Ask Dr. Z

Good afternoon, Dr. Z and Dr. Dunn. I have a lot of questions about the following op report. I'm debating whether to represent the angioplasty with 35456,LT or 35459,LT, along with 75962,26,LT. I'm leaning towards 35456,LT, because the doctor says it was done in the mid thigh, but 35456,LT is considered bundled with 35566,LT, according to NCCI edits, while 35459,LT isn't. It also seems as if 36140,LT is considered bundled with 35566,LT, but would that be added with a 59 modifier if an angioplasty of the graft is done? On the other hand, does the statement, "Primary vascular procedure listings include establishing, both inflow and outflow, by whatever procedures necessary.", pertain to this situation? How about the repairs due to extravasation, during the angioplasty of the graft? Could 35226,LT be used as an additional code? If so, how many units? I decided against using 35682,LT, because the doctor basically did a resection and anastomosis of the same vein, as opposed to merging two veins from different locations. Was that the correct decision? Is there another code you'd use to describe this procedure? If not, does this warrant billing with modifier 22? The doctor also mentions several angiograms. How many units of 75710,26,LT can I use? On top of that, the doctor mentions that a Doppler was brought onto the field. Does this statement warrant the use of 93922,26,LT? I know the narrative says "noninvasive", so is there another code you'd use, like 37250,LT and/or 75945,26,LT, or is it just included in 35566,LT? I don't see any NCCI edits saying either of those codes are included in the bypass. As you can see, I'm extremely confused. Your assistance would be greatly appreciated. Your answers to this might help point me in the right direction with a lot of future op reports. Thanks, in advance. Here's the op report: DATE OF OPERATION: 03/29/2010 ANESTHESIA: General. PREOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. POSTOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. PROCEDURES: 1. Left lower extremity angiograms. 2. Left superficial femoral artery to anterior tibial artery bypass with composite great saphenous vein graft. 3. Angioplasty of vein graft. 4. Completion angiograms. INDICATION: This is an 88-year-old female who presented with rest pain and ischemia to the left foot with some mild motor dysfunction of her toes. The patient did undergo a cardiac evaluation. She was brought to the operating room for elective femoro-anterior tibial bypass after having undergone aortoiliofemoral and left lower extremity angiograms earlier in the week. The patient had this performed with composite nonreversed great saphenous vein graft from the left leg. Completion angiogram demonstrated areas of stenosis in the vein graft and angioplasty was performed. This was complicated by a linear tear with some extravasation in the mid thigh, which was directly repaired with interrupted stitches of 6-0 Prolene. There also did appear that the vein graft requiring a repair was an interrupted stitch of 6-0 Prolene. Completion angiograms demonstrated very good result with good caliber of the vein graft and run-off onto the dorsalis pedis artery in the foot. PROCEDURE: The patient was identified and brought to the operating room. She was placed in the supine position on the operating room table. After administration of general anesthesia by the anesthesia department, the patientâ?Ts lower abdomen, groin, entire left lower extremity, and right thigh were prepped and draped in the usual surgical sterile fashion. Attention was turned to the left lower extremity and in the distal third of the leg, a lateral skin incision was made approximately 8 cm in length. This was carried down through the skin, subcutaneous tissue, and fascia. The anterior tibialis muscle was retracted medially and the extensor digitorum longus retracted laterally. Dissection was carried down and the neurovascular bundle was identified as well as the anterior tibial nerve. The anterior tibial artery was dissected out. The Doppler was brought onto the field. The proximal portion was without evidence of flow and dissection was carried more distally to where collateral flow was heard in the artery. For this reason the incision was extended more distally. The artery was harder and calcified more proximally where it was occluded. The artery was softer more distally. A portion of the artery was dissected out where the vessel was soft and suitable caliber being 2 to 2.5 mm in diameter. Attention was turned to the left groin. Incision was carried down through the skin with the scalpel. Dissection was then carried down through the subcutaneous tissue and fascia and femoral sheath. The common femoral artery, profunda femoris, and superficial femoral arteries were identified and dissected out, and vessel loops placed. The great saphenous vein was identified. A bridge incision was made in the thigh and the dissection carried down through the subcutaneous tissue and the saphenous vein exposed. Continuous incision was then made along the medial leg and the saphenous vein was exposed along its length. Below the knee at about the proximal to mid calf, the saphenous vein became of smaller caliber dividing into two tributaries. The larger branch was followed. The vein was smaller and more disadvantaged at this site and in the distal leg, the vein then became larger again and was with good caliber to the medial malleolus. This was dissected out. As there was the disadvantage portion of vein measuring less than 2.5 mm, the plan was to do a venovenostomy to use the portion of the vein greater than 2.5 mm. For this reason, the dissection was carried farther down the superficial femoral artery proximally where it was still with good caliber with minimal disease based on the angiogram through the proximal thigh incision. Dissection was carried down through the subcutaneous tissue and fascia, and several centimeters, approximately 8 cm distalfrom the bifurcation, the superficial femoral artery was dissected out and vessel loops placed. Following this, a subcutaneous tunnel was made traversing to the lateral thigh with a gentle curve and then along the lateral aspect of the leg in a subcutaneous position and down to the distal wound. The saphenous vein was controlled at the saphenofemoral junction. The saphenous vein had been dissected out along its length, ligating and dividing the tributaries between 3-0 and 4-0 silk ties and clips on the tissue side. The dissection was routine, but on distending the vein through a tributary, which controlled the vein proximally, the vein did require repair of multiple small areas with 7-0 Prolene. The vein was clamped at the saphenofemoral junction taking a cuff of the femoral vein excising the saphenous vein and oversewing the femoral vein with 6-0 Prolene. Attention was then turned to performing the proximal anastomosis. The first vein valves were cut under direct vision. with LeMaitre valvulotome with two passes. The blood flow was pulsatile through the vein. The mid-distal third was smaller, disadvantaged as noted. Proximal anastomosis was performed by controlling the superficial femoral artery. About 5000 units of intravenous heparin was given under my direction. An additional dose was given as needed. Vertical arteriotomy was made in the superficial femoral artery and extended with the Potts scissors. The vein was used in nonreversed fashion, spatulated, and anastomosed, end-to-side using a running stitch of 6-0 Prolene. Prior to completing the anastomosis, the femoral artery was back bled and antegrade flushed. There was a good inflow. The anastomosis was then completed. It was then that the valves were cut with a valvulotome. The first two valves had been cut under direct vision. The remainder of the valves was then cut using LeMaitre valvulotome with two passes. Blood flow was pulsatile through the vein, although the smaller disadvantage segment of the vein was as noted in the mi-distal portion of the vein. The vein was then passed through the subcutaneous tunnel and brought out to the anterior tibial wound. The anterior artery was then controlled where the artery appeared of good caliber and was soft. This was opened with the #11-blade and extended with the Potts scissors. There was reasonable backbleeding in the artery as well as some antegrade flow via collaterals. Angiogram was performed, which demonstrated that this was a good site for the anastomosis with flow into the dorsalis pedis artery with the artery being of good caliber without significant stenosis. The vein length was then measured. The vein graft was then cut to remove out portion of the disadvantaged segment of vein. Venovenostomy was then performed over #8 pediatric feeding tube. When this was complete, the end of the vein was then spatulated and anastomosed end-to-side to the anterior tibial artery using a running stitch of 7-0 Prolene. Prior to completing the anastomosis of the vein graft, the artery was back bled and flushed. The artery was flushed with heparinized saline solution. The vein graft was flushed, and the air was released. The anastomosis was then completed. Flow was allowed to propagate down the foot. There was a palpable pulse in the dorsalis pedis artery in the foot and an excellent Doppler signal distal to anastomosis. The vein graft was pulsatile but still did not appear to distend fully, being on the smaller side despite excising the smaller portion. Completion angiogram was performed through a side branch just distal to the proximal anastomosis. This did demonstrate a couple areas of severe narrowing, the first being in the anterior thigh. The area was marked with a glow tape. A #5 French sheath was placed through the side branch, and a glidewire followed by angioplasty balloon was passed through the mid thigh and angioplasty was performed. On the post-completion angiogram, unfortunately there was some evidence of extravasation and cutdown was done in the mid thigh and a linear tear in the vein was directly repaired. It was also noted along the distal lateral incision and again evidence of a frail vein that the guidewire had transversed thru the vein wall. The wire was pulled back and this was repaired with a 3-0 interrupted stitch of Prolene. The wire was negotiated down the vein, and completion angiograms demonstrated also two other areas of narrowing, and the angioplasty balloon was applied lightly in these areas with excellent result on completion angiogram. Due to the presence of the sheath and the angioplasty balloon, intermittently the vein graft was flushed with heparinized saline solution. Intra-arterial papaverine had also been given due to some spasm of the artery distal to the anastomosis after controlling the vessel. The artery here is soft. Completion angiograms demonstrate excellent result of the vein graft and the distal anastomosis to be patent with the anterior tibial artery patent into the dorsalis pedis artery on the foot. The guidewire, the balloon, and the sheath were then removed from the vein and the branch stump was ligated with 3-0 silk. Flow was allowed to propagate down the vein graft into the foot. The patient did have a strong dorsalis pedis pulse as well as a palpable vein graft pulse along the lateral leg. Hemostasis at the anastomoses was obtained with thrombin and Gelfoam. Hemostasis of the subcutaneous tissue was obtained with diathermy. Attention was turned to closing the wounds when hemostasis was satisfactory. The groin wound was closed in two layers using 2-0 and 3-0 Vicryl. The skin was reapproximated with skin clips. Similarly over the SFA and proximal anastomosis, subcutaneous tissue was closed in two layers. The remainder of the saphenectomy site along the medial leg was reapproximated in one or two layers with Vicryl and the skin was reapproximated with skin clips. The lateral leg wound was closed using subdermal stitches proximally. Due to the thin subcutaneous tissue and some leg swelling, the distal portion of the incision was reapproximated using interrupted stitches of 3-0 nylon. The incisions were cleansed and sterile dressings were applied. The patient tolerated the procedure and was taken to the recovery room in stable condition.

Billing heart catheterization with 59 modifier

I have a provider that did a radial access attempts to advance the J wire into the aorta from the right radial was not successful, therefore a JR cath was advanced to the level of proximal subclavian and an angiogram was performed. Apparent that the pt had about 75-80% right sublcavian stenosis. Glide wire was advanced into the ascending aorta and the JR-4 and AL-2 multiple angulated view of the Rt and Lt coronary performed. JR-4 was used to selective engage the vein graft to the RAMUS and vein graft to the marginal and selective angiography of these grafts were performed. LIMA was patent because of competitive flow in LAD. No attempt was made initially to engage the LIMA. At this point the provider did a common femoral arterial access was obtained, LIMA cath was selective engaged into the left internal mammary, angio performed. Pigtail cat was advanced into the ascending aorta, aortic root ang was performed. AL-6 guiding cath then selectively engaged into the the Rt coronary artery, multiple agulated views of Rt coronary artery were performed. This was performed after 300mics of IC nitroprussied. Pt given ANGIOMAX bolus and drip in .014 whisper wire dilated from distal RCA to mid RCA. Drug eluting stent was then done.

My question on this case is can I bill anything for the first access that was not able to complete the heart cath?
I have one coder that feels we should bill 93459, 93459-59 or 74, G0290,93567.

The other coder feels we should bill 93459,G0290,93567 and 36216 and 75710 for the subclavian access and angio.

Any guidance you can give use on this case would be greatly appreciated.
Thank you for your assistance.
 

Code 36870

For the following case I reported codes 36831, 36147, 35475, 75962-26, 37205, and 75960-26. I was told I should use code36870, but embolectomy appeared to be open not percutaneous. I also questioned the two sheaths that were placed...can I bill for both??

"Patient presented with malfunctioning AV graft. DESCRIPTION OF PROCEDURE: The patient's left arm was sterilely prepped and draped after he received general anesthetic. Over the old graft on the distal part of the arm, a small incision was made approximately 1.5 cm. The graft was identified. An arteriotomy was performed of the graft and a 4 Fogarty was passed proximally. There was some resistance with the brachial artery anastomosis and there was poor inflow. Also, it was passed into the graft, into the subclavian vein and much thrombus was removed. After this was done, I now repaired the arteriotomy with a 5-0 interrupted Prolene. A sheath was placed in an antegrade and retrograde fashion so that crossing sheaths were in place. With the first sheath, a wire was passed over into the brachial artery. A KMP catheter was passed to prove that it was in the true lumen and then a 6 x 40 was gently insufflated across this area. A fistulogram had been previously performed that showed that there was a large amount of thrombus still present at the brachial artery anastomosis and this was softly/gently dilated. Now, there was good inflow into the graft. Through the other crossing sheath that was in place through the arteriotomy, a venogram was performed through the arm and followed centrally. The flow was very slow and sluggish. There was a high-grade stenosis at the venous anastomosis at the axillary vein within the chest. At this time, a 5 x 40 balloon was insufflated as this was a 6-mm graft. A 6 x 40 balloon expandable stent was then placed across the high-grade stenosis at the venous anastomosis. A venogram was now performed and showed that there was good flow through the graft and this was followed centrally and there was good flow into the SVC into the right atrium."

Direct Puncture Therapy

Here is a procedure that was performed that I need some assistance in correctly coding. These unusual procedures can get very confusing. 

DEVICES UTILIZED: Two separate 21 gauge micropuncture needles were utilized. PROCEDURES: 1. Ultrasound and fluoroscopically guided percutaneous access into the venous malformation in two separate areas. 2. Percutaneous venography of the venous malformation, times two. 3. Injection of Sotradecol into the lesion, three separate times, ten minutes apart. Using sterile technique, local anesthesia, general anesthesia, ultrasound and fluoroscopic guidance, two separate 21 gauge needles were placed within the lesion. Injection of contrast material was performed, demonstrating the extent of the filling of the lesion. The contrast material was then allowed to drain and the volume was replaced with Sotradecol. The Sotradecol was allowed to stand for ten minutes before attempting to remove it and reinjecting the same space with Sotradecol. This was performed twice from the first needle position and once from the second needle position. At the termination of the procedure the needles were removed, and band-aids were placed over the skin puncture site(s). The patient tolerated the procedure well, and no complications were encountered during or immediately following the procedure. FINDINGS: The first injection from the first needle placement demonstrated excellent filling of the lesion, representing the majority of the lesion, with a multi-lobulated appearance. The venous drainage was into an external jugular branch draining inferiorly. The second injection was in the most superior part of the lesion, filling the superior third. Venous drainage was as outlined above. IMPRESSION: Good filling of the lesion was achieved with Sotradecol, for purposes of sclerotherapy of the venous malformation within the substance of the left masseter, as described above.

tibial/peroneal trunk

Hi Dr. Z. I saw the errata regarding the tibio-peroneal trunk for vascular interventions: CODING INSTRUCTIONS 18. The tibial/peroneal territory includes three vessels that are separately coded: the anterior tibial, posterior tibial, and peroneal arteries. The tibial/peroneal trunk is considered part of any distal vessel intervention in the posterior tibial and peroneal arteries (similar to the left main coronary artery). The tibial/peroneal trunk is considered a separate vessel from the anterior tibial artery. The dorsalis pedis is considered part of the anterior tibial artery, and the medial malleolar artery is considered part of the posterior tibial artery. However, the SIR 2011 updates state this: 3 Tibial/peroneal territory: subdivided into anterior tibial, posterior tibial and peroneal a 37228–37235 b Report the initial vessel treated as the primary code for the highest level of service provided within the tibial-peroneal territory with addon codes for additional vessels treated (not additional lesions or procedures in the same vessel) c The tibioperoneal trunk is not considered a separate vessel So now I am confused. The CPT books says: “The common tibio-peroneal trunk is considered part of the tibial/peroneal territory but is not considered a separate, fourth segment of vessel in the tibio-peroneal family for CPT reporting of endovascular lower extremity interventions. For instance, if lesions in the common tibio-peroneal trunk are treated in conjunction with lesion sin the posterior tibial artery, a single code would be reported for treatment of this segment.” Is this where you are getting the information in your errata....and counting the tibioperoneal trunk lesion as a separate vessel from an anterior tibial vessel lesion? I just want to be sure where it came from as my staff are going to want to know given the SIR advice. Thanks again. I know if anyone has the answer it is going to be you!

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. - -

37227

Per new CPT coding rules If pt has fem pop intervention and a Fem Pop graft intervention. would you still consider this to be one vessel for Native and graft? I am including the report. Thank you for your consideration. ************************************************************** 1. Left common femoral artery retrograde access. 2. Aortoiliac angiography. 3. Right lower extremity runoff. 4. Atherectomy of the right distal common femoral artery as well as the right profunda femoris artery, followed by balloon angioplasty. 5. Atherectomy using Jetstream device of the femoral-popliteal graft, followed by balloon angioplasty and stent placement in the proximal as well as distal portions of the graft with the stent extending into the right popliteal artery. 6. Monitoring of conscious sedation by a trained observer for 3 hours. 7. Complex peripheral intervention with greater than 30 minutes per vessel segment, requiring multiple catheter and wire exchanges and extra thought process. INDICATIONS FOR THE PROCEDURE: The patient is a 59-year-old male who has a history of intermittent claudication. For this, he had recently undergone balloon angioplasty for in-stent restenosis of the right external iliac stent. He did not experience significant relief of his claudication symptoms and requested further intervention to the right leg. He has a known history of femoral-popliteal graft in 2007, which is known to be occluded. Prior to the procedure, I discussed the risks, benefits, alternatives, and complications of the procedure with the patient, including somewhat high risk of complications due to his high-risk anatomy, and he was in agreement to proceed. ANESTHESIA: Moderate sedation administered with a trained independent observer in attendance to monitor the level of consciousness and physiological status for a total of 3 hours. Please see procedure log for all drug administration and monitoring data and further information. Conscious sedation with local anesthesia. DESCRIPTION OF PROCEDURE AND FINDINGS: The planned procedures were explained to the patient in detail including all pros, cons, risks, benefits and all possible complications including and not limited to death, myocardial infarction, retroperitoneal bleed, CVA, hemorrhage, limb loss, renal failure, the need for renal dialysis, blood transfusions, emergency surgery, emergency endovascular angiography with treatment of unanticipated vascular disease or vascular complications, use of antibiotics, consultations with other physicians and use of all accepted surgical/medical modalities for the benefit of the patient. The patient understands and verbalizes and agrees to proceed with the planned procedures. All exclusion criteria have been met to be able to do this procedure as an outpatient procedure. TECHNIQUE: Left common femoral artery access was obtained using a 4-French sheath. Office Procedure A 4-French UF catheter was passed into the contralateral left external iliac artery after obtaining aortoiliac angiography. After this, right lower extremity runoff was obtained. We then exchanged for a 7-French Terumo 65 cm Destination sheath over an Amplatz wire. The patient was heparinized. A slime wire and a 4-French IMA catheter were used to advance the catheter into the profunda femoris artery. We measured the pressure in the profunda femoris artery, and this was 40 mmHg without much pulsatility, indicative of the severe stenosis at the ostium of the profunda femoris as well as the distal common femoral artery. We exchanged out for a Platinum Plus 0.014-inch wire and performed SilverHawk atherectomy with an LS device using 4-quadrant atherectomy in the distal common femoral artery as well as the profunda femoris artery. This achieved excellent results with good flow down the profunda femoris artery. There was some residual stenosis which was treated using a 6 x 40 LP 0.018 balloon, inflated up to 2 atmospheres. Stenosis in the common femoral artery and the profunda femoris artery was reduced to less than 30%. After this, we used a 4- French angled CXI catheter and a slime wire to cross the occluded portion of the femoralpopliteal graft. We were eventually able to get through with a stiff shaft glidewire. The glidewire was advanced to the distal anastomosis. However, we were subintimal in the very distal popliteal artery. This eventually required an Outback catheter to perform reentry to the popliteal artery. We then attempted to pass a 5 x 80 balloon. However, we were unable to pass this through the site of reentry. We exchanged out for a coronary 3 x 30 balloon, which were able to cross and inflate it. We performed multiple inflations with this balloon. After this, there was still significant amount of thrombus visualized in the entire grafted segment. We switched for a Jetstream device and performed atherectomy with a 2.1 mm Pathway Jetstream catheter. This was performed after exchanging through a Platinum Plus wire. TPA was added to the infusion, and multiple runs were performed with the blades up and blades down to achieve adequate lumen. There was still slow flow due to resultant stenoses in the distal graft segment as well as the popliteal vessel and the proximal graft segment as well. We ballooned these areas with a 7 x 40 balloon. We then attempted to deploy a 6 x 80 IDEV Supera stent in the popliteal vessel extending into the grafted segment. However, the stent was under-deployed in the site of reentry as well as in the proximal grafted segment. Therefore, the stent was removed. We then exchanged out for an 8 x 80 self-expanding stent. We had to perform predilation again using a 6 x 40 Cook balloon. The stent was successfully deployed in the distal popliteal segment extending into the distal portion of the graft. We also put another 8 x 80 overlapping with a second 7 x 80 stent in the proximal portion of the graft. After this, the under-expanded areas within the stent were post dilated using a 7 x 40 mm balloon. There was still persistent under-expansion in the overlapped segment in the proximal graft. This was treated using a 7 x 40 V-access balloon, which achieved adequate expansion. Final angiographic runoff showed that we had excellent patency of the common femoral artery as well as profunda femoris artery and brisk flow down the femoral-popliteal graft into the popliteal vessel. There was preserved flow down to the trifurcation into the foot. There was some decreased flow in the very distal dorsalis pedis, which petered down. DETAILED FINDINGS OF DIAGNOSTIC ANGIOGRAPHY: 1. Aortoiliac angiography: The distal abdominal aorta as well as bilateral, common, and external iliac arteries are patent with mild-to-moderate disease. The previous site of angioplasty is widely patent. 2. Right lower extremity runoff: The right common femoral artery has a distal 90% stenosis, followed by 90% stenosis in the ostium of the profunda. The entire SFA, including the femoral-popliteal graft, is occluded with reconstitution of the popliteal by collaterals. There is preserved 3-vessel runoff to the foot. SUMMARY: 1. Atherectomy of the right common femoral artery into the profunda femoris artery, followed by balloon angioplasty with achievement of excellent results. There was some diffuse 30% to 40% disease in the common femoral artery proximal to this. 2. Atherectomy with the Jetstream device of the femoral-popliteal graft, followed by angioplasty and stent placement with restoration of brisk flow down the graft. 3. Three-vessel runoff to the foot with occlusion of the very distal dorsalis pedis vessel.

Congenital Cardiac Catheterizaion

Good Morning Dr Z, once again I need your help in determining the correct way to code/bill this procedure. We coded 93799, 93544, 75774, 36215,75898 and 37204. Can we code 36215 for the selective catheterization for the AP collateral off of the aorta? I attended one of your Webinar's (which was wonderful) and you addressed the issue of collateral catheterization, but I cannot remember just what you said about these when a HC is done. ~thanks Catheterization for PDA occlusion. Procedure Note: A complete right and left heart cardiac catheterization was performed. All the appropriate chambers and vessels were entered, including SVC, RA, RV, MPA, LPA, LV, AAO and DAo. Oxygen saturations and pressure measurements were obtained by standard catheterization technique. After the hemodynamic data was obtained, a pigtail catheter was advanced to the base of the distal aortic arch and a descending aorta gram was performed. The PDA was identified. There was a moderate-sized PDA that tapered to approximately 2mm at the pulmonary artery insertion site. The geometry was suitable for a ductal occluder. We also noticed a very prominant bronchial collateral supplying the right lung which was felt to be hemodynamically significant and also likely require intervention. We then proceeded with the occulsion of the PDA usinga 6-French delivery sheath. By way of the right femoral vein, over a wire, we positioned the delivery sheath in the descending aorta. We loaded a 6/4 ductal occluder in the usual fashion and deployed the device. We then performed an angiogram with the device still attached to the delivery cable. It was in excellent position fo released in the usual fashion. We then turned our attention to the AP collateral. Using a 4-French angled Glidecatheter, we engaged the collateral which was just to the right of the PDA. We then performed select hand injection in the collateral. There was a very prominent collateral that supplied both the right middle and right lower lobes of the right lower lind. Measured 2 mm in diameter. We selected a 2x3 diamond shaped Vortex coild with the microcatheter positiioned deep in the AP collateral we depolyed in the usual fashion, followed by a 3mmX6cm.

Iliac angioplsty with EVAR placement

Dear docs-I was hoping you could help with when can you charge ballooning the iliac for an EVAR placement (and anything else I might be missing)Can I charge 37220 for stenosis when I am not sure that this isn't just for the clearing the way for deployment? And is there really an extension being placed? (including preop discussion, hopefully that helps) In the office in the preoperative area, we had a discussion with the patient regarding the difficult nature of the aneurysm including poor iliac access, high-grade stenosis of the iliac and the need for fem-fem bypass graft. We explained the creation or placement of an aortomonoiliac bypass graft with a fem-fem crossover. Bilateral groins were opened in a vertical fashion. We dissected down to the common femoral, profunda femoris, superficial femoral artery junction. 34812-50 I cannulated the right common femoral artery without complications or difficulty and inserted a wire into the aorta. This was followed by a sheath, flush catheter and then the wire was switched out for stiff wire. Catheter and wires were removed as needed to perform angiography. Please recall that the left common iliac artery is completely occluded. 36200-59RT We performed balloon dilatation of the external iliac artery prior to deployment of the stent graft. 37220-LT The patient was heparinized prior to any ballooning and we planned for the placement of a distal extension and this was carried out by placing a 1610 limb with 124 length in the aneurysm sac and out into the common iliac artery through preexisting stents. 34825/75953-26 A 20 20, 82 limb was then placed with sufficient overlap with the 10 16, 124 graft and finally an Endurant cuff, which was a 32 32 x 49 was placed in an infrarenal location. 34802-75952-26? Completion angiography demonstrated patent renal arteries bilaterally, no evidence of endoleak and widely patent aorto-mono-iliac bypass graft. Having this in mind, we removed the wires, catheters and sheaths and tunneled a piece of 8 mm ringed Gore-Tex from one incision to the other, created arteriotomies on the common femoral arteries and performed anastomosis of the end of the 8 mm bypass graft to the side of the common femoral artery with 6-0 Prolene suture. 34813 thank you so much for your expert opinion!!

Thoracic Aortic Injection

I'm not sure what I should bill for the following:

INDICATIONS: This lady had a stent-assisted coil embolization of left cervical ICA. This is a follow-up angiogram. Benefits and risks were discussed in detail with the patient, including bleeding, femoral artery injury, loss of blood supply to the leg, loss of the leg, dissection of the aorta, stroke, TIA, and dissection of the carotid and benefits. The patient consented procedure and was brought to the operative room. DESCRIPTION OF OPERATION/PROCEDURE: The patient was brought to the operative room by the Neuro Anesthesia team. Monitored aesthetic care was induced in supine position. All the pressure points were padded appropriately. The groin was prepped and draped in the usual sterile fashion. Lidocaine was injected along the right groin crease. Skin knife was used to make 2 mm skin incision. Eighteen gauge needle and single wall technique was used to access the right common femoral artery. 5 French sheath was placed over the guidewire provided. Using 5 French Berenstein diagnostic catheter and Terumo 038, multiple coils vessels were imaged. FINDINGS: Right common femoral artery selective injection: The right common femoral artery was selected. The catheter was advanced in it. AP view showed the internal iliac artery, right common femoral artery, right superficial, and profunda femoral arteries to have normal caliber and branching. The puncture site was appropriate for Angio-Seal device deployment. Common iliac selective injection: The right common iliac was selected. The catheter was advanced in it. AP view showed there was a possible dissection of the common iliac artery. Thoracic aortic injection. Thoracic aortic injection. The catheter was kept in the thoracic aortic area. An injection was noted that there is a dissection. At that time, the patient was complaining of chest pain and we consulted the Vascular Surgery and Cardiothoracic. The patient was then intubated and a TEE was performed to ensure there was no dissection of the ascending aorta or the arch. Following that, the patient was transferred to the CT for obtaining a CT of the chest and abdomen. Also, we sent for labs to make sure there is no troponin increase or worsening of the creatinine. I applied manual compression for 15 minutes.

Echo requirements

In reveiwing the two Echo interps below, I don't see documentation to support that the pericardium was evaluated. Per CPT guidelines, that is the only thing I see that is lacking in order to bill each of them as a complete Echo. Am I missing it? Thanks so much for your help! 1st Patient Example Indications for Study:TETRALOGY OF FALLOT. 745.2, F/U Procedures:CONGENITAL COMPLETE W/ DOPPLER AND COLORFLOW, Congenital Echo, Doppler and Color, Ekg, Colorflow Mapping, Echo Congenital Limited, Intracardiac Doppler Race:Caucasian Session ID: ************************************ SUMMARY: ************************************ Poor acoustic window. s/p repair of Tetralogy of Fallot, pulmonary atresia. with unifocalization. S/p bilateral branch PAs stent. H/o para-aortic abscess. s/p RV to PA conduit replacement. Stable paraaortic abscess pouch, unchanged from the previous study. Mild aortic regurgitation, stable. No residual VSD. No RVOT Doppler interrogation. Trivial regurgitation. Unobstructed flow through the steneted branch PAs. Mild dilatation of right ventricle with qualitatively normal systolic function. Normal LV systolic function. Atria: Situs: Solitus. RA Size: Normal. LA Size: Normal.Septum: Normal Defect sz. None. Shunt: None. Ventricles: D-looped LV size: Normal. LV function:Normal. Rv size: Dilated. RV function: Normal. IVS: Motion: Normal. Defect Type/Size: None./None. Shunt: None. ___________________________________________________________________________________________________ Grt Vessls: Normal. Aortic Root: Normal. MPA: RV-PA conduitLPA: StentedRPA: Stented Coarctation: No. PDA: No. Shunt:None. Coronaries: NOT VIEWED Systm Veins: SVC: Normal. IVC: Normal. Pulm Veins: Visualized: 2/4. Connections: 2/4 visualized ___________________________________________________________________________________________________ Mitral Valve: Structure: Normal. Stenosis: No. Regurgitation: No Tricuspid Valve: Structure: Normal. Stenosis:No. Regurgitation: Mild , estimated RVSP 40 mmHg+RAp. Pulmonary Valve: Structure: S/P HOMOGRAFT Stenosis: Not interrogated Regurgitation: Trivial. Aortic Valve: Structure: Normal. Stenosis: No. Regurgitation: Mild ************************************ MEASUREMENTS: ************************************ MMODE Left Ventricle LVIDd 5.29 cm (3.81-4.63)* LV%fs 37.8 % (28-40) LVIDs 3.29 cm (zsc -0.08) 2nd Patient Example ************************************ SUMMARY: ************************************ Limited subcostal views LV normal size and systolic function Atria: Situs: Solitus. RA Size: Normal. LA Size: Normal.Septum: Limited views Defect sz. None. Shunt: None. Ventricles: D-looped LV size: Normal. LV function:Normal. Rv size: Normal. RV function: Normal. IVS: Motion: Normal. Defect Type/Size: None./None. Est. LV-RV Press. Gradient:____mmHg. Shunt: None. ___________________________________________________________________________________________________ Grt Vessls: Normal. Aortic Root: Normal. MPA: Normal. LPA: Normal.RPA: Normal. Coarctation: No. Type: _____. Est. Pressure Gradient: _____mmHg. PDA: No. Shunt:None. Coronaries: Normal LCA, RCA origin not seen Systm Veins: SVC: Not viewed IVC: Not viewed Pulm Veins: Visualized: 2/4. Connections: Normal. ___________________________________________________________________________________________________ Mitral Valve: Structure: Normal. Stenosis: No. Regurgitation: No. Mitral 1/2 time____. Tricuspid Valve: Structure: Normal. Stenosis:No. Regurgitation: Trivial Est. RV pressure_____.+ RAp. Pulmonary Valve: Structure: Normal. Stenosis: No. Mean ___mmHg, Peak___mmHg. Regurgitation: No. Aortic Valve: Structure: Normal. Stenosis: No. Mean ___mmHg, Peak___mmHg. Regurgitation: No.

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.

EP Possible Parent Coding 93653 and 93654

Below is a report from one of our physicians. Both coders disagree on the coding, and I would like your input, as it involves parent codes 93653 with 93654. Coder #1 reported codes 93654 and 93623. Coder #2 reported codes 93653 and 93621.

PREPROCEDURE DIAGNOSIS Supraventricular tachycardia. POSTPROCEDURE DIAGNOSIS Typical atrioventricular nodal reentrant tachycardia. PROCEDURES PERFORMED 1. Comprehensive electrophysiology study with coronary sinus pacing and recording. 2. Arrhythmia indJction. 3. Drug infusion with isoprotereno~ 4. ~electroanatomic mapping. 5. Radiofrequency ablation of typical AV nodal reentrant ta~rdia with modification of the AV nodal slow pathway. HISTORY OF PRESENT ILLNESS This is a 61-year-old female ~.~tmedical history significant for recurrent frequent episodes o~dpalpitations. The patient had a recent visit to the hospital at Flagler where she was noted to have heart rate of approximately 200 beats per minute, which terminated with adenosine. The patient now presents to electrophysiology laboratory for further evaluation and management. DESCRIPTION OF PROCEDURE The patient was brought to electrophysiology laboratory and appropriately identified on the table. Twelve-lead ECG electrodes were placed in the patient and vital signs were recorded at baseline. A conscious sedation was administered by the nursing staff with intravenous fentanyl and Versed. The patient was prepped and draped in standard sterile fashion. Sheaths were inserted using modified Seldinger technique as indicated below. Catheters were then subsequently advanced to the sheath and placed in the heart under a cardiac fluoroscopy. Baseline intracardiac recordings were obtained followed by standard EP study. During the entire procedure, the patient's vital signs were continuously monitored, remained stable. Details of the EP study and subsequent ablation were outlined below. The patient remained hemodynamically stable and com£ortable throughout the en~ire procedure. At the conclusion of the procedure, all catheters were removed from the heart and woa~d sites were then dressed and the patient wls transferred to t~e Recovery Room '£~ea in stable condition. The postoperative orders were wfitten at that t~e. ; SUPPLIES < Diagnostic catheters were placed at the level of the high right atrium, His, right ventricular apex. A diagnostic catheter was also placed in the main body of the coronary sinus. A 4-mm radiofrequency ablation bidirectional catheter was used for right atrial mapping and ablation. BASIC EP STUDY FINDINGS 1. The AH interval was 101 msec, the HV interval was 39 msec. 2. The VA Wenckebach cycle length was 360 msec at baseline. The right ventricular effective refractory period while pacing from the right ventricular apical catheter was 220 msec at a pacing cycle length of 600 msec. 3. The AV Wenckebach cycle length was 400 msec while pacing from the high right atrial catheter. 4. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec. ARRHYTELl\,fIA AND ABLATION The patient presents to the electrophysiology laboratory in normal sinus rhythm. Following administration of conscious sedation, we proceeded with a basic EP study. The patient had normal EP study findings at baseline. Upon insertion of the catheter, she immediately went into a spontaneous supraventricular tachycardia. The tachycardia was typical AV nodal reentry for the following reasons. 1. The septal VA t~~e during SVT was approximately 0 msec, making typical AV nodal reentry the likely diagnosis. 2. The SVT tachycardia cycle length was 410-420 msec. 3. During a right ventricular apical pacing, the atrial activation sequence in the coronary sinus catheter was concentric, making left lateral pathway and AVRT unlikely. 4 .. During SVT, entrainment from the right ventricular catheter revealed a VAHV response to pacing, making atrial tachycardia unlikely. 5. During supraventricular tachycardia, right ventricular entrainment revealed a post-pacing interval minus tachycardia cycle length of 145 msec, making AV nodal reentrant tachycardia the likely diagnosis. 6. His-synchronized ventricular premature depolarizations during SVT did not reveal the presence of a septal bypass tract and was not able to the atrium. The patient had easilY sustained episodes of supraventricular tachycardia, which were spontaneous and also reproducible with both ventricular and atrial extrastimuli from the high right atrial, coronary sinus, and right ventricular catheters. We observed both echo beats and sustained tachycardia. At this t~~e, we proceeded with modification of the AV nodal slow pathway. The ablation catheter was positioned across the posterior septum just posterior t{ i the coronary sinus ostia. 3D electroanatomic mapping prior to this was used to identify the dehisced as well as the coronary sinus ostia. Ablation catheter was positioned across the tricuspid valve annulus with an A-V ratio of approximately 1-4. Using power controlled settings of 50 watts and 55 degrees under temperature, serial ablation was performed in this area. We monitored the AH and HV intervals during this time and a junctional ectopy was observed throughout the duration of these lesions. At final conclusion of my ablation, I rechecked the patient for dual AV nodal physiology. No sustained tachycardia was observed. Isoproterenol w~started up to 2 mcg per minute and no evidence of inducible SVT was no~ecr. With frequent atrial and ventricular extrastimulus pacing, the patient did have 1 echo beat with atrial extrastimuli; however, with continued decremental pacing on our extrastimulus beat, the patient would block on the subsequent beat. At this time, this was considered an acceptable endpOint as the patient previous to my ablation had easily inducible SVT. After waiting period, we attempted arrhythmia induction again and SVT was no longer observed. At this time, the procedure was terminated. AH and HV intervals remained stable and comparable to baseline. The postablation AH and HV intervals were 85 and 42 ITsec respectively. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec at this time. The catheters and the sheaths were then removed from the heart and body. Hemostasis was achieved. The patient made a complete neurologic and hemodynawic recovery. CONCLUSIONS 1. Normal EP study findings. 2. Typical AV nodal reentrant tachycardia. 3. Successful ablation of typical AV nodal reentrant tachycardia with modification of the AV nodal slow pathway.