March 2016 Q & A

Question: Angioplasty or Primary Thrombectomy with No Stenosis Documented

Patient is on Day 2 of lower extremity arterial thrombolysis with EKOS catheter. The patient was placed on the angio table and the catheter was injected showing significant residual heavy clot burden. The physician ballooned the thrombus in the anterior tibial, posterior tibial and peroneal arteries with a 3mm balloon, then used an aspiration catheter in each vessel post ballooning due to loose clot seen within these vessels. There is no physician documentation of any underlying anatomical stenosis in these vessels. Thrombolysis was restarted with the EKOS catheter and sent to the floor for overnight monitoring. On Day 3, the patient is brought back for AngioJet thrombectomy, repeat ballooning of the peroneal along with thrombolytic spray through the AngioJet for 20 min. This is repeated in the posterior tibial artery. Follow-up angiography demonstrates a flow limiting dissection requiring stent placement.

Day 2 was coded as 37213, 37228, and 37232. Based on how I understand what I read in your book, it should be 37213, 37184 (post Tib), 37185 (anterior Tib), 37185 (peroneal), 36247. Day 3 should be 37214, 37184, 37185, 37230? Is that correct? There is disagreement and confusion on what is angioplasty and what is thrombectomy in cases like these.
Answer:
Use of a balloon for maceration of thrombus is thrombectomy. You are correct that angioplasty requires documentation of a true, underlying, hemodynamically significant stenosis (50%). Placing a stent for a treatment of a flow-limiting dissection is a stent with 37230 in a tibial artery. I agree with most of your codes, except that 37185 includes all additional vessels treated after the initial one in a single surgical site (one lower extremity) and should only be submitted once per session per leg. Since a leg angioplasty is not submitted on Day 2, the catheter placements 36247, 36248 x 2 can be submitted if for some reason they weren’t on Day 1. My guess is a catheter placement was initially coded on Day 1, so I would only add the additional catheter codes 36248 x 2.  So, Day 2 codes are 37213, 37184, 37185, 36248 x 2 and Day 3 codes are 37214, 37184, 37185 and 37230.