CIRCC, CPC- H, CCC, CCS, RCC

Transcription

1 Peripheral Procedures in the Cardiac Cath Lab Na#onal AAPC April 2, 2012 Presented by: David Zielske, MD CIRCC, CPC- H, CCC, CCS, RCC Agenda Peripheral Diagnos4c Angiography: Renal, Visceral, Extremity, Caro4d and Pulmonary Angiography IVC Filter Placement, Reposi4oning, Removal Peripheral Interven4ons: Angioplasty, Atherectomy and Stent Placement Thrombolysis, Thrombectomy, IVUS Combined Complex Cardiac and Peripheral Examples 2 1

2 DiagnosAc Imaging of the Arterial System Renal Angiography 3 Non- selecave Renal and Variant Renal Arterial Anatomy First order Second order Third order 4 2

3 2012: DiagnosAc Renal Angiography Unilateral selec1ve renal angiography Bilateral selec1ve renal angiography Unilateral superselec1ve renal angiography Bilateral superselec1ve renal angiography These new codes include all catheter placements, all accessory renal artery selec4ons, all contrast injec4ons (including C02), imaging, post- processing of images (including 3D), abdominal aortography, pressure gradients, fluoroscopy, moderate seda4on and closure device placement. (Superselec4ve refers to second order or higher selec4on and all addi4onal selec4ons in that trunk.) : Renal Codes Use or for horseshoe kidney (when half or all of the kidney is selected and imaged respec4vely). Use and when unilateral selec4ve angiography is performed on one side and super- selec4ve catheter placement and angiography is performed on the other side. Do NOT code for addi4onal selec4ve renal angiography of accessory renal arteries in (Code is s4ll valid for other loca4ons, e.g., external caro4d branches, visceral branches.) Catheter placement codes are bundled in 2012 with the renal diagnos4c codes BUT can use them for renal interven4on without diagnos4c selec4ve renal angiography. 6 3

4 Renal Angiography Case 1: Non- selec4ve bilateral renal arteriogram with pigtail catheter placement in aorta (without heart cath) 7 Renal Angiography Case 2: Non- selec4ve bilateral renal arteriogram with pigtail catheter placement in aorta (with heart cath) 8 4

5 Renal Angiography Case 3: Le^ heart catheteriza4on with na4ve coronary angiography, followed by selec4ve bilateral renal angiography. The catheter is placed in each main renal artery for contrast renal angiography a^er non- selec4ve CO2 abdominal aortography. Pa4ent has history of uncontrolled malignant hypertension. 9 Renal Angiography Case 4: Unilateral right renal arteriogram with catheter placement in the main renal artery, two accessory right renal arteries off the aorta and one accessory off the right common iliac. 10 5

6 Renal Angiography Case 5: Abdominal aortography with pigtail catheter shows bilateral 95% renal artery origin stenosis. 3mm balloons are used to predilate the lesions. This is followed by deployment of 6mm balloon deployable stents across the residual stenoses. 11 Renal Angiography Case 6: History: 28 year old with malignant hypertension. Bilateral selec4ve renal angiography is performed. On the le^ there appears to be intra- renal FMD stenosis. The catheter is advanced to the second order anterior division for further evalua4on. A 90% stenosis due to an FMD web is seen. This is treated successfully with a 4mm balloon. 12 6

7 Non- selecave First order Second order Third order 13 Visceral and Renal Arterial Anatomy Transfemoral Approach Visceral Angiography Case 7: Abdominal aortogram from a brachial approach shows a 95% proximal SMA stenosis. The celiac and inferior mesenteric arteries are occluded. Guiding sheath is placed into the SMA followed by 6mm angioplasty. Dissec4on with occlusion requires placement of a 6mm stent resul4ng in a widely patent vessel. 14 7

8 Non- selecave Visceral and Renal Arterial Anatomy Transfemoral Approach First order Second order Third order 15 Visceral Angiography Case 8: Aorto- ilio- femoral angiography (abdominal aorta and pelvic obliques) followed by selec4ve catheter placements and imaging of the right and le^ renal, celiac, superior and inferior mesenteric arteries. 16 8

9 Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selecave First order Second order Third order Antegrade Right Femoral Approach Retrograde Right Femoral Approach 17 Lower ExtremiAes Case 9: Abdominal aortography from high catheter posi4on and oblique pelvic angiography from low aor4c catheter posi4on for aor4c aneurysm evalua4on. 18 9

10 Non- selecave Visceral and Renal Arterial Anatomy Transfemoral Approach First order Second order Third order 19 Lower ExtremiAes Case 10: Abdominal aortography from high catheter posi4on (to look at renals) and oblique pelvic angiography from low aor4c catheter posi4on, (to look at iliacs and proximal femorals) all done during a le^ heart cath

11 Lower ExtremiAes Case 11: Abdominal aortography with run- offs from one catheter posi4on (or they forgot to men4on any catheter movement between exams!) 21 Lower ExtremiAes Case 12: Catheter posi4on to the abdominal aor4c bifurca4on with oblique pelvic angiography (abdominal aorta findings are limited or not men4oned while the iliac and femoral arteries are fully described) 22 11

12 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Femoral Approach Retrograde Right Femoral Approach Non- selecave First order Second order Third order 23 Lower ExtremiAes Case 13: Abdominal aortography from high catheter posi4on (at the level of the renals) and run- offs from low catheter posi4on (aor4c bifurca4on)

13 Lower ExtremiAes Case 14: Abdominal aortography followed by catheter reposi4oning to the bifurca4on, oblique views of the pelvis for iliofemoral angiography, selec4ve catheter placement to each common femoral with selec4ve unilateral run- offs to complete the study. 25 Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selecave Antegrade Right Femoral Approach Retrograde Right Femoral Approach First order Second order Third order 26 13

14 Lower ExtremiAes Case 15: Abdominal aortography high catheter placement. Complete run- offs to the feet a^er catheter reposi4oning to the aor4c bifurca4on, followed by addi4onal selec4ve imaging a^er selec4on of contralateral common femoral and ipsilateral common femoral arteries. 27 Lower ExtremiAes Case 16: Abdominal aortography high catheter placement. Complete run- offs to the feet a^er catheter reposi4oning to the aor4c bifurca4on, followed by addi4onal selec4ve imaging a^er selec4on of le^ and right common femoral arteries from a le^ brachial approach

15 29 Lower ExtremiAes Case 17: Pa4ent with right ax- fem, fem- fem x- over bypass gra^s. Via direct puncture of the ax- fem gra^, a catheter was advanced into the subclavian artery, then the aorta for subclavian inflow angiography, followed by advancement to the renal level for abdominal angiography, then pulled back for imaging down the ax- fem gra^ and both lower extremi4es. Both anastomoses of the ax- fem gra^ are balloon dilated for stenoses

16 Non- selecave First order Second order Third order Normal Arch Arterial Anatomy - Detailed Transfemoral Approach 31 Non- selecave First order Second order Third order Variant Arch Anatomy Bovine Transfemoral Approach 32 16

17 AorAc Arch Anomalies Type I arch. The arch vessels arise from the outer curvature of the arch in the same horizontal plane (no angula4on). The ver4cal distance from the origin of the innominate artery to the top of the arch is < 1 diameter of the le^ common caro4d artery (CCA). Type II arch. The arch vessels arise between the parallel planes delineated by the outer and inner curves of the arch (moderate angula4on). The ver4cal distance from the origin of the innominate artery to the top of the arch is between 1 and 2 le^ CCA diameters. Type III arch. The arch vessels arise proximal or caudal to the lesser curvature of the arch or off the ascending aorta (severe angula4on). The ver4cal distance from the origin of the innominate artery to the top of the arch is > 2 le^ CCA diameters (Figure 1c). Type IV arch. The arch vessels arise w/ severe angula4on, accompanied by increased length and transverse diameters of the arch. This arch type is associated with redundancy of the CCA. It is more frequently noted on the right, where tortuosity and the redundant loop exist in the proximal segment of the CCA. 33 Cervicocerebral Case 18: Arch injec4on with cervicocerebral arch and bilateral caro4d cervical imaging

18 Cervicocerebral Case 19: Arch injec4on with cervicocerbral arch, bilateral caro4d cervical, bilateral caro4d cerebral and bilateral vertebral imaging. 35 Cervicocerebral Case 20: Selec4ve bilateral caro4d cervical and caro4d cerebral imaging with selec4ve le^ vertebral imaging. Normal anatomy. No arch

19 Cervicocerebral Case 21: Cervicocerebral arch imaging followed by selec4ve bilateral caro4d cervical and caro4d cerebral imaging on pa4ent with a bovine arch, findings include normal arch, normal cerebrals and 70% bilateral external caro4d artery stenoses. 37 Non- selecave First order Second order Venous Anatomy Right Transfemoral Approach 38 19

20 Pulmonary Angiography Non selec4ve pulmonary angiography Selec4ve pulmonary angiography, unilateral Selec4ve pulmonary angiography, bilateral Catheter placement, non- selec4ve RA or main PA Catheter placement 1 st order pulmonary Catheter placement 2 nd order or higher pulmonary Selec4ve or non- selec4ve pulmonary angiography, including selec4on of any or all of the pulmonary arterial and/or venous branches (if done) during a cardiac catheteriza4on Vena Cava Filter Placement New Codes for 2012 IVC filter placement (temporary or permanent) SVC filter placement Iliac filter placement vs Reposi4oning temporary vena cava filter Removal temporary vena cava filter Codes bundle catheter placement(s), venography before, during and a^er filter interven4on, ultrasound and fluoroscopy during the procedure (includes ICU bedside US guided filter placement)

21 Vena Cava Filter Placement New Codes for 2012 Code for both placement and removal (37191 and 37193) if a filter is placed for prophylaxis against pulmonary embolus from lower extremity venous clot therapy, and, a^er the thrombectomy/thrombolysis is successful and the pa4ent no longer requires the filter, the filter is removed. Code for removal and placement (37193 and 37191) if a old temporary filter is removed and a new filter is placed. Do NOT code for removal of a newly placed filter due to ini4al poor placement. Just code the placement (or eventual replacement at the same session) with Vena Cava Filter Placement New Codes for 2012 Code for catheter placement and diagnos4c imaging if thrombus is present in the filter, so the decision is made to cancel the filter retrieval or reposi4oning (36010, 75825). Code twice for duplicated vena cava systems (with - 59 modifier) with two filter placements. Codes bundle mul4ple accesses if they were necessary

22 Venous Thoraco- Abdominal Case 22: Pa4ent with pulmonary embolism needs filter. Inferior vena cavagraphy and selec4ve bilateral renal venography, then an IVC filter is placed below the renal veins. 43 Venous Thoraco- Abdominal Case 23: Pa4ent no longer needs filter. US guidance for right jugular vein access followed by sheath placement is performed. The sheath is advanced into the inferior vena cava. IVC- gram is performed showing patent filter with no evidence of filter leg perfora4on. The filter is snared, collapsed and retrieved in the sheath and removed without complica4on

23 Pulmonary Case 24: Selec4ve right and le^ pulmonary artery catheter placement and imaging followed by superselec4ve le^ lower and right lower lobe pulmonary artery imaging, right pulmonary arterial thrombectomy, IVC- o- gram (shows no clot) and IVC filter placement. Non- Medicare pa4ent (percutaneous pulmonary artery thrombectomy is considered a non- covered for Medicare per NCD). 45 Pulmonary Case 24 Answers: 46 23

24 Angioplasty Percutaneous Renal or visceral artery Aorta Brachiocephalic trunk or branches Venous angioplasty (venoplasty) 47 Angioplasty Bill separately for Catheter placement (however NOT for lower extremi4es) Diagnos4c angiography (will require - 59 modifier to let CMS know this was a true diagnos4c study) Do not bill separately for angiography related to Guiding shots Road mapping/trace subtrac4on/ Posi4oning Sizing Localiza4on Comple4on 48 24

25 Do not code pre- dila4on angioplasty prior to stent placement. Do not code post- stent deployment angioplasty to fully dilate or deploy the stent or for residual stenosis in the self- deploying stent. Do not code angioplasty when the intent was to stent the vessel from the start. Do not code angioplasty, when the angioplasty gives a great result, but we stented the vessel anyways. Do not code angioplasty when the original balloon is too small to give a good result to start with and stent is then required. Do not code mul4ple angioplas4es in a single vessel. Do not code two angioplas4es when trea4ng a short bridging lesion across two adjacent vessels. Do not code angioplasty when macera4ng clot, this is part of a thrombectomy procedure. Do not code angioplasty when done with atherectomy or stent placement in the lower extremi4es. 49 Terminology Atherectomy removal of atheromatous material with a catheter equipped with a rota4ng burr, side- cunng device or photoabla4on ability (Cardiovascular Systems: Diamondback 360 Orbital Atherectomy System & Stealth 360 Orbital PAD System. EV3: Fox Hollow Silverhawk/Turbohawk. Boston Scien4fic: Rotablator Rota4onal Atherectomy. Spectrane4cs: Excimer Laser. Pathway Medical Technologies: Jetstream G2/G3 [also thrombectomy]. Bard: Simpson Atherectomy Device, Crosser Recanaliza4on System. Others?) 50 25

26 Supra- Inguinal Atherectomy Percutaneous or Open, including S&I for procedure Supra- Inguinal 0234T Renal artery 0235T Visceral artery 0236T Aorta 0237T Brachiocephalic trunk or branches 0238T Iliac artery Venous Bill catheter placement, diagnos4c angiography, closure device, and angioplasty or stent placement in the same vessel/site as indicated. 51 Stent Placement: Visceral, Renal and Brachiocephalic Arteries, Aorta, and Veins Percutaneous stent placement ini1al vessel (not coronary, vertebral, caro1d, cerebral or lower extremity artery) stent placement each addi1onal vessel (not coronary, vertebral, caro1d, cerebral or lower extremity artery) Transcatheter introduc1on of stent percutaneous or open, not coronary, vertebral, caro1d, cerebral or lower extremity artery, S&I 52 26

27 CaroAd Stent Placement Caro4d cervical stent placement with embolic protec4on Caro4d cervical stent placement without embolic protec4on & include: Ipsilateral selec4ve catheteriza4on Ipsilateral caro4d cervical and cerebral artery S&I All other related S&I during stent placement procedure All road- mapping, guiding shots and follow- up images All angioplas4es within the region of stent deployment remains an inpa4ent C- status indicator procedure in 2012 Code not appropriate as the caro4d artery is not a peripheral artery 53 Lower Extremity Endovascular RevascularizaAon Codes

28 55 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Femoral Approach Retrograde Right Femoral Approach Non- selecave First order Second order Third order 56 28

29 2011 Guidelines for Lower Extremity Arterial RevascularizaAon Procedures The following guidelines apply to codes , and refer to interven4ons described by angioplasty, atherectomy and stent placement for treatment of occlusive vascular disease. Angioplasty u4lizes a balloon to dilate a hemodynamically significant vessel stenosis. The balloon may be a compliant or non- compliant balloon, a cryoplasty balloon, a cunng balloon, etc. Atherectomy is performed u4lizing photoabla4on (Laser), rota4onal (Rotoblater, Diamondback Orbital), direc4onal cunng (Silver Hawk, JetStream G3), or pulveriza4on (Crosser) devices. Stent placement u4lizes a bare metal, drug- elu4ng, balloon- expandable, self- expanding, or covered stent to effec4vely treat the lesion(s). Codes all include an angioplasty if performed. 57 Guidelines for Lower Extremity Arterial Endovascular RevascularizaAon Procedures These codes are specific for 3 dis4nct lower extremity vascular territories: the iliac, femoral/popliteal, and 4bial/peroneal. There are 3 separately billable arteries in the iliac territory: the common, external and internal iliac arteries. There is only 1 separately billable code submited for interven4on within the femoral/popliteal system, regardless of the types and numbers of separate and dis4nct vascular interven4ons (angioplasty, atherectomy and/or stent placements) that are performed in the CFA, SFA, PFA and popliteal arteries. There are 3 separately billable arteries below the knee: the peroneal, anterior 4bial and the posterior 4bial. The 4bial/peroneal trunk is considered part of any distal interven4on (in the posterior 4bial or peroneal. The anterior 4bial is considered a separate vessel for interven4on when 4bial/peroneal trunk interven4on is also performed

30 Guidelines for Lower Extremity Arterial Endovascular RevascularizaAon Procedures Codes are applicable to both open or percutaneous approach and include closure of the open or percutaneous access site with s4tches, pressure, or device placement. These codes include conscious seda4on, vascular access, catheter placement, work involved with crossing the lesion (including use of specialty guidewires, subin4mal recanaliza4on, ultrasound vibra4on, etc.), imaging related to the en4re procedure, use of an embolic protec4on device, angioplasty (if done), and closure device angiography. Atherectomy bundling for codes only applies to infra- inguinal arteries. Use Category III code 0238T for supra- inguinal iliac atherectomy. Thrombolysis (37201, 75896), thrombectomy procedures (37184, and 37186), emboliza4on (37204, 75894), and extensive repair or replacement of the artery (35226, 35286) can be addi4onally reported. 59 Stent with atherectomy > atherectomy > stent placement > angioplasty (even though codes not listed in this order in CPT) This actually only affects coding for the 4bial/peroneal arteries. The femoral/popliteal and 4bial/peroneal territory codes incorporate atherectomy procedures. The iliac territory does not as the iliac territory codes only describe angioplasty and stent placement (+- angioplasty). Iliac atherectomy is addi4onally coded with 0238T if performed and is coded per iliac vessel treated (up to three 4mes). Guidelines for Lower Extremity Arterial Endovascular RevascularizaAon Procedures Code may be billed for each separate access made with ultrasound guidance for lower extremity revasculariza4on procedures. Must be documented per CPT guidelines

31 Guidelines for Lower Extremity Arterial Endovascular RevascularizaAon Procedures Diagnos4c angiography IS NOT separately coded at the 4me of these interven4ons if: The angiography is included in the interven4onal procedural code descrip4on Performed for vessel measurement and sizing, lesion localiza4on, roadmapping, and consists of contrast injec4ons and imaging rela4ng to guidance necessary to perform the interven4on Follow- up a^er angioplasty, atherectomy, stent placement, thrombectomy, etc. Diagnos4c angiography IS separately coded at the 4me of these interven4ons if: There has not been a prior catheter based angiogram and a complete study is performed and the decision for interven4on is based on this angiographic study There is a prior study, but There is change in clinical status since prior study The prior study was inadequate for visualiza4on of the area of concern There is change in the clinical status during the interven4on that requires imaging outside the area treated Guidelines Update for Lower Extremity Arterial RevascularizaAon Procedures Catheter placement in leg for thrombolysis and diagnos4c imaging day 1 with stent placed on day 2 is separately billable. Catheter placement in leg for thrombolysis and diagnos4c day 1, stent day 1 is separately billable IF at separate sessions. Catheter placement in 2 4bial vessels for secondary thrombectomy a^er an iliac stent placement is bundled if via same access and in the same vascular family as iliac stent. Guiding IVUS for recanaliza4on is bundled as used to cross the lesion. Diagnos4c IVUS to determine if interven4on is necessary or a^er stent deployment to determine if appropriately deployed or complica4on of procedure is separately billable. Stent- gra^ placement for popliteal aneurysm: Use Stent- gra^ placement for iliac aneurysm: Use or 0254T, 0255T

32 2012 Guidelines Update for Lower Extremity Arterial RevascularizaAon Procedures Crosser CTO Catheter: FDA approved as an atherectomy device on July 28, U4lizes high frequency mechanical vibra4ons to cross total occlusions. Discuss physician documenta4on for coding. JETSTREAM G3: FDA approved as both an atherectomy and a thrombectomy device. If thrombectomy also performed in the same vessel as an atherectomy, only code for the atherectomy procedure. DO NOT code for thrombectomy for removal of some thrombus at the 4me of an atherectomy. (Blades up, blades down, in the same vessel is an atherectomy procedure only.) Extensive repair or replacement of an artery can be addi4onally reported (35286, 35226) at the 4me of a lower extremity endovascular revasculariza4on. Codes 36200, 36245, 36246, 36247, and bundle conscious seda4on in 2012, along with filter codes and renal angiography codes. 63 LE Endovascular RevascularizaAon Case 25: Via right femoral approach, diagnos4c aortogram, cath reposi4on to bifurca4on, bilateral run- off, addi4onal selec4ve catheter placement with images in contralateral SFA. New le^ antegrade CFA puncture with le^ SFA recanaliza4on of occlusion mid- SFA to Hunter s canal. Angioplasty and covered stent placement in SFA. Laser is performed in the mid popliteal, throughout the 4bial/peroneal- trunk, in the mid posterior 4bial, mid and distal anterior 4bial, and dorsalis pedis arteries. Adjunc4ve angioplasty is performed in all these 4bial/peroneal vessels a^er the atherectomy. Stent placement is necessary in the 4bial/ peroneal trunk for flow- limi4ng dissec4on

33 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Femoral Approach Retrograde Right Femoral Approach Non- selecave First order Second order Third order 65 LE Endovascular RevascularizaAon Case 25 Answers: 66 33

34 LE Endovascular RevascularizaAon Case 26: Pa4ent with le^ leg pain. Via right femoral approach, aortogram from high cath posi4on, followed by selec4ve (1 st order) bilateral renal angiography. The catheter is pulled down for complete bilateral lower extremity run- off from le^ common iliac artery and right femoral sheath injec4ons. Sheath is advanced to contralateral SFA and IVUS is performed throughout the en4re SFA and popliteal. Angiographic 90% stenoses of the le^ external iliac with 70-80% diffuse disease throughout the en4re SFA and popliteal with dissec4on of the popliteal documented (with IVUS). The 4bial/peroneal vessels are patent. Angioplasty is performed in the external iliac, SFA and popliteal arteries with stent required in the popliteal for dissec4on. Suc4on thrombectomy of an embolus in the 4bial/ peroneal trunk is necessary at the end of the procedure. 67 Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selecave Antegrade Right Femoral Approach Retrograde Right Femoral Approach First order Second order Third order 68 34

35 LE Endovascular RevascularizaAon Case 26 Answers: 69 Percutaneous Thrombectomy (non- coronary, non- AV- shunt) Primary arterial mechanical thrombectomy. Includes intraprocedural thromboly1cs and guidance Second and all subsequent vessels in the same vascular family (add- on code) Secondary arterial thrombectomy, at 1me of another interven1on (small emboli or short segment of clot either before or aler another percutaneous interven1on, such as angioplasty or stent) These interven4ons do not include catheter placement, diagnos4c imaging, angioplasty/stent or other interven4ons, thrombolysis before or a^er the thrombectomy. If intent is to perform thrombectomy and an underlying stenosis is found and treated, BOTH the thrombectomy and stenosis treatment are billable and the thrombectomy IS considered a PRIMARY thrombectomy

36 Percutaneous Thrombectomy (non- coronary, non- AV- shunt) Venous thrombectomy includes intraprocedural thromboly1cs Venous thrombectomy, repeat treatment on subsequent day during course of thromboly1c therapy. Venous interven4ons do not include catheter placement, diagnos4c imaging, angioplasty/stent or other interven4ons, thrombolysis before or a^er the thrombectomy. Mechanical thrombectomy means removal of thrombus by use of a device, these devices include MERCI retrieval device (commonly used for intracranial thrombectomy), Treortola or Angiojet catheters (and others), Rheoly4c devices, suc4on removal of clot with a sheath and balloon macera4on of the thrombus with removal or displacement with a Fogarty catheter Percutaneous dialysis gral thrombectomy Percutaneous coronary artery thrombectomy 71 IntervenAonal Cardiology Thrombectomy (e.g., currently Expedior AngioJet Catheter only. Not for aspira4on catheters like Pronto, Export, Fetch, Diver CE. Per 2011 ACC coding manual and recent guidance from the AMA, August Based on RUC survey for ini4al code crea4on in 2002) Use of an aspira4on catheter is considered part of the coronary interven4on (angioplasty, atherectomy, stent placement). If done as stand- alone, use code Each vessel (add- on code, some payers do not allow with atherectomy or angioplasty NGS ) (Use of a distal embolic protec4on device is considered part of the interven4on. It is not a thrombectomy.) 72 36

37 Non- Coronary Thrombolysis 37201, Code for selec4ve catheter placement. Code for diagnos4c imaging performed. Per surgical site (i.e., right leg, le^ leg, both legs, right lung, le^ lung, both lungs) Code for each follow up angiography Code for addi4onal interven4ons (angioplasty, stent placement). Different guidelines than coronary thrombolysis 73 Non- Coronary Thrombolysis Exchange of Intravascular Infusion Catheter During Thrombolysis 37209, Includes contrast monitoring Follow up angiography (- 59 for each addi4onal) Appropriate for use in both the arterial and venous system New codes an4cipated for 2013, as physicians currently performing RUC survey for thrombolysis procedures 74 37

38 Peripheral IVUS 37250, IVUS, non- coronary, ini1al vessel 37251, IVUS, non- coronary, each addi1onal vessel Different codes for coronary IVUS 75 Thrombolysis Case 27: 72 year old pa4ent with cold right leg presents at 8am. A le^ sided femoral puncture is performed. A catheter is placed into the right common iliac artery followed with angiography of the right lower extremity, followed by catheter placement into a thrombosed femoral- below knee popliteal vein gra^. Trifurca4on vessels show severe stenoses in the peroneal and posterior 4bial arteries. TPA infusion is started. The pa4ent is brought back at 1pm due to increasing pain and the catheter checked. Distal emboliza4on is seen. Suc4on thrombectomy with an Export catheter is performed The catheter is exchanged over a guide wire for a longer infusion length. The old catheter is discarded. TPA is con4nued. At 6pm the catheter is rechecked showing severe anastomo4c stenoses both proximally and distally. A Viabahn covered stent gra^ is placed at the proximal anastomosis and Orbital atherectomy with a 4mm device is performed at the distal anastomosis. Orbital atherectomy (3mm) is used to treat stenoses of the posterior 4bial and peroneal arteries. Bounding distal pulses are present so the sheath is removed and the pa4ent discharged home (as an outpa4ent)

39 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Femoral Approach Retrograde Right Femoral Approach Non- selecave First order Second order Third order 77 Thrombolysis Case 27 Answers: 78 39

40 DiagnosAc CatheterizaAon Case 28: HISTORY: 67yo with prior CABG, now with recurrent angina. PROCEDURE and FINDINGS: A 7 Fr sheath is placed in the right femoral artery. Selec4ve na4ve coronary angiography is performed with #4 Judkins le^ and right catheters. Selec4ve le^ internal mammary angiography along with selec4on of 2 vein bypass gra^s is also performed. A fistula is iden4fied off the le^ IMA supplying the le^ upper lobe bronchial vasculature resul4ng in steal phenomena from the LD. FFR with WaveWire across this region confirms drama4c drop in flow beyond the fistula. The LC vein bypass gra^ is patent. The RC vein bypass gra^ is stenosed 90% proximally. An emboliza4on with two 3mm coils is performed in the IMA branch fistula followed by repeat FFR showing normal veloci4es distally. Follow- up angiography of the IMA shows complete occlusion of the IMA branch fistula with good coronary perfusion to the LD distribu4on. Next, the RC saphenous vein bypass gra^ is selected and a distal embolic protec4on device is placed. A Promus DES is then deployed and the EPD removed. Follow- up angiography on the right shows complete occlusion of the na4ve RC just beyond the distal SVBPG anastomosis consistent with development of an embolus or thrombus a^er placement of the SVBPG stent. An Export catheter is advanced to na4ve RC and extensive thrombus is removed. There is ques4onable haziness at the na4ve RC site post thrombectomy so IVUS is performed showing a severe dissec4on with 80% luminal loss. Three overlapping bare metal stents are placed across the site of dissec4on. Follow- up IVUS shows resolu4on of the dissec4on while follow- up angiography shows excellent flow and distal perfusion. The abdominal aorta and iliofemoral arteries were evaluated via a single injec4on as an AAA is noted. 79 DiagnosAc CatheterizaAon Case 28 Answers: 80 40

41 Peripheral 37204, Per surgical site EmbolizaAon Add selec4ve catheter placement codes Add diagnos4c imaging performed Follow up angiography (Use only once per surgical site for comple4on study.) 81 David Zielske, MD, CIRCC, CPC- H, CCC, CCS, RCC Copyright 2012 ZHealth Publishing CPT 2011 American Medical AssociaAon 41