March 2023
H&P: 83 y/o female presents to vascular clinic with PMH of intermittent transient attacks. Patient admitted to hospital last month with confusion and stroke-like symptoms. MRI and CT scan negative. Angiography of the carotid arteries performed and found to have right internal carotid artery stenosis. Patient referred for evaluation for possible transcarotid artery revascularization (TCAR) due to age, history of CHF, CKD, and HTN. Patient now admitted for right TCAR.
PMH: Chronic systolic CHF, EF 40%, HTN, CKD stage 3 (baseline creatinine 2.0). No history of DM.
Home medications: Lasix, Lisinopril, ASA.
OR report Synopsis: A transverse 2-4 cm incision was made between the sternal and clavicular heads of the sternocleidomastoid muscle, below the omohyoid. Following longitudinal division of the carotid sheath the jugular vein was partially dissected and retracted medially. Once 3 cm of common carotid artery (CCA) were isolated, umbilical tape was placed around the proximal 1/3 of the CCA under direct vision. A 5.0 polypropylene suture was pre-placed in the anterior wall of the CCA, in a “U stitch” configuration, close to the clavicle to facilitate hemostasis upon removal of the arterial sheath at completion of the TCAR procedure. A 4-French non-stiffened ENHANCE® Transcarotid / Peripheral Access set was used, puncturing the artery with the 21G needle through the pre-placed “U” stitch while holding gentle traction on the umbilical tape to stabilize and centralize the CCA within the incision. The provided 0.035″ J-tipped guidewire was inserted as close as possible to the bifurcation without engaging the lesion. After micropuncture sheath removal, the Transcarotid Arterial Sheath was advanced to the 2.5cm marker and the 0.035” wire and dilator were then removed. Arterial Sheath position was assessed under fluoroscopy in two projections to ensure that the sheath tip was oriented coaxially in the CCA. The Arterial Sheath was sutured to the patient with gentle forward tension. Blood was slowly aspirated followed by flushing with heparinized saline. No ingress of air bubbles through the passive hemostatic valve was observed. The stopcocks were closed. Traction applied to the CCA previously to facilitate access was gently released. The Flow Controller was connected to the Transcarotid Arterial Sheath, prepared by passively allowing a column of arterial blood to fill the line and connected to the Venous Return Sheath. CCA inflow was occluded proximal to the arteriotomy with a vascular clamp to achieve active flow reversal. To confirm flow reversal, a saline bolus was delivered into the venous flow line on both “High” and “Low” flow settings of the Flow Controller. Angiograms were performed with slow injections of a small amount of contrast filling just past the lesion to minimize antegrade transmission of micro-bubbles. Prior to lesion manipulation, heart rate (70bpm) and systolic BP (140-160mmHg) were managed upwards to optimize flow reversal and procedural neuroprotection. The lesion was crossed with an 0.014” ENROUTE® guidewire and pre-dilation of the lesion was performed with a 5mm x 20mm rapid exchange 0.014” compatible balloon catheter to 8 atmospheres for 10 seconds. Stenting was performed with an 9mm x 40mm ENROUTE® Transcarotid stent, sized appropriately to the right CCA. AP and lateral angiograms (gentle contrast injections) were performed to confirm stent placement and arterial wall stent apposition. At TCAR case completion, antegrade flow was restored by releasing the clamp on the CCA then closing the NPS stopcocks to the flow lines. The Transcarotid Arterial Sheath was removed and the pre-closure suture was tied. Heparin reversal was employed and a drain was placed. The Venous Return Sheath was removed and hemostasis was achieved with brief manual compression.
Discharge Summary: Right carotid artery stenosis, s/p right TCAR
Discharge Medication: ASA, Plavix, continue home medications
Discussion of Transcarotid Artery Revascularization:
Transcarotid artery revascularization (TCAR) is a fairly new procedure used for patients at high risk for CEA that uses a new technology – Reverse Flow Embolic Neuroprotection. The Reverse Flow Embolic Neuroprotection procedure is performed during TCAR to reduce the risk of stroke with placement of a carotid artery stent. Conventionally, access for carotid artery stenting is obtained via the femoral artery with the instrumentation being advanced under fluoroscopy to the site of plaque obstructing the carotid artery. TCAR is a variation on placement of a carotid artery stent. In TCAR, access is obtained directly at the carotid artery below the plaque, precluding the need to navigate instrumentation throughout the peripheral and central vasculature and reducing fluoroscopy exposure time. During the Reverse Flow Embolic Neuroprotection procedure performed with TCAR, an extracorporeal circuit is created intraoperatively to temporarily redirect and reverse blood flow away from the carotid artery during placement of the stent. Flow reversal keeps debris moving away from the brain, protecting it from emboli.
-TCAR with Reverse Flow Embolic Neuroprotection is coded with two ICD10 PCS codes – one for the TCAR (percutaneous dilation of vessel using an intraluminal device) and the New Technology Add-On Payment for the Reverse Flow Embolic Neuroprotection device – either X2AH336 or X2AJ336 depending on which artery was used.
What to look for: Within the OR report, look for flow reversal using the Enroute System or NPS system – both of these are indictive of the Reverse Flow Embolic Neuroprotection device being used.
UASI Recommends: Since all TCARs are performed with the reverse flow embolic neuroprotection, if the operative procedure doesn’t specify this, a query would be recommended to capture the second procedure code. There is no change to the DRG/SOI/ROM, but there is additional revenue with the new technology add on payment
Documentation without Clarification:
- Principal Diagnosis: Right internal carotid artery stenosis
- Secondary Diagnosis: Chronic systolic CHF, HTN, CKD stage 3
- Procedure Code: 037K3DZ- Dilation of right Internal carotid artery with intraluminal device, percutaneous approach
- Working DRG: 035 Carotid artery stent procedures with CC; RW: 2.2838 GLMOS: 2 SOI/ROM: 2/2
Documentation with Clarification:
- Principal Diagnosis: Right internal carotid artery stenosis
- Secondary Diagnosis: Chronic systolic CHF, CKD stage 3, HTN
- Procedure Code: 037K3DZ- Dilation of right Internal carotid artery with intraluminal device, percutaneous approach; X2AH336- Cerebral embolic filtration, extracorporeal flow reversal circuit from right common carotid artery, percutaneous approach new technology group 6
- Working DRG 035- Carotid artery stent procedures with CC with new technology add-on payment RW: 2.2838 GLMOS: 2 SOI/ROM: 2/2
CDI Educational Tips:
- Transcarotid artery revascularization procedures are performed with Reverse Flow Embolic Neuroprotection. This is a new-technology add-on payment. It is imperative for CDI to work with coding Professionals in capturing appropriate procedure codes to ensure accurate reimbursement for complex procedures.
Reference: SilkRoad Medical. “Enroute Transcarotid Neuroprotection System”. Accessed February 8, 2023.
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This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.