Ask Dr. Z

"The left femoral artery was accessed under fluroscopic guidance with a micropuncture needle, wire, then sheath. A 4 French sheath was inserted over a wire. A wire, then catheter was inserted into the aorta. An aortoiliac arteriogram was performed. A bilateral lower extremity arteriogram was performed. The right iliac, then common femoral artery was selectively catheterized, and an arteriogram was performed. The right superficial femoral artery was selectively catheterized and angiography performed. Two severe stenoses were identified in the right popliteal artery, in the P1 and P2 segments. An up-and-over 5 French sheath was inserted over the wire into the right superficial femoral artery after 3000 units of intravenous heparin was administered and three minutes allowed to elapse. Balloon angioplasty of the right popliteal artery was performed using a 5 mm cutting balloon." How would you code the S&I: 75630 or 75625, 75716?

Which code(s) would you recommend for an open thrombectomy of right upper arm AV graft with an open angioplasty and stent placement for a tight stenosis at the venous outflow? "Patient had near complete thrombosis of AVG. A graftotomy was performed, and a Fogarty was used for thrombectomy of the arterial and venous limbs. A fistulogram was then performed, which demonstrated tight stenosis at the venous anastomosis. The stenosis was treated with balloon angioplasty and subsequent stent placement. Graftotomy was then repaired and wound closed in layers." Can we assign both codes 37238 and 36831? There is an NCCI edit that says code 36831 is a component of code 37238. Is thrombectomy included in code 37238?

Is this coded correctly? Can code 36246-XU be reported in this scenario? 75710 59, 37252, 37253 x 3, 37226, 37221, 37222. "1 U/S guide cannulation RT C Femoral A 2 Aortoiliac angiogram 3 LT LE angiogram 4 IVUS pre/post LT C ext. Iliac, c femoral, sfa, popliteal, tpt trunk arteries 5 angioplasty lt sfa 6 stent lt sfa and popliteal 7 stent lt c iliac 8 angioplasty lt external iliac PROC: RT C Femoral A cannulated, sheath placed, cath positioned in infrarenal aorta and aortoiliac angiogram done...stenosis in C Iliac A and bifurcation. Up and over technique, cath positioned in LT C femoral A. LT LE angiogram done. Occluded SFA and Popliteal w. fx stent in P SFA. 1 vessel runoff. Heparinized. Quick cross and wire traversed occluded stents and reenter TPT trunk. angiography. Emboshield. Balloon angioplasty SFA and popliteal. both IVUS. stenosis along SFA. Both Stented and angioplasty. IVUS C. Femoral A, stenosis. Stent and angioplasty to C. Iliac A. Balloon angioplasty entire external Iliac A. IVUS E Iliac A."

My question is regarding removal of an intracoronary thrombectomy at time of a stent placement. Biller says it's bundled, I believe there has to be a separate code when it’s a STEMI acute MI. Study performed reads: "Left heart catheterization, left ventriculography, selective coronary angiography, complex percutaneous coronary intervention to right coronary artery involving balloon angioplasty, suction thrombectomy, and intracoronary stent placement." Keyed codes: 93458-XU and C9606-RC.

I am unsure whether the cath for the right side for the angiogram would be billable. There was intervention on both the right and left sides, but it was through the left access. "The decision to intervene was based on today's study, and there were no prior cath based studies to compare. Percutaneous 5 French RIGHT common femoral artery access. Cannulation of abdominal aorta. Pelvic arteriogram. Percutaneous 6 French LEFT common femoral artery access. 6 mm balloon angioplasty of the LEFT external iliac artery. Cannulation of RIGHT common iliac artery. Recanalization of chronically occluded RIGHT internal iliac artery. Primary balloon angioplasty to 4 mm of the origin of the RIGHT internal iliac artery."

Patient comes into the cath lab and has a left heart cath with LV pressures, an FFR of the LAD, and also intervention with a stent placed to the LAD. The patient started to experience chest pain before leaving the cath lab. A left coronary angiogram was performed and showed thrombus of the proximal portion of the previously deployed stent, and aspiration thrombectomy was performed along with balloon angioplasty of the LAD. The procedures originally coded were 93458-26XU, 93571-26, and 92928-LD. Since the patient developed the symptoms before leaving the cath lab, it would not be appropriate to code another coronary angiogram with a PTCA of the LAD, correct?

Can you help verify if I understand the coding hierarchy for the cardiac intervention codes? The patient had a diagnostic heart cath (93458), followed by: 1) successful orbital atherectomy with balloon angioplasty to the heavily calcified right coronary artery, 2) successful balloon angioplasty and stenting to the right posterolateral branch by deploying one bare metal stent. Should I report code 92924 for the RCA atherectomy and code 92929 for the vision stent and PTCA of the posterolateral branch?

Can you tell me if this would be considered an open procedure and if you would only report code 36832? "DuraPrep and sterile draping of the left upper extremity in the routine manner. Using the SonoSite, the location of the collateral vein arising from the left brachiocephalic arteriovenous was identified. An axial incision was made over the fistula at this location. Sharp dissection down to the fistula and the collateral vein, which was controlled by circumferential dissection and secured with 0 silk ties. Access through this large collateral vein with a micropuncture kit into the left upper arm brachiocephalic arteriovenous fistula. Insertion of a 6 French sheath. Wire exchange, which was advanced across the stenosis. Viabahn stent graft was then deployed across the stenosis. Post deployment balloon angioplasty conquest balloon up to 18 atm with 0% residual stenosis. The large collateral vein was then triply ligated with 0 silk. Irrigation and hemostasis. Wound closure in layers dermal closure staples."

I am very new to IR coding, so I am not real sure on how to code this report, which reads as follows: "Under ultrasound guidance the left upper arm dialysis access graft was catheterized. Images of the graft were recorded. Subsequently under fluoro guidance a catheter was placed in the graft, and fistulogram was obtained. A questionable stenosis at the arterial anastomosis was dilated with a 5 mm angioplasty balloon. FINDINGS: Ultrasound shows markedly thickened wall of the graft consistent with mural thrombus. The fistulogram shows very slow flow through the graft with very small lumen. There was a questionable stenosis at the arterial anastomosis, but there was really no change with the angioplasty. The distal anastomosis at the venous end is unremarkable. Central veins are patent." I was going to report codes 36147, 35475, and 75962 because he stated "at the arterial anastomosis". However, another coder thinks we should only code for fistulogram (36147) because the doctor did not give the percentage of the stenosis. What is your opinion?

The patient has an indwelling subclavian and axillary vein stent with thrombosis. The physician ballooned the area with a cutting balloon. Would this be considered angioplasty or atherectomy?

Do we have the same guidelines with CPT? Need help on CPT and PCS. "Ischemic right foot ulceration with arterial occlusive disease. History of prior left left revascularization, gangrene, and foot salvage. Procedures performed: Abdominal aortoiliac angiogram and right left runoff via left common femoral artery approach. Selective right common femoral artery angiography and right leg doralis pedis artery angiography. Percutaneous right leg superficial femoral artery and above-knee popliteal artery atherectomy (SXC Turbohawk). Percutaneous right leg superficial femoral artery and above-knee popliteal artery cutting balloon angioplasty (4 mm x 6 cm VascuTrak Bard balloon. Percutaneous right leg anterior tibial artery and dorsalis pedis artery atherectomy (EXL SilverHawk and SXC TurboHawk). Percutaneous right leg anterior tibial artery and dorsalis pedis artery cutting balloon angioplasty (2.5 mm x 10 cm VascuTrak Bard balloon). Left femoral retrograde, angiography with interpretation and supervision of direct fluoroscopy, radiography, and intervention. Total contrast volume used: 60 mL of diluted Visipaque."

Operative report indicates aortic arch, selective innominate artery, left common carotid, and selective left subclavian angiography. In addition, balloon angioplasty and stenting of the ostium of the innominate and ostium of the left common carotid. Greater than 80% stenosis in innominate and left common carotid verified by CT angiography sometime prior to procedure. Procedure included access from right radial and right femoral. It appears that code 37216 has an MUE of 1, and it is not appropriate based on Medicare Fee Schedule to use modifiers -RT/-LT. Should code 37216 be reported separately for the right common carotid and the innominate? Would modifier -59 be appropriate? Is everything else performed bundled?

Can you clarify the definition of "within the graft" as it relates to open surgical revision of an AV fistula/graft with balloon angioplasty in the venous outflow? Is the entire peripheral segment considered "within the graft" or just the anastomoses, graft material between the anastomoses, and the immediately adjacent areas? For example, a physician creates a surgical incision over the venous anastomosis of an AV graft. He opens the graft and retrieves thrombus using a Fogarty and places a patch angioplasty at the venous anastomosis to treat an area of stenosis there. He then performs a balloon angioplasty of an area of stenosis in the venous outflow in the cephalic vein through the same surgical incision (the stenosis is proximal to the venous anastomosis and not immediately contiguous with the anastomosis). Would you agree with 36833, 35460, and 75978 here? Or can I only report the angioplasty and radiology S&I (either 35460/75978 or 35476/75978) if these additional procedures are performed in the central segment?

"Patient had 80% stenosis of a main superior sub-branch of OM3 and also had 60% ostial stenosis of an inferior sub-branch of OM3. The 80% superior was treated with a drug-eluting stent across the lesion, jailing the inferior sub-branch. Angiogram then revealed a 90% inferior side branch stenosis, not improving after nitroglycerin administration. Plain balloon angioplasty then was performed at ostium of inferior branch. Then kissing balloon inflations were done in the superior sub-branch and ostium of inferior sub-branch, resulting in 0% residual in the main superior and 5-10% residual in the inferior sub-branches." Would it be appropriate to report codes 92928 and 92921? Or should I only report code 92928 since these were both sub-branches of the OM3?

My provider submitted codes 37215, 35475, 75898, and 75962 for percutaneous transluminal balloon angioplasty and stenting of the left ICA. This does not seem correct to me, as they bundle, and also the description of code 35475 says "brachiocephalic or branches" (and this is the left ICA). Can you help me with this scenario please?

Hi Dr Z, Coding Open and Catheter use procedure? Senario: Discected upper ext. graft and performed graftotomy. Thrombectomized venous end graft which inadvertently thrombectomized arterial limb. Arterial limb clamped. Patient heparinized with 3000 units. After thrombectomy performed, then contrast inj, show residual thrombus at venous outflow of graft. Using clot catheter removed residual thrombus. Inj. contrast. Balloon angioplasty 7mm Armada balloon, then deployed 7x50 mm Viaben stent graft. Resulting arteriography demonstrated wide patency, no residual stenosis and nice luminal surface. We then utilized balloon to perform contrast inj centrally which demonstrated in-stent stenosis of innominate vein stent. Therefore use a 12mm x 60mm Armada balloon angioplastied innominate vein stent. Removed catheter, wire and sheath, locally heparanized and performed contrast inj. through arterial limb of graft, demonstrating wide patency. Closed graft with running 6-0 Prolene suture. Verified homstasis, irrigated wound and close wound with deep layer closer.

This Q& A below was in the ZHealth coding newsletter of December 2011. Does this still apply, or has there been changes to billing angioplasty with stent placement based on intent? Original Question: "Can you bill angioplasty code 35476 and stent placement code 37205 in the same venous (SVC-IVC) or pulmonary artery (92997, 37205) when angioplasty is not just for inflating a stent that is placed?" Original Answer: "Depends. There needs to be an intent to only perform balloon angioplasty, with a suboptimal outcome requiring stent placement to code for both. If this is not documented, I would only code the stent placement."

How would we code the following? "OPERATION: 1. Right and retrograde left heart cardiac catheterization. 2. Angiography: Left internal mammary artery/left coronary artery, main pulmonary artery, aorta. 3. Balloon angioplasty of right ventricle to pulmonary artery conduit with 20 mm BIB balloon and 22 mm Vida balloon. 4. Endovascular stent placement, right ventricle - to - pulmonary artery conduit (4010 Palmaz stent on 22 mm BIB balloon). 5. Percutaneous pulmonary valve placement (Melody transcatheter valve, 24 mm Ensemble delivery system)."

Patient with right MCA occlusion with stroke. CT with contrast demonstrates evidence of RT MCA occlusion with a large area penumbra on the perfusion imaging. Now for attempted thrombectomy and revascularization of the right middle cerebral artery. Selective right ICA and cerebral angiogram, catheter advanced up to the edge of the clot and aspirated for 60 seconds, after removing catheter there was no evidence of clot within the tube. Following mechanical thrombectomy with direct aspiration technique and stent retriever x2,we were unable to obtain revascularization(37184), most likely due to the high-grade stenosis from an atherosclerotic plaque of the distal M1 segment. There appeared to be a very firm lesion at the distal MCA consistent with possible atheroma, and at this point we advanced a balloon across the stenosis and performed transluminal balloon angioplasty (61630). This resulted in partial revascularization. Can we report both codes since thrombectomy attempted but results were not to his satisfaction then he proceeded to angioplasty of stenosis?

Condensed version of AAA 2 providers involved - bilateral femoral cutdowns were made on common fem, Seldinger tech. wires and sheaths were introduced in to each groin. Initially an aortogram was performed to delineate anatomy. the main body graft was placed via Rt. fem artery was Medtronic 28x16x124 graft, contralateral limb was placed via Lt fem artery 16x24x156 and then Rt. limb extension was placed via Rt. groin 16x28x93 which was a flare type graft. balloon angioplasty was then carried out. A second arteriogram was then performed for an endoleak. No endoleak all catheters & sheaths withdrawn fem artery repaired with 5-0 prolene suture. I have coded 34802,62 / 34825,62 / 34812,50,62,XS,51 / 75952,26 / 75953,26 / 36200, XS,51/ 36200,XS,51 - Am I coded this right my surgeons never say placed the catheters in aorta for aortogram simply say aortogram x 2 and do I coded the cutdown part correct with modifiers since cvt surgeon and cardiologist both doing this. I really thank you for your expertise.

"The patient has outflow stenosis around the elbow with flow through the perforator vein into the brachial vein with stenosis there. The fistula was opened, and a large amount of thrombus was evacuated. A Fogarty was passed proximally and retrieved clots from there as well. After this the fistulotomy was repaired, and the fistula was then punctured with a needle wire and sheath, and fistulogram was performed. This demonstrated high-grade stenosis of the brachial vein down the perforator, which is the sole outflow of this fistula. We crossed the lesion with a wire and noted that we were in two different perforator systems and ultimately engaged each. These were treated with 6 mm balloon angioplasty. We then also treated the proximal fistula lesion with 8 mm balloon angioplasty. Repeat injection demonstrated improvement. The sheath was removed and the puncture site repaired." Can we report codes 36831, 35476, and 36147 for the same encounter/same physician? There is an NCCI edit on codes 36831 and 36147. Would it be appropriate to assign modifier -59 or-XU to 36147 in this scenario?

"PROCEDURES PERFORMED: 1) Left upper extremity angiography. 2) Successful percutaneous recanalization of a chronically occluded left subclavian artery utilizing the Frontrunner and Pioneer catheter was followed by IVUS-guided angioplasty and stenting with an Omnilink balloon expandable stent. Left radial access with cath placement into the aorta. Right common femoral access with cath placement into the left subclavian. Performed balloon angioplasty of the subclavian from the radial access. Performed stenting of the subclavian from the right femoral access." Please advise on the proper codes for this procedure including cath placements.

Provider performed left common femoral endarterectomy with patch angioplasty, then a right external iliac balloon angioplasty. Can I report the iliac angioplasty, or is it included?

"Catheter from left femoral artery access was advanced to the thoracic aorta where aortogram was obtained. Based on this finding it was decided to proceed with a 14 x40 balloon angioplasty. Repeat aortogram showed no change, so a 39 x10 mm Palmaz stent was placed at the level of the coarctation." How would you code this?

Please code the following procedure done for aortic stenosis: "Stent graft repair of the patient's abdominal aorta and common iliac arteries and then address residual disease in the external iliac arteries. We utilized the AFX stent graft system. We then used two 8 x 40 mm Armada balloons to perform kissing balloon angioplasty of the aorto-iliac bifurcation, as well as the right and left common iliac arteries. There was still some concern about a possible stenosis or dissection in the distal right common iliac artery and proximal right external iliac artery. IVUS revealed an area of dissection or residual thrombus in the distal right common iliac artery beyond the right limb of the endograft. There was also an area of dissection seen in the proximal to midportion of the right external iliac artery. We placed a covered stent across the distal right common iliac artery immediately above the takeoff of the right hypogastric artery. To cover the area of dissection in the right external iliac artery, we used an Absolute stent."

PROCEDURE: R/L CATH, COROS, NO LV; AORTOGRAM. PTA WITH STENT OF THE DISTAL AORTA AND RIGHT ILIAC ARTERY. INDICATION: SOB, RIGHT LEG PAIN, AND PAD. Taken from op report: "Decision to intervene on the total right ostial iliac occlusion and the distal aorta with balloon angioplasty first, after deployed stent. Balloons were used to predilate and inflated/deployed stent at the level of the bifurcation not to preclude or occlude the access to the left illiac ostium. The distal aorta was also predilated with the above balloons, and there were excellent angiographic results." I am enclined to code for PTA/stent to right iliac, 37221 (stent placement, w/wo angioplasty illiac artery, and PTA to aorta). I did not read anywhere on report that he stented the aorta. I'm not sure what to code. I came up with 35472 (percutaneous angioplasty, aortic). Please help.

"Balloon angioplasty of an AV fistula resulted in the rupture of the vein at the second of the two strictures. Attempts at sealing the rupture were unsuccessful. Therefore, thrombin was injected directly into the hematoma under direct ultrasound guidance, resulting in closure of the rupture." How would this be coded? Or is this included in the procedure?

Could you please review this example and help with the coding of 92928 and 92921 or just 92928? "A wire was advanced into the distal portion of the left anterior descending. A wire was advanced into the distal portion of a medial branch of the first diagonal branch. The diagonal was dilated at its ostium and mid portion with a 2.0 x 15 mm Mini TREK balloon. The ostium was then dilated using a 2.25 x 8 mm NC TREK. Subsequently, a 2.25 x 8 mm Xience Alpine drug-eluting stent was deployed at the ostium of the diagonal. Post-dilation was performed using a 2.5 x 6 mm NC TREK balloon at the ostium of the diagonal and a 3.25 x 12 mm NC TREK balloon within the left anterior descending. Successful stenting of ostial diagonal lesion using drug-eluting stent. The initial stenosis of 90% was reduced to final residual stenosis of 0% with an excellent angiographic result. Successful balloon angioplasty of lesion in a medial branch of the diagonal branch of the left anterior descending."

Can aspiration thrombectomy of the lower extremity be considered a mechanical thrombectomy and reported with codes 37184-37186? Or does an AngioJet need to be used to report for these codes? The patient had tPA for 18 hours (second and final day) and was brought back for a re-look. Infusion catheter was removed. The thrombus was still present in the popliteal artery. Aspiration thrombectomy was performed, still not sufficiently removing the thrombus. The physician then performed balloon angioplasty. I am thinking of reporting code 37214 for the final day of tPA infusion, code 37184 for a primary thrombectomy of the popliteal, and code 37224 for the PTA of the popliteal. Am I reporting the correct codes?

When billing code 34803, would I also report code 34812 if that is done? In our Encoder pro software it says that code 34812 is included in code 34803. "34803 - INCLUDES: Balloon angioplasty/stent deployment within the target treatment zone; introduction, manipulation, placement, and deployment of the device; open exposure of femoral or iliac artery/subsequent closure (34812)." Not sure if I should be billing code 34812 with a -59 (-XS) modifier or just not using it at all.

Could you please assist with the correct procedure code? I am unsure of which code is most appropriate (37799 or 37220). "5 French Cobra Glidecath was advanced through the sheath into the distal aorta and advanced over a Glidewire to the contralateral left internal iliac artery. Digital subtraction arteriography was performed over the pelvis and upper thigh. Cobra catheter was exchanged over a guidewire for a 12 mm diameter by 4 cm long angioplasty balloon, which required exchange of a 5 French angiographic sheath, a 4 a 7 French Balkan cross-over sheath, into the contralateral persistent sciatic artery. The antiplastic balloon was inflated across the arteriovenous fistula in the distal persistent sciatic artery, and digital subtraction arteriography of the popliteal and lower leg region was performed to the level of the hindfoot. The balloon was deflated and exchanged over a guidewire for a 5 French Davis catheter, which was advanced into the pseudoaneurysm arising from a persistent sciatic artery, and digital subtraction arteriography was performed."

Does using a "micropuncture" needle/sheath mean that a procedure was done percutaneously, or can it sometimes mean open? Examples: 1) Dissected out the fistula and then accessed the aneurysm with a micropuncture 6 French sheath. 2) A right upper arm incision was made distal to the axilla. The brachial artery and vein were identified. The brachial artery was circumferentially dissected and encircled with Vesseloops. Needle access to the brachial vein was obtained with a micropuncture needle, allowing placement of a micropuncture sheath. Right upper extremity and central venograms performed, showing occlusion of a previously placed right innominate vein stent. A 6 French sheath was inserted. A guidewire was advanced across the right subclavian and innominate vein occlusion. Balloon angioplasty of the stent performed. The 6 French sheath was exchanged for 12 French peel-away sheath. Gore hybrid stent graft was inserted using the introducer sheath. It was placed into the right brachial vein and deployed after removing the peel-away sheath. The graft was tunneled in a loop fashion.

"Patient with history of congenital aortic stenosis who had valvuloplasty done at 3 days old followed by Ross procedure with bioprosthetic valve in 2009. Now comes in with severe stenosis of the bioprosthetic valve. Doctor performed a balloon angioplasty with bare metal stent placement in the bioprosthetic valve (Palmaz 3110 XL stent inflated to 20mm) and a transcatheter placement of a Melody valve on a 20 mm Bib balloon within the stent complex." I am thinking of using code 37236 for the stent placement, but I'm not sure about the placement of the Melody valve within the stent.

I thought I had this figured out but I need to clarify. I always coded a fistula anastomosis plasty to an arterial. But then reading up in your book, you state that there are both venous anastomosis and arterial anastomsis in a graft. You also state we should code arterial anastomosis or perianastomotic region angioplasty to an arterial 35475/75962. If the physician states that the angioplasty is of the anastomosis,how do you know if it was arterial or venous anastomosis? Does it matter? Do all anastomotic strictures of the fistula automatically get an arterial angioplasty code assigment?

Would you code separately for drainage of the pseudoaneurysm during the following AV graft stenting case? Would you use code 10030? "Through the existing sheath an 8 mm x 10 cm Viabahn covered stent was subsequently deployed with post-deployment venogram revealing excellent exclusion of aforementioned pseudoaneurysm. Under fluoroscopic guidance a percutaneous angiocatheter was introduced into the pseudoaneurysm sac at a separate site in the pseudoaneurysm and was drained after exclusion. Antegrade access was then acquired, being careful to avoid the recently placed stent. A 9 French sheath was introduced over wire and a 9 mm x 5 cm via bond stent was deployed at the cephalic origin into the innominate. Post deployment venography reveals exclusion of the primary collaterals and no significant intrusion centrally. Balloon angioplasty was subsequently performed with an 8 mm balloon within and adjacent to the more central stent."

The provider performed a diagnostic angiography of the right lower extremity accessed through the ipsilateral CFA and stopping in the SFA (billing 36245-59, 75710-26-59). Then tried to cross the SFA to treat occlusion and was unable to. Closed this access up. Accessed the posterior tibial artery and advanced catheter to the SFA occlusion and did an atherectomy through this access (billing 37225). There was spasm in the posterior tibial artery, and the provider proceeded to balloon angioplasty the posterior tibial artery spasm (provider would like to bill code 37228). Can we bill code 37228 for treating the vasospasm?

I'm trying to code for a balloon angioplasty of the right jugular vein, and I'm not sure of the correct code. Also with contrast veno of inferior vena cava, superior vena cava, and right internal jugular vein.

The physician made several attempts to cross the lesion in order to place a stent. It was unsuccessful. He ended up doing a plain old balloon angioplasty. The stent will be replaced by rep. What should we bill for hospital, code 92928-74FD or 92920? And what codes for physician billing, code 92928-53 or 92920 (with location modifier added also)?

2014 codes, balloon angioplasty and stent placement left proximal and mid subclavian, also with left subclavian angiogram. Also for angiogram the vertebral was viewed and noted to have stenosis. Diagnosis for subclavian is PVD with claudication.

Patient had severe vasospasm in the left M1, left ICA, and right ICA. The doctor did a nicardipine infusion over time in all three arteries and then had to do a balloon angioplasty of the same arteries. The doctor only placed the catheter into the cervical portion of the right internal carotid. Would it be permissible to use code 61642, or would you consider using an unlisted code for the right internal carotid extracranial portion?

Can you help with coding for the Snorkel repair in 2013?

"DX: infrarenal abdominal aortic aneurysm. 2. L & R common iliac artery aneurysm 1. Percutaneous endovascular repair of the abdominal aortic aneurysm as well as the common iliac artery aneurysms using the Endologix AFX graft (main graft 22 mm x 120 mm x 16 mm in diameter for both limbs with suprarenal extension measuring 28 mm x 75 mm and a second suprarenal extension placed for proximal endoleak measuring 28 mm x 75 mm. 2. Left limb extension 16 mm x 75 mm and right limb extension 20 mm x 120 mm. 3. Snorkel repair of left hypogastric artery using an 8 mm x 15-mm Gore Viabahn covered stent...The left hypogastric artery was then selectively cannulated using a crossover sheath followed by deployment of an 8-mm x 15-mm Gore Viabahn covered stent in this area and a left-sided limb extension was then placed measuring 16 mm x 75 mm. On the right side, a right-sided limb extension was then done using a 20 mm x 120 mm in length covered stent sealing above the right hypogastric artery. Balloon angioplasty was then perfo..."

"The balloon was inflated, but there was no reduction in stenosis. An unsuccessful attempt at balloon angioplasty was performed on the 100% lesion in the mid RCA. Following intervention there was no improvement in angiographic appearance with a 100% residual stenosis. This was an ACC/AHA type C 'high risk' lesion for intervention. The residual lesion demonstrated a large filling defect consistent with thrombus. There was TIMI 0 flow before the procedure and TIMI 0 flow after the procedure. There were no site complications. Balloon angioplasty was performed, using a Trek RX 2x12 balloon, with two inflations and a maximum inflation pressure of 6 ATM. The resulting stenosis was 100%." Would a -52 modifier be applied to the angioplasty?  Would code 92920 be reported with a -52 or -53 modifier?

Our physician was trying to access and place a left vertebral artery stent for vertebral artery stenosis, but he was unsuccessful after multiple attempts. He did perform a balloon angioplasty at the left vertebral artery ORIGIN. Would this be considered a subclavian artery angioplasty or a vertebral artery angioplasty? What do you recommend for coding?

I may be overthinking this, but I need your expertise. Patient presented for intervention for a pseudoaneurysm within the arterial end of an upper extremity dialysis AVG. In addition, he had 70% stenosis in the venous outflow. Balloon angioplasty of the venous outflow and stent of the arterial pseudoaneurysm were performed, two distinct locations but within one graft. My inclination is to only code the stent, as PTA is bundled into stent placement and the AVG is considered one vessel. Is this correct, or may I separately code for the PTA?

Our physician did a diagnostic left heart catheterization with left ventriculography, coronary artery angios, and bypass graft angios. He then did an angioplasty at the anastomosis of the LIMA graft to the distal LAD. Following this, he placed a drug eluting stent in the circumflex artery and performed a kissing balloon angioplasty of the proximal circumflex and the proximal LAD. I am thinking of reporting codes C9600-LC, 92937-LD, and 93459-59. Could I also report code 92921-LD for the proximal LAD kissing balloon angioplasty since it was via the native arteries and not through the bypass graft?

If a cutting balloon is used to do an angioplasty, do we report an atherectomy?

What is the CPT code for ligation of accessory vein?

ESRD with a poorly matured right arm fistula. Procedure: Balloon angioplasty of the cephalic arch and peripheral cephalic vein, ligation of the accessory vein to improve blood flow. Incision through the subcutaneous tissue to the accesory vein and was freed up from the surrounding tissue and ligated with 2-0 silk tie.

How would you code the following?  Stent graft angioplasty of old cadaeric vein bypass, balloon angioplasty of right anterior tibial vessel, selective angiography of right lower extremity with third order catheter placement, and replacement of infusion cath for another 24 hours.

The following case was coded with 35476, 36870, 75978, 36147. We were asked to add codes 37212 and 75791 by our HIMS dept. Not sure if this would be appropriate. "The graft was accessed with a micropuncture needle in an antegrade fashion. A fistulogram was then performed from the right atrium to the level of the fistula. Two improve visualization of the central stenosis a Kumpe catheter was advanced to the subclavian vein and subsequent venography performed. Fistulogram demonstrated a large thrombus within the fistula distal to the venous anastomosis. Thrombolysis was performed and this thrombus was laced with 6 mg of TPA. After a short waiting period a catheter and wire were advanced beyond the thrombus. Another 6 mg of TPA were used to lace the venous outflow thrombus. Mechanical thrombectomy was performed through the outflow vein and the fistula thrombus. The above described conduit and venous outflow stenosis was negotiated with a glide wire. Subsequent balloon angioplasty was carried out without significant residual. Brisk flow was acheived."

Can you clarify what, if anything, would be appropriate to bill for the following circumstance? "The physician went into the right femoral artery performed a left heart catheterization and stent x 2 in the RCA (overlapping), and prior to getting the patient off the cath table to physician noted the patient had an ST-elevation. He proceeded on with cannulating the left groin to the RCA where the stents were placed and by a guided projection taken showed TIMI III through the RCA with thrombus formation in the nmiddle of the stent. He then placed a balloon, which he had to inflate x 3. After removal of balloon, the thrombus had resolved." What code(s) would the physician be able to bill for the post angioplasty for the thrombus formation? Can we bill anything?