Ask Dr. Z

Good afternoon, Dr. Z. I'm having a warm time with this op report. The surgeon makes mention of a duplex, several different angiograms, and several different views and projections. I'm not sure if I should bill an ultrasound service for the duplex, any additional radiological services for the views and projections, or how many angiograms I should bill for. On top of that, she mentions angioplasties and stents in the heading, but according to the narrative of the body, I feel as if the coding of the stents is all that's appropriate. Please, help. Thanks, in advance. So far, I've coded 37205,RT, 37206,LT, 75960,26,RT, 75960,26,LT, 75716,26, 75625,26, 75710,26,59,LT, and 75774,26,RT. The dxs are 440.22 (I upgraded from 440.21 because of the surgeon's mention of possible rest pain in the body of the report), 996.74 (I'm not sure if 996.1 fits better to describe the fact that the distal anastomosis of the previous fem-pop bypass can't be demonstrated, due to the knee replacement), 709.2, and v43.65. Here's the op report: DATE OF OPERATION: 03/25/2010 ANESTHESIA: Conscious sedation and local anesthesia. PREOPERATIVE DIAGNOSIS: Atherosclerosis with claudication right le POSTOPERATIVE DIAGNOSIS: Atherosclerosis with claudication PROCEDURES: Via Left common femoral artery approach: 1. Aortogram. 2. Aortoiliofemoral angiogram. 3. Selective right lower extremity angiogram. 4. Nonselective left lower extremity angiogram via the left common femoral artery sheath. INTERVENTIONS: 1. Angioplasty, of severe greater than 90% focal stenosis at the junction of the distal left common iliac and external iliac artery, angioplasty with 8 mm x 40 mm angioplasty balloon. 2. Angioplasty/stent placement of proximal right external iliac artery, severe greater than 90% focal stenosis with 8 mm x 36 mm Valeo balloon expandable stent. 3. Placement in the distal left common/proximal left external iliac artery, a 10 mm x 40 mm nitinol self-expanding stent and finally completion lower extremity angiograms. PROCEDURE: The patient was identified and brought to the catheterization suite. She was placed on supine position on the table. Bilateral groins were prepped and draped in the usual surgical sterile fashion. The left common femoral artery was accessed with the micropuncture needle. There was evidence of some dense scar tissue at the site of the previous groin incision. Micropuncture sheath was placed followed by a short 5-French sheath over the introducer wire. There was some resistance of the wire at the level of the left common iliac, so this was not traversed further. Retrograde angio was performed thru the sheath demonstrated severe focal iliac stenosis. Once the 5-French sheath was in place, we were able to negotiate through a left common iliac stenosis with a glidewire in conjunction with a Glidecath. Omniflush catheter was then placed at L1. Aortograms were performed. The Omniflush catheter was pulled down to distal aorta and the aortoiliofemoral angiograms were performed. This demonstrated a severe greater than 90% stenosisl, focal, at the junction of the distal common iliac/ left external iliac artery. This was pre-dilated with an 8 mm x 40 mm angioplasty balloon. Oblique projections were performed. This was done as attention was to be directed first to completing angiograms of the symptomatic right leg with possible intervention. There was evidence of known bypass graft coming off the mid-external iliac artery. Below the level of the bypass, there was severe disease of the distal left external iliac artery and severe disease of the common femoral artery with sheath nearly occlusive. The aorta was patent without significant disease. In the right iliac system, the proximal common iliac artery was patent as was the external iliac artery. There was question of stenosis also at the level about at the right distal common and external iliac artery with the internal iliac artery at that site, oblique projections needed to be done for further evaluation. There was moderately severe disease at the distal external with severe stenosis right crossing the inguinal ligament and moderate disease of the proximal right common femoral artery. Oblique projections of the right iliac system demonstrated a severe stenosis, focal greater than 90% of the proximal external iliac artery. This was able to be traversed with an 0.018 Whisper wire in conjunction with a Glidecath, which was positioned on the distal right external iliac artery. Right lower extremity angiograms were performed. The profunda femoris was open and the proximal superficial femoral artery was open and then occluded in its proximal portion. Via collaterals, the popliteal artery reconstituted at the level of tibial plateau. The patient had bilateral knee replacement, and so there was difficulty in completely demonstrating the popliteal artery. The popliteal arteries were evaluated with 2 views with maximal obliquity, demonstrating the majority of the vessel. This was correlated with duplex therefore and the flow was brisk to the popliteal artery and visualized the portions were without irregularity with good diameter to the below-knee popliteal artery. There was severe tibial vessel disease in the right leg. Tibioperoneal trunk was patent. The posterior tibial and peroneal arteries were occluded at approximately 5 cm and 10 cm. The anterior tibial artery was patent with mild-to-moderate disease in its proximal portion. The popliteal artery via collaterals was recanalized at the level of the mid tibial plateau of the femur. There was good luminal caliber to the popliteal artery where it reconstituted to the infrapopliteal segment and the flow was brisk, but a small portion of the midportion was not able to be demonstrated. This is correlated with the duplex which does not suggest any mid-popliteal stenosis. There was mild-mod irregularity of the terminal popliteal artery. Tibioperoneal trunk is patent. There is severe tibial vessel disease. The peroneal artery and posterior tibial arteries were then occluded after the first proximal 5-cm. The anterior tibial artery is patent with mild-to-moderate disease origin and then demonstrates mild disease and is patent where it becomes more diminutive as the dorsalis pedis artery onto the foot with very diminutive and incomplete plantar arch. The plan for the right leg done in this patient with claudication symptoms and question of developing some rest pain was some discomfort now in her toes which is new, is to treat the greater than 90% right external iliac artery stenosis and then based on re-evaluation of her sx to perform right common femoral artery endarterectomy with endarterectomy/angioplasty of the distal external iliac and possible right common femoral artery to ATA artery bypass with better views of the popliteal artery in the OR. The 0.018 Whisper wire was tracked back through the Glidecath and positioned on the distal right external iliac artery. The Glidecath was pulled back to the proximal right common iliac artery. A copilot was attached to the Glidecath and a hand injection was performed and the proximal right external iliac artery stenosis was located. Stiff glidewire was placed in the CFA. Right severe EIA stenosis was then treated with an 8 mm x 40 mm balloon expandable Valeo stent. Completion angiograms demonstrated very good results. Following this, the guidewire was tracked back into the aorta and this was exchanged for a SupraCore wire. A SuperCore wire was then placed in the aorta via the left iliac system. Angiogram was performed and the left iliaclesion was marked. The severe stenosis of the distal left common iliac, junction of the external iliac artery was then treated with a 10 mm x 4 mm nitinol self-expanding stent. Completion angiogram demonstrated excellent result. after the stent was postdilated with a 10 mm x 40 mm balloon. Following this, the Omniflush catheter was tracked over the wire and the completion angiograms were done through the Omniflush catheter in the distal aorta, both iliacs with excellent results and 0-10% residual stenosis of the proximal right external iliac and the left distal common/proximal left external iliac artery lesion. Following this, guidewire was tracked back to the Omniflush catheter and both were removed via the left common femoral artery sheath. I should mention that 5000 units of intravenous heparin was given under my direction and an additional dose was given and ACT monitored throughout the procedure. Now via the left common femoral sheath, left lower extremity angiograms were performed. This demonstrated the distal common femoral artery to be either occluded or the sheath occluding the artery so that the common femoral and profunda were not demonstrated. The bypass graft was demonstrated and was patent. There was one area of some mild narrowing, which did not appear significant in the proximal third of the thigh, which may be from some mild compression of the muscle. This appeared to be less than 30%. The bypass graft was patent and was anastomosed to the popliteal artery. The distal anastomosis of the fem-pop bypass graft is not demonstrated with the knee prosthesis despite the maximal oblique projection. Runoff is via the anterior tibial with moderately severe disease approximately 5-cm in the proximal anterior tib and then severe greater than 99%, functional occlusion of the anterior tibial in its mid section. The distal anterior tibial artery was of better caliber and patent onto the foot and the dorsalis pedis artery is extremely diminutive on the foot. The patient tolerated the procedure. At the completion of the procedure, she was taken to the recovery room in stable condition and the sheath is to be pulled when the ACT is less than 180.