by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC
Question:
A provider performed angioplasty of the tibioperoneal trunk. Pre-treatment stenosis was 100%, post-treatment stenosis is documented as 50%, and it is documented as follows in the report:
“We balloon dilated the right tibioperoneal trunk to 6 Atm for 2 min with a 2.5 mm by 100 mm Coyote balloon from Boston Scientific. Pre-treatment stenosis was 100%. Post-treatment stenosis was 50%. The distal most peroneal artery could not be traversed but there appeared to be improvement of flow into collaterals.”
The payer is denying payment with these remarks:
“Per CPT, the clinical documentation provided in the narrative operative report does not sufficiently describe or support the requisite criteria for approval of the requested CPT code. As such, CPT 37228 is denied as not documented. A significant residual stenosis is documented.”
So, basically, they’re denying payment of revascularization because he could only open this completely occluded vessel to 50%. Is there some definition of technical success that must be met in order to bill a revascularization?
Answer:
Not to our knowledge. Angioplasty was done and should be paid as such. If only attempted, for OPPS coding, we would report with a -74 modifier. But in this case, it was actually done.
We would definitely appeal. It went from 100% occlusion to 50%, which obviously shows a positive result from the angioplasty!
Updated for 2023!
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