Interventional Radiology Coding Case Studies Prepared by Stacie L. Buck, RHIA, CCS-P, RCC, CIRCC, AAPC Fellow President & Senior Consultant Week of November 19, 2018 Abdominal Aortogram, Bilateral Runoff Arteriogram, Angioplasty, & Stent Placement EXAM DESCRIPTION: Abdominal aortogram, bilateral runoff arteriogram, angioplasty, and stent placement. INDICATION: A 73-year-old male with chronic bilateral calf claudication. Diffusely abnormal waveforms are demonstrated on arterial duplex study. PROCEDURAL STEPS 1. Percutaneous access of the right common femoral artery. 2. Nonselective digital selective abdominal aortogram. 3. Nonselective bilateral oblique digital pelvic arteriography. 4. Nonselective bilateral lower extremity digital runoff arteriography. 5. Selective catheterization of the left popliteal artery with angioplasty. 6. Percutaneous transluminal angioplasty of the left superficial femoral artery with stent graft placement. 7. Post-stenting left femoral arteriogram. 8. Percutaneous transluminal angioplasty of the left hypogastric. 9. Percutaneous transluminal angioplasty of the left external iliac artery. 10. Post-angioplasty left iliac arteriogram. ANESTHESIA: Conscious sedation using Versed and fentanyl (see report); local anesthesia using buffered 1% Lidocaine. OTHER MEDICATIONS: Heparin 2500 units IV, Plavix 300 mg p.o. TOTAL CONTRAST: 74 ml Isovue 370; 182 ml Visipaque 320. TOTAL FLUOROSCOPIC TIME: 26.2 minutes. Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
TECHNIQUE: After informed consent was obtained, the patient was placed supine on the angiography table. The right groin was sterilely prepped and draped. Skin and underlying soft tissues were locally anesthetized with buffered 1% Lidocaine. A small skin nick was then made. Using a Seldinger technique, the right common femoral artery was percutaneously accessed, followed by placement of a 5-French sheath. Over a guidewire, a 5-French pigtail catheter was passed into the abdominal aorta to the level of the renal arteries, followed by power injection of contrast for digital abdominal aortogram. The catheter was then repositioned just above the aortic bifurcation, followed by power injection of contrast for bilateral oblique digital pelvic arteriography. With the catheter left in place, subsequent bilateral lower extremity digital runoff arteriography was then performed. Images were then evaluated. Over a guidewire, the catheter was exchanged for a SOS Omni catheter, which was formed in the upper abdominal aorta and was used to select the origin of the left common iliac artery. A 0.035-inch guidewire was then passed distally into the superficial femoral artery. Over this, catheter and sheath were exchanged for a 6-French Raabe sheath. Over the wire, a 5-French angled glide catheter was passed into the superficial femoral artery to a focal segmental occlusion at the mid thigh. With the aid of a 0.035-inch glidewire, the catheter was successfully passed across the occlusion and into the proximal popliteal artery. Over the wire, the catheter was exchanged for a 4 mm angioplasty balloon catheter, was used to serially dilate the occluded segment of the superficial femoral artery. Over the wire, the catheter and sheath were exchanged for a 7-French sheath, positioned up and over the bifurcation into the left external iliac artery. Over the wire, a 5 x 150 mm Viabahn stent graft was passed and deployed across the superficial femoral artery. This was followed by serial balloon angioplasty with both 4 and 5 mm angioplasty balloon catheters. Almost the entire length of the superficial femoral artery was angioplastied. Follow-up superficial femoral arteriogram was then obtained. The 4 mm balloon catheter was then passed to the proximal popliteal artery for focal balloon angioplasty. Repeat superficial femoral arteriogram was obtained. Catheter and wire were then withdrawn. The wire was redirected into the left hypogastric. Over this, a 7 mm balloon catheter was passed for serial balloon angioplasty of its origin. The guidewire was then repositioned in the external iliac artery, and the 7 mm balloon catheter was again used to angioplasty its origin. The balloon catheter was removed, and a subsequent iliac arteriogram was obtained, showing an improved appearance to both vessels without significant residual stenosis. The sheath was then removed and an Angio-Seal hemostasis device was used to obtain hemostasis at the groin site. However, because of persistent oozing around the Angio-Seal, hemostasis was additionally obtained with the use of a FemoStop device. Sterile bandages were applied. The patient was sent to the floor for overnight observation. He otherwise tolerated the procedure well with no immediate complications. Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
FINDINGS: Abdominal aorta: The suprarenal abdominal aorta is unremarkable. Single renal arteries are demonstrated bilaterally. The right renal artery demonstrates minimal atherosclerotic change near its origin, but is widely patent. There is a mild origin stenosis of the left renal artery. Arising approximately 5 cm below the takeoff of the renal arteries, there is a fusiform abdominal aortic aneurysm, largely calcified, measuring up to 5.3 cm in diameter, extending over an approximately 7.5 cm length, involving the aortic bifurcation. There is prominent mural thrombus with nonopacification of the lumbar and inferior mesenteric arteries. Right runoff: There is moderate diffuse disease involving the right common iliac artery without significant stenosis. The right hypogastric is patent, but is mildly diseased at its origin. Otherwise, no significant inflow disease is demonstrated through the level of the common femoral artery. Mild nonstenotic atherosclerotic plaquing, however, does involve the common femoral artery. The profunda femoral artery and its distal branches appear unremarkable. The superficial femoral artery shows moderate diffuse disease over its proximal 1/2. There is a 5 cm segmental occlusion at the mid thigh just above the adductor canal. Superficial and profunda collaterals reconstitute flow in the superficial femoral artery at the adductor canal. The popliteal artery is widely patent. There is good 3- vessel runoff to the right foot demonstrated. Left runoff: The origin of the left common iliac artery is aneurysmal, as part of the aortic aneurysm. There is marked diffuse disease of the iliac inflow vessels, including at least a 70% origin stenosis of the external iliac artery. Multilevel atherosclerotic plaquing is seen throughout, but no other significant stenoses are identified. The profunda femoral artery and its distal branches appear to be unremarkable. The superficial femoral artery shows mild diffuse disease over its proximal 1/2. However, just above the adductor canal, there is an approximately 5 cm segmental occlusion with distal collaterals seen to the level just above the adductor canal. The popliteal artery shows a mild proximal stenosis, but is otherwise patent throughout. There is good 3-vessel runoff to the left foot demonstrated. Following stent graft placement in the left superficial femoral artery, there is reconstitution of flow throughout this vessel, which is now widely patent. There is a mildly improved appearance to the proximal popliteal arterial stenosis. Post-angioplasty images of the left iliac bifurcation show an improved appearance to both the proximal hypogastric and the left external iliac arteries. Focal intimal dissection, however, is seen at the origin of the hypogastric. No focal extravasation is demonstrated, however. Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
CONCLUSION 1. Abdominal aorta: A 5.3 cm fusiform infrarenal abdominal aortic aneurysm extending to and involving the bifurcation. 2. Right runoff: Mild to moderate diffuse disease at the common iliac artery without significant stenosis. Otherwise, no significant inflow disease. Diffuse disease of the superficial femoral artery with a 5 cm segmental occlusion at the mid thigh. There is distal reconstitution just above the adductor canal. Good 3-vessel runoff to the right foot. 3. Left runoff: At least 70% focal origin stenosis of the external iliac artery. Although there is moderate diffuse disease, no significant inflow stenosis is otherwise demonstrated. Mild to moderate diffuse disease of the superficial femoral artery with a subsequent 5 cm segmental occlusion at the mid thigh, with reconstitution distally just above the adductor canal. Status post percutaneous transluminal angioplasty with stent graft placement without residual stenosis and return of brisk flow throughout. Good 3-vessel runoff to the left foot. 4. The patient's right-sided superficial femoral arterial occlusion would likely be amenable to percutaneous treatment, as was the left side. However, because of limitations on contrast dosing, this was not performed at this setting. This could be scheduled for a later date unless surgical bypass is anticipated. From an anatomical standpoint, the patient's aortic aneurysm would be amenable to percutaneous endovascular repair. Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
Interventional Radiology Coding Case Studies CPT Codes Week of November 19, 2018 Abdominal Aortogram, Bilateral Runoff Arteriogram, Angioplasty, & Stent Placement Procedure Codes: 37220-LT PTA External Iliac/Hypogastric Origin 37226-LT PTA & Stent Superficial Femoral/Popliteal 75625 Abdominal Aortogram 75716(59) Bilateral Extremity Runoff Q9967 x256 LOCM 300-399 MG/ML Diagnosis Codes: I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs I71.4 Abdominal aortic aneurysm I72.3 Iliac artery aneurysm Comments: Code 37220 is assigned for the angioplasty performed at the origin of the external iliac and hypogastric origin. Two separate lesions were not treated, only one, so only one angioplasty code is assigned for the iliac territory. Code 37226 is assigned for angioplasty and stenting performed in the femoral/popliteal territory. Code 75625 is assigned for the aortogram, and code 75716 is assigned for the bilateral extremity run off. These were two separate studies from two different catheter placements (high and low) in the abdominal aorta. Moderate sedation time is not noted in the report. Drugs and supplies are billed by the facility performing the procedure and should not be assigned for professional fee coding. Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
Applicable Coding Rules: Catheterization Codes As a general rule, accessing the vessel, selective catheterization of the vessel and crossing of the lesion is bundled into the lower extremity revascularization codes. All catheter placements related to performance of the therapeutic intervention, including catheter placements for any diagnostic angiography associated with the therapeutic intervention should not be coded separately. There are a few instances in which catheterization codes may be reported in conjunction with a lower extremity revascularization code: Diagnostic angiography for the revascularization is performed at the same time as revascularization from a separate access. Example: Catheterization of the aorta for an aortogram may be performed via a left groin puncture, yet the revascularization is performed on the right iliac via a right groin puncture. The catheterization of the aorta (36200) via the left groin is reported with modifier 59. Diagnostic angiography performed at the same time as the intervention requires a higher degree of selectivity than does than the one used for the lower extremity intervention. This applies when the catheter is manipulated beyond the vessel treated through the aorta and into the contralateral extremity for additional imaging. Example: Access at the right common femoral artery, revascularization of right internal iliac, catheterization and imaging of contralateral (left) leg (36245 36247). Modifier 59 will be needed on the selective catheterization code for imaging of the left extremity. Another catheterization is performed through the same access for another diagnostic or therapeutic procedure requiring catheterization in a different vascular bed. Example: Performance of a renal PTA in conjunction with a lower extremity revascularization. Modifier 59 will be needed on the selective catheterization code for the renal PTA. Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
Applicable Coding Rules (continued): A separate vessel punctured for an additional access that is not part of the revascularization procedure (different vascular bed) and another vessel is selectively catheterized for another purpose. Another procedure is performed on the same date of service at a different session. Remember in the lower extremities, the external iliac and common femoral are considered one vessel for coding purposes. Diagnostic Angiography An initial diagnostic angiogram may be reported when performed. If a prior diagnostic angiogram has been performed, diagnostic angiography should only be reported separately in accordance with guidelines established for reporting with transcatheter procedures. Revascularization Codes The revascularization codes include transluminal angioplasty, atherectomy and stent placement in the lower extremities. CPT has designated three distinct vascular territories: iliac, femoral/popliteal, and tibial/peroneal. The revascularization codes are unilateral; therefore both a primary code and an add on code may be reported once for each side in each territory. Use of an embolic protection device for performance of the services as described by the revascularization codes should not be reported separately. The closure of the arteriotomy through any means when associated with a revascularization procedure should not be coded separately. Single vs. Multiple Vessels. Revascularization codes are assigned one time per vessel (lesion) treated, with the exception of the femoral/popliteal territory. Note that the common iliac and external iliac are two different arteries, however the external iliac and common femoral arteries are considered a single vessel for interventional coding purposes. Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
Applicable Coding Rules (continued): Multiple Stents. When there are multiple stents placed in the same vessel, only one stent placement is reported. Multiple Lesions. When there are multiple lesions treated within the same vessel, only one revascularization code is reported for that vessel. Bridging Lesions. At times a bridging lesion may be encountered. This is a single lesion that spans two vessels. Only one revascularization code should be assigned in these instances. Kissing Angioplasty. This term is used when angioplasty is performed on both the left and right common iliac arteries into the distal aorta. This technique is used to treat aortoiliac occlusive disease. Angioplasty is reported for each vessel. Kissing Stents. This term is used when stenting is performed on both the left and right common iliac arteries with the stents meeting in the distal aorta. This technique is used to treat aortoiliac occlusive disease. Stent placement is reported for each vessel. Administration of Heparin, Nitroglycerin, etc., during the procedure is not coded separately. RS&I Codes Bundled Components. All RS&I work directly related to the intervention is bundled into the surgical codes for lower extremity revascularization. This work includes the following services: contrast injections, angiography, roadmapping, and fluoroscopic guidance for the intervention, vessel measurement, and completion angiography. Choosing the Correct Code Lower extremity revascularization codes are assigned for each vascular territory. To select the appropriate codes for these therapeutic interventions determine the following for each vascular territory: Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
Applicable Coding Rules (continued): (1) each vessel that was treated (2) the intervention(s) performed in each vessel (3) the most extensive procedure performed. The most extensive procedure performed in each territory will determine the primary CPT code for each territory as well as the appropriate add on codes. The Society for Interventional Radiology has established the following hierarchy to determine the most extensive procedure. The list is ordered from lowest to highest: Angioplasty Stent Atherectomy Stent with atherectomy Iliac Territory. The iliac territory is made up of the common iliac, internal iliac and external iliac arteries. Each artery is considered a separate vessel for coding purposes. Up to three codes may be reported for this territory one primary code to describe the most extensive procedure, followed by up to two add on codes for two additional vessels. Atherectomy of the iliac arteries is not included in the iliac revascularization codes. Code 0238T Transluminal peripheral atherectomy, open or percutaneous, including RS&I; iliac artery, each vessel is utilized to report atherectomy of the iliac arteries. Code 0238T is reported per iliac vessel and in addition to codes 37220 37223 when performed. When iliac atherectomy is performed alone, codes for catheterization (36140, 36245 36247) and for placement of a closure device (G0269) may be reported separately. (See Atherectomy) Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.
Applicable Coding Rules (continued): Femoral/Popliteal Territory. The femoral/popliteal territory is made up of the common femoral, superficial femoral, deep femoral arteries and the popliteal artery. The entire territory has been designated as one vessel for coding purposes; therefore only one code will be reported for multiple interventions for multiple vessels within this territory. There are no add on codes for this territory. Tibial/Peroneal Territory. The tibial/peroneal territory is made up of the anterior tibial, posterior tibial, peroneal and tibioperoneal trunk arteries. Each artery is considered a separate vessel for coding purposes. Up to three codes may be reported for this territory one primary code to describe the most extensive procedure, followed by up to two add on codes for two additional vessels. When revascularization is performed of the tibioperoneal (TP) trunk in conjunction with either the posterior tibial or peroneal, the TP trunk is considered part of those vessels and the intervention on the TP trunk would not be coded separately. When an intervention is performed in the anterior tibial and TP trunk only, both are coded as separate vessels. Weekly Interventional Case Studies. Email info@radrx.com to purchase a subscription.