Ask Dr. Z

Hi Dr. Z-- A patient presented for a standard left heart cath, coronary angiogram, and left ventriculogram (93458). Decision was made to go on to intervention. The physician attempted for 30 minutes to cross the lesion with multiple wires and a support balloon but each attempt was unsuccessful. I remember hearing somewhere that if the wire doesn't cross the lesion a PTCA cannot be billed for. Is this true? Or would 92982-74 be more appropriate for facility charges?

Please do NOT include any actual patient medical records with your question. Please consider my scenario below: A 6 french sehath was placed in the left femoral artery and a Quickcross catheter was then placed in the left anterior tibial artery, and selective angiogram was performed through the catheter. The catheter was placed distally in the left anterior tibial artery and subsequently a 0.014 Viper wire was placed and atherectomy was performed using a 1.5 Classic Diamondback Crown at low and medium speeds. Post atherectomy there was significant improvement with residual stenosis, 50-60%, which was treated with angioplasty at low pressure with a 2.4 mm long balloon catheter. Post angioplasty reduced to about 20% with much improved distal flow. In relation to the therapy performed, what would you suggest to report? Thank you for your consideration.

Hi Dr. Z! We have a question regarding online Q&A 1768 from 2008. Our office recently went through an external audit and our auditor marked one of our charges incorrect for not billing the additional endarterectomy of the iliac/femoral along with the bypass. In the procedures performed the provider listed them as 1. Right iliac and right femoral endarterectomy with patch angioplasty and 2. Right above-knee femoral to popliteal bypass with 6 mm Gore-Tex graft. As we know some coding rules change, we are wondering if something has been updated from the date this Q&A was published or if you have any other advice. I know it’s long, but I have pasted the report data below. We coded only 35656. What is your opinion about the use of 35355 as well? Thanks, TN Subscriber 9.1.10 DESCRIPTION OF PROCEDURE: A right groin incision was made. The dissection was carried out through the subcutaneous tissue down below the femoral sheath. The femoral sheath was then opened. There was a modest amount of scarring around the area of the previous puncture site where the closure device had been inserted. The common femoral artery was then dissected free along the entire length for clamping. Next, dissection was then carried up underneath the inguinal ligament as adequate retraction was obtained with a Martin Arm. The distal external iliac artery was then dissected free with the crossing vein across the external iliac artery was ligated and divided with multiple hemoclips. Next, once I had obtained adequate exposure for iliofemoral endarterectomy a skin incision was then made on the above—knee medial aspect of the leg. Next, dissection was carried down through the subcutaneous tissue down to the level of the sheath. The sheath was then opened. The popliteal space was then entered. Dissection was then carried down to the level of the popliteal artery, it was then dissected free circumferentially. Potts tie, silk ties were placed around multiple side branches of the vessel. The vessel was small in caliber, probably 4 mm. Next, a 6 mm ringed Gore-Tex graft was then obtained and tunneled subsartorially between the 2 incisions. Next, the patient was then heparinized and following an appropriate time the external iliac artery was then clamped with a Satinsky clamp. Then, the common femoral artery was then clamped with a profunda clamp distally. Next, an arteriotomy was made and extended with the Potts scissors. Next, the endarterectomy was then performed with the common femoral artery and external iliac artery. Next, the remaining debris was then removed and the distal plaque within the common femoral artery was tacked down with 6-0 Prolene sutures. Next, a Vascu-Guard patch was obtained and soaked appropriately and then subsequently used and sewn in place with a running 5-0 Prolene stitch. Prior to completion of the patch angioplasty the lumen was flushed and heparinized with saline solution. The artery was allowed to back-bleed proximally and distally by virtue of removing the clamps. Next, the anastomosis then completed. Three interrupted repair stitches were used to control some suture line bleeding. Next, the vessel was once again clamped proximally and distally. A patchotomy was made standard with the Potts scissors. Next, the graft was then cut to fit and sewn to the patch repair in an end—to-side fashion with a running 5-0 Prolene stitch. Following completion of anastomosis the proximal and distal clamps were removed. A distal graft clamp was placed. Next, there were no repair sutures needed. Next, a graft clamp was then placed proximally. Next, the popliteal artery was then clamped proximally and distally. An arteriotomy was made and extended with Potts scissors. Next, the graft was then cut to fit and sewn in place in an end-to-side fashion to the popliteal artery with a running 6-0 Prolene stitch. Just prior to completion of the anastomosis, the lumen was flushed with heparinized saline solution. The artery was allowed to back-bleed proximally and distally as well as the graft by briefly removing the clamps. Next, the lumen was once again, flushed with heparinized with a saline solution. Next, the anastomosis was then completed. Next, the proximal and distal clamps are removed. The graft clamp was then removed. There was a palpable pulse in the foot upon completion of the anastomosis. Next, protamine was given. Adequate hemostasis was obtained with Surgicel and thrombin spray. Next, all wounds were then irrigated and closed with 2 running 3-0 sutures in the above-knee popliteal incision and in 4 layers in the groin with Vicryl sutures. Skin clips were used in the skin. Sterile dressings were applied. The patient was awakened, extubated, returned to the recovery area in satisfactory condition. All instrument, needle and sponge counts were reported as correct on 3 occasions.

Greetings, This patient has a AV graft. The physician does a open thrombectomy of the arterial and venous sides of the graft. Following this a AV shuntogram is performed. This shows irregular calcifications in the graft. A curettage of the graft was performed to remove calcifications. Follow up angio showed a stenosis at the venous anastomosis which is ballon angioplastied. Due to pt history of strictureplasty a stent was placed. I think I can code 36831-59 thrombectomy / the shuntogram with code 75791-26-59/ Angioplasty is bundled with the stent placement / Stent codes 37207, 75960-26. What about the curettage? I'm not sure about the curettage. Would I code this as a 36833 and think of the curetage as a revision with thrombectomy along with code 75791-26-59 and then the angioplasy and stent are bundled as they are completed in the same zone as the revision. Any clarification would help. Thanks, LW

Hi Dr. Z and Dr. Dunn,I have a combined procedure between surgeon and interventional radiologist for bilateral popliteal aneurysms with endartarectomy on one side. I'm unsure as to whether this is coded as open stent placements, popliteal aneurysm repair or exclusion of the aneurysm which leads me to an embolization code. The surgeon exposed the arteries via cutdown so I'm clear on this being an open procedure. The dictation describes the following: Access to the common femoral arteries was provided by the vascular surgeon, who performed bilateral cut-downs. Single-wall needles were utilized to access the common femoral arteries bilaterally directed in an antegrade fashion. Eventually vascular sheaths were advanced into the proximal superficial femoral arteries and bilateral selective angiography was performed, confirming large bilateral popliteal aneurysms (right greater than left). Additionally, there is severe stenotic disease noted in the left superficial femoral artery. Utilizing 0.035 Glidewires, 5-French catheters were advanced into the distal popliteal arteries and over 0.035 guidewires, overlapping Viabann stents were deployed at the site of the aneurysm and post-dilated using 7mm angioplasty balloons. Completion angiography demonstrated excellent exclusion of the aneurysms with preserved distal flow bilaterally. The vascular surgeon now picks up the dictation and continues: Upon completion of the endo-stenting angiograms sluggish flow to the right side was demonstrated. The superficial femoral artery on the righ had very weak pulsation. It was noticed to be due to a large plaque in the common femoral, which was partially lifted during the previous procedure. The arteriotomy was extended and a large plaque removed from the base of the common femoral and into the entrance of the profunda femoral. A patch was needed in order to establish a better flow in to the superficials and this was done with an Impra patch. The surgeon goes on to describe repair and closure of the groins. What I'm most concerned with is the IR portion of the stent placements. I initially coded as 37207/75960 and 37208/75960 X2 for the two popliteals, then saw the implant documentation indicated for all four stents as Right SFA, Left SFA, Right Popliteal and Left popliteal. I'm hesitant to code the SFA as additional vessels for stent placement since I don't have documentation of why the stents were extended into that vessel. The encoder software wants to code this as an exclusion of the aneurysm cpt 37204. I have never used the popliteal aneurysm 35151 code so not sure this is the right code either or if that requires excision of the aneurysm. I am not coding any angiography as he states this was only to confirm the aneurysm. Catheter placements from common fem to popliteal antegrade I believe would be 36246 on both sides. Any help is greatly appreciated.

Hi, Dr. Z: Our surgeon has been using some atherectomy devices that can also retrieve thrombus. He is dictating thromboembolectomy and then also angioplasty on the same case. We are not sure if we should be coding these as an atherectomy or thrombectomy. here is an example:Procedure: thromboembolectomy of the RT popliteal extending into the tibial peroneal trunk and into the peroneal artery; angioplasty of RT popliteal artery extending into the tibial peroneal trunk and also peroneal artery; angioplasty of RT popliteal artery; angiplasty of RT SFA. From the Description: A mini Pathway device was introduced over the gguidewire and multiple passes were made throught the complete occlusion of the distal popliteal artery extending into the tibial peroneal trunk and then into the peroneal artery. Post thromboembolectomy revealed residual stenosis greater that 50%. Thus a 2.5 mm x 150 mm angiplasty balloon was introduced over the guidewire, and angiplasty at the level of the distal right popliteal artery extending into the tibial peroneal trunk and into the peroneal artery was carried out. post angioplasty revealed significantly improved results. Catheter removed. A 5mm x 150 mm angiplasty balloon was then introduced over the guidewire and angioplasty of the right popliteal artery was carried out. Due to heavy calcification, the angioplasty of the distal right superficial femoral artery was carried out. Would you code the procedures: 35495, 35474x 2 or 37186, 35474 x 2? Thank you so much for your help!

Question: Our physician completed a femoral angiography with an attempted PTA of the SFA. The physician made several attempts to pass several different wires. The physician also tried to pass a frontrunner catheter (a catheter used for total occlusions) but was not able to pass the lesion. No balloon was used. The patient was on the table for about an hour. Can we bill 35474 with modifier 74? Michelle Moreno,RHIT,RCC Scottsdale Healthcare

Dr.Z, This is pedi case. During pulmonary valvuloplasty was performed and during the procedure the MD covered the valve as well as pulmonary artery stenosis and used the same balloon inflation to dilate areas of stenosis. Since a single balloon was used and covered both areas of stenosis (valvular and supravalvular) can we charge only 92990 or both 92990 and 92997? Please advice. Thanks

Dr Z can you help with this case?? The Doctors notes a type 3 aortic arch. He punctures the right common femoral artery in a retrograde direction, he goes up and does an arch angiogram. He then selectively catheterizes the left sublclavian artery. Additional images of the left subclavian artery are obtained. He then selectively caths the left subclavian artery distally and was able to advance a sheath over a stiff wire into the left subclavian artery. The shuttle sheath was advanced distal to the left vertebral artery and a atrium stent was deployed in the distal subclavian lesion. This was post dialated with a balloon to a more acceptable caliber across the lesion. He then places a genesis stent within the sheath and pulls the sheath back to the origin of the left subclavian artery where another stent was deployed across the origin of the artery. He then removes the catheters and wires from the left subclavian position and pulled down to the abdominal aorta. Additional images of the right iliac system where obtained and this demonstrated a very significant external iliac artery lesion of approx. 70% and a common iliac artery multifocal calcified lesion. He then does an angioplasy of the external and common iliac arteries with significant recoil. A Smart stent was deployed across the lesion and this stent was postdilated with a balloon. He then goes on to deploy a closure device. Can you help me code this?? Thanks

Hi Dr. Z. I have a central stenosis treatment question with access from an AV fistula. I know some rules changed this year and the CPT codes. I was on your call in May, but there were no real examples of treatment of central stenosis. We accessed with a micropuncture needle, wire, and sheath. The fistulograms were obtained up to and including the central venous circulation. The patient has a very large fistula. The outflow is fairly rapid. Visualization of the central circulation was difficult, but there was persistent retrograde filling into the internal jugular and other branches around his shoulder consistent with the clinical impression of central obstruction. I ended up placing a #7-French sheath and passing a guide wire. We meet obstruction about the level of the trachea in the innominate vein. We passed a Bern catheter and performed selective injections in this area which appear to confirm a stenosis just at about the level of the trachea and left of the trachea and central vessels there. With some difficulty with an angled wire, I eventually crossed this lesion. I selected a 10-mm balloon and performed 2 inflations to angioplasty the area with good resolution of a mild wasting in the area. I do not feel there was any real indication to aggressively dilate this further. Follow-up images appear to show improved outflow. Finally, there is clearly adequate outflow for this thing to function. My question is about the catheter coding and S&I for the central stenosis now. I know the 36147 now includes the visualization of the central vessels, so does this also then includes the cath placement to the central vessels as well? At what point now would you use the 36010 via AV Fistula access and do you have an example of the 75791? We coded the above as 36147 since the 36010 is a CCI edit and he only goes to the inomminate and not the SVC. We also coded the 35476 and 75978 for the angioplasty of the vein. Are we on target or totally missing this? Thanks Dr. Z. TN Subscriber 8.26.10.

Hi Dr. Z: In your Q&A database, I found a question dated 2/14/06 about coding for interventions of the dorsalis pedis. In your answer, you weren't sure whether or not the dorsalis pedis artery would be considered part of the tibial or a separate vessel. I haven't found anything about coding for interventions of the dorsalis pedis other than the above reference. Have you come across anything since this question was submitted from the AMA or SIR that addresses this?

Question: Our physician completed a femoral angiography with an attempted PTA of the SFA. The physician made several attempts to pass several different wires. The physician also tried to pass a frontrunner catheter (a catheter used for total occlusions) but was not able to pass the lesion. No balloon was used. The patient was on the table for about an hour. Can we bill 35474 with modifier 74? Michelle Moreno,RHIT,RCC Scottsdale Healthcare

Greetings, Now that the rule has changed: Would you now use code 35485 when a angioplasty is performed on the arterial side and venous side of a AV graft (arm) when performed through the open incision instead of 35460? Thanks, Lesley

Hi Dr. Z, I've gotten better at coding the peripherals since you were here in January. This is the first AV fistula procedure that's been done in our cath lab and with the G codes being deleted, I'm hoping you can help me. Here's what the doctor documented: The patient is a 34 year old male with the following indications: abnormal fistula duplex, failure to mature AV fistula . The patient has the following Comorbidities/Risk Factors: Hypertension, On Dialysis, Renal Failure Prior to PCI. DIAGNOSTIC PERIPHERAL VASCULAR PROCEDURE Under ultrasound and fluoroscopic guidance, the left AV fistula was locally anesthetized and accessed with a micro puncture needle using the standard percutaneous technique. After injection and visualization of the brachial AV fistula anastomosis, the microsheath was exchanged over a wire a short 6F Brite-tip was placed in the AV fistula. With occlusive pressure of the distal fistula, angiography was performed in mulitple views. PERIPHERAL ANGIOGRAPHIC FINDINGS Subclavian: There was severe stenoses at proximal anastomosis and inflow segment of fistula. There was normal flow through the mid and distal portions of the AV fistula. The brachial artery was normal in size and did not have any significant stenosis. The primary indication for PVI was abnormal duplex of stenosis fistula. Additional indications include: abnormal fistula duplex, failure to mature AV fistula. INTERVENTIONAL PERIPHERAL VASCULAR PROCEDURE PVI of the left AV fistula artery was indicated for failure to mature graft due to proximal stenosis. A 6F sheath was chosen for the intervention. This sheath gave good support in the left AV fistula. A heparin bolus was given. The lesion in the left AV fistula stenosis was crossed successfully with an 0.035 inch stiff angled Glide wire and a 4F multipurpose catheter. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon at the anastomsis of left AV fistula and brachial artery two times. The maximal inflation pressure was 3 and 6 atm. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon in the residual vein in the proximal left AV fistula artery three times. The maximal inflation pressure was 3,4 and 8 atm each time. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon at the anastomsis of left AV fistula and brachial artery. The maximal inflation pressure was 8 atm. We then inflated a 6.0mm diameter of 40mm length Dorado balloon in the proximal left AV fistula three times. The maximal inflation pressure was 6, 10 and 9 atm each time. Repeat angiography revealed improved flow in the fistula with mild residual stenosis and no evidence of compromise of the left brachial artery. I appreciate any guidance you can give me. Kathy

Can you please calrify the difference between dialysis fistulas and dialysis grafts. Reviewing your coding information, it seems as though you are only discussing coding rules for dialysis grafts. How do I code for an angioplasty at the anatomosis of a native fistula. Would it be correct to code 35476 since the artery and vein are directly anastomsed to form the fistula?

How do you code a thromboendarterectomy and patch angioplasty to a bypass graft (femoropopliteal vein bypass)? Thanks for your help.

Getting mixed answers on this one too! PROCEDURE(S): Percutaneous Nephroureteral Stent Placement (Internal/External) Foreign Body Retrieval - Non Vascular HISTORY: Nephrolithiasis INDICATION: Urinary Obstruction MEDICATIONS: Fentanyl 200mcg; Midazolam 6mg CONTRAST: Omnipaque 350, 30 ml COMPLICATIONS: None. TECHNIQUE: Following informed consent and verification of the correct patient identity and planned procedure, the patient was placed in the prone position and the right flank was prepped and draped in the usual sterile fashion. Local anesthesia with two lidocaine 2%. Puncture of the right renal pelvis was performed using Chiba 22 gauge needle. Contrast and air was injected and spot film imaging was performed as a percutaneous antegrade pyelogram. A posterior upper pole calyx was then punctured under fluoroscopic guidance using a 21 gauge needle. A Jeffrey sheath dilator set was placed. Catheter access to the bladder was achieved using a 5-French Bernstein catheter and angled Terumo guide wire. An Amplatz super stiff wire was placed. Over the wire a 9-French vascular sheath was placed. Through this a 25-mm Amplatz gooseneck snare was advanced and used to engage the occluded internal ureteral stent. The sheath and ureteral stent were then removed intact while maintaining wire access. Over the wire, a 10.2 French x 22-cm percutaneous internal/external nephroureteral stent was placed. The distal loop was formed in the bladder and proximal pigtail was formed and locked in the renal pelvis. Post placement nephrostogram confirmed appropriate position. The catheter was sutured to the skin and placed to external drainage. FINDINGS: There is moderate right hydronephrosis, especially a lower pole calyx. There is a large stone impacted in the renal pelvis, which partial balloon partially obstructs the lower pole calyx. The internal ureteral stent was occluded. This was successfully removed. INTERPRETATION:Successful percutaneous drainage of the right kidney with placement of a percutaneous internal/external nephroureteral stent as described above.

Dr.Z, In online Q&A 2145 posted March 25, 2010, in your answer you refer to the fact that that there are new edits preventing billing of angioplasty and atherectomy in the same vessel, effective for MD's 1/1/2010 and hospitals 4/1/2010. I had heard that somewhere else, probably a webinar and had been advising my clients of the upcoming CCI edits, however when I look at the CCI tables on CMS website there are no edits whatsoever for any atherectomy or angioplasty codes. I have read the reference in the NCCI Manual, 15.3, but your reference to them being effective Jan. 2010 for physicians and April 2010 for hospitals leads me to believe that there would have been true CCI edits as hospitals are one quarter behind physicians on CCI edit effective dates. Any additional information would be greatly appreciated. Thank you

Pt. has a unruptured ophthalmic aneurysm in which we did a crani/aneurysm clipping, they also did a balloon temporary occlusion for assisting with the clipping, can we bill 61623 with the crani ?

Good afternoon, Dr. Z and Dr. Dunn. I have a lot of questions about the following op report. I'm debating whether to represent the angioplasty with 35456,LT or 35459,LT, along with 75962,26,LT. I'm leaning towards 35456,LT, because the doctor says it was done in the mid thigh, but 35456,LT is considered bundled with 35566,LT, according to NCCI edits, while 35459,LT isn't. It also seems as if 36140,LT is considered bundled with 35566,LT, but would that be added with a 59 modifier if an angioplasty of the graft is done? On the other hand, does the statement, "Primary vascular procedure listings include establishing, both inflow and outflow, by whatever procedures necessary.", pertain to this situation? How about the repairs due to extravasation, during the angioplasty of the graft? Could 35226,LT be used as an additional code? If so, how many units? I decided against using 35682,LT, because the doctor basically did a resection and anastomosis of the same vein, as opposed to merging two veins from different locations. Was that the correct decision? Is there another code you'd use to describe this procedure? If not, does this warrant billing with modifier 22? The doctor also mentions several angiograms. How many units of 75710,26,LT can I use? On top of that, the doctor mentions that a Doppler was brought onto the field. Does this statement warrant the use of 93922,26,LT? I know the narrative says "noninvasive", so is there another code you'd use, like 37250,LT and/or 75945,26,LT, or is it just included in 35566,LT? I don't see any NCCI edits saying either of those codes are included in the bypass. As you can see, I'm extremely confused. Your assistance would be greatly appreciated. Your answers to this might help point me in the right direction with a lot of future op reports. Thanks, in advance. Here's the op report: DATE OF OPERATION: 03/29/2010 ANESTHESIA: General. PREOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. POSTOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. PROCEDURES: 1. Left lower extremity angiograms. 2. Left superficial femoral artery to anterior tibial artery bypass with composite great saphenous vein graft. 3. Angioplasty of vein graft. 4. Completion angiograms. INDICATION: This is an 88-year-old female who presented with rest pain and ischemia to the left foot with some mild motor dysfunction of her toes. The patient did undergo a cardiac evaluation. She was brought to the operating room for elective femoro-anterior tibial bypass after having undergone aortoiliofemoral and left lower extremity angiograms earlier in the week. The patient had this performed with composite nonreversed great saphenous vein graft from the left leg. Completion angiogram demonstrated areas of stenosis in the vein graft and angioplasty was performed. This was complicated by a linear tear with some extravasation in the mid thigh, which was directly repaired with interrupted stitches of 6-0 Prolene. There also did appear that the vein graft requiring a repair was an interrupted stitch of 6-0 Prolene. Completion angiograms demonstrated very good result with good caliber of the vein graft and run-off onto the dorsalis pedis artery in the foot. PROCEDURE: The patient was identified and brought to the operating room. She was placed in the supine position on the operating room table. After administration of general anesthesia by the anesthesia department, the patientâ?Ts lower abdomen, groin, entire left lower extremity, and right thigh were prepped and draped in the usual surgical sterile fashion. Attention was turned to the left lower extremity and in the distal third of the leg, a lateral skin incision was made approximately 8 cm in length. This was carried down through the skin, subcutaneous tissue, and fascia. The anterior tibialis muscle was retracted medially and the extensor digitorum longus retracted laterally. Dissection was carried down and the neurovascular bundle was identified as well as the anterior tibial nerve. The anterior tibial artery was dissected out. The Doppler was brought onto the field. The proximal portion was without evidence of flow and dissection was carried more distally to where collateral flow was heard in the artery. For this reason the incision was extended more distally. The artery was harder and calcified more proximally where it was occluded. The artery was softer more distally. A portion of the artery was dissected out where the vessel was soft and suitable caliber being 2 to 2.5 mm in diameter. Attention was turned to the left groin. Incision was carried down through the skin with the scalpel. Dissection was then carried down through the subcutaneous tissue and fascia and femoral sheath. The common femoral artery, profunda femoris, and superficial femoral arteries were identified and dissected out, and vessel loops placed. The great saphenous vein was identified. A bridge incision was made in the thigh and the dissection carried down through the subcutaneous tissue and the saphenous vein exposed. Continuous incision was then made along the medial leg and the saphenous vein was exposed along its length. Below the knee at about the proximal to mid calf, the saphenous vein became of smaller caliber dividing into two tributaries. The larger branch was followed. The vein was smaller and more disadvantaged at this site and in the distal leg, the vein then became larger again and was with good caliber to the medial malleolus. This was dissected out. As there was the disadvantage portion of vein measuring less than 2.5 mm, the plan was to do a venovenostomy to use the portion of the vein greater than 2.5 mm. For this reason, the dissection was carried farther down the superficial femoral artery proximally where it was still with good caliber with minimal disease based on the angiogram through the proximal thigh incision. Dissection was carried down through the subcutaneous tissue and fascia, and several centimeters, approximately 8 cm distalfrom the bifurcation, the superficial femoral artery was dissected out and vessel loops placed. Following this, a subcutaneous tunnel was made traversing to the lateral thigh with a gentle curve and then along the lateral aspect of the leg in a subcutaneous position and down to the distal wound. The saphenous vein was controlled at the saphenofemoral junction. The saphenous vein had been dissected out along its length, ligating and dividing the tributaries between 3-0 and 4-0 silk ties and clips on the tissue side. The dissection was routine, but on distending the vein through a tributary, which controlled the vein proximally, the vein did require repair of multiple small areas with 7-0 Prolene. The vein was clamped at the saphenofemoral junction taking a cuff of the femoral vein excising the saphenous vein and oversewing the femoral vein with 6-0 Prolene. Attention was then turned to performing the proximal anastomosis. The first vein valves were cut under direct vision. with LeMaitre valvulotome with two passes. The blood flow was pulsatile through the vein. The mid-distal third was smaller, disadvantaged as noted. Proximal anastomosis was performed by controlling the superficial femoral artery. About 5000 units of intravenous heparin was given under my direction. An additional dose was given as needed. Vertical arteriotomy was made in the superficial femoral artery and extended with the Potts scissors. The vein was used in nonreversed fashion, spatulated, and anastomosed, end-to-side using a running stitch of 6-0 Prolene. Prior to completing the anastomosis, the femoral artery was back bled and antegrade flushed. There was a good inflow. The anastomosis was then completed. It was then that the valves were cut with a valvulotome. The first two valves had been cut under direct vision. The remainder of the valves was then cut using LeMaitre valvulotome with two passes. Blood flow was pulsatile through the vein, although the smaller disadvantage segment of the vein was as noted in the mi-distal portion of the vein. The vein was then passed through the subcutaneous tunnel and brought out to the anterior tibial wound. The anterior artery was then controlled where the artery appeared of good caliber and was soft. This was opened with the #11-blade and extended with the Potts scissors. There was reasonable backbleeding in the artery as well as some antegrade flow via collaterals. Angiogram was performed, which demonstrated that this was a good site for the anastomosis with flow into the dorsalis pedis artery with the artery being of good caliber without significant stenosis. The vein length was then measured. The vein graft was then cut to remove out portion of the disadvantaged segment of vein. Venovenostomy was then performed over #8 pediatric feeding tube. When this was complete, the end of the vein was then spatulated and anastomosed end-to-side to the anterior tibial artery using a running stitch of 7-0 Prolene. Prior to completing the anastomosis of the vein graft, the artery was back bled and flushed. The artery was flushed with heparinized saline solution. The vein graft was flushed, and the air was released. The anastomosis was then completed. Flow was allowed to propagate down the foot. There was a palpable pulse in the dorsalis pedis artery in the foot and an excellent Doppler signal distal to anastomosis. The vein graft was pulsatile but still did not appear to distend fully, being on the smaller side despite excising the smaller portion. Completion angiogram was performed through a side branch just distal to the proximal anastomosis. This did demonstrate a couple areas of severe narrowing, the first being in the anterior thigh. The area was marked with a glow tape. A #5 French sheath was placed through the side branch, and a glidewire followed by angioplasty balloon was passed through the mid thigh and angioplasty was performed. On the post-completion angiogram, unfortunately there was some evidence of extravasation and cutdown was done in the mid thigh and a linear tear in the vein was directly repaired. It was also noted along the distal lateral incision and again evidence of a frail vein that the guidewire had transversed thru the vein wall. The wire was pulled back and this was repaired with a 3-0 interrupted stitch of Prolene. The wire was negotiated down the vein, and completion angiograms demonstrated also two other areas of narrowing, and the angioplasty balloon was applied lightly in these areas with excellent result on completion angiogram. Due to the presence of the sheath and the angioplasty balloon, intermittently the vein graft was flushed with heparinized saline solution. Intra-arterial papaverine had also been given due to some spasm of the artery distal to the anastomosis after controlling the vessel. The artery here is soft. Completion angiograms demonstrate excellent result of the vein graft and the distal anastomosis to be patent with the anterior tibial artery patent into the dorsalis pedis artery on the foot. The guidewire, the balloon, and the sheath were then removed from the vein and the branch stump was ligated with 3-0 silk. Flow was allowed to propagate down the vein graft into the foot. The patient did have a strong dorsalis pedis pulse as well as a palpable vein graft pulse along the lateral leg. Hemostasis at the anastomoses was obtained with thrombin and Gelfoam. Hemostasis of the subcutaneous tissue was obtained with diathermy. Attention was turned to closing the wounds when hemostasis was satisfactory. The groin wound was closed in two layers using 2-0 and 3-0 Vicryl. The skin was reapproximated with skin clips. Similarly over the SFA and proximal anastomosis, subcutaneous tissue was closed in two layers. The remainder of the saphenectomy site along the medial leg was reapproximated in one or two layers with Vicryl and the skin was reapproximated with skin clips. The lateral leg wound was closed using subdermal stitches proximally. Due to the thin subcutaneous tissue and some leg swelling, the distal portion of the incision was reapproximated using interrupted stitches of 3-0 nylon. The incisions were cleansed and sterile dressings were applied. The patient tolerated the procedure and was taken to the recovery room in stable condition.

Dr. Z..Can you please help with this endovascular repair? Right and left side common femorals were dissected out and arteries were punctured and guidewires were advanced into the aorta (34812-50 and 36200-50). At this point a retrograde arteriogram was done demonstrating that the iliac arteyr was patent and this probably represented stenosis (yes, he says patent) Patient was systemically heparinized. I made a decision to perform angioplasty of the right and left common iliac arteries to try to assist us in being able to get a device up. Next from the right side an 8 mm stent and the left a 7 mmstent was then placed. and insufflated to approx 8 atmospheres and deflated. Following this a sheath was then placed up into the external iliac artery as far as it could be passed. On the right side, I placed Amplatz wire and used the renal dilators. At this point, I obtained the main body (34802) and was able to advance up into the aorta. Next the pigtail cath was placed on the left and using a series of injections, the main body was deployed to the point that the gate was open. Next on the left side, using a banshee cath, the gate was cannulated and advanced up into the device. a balloon was then placedm, pulled down and appeared to be in good position. arteriogram again (75952-26) a 14 x 11.5 was advanced up into the gate. However, during the deployment it did come down some. therefore to bridge this we placed a 14 x 5.5 which actually fit very nicely. (extension? 34825? 75953-26) deployment was then completed on the right. I shot a retrograde arteriogram on the right and decided to place a 14 x 8.5 (34826? 75953-2659?) The graft was then angioplastied on both sides. Completion angio showed no endoleak however the left internal iliac was no longer visible. We then placed a 8 mm balloon into the left limb of the graft and pushed it up proximally and angio demonstrated the left internal iliac is now patent. Do I have all of the codes that can be charged? is the bridge an extension graft? Thank you for your help!

When treating an ostial right renal artery lesion, the intervetionalist did angioplasty, post angiography demonstrated a dissection and recoil at the site of the lesion. A 6 x 18 x9 Express monorail balloon expandable stent was advanced across the lesion. Post deployment demonstrated stent deployment across the lesion, with proximal portion of the stent approximately 1.0 mm into the aorta. Can we report the angioplasty and stent placement when treating an ostial lesion? Another coding resource that we have access to states if treating an ostial renal artery lesion, code only for stent placement. Thank you.

Our patient has a left chest fistula with a left pseudoaneurysm. The interventional radiologist performs a fistulogram and subsequent angioplasty of venous outflow stenoses. There is a sidehole within the graft which fills a very large aneurysm. The hole is repaired using a FLAIR stent graft and tacked into place using a DORADO balloon. Post stent graft deployment documents complete repair of the pseudoaneurysm. Additionally, a Yueh catheter was inserted into the pseudoaneurysm and complete evacuation of the extra blood in the pseudoaneurysm was performed. My question is how to code the catheter evacuation of extra blood in the pseudoaneurysm space? Or would this evacuation be inclusive in the stent graft placement for treatment of the pseudoaneurysm? Thanks for your advice Dr. Z.!

Dr Z, how would you code for a stent used to trap debris that had floated down stream after atherectomy and angioplasty? thank you

Dear Dr. Z, we've got a case that's challenging my understanding of the new dialysis graft/fistula codes. Your comments & advice would be welcome. CLINICAL DATA: PT W/HX OF RT.FOREARM LOOP GRAFT AND RT. UPPER ARM AV GRAFT, REFERRED FOR EMBOLIZATION OF RT.FOREARM LOOP GRAFT AS WELL AS DIAGNOSTIC FISTULOGRAPHY OF RT.UPPER ARM AV GRAFT. Procedures performed: 1. Retrograde access of rt.forearm loop graft. 2. Diagnostic fistulogram. 3. Selection of axillary artery & performance of a rt. upper extremity arteriogram for eval. of brachial artery. 4. Amplatz embolization of arterial limb of rt. forearm loop graft. 5. Antegrade access of right upper arm AV graft. 6. Diagnostic fistulogram of rt. upper arm AV graft 7. PTA of venous anastomosis with an 8mm balloon. 8. Removal of sheath & catheters and hemostasis obtained w/manual compression. (Note:I have not typed out the body of the report because physician did such a good job in this procedure heading list, but if you need, will be glad to provide) I've arrived at these CPT codes: 37204 + 75894; 36147, 75658-59 for study/work on forearm graft. 36147(?-59) and 35476 + 75978 for study/work on upper arm graft. My question: 36147 did not edit out in our Encoder when coded x2; do you think it will be correct to submit x2 since pt has 2 different grafts in one arm? Also do you agree with 75658-59 for studying brachial artery? Did not code 36120 since brachial artery not directly punctured; axillary artery selected after retrograde access in rt forearm loop graft. Any suggestions you have would be appreciated. THANKS SO MUCH FOR YOUR HELP! :D

Hi Dr Z, During a dialysis catheter exchange, the physician documents a fibrin sheath treated with venous angioplasty. Do you recommend coding 35476/75978 in addition to the catheter exchange code 36581/77001? Are you familiar with the Coding Guide from the American Society of Diagnostic & Interventional Nephrology? This guide suggests this venous angioplasty is warranted and should be separately codeable. Any advice you could provide would be greatly appreciated!

I would appreciate some guidance on this scenario. I have searched the database relentlessly and cannot locate a similar case. Right CFA is accessed. catheter is advanced to the origin of the innominate artery. A stent only was initially attempted but due to the angulation and heavy calcification at the origin of the innominate, a pre-dilating balloon was utilized but the stent still could not be deployed. Therefore, angioplasty catheter was re-inserted into the right subclavian artery (36216) and a smaller, low profile stent was finally deployed at the origin of the innominate artery (37205). Subsequently, the angioplasty was performed as an assistive effort to deploy the stent due to angulation and heavy calcification. Then, the ipsilateral right EIA 80-90% lesion at its origin was angioplastied and stented (37206). The documentation for the angioplasties lack the requirement to code as a 'therapeutic' procedure in my opinion. My codes are: 37205, 37206, 36216. I did not code 36160 for the ipsilateral stenting of the EIA because I am thinking that it bundles into the 36216 (subclavian). Is this correct? Or, would it be separately coded since one selective catheter placement is above the diaphragm and the other is below it? Thank you Dr. Z as always!

The physician wants to code a venoplasty and a stent placement in this case. I am leaning more towards a thrombectomy since the physician is describing clot not stenosis and I'm aware that mashing a clot with a balloon catheter is not an angioplasty. It seems that the underlying issue here is compression from a tumor with resulting narrowing of the vessel. Please tell me if my codes are correct: 36299, 75827, 36010, 37187, 37205, 75960. I chose the 36299 as I can't tell from his dictation where he was when he initially injected contrast but since he accessed the IJ it seems he was nonselective. Thank you very much! Patient with lung cancer and significant face and head swelling secondary to SVC syndrome. Patient is here for further evaluation and possible treatment. PROCEDURE: Using a micropuncture kit and under direct ultrasound visualization, the right internal jugular vein was accessed and an 0.018 wire advanced. The needle was removed and a 4 FR conversion sheath inserted over the wire. Wire and introducer were removed and runs were done demonstrating extensive clot and tumor burden seen within the right internal jugular vein. The right braciocephalic vein and the proximal SVC. Using glidewire, access into the right atrium was achieved. Sheath was up-sized to a 7-French vascular sheath. Angioplasty was performed using a 10X6 balloon. Using a 12X40 Smart stent, this area was then secondarily stented as there was no significant interval improvement. Follow-up runs demonstrated mild improvement with residual high-grade stenosis and using a 12X40 Atlas stent, this area was then re-angioplastied. Follow-up runs demonstrated marked improvement but with significant residual stenosis which was refractory to further angioplasty. There is, however, no relux seen up towards the head. Tumor involvement is seen within the proximal right atrium.

Dr.Z, Patient came for declot of the stent placement from the distal right subclavian vein to the proximal SVC for dialysis. Fistulogram peformed and there is no stenosis other than the previously placed stent which is occluded. The stent was recanalized using a guidewire combination which was then advanced through the right into the IVC. The occluded stent was then sequentially dilated up to 12 mm. There was dissolution of the thrombus from the distal aspect of the stent but there was residual thrombus in the proximal stent. After failed angioplasty of these residual thrombuses the decision was made to insert a new 12x16 mm stent. My question is since there is no stenosis but only thrombus can we code PTA? Please explain. Thanks

Good afternoon, Dr. Z. I'm having a warm time with this op report. The surgeon makes mention of a duplex, several different angiograms, and several different views and projections. I'm not sure if I should bill an ultrasound service for the duplex, any additional radiological services for the views and projections, or how many angiograms I should bill for. On top of that, she mentions angioplasties and stents in the heading, but according to the narrative of the body, I feel as if the coding of the stents is all that's appropriate. Please, help. Thanks, in advance. So far, I've coded 37205,RT, 37206,LT, 75960,26,RT, 75960,26,LT, 75716,26, 75625,26, 75710,26,59,LT, and 75774,26,RT. The dxs are 440.22 (I upgraded from 440.21 because of the surgeon's mention of possible rest pain in the body of the report), 996.74 (I'm not sure if 996.1 fits better to describe the fact that the distal anastomosis of the previous fem-pop bypass can't be demonstrated, due to the knee replacement), 709.2, and v43.65. Here's the op report: DATE OF OPERATION: 03/25/2010 ANESTHESIA: Conscious sedation and local anesthesia. PREOPERATIVE DIAGNOSIS: Atherosclerosis with claudication right le POSTOPERATIVE DIAGNOSIS: Atherosclerosis with claudication PROCEDURES: Via Left common femoral artery approach: 1. Aortogram. 2. Aortoiliofemoral angiogram. 3. Selective right lower extremity angiogram. 4. Nonselective left lower extremity angiogram via the left common femoral artery sheath. INTERVENTIONS: 1. Angioplasty, of severe greater than 90% focal stenosis at the junction of the distal left common iliac and external iliac artery, angioplasty with 8 mm x 40 mm angioplasty balloon. 2. Angioplasty/stent placement of proximal right external iliac artery, severe greater than 90% focal stenosis with 8 mm x 36 mm Valeo balloon expandable stent. 3. Placement in the distal left common/proximal left external iliac artery, a 10 mm x 40 mm nitinol self-expanding stent and finally completion lower extremity angiograms. PROCEDURE: The patient was identified and brought to the catheterization suite. She was placed on supine position on the table. Bilateral groins were prepped and draped in the usual surgical sterile fashion. The left common femoral artery was accessed with the micropuncture needle. There was evidence of some dense scar tissue at the site of the previous groin incision. Micropuncture sheath was placed followed by a short 5-French sheath over the introducer wire. There was some resistance of the wire at the level of the left common iliac, so this was not traversed further. Retrograde angio was performed thru the sheath demonstrated severe focal iliac stenosis. Once the 5-French sheath was in place, we were able to negotiate through a left common iliac stenosis with a glidewire in conjunction with a Glidecath. Omniflush catheter was then placed at L1. Aortograms were performed. The Omniflush catheter was pulled down to distal aorta and the aortoiliofemoral angiograms were performed. This demonstrated a severe greater than 90% stenosisl, focal, at the junction of the distal common iliac/ left external iliac artery. This was pre-dilated with an 8 mm x 40 mm angioplasty balloon. Oblique projections were performed. This was done as attention was to be directed first to completing angiograms of the symptomatic right leg with possible intervention. There was evidence of known bypass graft coming off the mid-external iliac artery. Below the level of the bypass, there was severe disease of the distal left external iliac artery and severe disease of the common femoral artery with sheath nearly occlusive. The aorta was patent without significant disease. In the right iliac system, the proximal common iliac artery was patent as was the external iliac artery. There was question of stenosis also at the level about at the right distal common and external iliac artery with the internal iliac artery at that site, oblique projections needed to be done for further evaluation. There was moderately severe disease at the distal external with severe stenosis right crossing the inguinal ligament and moderate disease of the proximal right common femoral artery. Oblique projections of the right iliac system demonstrated a severe stenosis, focal greater than 90% of the proximal external iliac artery. This was able to be traversed with an 0.018 Whisper wire in conjunction with a Glidecath, which was positioned on the distal right external iliac artery. Right lower extremity angiograms were performed. The profunda femoris was open and the proximal superficial femoral artery was open and then occluded in its proximal portion. Via collaterals, the popliteal artery reconstituted at the level of tibial plateau. The patient had bilateral knee replacement, and so there was difficulty in completely demonstrating the popliteal artery. The popliteal arteries were evaluated with 2 views with maximal obliquity, demonstrating the majority of the vessel. This was correlated with duplex therefore and the flow was brisk to the popliteal artery and visualized the portions were without irregularity with good diameter to the below-knee popliteal artery. There was severe tibial vessel disease in the right leg. Tibioperoneal trunk was patent. The posterior tibial and peroneal arteries were occluded at approximately 5 cm and 10 cm. The anterior tibial artery was patent with mild-to-moderate disease in its proximal portion. The popliteal artery via collaterals was recanalized at the level of the mid tibial plateau of the femur. There was good luminal caliber to the popliteal artery where it reconstituted to the infrapopliteal segment and the flow was brisk, but a small portion of the midportion was not able to be demonstrated. This is correlated with the duplex which does not suggest any mid-popliteal stenosis. There was mild-mod irregularity of the terminal popliteal artery. Tibioperoneal trunk is patent. There is severe tibial vessel disease. The peroneal artery and posterior tibial arteries were then occluded after the first proximal 5-cm. The anterior tibial artery is patent with mild-to-moderate disease origin and then demonstrates mild disease and is patent where it becomes more diminutive as the dorsalis pedis artery onto the foot with very diminutive and incomplete plantar arch. The plan for the right leg done in this patient with claudication symptoms and question of developing some rest pain was some discomfort now in her toes which is new, is to treat the greater than 90% right external iliac artery stenosis and then based on re-evaluation of her sx to perform right common femoral artery endarterectomy with endarterectomy/angioplasty of the distal external iliac and possible right common femoral artery to ATA artery bypass with better views of the popliteal artery in the OR. The 0.018 Whisper wire was tracked back through the Glidecath and positioned on the distal right external iliac artery. The Glidecath was pulled back to the proximal right common iliac artery. A copilot was attached to the Glidecath and a hand injection was performed and the proximal right external iliac artery stenosis was located. Stiff glidewire was placed in the CFA. Right severe EIA stenosis was then treated with an 8 mm x 40 mm balloon expandable Valeo stent. Completion angiograms demonstrated very good results. Following this, the guidewire was tracked back into the aorta and this was exchanged for a SupraCore wire. A SuperCore wire was then placed in the aorta via the left iliac system. Angiogram was performed and the left iliaclesion was marked. The severe stenosis of the distal left common iliac, junction of the external iliac artery was then treated with a 10 mm x 4 mm nitinol self-expanding stent. Completion angiogram demonstrated excellent result. after the stent was postdilated with a 10 mm x 40 mm balloon. Following this, the Omniflush catheter was tracked over the wire and the completion angiograms were done through the Omniflush catheter in the distal aorta, both iliacs with excellent results and 0-10% residual stenosis of the proximal right external iliac and the left distal common/proximal left external iliac artery lesion. Following this, guidewire was tracked back to the Omniflush catheter and both were removed via the left common femoral artery sheath. I should mention that 5000 units of intravenous heparin was given under my direction and an additional dose was given and ACT monitored throughout the procedure. Now via the left common femoral sheath, left lower extremity angiograms were performed. This demonstrated the distal common femoral artery to be either occluded or the sheath occluding the artery so that the common femoral and profunda were not demonstrated. The bypass graft was demonstrated and was patent. There was one area of some mild narrowing, which did not appear significant in the proximal third of the thigh, which may be from some mild compression of the muscle. This appeared to be less than 30%. The bypass graft was patent and was anastomosed to the popliteal artery. The distal anastomosis of the fem-pop bypass graft is not demonstrated with the knee prosthesis despite the maximal oblique projection. Runoff is via the anterior tibial with moderately severe disease approximately 5-cm in the proximal anterior tib and then severe greater than 99%, functional occlusion of the anterior tibial in its mid section. The distal anterior tibial artery was of better caliber and patent onto the foot and the dorsalis pedis artery is extremely diminutive on the foot. The patient tolerated the procedure. At the completion of the procedure, she was taken to the recovery room in stable condition and the sheath is to be pulled when the ACT is less than 180.

Dr.Z, Should we report 36831 open thrombectomy of AV fistula for dialysis and 35460 open angioplasty when they remove thrombus and find a stenosis at the venous outlet. I get message suggesting I append modifier 59 to 36831. Thank you Jane

Hi, Dr. Z! My question is in regards to cases where the physician does an atherectomy first - it is suboptimal and he then does an angioplasty. From what I have read, we are only allowed to bill for the successful procedure which would be the angioplasty in this case. Is it appropriate to bill the radiology S&I for the atherectomy (75992/26), since the physician did that reading as well? Thank you!

We are asking for further clarification when coding an Atherectomy of the Common Femoral artery. As advised by our Cath Lab staff the procedure documented below should code to 35492 Atherectomy iliac. We agree in Coding that the external iliac and the common femoral are the same vessel. But, CPT 2010 does not include in the index or in the Transluminal Atherectomy section any direction to code documentation specified to common femoral to the iliac. I have provided the case as documented below. ENDOVASCULAR INTERVENTION: SUCCESSFUL ENDOVASCULAR ATHERECTOMY OF THE LEFT COMMON FEMORAL 99% TO 20% AN ATHERECTOMY DEVICE WAS PLACE (MS-M FOX HOLLOW) IN THE LEFT COMMON FEMORAL ARTERY AND CUTS WERE PERFORMED. THE GLIDEWIRE WAS PLACED AND THE DEVICE WAS REMOVED. A BALLOON WAS THEN PLACED IN THE LEFT COMMON FEMORAL (6X4X130 EV3 EVERCROSS) AND INFLATIONS WERE PERFORMED. THE BALLOON WAS REMOVED. ENDOVASCULAR FINDINGS: LEFT COMMON ILIAC -- 50% (NO GRADIENT) LEFT COMMON FEMORAL -- 99% STENOSIS

Could you help me? Would this be coded 36247,35475 and 75962 or 36247,35475, 75978(angioplasty for the arterial side of the fistula)AND 36247 59,7507859 (angioplasty of the brachial artery)? The radiologist refuses to say native brachial artery. He also does not say how far above the anastomosis. I was audited a few weeks ago and now I am second guessing myself(I work for the hospital).I have your coding book and love it. Thank you. Frances () AVS(FISTULOGRAM) PROCEDURE - INDICATIONS: Poor blood flow at dialysis and pulling clots. RESULT: ARTERIAL VENOUS FISTULA: Technique: Informed consent was obtained from the patient. Access was gained into both the arterial venous side of the patient's arterial venous fistula. Contrast was then injected. This was then followed by angioplasty at the arterial side of the fistula with a 5 mm. balloon. The brachial artery was also angioplastied with a 5 mm. balloon. The catheters and sutures were then removed. Hemostasis was obtained. Complications: No immediate complications were encountered. Medications: 1% local Lidocaine to the skin, Versed and Fentanyl for conscious sedation. Approach: Fluoroscopy. Physical status: ASA-4 Findings: The patient demonstrates a brachiobasilic fistula. There is narrowing involving the arterial side of the fistula in the range of 80% to 90% with some mild aneurysmal formation. This was successfully treated with angioplasty with improved patency. There was an area of irregularity involving the brachial artery above the anastomosis which was angioplastied. This resolved after this. There is an indwelling stent involving the outflow venous structure. Just some minimal narrowing in this was identified but this was not treated because this was in the range of 20% to 30%. There is also an indwelling stent within the right brachiocephalic vein into the superior vena cava. This appears patent. IMPRESSION: Successful arterial venous fistulogram with arterial side angioplasty and brachial artery angioplasty for abnormalities.
 

Hi Dr Z, This is for HOPPS. Can we code/charge for supplies related to an attempted embolization? We appended modifier -52 to the embolization code. The radiologist's dictation states: Following the diagnostic arteriogram, and through a left internal carotid artery approach, a single lumen occlusion balloon catheter was introduced in the inferior division of the left middle cerebral artery across the neck of the aneurysm. A microcatheter was then maneuvered in the fundus of the aneurysm. Multiple attempts to embolize aneurysm with platinum coils using the balloon-assisted technique proved to be unsuccessful due to the shallow nature of the aneurysm and to the tortuosity of the cervical segments of the left internal carotid artery. The endovascular procedure was then aborted without any complications. The post-treatment left internal carotid arteriogram showed no branch occlusion or other intraluminal filling defects. Thank you for your help!

I am confused about code 47801 for choledochal stent. In one of your questions in 2006 a case was provided where code 47556 was recommended whether dilation occured or not prior to stent placement. I have a case where the physician placed a 10mmx6mm stent across the common bile duct with post angioplasty with 10mm balloon. Contrast injection to confirm patency. Since the intent of the balloon was for post dilitation would code 47801 be correct? I am confused about this code and when to use vs 47556 when stent is implanted. Thank you.

The H&P says the patient has a Fem-Tib bypass graph. The Preoperative diagnosis on the Op report says Stenosis of the left leg anterior tibial bypass. If this is an open procedure, do I code to the vessel that was bypassed or as a vein angioplasty 35460? The operative report reads as follows:

"A 1cm transverse incision was made over the vein bypass on the lateral aspect of the patient's left knee. A pursestring sture of 6-0 Prolene was placed and the patient was heparinized with 5000 units. Seldinger technique ws used with a micropuncture set and a 5 French sheath was placed. Catheter was advanced up to the area of stenosis near the proximal anastomosis and an angiogram revealed a 90% stenosis proximally. It was crossed with a 014 wire, dilated with a 3 mm balloon and it was improved to about 30% stenosis. No stent was felt optimal in this locatin in the groin and the heparin was not reversed. The flow in the bypass was much better and the pulse distally was palpable. The sheath was removed, pursestring tied. Wound was closed with 4-0 vicryl subcuticularly. Benzoin, Steri-Strips, and Opsite dressing were applied. "

Thank you again for your help.
 

When a vascular surgeon performs an angioplasty of a femoral vein graph and documents he made a 1 cm incision above the graph prior to utilizing seldinger technique, would the incision make this an open procedure? Does any incision make a procedure open even if the vessel is entered by seldinger technique?
 

The intent of the procedure is to declot a left arm graft by using an angioplasty balloon. The anastamosis itself was also angioplastied using a 5mm balloon contrast injection demonstrated clearing of the thrombus within the graft. please tell me if the above statement warrants an Angioplasty CPT code or just thrombectomy code?

I have read and re-read your information so far on the new AV fistula codes as well as CPT and CPT assistant and am going to take a stab at this (no pun intended, ha ha), but would really appreciate hearing your thoughts on the best way to code, given the information so far available on the application of these new codes. PREOP DX: Chronic renal failure, failing left thigh arteriovenous fistula. POSTOP DX: Chronic renal failure, failing left thigh arteriovenous fistula, stenosis of the arteriovenous fistula, long segment, approx 12cm. OPERATION: Right groin puncture, sonographic guidance into the right common femoral artery, aortic and left lower extremity angiogram, non-selective, sonographic-guided puncture of the left thigh arteriovenous fistula, fistulogram, and angioplasty of the arteriovenous fistula and the arteriovenous anastomosis. The patient has an AV fistula of the left greater saphenous vein in the left thigh. We have dilated about three weeks before and again the fistula was failing. We thought that there was some arterial component. We decided to do an angiogram first and then possible angioplasty of the AV fistula. DESCRIPTION OF THE PROCEDURE: Both groins and left thigh were prepped and draped. We then infiltrated lidocaine in the right groin and under sonographic guidance we did a direct puncture into the right common femoral artery. We then placed a wire and a 4-French sheath over the wire. We went in with a diagnostic Omni flush catheter into L1 and then proceeded to move the catheter down to the bifurcation and do a different injection. Findings were as follows. Abdominal Aorta: The abdominal aorta was patent with no evidence of stenosis. Both renal arteries were patent with no evidence of stenosis. The SMA was patent with no evidence of stenosis. The bifurcation was patent with no evidence of stenosis. The common iliac arteries bilaterally were patent with no evidence of stenosis. The left superficial femoral artery was patent with no evidence of stenosis. We then visualized the anastomosis. It was patent with a severe stenosis of the AV fistula right at the anastomosis, and beyond that a segment of approx 12cm. At this point, then we infiltrated lidocaine in the AV fistula. Under sonographic guidance, did a direct puncture into the fistula, and proceeded to do a fistulogram directly and then passed a wire through the stenosis. After that, we placed a 5X6 angioplasty balloon and inflated right at the anastomosis and beyond that, for a long area that was stenotic. After this was done, then we proceeded to do a completion fistulogram, and it showed that there was a complete patency of the AV fistula. There was no evidence of extravasation, and the fistula at this point was patent. There was a complete resolution of the stenosis. There was no residual stenosis. We then proceeded to pull on the sheath and the patient received 2000 units of heparin. We pulled first the puncture in the AV fistula. There was no evidence of any bleeding or hematoma at this point, patient was stable. Here are my questions: My initial thought was to code 75791 for the first puncture to the right common femoral artery. However, there is no description of any venous imaging/outflow on either the initial angiogram from the right femoral access, nor of the direct puncture of the AV fistula so would either 75791 or 36147 be appropriate? I know I can't use both of these codes together, but it really seems like this would be the answer if the lack of venous outflow imaging isn't an issue. 36147 would indicate the initial access to the fistula, and although 36148 refers to access for intervention, that seems to be for an additional access into the fistula and there was only one direct access. If I think about the reference to access for intervention I could choose 36148 but then I can't use that without using 36147 first. Should this be coded as an abdominal arteriogram 36200-75625, then 36147? I'm not clear on whether this is an angioplasty in the arterial side or the venous side and the whether the 12cm segment is within the graft? So it would be either 35474/75962 or 35476/75978? And if 36147 is supposed to include all catheter placements does that wipe out the 36200 if I go that route? The direct puncture came second but does that matter if it includes all catheter placements? I am really stumped. I realize I may just have to take my best shot and wait to see as info develops for these codes, but I'm really not sure what my best shot should be! Thanks, I'm sure you will want to edit as this is long winded, but you did ask for thought process!! I am not coding the sono guidance as I have no documentation or images captured for that. I also was hesitant to code an extremity angiogram as all he described of the left leg was the SFA and profunda femoral were patent. Thanks again!!!
 

Dr. Z, Really need your thoughts on the appropriate codes for a dicyphor discogram. We have an IR doc performing these. His documentation has changed a little since he began and not sure if this makes a difference or not. Now he documents " Dicphor needle advanced into the disk space. Dicyphor balloon positioned in the center of the disc space. Slight amount of contrast and 0.5 milliliters of lidocaine and 1.5 milliliters of bupivacaine were instilled into the disk space.....do I use the appropriate Diskogram codes or do I use an unlisted code? Thanks for you help.

Dr Z - Wondering how to code AVF access when there is only an intervention, not an angio. In this case access venous end going directly to thrombectomy and angioplasty. A second access arterial end, also thrombectomy / angioplasty. I don't think I can use 36147 without the angio and cannot use 36148 as it is an add-on code. Thank you for your help!
 

With the new 2010 AV fistula codes I am not sure how to code a cath placement. Fistula was accessed with a needle, contrast imaging done (36147). Tapered narrowing approaching the arterial anastomosis. The arterial anastomosis itself is moderately narrowed. The entire juxtaanastomotic segment was irregular in contour with two discrete moderate foci of stenosis. Balloon cath was advanced over the wire. Angioplastied the inflow segment down to the radial artery in an overlapping fashion (35475 & 75962). Can I also charge for catheter placement in the radial artery 36140? Thanks for your help.
 

Greetings,

This site has been my life line. Here I go with another AV fistula creation.
Local anesthetic was infiltrated along the previous surgical scar in the antecubital fossa. The skin incision was made overlying the previous incision and cautery was used to dissect down to the aneurysmal portion of the fistula. This segment of the fistula was mobilized circumferentially and the arteriovenous anastomosis was identified and dissected free. The fistula was doubly clamped and divided. The stump of the fistula, which was still attached to the vein, was oversewn with a GoreTex suture. This allowed the very small stump to act as a vein patch angioplasty to the brachial artery. The remaining segment of the aneurysmal portion of the vein was excised. The wound was then closed in layers with interrupted Vicryl in the deep tissue and a running Vicryl suture for the skin. Is this a revision of a fistula or ligation?

We did a diskogram at three different lumbar levels, so I have coded 62290x3 and 72295x3 with modifiers. Our Radiologist is also wanting us to code CPT 64999 additionally for what he is calling a functional anesthetic diskography. He placed these tiny little, what he is calling functional micro balloon catheters at each level. After the conventional diskogram he left the catheters in place and stood the patient up and injected lidocaine at each level waiting 20 minutes between levels and had the patient bend forward and back and from side to side as well. All of this is documented in his dictation with pain levels from the patient. Would you suggest additional coding for this? Your help is greatly appreciated! Thank you!

Are the new codes for AV fistula angioplasty only for hospitals and out-patients facilities. We bill for radiologist on hospital base. Do we need to use these new codes or the oldest ones.