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Bilateral Selective Renal Angiogram & Bilater Renal Stent with Renal Angioplasty

Oscar Posted Wed 02nd of July, 2014 16:52:58 PM

Hi, Could someone please help me with following coding scenario.

My doctor has performed following procedures on a Medicare Patient.

1) LHC with Coronary Angiogram
2) FFR of LAD
3) Bilateral Selective Renal Angiogram.
4) Bilateral Renal Angioplasty and Stents Placement.

Per my knowledge I am reporting following codes. Please correct if anything wrong.
1)93458
2)93571
3)36252-59
4)37205-RT - Right renal stent
75960-26,59 - RS&I
35471-RT - Right renal Angioplasty.
75966-26,59 - RS&I

37205-LT or 37206 - Left renal stent or Stent additional vessel,renal
75960-26,59 - RS&I
35471-LT - Left renal Angioplasty.
75966-26, 59 - RS&I

Majorly my question here is, can we report Angioplasties separately in renals?
and
If bilateral stents placed, should we report 37205(for one side/initial vessel)and 37206 (for other side/additional vessel)?

I appreciate your help.

SuperCoder Answered Fri 04th of July, 2014 08:12:13 AM

I will need detailed report to better understand the scenario. If you can paste it here or may be broad description of procedure performed from the operative note.

Thanks !!

Oscar Posted Wed 09th of July, 2014 16:50:38 PM

BILATERAL SELECTIVE RENAL ANGIOGRAM:
Bilateral selective renal angiogram was performed using a 5-French JR4 catheter. This angiogram showed the right renal artery shows no obstruction. There is no gradient across the ostium of the right renal artery. The left renal artery showed about 95% in-stent restenosis with 40 mm gradient across the ostium.

PERIPHERAL INTERVENTION OF THE LEFT RENAL LESION:
The lesion in the left renal artery: Stenosis is 95% in-stent restenosis. Gradient of 40 mm across the ostium. A 6-French RDC guide catheter was used initially which was changed to a 7 French RDC guide catheter for accommodating balloons and stents. Then,I initially dilated with a 6.0 x 20 mm Mustang over the wire balloon at up to 8 atmospheres of pressure. This balloon initially did not go. I used a 4.0 balloon which is a 4 x 20 mm balloon which is a Sterling balloon and predilated the lesion at
about 10 atmospheres of pressure. Then I used the 6.0 x 20 mm Mustang over the wire balloon. So, before placing the 7-French guide, I had to change a 6-French sheath in the right common femoral artery to a 7 French Terumo Pinnacle sheath. Then I delivered the stent, actually I opened two balloons, the first one a 6 x 20 x 75 Mustang balloon which did not cross. Then I used another balloon which was 6 x 20 x 80, which was
crossed and dilated the lesion after dilating with a 4.0 x 20 mm balloon. Then I used the stent which is a Genesis stent, a 7 x 15 mm stent, and deployed at about 10 atmospheres of pressure. Initially after ballooning at 4.0 and 6.0 balloons there was still a 20 mm gradient. Then a stent which is 7.0 x 15 is deployed and then the gradient is ablated. There is no gradient across the lesion. The lesion is reduced to less than 10% with good refluxfrom the ostium. No complications. This was a
successful intervention of the 95% in-stent restenosis of the left renal artery stent with PTA and stenting.

Conclusion:
- A 95% lesion which is in-stent restenosis of the left renal stent with 40 mm gradient across the ostium.
- Successful PTA and stenting of the left renal artery lesion which is 90% in-stent restenosis with post-procedure gradient of 0 across the ostium.

Please remember that this patient had 93458 & 93571 in the same session.

SuperCoder Answered Thu 10th of July, 2014 09:32:11 AM

Code 37205 is deleted effective January 1, 2014. New range of codes 37236-37239 have been introduced.

37236 - Transcatheter placement of an intravascular stent(s) (except lower extremity arteries for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery

37237 - Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)

37238 - Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein

These codes includes the radiological supervision and interpretation and angioplasty if performed within same vessel as stent placement.

So the appropriate codes will be:

Right and left renal stent placement and angioplasty - 37236-50.

Bill - 93458, 93571, 36252-59, 37236-50.

Thanks !!

Oscar Posted Fri 11th of July, 2014 15:20:01 PM

Hi Thank you so much for your reply. I am clear with this reply. But, I need to have the clarity about these codes according to 2013 AMA CPT. Because I have submitted this type of renal stents and angioplasty services as I mentioned in my first question in this conversation. But, now upon reviewing the coding guidelines again, I am doubt about reporting Angioplasty codes 35471 & 75966 along with stent codes 37205 & 75960.
Also, my other doubt is for bilateral renal stents reporting 37205-50 was correct or 37205 & 37206 was correct? Please clarify according to 2013 CPT guidelines.

Thanks again

SuperCoder Answered Mon 14th of July, 2014 09:46:20 AM

Technically, you may report both angioplasty and stent placement in a single renal artery, but medical necessity may limit you to reporting the stent services:

37205, Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; initial vessel

75960-26, Transcatheter introduction of intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity artery), percutaneous and/or open, radiological supervision and interpretation, each vessel; Professional component.

You should report only the stent services if the physician's intent going into the surgery was to place the stent, as is likely for an ostial lesion (one at the opening of the vessel). If angioplasty was the intended treatment, but it failed, leading to stent placement, then documentation needs to be very clear on that point. You may be able to report both services in that case, but coverage is at the payer's discretion.

As per 2013 AMA CPT guidelines, if bilateral stents placed, you should report 37205(for one side/initial vessel)and 37206 (for other side/additional vessel.

Thanks !!

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