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Coding for Angioplasty Stent Procedures

Ctcy
Academic year: 2023/2024
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vismitha k.v
Mangalore University
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Coding for Angioplast y

& St ent Procedures

July 2020

Jennifer Bash, RHIA, CIRCC, RCCIR, CPC, RCC

Direct or of Coding Educat ion

Disclaimer

The informat ion present ed is based on t he experience
and int erpret at ion of t he present ers. Though all of t he
informat ion has been carefully researched and checked
for accuracy and complet eness, ADVOCATE does not
accept any responsibilit y or liabilit y wit h regard t o
errors, omissions, misuse or misint erpret at ion.
CPT codes are trademark and copyright of the American
Medical Association.

Resources

  • AMA
  • CMS
  • ACR/SIR
  • ZHealth Publishing

Angioplast y

Angioplasty, also known as balloon angioplasty and percutaneous
transluminal angioplasty, is a minimally invasive endovascular
procedure used to widen narrowed or obstructed arteries or veins,
typically to treat arterial atherosclerosis.

Vascular St ent

A stent is a tiny tube placed into the artery or vein used to treat
vessel narrowing or blockage. Most stents are made of a metal or
plastic mesh-like material.

General Angioplast y & St ent Coding

Guidelines

  • Bridging/Contiguous lesions
    • Short lesion between 2 vessels=1 intervention
    • Long lesion crossing entire length of 2 adjacent vessels with

####### separate balloon or stent = 2 interventions

  • Two distinct lesions in adjacent vessels = 2 interventions
  • Hemodynamically significant stenosis
  • Angiography not separately billable
  • Exception:
  • No prior angiographic imaging
  • Prior imaging is suboptimal/inadequate visualization
  • Change in patient condition/worsening of symptom
  • New problem outside area of intervention
  • Should be modified (-59 or –XU)

Angioplast y & St ent Procedures

PRESENTING PROBLEMS

  • Atherosclerosis
  • Stenosis
  • Occlusion
  • Blockage
  • Dissection
  • Vascular ischemia
  • Fibromuscular dysplasia MEDICAL NECESSITY
  • Hemodynamically significant stenosis
  • Medicare coverage

Angioplast y & St ent -General

  • Angioplasty
    • Arterial-37246-
    • Venous-37248-
  • Stent
    • Arterial-37236-
    • Venous-37238-
  • Only 1 “initial” angioplasty/stent per session
  • Codes are for open/percutaneous
  • Renal Guidance/Exception
    • Diagnostic renal angiography followed by angioplasty or stent, the catheter placement is bundled
    • If known lesion, catheter placement is separately coded

Angioplast y-Case St udy

Exam: IR ANGIOGRAM RENAL UNILAT COMPLETE LT; IR TRLUML BALL PTA 1ST ART CLINICAL: Patient with a history of suspected renovascular hypertension. Was treated in the past of the left renal artery stent. Duplex follow-up has been equivocal at times and therefore we have been asked to evaluate stent angiographically. Expected benefits of the procedure and potential risks including the small risk of bleeding and infection were discussed and all questions were answered with the patient then gave oral and written informed consent. TECHNIQUE: Using modified Seldinger technique the right common femoral was punctured allowing placement of 6 sheath. Through this a Omni flush catheter was advanced just above the level of the renals for an aortogram. Subsequently the left renal artery was selectively catheterized and a pressure wire left across the stenosis. The FFR was approximately 0 normal being a value of 1. Subsequent ultrasound showed some narrowing in the region of the left renal artery stent. Subsequently angioplastied to 6 mm this was performed for follow-up FFR of 1. At this point the procedure was completed. The sheath was removed and hemostasis obtained using a Mynx closure device. This procedure was performed using all elements of maximal sterile barrier technique cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2%% chlorhexidine for cutaneous antisepsis STERILE TECHNIQUE WAS USED FOR ULTRASOUND GUIDANCE INCLUDING STERILE GEL AND STERILE PROBE COVER. Findings: In-stent restenosis on the left renal artery stent treated successfully with angioplasty. MEDICATIONS: Midazolam 1 mg, Fentanyl 50 mcg, heparin 5000 units, nitroglycerin 200 units intra-arterial CONTRAST: Omnipaque 85 ml RADIATION DOSE: Flouro Dose 780 dgy, Flouro Time 28 mins, Air Kerma 869 mGy Moderate Sedation was administered and I personally spent 55 minutes of face-to-face sedation time with the patient. A Registered Nurse was present throughout the procedure to serve as an independent trained observer to assist in the monitoring of the patient's level of consciousness and continuous monitoring of physiological status including pulse oximetry, heart rate, and blood pressure. Impression: Successful angioplasty of an in-stent restenosis of the left renal artery stent treated to 6 mm.

St ent -Case St udy

BILATERAL RENAL ANGIOGRAM AND BILATERAL RENAL ARTERY STENTS INDICATION 58-year-old female smoker with history of diabetes who presents with difficult to control hypertension and ischemic nephropathy. GFR measures 38. Renal artery Doppler performed on suggested a high-grade left renal artery stenosis. CT angiography of the abdomen performed suggests right worse than left renal artery stenosis. SURGICAL PROCEDURE After informed consent was obtained the patient was placed on the angiography table in the supine position. The right groin was prepped with chlorhexidine and alcohol. Buffered lidocaine was utilized to anesthetize the skin overlying the right common femoral artery. The right common femoral artery was punctured with a 19 gauge double wall needle and a 5 French sheath was inserted into the right common femoral artery. A 5 French pigtail catheter was advanced into the proximal abdominal aorta. Digital subtraction angiography of the abdomen was performed. The catheter was exchanged to a 5 French C2 catheter. Selective catheterization of the right renal artery was performed and digital subtraction angiography of the right renal artery was performed with magnification. A 0 Rosen guidewire was advanced into a branch of the right renal artery. The 5 French sheath and 5 French C2 catheter was exchanged to a 6 French Ansel 2 sheath. The sheath tip was positioned in the proximal right renal artery. 5000 units of heparin was delivered through the sheath. 150 micrograms of nitroglycerin was delivered through the sheath into the right renal artery. A 6 mm x 17 mm Visipro balloon expandable stent was advanced through the sheath and positioned across the stenosis at the origin of the low right renal artery. The stent was deployed to 12 atmospheres of pressure. The results of the right renal artery stenting were assessed with digital subtraction angiography through the 6 French sheath. Multiple attempts were made to catheterize the left renal artery with the 5 French C2 catheter and an angled 0 hydrophilic glidewire. These were unsuccessful due to a severe web-like stenosis at the origin of the left renal artery. The C2 catheter was exchanged to a 5 French Sos catheter. The 5 French Sos catheter was eventually successful in catheterizing the left renal artery and crossing the left renal artery stenosis.

St ent -Case St udy

Digital subtraction angiography of the left renal artery was performed with magnification through the Sos catheter. The 0. Rosen guidewire was advanced into a branch of the left renal artery. The 6 French sheath was advanced across the left renal artery stenosis. 150 micrograms of nitroglycerin was delivered into the left renal artery. A 5 mm x 17 mm Visipro balloon expandable stent was advanced through the 6 French sheath into the proximal left renal artery. The stent was positioned across the stenosis at the origin of the left renal artery and was successfully deployed to 12 atmospheres of pressure. The results of the left renal artery stenting were assessed with digital subtraction angiography through the 6 French sheath. A 5 French pigtail catheter was advanced into the proximal abdominal aorta and digital subtraction angiography of the abdomen was performed. At the completion of the procedure hemostasis was achieved in the right groin with the help of a Proglide closure device. No hematoma was present. The patient tolerated the procedures very well. FINDINGS: Digital subtraction angiography of the abdomen reveals mild atherosclerosis in the abdominal aorta and no aortic stenosis or abdominal aortic aneurysm. The flush aortogram and selective right renal artery angiogram reveal a high-grade stenosis of approximately 80 percent in the proximal right renal artery with poststenotic dilatation in the right renal artery. The flush aortogram and selective left renal angiogram reveal a web-like high-grade stenosis at the origin of the left renal artery estimated at 90 percent. Renal artery branches are well-preserved bilaterally and the nephrograms appear promptly bilaterally. Following right renal artery stenting an excellent angiographic result is seen with no residual stenosis and excellent positioning of the right renal artery stent extending into the abdominal aorta for 1-2 mm. Following left renal artery stenting an excellent angiographic result is seen with no residual stenosis and the left renal artery stent extending into the abdominal aorta for approximately 1 mm. There is preservation of renal artery branches in both renal arteries. CONCLUSION

  1. High-grade proximal right renal artery stenosis. This responded well to 6 mm balloon expandable stenting.
  2. High-grade proximal left renal artery stenosis. This responded well to 5 mm balloon expandable stenting.
  3. The patient has been instructed to watch her blood pressure closely. She may need adjustment of her hypertensive medications in light of the bilateral renal artery stents.
  4. The patient will return for a follow-up renal artery Doppler and outpatient interventional radiology visit in 2 months.

Cervicocerebral Procedures

  • Clinical Indications
    • Atherosclerosis/Stenosis
    • Vasospasm (PTA)
  • Intracranial Territories
    • Right Hemisphere
    • Left Hemisphere
    • Posterior Fossa When medically necessary INCLUDED SEPARATELY CODED RS&I Cath placements outside of vascular family Ipsilateral catheter placement Diagnostic angio in other vascular family Ipsilateral/same vascular family angiography Arch angio* Closure Device Vascular US guidance Stent inclusive of angioplasty Sedation

Cervicocerebral Procedures-Angioplast y

  • Intracranial:
    • Atherosclerosis-
      • Inpatient Only
      • ≥50% stenosis
      • FDA Approved Clinical Trial
      • Restricted coverage
    • Vasospasm:
      • 61640/61641-same vascular territory
      • 61642-ea add’l different vasc territory
  • Cervical Carotid/Vertebral-Noncovered for CMS
    • 37246/37247-Arterial
    • -GZ modifier
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Coding for Angioplasty Stent Procedures

Course: Condensed Matter Physics IV (PHS 556)

University: Mangalore University

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Coding for Angioplasty
& Stent Procedures
July 2020

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