  Fogarty was passed proximally and distally in the common femoral artery as well as in the superficial profunda femoral artery.  There appeared to be no clot.  There were no thrombus.  There was good inflow and there was good back bleeding through both SFA and profunda.  All these arteries were flushed with half saline in an olive-tip.  Next, a bovine pericardial patch was used for performing the femoral patch angioplasty of the common femoral artery with the help of 5-0 Prolene, just before completion of anastomosis, forward flush, backward flush were performed with anastomosis appeared intact.  Anastomosis was completed and the flow was released.  There were palpable pulses in the superficial femoral artery and profunda femoris artery; however, we were not able to obtain Doppler signal in the foot.  However, at this point in time, the patient has been hemodynamically unstable, and we were in the OR for more than an hour.  Since the muscles of the right lower extremity were not contractile, I made a decision not to perform further revascularization of right lower extremity because of the concern that the leg may not be viable at all and the fact that the patient may not tolerate any more surgery at this point in time.  We placed the VAC therapy in the right groin where plan is to follow the right leg for next 24 to 48 hours.  Even after restoration of the blood supply  if her legs remain mottled for next 24 to 48 hours, she may need a high amputation possible above knee amputation, possible  amputation hip disarticulation level.  Wound VACs were placed and the patient was transferred back to Intensive Care Unit in critical condition.

37221 vs 34900 (dissection with incidental small iliac aneurysm)

A recent comment by a vascular surgeon caused me to research the appropriateness of using Iliac Vascular Repair(75954)vs. Iliac Stent(37221). Ex.1 - A patient developes a dissection in External Iliac Artery during a procedure. Attempt to "tack it up" with angioplasty is unsuccessful leading to a Viabahn covered stent placement. Ex. 2 - A patient presents for stenting of External Iliac and small aneurysm is found when roadmap image is taken. Use a Viabahn covered stent for stenosis and to cover area of aneurysm. The comment was made that anytime you "repair" an iliac regardless of product used - it is 75954. The CIRCC study guide states the codes are specific to the devices and techniques used and to the location of the abnormalities. So does 75954 require a specific device in addition to technique and location? Thank you for clarifying and for your assistance!

Complex aortic and iliac stent graft procedures

Please do NOT include any actual patient medical records with your question. Would you be able review these codes and let me know if the case was coded correctly. Operation : Aortagam with pelvic runoff, occlusion of right internal iliac artery with Amplatzer plug, repir of left iliac aneurysm with branched iliac device, repair of infrarenal aorta with bifurcation stent graft (cook zenith) angioplasty and stent of left external iliac artery. Dx is aneurysms of infrarenal aorta and bilateral common iliac arteries. The cpt codes chosen are: 34803,34900,34825,34808,37221,36247-59,75952-26,75952-26/59,75953-26,76937-26,75937-26/59 Should you need copy of pt. case please let us know. Thanks, Renata

37224, 35371, 37224-53

could you tell me how you would code this for physician billing…this is what I'm coming up with from what's in the note

35371
37224-51
36246-59-51
75710-59

thanks!

OPERATION PERFORMED:
1.  Right common femoral endarterectomy.
2.  Right superficial femoral artery angioplasty with 5 mm x 6 cm balloon.
3.  Third-order selective catheterization of the left superficial femoral artery.
4.  Aortoiliac angiogram.
5.  Bilateral lower extremity arteriogram.

ANESTHESIA:  General endotracheal anesthesia.

INDICATIONS:  This 71-year-old female with a history of tobacco use and bilateral lower extremity claudication presented for a second opinion regarding her lower extremity claudication in trying to avoid bypass surgery.  I reviewed her angiograms and we performed a duplex and I felt that endarterectomy of the common femoral artery with concomitant angioplasty may be of benefit to her.  She understood these risks and benefits and wished to proceed.

OPERATION:  The patient was brought to the hybrid operating room and placed in a supine position.  After adequate general endotracheal anesthesia was achieved and time-out performed, the right groin was prepped and draped in a sterile fashion.  Via an oblique incision, the soft tissues were divided and the common femoral, profunda femoris, and superficial femoral arteries were looped gently with vessel loops.  There was a very focal, approximately 2 cm area of near occlusive plaque palpated in the mid common femoral artery.  The patient was systemically heparinized with 5,000 units of heparin.  After 3 minutes, the vessels were controlled and a longitudinal arteriotomy created in the common femoral artery.  There was a 2 cm length plaque, near occlusive which was endarterectomized.  A bovine pericardial patch was then anastomosed with 5-0 Prolene suture and the anastomosis was completed.  Seldingerneedle access was then gained in an antegrade fashion through the patch and I was able to traverse the chronic total occlusion of the superficial femoral artery.  A 6-French sheath was placed and with the 5-French Glide catheter, and 0.035 angle-tipped stiff Glidewire, I was able to gain true lumen reentry in the mid superficial femoral artery as confirmed by arteriography.  Balloon angioplasty was then performed with a 5 mm x 6 cm balloon with excellent results.  The patient had 2-vessel runoff via the peroneal which reconstituted the posterior tibial artery.  The anterior tibial artery appeared to occlude in the mid calf.  This sheath was then removed and the wire access closed with an interrupted 5-0 Prolene suture.  Next, retrograde access was obtained in the patch and aortoiliac angiogram performed showing no significant occlusive disease.  With an 0.035 angle tipped stiff Glidewire, I cannulated the left common iliac, external iliac, and common femoral artery, and the 5-French Omniflush catheter was advanced over the bifurcation with the tip positioned in the distal left external iliac artery.  A left lower extremity arteriogram was then performed showing a flush occlusion of the superficial femoral artery.  This was reconstituted in the distal SFA just proximal to the <_____> popliteal artery and continued down below the knee with again a 2-vessel runoff essentially via the peroneal and posterior tibial artery.  A 6-French 45 cm Destination sheath was then placed with thetip positioned in the distal common femoral artery on the left.  With the Quick-Cross catheter and 0.035 angle tipped stiff Glidewire, I was able to cross the occlusion; however, we had difficulty getting back into true lumen.  At this point, I felt that we would continue with medical management of the patient and see how things went with regard to her left leg from a clinical standpoint.  At this point, the sheath was then removed and the patch repaired with figure-of-eight 5-0 Prolene suture.  The incision was inspected for hemostasis and when this was assured, the layers were closed with running 3-0 Vicryl followed by 4-0 Monocryl and Dermabond to the skin.  Patient was awakened from anesthesia and appeared to tolerate the procedure well without immediate complication.  Sponge, needle, and instrument counts were reported as correct at the end of the case.  I was present for the entire portion of the procedure.

Catheter placement and multiple interventions in lower extremity

Do you code the catheter placement after Infusion therapy such if the patient comes back and a mechanical thrombectomy has to be performed. please see the case below..the doctor is saying mechanical thrombolisis but i am coding it as a thrombectomy after infusion 37184,37185 for leg thrombectomy and 37184-51 for the Aortic thrombectomy, 37224, 75989 x2 as there is to different access sites. My guestions is also on the catheter placement codes. do I code 36245 for Iliaca balloon occlusion. Thanks PROCEUDRE: 10 hour thrombolysis follow-up. CLINICAL INDICATION: Aortic thrombus and left lower extremity thrombus. OPERATORS: Bick-Forrester (Fellow), Hardley (Attending) CONSENT: The patient was informed of benefits, risks, and alternatives to the procedure and agreed to sign informed consent. Any and all questions were answered at the time of consent. MEDICATIONS: Vancomycin 500mg IV, Heparin 5000 units IV, Fentanyl 100mcg IV, 5mg metoprolol, 1 mg Versed IV. CONTRAST: 78 mL FLUORO TIME: 25.5 min. TECHNIQUE: The patient was placed supine on the angiography table and the existing sheaths and catheters in bilateral groins were prepped and draped in standard sterile fashion. Angiography was performed through the existing infusion catheters, showing no significant improvement. Both infusion catheters were removed, and the Angiojet device was prepped. The bilateral existing 5F sheaths were exchanged for bilateral 6F sheaths. The 6F Angiojet thrombectomy device was then advanced through the left groin into the infrarenal aorta, and mechanical thrombolysis was performed. The Angiojet device was then advanced through the right femoral sheath, over the bifurcation, and into the left common femoral artery. Mechanical thrombolysis was then performed in the common femoral artery to the superficial femoral artery. A pigtail catheter was then advanced through the left common femoral sheath into the aorta and angiography was performed, demonstrating persistent thrombus in the infrarenal aorta and extensive irregularity of the left common femoral artery. The pigtail catheter and left femoral sheath were removed, and an 8F sidearm vascular sheath was advanced into the left common femoral artery. A 5F Fogarty balloon was advanced from the right femoral access site to the origin of the right common iliac artery and was inflated to occlude the right iliac origin. A second, 6F 80cm Berenstein balloon was advanced proximal to the aortic thrombus, inflated, and retracted into the left common and external iliac arteries. Repeat angiography in the aorta showed no residual aortic thrombus, but significant thrombus in left common and external iliac arteries. The Fogarty balloon was removed, as was the right femoral sheath which was exchanged for 6F 40cm up and over Balkan sheath. Angiojet thrombolysis was then again performed throughout the left common iliac, external iliac, common femoral, and superficial femoral arteries. While significant improvement was noted on angiography performed through the Balkan sheath, there is persistent irregularity and stenosis of common femoral artery. No definite thrombus is noted to persist in the common iliac, external iliac, or common femoral arteries. There is persistent thrombus noted in the distal superficial femoral artery into the popliteal artery. The left femoral arteriotomy site was closed with an 8F Angioseal device which achieved immediate hemostasis. Angiojet thrombolysis was again performed from the popliteal artery to the common femoral artery, and angiogrpahy was again performed showing marked improvement. No significant thrombus is noted from the iliac vessels to the the trifurcation, however there were areas of irregularity and stenosis in the common femoral artery and popliteal artery. The popliteal artery demonstrated long segment of marked narrowing from the abductor hiatus to the trifurcation. There is minimal antegrade flow noted. A 5 mmx4cm ultra-thin Diamond balloon was then used to perform angioplasty from along the course of the popliteal artery. Repeat angiography was performed showing some improvement. Angioplasty was again performed from the level of the trifurcation proximally to the common femoral artery. Angiography showed marked improvement in the arteries from the pelvis to the trifurcation. There was persistent decreased and absent flow distal to the trifurcation. A 5F angled glide catheter was left in place just proximal to the trifurcation, and TPA infusion initiated at 1mL/hour. IMPRESSION: 1. Initial angiogram shows persistent aortic and left external iliac thrombus extending distally, not significantly changed from prior angiogram. 2. Aortic thrombus resistant to Angiojet mechanical thrombolysis was retracted into left common iliac artery with balloon. Aorta now angiographically free of thrombus. 3. Left common iliac, external iliac, common femoral and superficial artery thrombus treated with Angiojet mechanical thrombolysis, with good result. Several areas of persistent stenosis and irregularity noted, most prominently in the common femoral artery and popliteal artery. 4. Balloon angioplasty performed along length of common femoral artery, superficial femoral artery, and popliteal artery with good result. 5. Persistent absence of antegrade flow distal to trifurcation. 5F angled glide catheter left just proximal to the trifurcation for infusion of 1mg/hr TPA. Plan follow-up angiography in approximately 4 hours.

37201, Trellis, bilateral venous

I researched the Q&A list. I have a question on a patient that had thrombus, extending from the IVC (inluding pt's IVC filter) into bilateral femoral veins and left popliteal vein. The MD did mechanical thrombectomy and thrombolysis, bilateral iliac and femoral vein angioplasty, and right common iliac venous stent. My questions are: 1)do we code for only the thrombectomy, only the thrombolysis, or both? The MD dictation states: "approximately 3mg of TPA was pulse injected via the Berenstein catheter into the thrombus within and just below the IVC filter and allowed to dwell there for the duration of the procedure (which was approx 2.5 hrs). 8Fr Trellis catheters (30cm treatment lengths) were inserted bilaterally and positioned within the vena cava just inferior to the IVC filter and extending to the left common femoral vein and the proximal right superficial femoral vein. The Trellis was activated for total 12min and 5mg TPA pulse sprayed through each catheter. Suction aspiration was performed from both catheters for approximately 60-80cc each side. Both catheters were then repositioned distally extending to the mid-SFV on the left and distal-SFV on the right (just above the sheath). The Trellis was run again for another 12min and instilling 4mg TPA on the left and 3mg TPA on the right. Aspiration was performed for an additional 60cc each side and with the Trellis motor cannula removed. Aspiration flow this time was brisk on both sides." 2)how many angioplasties are allowed? Prior to the section of the procedure quoted above, the MD states: "Balloon angioplasty was performed of both femoral and iliac veins, beginning above the sheaths and continuing to the IVC filter with a 6mm x 20cm Dorado. This was done to disrupt the fibrin crosslinking of the thrombus (given its subacute age) and allow better penetration of thrombolytic." Do we code for 4 angioplasties,or is this treated like a pre dilation and considered part of the thrombectomy or thrombolysis? Then after the completion of the thrombectomy/thrombolysis procedure, the MD also did 1 angioplasty in the right iliac for residual 70% stenosis for which I planned to code. Thank you very much for your help.

37205 vs 37221

Hi Dr. Z. could you help us out with this senario? Patient presents with clinical characteristics of Lerich syndrome. Pt. was denied MRA. Initail Lt. radial approach. Catheter placement in AO above the renal arteries. Abd AO with Bi-Lat Runoff. There was a 3.5cm occlusion of the abd ao to the aorotoiliac bifurcation. Since the equipment in stock might not reach, due to the distance, both fermoral arteries were cannulated. Kissing balloon angioplasty followed by kississing stent placement. Comments and Conculsion: Leriche syndrome distal abdominal occlusion extending into both cmn iliac arteries, successfully recanalized and stented with visis-pro stents. Would this be??? 36200-59, 75630-59 and 37221-50???? Or would you just code 36200 x3 w/59's 75630 -59 37205 and 75960??? Thank you very much!

CPT codes for embolectomy and iliac angioplasty

Hello Again, I am having a hard time with this case. I am debating between cpt codes 32401 with 75710-59,37220 or 35371,37184, 37220 and 75710-59. I am helding more on 32401 codes as i see the incision and repair and a catheter is also used. for the second pair of codes i really dont see the andarterectomy 35371 done as the surgeon states. Please help as the more i read it the more confused i get. Thanks for your help.... PROCEDURE: 1. Right common femoral artery exploration with endarterectomy. 2. Right SFA embolectomy. 3. Right common femoral embolectomy. 4. Right external iliac embolectomy. 5. Right iliac angiogram. 6. Right common iliac embolectomy with over the wire Fogarty, 4 French. 7. Right common femoral angioplasty with 8 millimeter x 60 millimeter balloon. 8. Right common femoral artery repair with patch angioplasty. - SURGEON: Kin-Man Lai, M.D. - ASSISTANT: John Beemer, Physician's Assistant. - ANESTHESIA: General endotracheal anesthesia. - ESTIMATED BLOOD LOSS: 50 cc. - ESTIMATED FLUID: A liter of normal saline. - COMPLICATIONS: None. - DISPOSITION: To the recovery room in stable condition. - BRIEF DESCRIPTION OF PROCEDURE: This is a 52-year-old gentleman with known peripheral vascular disease status post right common iliac angioplasty and stenting with double stent in the past and status post left common femoral artery endarterectomy and patch angioplasty repair 2 years ago who presented to the emergency room today with a four day history of right lower extremity numbness. The patient's symptoms progressively worsened with inability to walk and pain. - The patient was immediately evaluated with bedside ultrasound which noted there was little to no flow in the common femoral artery. The patient has flow in the SFA and profunda femoral artery via collateral. The patient also has no flow in the external iliac artery. Due to these findings and history of peripheral vascular disease and stenting, the patient was deemed to have evidence of acute on chronic ischemia. The patient was then given the option to go to the operating room to have this repair emergently. The risks and benefits of this procedure were carefully explained to patient and wife in full detail who wished to proceed. - The patient was then brought to the operating room, placed on the operating room table. After adequate anesthesia was achieved, the patient was appropriately prepped and draped. We made an incision approximately 3 inches above the groin crease. The subcutaneous tissue was then dissected with cautery device. With Weitlaner in place we dissected all the way down to the common femoral vein following the epigastric branch. We also ligated the epigastric branch and saved it for patch angioplasty repair at the end of the procedure. - We isolated the common femoral artery which has no pulse. A vessel loop was then placed around each one, the distal aspect of the common femoral artery. The patient was given 5000 units of heparin. When the heparin had been in for five minutes we opened up the arteriotomy with an 11 blade, extended it with Potts scissors. We then performed a Fogarty angioplasty with #3 Fogarty down the SFA and then #4 Fogarty at the common femoral and external iliac. We were not able to pass the Fogarty retrograde past 15 millimeters. Due to these reasons, I suspected a possible occlusion or stenosis of the previous atrium stent. We therefore placed a 6 French sheath in place and used 4 French over the wire Fogarty to open up a small passage. Under fluoroscopic guidance we were able to gain access to above common iliac artery on the right side. - Angiogram with Kumpfe catheter revealed no flow into the right limb of the iliac artery. We therefore proceeded to perform over the wire Fogarty with a 4 French system. We removed a small amount of clot. At this point we did not have good flow under completion angiogram. We therefore used an 8 millimeter x 60 millimeter Admiral balloon and performed angioplasty of this stent. This was performed successfully. Post procedure we had an open channel in the common iliac. We had good flow into the right iliac and retrograde flow into the aorta and the left iliac system. - At this point, after multiple angioplasty was performed, we elected to remove the sheath and proceeded to irrigate the arteriotomy and then we paired this arteriotomy with the epigastric branch saphenous vein. This was repaired with a 6-0 Prolene. This was repaired without any difficulty. We backflushed and foreflushed the conduit and irrigated the repair area with heparinized saline. The patient has good pulse at the end of the procedure. - We then proceeded to apply thrombin soaked Gelfoam for hemostasis. We then proceeded to close the wound with 2-0, 3-0, and 4-0 Vicryl and then Biosyn. The patient's wound was then carefully cleaned off and local anesthesia was infused. DermaFlex was then used as a sterile dressing. The patient tolerated the procedure well. No complications. The patient was then taken to recovery in stable condition. - -

Placement of infusion wire beyond location of LE revascularization

Patient was brought to IR suite with an ishemic foot. A pelvic angiogram was performed and the catheter was advanced to the right external iliac and a lower extremity angiogram was performed. The catheter was advanced into the fem-pop graft an angiogram was performed showing thrombosis. Catheter advanced to the above knee jump graft to below knee angiogram showed a 90% stenosis. Angioplasty was performed at the jump graft anastomosis. Next an infusion catheter was placed in the fem-pop graft and an infusion wire was then advanced through the infusion catheter to the peroneal artery. Overnight thrombolysis was performed. I know catheter placements are bundled into angioplasty codes. Can we code 36247 for placing the infusion wire in the peroneal artery since it is past the location of the angioplasty?

37220 and 37224 for iliac and SFA angioplasty

would you do 37220 and 37224 for this one? PROCEDURE IN DETAIL: The patient was brought to the Angio Suite and placed in supine position. After a time-out was performed, the bilateral groins were prepped and draped in sterile fashion. Ultrasound guided access was attempted in the right common femoral artery. However, we could not advance the wire. The patient did have a known external iliac artery stenosis. However, despite multiple attempts, we could not get the wire to traverse proximally. In order to treat the left external iliac artery and superficial femoral artery occlusive disease, I needed to establish access from the left brachial artery. This was performed under ultrasound guidance with a micropuncture kit. A 5 French sheath was ultimately placed and the 90 cm pigtail catheter placed in the distal infrarenal abdominal aorta. Aortoiliac angiogram should distal external iliac artery occlusive disease bilaterally as was depicted on the arterial duplex. The 0.035 angle tip stiff glidewire was then used to carefully select the left common iliac, common external iliac and common femoral artery. The short 5 French sheath was exchanged for a 90 cm 6 French sheath with the tip positioned in the left iliac system. Iliac and left lower extremity arteriogram was then performed to the extent of the knee due to the reach of the table from the brachial position. There was approximately 60-70% stenosis of the left external iliac artery and occlusion and approximately 20 cm occlusion in the left superficial femoral artery. I was able to traverse the external iliac artery stenosis as well as the superficial femoral artery occlusion to the mid thigh. However, this was the extent of the length of the balloon at 135 cm. A 5 mm x 10 cm balloon was then used to angioplasty the origin of the left superficial femoral artery as well as the upper third of the superficial femoral artery into the mid thigh. I did over-inflate this balloon to angioplasty the left external iliac artery with good results. Completion arteriography showed excellent flow through the proximal superficial femoral artery and the known residual distal stenosis which we could not reach from the arm. There was reconstitution of the above knee popliteal artery which continues relatively disease free below the knee. The trifurcation shows only runoff through the peroneal artery. A total of 58 ml of contrast was utilized. The 90 cm 6 French sheath was exchanged for a short 6 French sheath to be removed once the ACT was less than 175 seconds. I was present the entire portion of the procedure.

dottering of iliac artery angioplasty stent placement aorta

On the following procedure we are questioning if we can code the stent and the angioplasty and also would you code abdominal aortogram and iliac? In your opinion did he do an angioplasty of the iliac? Another question?? Is this an Inpatient only procedure since he did cut down? DESCRIPTION OF PROCEDURE: With patient lying in a supine position on the operating table, a #16 Coude catheter was used to place in the urinary ostomy. Prior to the procedure by myself, I modified this catheter to cut the tip of it off very short since palpating the urinary bladder, it was only about 3 cm in depth. I placed a 5 mm balloon catheter in the stoma, by holding pressure on it and then cutting the end of this in 3 different places,I was able to get urine and irrigant with saline through this area from the stoma. This was then excluded from the field with an loban drape, and then the abdomen was sterilely prepped and draped. Another loban was placed over the entirety of the abdominal prepped area, after towels were placed and then a full draping. The operation was begun with a transverse incision right over the inguinal ligament. This basically was the same incision as previously, it is approximately 8 cm in length, and since this was exactly in the groin crease, I dissected upwards after dividing through the subcutaneous tissue and actually divided about 1 inch of the inguinal ligament in order to get control of the distal external iliac artery, which had not been dissected out preVioUsly. This was a small artery about 5 mm in size and so went ahead and dissected it out, and then dissected back on the extensive scar tissue over the common femoral, and in so doing, I was able to get control of about 2.5 cm of the distal external iliac and proximal commoril'emoral. There was 1trip branch that I had to tie off that was about a 2 mm collateral that took off laterally from the external iliac vessel and this was closed over with a figure-of-eight•.5-0 Prolene suture. Then, the patient was heparinized with a total of 7000 units of heparin. Seldinger needle was used to access the vessel and a .f-wire was placed through this and then a short 6-French sheath was placed over that into the vessel. Arteriogram revealed that the wire hung up at the distal stent graft'and th;tihe iliac was of narrow caliber. It appeared to be about a 5-6 mm vessel all way up to the common iliac. At any rate, Iwent ahead then and because the f-wire would not pass up through the stent, I went ahead and got a angled glide catheter (a Berenstein catheter) and then using this was able to advance the j-wire through the midportion of the stent. It went smoothly up into the distal thoracic aorta, and then the Berenstein catheter was rernoved'Ieavinq the J-wlre in place and then a 4-French angioplasty ealloon catheter was inflated and passed through this and then passed up with it being already inflated up the wire and it went smoothly through the stenotic lesion of the aorta and therefore I felt that the wire was through the midportion of the graft and had not gone underneath 1 of the stents. Then, the balloon catheter was advanced to the distal thoracic aorta and through this, I passed a Lunderquist wire to obtain stiff wire access through the lesion and then once that was accomplished, the Berenstein catheter was removed and then a 16-French long sheath was exchanged for the 6-French sheath, which was in the groin. This was passed up with some difficulty and went very slowly and with push-pull maneuver, was able to advance it through some areas, which felt like a stenosis but ifl fact this performed probably a Dotter dilatation of the iliac and once it was in place, it was advanced up to the distal to the level above the renal arteries. Then, a 40 diameter Palmaz stent approximately 3 cm in-lenqth was placed on a Coda balloon and then advanced through the long sheath and I neglected to say that an aortogram ha'd been accomplished through the sheath. A glow tape had been placed on the abdomen and I precisely identified the stenosis, which was right in the mid portion of the previously placed stent graft. I then pulled back on the long sheath, exposing the Palmaz stent, which was loaded on the Coda balloon and then deployed it by inflating the Coda balloon. Unfortunately, the Coda balloon was.not strong enough which with a low pressure balloon to dilate the lesion. The Coda balloon was removed leaving the stent in good position, and then a 14 mm diameter and 4 cm in length angioplasty balloon was exchanged for the Coda and placed in so that it extended on either side of the Palmaz stent and insufflated. There was an obvious waist on this where the in-stent stenosis had been, but it dilated nicely and dilated the Palmaz stent very successfully. This is a nice 14 mm lumen and a confirmatory arteriogram by hand injection through the long sheath, confirmed that the lesion was nicely dilated. Then, I removed the long sheath, slowly and pulled it back into the iliac and performed 3 hand injections as I pulled this back to confirm that there was no leak from the iliac artery, since I had felt that this had dilated the iliac considerably when it went in. Once it was back to the external iliac, and no leak from the iliac vessel was seen on the 3 arteriograms that I did and there was good flow all the way down and up across the bifurcation. The stent was then removed. Tapes were pulled up on the distal external iliac and common femoral vessel and then I closed the common femoral vessel with interrupted stitches of 5-0 Prolene and 6-0 Prolene suture. I used an interrupted closure so as to not create any stenosis of the femoral at that level. Once that was accomplished, a Doppler signal and palpable pulse was much stronger since the initial pulse was barely palpable in the groin and it was not palpable through the skin, but was barely palpable when the artery was exposed. It was much stronger and when hemostasis was felt to be secure, I closed the groin incision with 2 layers of running 2-0 Vicryl suture and skin clips were applied to the skin. An occlusive dressing with Betadine ointment and 4x4s were placed over the incision and then lastly the Foley catheters removed from the urinary stoma and an occlusive urinary stoma dressing was applied with Stomahesive and a small flange was placed over this and then attached to urinary drainage bag. The patient had a triphasic dopplerable signals in the foot at termination of procedure, and both right and left foot indicating much a very good result. The patient tolerated the procedure well and was extubated in the operating room, transferred to the recovery room in good condition.

34803

This patient was brought in for repair of iliac aneurysm and AAA. A bifurcated graft was placed and in addition, a stent was placed inside of the iliac limb of the graft due to vessel tortuosity. CPT book indicates that 37221 iliac stent is for occlusive disease. We have 34803, 75952, 36200 x2. Main body stent graft 32 x 96 was advanced from a right approach into the abdominal aorta. The contralateral limb was oriented anterolaterally. Proximal 2 stents were deployed and position adjusted to just below the level of the renal arteries. Contralateral limb was deployed. The suprarenal stent was deployed and catheter was pulled back to the distal abdominal aorta. Catheter was exchanged to a Kumpe catheter and later a Vanshee catheter. Contralateral gate was cannulated using the Vanshee catheter. Intraluminal position was confirmed by injecting a small amount of contrast within the graft. Lunderquist wire was advanced to the upper descending thoracic aorta. The catheter was removed. Left iliac arteriogram was performed to evaluate the common iliac bifurcation. A left limb 14 x 90 was advanced from a left approach to about 1-1/2 stent overlap. The stent was deployed proximal to the common iliac bifurcation. Due to tortuosity of the common iliac artery, it was decided to place a self expanding stent to increase radial force. A 14 mm x 60 mm SMART stent was deployed within the left iliac limb. The remaining 2 stents from the main body were deployed and nose cone was retrieved. Right iliac arteriogram was performed. Right limb 12 x 107 was advanced from a right approach to the right iliac limb. 2 stents overlap proximally and distally. The stent was deployed in the proximal right external iliac artery covering the origin of the right hypogastric. The infrarenal neck areas overlap and distal limbs were dilated using compliant balloons. The stent on the left was dilated using a 12 mm angioplasty balloon. Completion arteriogram was performed through a pigtail catheter from a left approach.

Stent placement common femoral, common iliac, external iliac

I have a question on how to code a lower extremity venoplasty and subsequent stent placement on 3 vessels. My documentation states angioplasty of the left common iliac vein, left external iliac vein and the left common femoral vein. Flow limiting elastic recoil with virtually no antegrade flow. Then 4 stents were placed in overlapping fashion. The diagnostic venogram showed that the common femoral vein is moderately narrowed and has a large web in it. Common and external iliac venous stents are occluded. Can I use 35476/75978 three times? How about the stent placement- can I use this three times 37205/37206x2/75960x3? Thank you for you help.

37221, 93223, 95371

I am struggling with the coding on this one and not sure I coded correctly as: 37221 37221-59 37223 37223-59 35372-RT 35371-50,59 75716-26,59 Bilateral common femoral and right profunda femoris endarterectomy with bovine pericardial patch angioplasty, aortic catheterization from open right common femoral access, second order right external iliac artery catheterization from left common femoral access, aortogram with bilateral runoff, bilateral common iliac artery stent placement (Smart 7X60 mm), bilateral external iliac artery stent graft placement (Fluency 6X80mm bilaterally, also right Smart 6X40 and left Smart 7X40) Thank you Carol