Ask Dr. Z

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.