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. RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2018. All Rights Reserved. www.radrx.com Distribution of this document is strictly prohibited. The content is created exclusively for those individuals who have a paid subscription to the RadRx Weekly Interventional Case Studies. Email [email protected] 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. RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2018. All Rights Reserved. www.radrx.com Distribution of this document is strictly prohibited. The content is created exclusively for those individuals who have a paid subscription to the RadRx Weekly Interventional Case Studies. Email [email protected] 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 non- opacification 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. RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2018. All Rights Reserved. www.radrx.com Distribution of this document is strictly prohibited. The content is created exclusively for those individuals who have a paid subscription to the RadRx Weekly Interventional Case Studies. Email [email protected] 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