Peripheral Angioplasty and Stenting (Iliac / Femoral / Tibial)
Right [left] lower extremity [critical limb ischemia / claudication / rest pain / tissue loss]: [iliac / superficial femoral / popliteal / tibial] artery [stenosis / occlusion] on imaging
Same
Right [left] [iliac / superficial femoral / popliteal] artery percutaneous transluminal angioplasty [and stenting]
[***, MD/DO]
[Resident/PA name]
Monitored anesthesia care with local: [X] mL 1% lidocaine at access site
The patient is a [age]-year-old [male / female] with [critical limb ischemia / disabling claudication / ABI X] secondary to [iliac / SFA] [stenosis / occlusion] confirmed on [CTA / MRA / duplex]. The risks, benefits, and alternatives including open bypass and conservative management were discussed and informed consent was obtained.
[Ipsilateral / contralateral] femoral access was obtained. Diagnostic angiography confirmed [focal / diffuse] [stenosis / occlusion] of the [iliac / SFA / popliteal] artery [X] cm in length. The lesion was crossed [with difficulty / without difficulty]. Post-intervention angiography demonstrated [<20% / <30%] residual stenosis with [no flow-limiting dissection / no distal embolization]. Runoff vessels showed [single-vessel / two-vessel / three-vessel] runoff to the foot.
The patient was positioned supine on the angiography table. The [right / left] common femoral artery was accessed [ipsilaterally / via contralateral crossover technique] using a [21-gauge micropuncture / 18-gauge access] needle under ultrasound guidance. A [6 Fr] sheath was placed.
Heparin [70-100 units/kg] was administered intravenously with a target ACT >200-250 seconds; additional heparin was administered as needed. Diagnostic angiography of the [iliac / femoral / popliteal] system was performed in [AP / oblique] projections. The target lesion was identified: [description of lesion: stenosis vs occlusion, length, location].
A [0.035-inch / 0.018-inch] guidewire was advanced across the lesion. [For occlusion: the lesion was crossed with a [recanalization catheter / support catheter] using [intraluminal / subintimal] technique.] A [X]-mm × [X]-mm angioplasty balloon was advanced and inflated to [X] atm for [X] seconds. Post-angioplasty angiography demonstrated [residual stenosis / flow-limiting dissection], prompting stent placement.
A [X]-mm × [X]-mm [self-expanding nitinol / balloon-expandable] stent was deployed across the lesion under fluoroscopic guidance. Post-stent angioplasty was performed to [X] atm. Completion angiography confirmed [<20%] residual stenosis with no dissection and preserved runoff.
The sheath was removed and hemostasis achieved with [manual compression / closure device (Angioseal / Perclose ProGlide)]. Distal pulses were confirmed.
None
None
Minimal
None
The patient tolerated the procedure well. Distal pulses were confirmed post-procedure. The patient was monitored for [2-4 hours] and discharged with [dual antiplatelet therapy (aspirin 81 mg + clopidogrel 75 mg) for [1-3 months] per SVS guidelines] and follow-up ABI at [4-6 weeks].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** lower extremity ischemia, *** stenosis/occlusion
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** artery PTA [and stenting]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: MAC with local
INDICATIONS: .PTAGE-year-old .PTSEX with *** ischemia/ABI ***. *** lesion on imaging. Consent obtained.
FINDINGS: *** access. Angiogram: *** [stenosis / occlusion], *** cm. Crossed ***. Post-intervention: <20% residual, no dissection. Runoff: *** vessel.
PROCEDURE:
Supine on angio table. *** femoral access under ultrasound. *** Fr sheath. Heparin *** units/kg, ACT ***. Diagnostic angio: *** lesion [stenosis / occlusion]. Wire across lesion. *** × *** mm balloon, *** atm × *** sec. [Stent: *** × *** mm self-expanding/balloon-expandable deployed.] Post-stent PTA. Completion angio: <20% residual, preserved runoff. Sheath removed, hemostasis with ***. Distal pulses confirmed.
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Monitored *** hours. DAPT *** months. ABI follow-up 4-6 weeks.
Signed: .ME, .MYDEGREE
.TODAYVariants
Subintimal Angioplasty (Chronic Total Occlusion)
The SFA occlusion was crossed via subintimal technique. A loop was created in the subintimal space with a hydrophilic wire and support catheter. Re-entry into the true lumen was achieved [spontaneously / with a re-entry device (Outback / Pioneer)] at the distal SFA / popliteal artery. Balloon angioplasty of the subintimal channel was performed. Stenting was required to maintain patency of the re-entry segment. Total occlusion supports the complex reporting designation; document "occlusion" explicitly.
Drug-Coated Balloon (DCB) Angioplasty
Given the femoropopliteal location and lesion characteristics [de novo / restenotic], a drug-coated balloon (paclitaxel-eluting) was used following pre-dilation with a standard balloon. The DCB was inflated for [2-3 minutes] per manufacturer protocol to allow drug transfer to the vessel wall. Stenting was avoided to preserve future bypass options. DCB angioplasty is preferred for femoropopliteal disease to reduce restenosis rates compared to plain balloon angioplasty.
Charting Tips
- Document the access site hemostasis method. Arteriotomy closure devices (Angioseal, Perclose) require specific documentation of device use and that hemostasis was confirmed before the patient left the table. Manual compression should note duration and that pulses were rechecked.
- Record runoff vessel status on completion angiography. Number of tibial vessels with runoff to the foot is a key quality metric and affects prognosis. Single-vessel runoff carries higher amputation risk and should be documented.
- For stent placement, document stent type (self-expanding vs. balloon-expandable), size (diameter × length), and final position. Self-expanding nitinol stents are standard for femoropopliteal disease; balloon-expandable stents are preferred for ostial common iliac lesions where precision deployment is required. For non-ostial external iliac and longer iliac lesions, self-expanding stents demonstrate superior outcomes (ICE trial, JACC CI 2017).
- ICD-10: I70.211-I70.213 (claudication by laterality), I70.221-I70.223 (rest pain), I70.231-I70.244 (with ulceration), I70.261-I70.268 (with gangrene). I70.92 (chronic total occlusion of artery of extremity) is sequenced as an additional code after the primary atherosclerosis code when CTO is present.
Documentation & Reimbursement Considerations
- Report Peripheral Angioplasty and Stenting (Iliac / Femoral / Tibial) as the primary service when it is the definitive operation performed.
- 2026 reporting lower extremity revascularization (LER) codes are organized by vascular territory. Each territory has standalone primary codes (0-day global) for the first vessel and true add-on services (ZZZ global) for each additional vessel.
- Straightforward vs complex: straightforward = any lesion with residual luminal patency (stenosis, even severe); complex = total occlusion (100%, no flow). In-stent restenosis is NOT automatically complex — classify based on whether it is a stenosis (straightforward) or an occlusion (complex). Primary codes carry 0-day global; add-on services carry ZZZ global (follows the primary's global period).
- Bilateral iliac interventions: for Medicare, report on a single line with bilateral-procedure reporting; reimbursement is 150% of the unilateral fee schedule amount. Do NOT use right- or left-side reporting on two separate lines for Medicare — that format applies to some commercial payers only. Verify payer policy before submitting.
- Selective catheterization reporting options are bundled into the 2026 LER primary codes when catheterization is performed to access and cross the vessel being treated.
- Document all three elements to support separate billing.
- Follow-up duplex surveillance, ABI checks, and subsequent interventions at different sessions are separately billable.
- Document vessel(s) treated with laterality, lesion characteristics (straightforward stenosis vs total occlusion, lesion length in cm), catheter access site, devices deployed (stent type, size, length), and clinical response. Straightforward vs complex designation determines the reporting tier and must be explicitly documented — 'occlusion' must appear in the note to support a complex code.