Ask Dr. Z

Post-Stent Balloon Angioplasty

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?

Arch Aortogram (36221)

I am a little confused when a non-selective catheter placement of the aortic arch can be reported with a selective intervention of an upper extremity artery. It would seem in the report below that the physician had plans to perform the therapeutic procedure based on the history. In these cases, is the determining factor as to whether the non selective cath placement (36221) can be reported based on if it is related or not to the subclavian stent placement done? How would a coder make that distinction? Thanks.

PROCEDURE: LEFT GROIN CANNULATION WITH LEFT SUBCLAVIAN ARTERY CANNULATION, BALLOON ANGIOPLASTY AND STENT PLACEMENT. ANESTHESIA: 1% lidocaine for local with intravenous fentanyl and Versed for a nurse-monitored anesthesia time of 1.5 hours. ESTIMATED BLOOD LOSS: Minimal. PATHOLOGY SPECIMEN: None. PROSTHETIC IMPLANT: Genesis balloon expandable stent, 8 x 39 mm placed within the origin of the left subclavian artery. REASON FOR PROCEDURE: This is a 61-year-old gentleman with coronary artery disease status post coronary artery bypass grafting including a left internal mammary artery graft to the left anterior descending artery. The patient presented to ABC Medical Center with an acute myocardial infarction. Cardiac catheterization was performed demonstrating two patent coronary artery bypass grafts with a high-grade left subclavian artery stenosis. Patient was transferred to XYZ Hospital for definitive treatment including stenting of his left subclavian artery stenosis. I evaluated the patient and recommended left groin cannulation given his recent cannulation within his right groin with selective catheterization of the left subclavian artery and stenting as appropriate. The indication is to treat the subclavian lesion restoring perfusion to his left anterior descending artery bypass graft. The risks include bleeding, arterial injury, failure to revascularize his left subclavian artery as well as atheroembolization. In addition, potential recurrent stenosis. The patient requested we proceed. PROCEDURE AS FOLLOWS: On 02/26/2013, after obtaining informed consent, the patient was taken to the angiography suite and placed on the angiography table in the supine position. After prepping and draping his left groin in the usual fashion with ChloraPrep, patient identification and operative checklist was performed. Utilizing ultrasound guidance, the left common femoral artery was cannulated overlying the femoral head in a retrograde fashion with a Micropuncture needle. A Microwire was advanced under fluoroscopic guidance to the aortic bifurcation. This was exchanged through a coaxial dilator for a 5 French sheath and eventually a 6 French Raabe sheath, 55 cm. The guidewire was placed in the ascending aorta. Patient was heparinized with 4000 units of IV heparin. A pigtail catheter was placed in the ascending aorta. Arch aortography was performed with a steep left anterior oblique view demonstrating the left subclavian artery origin with subtotal occlusion with retrograde filling of the left upper extremity through the vertebral artery. The left internal mammary artery is identified distally and found to be patent. The left common carotid artery is patent as is the innominate. A 6 French Raabe sheath was then placed over the guidewire to the origin of the left subclavian artery. The left subclavian origin was selected with a vertebral artery catheter and a 0.014 inch Thruway guidewire. The guidewire was placed in the proximal brachial artery. Balloon angioplasty of the stenosis was performed with a 4 mm balloon angioplasty catheter followed by placement of an 8 mm balloon expandable Genesis stent. The stent was dilated within its mid segment and proximally and very gently distally. Selective angiography demonstrates a patent result without evidence of a residual stenosis. Guidewire and catheters were removed. Angiography of the left groin demonstrates extensive calcification just distal to the cannulation site, therefore, the catheter was removed and hemostasis was obtained with manual compression. The patient tolerated the procedure and was transferred to his room in stable condition. IMPRESSION: Successful balloon angioplasty with stent placement, left subclavian artery origin stenosis.

Angioplasty of the Right Internal Carotid Artery

A patient has a duplex scan that suggests significant increase in velocity of a high grade in-stent re-stenosis of the right internal carotid artery. The physician successfully treats by balloon angioplasty in the right internal carotid artery. Is there a code for this procedure, or is an unlisted code our only option?

Open Revision/Trombectomy vs. Percutaneous Fistulogram/venous angioplasty vs Ligation/AV Fistula Creation

I hope you can give some insight into this procedure. Basically the physician performed open revision with thrombectomy (36832), then performed fistulogram (36147), followed by percutaneous venous angioplasy (35476 and 75978-26), and then decided to ligate the entire fistula (37607) and create a whole new graft (36830).  Based on the below documentation, would you bill all those codes? Or should only the open procedure be coded as per NCCI Chapter 5, Section D, #9? Any assistance will be appreciated!

A linear incision was made in the fistula at the arterial anastomosis. I noted immediately that the thrombus was well organized and adherent to the fistula walls. It required mechanical removal. I carefully inspected the area of the arterial anastomosis, removing the fibrin plug. I passed a #3 Fogarty catheter distally in the brachial artery and retrieved no additional thrombus. I sounded the proximal brachial artery with the right angle, and there was no evidence of a stricture at the arterial anastomosis. I removed as much thrombus from the body of the fistula as allowed by the arterial cuff, which had been placed proximally. In order to control the arterial inflow and to avoid stricturing of the fistula, I acquired a bovine patch and partially closed the fistulotomy with the bovine patch and 6-0 Prolene suture. This allowed for application of an atraumatic clamp at the arterial anastomosis and removal of the proximal arterial tourniquet. I evacuated the clot from the remaining portion of the fistula body by vigorous manipulation beginning at the axilla. I removed a relatively small amount of clot. I did retrieve venous backbleeding. Heparinized saline was instilled, and an atraumatic clamp was placed on the body of the graft. The patch angioplasty was completed. There was a pulse within the graft with removal of the arterial tourniquet. This was not accompanied by a thrill though there was a continuous Doppler signal. I cannulated the patch with a 21 gauge micropuncture needle. I advanced the 0.018 guidewire under fluoroscopy. The needle was exchanged for a 5 French transitional dilator. I removed the inner stiffener and 0.018 guidewire, and through the transitional dilator, I performed a fistulogram. Although there was continuous flow in the fistula the fistula was noted to be quite sclerotic. This did not appear to be thrombus. A retrograde filling of the brachial artery revealed the arterial anastomosis to be widely patent. I attempted to pass a short 0.035 guidewire through the transitional dilator, but it would not negotiate the fistula. I acquired a 0.035 Glidewire, and with some manipulation the Glidewire traversed the fistula and was placed in the superior vena cava. I removed the 5 French dilator and advanced a 6 French short sheath. I advanced a 5 French Kumpe catheter over the Glidewire and exchanged the Glidewire for a 0.035 Rosen wire. I repeated the fistulogram documenting the fairly extensive sclerotic changes within the fistula. Again, these did not appear to be thrombus. I acquired a 5 French and subsequently a 6 French x 4 centimeter balloon catheter and proceeded to dilate the entire fistula from the end of the sheath to the basilic vein junction with the brachial vein. There was no evidence of a central stenosis. The balloons were inflated to pressures of 14 millimeters of mercury. Following the balloon angioplasty, I repeated the fistulogram. While there was some improvement in the luminal diameter of the fistula, it remained quite ratty and there was sluggish flow. I did not feel that further efforts at maintaining the fistula would be productive. I ligated the fistula just beyond the arterial anastomosis. I proceeded with an AV graft insertion. A short incision was made in the axilla, and I identified a 12 millimeter brachial vein. I carefully dissected between the nerve trunks and identified a 6-7 millimeter axillary artery. The artery lies medial and deep to the vein. A counterincision was made on the upper arm to allow for tunneling in a loop configuration. The patient was given an additional 1000 units of heparin. I carefully exposed the artery, placing no tension on the nerve trunks. An end-to-side arterial anastomosis was completed with 5-0 Prolene suture. Two of the three large nerve trunks lie medial to the graft and one lies lateral. Upon completion of the anastomosis, there was no anastomotic bleeding. The bovine graft was then withdrawn through the subcutaneous tunnel in two movements. It was allowed to lie in a gentle loop configuration. A partial occlusion clamp was placed on the axillobrachial vein, and an end-to-side anastomosis was completed between the bovine graft and the vein with a 5-0 Prolene suture. Whereas the arterial anastomosis is 5-6 millimeters in length, the venous anastomosis is 8-10 millimeters in length. Prior to completing the anastomosis, the vessels were vented and were flushed with heparinized saline. There was minimal anastomotic oozing. This was readily controlled with Fibrillar. Once hemostasis was confirmed, the three operative wounds were closed with two layers of absorbable suture.

Fibrin Sheath vs. PTA

Is the following coded as a fibrin sheath (36595-52), a PTA (35476), or both?  "A pull-back SVC venogram was then performed, revealing a fibrin sheath and stenosis at the superior cava/right atrial junction. The existing catheter was exchanged for an 11 French vascular sheath. Balloon angioplasty was performed using a 12 mm balloon, followed by a 14 mm balloon for fibrin sheath disruption and stenosis dilation. Follow-up venogram demonstrated satisfactory results with disruption of the fibrin sheath and slight improvement in the SVC stenosis."

Code 75945 with 36147

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

Four Coronary Artery Stents

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

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

Balloon occlusion

PTA vs PTA - 74 or angio? This patient was brought to IR and aortobifemoral angiogram demonstrates severe and total occlusion of the SFA. A wire was used to go subintimal to cross this lesion and when he attempted to cross with the catheter he was not able to get through. It was then determined there was extraluminal contrast. A balloon angioplasty was performed for two minutes with a #4 balloon. There was no evidence of bleeding. What can we charge for this? Thanks again for all your help.

Use of 75898 with stent placement

Dr. Z,  Can code 75898 be used as a follow-up code for a stent, angioplasty, or balloon angioplasty.

61630

Hi Dr Z, Need clarification please, our physician is coding a 37184 for a percutaneous transluminal balloon angioplasty of the basilar artery. This was confirmed 99% stenosis of the basilar just distal to the ICA on the right. They obtained a roadmap image of the left vertebral artery and used a Glidewire to position the diagnostic catheter to the distal cervical vertebral artery up to the V4. Wouldn't this be a 61630 and all ipsilateral catheters and angio's included? The final angiographic/impression states: successful PTA of the basilar artery, resulting in interval improvement of caliber of the artery. The P1 segment is seen to fill following balloon angioplasty. Please advise. Thank you in advance.

37224, 35371, 37224-53

could you tell me how you would code this for physician billing…this is what I'm coming up with from what's in the note

35371
37224-51
36246-59-51
75710-59

thanks!

OPERATION PERFORMED:
1.  Right common femoral endarterectomy.
2.  Right superficial femoral artery angioplasty with 5 mm x 6 cm balloon.
3.  Third-order selective catheterization of the left superficial femoral artery.
4.  Aortoiliac angiogram.
5.  Bilateral lower extremity arteriogram.

ANESTHESIA:  General endotracheal anesthesia.

INDICATIONS:  This 71-year-old female with a history of tobacco use and bilateral lower extremity claudication presented for a second opinion regarding her lower extremity claudication in trying to avoid bypass surgery.  I reviewed her angiograms and we performed a duplex and I felt that endarterectomy of the common femoral artery with concomitant angioplasty may be of benefit to her.  She understood these risks and benefits and wished to proceed.

OPERATION:  The patient was brought to the hybrid operating room and placed in a supine position.  After adequate general endotracheal anesthesia was achieved and time-out performed, the right groin was prepped and draped in a sterile fashion.  Via an oblique incision, the soft tissues were divided and the common femoral, profunda femoris, and superficial femoral arteries were looped gently with vessel loops.  There was a very focal, approximately 2 cm area of near occlusive plaque palpated in the mid common femoral artery.  The patient was systemically heparinized with 5,000 units of heparin.  After 3 minutes, the vessels were controlled and a longitudinal arteriotomy created in the common femoral artery.  There was a 2 cm length plaque, near occlusive which was endarterectomized.  A bovine pericardial patch was then anastomosed with 5-0 Prolene suture and the anastomosis was completed.  Seldingerneedle access was then gained in an antegrade fashion through the patch and I was able to traverse the chronic total occlusion of the superficial femoral artery.  A 6-French sheath was placed and with the 5-French Glide catheter, and 0.035 angle-tipped stiff Glidewire, I was able to gain true lumen reentry in the mid superficial femoral artery as confirmed by arteriography.  Balloon angioplasty was then performed with a 5 mm x 6 cm balloon with excellent results.  The patient had 2-vessel runoff via the peroneal which reconstituted the posterior tibial artery.  The anterior tibial artery appeared to occlude in the mid calf.  This sheath was then removed and the wire access closed with an interrupted 5-0 Prolene suture.  Next, retrograde access was obtained in the patch and aortoiliac angiogram performed showing no significant occlusive disease.  With an 0.035 angle tipped stiff Glidewire, I cannulated the left common iliac, external iliac, and common femoral artery, and the 5-French Omniflush catheter was advanced over the bifurcation with the tip positioned in the distal left external iliac artery.  A left lower extremity arteriogram was then performed showing a flush occlusion of the superficial femoral artery.  This was reconstituted in the distal SFA just proximal to the <_____> popliteal artery and continued down below the knee with again a 2-vessel runoff essentially via the peroneal and posterior tibial artery.  A 6-French 45 cm Destination sheath was then placed with thetip positioned in the distal common femoral artery on the left.  With the Quick-Cross catheter and 0.035 angle tipped stiff Glidewire, I was able to cross the occlusion; however, we had difficulty getting back into true lumen.  At this point, I felt that we would continue with medical management of the patient and see how things went with regard to her left leg from a clinical standpoint.  At this point, the sheath was then removed and the patch repaired with figure-of-eight 5-0 Prolene suture.  The incision was inspected for hemostasis and when this was assured, the layers were closed with running 3-0 Vicryl followed by 4-0 Monocryl and Dermabond to the skin.  Patient was awakened from anesthesia and appeared to tolerate the procedure well without immediate complication.  Sponge, needle, and instrument counts were reported as correct at the end of the case.  I was present for the entire portion of the procedure.

Catheter placement and multiple interventions in lower extremity

Do you code the catheter placement after Infusion therapy such if the patient comes back and a mechanical thrombectomy has to be performed. please see the case below..the doctor is saying mechanical thrombolisis but i am coding it as a thrombectomy after infusion 37184,37185 for leg thrombectomy and 37184-51 for the Aortic thrombectomy, 37224, 75989 x2 as there is to different access sites. My guestions is also on the catheter placement codes. do I code 36245 for Iliaca balloon occlusion. Thanks PROCEUDRE: 10 hour thrombolysis follow-up. CLINICAL INDICATION: Aortic thrombus and left lower extremity thrombus. OPERATORS: Bick-Forrester (Fellow), Hardley (Attending) CONSENT: The patient was informed of benefits, risks, and alternatives to the procedure and agreed to sign informed consent. Any and all questions were answered at the time of consent. MEDICATIONS: Vancomycin 500mg IV, Heparin 5000 units IV, Fentanyl 100mcg IV, 5mg metoprolol, 1 mg Versed IV. CONTRAST: 78 mL FLUORO TIME: 25.5 min. TECHNIQUE: The patient was placed supine on the angiography table and the existing sheaths and catheters in bilateral groins were prepped and draped in standard sterile fashion. Angiography was performed through the existing infusion catheters, showing no significant improvement. Both infusion catheters were removed, and the Angiojet device was prepped. The bilateral existing 5F sheaths were exchanged for bilateral 6F sheaths. The 6F Angiojet thrombectomy device was then advanced through the left groin into the infrarenal aorta, and mechanical thrombolysis was performed. The Angiojet device was then advanced through the right femoral sheath, over the bifurcation, and into the left common femoral artery. Mechanical thrombolysis was then performed in the common femoral artery to the superficial femoral artery. A pigtail catheter was then advanced through the left common femoral sheath into the aorta and angiography was performed, demonstrating persistent thrombus in the infrarenal aorta and extensive irregularity of the left common femoral artery. The pigtail catheter and left femoral sheath were removed, and an 8F sidearm vascular sheath was advanced into the left common femoral artery. A 5F Fogarty balloon was advanced from the right femoral access site to the origin of the right common iliac artery and was inflated to occlude the right iliac origin. A second, 6F 80cm Berenstein balloon was advanced proximal to the aortic thrombus, inflated, and retracted into the left common and external iliac arteries. Repeat angiography in the aorta showed no residual aortic thrombus, but significant thrombus in left common and external iliac arteries. The Fogarty balloon was removed, as was the right femoral sheath which was exchanged for 6F 40cm up and over Balkan sheath. Angiojet thrombolysis was then again performed throughout the left common iliac, external iliac, common femoral, and superficial femoral arteries. While significant improvement was noted on angiography performed through the Balkan sheath, there is persistent irregularity and stenosis of common femoral artery. No definite thrombus is noted to persist in the common iliac, external iliac, or common femoral arteries. There is persistent thrombus noted in the distal superficial femoral artery into the popliteal artery. The left femoral arteriotomy site was closed with an 8F Angioseal device which achieved immediate hemostasis. Angiojet thrombolysis was again performed from the popliteal artery to the common femoral artery, and angiogrpahy was again performed showing marked improvement. No significant thrombus is noted from the iliac vessels to the the trifurcation, however there were areas of irregularity and stenosis in the common femoral artery and popliteal artery. The popliteal artery demonstrated long segment of marked narrowing from the abductor hiatus to the trifurcation. There is minimal antegrade flow noted. A 5 mmx4cm ultra-thin Diamond balloon was then used to perform angioplasty from along the course of the popliteal artery. Repeat angiography was performed showing some improvement. Angioplasty was again performed from the level of the trifurcation proximally to the common femoral artery. Angiography showed marked improvement in the arteries from the pelvis to the trifurcation. There was persistent decreased and absent flow distal to the trifurcation. A 5F angled glide catheter was left in place just proximal to the trifurcation, and TPA infusion initiated at 1mL/hour. IMPRESSION: 1. Initial angiogram shows persistent aortic and left external iliac thrombus extending distally, not significantly changed from prior angiogram. 2. Aortic thrombus resistant to Angiojet mechanical thrombolysis was retracted into left common iliac artery with balloon. Aorta now angiographically free of thrombus. 3. Left common iliac, external iliac, common femoral and superficial artery thrombus treated with Angiojet mechanical thrombolysis, with good result. Several areas of persistent stenosis and irregularity noted, most prominently in the common femoral artery and popliteal artery. 4. Balloon angioplasty performed along length of common femoral artery, superficial femoral artery, and popliteal artery with good result. 5. Persistent absence of antegrade flow distal to trifurcation. 5F angled glide catheter left just proximal to the trifurcation for infusion of 1mg/hr TPA. Plan follow-up angiography in approximately 4 hours.

37201, Trellis, bilateral venous

I researched the Q&A list. I have a question on a patient that had thrombus, extending from the IVC (inluding pt's IVC filter) into bilateral femoral veins and left popliteal vein. The MD did mechanical thrombectomy and thrombolysis, bilateral iliac and femoral vein angioplasty, and right common iliac venous stent. My questions are: 1)do we code for only the thrombectomy, only the thrombolysis, or both? The MD dictation states: "approximately 3mg of TPA was pulse injected via the Berenstein catheter into the thrombus within and just below the IVC filter and allowed to dwell there for the duration of the procedure (which was approx 2.5 hrs). 8Fr Trellis catheters (30cm treatment lengths) were inserted bilaterally and positioned within the vena cava just inferior to the IVC filter and extending to the left common femoral vein and the proximal right superficial femoral vein. The Trellis was activated for total 12min and 5mg TPA pulse sprayed through each catheter. Suction aspiration was performed from both catheters for approximately 60-80cc each side. Both catheters were then repositioned distally extending to the mid-SFV on the left and distal-SFV on the right (just above the sheath). The Trellis was run again for another 12min and instilling 4mg TPA on the left and 3mg TPA on the right. Aspiration was performed for an additional 60cc each side and with the Trellis motor cannula removed. Aspiration flow this time was brisk on both sides." 2)how many angioplasties are allowed? Prior to the section of the procedure quoted above, the MD states: "Balloon angioplasty was performed of both femoral and iliac veins, beginning above the sheaths and continuing to the IVC filter with a 6mm x 20cm Dorado. This was done to disrupt the fibrin crosslinking of the thrombus (given its subacute age) and allow better penetration of thrombolytic." Do we code for 4 angioplasties,or is this treated like a pre dilation and considered part of the thrombectomy or thrombolysis? Then after the completion of the thrombectomy/thrombolysis procedure, the MD also did 1 angioplasty in the right iliac for residual 70% stenosis for which I planned to code. Thank you very much for your help.

Fontan Fenestration dilation

Dr Z, What is the appropriate code for balloon angioplasty of a Fontan fenstration? " we then turned out attention to the Fontan fenestration. We crossed the Fontan fenestration with a coronary wire and glide catheter. We then exchanged the Glide catheter for an Apex RX 4.5 mm x 20 mm balloon. We advanced the balloon over the wire, across the Fontan fenestration and made a total of 3 inflationsfor a total of 6 seconds each. We then repeated the IVC angiogram and this revealed much improved shunting throught the Fontan fenestration and a slight drop in arterial saturations." Cath lab is using 92992, however I don't think that's correct. Is this an unlisted 93799 or would it code to a valvuloplasty code? Thanks!

37205 vs 37221

Hi Dr. Z. could you help us out with this senario? Patient presents with clinical characteristics of Lerich syndrome. Pt. was denied MRA. Initail Lt. radial approach. Catheter placement in AO above the renal arteries. Abd AO with Bi-Lat Runoff. There was a 3.5cm occlusion of the abd ao to the aorotoiliac bifurcation. Since the equipment in stock might not reach, due to the distance, both fermoral arteries were cannulated. Kissing balloon angioplasty followed by kississing stent placement. Comments and Conculsion: Leriche syndrome distal abdominal occlusion extending into both cmn iliac arteries, successfully recanalized and stented with visis-pro stents. Would this be??? 36200-59, 75630-59 and 37221-50???? Or would you just code 36200 x3 w/59's 75630 -59 37205 and 75960??? Thank you very much!

renal angioplasty and stent placement

Regarding renal artery interventions, i was informed when renals are treated with a balloon angioplasty and a stent, regardless of 'recoil' or lack of improvement of stenosis only the stent placement procedure code is allowed to be billed and not the angioplasty and is considered a predilation unless the patient has a congenital condition. is this accurate for renals?

35475/75962 AV shunt

Dr. Z, I feel like I'm always having trouble determinig the right CPT code when it comes to angioplasty of fistula. Please see the example of Op note that I need help on. Thanks! The patient's left arm and right groin were prepped and draped in the usual sterile fashion. Initially 1% plain Xylocaine was infiltrated over the course of the left arm fistula just above the AV anastomosis. This area of the fistula was accessed percutaneously using a micropuncture set and a 6-French short sheath placed. A left arm fistulography was then performed from the level of the antecubital fossa to the right atrium and revealed a moderate stenosis of the cephalic vein at the level of the humeral head which was then balloon dilated using an 8-mm x 40-mm Conquest balloon with good result. At this time, the sheath was removed from the left upper arm and we tried to redirect our puncture toward the antecubital fossa but were not able to get into the fistula at this point despite trying multiple attempts. At this point, the percutaneous right femoral artery access was obtained and a 5 F short sheath placed. A retrograde right iliofemoral sheath angiography was performed and revealed a good caliber right common femoral artery at site of puncture. The patient was then given 4000 units of Heparin IV. An angled Glidewire was then passed through the 6-French sheath placed in the groin and passed to the level of the aortic arch and exchanged for a vertebral catheter, which was used to selectively cannulate the left subclavian artery followed by cannulation of the left brachial artery. Left brachial angiography was performed and revealed a severe stenosis of the fistula at the AV anastomosis. The vertebral catheter was exchanged for a 90-cm Shuttle sheath through which wire crossing of the area of stenosis of the fistula in the antecubital fossa was done followed by balloon angioplasty using 8-mm and 10 mm balloons with good result. There was still a residual stenosis noted to be present of about 20% just above the AV anastomosis.

av shunt atherectomy, 37799

Dr's I'm totally in the dark on how to complete the coding this one. The patient has a malfunctioning upper arm brachiocephalic fistula with in-stent stenosis of the proximal cephalic vein and recurrent stenosis of the distal cephalic vein. Selective catheterization of the fistula with fistulagram was performed and then Silver Hawk atherectomy of recurrent stenosis within the cephalic venous stent, proximal vein followed by balloon angioplasty of the recurrent stenosis, distal cephalic vein. I coded 35476/75978/36147 for the balloon angioplasty of the distal cephalic vein, but frankly I am at a loss for how to code the atherectomy of the proximal cephalic portion of the fistula. 0237T atherectomy of brachiocephalic trunk doesn't seem correct. Would I use an unlisted code? Any advice would be greatly appreciated.

36831

Hi Dr. Z. We have a case in which we want to know if the PTA that is done after an open graft revision and thrombectomy (36833) is coded open 35460 or not reported per the information after the op note below. I am assuming the venogram is not reportable. OPERATIVE REPORT Occluded left arm arteriovenous graft. POSTOPERATIVE DIAGNOSIS: 1. Occluded left upper arm arteriovenous graft. 2. Pseudo-aneurysms times two. PROCEDURES PERFORMED: 1. Aneurysmectomy times two. 2. Thromboembolectomy and balloon angioplasty of the venous anastomosis. 3. Intraoperative venogram. ANESTHESIA: General anesthesia. BLOOD LOSS: About 100 mL BACKGROUND: The patient is a 64 year old African American male who has been undergoing dialysis for some time secondary to his end stage renal failure. He had developed two aneurysms on an arteriovenous graft; one proximally and one distally, resulting in occlusion of this graft. He was taken to the operating room at this time. DESCRIPTION OF PROCEDURE: With the patient prepped and draped in a standard fashion, incisions were established over each of the aneurysms by blunt and sharp dissection. The aneurysms were isolated from the graft, opened and then resected down to opening the graft proper. There was sufficient graft to establish a primary resection of the defected graft and complete and end-to-end anastomosis using 5-0 Prolene suture. Prior to securing the suture line, a 4 Fogarty catheter was passed proximally and distally removing both arterial and venous thrombus, resulting in both forward flow and back flow. The suture line was then secured. A venogram was then performed. This indicated a stenotic area in the venous anastomosis. Using a 7 mm x 4 cm balloon angioplasty catheter, this was inserted across the anastomosis, inflated to 12 atmospheres, and allowed to remain in position for approximately five minutes. The balloon was then deflated, withdrawn, and a second venogram performed indicating excellent resolution in the stenotic region. The catheter was then removed and the access site was closed with a single Figure 8. 5-0 Gore-Tex suture. There was excellent pulsatile flow through the graft at this point. There was no evidence of active bleeding. The wounds were irrigated with warm saline solution with 1 gram of Amikacin. The wounds were then closed in a subcutaneous fashion using 3-0 Vicryl suture. Sterile dressings were applied. COUNTS: The sponge and instrument counts were correct. The patient tolerated the procedure well and was taken to the recover. VASCULAR CODING BOOK: 8. If an open surgical declot and surgical revision of the graft or anastomosis is performed, use code 36833, and do not code for additional angioplasty/stent within the graft (anastomosis to anastomosis). If an additional angioplasty or stent is performed outside of the graft, code for the additional intervention as well. This would be codes 75978 and 35460 (open) or 35476 (percutaneous) for angioplasty. Utilize codes 75960 and 37205 (percutaneous) or 37207 (open) for stent placement if performed. Dr. Dunn Q&A: ZHealth Online Q&A 2618 Date: Tuesday, March 15, 2011 Question: Hello, I need help :) The surgeon did a Graft Thrombecomy with revision (36833). He then did a fistula gram (36147) and because of stenosis in the venous outflow did an PTA (35476 & 75978-26). And a segmental incisiion of graft & overlying skin with primary closure??? Separate incision and closure.. Diag: End-stage renal disease, thrombosed graft fistula with recurrent bleeding from the false aneurysm of arterial limb of the graft with skin erosion. After revison/thrombecomy proc; The inflow was then tapered due to the incision..sheath removal of the graft was clamped proxiamally and distally, sheath withdrawn and sheath hole closed with sutures. Clamps released and palpable thrill was present along the graft, hemostasis was obtained. Counts ere correct x2. The wounds were closed in layers with Vicryl & Monocryl for the skin Dermabond waa applied to seal wounds. This is what I am not sure about: Incision was then made to excise the sutured skin at the site of graft bleeding. The skin was excised as well as the underlying graft. No evidence of infection. The wound was reapproximated with nylon suture. Because this was a separate incision and it was done after the revision was completed, he feels he should get credit for the work. Since the graft was no infected, I am thinking this is still a part of the revision but not 100% sure. Your advice would be so appreciated! Thanks you! Answer: I would code as one revision only as you suggested. When we do thrombectomies, we often open the arterial as well as venous anastomosis with separate incisions but can only code one thrombectomy. Lastly, when we do angioplasties via an open incision like here, would use the open venoplasty code 35460 instead of 35476. Thanks, Dr. D David Dunn, MD, FACS

37227

Per new CPT coding rules If pt has fem pop intervention and a Fem Pop graft intervention. would you still consider this to be one vessel for Native and graft? I am including the report. Thank you for your consideration. ************************************************************** 1. Left common femoral artery retrograde access. 2. Aortoiliac angiography. 3. Right lower extremity runoff. 4. Atherectomy of the right distal common femoral artery as well as the right profunda femoris artery, followed by balloon angioplasty. 5. Atherectomy using Jetstream device of the femoral-popliteal graft, followed by balloon angioplasty and stent placement in the proximal as well as distal portions of the graft with the stent extending into the right popliteal artery. 6. Monitoring of conscious sedation by a trained observer for 3 hours. 7. Complex peripheral intervention with greater than 30 minutes per vessel segment, requiring multiple catheter and wire exchanges and extra thought process. INDICATIONS FOR THE PROCEDURE: The patient is a 59-year-old male who has a history of intermittent claudication. For this, he had recently undergone balloon angioplasty for in-stent restenosis of the right external iliac stent. He did not experience significant relief of his claudication symptoms and requested further intervention to the right leg. He has a known history of femoral-popliteal graft in 2007, which is known to be occluded. Prior to the procedure, I discussed the risks, benefits, alternatives, and complications of the procedure with the patient, including somewhat high risk of complications due to his high-risk anatomy, and he was in agreement to proceed. ANESTHESIA: Moderate sedation administered with a trained independent observer in attendance to monitor the level of consciousness and physiological status for a total of 3 hours. Please see procedure log for all drug administration and monitoring data and further information. Conscious sedation with local anesthesia. DESCRIPTION OF PROCEDURE AND FINDINGS: The planned procedures were explained to the patient in detail including all pros, cons, risks, benefits and all possible complications including and not limited to death, myocardial infarction, retroperitoneal bleed, CVA, hemorrhage, limb loss, renal failure, the need for renal dialysis, blood transfusions, emergency surgery, emergency endovascular angiography with treatment of unanticipated vascular disease or vascular complications, use of antibiotics, consultations with other physicians and use of all accepted surgical/medical modalities for the benefit of the patient. The patient understands and verbalizes and agrees to proceed with the planned procedures. All exclusion criteria have been met to be able to do this procedure as an outpatient procedure. TECHNIQUE: Left common femoral artery access was obtained using a 4-French sheath. Office Procedure A 4-French UF catheter was passed into the contralateral left external iliac artery after obtaining aortoiliac angiography. After this, right lower extremity runoff was obtained. We then exchanged for a 7-French Terumo 65 cm Destination sheath over an Amplatz wire. The patient was heparinized. A slime wire and a 4-French IMA catheter were used to advance the catheter into the profunda femoris artery. We measured the pressure in the profunda femoris artery, and this was 40 mmHg without much pulsatility, indicative of the severe stenosis at the ostium of the profunda femoris as well as the distal common femoral artery. We exchanged out for a Platinum Plus 0.014-inch wire and performed SilverHawk atherectomy with an LS device using 4-quadrant atherectomy in the distal common femoral artery as well as the profunda femoris artery. This achieved excellent results with good flow down the profunda femoris artery. There was some residual stenosis which was treated using a 6 x 40 LP 0.018 balloon, inflated up to 2 atmospheres. Stenosis in the common femoral artery and the profunda femoris artery was reduced to less than 30%. After this, we used a 4- French angled CXI catheter and a slime wire to cross the occluded portion of the femoralpopliteal graft. We were eventually able to get through with a stiff shaft glidewire. The glidewire was advanced to the distal anastomosis. However, we were subintimal in the very distal popliteal artery. This eventually required an Outback catheter to perform reentry to the popliteal artery. We then attempted to pass a 5 x 80 balloon. However, we were unable to pass this through the site of reentry. We exchanged out for a coronary 3 x 30 balloon, which were able to cross and inflate it. We performed multiple inflations with this balloon. After this, there was still significant amount of thrombus visualized in the entire grafted segment. We switched for a Jetstream device and performed atherectomy with a 2.1 mm Pathway Jetstream catheter. This was performed after exchanging through a Platinum Plus wire. TPA was added to the infusion, and multiple runs were performed with the blades up and blades down to achieve adequate lumen. There was still slow flow due to resultant stenoses in the distal graft segment as well as the popliteal vessel and the proximal graft segment as well. We ballooned these areas with a 7 x 40 balloon. We then attempted to deploy a 6 x 80 IDEV Supera stent in the popliteal vessel extending into the grafted segment. However, the stent was under-deployed in the site of reentry as well as in the proximal grafted segment. Therefore, the stent was removed. We then exchanged out for an 8 x 80 self-expanding stent. We had to perform predilation again using a 6 x 40 Cook balloon. The stent was successfully deployed in the distal popliteal segment extending into the distal portion of the graft. We also put another 8 x 80 overlapping with a second 7 x 80 stent in the proximal portion of the graft. After this, the under-expanded areas within the stent were post dilated using a 7 x 40 mm balloon. There was still persistent under-expansion in the overlapped segment in the proximal graft. This was treated using a 7 x 40 V-access balloon, which achieved adequate expansion. Final angiographic runoff showed that we had excellent patency of the common femoral artery as well as profunda femoris artery and brisk flow down the femoral-popliteal graft into the popliteal vessel. There was preserved flow down to the trifurcation into the foot. There was some decreased flow in the very distal dorsalis pedis, which petered down. DETAILED FINDINGS OF DIAGNOSTIC ANGIOGRAPHY: 1. Aortoiliac angiography: The distal abdominal aorta as well as bilateral, common, and external iliac arteries are patent with mild-to-moderate disease. The previous site of angioplasty is widely patent. 2. Right lower extremity runoff: The right common femoral artery has a distal 90% stenosis, followed by 90% stenosis in the ostium of the profunda. The entire SFA, including the femoral-popliteal graft, is occluded with reconstitution of the popliteal by collaterals. There is preserved 3-vessel runoff to the foot. SUMMARY: 1. Atherectomy of the right common femoral artery into the profunda femoris artery, followed by balloon angioplasty with achievement of excellent results. There was some diffuse 30% to 40% disease in the common femoral artery proximal to this. 2. Atherectomy with the Jetstream device of the femoral-popliteal graft, followed by angioplasty and stent placement with restoration of brisk flow down the graft. 3. Three-vessel runoff to the foot with occlusion of the very distal dorsalis pedis vessel.

37224, 37228

Would like reassurance on coding an op note. Rt femoral artery entry up to non selective aortogram 36200 came back down bilateral runoff 75716 changed to 75710 left hypogastric (internal iliac) film (cath stopped here) 36246 back up and down the right side arteriogram at the SFA Balloon angioplasty w/o stent at the Popliteal 37224 and Anterior Tibial 37228 arteries Here is what we are thinking. Drop the 36200 because no longer non selective. Change the bilateral S&I angiography from 75716 to 75710 because the right side interventions will include that. Bill for the angioplasties as 37224 & 37228 This seems awfully simple compared to last year. 36246 37224 37228 75710 Are we correct?

37220

Are the vessels branching off the internal iliac artery, the obturator, the gluteal, etc., considered part of the internal iliac artery for lower extremity revascularization coding? For example, if a balloon angioplasty is done on the right internal iliac and another balloon angioplasty is done on the right oburator in the same session, would 37220 cover both interventions? If not, how would the angioplasty of the right obturator be coded? Thank you.

AV graft thrombectomy

I have a question about an AV graft thrombectomy converted to a systemic heparanization with follow up the next day. This was done in January 2010 so the new AV graft codes were used. The AV fistula was accessed and a fistulagram performed. The cephalic vein was thrombosed and basilic vein was small in caliber. tPA was given and the cephalic segment manually massaged. Following this, balloon angioplasty was perfomed throughout the basilic vein and the thrombosed segments of the fistula. Due to adherent thrombus in the fistula and residual clot burden, an additional 4 mg tPA was injected into the fistula. The patient was converted to systemic anticoagulation through the access sheath and will return the following day for re-eval. The patient returns the following day for a follow up fistulagram. There was re-angioplasty of the basilic vein because it was still small in caliber. A Trerotola thrombectomy basket was advanced into the distal AV fistula due to some clot still present. This was cleared. Note that a second sheath was placed within the more proximal fistula and served as a working sheath for today's procedure. Hopefully, I have included the main parts of both reports. The codes I got for the first day are 36147 for the fistulagram and 36870 for the thrombectomy. Should I code the angioplasty of the basilic vein? For the second day, should the codes be 75898, 36148, 35476 and 75978? Can a second thrombectomy be coded since this was an ongoing infusion from the day before? Thanks for any guidance on this one.

Catheter selection

Dr. Z -- I would appreciate your interpretation of the procedure description below as to the code/charge for selective catheterization. “The 6-French sheath was placed in the right femoral artery. The right lower extremity angiography was performed through the sheath. Following this, the sheath was exchanged out for an AccessPro which was advanced TO THE CONTRALATERAL COMMON ILIAC.” (Angio findings are documented.) Then says, “An intervention was performed on the LEFT INTERNAL ILIAC. An 0.014 Stabilizer Plus WIRE was advanced out INTO THE INTERNAL ILIAC and balloon angioplasty…etc., etc.” (Stenting followed the angioplasty.) I do not have any problem with the procedure codes. However, as far as selectivity, should we code/charge 36245-LT (first order to common iliac) OR 36246-LT (second order to internal iliac)? Does the WIRE placement described above equal selective catheter placement? Is the "default" that the vessel is selectively engaged/cathed if it is treated?? MANY THANKS FOR YOUR ASSISTANCE!

High grade stenosis at cephalic/subclavian junction of AV fistula; atherectomy of stenosis using Diamondback device.Fluoroscopy used, cannulation of AV fistula on arterial site, fistulogram , patent arterial side anastomosis. On the venous side of the fistula, multiple areas of stenoses seen, especially 95% at cephalic/subclavian junction. Atherectomy performed using Diamondback device, total spin time was 1 minutes. Stenosis improved to 60%;decision to perform balloon angioplasty at the same site. Subsequent fistulogram performed revealing complete restoration of the caliber of the vessel. Please verify 36147, 36148, 35494, 35476.

AV shunt intervention

Dr. Z; I have reviewed your book for the Av fistulogram and interventions. I would like to know if my coding is correct given this episode of care on this pt. My codes are 36120, 75790, 35476, 36147, 36148, 75978, 35476-59, 75978-59. I have the use of three catheters and three puncture sites. Under ultrasound guidance access was gained into the left brachial artery, guidewire was introduced and the needle removed. Through this 5 french dilator, a left upper ext atrteriogram, fistulogram and venogram preformed. Images reveal patency of left axillary & brachial arteries with patency of proximal radial, ulnar and interosseous arteries. An Av fistula is seen arising from the distal portion of the brachial artery at approx. the level of the elbow joint to a drainign cephalic vein. The remainder of the cephalic vein is seen to be patent. The left axillary and proximal left subclavin veins are seen to be patent however, thereis a short segmental occlusion of the mid subclavin vein at the entry of a pacemaker wire. Thid distal portion of the subclavian is patent and there is patency of the innominate vein and the superior vena cava. Under ultrasound guidance access was gained into the draining cephalic vein with the needle directed towards the arterial anastomosis. A stiff guidwire introduced and a 6 french sheath was advanced. The stenotic segment of the draining cephalic vein was traversed. Mutiple angioplasties of these segments of he proximal draining cephalic vein preformed. Repeat fistulogram reveals significant improvement in the degree of stenosis with some minimal residula stenosis. Acess was also gained into the drainign cephalic vein with needle towards the central venous circulation. A sheatlh dilator system was advanced, serial dilatiations were preformed at the entry site. Utilizing a guidwire and cath combination, the occluded segment of the subclavin vein was successfully traversed, mutliple angioplasties of the segment were performed utilizing balloon angioplasty catheters. Repeat venogram completely callous aeration of the subclavian vein with no residual areas of stenosis. All 3 catheters were removed>>>>>>>>>>

 Dr. Z, I hope you can help us resolve this coding issue. HIM and I are coming up with different codes. I read the following as an open procedure of an AV graft including angioplasty, thrombectomy, and thrombolysis. PROCEDURE: The patient was taken to the operating room and placed on the operating room table in supine position. General anesthesia was given. The right upper extremity was washed circumferentially and prepped and draped in traditional sterile fashion. A small transverse incision was made right over the graft above the bicipital fossa. Through that incision, the graft was identified and was encircled with umbilical tape. A small graftotomy was performed and then using a 5 French and then a 4 French Fogarty embolectomy catheter, thrombectomy of the venous limb was carried out. After removal of well organized clots, we noticed that the patient will develop new fresh clots right at the same time undergoing the thrombectomy. The patient was then given 5,000 units of heparin. Then thrombectomy of the arterial limb was carried out with return of brisk pulsatile flow. The graft was clamped proximally and a 6 French sheath was inserted, directed toward the venous anastomosis, and a fistulogram was obtained. It showed a slight narrowing at the venous anastomosis and then a patent right subclavian axillary system, high-grade stenosis at the level of the right innominate vein with flow being diverted to large collaterals. Superior vena cava was patent without significant stenosis demonstrated there. A 0.035 inch Glidewire was advanced through the 6 French sheath and then sequential balloon angioplasty of right innominate vein was performed, first using a 10 x 40 mm conquest balloon and then a 12 x 40 mm conquest balloon. Then using a 6 mm Fox balloon, we gently inflated the balloon at the venous anastomosis. A repeat injection of contrast was satisfactory with no residual stenosis demonstrated. Then the sheath was removed and the angioplasty of the right innominate vein was performed through a 8 French sheath and then the 8 French was removed. The graft was clamped toward the venous anastomosis. The 6 French sheath was inserted, directed to the arterial anastomosis. An injection of contrast demonstrated a patent anastomosis, however, there was thrombus present into the radial artery and the distal brachial artery. A .035 inch Glidewire was advanced through the brachial, then the radial artery, down to the level of the wrist, and then a Fogarty embolectomy catheter was used, and embolectomy was performed of the radial artery and the distal brachial artery using a 4 French Fogarty embolectomy catheter. A repeat injection of contrast showed a persistent defect into the proximal right radial artery. Unclear whether it was a plaque. It persisted after a repeat embolectomy. Then it was angioplastied using a 4 x 40 mm balloon. A repeat injection of contrast after angioplasty showed some improvement. Intraoperative infusion of thrombolytic therapy was used. Approximately 3 mg of TPA was administered. Then a repeat injection of contrast was satisfactory with no further defects demonstrated to be present and good flow going down the radial artery into the end. We then had a palpable radial pulse present. The sheath was removed. The small opening in the graft was closed using interrupted sutures of CV-6 Gore-Tex suture. The wound was closed in two layers using 3-0 Vicryl in the subcutaneous tissue and the skin was closed using subcuticular suture of 4-0 Monocryl. Dermabond was applied and a small sterile dressing. SUPERVISION AND INTERPRETATION: Following a surgical thrombectomy of the right arm arteriovenous graft, a fistulogram was obtained and the findings are as outlined above. Balloon angioplasty was performed, first of the right innominate vein using up to a 12 x 40 mm balloon and then at the venous anastomosis using a 6 x 40 mm Fox balloon. Subsequently, injection of contrast demonstrated there was interruption of flow and thrombus into the distal brachial artery and the proximal radial artery and was it treated with thromboembolectomy and intraoperative infusion of thrombolytic therapy and also balloon angioplasty of the proximal right radial artery where there was narrowing and what appears to be a plaque present. A repeat completion angiogram was satisfactory with good flow demonstrated to the brachial artery, the radial artery to the hand. Here are the codes that I think should be assigned: 36381, 75790, 75798-59, 35460, 75798-59, G0393, 34101, 34111, 75962, 35458, 75986, 37201. I should add that this was done during 2009. We need all the education and help we can get. Thanks,

 

Dr Z, We have a case where there was a stenosis of the main hepatic artery treated with balloon angioplasty. Following this there was poor antegrade flow and a small amount of thrombus within the main hepatic artery. This was treated with intra-arterial TPA and Papaverine. Final injection showed excellent flow within the main hepatic artery with markedly improved perfusion of the liver. Our question is, does this constitute billing for a secondary thrombolysis (37186) along with the angioplasty codes? Thank you!

Brachiobasilic Arteriovenous Fistula

"A site was selected just above the bifurcation of two joining basilic veins just a few cm above the elbow. The left basilic vein was identified during sharp dissection and mobilized circumferentially. The lateral most vein branch was divided with silk ties so that a tensionless anastomosis could be created. The vein was transected a few cm below the elbow for sufficient length. Sharp dissection with Bovie was used to circumferentially dissect the brachial artery and adjacent branchial veins. The left brachial artery was controlled with vessel loops and vascular clamps. The artery was opened with an 11 blade, and the arteriotomy was extended with Potts. The vein was spatulated and sewn in a 4 quadrant heel-to-toe anastomosis with Prolene in end-to-side fashion. The fistula was patent, but a sclerotic area was noted proximal. A Fogarty was passed, and this was ballooned several times until thrill and color flow duplex improved." 

Would this be reported with code 36821 or 36819? Would there be an additional code for the balloon?

Bypass com femoral to post tibial artery with endarterectomy of profunda

“We dissected out the distal external iliac artery as well as the CFA, SFA, tertiary & quaternary branches of the profunda femoris artery which is severely diseased. Arteriotomy created in common femoral artery & extended down the profunda femoris into that large lateral branch as described above. I endarterectomized the CFA into the distal external iliac artery & down into the profunda femoris lateral branch as described above…. Nice flow through the femoral artery into profunda femoris artery. Bovine pericardial patch angioplasty performed.“

Then performed a bypass. “Performed arteriotomy in the patched portion of the CFA-passed through the tunnel…arteriotomy in the posterior tibial artery for side anastomosis.”

“It should be noted that this femoral endarterectomy was an attempt to reestablish the best flow possible into the deep femoral system for long-term limb salvage. This endarterectomy is not strictly done to provide inflow for the bypass. These are separate procedures designed to accomplish limb salvage by revascularization different vascular beds.

Iatrogenic Dissection

Physician was performing a TAVR, and on the way out there was a "valve delivery dissection in the right common iliac". A Viabhan stent was inserted, then a balloon was placed across the stent with a maximum inflation of 10 atm. I am reviewing iatrogenic laceration in Chp 5 of NCCI as my resource for not coding a repair for an injury caused by a surgeon.

Is the dissection repair with a stent a codeable procedure?

Transhepatic cholangiogram and biliary stent placement

"Right biliary system: The indwelling biliary drain was exchanged over a wire for a sheath through which contrast injection was performed. A guidewire was passed through the bile ducts and into the small bowel, and a biliary stent was deployed. An external biliary drain was placed, and final contrast injection was performed. Initial cholangiogram findings: Severe segmental distal CBD stenosis causing intra and extrahepatic biliary dilation. Stent(s) placed: 6 x 80 mm. Stent type: Uncovered. Stent position: Common bile duct. Balloon dilation of stent (mm): 8. Following this, repeat cholangiogram was performed through the sheath. This demonstrated mild delay of contrast passage into the duodenum distal to the inferior terminus of the newly placed CBD stent. The distal CBD inferior to the stent was then subsequently treated with cholangioplasty using an 8 x 40 mm balloon. Completion sheath cholangiogram demonstrated widely patent common bile duct stent with passage of bile into the duodenum. Subsequently a safety external biliary drain was placed." Should we add code 47542?

Percutaneous Transmural arterial bypass with cpt 35371, 37221.

How do you code for this procedure described below:

Completion of bilateral common femoral endarterectomies were done. Next a rt percutaneous transmural arterial bypass. Rt post tibial vein was accessed and a mirco-puncture kit was upsized to 6Fr sheath. A venogram was performed which demonstrated adequate caliber vein and bifurcated femoral venous system. A 8Fr sheath was used up/over the bifurcation using a support wire and Endo cross device was advanced into the SFA >than 3 cm beyond the origin of the profunda femoris. A snare was advanced up the femoral vein to the site of venous entry. The crossing device was deployed and wire advanced slowly retracting the needle with wire snared once within the venous lumen. Crossing device was advanced after ballooning the proximal anastomosis with 4 mm balloon. A rt LE angiogram was done to allow superposition of popliteal reconstitution and crossing catheter which was used to deploy needle and wire advanced to intra-arterial access. Lumen placement of wire and device were removed.

Percutaneous transluminal shockwave of lower extremities.

Left common and external iliac artery stenoses were so severe that there was difficulty getting just a Kumpe catheter to track over the bifurcation this required pretreatment prior to placing a sheath across the aortic bifurcation. This was done with a 5 mm balloon. Combination of wire and CXI catheter were used to traverse the stenoses and occlusions entering luminally distally into the distal popliteal artery. The diseased segments were treated with 3 mm balloon followed by a 4 mm shockwave balloon. Followed by stent column of 5 mm stent from the proximal popliteal artery to the proximal femoral artery. Right common and external iliac artery. These were treated using a 5 mm shockwave balloon the common iliac artery was additionally treated using a stent. Left common and external iliac artery t were treated using the 5 mm shockwave balloon. The left common iliac artery also had a stent placed. Left external iliac artery is treated using a stent. My codes C9765-50 and C9765-XU. Thank you for all your help.

CTO with angioplasty only, no stent placed

Successful IVUS-guided PTCA and recannulization of LAD CTO performed due to under-expanded stents. I spoke with the physician, and there was no intention of placing a new stent, just wanted to recannulate/open and expand existing stents in the artery. Would code 92920-22LD be appropriate? I'm trying to cover for the time spent on the CTO piece.

Stenosis Documentation for Dialysis Fistulagram

If a doctor documents high-grade stenosis or subtotal occlusion when an angioplasty is performed for a dialysis fistulogram, is this enough to code for the angioplasty? I know that the percent of stenosis is required, but I am not sure if those terms are acceptable as well.

Failed Coronary Stent

Physician states he utilized a 6 French cath for engagement of the RCA. It was difficult to engage the ostium and he attempted to use side holes. More stable support was achieved with AL 0.75 cath. Engaged without difficulty. Lesion was crossed utilizing 014 Prowater guidance. At this point after crossing the lesion attempted to cross the severe stenosis in the proximal RCA. He was unable to cross. Subsequently exchanged for 1.2 x 12 threader dilation sys. and PTCA was performed in the mid lesion with some improvement. Then attemped to dilate with 2.0 x 6 sprinter dilation sys. and was unable to cross utilizing the 2.25 x 12 resolute onyx stent. What is the correct way to code this? Code the attempted RCA stent with modifier 74? The angioplasty was successful but if you go with charging the PTA instead of the stent to the RCA, can you still change the supply charge for the stent? I understand you should charge was actually done, but how does your facility not lose the cost of stent that was attempted.

Intra aortic Balloon assist

Can you bill insert CPT 33967 and 33968 on same DOS?

Reflow Temporary Spur Stent

Our hospital is using a new device called the Reflow Temporary Spur stent. After performing an angioplasty, they insert the Temporary Spur Stent and inflate it which causes the drug-coated spurs to create channels in the vessel lining and the physician leaves it in place for a period of time to allow the drug to be deposited into the vessel lining to prevent recoiling after angioplasty.

Please note we code for pro-fee and facility. Would this procedure be coded as an angioplasty procedure with use of the reflow system included? Would this be an unlisted code? For pro-fee, if we can code the angioplasty code, would we also assign a -22 modifier for the extra work? 

TPA, PTA & ligation of a collateral vein of a Radiocephalic Fistula

Pt w/radiocephalic fistula. A large collateral vein was cannulated with micropunture set. Dilator advanced in a retrograde toward the arteriovenous anastomosis. Arteriogram showed a severe stenosis of the proximal cephalic vein distal to the anastomosis. PTA of the stenosis was performed. In order to treat the thrombus within the access TPA was instilled within the access. The thrombus was also macerated percutaneously. Prior to the completion of the procedure a 2-1 Vicryl suture was inserted through the skin & subcutaneous tissue surrounding the collateral vein. The suture was tied so that the flow through the vein was disrupted. Findings: A critical stenosis of the proximal cephalic vein was dilated with 5mm balloon with improvement in caliber. A small volume of thrombus within the fistula at the level of the antecubital fossa was treated with TPA as well as maceration of the clot. The large competing collateral vein was ligated using 2-1 Vicryl. Would the codes be 36000 (access), 36905 (Fistula TPA & PTA) and 36909 (vein ligated)?

Billing for a partially successful atherectomy

I have an appeal denial from UHC stating that cpt code 37233-59-LT (1 Unit) remains not supported. As per the Society of Interventional Radiology Coding Manual, if an angioplasty or atherectomy of an occlusion is unsuccessful because the lesion cannot be crossed, then the appropriate access and/or selection only should be coded. As such, the request for CPT code 37233 is denied as "Not Documented."

I don't understand this - our provider documented atherectomy/PTA in left AT, and a partially successful atherectomy and PTA of the left PT (residual stenosis). Are we not able to bill for code 37233 for the second vessel because it was partially successful?

Popliteal aneurysm repair and coil emboliztation

Is the coil embolization separately billed or included as part of 35151 for the popliteal aneurysm repair?

1. Right proximal popliteal artery to distal popliteal into the tibioperoneal trunk artery bypass with greater saphenous vein

2. Open thrombectomy of the right posterior tibial artery with fogarty balloon

3. Open thrombectomy of the right anterior tibial artery with fogarty balloon

4. Ligation of the right popliteal artery aneurysm

5. Right lower extremity arteriogram with supervision and interpretation

6. Embolization of two separate right popliteal genicular arteries using terumo azur 035 coils.

7. Selective catheterization of two separate genicular arteries

"We then used a navicross and glide wire advantage and selectively catheterized the popliteal artery genicular branch. Two terumo coils 5x11mm were then deployed. We then selectively catheterized a second genicular popliteal artery branch and coil embolized with a 6x17mm genicular branch"

Graft Angioplasty

When an angioplasty is performed only in a coronary SVG, do we report code 92920 or 92937? Code 92937 says a "combination of", so I'm not sure if it would be appropriate to report 92937. Please advise.

CPT 92972 with atherectomy/angioplasty/DES stent placement

Code 92972 has replaced 0715T in 2024 for percutaneous transluminal coronary lithotripsy. If atherectomy and/or angioplasty with stent is performed as well, should the C9600-C9608 series be coded or in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975?

Complicated Foley removal

I am really at a loss here. This is more than a straightforward Foley removal to charge as an E&M. Would this go to an unlisted and 77002?

"Ultrasound confirmed the presence of the Foley balloon in place within a contracted urinary bladder. Through the lumen of the Foley catheter, an 8 French dilator was advanced, and contrast was administered opacifying the contracted urinary bladder. Balloon was clearly identified as well. Under fluoroscopic guidance, the Foley catheter was advanced forward. An area in the suprapubic region was then infiltrated with 1% lidocaine. Under direct fluoroscopic and sonographic guidance, a 20-gauge needle was advanced into the region of the balloon and the balloon was punctured successfully. The balloon was deflated. Foley catheter was then removed intact. Patient tolerated the procedure well without immediate complications.”

COVERED STENT SUBCLAVIAN ARTERY PSEUDOANEURYSM REPAIR W/ BRACHIAL CUTDOWN

1. RT brachial artery open exposure. 2. RUE angiogram. 3. RT subclavian artery pseudoaneurysm repair with a covered Viabahn stent. Incision made on medial aspect of RT arm. RT brachial artery dissected out and encircled with vessel loops. Direct needle access gained into the RT brachial artery with placement of a sheath. Kumpe catheter was advanced to the level of the RT subclavian artery where angiogram was performed and confirmed CT findings of RT subclavian artery pseudoaneurysm. There appeared to be a 3-4 cm segment proximal to the pseudoaneurysm as well as a landing zone proximal to the RT vertebral artery. I passed a 11 x 5 cm Viabahn covered stent and deployed this just distal to the origin of the RT common carotid within the RT subclavian artery. Angioplasty was performed and imaging demonstrated no endoleak. 

Is this considered an open procedure and coded with 37799 (with comparable code 35011 since there is no CPT code for open subclavian artery aneurysm repair via brachial incision) OR an endovascular procedure with 37236 and 36140? Thank you!

AVF Angioplasty Medical Necessity

An AVF angioplasty and embolization was performed and provider queried because stenosis percentage was missing for intervention. The provider responded that the stenosis was greater than 50% but angioplasty was performed for low flow volume due to failure of maturation and treated with assisted maturation (angioplasty) to increase the diameter of the AV fistula to allow for access in dialysis and adequate flow volumes to achieve dialysis. The patient also underwent coil embolization to redirect outflow of the fistula at the same time to increase flow volumes in the distribution of access in the cephalic vein. When angioplasty is performed for this reason, is stenosis percentage still required in the documentation?

Initial AV synthetic vein graft along WITH neighboring vein graft

The patient came in for AV graft(36830) along with basilic vein graft after a diminished distal brachial pulse. Would there be a separate code for the vein patch angioplasty?

"Following initial construction of a brachial–axillary left upper arm AV graft, there was a complete loss of left radial pulse and Doppler signal, as well as a diminished pulse in the distal brachial artery. Due to significant concern for ischemic steal, I elected to revise the graft with more proximal looped inflow. The arterial anastomosis was taken down and the brachial artery was repaired with a patch of neighboring basilic vein. New inflow was constructed onto the axillary artery adjacent to our venous outflow anastomosis and a second graft segment was tunneled in the more medial upper arm. The 2 grafts were anastomosed to 1 another, creating a looped upper arm axillary–axillary AV graft. Upon completion, there was a palpable thrill in the graft, an ongoing faintly palpable radial pulse, and a multiphasic radial Doppler signal."

37215 and 61635

I know these two codes bundle, but are they billable together same side when cervical and cerebral artery stents are placed?

Angioplasty and stenting of left internal carotid artery origin with distal embolic protection

Angioplasty and stenting of the intracranial left internal carotid artery petrous/lacerum segment

37236 and 37246 for lower extremity bypass

If a patient has a stenosis in a lower extremity bypass, fem-pop for instance, and it is treated with stent or angioplasty would you code from 37236-37246 since it is not an 'artery' of the lower extremity? Or is the bypass now considered an artery of the appropriate territory and would be coded with 37224-37226? Thank you.