Lower extremity angioplasty with thrombolysis infusion.
I'm having difficulties coding the following procedures. I'm not sure if the interventions and infusion codes are billable together on the same day since both left and right sides done. Also on day 2 the left side infusion therapy was stopped. more angioplasty done and then the right side angiogram done and infusion started can I bill both? If you can help that would be great.
procedure day 1
1. Aortoiliac and left lower extremity angiography, percutaneous transluminal angioplasty.
2. Attempted thrombectomy and infusion catheter placement for t-PA of the left SFA and popliteal.
Cold/ischemic left foot
Description of the Procedure:
Following preparation the right groin was accessed and a pigtail was used for an aortoiliac angiogram and then used to select the left iliac system, advanced to the common femoral and a bolus chase angiogram performed to the level of the foot. At this point the patient was taken off the table for a CT by another physician due to complications which were cleared and patient was brought back to the table. The preexisting 4-French sheath was prepped, local anesthetic again used and sheath was exchanged for another 4-French sheath. A pigtail was then advanced to the distal aorta over the J wire and used to select the left iliac system again. It was advanced down to the common femoral and wire changed to a Rosen wire. Destination 6-French sheath was then advanced down to the level of the occlusion. CXI straight tip catheter was then obtained and we then entered the occlusion with the Glidewire. There were several times when the Glidewire appeared to be in a quite organized clot with a tortuous course but eventually we were able to obtain access to the distal popliteal and TP trunk with visualized runoff through the catheter to the peroneal and PT which themselves are diseased. We then exchanged for a Cougar wire and performed angioplasty with a 2.0 balloon up to 14 atmospheres and then angiography continued to show clot. Therefore a Export catheter was passed into the TP trunk and aspirated. Again good distal flow antegrade was not obtained therefore a Magic torque wire to infusion catheter and laced the occluded region of the distal SFA and popliteal with 10mg of TPA. The sheaths were sutured in place. after patient complained of pain the Destination sheath was used to perform fluoroscopic quick lokk from common iliac distal and showed everything patent without dissection visualized or any other angiographic complications. Vascular surgery was consulted and it was recommended for thrombolysis to continue.
Procedure 1 day 2
Procedure: Relook angio left lower extremity on thrombolytics PTA popliteal/TP trunk, PTA posterior tibial, right lower extremity angiography.
Ischemic foot on the left on thromolytics and diminished pulses on the right.
Description of Procedure:
The patient was brought to the cath lab he had an up-and-over sheath from the right groin. Infusion catheter was also in place. The infusion catheter was used to perform an angiogram of the left lower extremity which did demonstrate the majority of the popliteal clot was cleaned up. A focal lesion at the distal popliteal/TP trunk ostium and an occlusion of the PT. The decision was made to intervene on these focal lesions. A J wire and JR4 diagnostic catheter was placed in the left iliac through the sheath after removing the infusion catheter. We then retracted the sheath cleaned it up extensively with Chlorhexidine, rinsed it off, and placed it back in the artery around the left common femoral. We crossed the lesions with a MiracleBros 3.0 guidewire, and then angioplastied with the 1.5 balloon. A 2.0 balloon up to 14 atmospheres was used in the PT and a 4.0 coronary balloon was used up to 8 atmospheres in the distal popliteal at the TP trunk ostium. Acceptable angiographic result was obtained and this portion of the procedure was halted. We then retracted the sheath over the JR4 to the right external iliac and injected with stop shots to the right lower extremity. This demonstrated a popliteal occlusion and some collateralization to the BTK vessels. The ostial AT appeared to be present however, there is probably a mid occlusion and then distal reconstitution near the AT. No inline flow via the PT or peroneal. The patient discharged from the cath lab with a short sheath (7-French) in place for attempts at short lytic infusion to the right lower extremity.
Procedure 2 day 2
Procedure: Relook angiography, right lower extremity.
Description of Procedure:
Preexisting sheath used to inject with runoff distal SFA to the ankle. The sheath was pulled after the angiogram and the patient was discharged from the cath lab.