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Documentation Tip: Vascular Intervention

Posted on Mon, Feb 13, 2017
Documentation Tip: Vascular Intervention

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

“Peripheral Vascular Disease” is a huge, non-specific bucket. Operative notes need specificity for coding purposes.

Vascular interventionalists need to document three things for coding specificity:

1. Specific vessel(s) involved.

a. Anatomical name and laterality (R/L)

  • Artery
  • Vein
  • Previous bypass graft

2. Type(s) of lesion(s) identified and addressed.

a. Stenosis/blockage due to arteriosclerosis, embolus or thrombus. Note: the same area of blockage may have more than one etiology or two different lesions with different etiologies that are corrected in the same operation.

b. Detailed operative note with specificity is necessary for coding.
  • Example #1: The surgeon first removed an embolus from an artery and then they stent the stenosis where the embolus lodged. The embolus and its removal should be documented as should the arteriosclerosis and its stenting.
  • Example #2: The surgeon first stents an arteriosclerotic lesion proximally and then removes a thrombus distally. The surgeon should document a detailed procedure note that would include the specificity listed above in order to capture the accurate code.

3. Consequences of the blockages:
  • Claudication
  • Ulcers
  • Gangrene, dry/ischemic

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Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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2/14/2017 12:07:53 AM