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Debra Posted Tue 26th of November, 2019 09:48:03 AM
Patient presents for aortogram and selectivel left femoral angiogram; open thrombectomy left femoral stent; and femoral profundus bypass with 6 mm PTE and extensive profundoplasty. Patient in recovery room and demonstrated a right ischemic leg after angiogram percutaneously. Patient then had an open thrombectomy right SFA stent and right iliac stent; and right femoral artery to superficial femoral artery/profunda bypass with 6 mm PTE. How would this be coded? Thank you.
SuperCoder Answered Wed 27th of November, 2019 07:57:02 AM

Hi Debra,

For aortogram, open femoral thrombectomy, stent placement and bypass graft, CPT 36200, 34201-LT, 37226-LT and 35661-LT can be used, respectively. The order of the codes accordingly to the payment is 37226, 35661, 34201+ and 36200. In CPT 36200, the provider inserts a catheter into a distal artery and then into the aorta. He uses a needle and inserts a guidewire into the needle. The provider performs the procedure for aortography or for measuring pressure inside aorta. However, code 36200 is a column 2 code for 37226, but you may use a CCI-associated modifier 59 to override the edit under appropriate circumstances.

For the second part of the surgery for the right leg, CPT 34201 can be used for open thrombectomy of SFA with RT modifier, SFA stenting can be billed with CPT 37226 appending RT modifier, iliac artery stenting can be coded by the code 37221 appending modifier RT and bypass with 35661 appending RT modifier. Order of coding as per fee schedule should be: 37226, 37221, 35661 and 34201.

As per CCI edits, there is no bundling in the codes, however, when performing stent placement, some payers do not pay for thrombectomy procedure considering bundling of thrombectomy into stent procedure. So, it is suggested to go through the payer policy for the same.

Hope this helps!

Debra Posted Wed 27th of November, 2019 08:48:43 AM
Thank you for the above, it does help. Would you need a modifier -78 on the second portion of the surgery though (right leg), since it was unplanned?
Debra Posted Wed 27th of November, 2019 14:40:38 PM
A second question, the op note procedure states: open thrombectomy left femoral stent. In the description of the op note, physician states "Percutaneous access was gained with 18-guage needle into the right femoral artery. 6 French sheath was placed into the iliac stent on the right. There was pulsatile backbleeding. At this time an angiogram aortogram was undertaken. There was extensive stenosis within the stents bilateral. There was occlusion of the left femoral stent. At this time a cutdown was undertaken on the left lower extremity in the groin. The sheath was removed from the right groin and pressure was held. Flow was evident due to pulsatile bleeding in the groin." Findings: Significant stenosis within all of her stents both iliac and femoral femoral stent occlusion on the left. Based on this information, it looks to me like the stents were already in place. Would that mean that only the 36200, 34201-LT, and 35661 are billable for the first procedure?
SuperCoder Answered Thu 28th of November, 2019 04:07:37 AM

Hi Debra,

Hope you are keeping well.

Indeed, stent at the left side is already in place, since it has been performed on the left side first. So, angioplasty and stent placement (37226) can be billed for the left side.

Also, append modifier 78 to the codes only when that requires the patient to return to the operating room. The unplanned procedure should be related to an initial procedure. The provider performs the unplanned procedure during the initial procedure’s postoperative period.

Otherwise, append modifier 79 if the procedure is unrelated to the original procedure, when the same provider performs during the original procedure’s postoperative period.

It is suggeted to check your complete op-report and select the codes and modifiers accordingly.

Happy working!

Debra Posted Mon 02nd of December, 2019 12:53:41 PM
I think there is some confusion. I stated for the first procedure (which is the left side, not the right side) that it appeared that the stents were already in place. So based on this information, for the first procedure, if the patient already had a stent in the iliac artery, and the physician did a thrombectomy of the iliac stent in the iliac artery 34201 and angiogram performed establishing inflow and outflow, isn't the angiogram included with the thrombectomy? Physician also did a left common femoral to profunda bypass same leg. Which CPT procedure would that be? Doesn't the profunda femoral thrombectomy 35372 bundle with the bypass? Thank you.
Debra Posted Mon 02nd of December, 2019 13:15:33 PM
Correction to the last sentence: Doesn't the profunda femoral endarterectomy (not thrombectomy) bundle with the bypass?
SuperCoder Answered Tue 03rd of December, 2019 04:24:34 AM

Hi Debra,

Hope you are doing good.

Since, left stent is already in place, then do not use the stent placement procedure code. Also, angiogram of iliac artery would be clinically considered as a part of thrombectomy of the same artery. However, for femoral-femoral bypass, CPT 35661 can be used. Whereas, CPT 35372 is for the Thromboendarterectomy (including patch graft), although thrombectomy code already provided and documentation does not clearly mention about the endarterectomy. So, it is suggested to check the complete op-note and select the codes accordingly.

Happy working!

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