Ask Dr. Z

Can we report 36905 (balloon angioplasty, peripheral dialysis segment, including all imaging, radiological supervision) with 76937 (US guidance for vascular access requiring US)? We were previously told that 76937 is included.

A patient with an AV graft undergoes open thrombectomy of the graft, along with balloon angioplasty and stenting of the axillary vein. Selective cath and thrombectomy of the radial artery are also performed as follows: "....Fistulogram was performed, which showed evidence of persistent thrombus in the proximal AV graft. There was also evidence of thrombus at the origin of the radial and interosseous arteries. Wire was then directed in the radial artery under fluoro guidance. A Fogarty balloon was then passed into the proximal radial artery, and a thrombectomy was performed until all clot was evacuated. A completion angiogram was performed of the left forearm and hand that showed no residual thrombus and improved flow through the radial, interosseous, and ulnar arteries." We have 36833 for the open thrombectomy with axillary angioplasty and stenting. Is the radial artery thrombectomy to be reported with 34111? 37186 and 36215? Would we also need code 75710?

"A 2.2 cm CP covered stent mounted on a 16 mm x 2.5 cm BIB balloon was implanted in the proximal aspect of the RV to PA conduit (5ATM). After this stent was implanted, my doctor did balloon angioplasty again. The CP stent was future balloon dilated with a 16 mm x 2 mm Vida up to 14ATM." I know we cannot report balloon angioplasty before we implant the stent, but my doctor usually does balloon angioplasty again after he implants the stent. Should I report this balloon angioplasty (92997) ?

Would CPTs 36581, 36595-5952, 75901 or 36581, 77001 be appropriate for the following procedure? "The right neck was prepared and draped in sterile fashion. The patient's existing catheter was prepared and draped. A wire was passed through the catheter into the inferior vena cava under fluoroscopic guidance. The catheter was removed through the existing tunnel. A 10 mm x 4 cm balloon was placed through the existing tunnel into the lower superior vena cava and right atrium. Balloon angioplasty was performed with the intention to remove any residual fibrin sheath in the lower superior vena cava and right atrium. The balloon was removed. The patient's catheter was replaced with an identical line. The catheter was flushed and sutured into place. There were no immediate complications. A final spot radiograph shows the tip of the catheter to be in the right atrium."

"Diagnosis: Left arm AV graft pseudoaneurysm with very thin overlying skin. Procedure: Loopogram with stent placement and revision of left arm AVG. A 5 French micropuncture needle was used to access the AV graft at the apex, and the micropuncture sheath was inserted. A loopogram was performed, revealing the large pseudoaneurysm at the arterial limb. An 8 French sheath was then inserted and exchanged over a J-wire, then a Bentson wire was inserted across the lesion. A 7 mm x 10 cm Viabahn covered stent was deployed across the area of the pseudoaneurysm, and balloon angioplasty was performed. Repeat imaging revealed resolution of the pseudoaneurysm. Wire/sheath were removed. A 4-0 Prolene U stitch on an RB needle was performed. Next, the area of the thin overlying skin was removed in elliptical fashion, and then the healthy skin was closed with 3-0 nylon vertical mattress sutures in an interrupted fashion." Should we code separately for removal of skin, as the stent was placed percutaneously? What code(s) should be used?

"We started the procedure by locating the left arm cephalic vein fistula. Access was achieved, and a 5 French was advanced without difficulty. Left brachiocephalic AV fistula angiogram and central venogram done, and a recurrent stenosis at left cephalic arch was noted and crossed with torque wire. Balloon angioplasty of cephalic arch with 8 x 40 mm Charger balloon (36902). Completion angio shows excellent flow via cephalic arch without residual stenosis. We then noticed presence of chronic clot adherent to proximal cephalic vein at aneurysmal segment without complete occlusion. Another access was done with micro puncture kit and proximal location and upsized to 8 French. We utilized an 8 French LIMA guide for suction thrombectomy and were able to remove some clot from cephalic vein. Completion angio shows some residual clot at cephalic vein without any flow compromise. Repeat duplex US shows residual clot, which was not able to be removed with suction catheter." For the thombectomy, since it is being done via a separate access site, would this be 36905-59 or 37187-59?

"12-year-old male with congenital heart disease of double outlet right ventricle, ventricle septal defect, interrupted aortic arch, sub aortic stenosis, and hypoplastic ascending aorta. He is status post arch reconstruction, aortic balloon angioplasty, and balloon angioplasty of the RV-PA, pulmonary valve replacement, and pulmonary valve conduit homograft and a 2018 Melody Wave implant. A selective PA demonstrates moderate insufficiency of the Melody Wave; angiography provides severe distal Melody Wave stenosis secondary to moderate sized vegetation. Now - status post successful balloon valvuloplasty of Melody Wave." I am not finding a listed CPT code for a Melody Wave valvuloplasty. Would this be unlisted code 377999? Can I charge 93533, 93566, 93568, 93567 for this patient's cath procedures?

During an attempt to create an endovascular AV fistula, the physician performed a balloon angioplasty of a lateral branch of the cephalic vein to try to disrupt the valve in order to allow the deep system to fill the superficial system, allowing him to proceed with the endo AV fistula creation; however, it was unsuccessful. Would it be appropriate to code for the balloon angioplasty in this setting?

I see conflicting info on submitting 61645 and 37215 (with DEP) together. In some of these Q+A's on this site it says bill both, but #47 instruction states this: 47) Cerebral artery thrombectomy code 61645 bundles ipsilateral catheter placement, diagnostic imaging, thrombolysis, intracerebral balloon angioplasty, and/or stent placement, vasospasm therapy, and follow-up imaging." I just would like to know what is correct. I know some of the advice was older, but I'm wondering what your take on this is now?

Successful PCI of LAD and diagonal, initially treated with main branch stenting (3.0 x 30 mm in LAD, post-dilated to 3.25 mm) and provisional balloon angioplasty of diagonal however the diagonal branch did require stenting after this. Therefore, reverse mini-crush technique used with 2.5 x 15 mm DES placed to diagonal, crushed, final kissing inflation with 0% residual and TIMI 3 flow in both branches There is a bifurcation lesions-successful-crush technique. Would 92928-LT and 92929-LT be appropriate here for the intervention? I've not seen a crush technique before.

"Our physician performed a balloon angioplasty of a right-sided axillary-femoral artery bypass at both the proximal axillary and the distal profunda femoral ends of the bypass. Using an abdominal incision, we maneuvered to the proximal axillary end, performed angiogram and angioplasty, and then repeated the process at the distal profunda end." Is the selective catheter movement to the proximal axillary end of the bypass billable? We used two balloons to treat the stenosis at both ends of the graft; are both angioplasties billable?

Procedure performed 1. Right femoral and left femoral arterial access 2. Left femoral venous access 3. Temporary pacemaker placement and removal 4. Aortic valvuloplasty with a 20 mm balloon 5. With a transcatheter aortic valve replacement 23 mm sapien 3 valve 6. Balloon angioplasty of the right common femoral artery 7. Art Line.

Would the professional CPT code for this case only be 33361, as the other elements are included in the procedure?

Patient with bilateral 70% common iliac stenosis and 80% bilateral external stenosis treated with combination of bilateral orbital atherectomy and bilateral drug-coated balloon angioplasty. Would this be coded as 37220-50, 37222-50, 0238T x 4? Or 37220-50, 0238T-50 x 2? Thank you!

How should intravascular lithotripsy for peripheral vascular disease be reported? Description of procedure from report: "We confirmed placement of a 0.014 Quick-Cross and confirmed that we were in the dorsalis pedis artery beyond the occlusion. We then used the shock wave lithotripsy catheter to break the calcium in the dorsalis pedis vessel as well as anterior tibial artery using serial pulses. Contrast injection confirmed luminal gain, and this was then touched up with balloon angioplasty. We placed a 3.5 x 4 mm balloon in the dorsalis pedis and brought it up for prolonged inflation."

My physician stented a popliteal aneurysm and subsequently performed a balloon angioplasty of a lesion in the SFA of the same leg. Would both 37236 and 37224 be appropriate in this instance?

"With a NaviCross catheter and a stiff angled Glidewire, access was ultimately gained to the inferior vena cava, confirmed by injection in the inferior vena cava. The wire was then exchanged through the catheter for a Storq wire. The catheter was then withdrawn. A 7 mm percutaneous transluminal balloon angioplasty was performed to the level of the inferior vena cava, all the way to the level of the femoral vein, through the external iliac vein and common iliac veins via inflations to 10 atmospheres at 30 seconds x4. Venous balloon angioplasty was performed in order to expose more fibrin receptors in this chronic DVT setting for improved thrombolysis." I want to verify that the angioplasty cannot be coded. It was not done specifically for maceration, which is not allowed, but the reason for it does not seem justified for coding either.

"Procedures performed are: 1) Ultrasound-guided right femoral access. 2) Aortoiliac arteriogram. 3) Left lower extremity arteriograms with runoff. 4) Second order cannulation of the left popliteal and superficial femoral arteries. 5) Drug-coated balloon angioplasty of the left superficial femoral artery. Provider documentation: An Omniflush catheter was placed into the visceral segment of the aorta. Aortic and bilateral iliac arteriogram was performed. This revealed a widely patent infrarenal aorta. Patent common iliac arteries on both sides. Patent external iliac arteries and patent bilateral proximal internal iliac arteries. Internal iliac arteries after bifurcation into the anterior and posterior divisions had segmental mild to moderate stenosis. The catheter was then advanced into the left distal external iliac and left lower extremity arteriograms performed. Cath advanced to superficial femoral artery, angio performed and drug coated balloon angio was performed." Can we code 36246-LT for left external iliac angio, 37224, 75625, and 75710? 

"I then proceeded with interventional therapy that consisted of just wire manipulation past the RI/ostial occlusion. The wire traversed through the RI thrombotic occlusion and just with passage of the wire, we reestablished brisk TIMI 3 flow. We required no balloon angioplasty or thrombectomy." Patient came in with chest pain but did not meet criteria for a STEMI, but rather a non-STEMI. How would I code this intervention done with just the wire?

Patient has atherectomy performed of mid SFA to distal popliteal artery, then drug-coated balloon angioplasty of same vessels. Do you report two codes for atherectomy (one for each vessel), and do you also add the angioplasty with drug-coated balloon as additional code(s) (one per each vessel)?

For the following, should the angioplasty be charged separately? "RPA Stent: The RPA was entered using a 7 French wedge catheter for a placement of a 035 Amplatz SS wire. The sheath was advanced to the proximal RPA. The distal RPA measured 15 x 13 mm, while the area of stenosis measured 13 x 14 mm. Therefore, the decision was made to implant a 16 mm ev3 26 mm stent over a 16 x 3 BIB balloon. After verifying the stent position by performing a test angiogram through the sheath, the stent was deployed at 5 ATM. RUL Balloon Angioplasty: The RUL segment was being overlapped by the RPA stent. In order to preserve good flow to the RUL segment, the RUL was entered using a 014 Whisperwire over a 7 French wedge catheter. The wire was exchanged to a 018 V-18 wire for balloon angioplasty. An 8 x 2 Advance LP balloon was inflated across the RPA/RUL junction x 2 to 8 ATM. Post angioplasty angiogram showed widely patent and unobstructed perfusion to the RUL segment." 

Can 37246 be coded in addition to 36902 in this case, or is it part of the fistula? "POSTOPERATIVE: Flow dysfunction in left forearm radial artery to cephalic vein arteriovenous fistula plus greater than 70% stenosis of the left radial artery. PROCEDURES PERFORMED: 1) Retrograde needle access in the left cephalic vein with placement of sheath. 2) Selective catheterization of left radial artery. 3) Selective angiogram of the left radial artery with runoffs. 4) Angioplasty of the left radial artery. 5) Angioplasty of the left cephalic vein. DESCRIPTION: A needle was placed into the left cephalic vein retrograde. A wire was passed, a sheath was placed, and then over wire technique was used to place a catheter into the left radial artery. Left radial artery selective angiogram was performed with runoff showing a greater than 70% stenosis of the left radial artery and left cephalic vein. Balloon angioplasty was then performed in the left radial and left cephalic veins. Post angioplasty angiogram showed good results. No residual stenosis and good flow."

Can you advise what code we should use on this case? We are not sure if 36245, 37236 or unlisted? "There is no occlusive disease present in the celiac. DX: Focal aortic dissection of the paravisceral abdominal aorta. Balloon angioplasty and stenting of the celiac origin to cover aortic fenestration feeding focal aortic dissection. Under ultrasound the right common femoral artery was percutaneously accessed using a 21 gauge MP set. This was transitioned over a Wholey wire to a 7 French sheath. Next, a 7.0 French Oscor twist conformable sheath was advanced over the Wholey wire from the right femoral into the abdominal aorta. A lateral aortogram was obtained, which revealed the location of the origin of the celiac artery with fast filling of a focal aortic dissection adjacent to the celiac artery origin. Next, the conf sheath and Wholey wire were used to selectively catheterize the celiac artery. Next, a 7 x 19 mm Gore VBX balloon-expandable covered stent was positioned across the origin of the celiac artery and successfully deployed."

Patient presents with severe venous stenosis and occlusion in both legs. Bilateral caths were placed, and bilateral venograms and pullback IVUS were performed. “At this point, balloon angioplasty followed with placement of a pair of 14 x 6 Atlas balloons into the inferior vena cava filter and simultaneous balloon angioplasty for opening the filter and smashing it against the wall of the inferior vena cava, and this was successful. We then proceeded to treat down to the level of the femoral vein with balloon angioplasty.” After the destruction of the filter, bilateral stents were placed in the legs. How would you code this deliberate smashing of the filter? Would it be considered repositioning, angioplasty, or unlisted? There was no mention of a return to the OR for removal of the filter.

Would the following be coded as 36830? "Patient with left arm radiocephalic AVF presents for placement of hybrid graft. The left axilla was inspected with US. The previously placed axillary/basilic vein stents were ID'd. The axillary vein was punctured under US guidance. A small incision was made over the puncture site, and a short sub-q tunnel tract was created. A sheath was passed into axillary vein. The hybrid graft/Viabahn stent was passed through the sheath and into the axillary vein beyond the previously placed stents/known stenotic lesions. The stent portion of the graft was deployed. Venography of the graft/stent and axillary vein/central runoff was performed via the sheath. Severe stenosis was noted within the axillary vein stents. Balloon angioplasty was performed. The graft was flushed and clamped at the axillary incision. A tunneler was passed between the two incisions along the tunnel tract. The graft was pulled back through the tract. An arteriotomy was made on the anterior aspect of the brachial artery. The graft was sutured end-to-side to the brachial artery."

I'm confused on how to code when the left anterior descending artery is treated with a balloon angioplasty and then the branch of the LAD receives a stent. Is this coded as 92920-LD and then 92928-LD?

The physician performed a thrombectomy and balloon angioplasty on the left posterior cerebral artery and then performed a thrombectomy on the left middle cerebral artery. It appears only one code per vascular territory (which, in this case, is only one, the vertebral territory) can be used according to the CPT Codebook. If that is the case, should we use code 61630 since it is the higher weighted code? Or, are there exceptions to using both?

What is the most appropriate CPT code(s) that replaced 35475/75962-26? My physician is performing a percutaneous transluminal arterial angioplasty of the right cervical carotid artery critical stenosis with the balloon angioplasty, restoring luminal patency for atherosclerotic stenosis/occlusion. He is also trying to charge for selective catherization/angiograms of the following: 1) Right subclavian artery. 2) Bilateral common carotid artery (which I know I can't bill). 3) Bilateral internal carotid artery. 4) Left vertebral artery. He is trying to also bill for the following: QTY 2 for control angiograms from RICA existing guiding cath. QTY 1 for where he entered at left CFA (which I know is included and can't bill for it). Not sure what is the best code. I'm leaning toward 37246. Thanks for your time and helping me with this difficult MD.

In regards to Ask Dr. Z question ID 1#1065 (36833/36831), when a percutaneous balloon angioplasty and open thrombectomy are performed in the peripheral segment of an AV fistula this is reported as 36833, correct? CPT Assistant has stated "patch" angioplasties are considered revisions, but I was not aware that balloon angioplasties were. In my case the physician performs an incision into the graft and does a thrombectomy of the graft, closes the graft, and obtains percutaneous access of the graft. Through the percutaneous access, a balloon angioplasty of a 50% stenosis of the venous outflow was performed and procedure was ended. I don't believe 36902 can be reported, but I am not sure if this is 36831 or 36833.

"Patient with tetralogy of Fallot presents to the cath lab for placement of a stent in the right ventricular outflow tract. Angiography revealed multilevel obstruction of the RVOT with the infundibular area measuring 1.8 mm, and the MPA measuring 3.1 mm. The decision was made to proceed with placement of a 4 mm x 12 mm Rebel coronary stent. The valve was crossed using an angle glide catheter over a 0.014" BMW wire. The wire was stabilized in the LPA, and the catheter was removed. The stent was advanced over the BMW wire under fluoroscopy to the RVOT. Multiple check angiograms were performed to ensure appropriate positioning. The stent was deployed with inflation of the balloon to 18 atm. The balloon was removed, and repeat angiography was performed. The stent was widely patent with no evidence of injury. The final stent measured 4.5 mm. Patient returned a week later for balloon angioplasty and second stent placement of the RVOT." How are these two procedure reported? 1. Stent placement in the RVOT. 2. Balloon angioplasty with stent placement.

For the following, can codes 36901, 36907, and 37248 be billed? "Left brachiocephalic AV fistula with multiple areas of high-grade stenosis in upper and mid cephalic vein, extending into a previously placed metallic stent in shoulder region. Left basilic vein fistula fistulogram and central venogram with sequential balloon angioplasty of three stenoses. Two of the cephalic veins measure greater than 95%, and in-stent stenosis measures greater than 80% with 6 mm x 2 cm cutting balloon and 8 mm x 6 cm balloon."

"Patient had a thrombosed brachial-axillary AVG. We did an open thrombectomy (36831?) and closed. We then performed a fistulogram and a retrograde brachial arteriogram. It showed kinking and narrowing at the origin of venous end, subclavian, and SVC. Balloon angioplasty was done on both (36907 for the central segment?). As we were closing we could feel the flow turn very sluggish, and over the next 10 minutes had lost her flow completely. We felt we needed to re-evaluate. Therefore, we reopened and found the AVG was thrombosed again. Based on the previous fistulogram retrograde brachial arteriogram I felt we needed a larger arterial inflow and decided to revise and make this an axillary-axillary AVG. This was done utilizing a new graft (36832?). Flow was restored. Another fistulogram was performed and showed everything to be widely patent." Since the open thrombectomy was completed and closed up, would we be able to bill the open thrombectomy, angioplasty of the central segment, and then the new open revision? Or would we just bill the open revision with declot (36832)?

I have a case where, during an embolization procedure, it seems that the left gastric artery was accidentally punctured. After the embolization portion of the procedure was complete, they went back to the left gastric artery and performed a balloon angioplasty, leaving the balloon dilated for a prolonged period of time. When they removed the balloon they were able to determine there was no longer bleeding from the left gastric artery and concluded the procedure. Would the treatment of the left gastric artery injury with the balloon angioplasty be coded as 37246?

CPT codes 36905 and G0257 produce an NCCI edit, and it appears that code 36905 should be removed. When these two are coded together on the same DOS, should code 36905 be removed or can modifier -59 be appended? If the declot has to be performed in order to perform the dialysis, should it then be just the dialysis that is coded? Or if the patient presents for planned declot and then the facility goes ahead and performs dialysis after the procedure, could both be coded with a -59 modifier? Reference CPT Assistant, March 2017 page 3-5 and 9.

"A venogram was performed through the sheath. The balloon was advanced to level the popliteal vein and balloon angioplasty performed with a long inflation time of 2 minutes. Prior to balloon inflation,4000 units heparin was administered via peripheral IV the balloon was removed. A balloon was then utilized to dilate the popliteal vein and posterior tibial vein. Long inflation time was utilized to minutes. Balloon was then removed. Venography was performed through the sheath. Wire was removed. Sheath was removed. Pressure was held at the exit site until hemostasis was achieved." Is the tibial vein a separate family from the popliteal? 37248, 37248, and associated catheter placement of 36012?

I know you answered a similar question in 2012, but I'm wondering if the recommendation is still the same. We performed an EVAR in which the SMA was also stented. A few weeks later the patient returned to us for evaluation of a possible endoleak and evaluation of what appeared to be a stent fragment in her left external iliac artery. A diagnostic study was performed, and it was determined that her SMA stent had fractured and migrated to her left external iliac artery. The stent was balloon dilated in place in the external iliac. The stent was not otherwise manipulated, and no other interventions were performed. How would you bill for the balloon dilation of the stent?

"Patient with small veins with stenosis in brachial/cephalic fistula. Wire passed and 6 x 20 cutting balloon over wire; balloon angioplasty with excellent results. A wire was passed into the branch, and a small incision to dissect the vein and perform ligation. Bleeding was noted where branch had been ligated. There was a slight tear where branch joined main vein and stitch and pressure applied and bleeding stopped. Weak thrill noted and some clot noted at site of angioplasty. With wire in place, AngioJet thrombectomy was performed, but area had already restenosed. A 7 x 7.5 stent was deployed and ballooned. Following stent placement, excellent thrill was noted and good flow. Wire was removed and pursestring 3-9 nylon placed." Code 36906 doesn't seem to correct because the incision was made for ligation and thrombectomy. If 36833 is correct for ligation and thrombectomy, there is a PTP with 36903. Thoughts?

Can we use code 33363 for the following procedure? "Transcatheter aortic valve replacement using Medtronic Evolute R Pro 26 mm percutaneously from left axillary approach, balloon angioplasty of left subclavian artery at area of dissection just opposite the vertebral, second order catheter placement and angiography of the left subclavian, additional vessel after basic ×2."

Can you please provide assistance for the procedures listed below at your earliest convenience! Procedure 1 - 2-6-18 *CESSATION/REMOVAL OF THROMBOLYSIS CATHETER - 37211 CHARGED ON 2-5-18 *STAGED RELOOK ANGIO *MECHANICAL THROMBECTOMY OF PRIMARY ARTERIAL THROMBOSIS OF LEFT COMMON FEMORAL, SFA, AND PROFUNDA ARTERIES *BALLOON ANGIOPLASTY OF COMMON FEMORAL, SFA, AND PROFUNDA PROCEDURE 2 - SAME DAY OF SERVICE 2-6-18 - PATIENT BROUGHT BACK EMERGENTLY POST FIRST PROCEDURE *LEFT LOWER EXT. ANGIO *CATH PLACEMENT IN LEFT POPLITEAL ARTERY FROM CONTRALATERAL FEMORAL ACCESS *MECHANICAL THROMBECTOMY OF PROFUNDA *MECHANICAL THROMBECTOMY AND ANGIOPLASTY OF ANTERIOR TIBIAL *MECHANICAL THROMBECTOMY OF PERONEAL *MECHANICAL THROMBECTOMY AND ANGIOPLASTY OF POSTERIOR TIBIAL *PLACEMENT OF THROMBOLSIS CATHETER. Dr. Z IR states that 37211 and 37214 are not allowed on the same date of service. Are any special modifiers allowed? Current tentative code set: Procedure 1 - (37214?), 37184, 37224 Procedure 2 - (37211?), 75710-LT, 37186, 37228, 37232

If a stent was placed in the diagonal branch, and after this was done it was found that the occlusion was in the main LD and so the provider goes back 3 hours later and places a stent in the main LD and also performs a kissing balloon angioplasty in the main LD and the diagonal branch, would we be able to bill for both stents plus the angioplasty on the second attempt?

Physician placed a stent in the RC (92928-RC), followed by angioplasty in the RPDA (92921-RC). Then, he did kissing balloon angioplasty in the RPDA and RPLV (92921-59RC). Can I bill for the third procedure in the right coronary?

"The patient is a 74-year-old woman. Approximately 6 months earlier patient underwent treatment of left lower extremity femoral popliteal artery occlusive disease and disabling claudication with placement of covered stents in her left superficial femoral artery. She has developed recurrent disabling claudication symptoms. A recent ultrasound study revealed a new stenosis near the distal end of the stent in the popliteal artery. The decision was made to proceed with further evaluation with diagnostic arteriography and possible percutaneous reintervention. There was no CT scan done." Can I bill 75710-2659 as diagnostic study during the intervention, or would that be considered run-off angiography and bundled with stent placement? We are performing selective left lower extremity arteriography and left lower fem-pop balloon angioplasty.

"Once this was completed, we then accessed a second site more proximal in the arm, this time directed toward the arterial anastomosis and passed a wire through the anastomosis into the pulmonary arch hand injection arteriography through a catheter. We then performed over the embolectomy and Angioscore sculpting balloon angioplasty of the anastomosis using a 5 mm angioplasty balloon. As we performed over the wire embolectomy, we brought the clot within the system toward the tip of the opposite sheath where Penumbra When that was completed, hand injection fistulography showed excellent result proximally with a widely patent arterial anastomosis. More centrally, however, there had been re-occlusion with what appeared to be fresh clot, and we retrieved more clot in this location. We also identified a small venous anastomotic stenosis and angioplastied this with a 6 mm angioplasty balloon. At the completion of this, fistulography showed an excellent result." Should this be reported with codes 36905 and 36909? Or 36905 with 36215 and 75710?

"With real-time ultrasound guidance, the loop graft was accessed in the outflow direction. tPA was administered, and balloon angioplasty was then performed throughout the graft and outflow basilic vein. Access was obtained in the inflow direction, and a 7 French sheath was placed. Catheter wire passed the brachial artery where an arteriogram was performed. Balloon sweep embolectomy was performed across the arterial anastomosis. Fistulogram was performed. 8 and 10 mm angioplasty was performed within the subclavian vein. Wires, catheters, and sheaths were removed, and compression was held for hemostasis." Would code 36905 be the correct CPT code for this procedure?

"Patient with DVT right-sided common femoral vein, popliteal vein, common iliac vein, and left-sided common femoral vein and common iliac vein. Placement of 50 cm lysis catheter in vena cava via left-sided popliteal and right-sided popliteal posterior approach (37212, 36010-50). Balloon angioplasty of IVC (37248). Balloon angioplasty right-sided common iliac vein, external iliac vein, common femoral vein. Balloon angioplasty left-sided common femoral vein, common iliac vein." Would we submit code 37249 x 2 per extremity? 

Can you please advise what CPT codes would be appropriate for the following procedure report? The main question we have is: do we code the PTA of the central subclavian vein, or is it included in 36907? "Procedure report: 1) Ultrasound access to the outflow limb initially with a 5 French, then upsized to an 8 French for Angio-Jet suction. 2) Ultrasound access to the inflow with an 8 French. 3) Balloon angioplasty of the outflow using an 8 x 80 using up to 10 ATM. 4) Angio-Jet suction to the inflow. 5) The inflow 8 French was pulled out and hemostasis obtained with a Z-stitch. 6) Angio-Jet suction of the outflow. 7) Balloon angioplasty of the graft using a 7 x 60 to 10 ATM. 8) Balloon angioplasty of the central subclavian vein using a 12 x 6 initially, and then 14 x 6 up to 6 ATM. 9) Z-stitch to the outflow 8 French catheter." I tried sending the entire procedure note, but it will not allow me to send the complete note.

Our doctor is wanting to charge an acute MI intervention (92941), but the following text is from the report and this was all that was performed. "Placement of Pronto catheter intracoronary in the ramus intermedius with direct delivery of vasodilators including nitroglycerin, veramil, and nipride with improvement of vasospasm. Intervention on the ramus intermedius was performed as detailed above with no balloon angioplasty or stent placement." Would any of this warrant the billing of 92941?

"A sheath is placed in the carotid artery and connected to a system that will reverse the flow of blood away from the brain to protect against fragments of plaque that may come loose during the procedure. The blood is filtered and returned through a second sheath placed in the femoral vein in the patient’s thigh, allowing balloon angioplasty and stenting to be performed while blood flow is reversed." The manufacturer is recommending code 37215. However, code 37215 clearly states "distal embolic protection". Is code 37215 appropriate for this procedure?

"Physician entered the left upper pulmonary vein and removed the sheath…Then, after using dilators, attempted to advance the guide cath but could not advance it across the interatrial septum. During attempts lost access to the left atrium and had to re-access using transseptal sheath. We positioned the super stiff Amplatz wire in the left upper pulmonary vein and performed balloon angioplasty with a Mustang 8 x 2 sequentially in the interatrial septum. Then they were able to proceed with the mitral clip." When questioned, the physician indicated this was an anatomy issue not a blockage. Is the angioplasty included in the clip (33418) procedure? If not, what code(s) would be reported?

For the following, do you recommend reporting thrombectomy with code 37186 (in addition to 37224)? "Balloon angioplasty of right superficial femoral artery. Follow-up arteriogram revealed partial response of the SFA to the angioplasty especially in the proximal SFA; however, there was presence of significant amount of clot in the common femoral artery and profunda occluded and the collateral vessels into the popliteal artery. At this time given the absence of any mechanical thrombectomy devices in this hospital I proceeded to advance a 4 French sheath over the 6 French sheath and perform several passes aspirating the sheath as a thrombectomy device. She was advanced into the profunda femoral. Arteriogram revealed still remaining clot in the common femoral artery and 1 More Pass I was able to clean the common femoral artery; however, the SFA now was clotted. The branches were preserved as the initial arteriogram, and there was no evidence of any clot in the common femoral artery. At this point I was concerned that if I try to advance the sheath and aspirated the SFA I could deliver call back into the common femoral performed."

2017 CPT book, P247, “Codes 36907 and 36908 describe procedures performed through puncture(s) in the dialysis circuit. Similar procedures performed from a different access (e.g., common femoral vein) may be reported using 37248, 37249 or 37238, 37239.” 2017 CPT book, P255, continues to say “37248 and 37249 describe transluminal balloon angioplasty in a vein excluding the dialysis circuit (36902, 36905, 36907) when approached through the ipsilateral dialysis access.” I am confused about these two instructions. Can I understand in this way, for example, in a patient with dialysis circuit, if central dialysis segment angioplasty (e.g., external iliac vein) is performed through puncture in the common femoral vein, shouldn’t the procedure be coded with 36907 instead of 37248? Because the procedure is performed through dialysis circuit. (common femoral vein is part of the peripheral dialysis segment, which is part of the dialysis circuit). Only when the procedure is done in veins other than in the dialysis circuit, should the code 37248 be used?