Ask Dr. Z

Hi Dr. Z I have questions regarding multiple access sites. I understand for access sites with interventions the catheter placements are included but I have had two cases that I have questions. The first is right femoral access, the catheter is placed in the aorta and a high low is performed. With a diagnosis of left iliac stenosis, a second puncture site is performed on the left with subsequent angioplasty and stent. Bilateral common femoral artery StarClose deployed. I have coded 37221, 75625, 75716-59. My question, should I have coded 36200 and G0269 for the right access with diagnostic aortogram and closure given there was not intervention performed from the right? The second case is right femoral artery accessed with catheter placment into the external iliac, obstruction was identified, catheter was pulled and StarClosed deployed. The physician then punctured the left side performed diagnostics, identified two areas of obstruction and stented them. Of course I coded the diagnostics and stent placements for the left but once again the question of should I have coded the 36140 and G0269 for the right side?

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.

We are unclear about how to report the non-selective catheterization codes with the lower extremity therapeutic procedures when the catheter is not placed selectively. Our case is: LT access, catheter placed in aorta (high and low) for aortogram and runoff. Bilateral common iliac stensosis that needs stenting. RT access created and kissing angioplasty and stent placements to the bilateral common iliacs done each from there own access side (RT and LT). The catheters never cross over the aorta. So for 2010 - this would be coded 36200 and 36200-59 for the catheter placements. Do we drop 36200 for 2011 lower extremity procedures when the catheter never goes selective or no because they are not selective codes (36245-36248)? I guess another example is if the MD did the same scenerio above but only did the angioplasty/stent on the ipsilateral side after the aortogram and runoff - would you drop 36200 for going into the aorto for the aortogram? Thanks so much!

Dr. Z, I am having difficulty understanding the bundling and reporting for code 0238T. 1. In the case of an atherectomy in conjunction with a PTA in the iliac artery territory, would you add code 0238T to the primary code 37220? 2. In the case of an atherectomy in conjunction with a stent in the iliac artery territory, would you add code 0238T to the primary code 37221? Thank you for your time!

Hi Dr. Z, I just want to be sure of the new peripheral codes. The doctor accesses from the left femoral artery the right iliac, performs a right extremity diagnostic to the foot, then does an atherectomy in the right superficial femoral artery, an atherectomy in the right commom femoral artery, both followed by angioplasty, then closes with an angioseal. I'm reading the rules over and over, as far as I can tell I can only bill 37225, and 75710. The angioseal closure is included, and the right common femoral and right superficial femoral are in the same territory. The selective catheterization is included, I believe the only other code is the diagnostic extremity - am I correct?

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?

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.

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!

Got a question for you¦ I have a case here where the patient is coming in for angioplasty/stenting of the right common iliac artery (DOS 1-14-2010). The patient had a prior CT angiogram 11-13-2009 which was mentioned in the H&P and I did review the actual report. Essentially the same findings are seen in the prior study as what is seen in the current study; and there is nothing said by the MD that really gives medical necessity for a repeat study. I do believe that this is pretty cut and dry that the repeat study cannot be reported. However, my question is can the selective catheter placement still be reported even though the angiography is not going to be reported? In this case the right femoral was the puncture site. He takes the cath to the abdominal aorta for aortogram, then up and over to the left common femoral artery for left lower extremity angiography. At this point the cath placement is at 36246-LT. Then, he comes back to the right side, does injection for run-off, and performs angioplasty and stenting of the right common iliac artery. (If there had not been any angiography performed (or angiography of the right leg only), there would be no selective catheter placement; as the right side was the puncture site, and the right common iliac was the vessel intervened upon. The catheter placement code would be 36140-RT just for the puncture.) I am confused about whether to report the 36246-LT. Should this still be reported (even though the diagnostic study is not being reported)? I canâ?Tt find a specific resource to back that up. I looked in the Dr Z book and on the Q&A site. What do you think? Any guidance would be greatly appreciated! Pat

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

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

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

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

Stents were placed in common and external iliac arteries to reline the iliac system after open thrombectomy of iliac arteries and femoral endarterectomy via same arteriotomy. Can we report code 35371 along with 37221 and 37223 in this case, or is it just billed with code 35355?

Are you able to code an Ileofemoral endarterectomy (35355) and a profunda embolectomy (34201) with repair of CFA aneurysm with external iliac artery to profunda bypass (35141)? I'm not sure if a modifier would be appropriate.

"Percutaneous access was achieved in the left common femoral artery. A micro access sheath was placed. This was upsized to a 4 French sheath over a 0.035 wire. A UF catheter over a Glidewire was advanced over the iliac bifurcation and then exchanged for a 4 French endo catheter. An angiogram down the right leg was obtained."

There is no documentation that the catheter went into right leg, so should catheter placement be coded as 36140 or 36200?

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?

Please suggest. Indication: Esophageal varices bleeding. Paracentesis performed. left common iliac vein access , iliac venogram , IVUS performed to determine If the patient is a candidate for DIPS placement in future. US guided to puncture to get splenic access. After venogarm selection of gastric vein , gastric venogram, selection of 5 different branches supplying varices , embolization of them. I know procedure is 37244. Please suggest codes for this catheter placement? Can we report IVUS? cath placement for that? Thank you

Axillary bi-fem bypass was performed for infected aortitis Then through separate incisions an open lap was performed with excision of the infected aorta/iliac arteries. Would the excision of the infected aorta/iliacs be included in with the bypass procedure, or is it separately billable? If billable, how would you code this?

"Once we completed the axillary bifemoral bypass, we decided to resect the distal infrarenal aorta, aortic bifurcation, entire right common iliac artery, and proximal left common iliac artery. The tissue was sent for culture and pathology. We then performed further debridement along the left iliac vein and distal vena cava, confirming that all infected retroperitoneal peritoneal tissue was removed. We oversewed the right and left common iliac cuffs with a Blalock stitch, using 3-0 Prolene suture. The aortic cuff was oversewed in a similar fashion. We confirmed hemostasis. We then thoroughly irrigated the retroperitoneum with both saline and Betadine solution."

Hi Dr Z,

Which CPT code can be billed for following procedure.

This is facility billing

Left forearm arteriovenous graft declot

Fistulogram and central venogram

Balloon angioplasty of AV graft, venous inflow, and outflow basilic vein with 7mm x 60mm Dorado balloon, 6mm x 40mm Lutonix DCB, 8mm x 60mm conquest balloon

Findings: there is a Left forearm AV fistula with a PTFE interposition graft. There is significant stenosis > 75% in the inflow anastomosis between the vein and the graft. There is severe > 75% stenosis at the outflow forearm basilic vein.

Thank you in advance

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.

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.

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.

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.

Patient was referred for diagnostic right renal angiography with pressure gradients and possible renal artery stent for fibromuscular dysplasia of renal artery, after having a CT scan showing "The right renal artery stents are widely patent even the 1 in the branch vessel. However there is a subtle abnormality just proximal to the most proximal right renal artery stent that could represent an underlying severe stenosis or web from FMD."

Per procedure report, "the catheter was placed in the abdominal aorta via right common femoral artery with injection. Patent arterial vessels without significant disease: abdominal aorta, left renal, left common iliac, right renal and right common iliac. The catheter was placed in right renal artery via right common femoral artery with hemodynamics. No pressure gradient on pull back from inferior branch of right renal artery into the aorta. No renal artery hypertension." What is the appropriate coding for this diagnostic case?

We have a surgeon who places right femoral trialysis catheters, but he does not confirm where the tip of the catheter terminates. When I asked him he said post-op placement imaging for femoral catheters is not needed; he said there is no way to definitively confirm catheter placement in the iliac vein on plain film without cross-sectional imaging like a CT/MRI. In these cases do we report code 36556-52?

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? 

"5 French angled glide catheter was advanced over this wire into the distal radial artery. Fistulogram with radiological supervision and interpretation was then performed. This revealed near occlusive stenosis at the arteriovenous anastomosis and proximal outflow. 4 mm x 40 mm Mustang balloon was brought to the arteriovenous anastomosis, and balloon angioplasty was performed of the segment. The 4 mm x 40 mm balloon was also used to perform balloon angioplasty of the proximal outflow. Fistulogram was performed, which revealed significant improvement of the severe arteriovenous anastomotic stenosis. The 6 mm x 40 mm balloon was then brought into the proximal venous outflow, and balloon angioplasty was performed." 

Would you report codes 36215, 75710, and 36902 since the catheter was advanced to the distal radial artery? I reported code 36902 only. Can you give more explanation to what is considered arterial inflow in the dialysis circuit? Isn't this beyond perianastomotic segment for 36215 and 75710 to be used?

Our Vascular providers whenever they do abdominal aortic aneurysm repair with 34705 and coil embolization of internal iliac artery they also place an extension graft to the external iliac artery to cover internal iliac artery origin in that side. Do we bill 34709 for this extension into external iliac artery to cover internal iliac origin along with 34705, 37242, and catheter placement?

The right common femoral artery had pulsatile bleeding following deployment of both Perclose devices. A third Perclose device was deployed, however, the patient continued to have pulsatile bleeding from the access site. The 16 French sheath was then replaced into the common femoral artery for hemostasis. A 10 blade was then used to make a incision overlying the sheath access. Electrocautery was used to dissect through the subcutaneous tissue and the proximal common femoral and distal common femoral artery to the access site were dissected out and encircled in Vesseloops. The sheath was then removed and the Vesseloops were used for hemostasis. The arteriotomy was freshened with Potts scissors. Using multiple interrupted 5-0 Prolene suture the arteriotomy was then closed. A microcatheter was then placed through the Kumpe catheter into the primary trunk of the right internal iliac artery. 20 mm x 60 mm framing coils were then deployed into the trunk of the right internal iliac artery. This was then followed by four 8 mm x 60 mm filling coils.

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?

"The patient has acute bilateral iliac DVTs with IVC thrombus. The Excel mechanical thrombectomy catheter was advanced, and a single pass was performed through the left external iliac vein. Attention was then turned to the right common iliac, and using the Bold mechanical thrombectomy catheter and appropriate tension over the confluence. Subacute to chronic appearing thrombus was removed."

Can this be coded as 37187-50 since it was done on both sides, in two different vascular families? Or should it be coded as one 37187? And if they also did a mechanical thrombectomy of the IVC at the same session as the bilateral thrombectomies, can this also be picked up with 37187?

Left upper extremity fistulogram. The stenosis in the graft venous anastomosis was crossed with the wire. Angioplasty of the stenosis in the graft venous anastomosis was performed using 8x40 mm Balloon; then sheath was redirected towards the arterial inflow. Balloon angioplasty of the arterial anastomosis with a 6x40 mm balloon. (Same Access) do I bill both 36902 and 36907?

What if the physician uses a second access to access arterial anastomosis, any other access code to bill for second access? 

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.

If a patient received an IVL procedure in the iliac (just the IVL, e.g., C9764), and an atherectomy in fem-pop, how would this be coded by both the physician and the facility (hospital outpatient)?

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?

Would this be 35226 or 37799, or would it be something else entirely since technically its repair of a previously placed right common iliac to right external iliac bypass graft?

Approximately 3 mm x 4 mm defect in the proximal 3rd of the bypass graft in the posterior lateral aspect. After debriding the friable portion of the artery, there was too large of a defect for immediate primary closure and so after mobilization of the bypass graft and trimming of the edges of the artery for more sustainable tissue, we performed a end-to-end anastomosis of the existing bypass graft in a primary fashion.

“I did not feel comfortable repairing this without additional exposure and mobilization, so then I transected the artery to obtain a circumferential evaluation of the artery, CryoArtery. After additional debridement I felt comfortable reattaching each end in end-to-end fashion with 5-0 Prolene suture in simple interrupted fashion in its entirety.”

From right side femoral access,  catheter was placed in infrarenal aorta above bifurcation and performed angiogram, and catheter was placed in left external iliac for left leg runoff. Findings state aorta patent with iliacs and complete left leg findings. Can we report code 75625 in this case? Not sure whether significant portion of aorta was imaged since he said catheter was placed above bifurcation.

My provider is documenting that he placed a stent in common iliac vein, and placed a stent in external iliac vein. however he is only using 1 stent. Would this fall into "a single therapy"? Do I only bill 37238 since he used 1 stent? Or do I bill 37238,37239 since 2 different vessels were treated? 

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!

What codes are supported for billing the endovascular procedure and why?

"Ultrasound-guided cannulation right common femoral artery- Selective left leg angiogram- Left anterior tibial lithotripsy with 3 mm x 40 mm Shockwave lithotripsy balloon- Angioplasty distal left anterior tibial artery with 2 mm x 100 mm ultra verse balloon-

Operative findings:

#1. The left posterior tibial artery still patent with minor areas of disease proximally and distally. The posterior tibial goes into the foot but does not appear to supply much of any blood flow to the digits on the left foot.

#2. The anterior tibial was able to cannulated with 0.018 wire and 0.014 wire. The wires could not be advanced all the way into the foot. After treatment of the anterior tibial with 3 x 40 mm lithotripsy shockwave balloon, it was quite obvious that the lithotripsy balloon could not be advanced all the way into the foot. This was replaced with 2 mm x 100 mm balloon which once again could not be advanced across the heavily calcified and diseased distal anterior tibial artery into dorsalis pedis. The procedure was then terminated."

If the provider performs an endarterectomy of the external iliac artery to common femoral artery and places a stent in the common iliac artery, can we bill both codes 35355 and 37221? If so, does the documentation need to support two separate lesions to bill both, or can it be a contiguous lesion?

For iliac artery stent procedures, we understand the coding is first based on pathology and then based on the type of endograft used to treat the pathology. For an iliac artery dissection (not stated for occlusive disease), should we use code 37236 or 34707 when a Cook Zilver 8 mm x 60 mm stent is used? Would this type of stent qualify for the ilio-iliac tube endograft code 34707, or would this be considered a “regular" stent code 37236? If the dissection was caused during a lower extremity revascularization procedure, is the iliac artery dissection stenting still codeable?

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?

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."

How would you code the following? Surgeon accesses right IJV, advances the sheath and performs a bilateral LE venogram. After diagnostic venogram, they proceed with intervention. Catheter is placed in IVC, then in RT CIV, LT CIV, RT EIV, LT EIV, RT common femoral vein and LT CFV; all with IVUS performed in each vessel. Compression is found in each vessel and measurements are documented. Surgeon decides to place stent in RT CIV, RT EIV and RT CFV. I am coming up with 37238-RT, 36012-RT, 37252, 37253x5, 75822-59.

Left Femoral access was obtained; RT Common Iliac was imaged and the catheter would not advance further due to claudication. RT Anterior Tibial access was obtained; angiography was performed and the stented lesion could not be crossed. A third access was gained; antegrade of the RT Common Femoral Artery; to SFA where PTA was performed. The hospital is capturing: CPT-37224 only. Generally the catheter placements are bundled with the intervention; however here there are multiple access sites (3) obtained. Should the other access sites also be coded for RT Common Iliac and Rt Anterior Tibial and if so what CPT's would apply here? CPT-36247/CPT-36140 or just CPT-36140 times two? Thank you for sharing your expertise on this issue!

The patient was born with hypoplastic left heart syndrome who underwent staged palliation including Norwood/Sano, bidirectional Glenn anastomosis, fenestrated extracardiac conduit Fontan procedure, stent placement into Fontan fenestration and subsequent balloon angioplasty of stented Fontan fenestration and left pulmonary artery stent placement. She has plastic bronchitis and was scheduled for lymphatic imaging and possible occlusion of abnormal lymphatic collaterals to the lung. Transient balloon occlusion of Fontan fenestration was needed because of open fenestration with potential for right-to-left embolization of lipiodol droplets.

6F balloon wedge catheter was inserted thru right femoral venous sheath, advanced to extracardiac conduit and manipulated across stented Fontan fenestration. Transient balloon occlusion of Fontan fenestration was performed twice by interventional cardiologist during IR lymphatic procedure with lipiodol injection. I'd like to know how to report balloon occlusion of Fontan fenestration for facility and physician billing please.

Is 37238-RT, 37239-LT, 37239-LT appropriate?

64% compression in the right common iliac

58% compression in the right external iliac

57% compression in the left external iliac

60% compression in the left common femoral

Stent to the right CIV that covered the compression of the right EIV

Stent to the left EIV

Stent to the left CFV

IVUS shows separate compression of the left CFV.

Insurance has denied 37238 for modifier. "After review of the medical record, bilateral stent placement in the lower extremity venous system was supported. There is a more appropriate modifier available."

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