Ask Dr. Z

Hello Dr. Z, I'm having trouble coming up with a catheter placement code for this AAA repair, can you please give me your thoughts on this procedure? Appreciate your help. Judy, CPC 1. AAA Repair Due to the patient's underlying medical condition, informed consent was obtained from the patient's daughter. The patient was placed supine on the CT scanner and axial images were obtained to localize an access to the abdominal aortic aneurysm sac. It was elected to access the aneurysm sac from an anterior approach just to the right of midline, ultimately to access the flow lumen of the endoleak which was just ventral to the iliac limb portion of the Excluder endograft. CT-GUIDED ANTERIOR ACCESS TO THE ABDOMINAL AORTIC ANEURYSM SAC

IVC venography injected from ipsilateral common iliac for placement of caval filter. Venography showed patient already had a filter in place. 36005 states extremity. What cath code would be appropriate?

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

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

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

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

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

Hello! I am unsure if I can bill more than 1 set of 37204 & 75894-26 for the embolization part of this procedure. Also, an Amplatzer plug was used in internal iliac. I am OK with the cath placements. Dx: Growing AAA with a type II endoleak from multiple inferior lumbar arteries from different sources. 1. Coil embolization of a lateral lumbar and pelvic artery with the source coming from the internal iliac artery branch with a shared vascular supply from the contralateral internal iliac and coil embolization of 3mm Tornado and 5mm Tornado coils for a total of 5 coils. 2. Selective cath of an ascending lumbar artery and insertion of 0.75cc of NBCA embolization glue. 3. Selection of the origin of the right internal iliac artery and deployment of a 16mm Amplatzer plug to the right common internal iliac origin. Thank you,

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

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

Thank you again for your help.
 

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

 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!

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

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

Greetings,

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

During cardiac cath on a medicare pt. the phy. documents below with one cath position. Findings are both renal and iliacs, would you code both G0275 and G0278 from just one contrast shot from the renal area? "DESCENDING AORTOGRAPHY: The descending abdominal aorta has at least moderate atherosclerotic plaquing with some aneurysmal dilation distal to the renals. The left renal artery has a cleft-like 60 to 70% stenosis. The right renal artery was not well visualized, is overlapped with the inferior mesenteric. There is mild plaquing of the left iliac artery. The left internal iliac is not well visualized. Right iliac artery is aneurysmal with mild plaquing. There is moderate plaquing seen in the right external iliac artery." Thanks! Jim H.

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

I love your site! thanks for all your help. Could you help me code this case.
Fluoroscopically Guided Transvenous FB retrieval Using US guidance we acessed the rt common femoral vein. I advanced the guidewire to the level of the inf vena cava and then inserted a 6 fr sheath.
The sheath was flushed. I advanced the guidewire to the level of the SVC over a guidewire I inserted a 6 fr long sheath the guidewire was removed through the sheath and under fluoro I advanced a multiloop snare with maxium transverse diameter of 1.5 cm LOOP snare was positioned adjacent to the venous catheter fragment in the right atrium. Multiple attempts were made with the snare that were unsuccessful. I then exchanged for a separate multiloop snare with max transverse diameter of 3cm. Again attempts made were unsuccessful. the catheter fragment is felt to be lodged against the wall of the rt atrium. I then removed the long sheath and inserted a 5 french pigtail in the rt atrium. I then placed a Ampltz guidewire through the pigtail catheter to open the catheter loop. The loop was then gently placed across the waist of the catheter fragment. Counterclockwise traction was applied to the catheter and guidewire which allowed the catheter to entangle the waist of the catheter. Under Fluo I gently pulled the catheter away from the right atrium and into the vena cava. The catheter was then pulled lower to the level of the rt common iliac vein. I removed the catheter and guidewire and replaced the loop snare. The loop snare was then used to grasp the end of the catheter fragment. I then removed the intact catheter fragment, loop snare and sheath from the right common femoral vein.
The fractured catheter fragment measures 11 cm in length. During the procedure the patient had a prolonged episode of atrial tach which did not resolve the following repositioning of the cath Cardiology was asked to evaluate the patient. The patients heartrate did return to baseline and no cardioversion or addl cardiac intervention were required. Successful Fluoroscopically guided retrieval of Venous catheter fragment from the rt
atrium. Thanks for your help

Common femoral vein accessed percutaneously and a cannula placed with dye injected. Physician then uses IVUS to investigate the vein. How do I code the access? He never said there was select catheterization. Do I use 36005 or 36000?