Knowledge Base Article

Dilemma:What are the ICD-10-PCS codes for the following procedures?

CLINICAL HISTORY: A 72-year-old man with known PAD of his right lower extremity, status post right fem-pop and subsequent intervention.

The patient was counseled as to risks, benefits and alternatives of the procedure. After yielding a full and informed consent, he was brought to the cath lab where he was prepped and draped in the usual fashion.

Initially, a short 4-French sheath was introduced in the left common femoral artery using modified Seldinger technique. We went in with a 4-French universal flush catheter and engaged the right common iliac artery. We advanced a Glidewire Advantage into the right profunda and subsequently exchanged for a 6 x 45 cm destination sheath which we put in the distal right common femoral artery. We then took angiograms confirming occlusion of the right fem-pop stent with distal reconstitution of the popliteal artery by profunda collaterals with 3-vessel runoff below the knee.

We then used a Glidewire Advantage and a Quick-Cross catheter to blunt dissect through the occluded segments of the fem-pop graft. We were able to easily reconstitute into the distal true lumen, which we confirmed through a test injection. Due to the ease of traversing this occluded segment of the fem-pop, I was concerned of a significant thrombus burden. We therefore exchanged out for a 5-mm filter wire and performed AngioJet thrombectomy along the entire course of the graft. There was still occlusion at the proximal portion due to a proximal cap lesion. We therefore performed laser atherectomy of the entire graft with a 2.0 Turbo Elite laser paying particular attention to the previously stented segments of the proximal and distal ends. We subsequently ballooned with a 5 x 300 mm Pacific balloon. This did restore flow down the graft. There were still some issues at the stented segments with significant stenosis proximally and in the distal stented segment near the anastomosis. We therefore used a 6 x 120 balloon distally, this was a drug-eluting balloon. We then used a 6 x 80 mm drug- eluting balloon proximally. There was still hazy area with restricting flow down the graft in the very proximal portion of the graft at its anastomosis. I therefore elected to place a 9 x 20 mm self-expanding stent back into the common femoral across the profunda. We ballooned this with a 6 x 80 a drug- eluting balloon, the old balloon, and then took wire out shots. Initially there was some slowish flow due to the filter being clogged. We ended up capturing the filter and taking a subsequent angiogram which showed brisk flow down the leg with preserved 3-vessel runoff below the knee. The patient was given a 300 mg Plavix bolus. We did use Angiomax as the anticoagulant and an ACT was checked to ensure adequacy during the procedure.

PROCEDURES PERFORMED

1. Right lower extremity angiography.
2. Primary thrombectomy of the right fem-pop graft.
3. Laser atherectomy, balloon angioplasty and stenting of the right fem-pop graft.

Solution:

• 04CK3ZZ – for extirpation of the femoral artery. (AngioJet thrombectomy & laser atherectomy)         
• 047K3ZZ – for dilation with Pacific balloon
• 047K3Z1 – for dilation with drug-eluting balloon           
• 047K3D1 – for dilation with drug-eluting balloon and stent placement
• The angiograms cannot be coded without further clarification of what type of contrast was used, if applicable, and whether or not fluoroscopy was used.

Resource(s):

• Coding Clinic ICD-10-CM/PCS, 1Q 2015, page 36
• ICD-10-CM and ICD-10-PCS Coding Handbook, by Nelly Leon-Chisen, RHIA