IVUS in a peripheral procedure note

Rodeen Rahbar, MD

Intravascular ultrasound is reported with 37252 for the first vessel and +37253 for each additional vessel. Both are per-vessel, and both need the note to show what the ultrasound actually measured and what it changed — a sentence saying IVUS was performed supports neither the code nor the decision it informed.

The codes

Code	Descriptor
37252	Intravascular ultrasound, noncoronary vessel, initial vessel
37253	Intravascular ultrasound, noncoronary vessel, each additional vessel

These are vessel-based, and “vessel” follows the same grouping as the revascularization codes: the superficial femoral and popliteal arteries count as one IVUS vessel, so interrogating the SFA and then the popliteal is a single 37252, not an initial plus an additional. A second vessel means a different territory or a separately counted tibial — SFA then anterior tibial, for example — and each needs its own documented interrogation with its own findings.

What the note has to show for each vessel

Reference vessel diameter at the segments interrogated — this is the measurement that sizes the device
Maximum stenosis by planimetry, with the segment it was found in
Plaque characteristics — calcification and its distribution, thrombus, dissection
Whether the ultrasound changed the plan — device size, the decision to treat, the decision not to treat
Post-treatment interrogation, if performed, and the residual stenosis it confirmed

When IVUS and angiography disagree

They often do, and the note should say so plainly rather than quietly reporting one number. Intravascular ultrasound is the more precise measurement of lumen area, and where it shows a more severe stenosis than the 2-D angiogram, that is the number that justified the intervention and it belongs in the finding and in the impression. The generator cites the IVUS figure wherever it exceeds the angiographic estimate, and states that it was the more precise measurement.

Where IVUS does not fit

Catheter size limits where the interrogation is physically possible. In the pedal branches of the peroneal — the perforating branch to the dorsalis pedis and the communicating branch to the posterior tibial — it generally is not, and a note claiming otherwise invites a question it cannot answer. The generator does not offer IVUS entry on those branches for that reason.

A worked case with IVUS in two separately counted vessels

Produced by the generator from a worked example. No patient data: every identifier field is left as a blank for you to fill in your EMR.

IVUS section

Intravascular ultrasound (IVUS): IVUS of 2 distinct vessels was performed with interpretation provided. IVUS was medically necessary to assess stenosis severity in three dimensions, size balloons/stents appropriately, characterize luminal irregularities seen angiographically, and confirm the post-intervention result (ruling out dissection or inflow/outflow compromise).

Intravascular ultrasound was performed of the following vessels: Left Superficial Femoral Artery and Left Anterior Tibial Artery.
For coding purposes (per SIR guidelines), contiguous vessels sharing a common vascular segment count as a single billable vessel. The above group into 2 distinct billable vessels:
 IVUS initial vessel: Left Superficial Femoral and Popliteal Artery - grouped as one vessel per SIR guidelines (contiguous vascular segment)
 IVUS additional vessel #1: Left Anterior Tibial Artery - separate vessel (distinct branch from popliteal trifurcation)
Separate findings are documented for each vessel below:

Left Superficial Femoral Artery: Reference vessel diameters: proximal (ostial) 6 mm, mid 6 mm, distal (adductor canal) 5 mm. Maximum stenosis 88% by planimetry in the mid segment; eccentric calcified plaque
Left Anterior Tibial Artery: Reference vessel diameters: proximal 3 mm, mid 3 mm, distal 2.5 mm. Maximum stenosis 78% in the proximal segment

Treatment:
IV heparin was administered per the dose indicated in the medications. Medical necessity: Hemodynamically significant disease, as detailed in the diagnostic and IVUS segments previously, are causing symptoms consistent with clinical presentation. Intervention was therefore performed, as follows:

Leg: LEFT

...

Show the complete note this case produced

Vascular Procedure Report

Patient Name: ___________
Date of Birth: ___________
Medical Record #: ___________

Referring Physician: ___________
Operating Physician: ___________
Assistant Physician: ___________
Date of Service: ___________

Pre-Procedure Diagnosis: Atherosclerosis of the native arteries with non-healing wound, left leg.
Clinical classification: Left lower extremity - Rutherford category 5 (minor tissue loss).
ICD-10 Codes:
 I70.244 - Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot

Post-Procedure Diagnosis: Same.

Anesthesia: Versed ___ mg IV, Fentanyl ___ mcg IV, Toradol ___ mg IV, Lidocaine 1%: ___ ml sq.

Medications: Heparin ___ units IV

Fluoroscopy Time: ___ minutes

Radiation Dose: Air Kerma: ___ mGy | Dose Area Product: ___ uGy.m2

Contrast Used: Visipaque 320 - ___ ml

Indications: The patient is a ___ year old with multiple CV risk factors and diagnosed with atherosclerosis of the native arteries with non-healing wound (left leg). This corresponds to Rutherford category 5 (minor tissue loss) in the left lower extremity. In addition to medical management, diagnostic angiogram with possible intervention is recommended. Risks and benefits were discussed in detail with the patient and patient-requested family/power of attorney, and informed consent was obtained, signed, and witnessed.

Procedures Performed:
1. Left Superficial Femoral Artery: Balloon Angioplasty (straightforward) [Left]
2. Left Anterior Tibial Artery: Balloon Angioplasty (straightforward) [Left]
3. Intravascular ultrasound (IVUS): first vessel (L SFA/Popliteal)
4. Intravascular ultrasound (IVUS): each additional vessel (L Anterior Tibial)
5. US-guided vascular access, right common femoral artery

Procedure in Detail:
Initial access including ultrasound guidance: The patient was brought to the angio suite and placed supine on the table. The entirety of the right groin was prepped and draped in the standard sterile fashion. A time out was performed. Access was obtained using ultrasound guidance examining the right common femoral artery and all branches above and below under ultrasound, confirming vessel patency under ultrasound, confirming needle access to the correct vessel under ultrasound, and confirming suitable non-calcified access to the right common femoral artery with a micropuncture and then upsized to a 5 French sheath. All ultrasound findings were recorded in real time and saved to the PACS system. The 5 French sheath used for initial access was exchanged to an up and over 6 French by 45 cm sheath. Diagnostic angiogram and interventions were then performed per the sections detailed below.

Wires and catheters: Initial access was obtained with a micropuncture sheath over a .018 wire, followed by upsize to a 5 French short sheath (5 cm) over a .035 Bentson wire. A 5F curved pigtail was used for the aortogram with runoff. The catheter was then exchanged over a .035 wire for the 6F 45cm sheath, which was advanced up and over to the contralateral side. Prior to intervention, a single .014 wire was placed with its tip visualized to be in a safe distal position.

Diagnostic angiogram: A 5F curved pigtail was inserted into the aorta, and aortogram with runoff was performed. A catheter was then moved to the contralateral femoral artery, and angiogram performed. A catheter was then moved to the contralateral tibioperoneal trunk (Third order catheterization), and angiogram was performed. Third order catheterization was necessary and in addition to proximal treatment to obtain detailed imaging of the outflow vessels and flow into the foot. Due to limitations of angiogram whereby only two dimensions are seen, more precise measurements of stenosis were obtained using intravascular ultrasound. See intravascular ultrasound interpretation for precise stenosis measurements.

The diagnostic angiogram findings are as follows:

Aorta and iliac arteries:
 Aorta: Patent, no significant stenosis.
 Right Common Iliac: Patent, no significant stenosis.
 Right Internal Iliac: Patent, no significant stenosis.
 Right External Iliac: Patent, no significant stenosis.
 Left Common Iliac: Patent, no significant stenosis.
 Left Internal Iliac: Patent, no significant stenosis.
 Left External Iliac: Patent, no significant stenosis.

Leg: LEFT (Treatment Leg)

Common Femoral artery: Patent, no significant stenosis.
Profunda Femoris artery: Patent, no significant stenosis.
Superficial Femoral artery: Severe stenosis (70-99%) - involving the mid segment, moderately calcified.
Popliteal artery: Patent, no significant stenosis.
Tibioperoneal Trunk: Patent, no significant stenosis.
Anterior Tibial artery: Severe stenosis (70-99%) - involving the proximal segment.
Posterior Tibial Artery: Patent, no significant stenosis.
Peroneal Artery: Patent, no significant stenosis.

Leg: RIGHT (Access Leg)

Common Femoral artery: Patent, no significant stenosis.
Profunda Femoris artery: Patent, no significant stenosis.
Superficial Femoral artery: Patent, no significant stenosis.

Runoff Summary:

Left tibial runoff: 3-vessel in-line tibial runoff (anterior tibial artery, posterior tibial artery, and peroneal artery). There is straight-line in-line flow into the left foot. The pedal (foot) vessels were not imaged on this study. Of note, flow may be severely limited by severe (70-99%) stenosis of the superficial femoral artery and severe (70-99%) stenosis of the anterior tibial artery.

Intravascular ultrasound (IVUS): IVUS of 2 distinct vessels was performed with interpretation provided. IVUS was medically necessary to assess stenosis severity in three dimensions, size balloons/stents appropriately, characterize luminal irregularities seen angiographically, and confirm the post-intervention result (ruling out dissection or inflow/outflow compromise).

Intravascular ultrasound was performed of the following vessels: Left Superficial Femoral Artery and Left Anterior Tibial Artery.
For coding purposes (per SIR guidelines), contiguous vessels sharing a common vascular segment count as a single billable vessel. The above group into 2 distinct billable vessels:
 IVUS initial vessel: Left Superficial Femoral and Popliteal Artery - grouped as one vessel per SIR guidelines (contiguous vascular segment)
 IVUS additional vessel #1: Left Anterior Tibial Artery - separate vessel (distinct branch from popliteal trifurcation)
Separate findings are documented for each vessel below:

Left Superficial Femoral Artery: Reference vessel diameters: proximal (ostial) 6 mm, mid 6 mm, distal (adductor canal) 5 mm. Maximum stenosis 88% by planimetry in the mid segment; eccentric calcified plaque
Left Anterior Tibial Artery: Reference vessel diameters: proximal 3 mm, mid 3 mm, distal 2.5 mm. Maximum stenosis 78% in the proximal segment

Treatment:
IV heparin was administered per the dose indicated in the medications. Medical necessity: Hemodynamically significant disease, as detailed in the diagnostic and IVUS segments previously, are causing symptoms consistent with clinical presentation. Intervention was therefore performed, as follows:

Leg: LEFT

Superficial Femoral artery: Pre-intervention finding: Severe stenosis (70-99%) - involving the mid segment, moderately calcified. Medical necessity: Hemodynamically significant disease warranting intervention as detailed in the diagnostic section. Intervention performed: Balloon Angioplasty. Details: Treatment of the mid segment: plain balloon angioplasty with a 6 x 120 mm balloon. Post-intervention result: Improved luminal diameter with resolution of stenosis to less than 30%, restored antegrade flow, no dissection, perforation, or distal embolization, confirmed by intravascular ultrasound.
Anterior Tibial: Pre-intervention finding: Severe stenosis (70-99%) - involving the proximal segment. Medical necessity: Hemodynamically significant disease warranting intervention as detailed in the diagnostic section. Intervention performed: Balloon Angioplasty. Details: Treatment of the proximal segment: plain balloon angioplasty with a 3 x 80 mm balloon. Post-intervention result: Improved luminal diameter with resolution of stenosis to less than 30%, restored antegrade flow, no dissection, perforation, or distal embolization, confirmed by intravascular ultrasound.

Completion Angiogram:
Following all interventions, a completion angiogram of the treated vascular territory was performed, demonstrating successful treatment of the Left Superficial Femoral Artery and the Left Anterior Tibial Artery. Completion angiography demonstrates three-vessel in-line tibial runoff into the left foot (anterior tibial artery, posterior tibial artery, and peroneal artery).

Closure:
Hemostasis was achieved at the access site using an Angio-Seal VIP vascular closure device. The device was deployed successfully with adequate hemostasis confirmed. The patient was monitored and transferred to the recovery area in stable condition. All treated extremity pulses were assessed post-procedure. The patient will be monitored per institutional post-procedural protocol.

Impression:
1. Successful treatment of the mid segment of the Left Superficial Femoral Artery with balloon angioplasty. The Left Superficial Femoral Artery, which initially demonstrated severe (70 to 99%) stenosis on 2-D angiogram (involving the mid segment, moderately calcified) was reduced to less than 30% residual stenosis with overall improved luminal diameter, restored antegrade flow, and no evidence of dissection, perforation or distal embolization, confirmed by intravascular ultrasound.
2. Successful treatment of the proximal segment of the Left Anterior Tibial Artery with balloon angioplasty. The Left Anterior Tibial Artery, which initially demonstrated severe (70 to 99%) stenosis on 2-D angiogram (involving the proximal segment) was reduced to less than 30% residual stenosis with overall improved luminal diameter, restored antegrade flow, and no evidence of dissection, perforation or distal embolization, confirmed by intravascular ultrasound.
3. Left tibial runoff: 3-vessel in-line tibial runoff (anterior tibial artery, posterior tibial artery, and peroneal artery). There is now straight-line in-line flow into the left foot. The pedal (foot) vessels were not imaged on this study.

Plan:
The patient was transferred to recovery for ongoing clinical assessment, pulse checks.


--- SUGGESTED CODING (verify prior to submission) ---
Place of service: Office / OBL (POS 11)

CPT Codes:
  1. 37263 -LT - Fem-Pop revascularization, initial vessel (straightforward, pta) [Left]
  2. 37280 -LT, -51 - Tibial-Peroneal revascularization, initial vessel (straightforward, pta) [Left]
  3. 37252 -59, -LT - IVUS, first vessel (L SFA/Popliteal)
  4. +37253 -LT - IVUS, each additional vessel (L Anterior Tibial)
  5. 76937 - US-guided vascular access, right common femoral artery

ICD-10 Diagnosis Codes:
  1. I70.244 - Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot

Codes the generator suggested for this case

37263 — Fem-Pop revascularization, initial vessel (straightforward, pta) [Left]
37280 — Tibial-Peroneal revascularization, initial vessel (straightforward, pta) [Left]
37252 — IVUS, first vessel (L SFA/Popliteal)
+37253 — IVUS, each additional vessel (L Anterior Tibial)
76937 — US-guided vascular access, right common femoral artery

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