Ask Dr. Z

Patient had seizure earlier in day and is nonresponsive. CTA demonstrates basilar artery embolus, so a vertebral artery angiogram is done and confirms the occlusion, and then thrombectomy is performed. This angiography does not sound diagnostic to me, so is there any code for 2013 that can be billed for the catheterization of the artery in addition to the thrombectomy code (as code 36226 is for catheterization and angiography)?  These new cerebral codes are very confusing.

What code should be used for a suprapubic catheter check?  Existing suprapubic catheter was injected with contrast.  No evidence of occlusion but clot like mucous in drainage bag, which was treated by exchange of new bag.

Original Question: Can you help with this new (to me) device: EndoRE® Remote Endarterectomy Device.  I have a doctor using this procedure from an endarterectomy with distal atherectomy. Is this still considered an endarterectomy, or should these be billed as a true atherectomy? PRODUCT Description: "The MollRing Cutter® Transection Device is a tool designed to transect and remove the plaque core at the designated endpoint or site of the reconstitution of the artery. MollRing Cutters provide the ability to cut the core of the wall of the artery without tearing. The rounded bottom edge of the cutter ring allows for a smooth advancement from the proximal arteriotomy to the designated endpoint."

Follow-Up Question: Dr. Dunn answered a question for me last month. Is it possible to get a little more information? This group of doctors is doing an arteriotomy iliofemoral area. Doing an endarterectomy, then extending this "cutter" down and cutting the plaque in the popliteal and distally as far as the post tib. Should I be coding as endarterectomy iliofemoral and the popliteal etc.? Or when the cutting device is extended beyond the original vessels into seperately billable vessel, should I code these as atherectomy even though this isn't an approved device? These are all open procedures with an endarterectomy at the arteriotomy site, and then sometimes it is extended half way down the leg for a remote atherectomy.

I read the AMA Errata April 1, 3013 for ablations and the way it is worded... I thought that we no longer had to use modifier -52 or -74 (hospital) on the ablations codes where the EP portion is incomplete. But, I am told by a specialist that we still need to modify the ablations if there is not a complete EP study done. Is that correct?

Would you explain "inflow/outflow" and the "bypass zone"? Does the zone include the entire extremity or just the vessels and lesions that are contiguous to the graft? When would it be correct to code for other procedures (on the same extremity) during an open thrombectomy of a bypass graft?

The physician selectively cath/imaged the innonimate and then went to the left side via the left common carotid and did a left-sided unilateral study (intracranial).  I thought because the physician did not image the right side carotid/cerebral and only looked at the innonimate due to stenosis at the bifurcation at the arch/innonimate and then performed a left-sided study that the innonimate would be bundled into the left-sided study.  Can you report code 36222 separately for selective cath in the innonimate only?  Also, the vertebral comes off of the arch rather than the left subclavian.  If the doctor selectively cath/images the left vertebral, would it still be reported with code 36226?

I am aware of the rules surrounding multiple guidance; however, I had a case that caused me to pause. If a paracentesis or thoracentesis is performed along with a biopsy with guidance, will the guidance used with the biopsy not be coded since the guidance is bundled with the para/thora? My case was a para with ultrasound and a liver biopsy with CT guidance. Since CT is higher than the ultrasound, am I overthinking how this should look? Would it just be codes 49083 and 47000?

I have never coded for the epicardial access for EP ablation and have not been able to find information. Would you give your insight on what the following procedure coding would look like?

The patient was brought to the EP lab. The ICD was reprogrammed and interrogated. Both groins were prepped in the usual fashion. Local anesthetic was applied to the skin. Following a modified Seldinger technique, one 8 French sheath and one 11 French sheath were placed in the left femoral vein. A 4 French sheath was placed in the right femoral artery. Via the subxiphoid approach, epicardial access was obtained with an epidural needle and an 8 French flexible steel Arrow sheath. Mapping and ablation catheters were placed in the 9 French sheath and 9 French Arrow sheath. A 3D map of the epicardium was created. The 4 French arterial sheath was exchanged for an 8 French Arrow sheath due to the torturous nature of the aorta. During epicardial mapping an IBI HIS catheter was placed in the right and left ventricles for pacing. There was a patent foramen ovale present. The mapping and ablation catheter was advanced through the aorta to the left ventricle via the retrograde approach. Left ventricular pacing and recording were performed, a 3D map of the endocardium was created. Ventricular stimulation was performed and programmed ventricular stimulation was performed. Several different VT morphologies were induced by ventricular pacing. All of the VTs were mapped to an area posterior to the mitral valve. RF energy was delivered with termination of the VTs from within the left ventricle, epicardially, and from the anterior cardiac vein. Aspiration of the pericardial space was performed throughout the case. At the end of the procedure, protamine was given, Solumedrol 125mg was given via the epicardial sheath, the sheaths and catheters were removed, and good hemostasis was achieved with direct manual pressure.

What code should we use for AV fistula aneurysm excision? The graft wasn't revised at the end, and the transection wasn't quite at the anastomosis, so it wasn't like they repaired the native vessel's defect (so I guess I can't code it as a vessel repair). I know I wouldn't code it as revision with 36832. The doctor is coding it as 35011, but I don't agree. Please advise.

In your Interventional Radiology Coding Reference book (page 275) it states that if the stenosis is not hemodynamically significant to not code the venoplasty. What is considered hemodynamically significant? Our physicians frequently do venoplasty in the AV fistula for mild stenosis. What is considered "prophylactic"?

Is code 37607 used only when the AVF is completely ligated? Example: On page 363 of your Vascular & Endovascular Surgery Coding Reference, we are directed to use code 36832 for ligation of collateral veins that are preventing maturation. If the vein in the AVF is ligated due to steal of the flow, is 36832 still the correct code?

Physician performed: 1) Left carotid endarterectomy with patch repair - 35301.  2) Intraoperative carotid arteriogram (no cath placement documented).  3) Intracranial parenchymogram on the left side. 

I cannot find any information on what a parenchymogram is other than it has something to do with the capillaries. As it stands I can only see reporting code 35301.

We are having a debate at my facility... When the breast MRIs state CAD with 3-D for Non-Medicare, wouldn't this be reported with codes 77059 and 0159T for example, and an MC would have the C-code and 0159T? "INDICATION: Bilateral breast MRI new on-set microcalcifications patient history of breast CA. TECHNIQUE: The patient was positioned in the dedicated bilateral breast coil. Pre-Gadolinium sequences: Axial T2 TIRM, axial T2 turbo spin echo and axial T1 3D gradient echo. Post Gadolinium sequences: Following bolus intravenous administration of 10 ml of Gadavist, a dynamic series of T1 weighted 3D gradient echo sequences was obtained at one minute intervals out to 5 minutes. A high resolution sagittal T1 weighted series was also obtained. The images are submitted to the CAD stream dedicated breast MRI work station. The data from the dynamic series was used to construct angiogenesis maps displaying the enhancement characteristics. In addition coronal reformatted images were produced along with thin MIP, axial, sagittal and coronal images derived from the subtraction images as well as whole breast bilateral MIP reconstructions."

Would you recommend using code 92941 if the MD chooses the dx 410.XX (acute MI) diagnosis code, or does it have to specifically say "acute MI" or "AMI" in dictation? Most of our docs call it a STEMI or NSTEMI, but fail to mention the word "acute". I am assuming the most of them are acute?

I believe we can charge fluoroscopy guidance code 77003 with 64520. However, because there is an NCCI edit, I need a way to explain why we can modify this guidance. Would it be correct to say that the edit is for fluoroscopy related to the contrast injection only?

What is the difference between a limited Doppler (93321) and a complete Doppler (93320)?

IR order received for bilateral lower extremity venogram with embolization. "Clinical Indication: DVT with leg swelling. Right leg venogram performed with occlusion of common iliac vein with internal iliac vein collateral reconstitution of distal Iliac vein. IR physician performed PTA of right common iliac vein. Secondary to rebound change decision made to place common iliac vein stent to assist vessel patency."  My question is, should we request and receive an amended order?  Our IR physician is not her treating physician, but diagnostic venogram changed procedure needing to be done.

We had a patient present to the cath lab with AMI. Doctor documented that the "culprit" lesions were in both the LC and LD. Can we bill code 92941 more than once?

If the lesion that is stented is from the LC and extends into the OM1, do we code by the proximal location of the stent or the distal?

This is my second request regarding the correct coding for this particular procedure. It was an ultrasound/fluoroscopically-guided percutaneous access into the venous malformation in two separate areas. A percutaneous venography of the venous malformation times 2. Along with the injection of the Sotradecol into the lesion, three separate times, ten minutes apart. Would you be able to guide me to the correct codes for this procedure?

How should I code the following? "HISTORY: The patient is a 65-year-old female with previously placed right tunneled dialysis catheter. She has experienced persistent bleeding from the catheter tract. She was referred for catheter removal. After discussion with Dr. X, it was elected to attempt to thrombose the tract with FloSeal. PROCEDURE: Signed consent was obtained. The patient was prepped and draped in usual sterile fashion and local anesthesia was obtained with 1% lidocaine. A small dilator was inserted in the tract to the level above the retention cuff. The FloSeal gel matrix containing thrombin then injected into the tract. This procedure was repeated with several accesses along the tract. There is no evidence of continuation of the bleeding. CONCLUSION: Initially successful embolization of the bleeding catheter tract in the right chest using FloSeal."

We have a case where patient had a DES stent to the LD and PTCA the first diagonal. We reported codes C9600 and 92921; however, it keeps hitting an edit saying the add-on code is missing the base code. It seems that CMS has forgotten to add the DES codes to the edit. Is this correct?

How would you code an internal cardioversion through an existing ICD? I understand code 92961 is an open procedure and would not apply, and code 92960 would not be correct either. Can you help?

I am wondering how many times a sclerotherapy can be coded on a patient with multiple AV malformations (Klippel Trenaunay syndrome) within the same extremity.  They are all clearly documented as separate lesions.  There does not seem to be much information regarding this procedure, as it is currently coded with unlisted code 37799. Please define code 37799 and whether ot not it can be coded multiple times. Thanks!

Can both iliac stent placements be charged when they are used to treat occlusion on only one side?

During a stereotactic breast biopsy there was considerable bleeding at the puncture site. The physician administered D-stat through the biopsy need to stop the bleeding. I am not comfortable charging for this injection, as it was done during the procedure for a procedure-related problem. The techs would like to charge code 96372 for a therapeutic injection. What are your thoughts on this?

I have a question about codes 0078T/0079T etc. These procedures are done as co-surgeries mainly. When we bill the normal codes (34804), we bill them with a -62 modifier, but these temporary codes are not eligible for this. How should we handle this? Both of us are going to be billing. I know Medicare doesn’t reimburse, but are we okay to bill without the modifier?

One of our IR docs is taking a spot image after removal of a port and cath, and we are trying to determine if it is appropriate to bill code 77001-26 in this circumstance (pro fee side).  What are your thoughts?

Can code 75945 be reported with code 36147? The doctor did a fistulogram of the radiocephalic fistula (36147) with a balloon angioplasty of left cephalic vein (35476, 75978). He did an intravascular ultrasound of the left cephalic vein. The doctor states "intravascular ultrasound shows wide-open cephalic vein in the forearm but as suspected shows narrowing at the valve cusps, and the valve cusps can be seen on the IVUS, creating impingement of flow". I think that the IVUS is included in code 36147, but the department thinks it should be coded. What do you think?

Can we report code 93799 in 2013 for the following scenario? "60 year old male who presented with chest pressure and found to have a NSTEMI. EKG showed biphasic T-wave inversions in the anterior leads. Patient referred for coronary angiography. FINDINGS: 1) Co-dominant coronary circulation. 2) Hazy filling defect seen in the LAD ostium. 3) IVUS of the LAD revealed a thrombus in the LAD ostium with no lumen stenosis. 4) Successful aspiration (export catheter) thrombectomy with removal of the LAD thrombus no other intervention performed."

This question might be outside of your comfort zone, but I figure you have the resources at your disposal to give an authoritative answer. It revolves around the two codes 93797 and 93798. I want to know the AMA's thought processes behind the original intent of creating these two codes (with and without continuous ECG monitoring). Cardiac rehab has evolved since the creation of these two codes, including our payer's acknowledgement that cardiac rehab sessions involve more than just exercise (education, cardiac risk factor modification, counseling, etc.). As an organization, we are trying to determine if it is compliant to charge code 93798 for the initial Phase 2 session, which is comprised of gathering patient information, taking vitals, and a six minute treadmill test with continuous ECG monitoring. The session lasts approximately an hour, but only the treadmill test is performed with continuous ECG monitoring. Is that sufficient to report code 93798? What are your thoughts?

How would I code an open SMA thrombectomy that was performed from a brachial artery cutdown?

Patient had coil placed at a prior visit for an embolization of AV fistula collateral vein.  The patient is returning now exhibiting pain and redness to the area.  Physician performs cutdown to retrieve the coil.  Does this mean I should report code 36832, as physician is performing revision with removal of coils from collateral?  Or should I report unlisted code?

Please help us settle this great debate on whether this report should be coded as epidural steroid injections or a nerve root blocks. Should this be reported with codes 62311, 62311-59, 77003 or 64483, 64484? Your assistance is greatly appreciated.

CLINICAL HISTORY: Recurrent back pain and right radicular leg pain. FINDINGS: Fluoroscopically guided right L3-4 and L4-5 transforaminal epidural steroid injections. After informed consent is obtained the patient is brought to the interventional suite and placed in the prone position. Utilizing sterile technique after a local anesthetic under real-time fluoroscopic guidance 22-gauge needles are advanced into the epidural space at both levels via transforaminal approaches. A 5 cc injection containing 1 cc of 40 mg of Depo-Medrol, 2 cc of 2% Xylocaine, and 2 cc of 0.5% Marcaine is performed at each level. The needles are removed and hemostasis is spontaneously obtained. The patient tolerated the procedures well and there were no immediate complications. IMPRESSION: Fluoroscopically guided transforaminal epidural steroid injections as described in detail above.

 I work for a vascular surgeon, and I am not sure how to code this. I also know the thoracic surgeon has already billed and did not bill as cosurgeon, nor do I think they coded correctly. Co-Surgery approach - "Open removal of subclavian stent that is infected. Thoracic surgeon did thoracotomy with lung deflation on left. Vascular surgeon did removal of noncovered and covered stent in subclavian artery with transection and oversew of subclavian artery. Thoracic surgeon did closure and chest tube."

I can't find references for this question in your guide books. "Left femoral artery was accessed and up and over technique used to place the catheter into the right SFA. Angiogram was done. The catheter was then advanced to the distal popliteal and a second angiogram performed. Catheter was removed. Next the right femoral artery was punctured and a catheter was advanced to two branches the distal AT for angiography followed by embolization of an AVM."  Can I use codes 36247/36247-59 for third order catheter placements from two different access sites?

I am pretty sure that unlisted code 33999 would be reported for insertion of a temporary pacemaker through the femoral artery, into the left ventricle...correct?

I have a patient who already has a catheter in place draining a seroma/lymphocele in the breast. Via the catheter, absolute alcohol is administered and aspirated after a dwell time of an hour. I know that code 20500 can be billed for the sclerosing, but do I also bill code 76080 with it? Is code 76080 only billed when there is also an injection of contrast being done also? Can you explain why I would bill code 76080 in this instance?

I need help with a procedure for stenting of the lower extremity veins. The portion of the procedure I am in need of assistance with is included below.  Questions: 1) Can I charge for two stent placements in bilateral common iliac veins (37205, 37206, 75960, 75960-59), even though the right side was not stenosed? It seems to me the reason for the bilateral stent placements was done for the stenosis in the IVC. Or should I just charge for one stent for the left iliac stenosis? 2) Before stenting a balloon expanded, I don't think I should charge for angioplasty, as it is stated it was just for confirming the stenoses? Is this a correct assumption?

After wires were advanced into the iliac vein into the inferior vena cava a venography through the side arm of the sheath in the groin was carried out through the left side. Demonstrating a high-grade 80% stenosis of the left common iliac vein and distal inferior vena cava. Venography was then carried out through the side arm of the sheath in the right groin demonstrating a patent external iliac and common iliac artery, about 80% stenosis of the distal inferior vena cava as it joins the right common iliac vein with eccentric stenosis. A balloon was placed across the left common iliac vein. A waist confirmed the stenosis and a balloon was placed across the right common iliac vein and expanded confirming a waist in this area. The stents were then placed across both common iliac veins, extending into the distal inferior vena cava, 24 x 70 mm Wallstent on the left and 20 x 55 mm Wallstent on the right. These were postdilated with 18 x 40 mm XXL balloons in a kissing balloon technique. Completion venography shows good flow throughout the left external iliac, common iliac, and inferior vena cava. Venography through the right groin sheath showed good flow to the right external iliac and common iliac vein and into the inferior vena cava.

Original Question: Our physician is often lost with this "primary code to bill 76937".  He bills this with code 37221, and it often gets denied.

Follow-Up Question: Thank you for your responses on my previously sent question. I found today that Medical does not have code G0365 (vein mapping) in their Fee Schedule regardless of specialty. What are your thoughts on that?  Is there another code?

Original Question: Where can I find documentation on billing or not billing codes 35301 and 37215 on the same day in the same vessel?

Follow-Up Information Provided Upon Request: The doctor performed an endarterectomy of the carotid bifurcation into the internal carotid and also did one of the external carotid and did a patch angioplasty. Then he punctured the patch and placed a stent in the origin of the common carotid.

CPT describes code 36820 as "AV anastomosis open; by forearm vein transposition". CPT Assistant, July 2005, Vol 15, Issue 7 states: "CPT code 36820, Arteriovenous anastomosis, open; by forearm vein transposition, is used to report forearm vein transposition between the elbow and the wrist. CPT code 36818 represents a similar operation on the cephalic vein in the upper arm."  Would it be correct to think that code 36820 is the cephalic vein transposition in the forearm? Or can code 36820 be any vein? Any assistance would be appreciated.

We are in discussion with the hospital about billing for intervention on a branch of a major artery. We have a situation where the physician intervened on the LAD (92928, not during an MI), and there was some plaque shift into the diagonal branch of the LAD. Physician then did angioplasty (92921) on the diagonal branch. Can we show that this was performed? (I know we, as physicians, don’t get paid, but we need to show it was performed.) The hospital says no because the physician caused the shift of the plaque.

Provider inserted a dual chamber ICD with atrial and ventricular pace and sense shocking leads.  He additionally inserted an intravenous azygos vein defibrillation lead. Any coding recommendations on how to capture the azygos vein lead would be appreciated. Thank you!

Additional Information Received Upon Request: Percutaneous access to the left axillosubclavian system was then obtained in the usual modified Seldinger technique by inserting two J-tip wires into the inferior vena cava over a needle, using a front-wall puncture under fluoroscopic guidance over the first rib. A #10 blade was then used to incise skin around the fascia and the incision was carried down to the pectoralis fascia. The 9 French and 7 French side-arm sheaths were then advanced over the J-tip wires and placed in the superior vena cava. A 9 French SafeSheath, the right ventricular lead, which is Medtronic 694758, was inserted and prolapsed in the right ventricular outflow tract.  It was then positioned in the right ventricular septum and the helix was advanced under fluoroscopic guidance. Pacing and sensing thresholds were tested in this location. The sensed R-waves were 7.6 mV with a pacing threshold of 0.5 V at 0.5 msec. The impedance was 667 ohms. The lead was sutured to the underlying rectus fascia with suture sleeve, using two separate sutures of 0 braided silk. Following this, the right atrial lead, which was Medtronic #407645, was inserted through the 7 French side-arm SafeSheath and placed in the right atrium. It was then placed in the right atrial free wall. The helix was advanced under fluoroscopic guidance.  Pacing and sensing thresholds were tested. The sensed P-wave was 4 mV with a pacing threshold of 0.6 V at 0.5 msec with an impedance of 939 ohms. The lead was sutured to the underlying pectoralis fascial with suture sleeve using two separate sutures of 0 braided silk. Following this, the leads were connected to a Medtronic pulse generator, which is model number D314DRG. The entire system was then interrogated to confirm satisfactory functioning of the device. The sensed P-wave was 2.6 mV, and the sensed R-wave was 7.5 mV with pacing thresholds of 0.64 to 0.5 msec and 0.5 V at 0.5 msec respectively. The incision was extended to create a pocket to house the dual-chamber intracardiac defibrillator generator system and the leads. Defibrillation threshold was then performed. Initial defibrillation in the configuration of A to B (canned RV coil) were not successful at 20 joules, but they were successful at 35 joules x2, and defibrillation threshold testing was then attempted in the usual configuration of B to A, that is RV coil to superior vena cava coil and can, but it was not successful at 25 or 35 joules. Because of the absence of safety margin, and the patients severe left ventricular dysfunction, it was decided to implant an azygos transvenous coil to aid in lowering the defibrillation thresholds. Access to the axillary vein was then obtained over the second rib under fluoroscopic guidance. A J-tip wire was then advanced into the inferior vena cava, over which a 9 French side-arm SafeSheath was advanced, through which a 140 cm floppy Wholey guidewire was advanced into the inferior vena cava. A Worley 12 French SafeSheath was then advanced over the Wholey wire and was positioned in the superior vena cava in an Impress 5 French catheter. The azygos vein was cannulated in the AP projection, and the Worley Sheath was advanced into the azygos venous system.  An azygos venous lead, which was Medtronic 693758. Azygos venous shocking coil was then advanced and positioned behind the left ventricle. After the Worley Sheath was slit over the over the venous coil, this was connected to the superior vena cava port of the dual-chamber intracardiac defibrillator generator. The superior vena cava coil was then capped.  Defibrillation thresholds were then attempted again in configurations of RV coil to azygos coil and can, and reverse configurations of can to azygos coil and RV coil, and canned azygos coil alone. However, all the defibrillation thresholds failed at 35 joules, and the patient had to be externally rescued.  Finally, the patient was left with defibrillation vector of canned RV coil, which had been successful twice at 35 joules (please refer to the implant record for details regarding defibrillation threshold testing, including shock impedances, energies, charge times, pathways, cycle length of VF and VS configurations attempted. The pocket was then thoroughly flushed with antibiotic solution. The entire system was then placed into the pocket. The pocket was then closed in 4 layers with 2-0 Vicryl. Superficial skin closure was performed with Dermabond.

I am not able to get a straightforward answer on billing EVAR with modifier -62. Everything in print states that two surgeons are allowed to use this modifier. If an interventional radiologist and vascular surgeon are performing this procedure, but the radiologist does not make any incisions, then how can he or she be classified as a surgeon?

"1st lesion intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the 1st obtuse marginal 2nd intervention: A successful stent with balloon angioplasty was performed on the 99% lesion in the 2nd obtuse marginal 3rd intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the right posterior descending artery. 4th intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the mid RCA."

I am reporting codes 92928-RC, 92929-RC (right posterior descending), and 92929-LC (1st obtuse). Can you code for the 2nd obtuse (92929-LC)? Per CPT: Additional PCI in a third branch of the same major coronary artery is not separately reportable. Since there are two PCI in one branch and one PCI in another, could you use code 92929 three times? I understand that Medicare considers the add-on code bundled into the base code.

How would you recommend coding this case?

PROCEDURES: 1. Abdominal aortography. 2. Bilateral lower extremity runoff. 3. Access to the right and left common femoral arteries. 4. Successful percutaneous transluminal angioplasty and stenting of a left external iliac 70% stenosis to less than 10% with a 6 x 30 Zilver self-expanding stent. 5. Successful atherectomy, percutaneous transluminal angioplasty and stenting of a right 100% common iliac, external iliac and proximal common femoral artery with a 1.7 laser, 6 x 80 Zilver, 7 x 80 Zilver and a 7 x 40 Zilver self-expanding stent. DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the cardiac catheterization laboratory. Using approximately 10 mL of 1% lidocaine, the left groin was anesthetized and 5 French sheath placed in the left common femoral artery. I then placed an Omni Flush catheter to the level of the distal aorta and performed abdominal aortography, then pulled the catheter down to the level of the iliac bifurcation and performed bilateral lower extremity runoff. FINDINGS: Aortic pressure 156/72. ABDOMINAL AORTOGRAPHY: Normal bilateral renals. Diffusely diseased distal aorta, approximately 40% stenosis. BILATERAL EXTREMITY RUNOFF: The right lower extremity: The distal common iliac approximately 70% stenosed. The ostium of the internal iliac with approximately 80% stenosis. The proximal external iliac to the proximal common femoral artery is occluded. Widely patent profunda and SFA. Three-vessel runoff to the foot. Left lower extremity: The left common iliac approximately 70% stenosed. Internal iliac is patent. External iliac is widely patent. Common femoral artery and profunda are widely patent. SFA is widely patent with three-vessel runoff to the foot. INTERVENTION: We then placed a 5 French 55 cm Raabe sheath to the level of the right common iliac and then used a Prowater wire with the support of an 0.018 Quick-Cross and crossed the 100% CTO at the distal common iliac, external iliac to the common femoral artery. Then performed selective angiography at the level of the right SFA to confirm placement. Then performed intravascular ultrasound of the right common iliac, external iliac and common femoral artery showing homogenous/heterogenous plaque. Reference vessel approximately 4.5 mm and then used a 1.7 laser at 50/40 and 60/60 resulting in approximately 80% residual. I then placed a 6 x 80 and a 7 x 80 Zilver self-expanding stent to the level of the internal iliac. There was an obvious dissection proximally. I then tried to place a 7 x 40 stent across the proximal aspect but stenting could not pass it. After multiple attempts even posted the stents with a 6 x 100 Cook LP balloon. There was an obvious dissection proximal to the stent. Therefore, accessed the right common femoral artery and placed a 6 French sheath. Then through this 6-French sheath placed the 7 x 40 Zilver self-expanding stent in the right common iliac and then performed post-balloon inflation with a 6 x 100 balloon resulting in approximately 30% residual throughout; however, there was still the sheath in the right groin still obstructing flow. Therefore, performed PTA two more times in the distal external iliac stents with a 5 x 20 balloon. We then turned our attention to the left common iliac 70% stenosis and performed stenting with a 6 x 30 Zilver self-expanding stent resulting in less than 30% residual. ASSESSMENT AND PLAN: 1. Successful percutaneous transluminal angioplasty and stenting of a right common iliac, external iliac and common femoral artery 100% stenosis to less than 30% with a 1.7 laser, 6 x 80 Zilver self-expanding stent, 7 x 80 Zilver self-expanding stent, a 7 x 40 Zilver self-expanding stent resulting in approximately less than 30% residual. 2. Successful stenting of the left common iliac 70% stenosis to less than 30% with a 6 x 30 Zilver self-expanding stent.

I have a request for a misc charge 33999 to capture reposition of loop recorder. I'm not sure this would be a valid charge. Everything I find indicates that repositioning should be included at the time of the loop recorder insertion with code 93620. Please advise.

After my physician made an incision by the anastomosis, he placed a segment of PTFE graft around her fistula as a band (steal syn.). Then a separate long longitudinal incision was made, and this part of the fistula was mobilized.  Code 36832 is a separate procedure designation. So I do not think I can bill code 36832 with 37607. The patient has Medicare. Also when could I bill these two codes together? Any guidance is helpful.

Our vascular surgeon was asked to place a sheath for a cardiology intervention for VAD and RFA with a percutaneous placement on day 1 and an anticipated open closure on day 2. Please kindly review the reports below, as we would appreciate any guidance on appropriate code selection for these.

Day 1: Under ultrasound guidance, micropuncture needle was used to gain access into the common femoral artery. Micropuncture wire micropuncture sheath was placed. Oblique angiogram was performed confirming my entry site in the common femoral artery and a patent SFA, common femoral, and profunda over a 0.035 and then 10,000 units of systemic heparin was given. Over a 0.035 stiff wire serial dilatation was performed and a 14 French sheath was placed. At this time, I had stepped out and Dr. X is going to continue with his ablation and ventricular assist device and I will be back for the open closure of this arteriotomy. The sponge and instrument count for my part of the procedure was correct.

Day 2: The right groin, including the sheaths were prepped and draped under aseptic precautions. An oblique incision was made including the sheaths in the artery and the vein. Subcutaneous tissue was dissected. There was significant hematoma. There was a tear in the arterial sheath outside the artery that probably caused all this groin hematoma and scrotal hematoma. The common femoral, profunda and superficial femoral artery were controlled with vessel loops, clamped, and then the sheath was removed. Arteries were flushed antegrade and retrograde, and then the arteriotomy was closed with 6-0 Prolene interrupted sutures. Before finishing the closure, vessels were flushed antegrade retrograde and then flow was resumed into the leg. Then on the sheath in the venous part, the vein was controlled proximally and distally with vessel loops and an occlusion clamp was applied. The sheath was removed. Venotomy was closed with 6-0 Prolene interrupted sutures.  Irrigation was performed. Hemostasis was confirmed. Deep tissue was approximated with 2-0 Vicryl interrupted sutures. Subcutaneous tissue was approximated with 3-0 Vicryl interrupted sutures. Skin was approximated with 3-0 nylon vertical mattress sutures. Antibiotic ointment and a dry dressing was given. The patient was returned to the intensive care unit in stable condition. Sponge and instrument count was correct.