OBL PAD documentation

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: Drug-Coated Balloon Angioplasty, Atherectomy (straightforward) [Left]
2. Left Anterior Tibial Artery: Balloon Angioplasty (straightforward) [Left]
3. Intravascular ultrasound (IVUS): first vessel (L SFA/Popliteal)
4. Angiography, bilateral lower extremity (Left) (Separately reportable: No prior catheter-based study available)
5. Aortography, abdominal (Left) (Separately reportable: No prior catheter-based study available)
6. 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.

SEPARATELY REPORTABLE DIAGNOSTIC ANGIOGRAPHY: A complete diagnostic angiogram was performed and interpreted at this encounter, and the decision to intervene was made on the basis of that study. It is therefore separately reportable with modifier -59, as no prior catheter-based angiographic study was available for review. This diagnostic service is distinct from the intraprocedural imaging guidance included in the interventional codes (37254-37299).

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 and distal (adductor canal) segments, heavily 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: Total 100% occlusion (complex) - involving the proximal and mid segments, distally there is partial focal reconstitution by collaterals.
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: 2-vessel in-line tibial runoff (anterior 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. The left posterior tibial artery is occluded in the proximal and mid segments. 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 1 distinct vessel 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 vessel: Left Superficial Femoral Artery.
For coding purposes (per SIR guidelines), contiguous vessels sharing a common vascular segment count as a single billable vessel. The above group into 1 distinct billable vessel:
 IVUS initial vessel: Left Superficial Femoral and Popliteal Artery - grouped as one vessel per SIR guidelines (contiguous vascular segment)
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. Heavily calcified plaque, maximum stenosis 90% in the mid 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 and distal (adductor canal) segments, heavily calcified. Medical necessity: Hemodynamically significant disease warranting intervention as detailed in the diagnostic section. Intervention performed: Drug-Coated Balloon Angioplasty, Atherectomy. Details: Treatment of the mid and distal (adductor canal) segments: laser atherectomy using a 2.0 mm catheter at a fluence/repetition-rate setting of 60/80 (3 passes), followed by drug-coated balloon angioplasty with a 6 x 200 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 100 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.

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 two-vessel in-line tibial runoff into the left foot (anterior 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 and distal (adductor canal) segments of the Left Superficial Femoral Artery with drug-coated balloon angioplasty and atherectomy. The Left Superficial Femoral Artery, which initially demonstrated severe (70 to 99%) stenosis on 2-D angiogram (involving the mid and distal (adductor canal) segments, heavily 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.
3. The left posterior tibial artery demonstrates 100% complete occlusion, involving the proximal and mid segments.
4. Left tibial runoff: 2-vessel in-line tibial runoff (anterior 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. 37271 -LT - Fem-Pop revascularization, initial vessel (straightforward, atherectomy_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. 75716 -59 - Angiography, bilateral lower extremity [Left] (Separately reportable: No prior catheter-based study available)
  5. 75625 -59 - Aortography, abdominal [Left] (Separately reportable: No prior catheter-based study available)
  6. 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