Ask Dr. Z

Our provider performed a balloon angioplasty on the superior mesenteric artery. CTA demonstrated a high-grade stenosis on a previously stent in the same SM artery. Our system is telling us that it requires a laterality modifier (which we have used in the past for upper extremity interventions). Being that in this case we have the balloon intervention in the superior mesenteric artery, we are seeking information on if possibly another CPT code is required or if a laterality modifier will be required.

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.

Patient presents for a planned stent placement in the left external iliac vein due to a stenosis seen on a previous lower extremity venogram. Physician accessed the left common femoral vein and placed a stent in the left external iliac vein. Physician documented that stent deployed nicely and flow now open. Code 36005 is specific for injection procedure for extremity venography. What catheter placement code do we use in this case?

"The endograft was placed in the main body and two iliac components. Under angiographic imaging, I noticed some larger lumbar collaterals and they were marked as our limit to IVC coverage with a covered stent. cc x 7.5 Enodlogix infrarenal endograft was deployed within the IVC stent overlapping the previously placed bifurcated endograft. Distal end was deployed immediately below the lumbar collaterals. The remaining infrarenal segment of sclerosis was treated with 18x100 Abre stent. The pararenal and suprarenal segment of IVC was treated with 36x80 Zenith dissection endovascular bare metal stent."

Please help. What all stents would be coded? Also, regular vein stent codes or is there a code set for endograft stents in the IVC and vein? I only see the EVAR codes for aorta and arteries.

Patient has a previously placed EVAR device now with an endoleak of the iliac limb. An initial TEVAR was performed during the same session as delayed placement of an extension to the iliac. What would be the proper coding for this since code 34710 bundles with 33881?

Hello! We have a case where a provider did two separate bypasses via 2 arteriotomies and 4 anastomoses off of one vessel (right external iliac). He begins the procedure with a midline abdominal incision, lysis several adhesions due to extensive scar tissue to locate the mesenteric artery. He creates an arteriotomy and a PTFE graft is sewn end-to-side fashion to the right EIA. The graft was tunneled to the level of the SMA and perform an end-to-end anastomosis to the common hepatic artery. An arteriotomy was made and placed a 2nd PTFE graft onto the EIA in the region of the pelvis creating an end-to-side anastomosis and this limb of the mesenteric bypass was then tunneled in this retroperitoneal tissue up to the level of the SMA where an end-to-side anastomosis was created. Provider is choosing codes 35632 for the ilio-hepatic bypass and 35633 for the ilio-SMA bypass. My question is - can two bypasses be reported off of one vessel? If so, are these the correct bypass codes? Also, are lysis of adhesions separately reportable?

Devices used - Bifurcated stent graft - Access sheaths (15F, 7F)- cutdown- Diagnosis is not aneurysm. Can we report w a non-aneurysm diagnosis? revascularizing the aorto-iliac bifurcation because of occlusive disease at the aorto-iliac bifurcation, using a single unibody device . There is no repair of the infrarenal aorta. 34705?

"Patient brought to cath lab emergently. A 100% occluded vessel was located in the LD, RC, and LC. Our culprit lesion was in the LD and treated with a stent. The LC was treated with an Aspiration thrombectomy of the OM2. No angioplasty or stenting was preformed in this vessel. Then the RC an attempted angioplasty was preformed since they were not able to cross the lesion they are planning on brining the patient back at a later time."

We know that the aspiration is included in the primary intervention of the same vessel. In this case would we be able to bill code 92941-LD with 93799-LC for the thrombectomy that was completed in the LC?

"Aspiration thrombectomy of OM 2. Thrombus was visualized in the distal arm to causing a 100% occlusion/TIMI 0 flow. Following the intervention of the LAD, the Choice PT was reintroduced and used to cross the thrombotic lesion. Aspiration thrombectomy performed using priorityONE 6 French aspiration catheter."

Do you still recommend using code 37246 for lower extremity PTA for treatment of a thrombus? The physician documents a thrombus causing an 80% stenosis of the popliteal artery.

"There was separate thrombus resulting in 80% stenosis of the native distal (P3) popliteal artery and the tibioperoneal trunk. An additional 3000 the lesions were administered corresponding to a total of 100 units/kg. The lesion was angioplastied with a 3 x 200 mm followed by a 4 x 150 mm and a 4 x 60 mm Armada balloons. The final angiogram showed good results with less than 20% residual stenosis and only a minute amount of residual thrombus. The heparin effect was reversed with protamine.

Conclusion: This is a patient with acute thrombus of the native distal (P3) popliteal artery and tibioperoneal trunk treated with balloon angioplasty."

Patient presented with both AAA and iliac aneurysm. The physician placed an iliac branch endovascular graft in the internal and external iliac artery followed by an iliac extender graft. After this was deployed the physician started the AAA repair with a Gore main body with bilateral limbs. Would you code for the AAA 34705, iliac 34707, and 34709 since this was a completely separate repair from the AAA? If this repair had been performed with just an extension graft would you only use 34079?

What catheterization code would be used for the following? Is this considered non-selective or selective?

Access was obtained in the right axillofemoral graft near the anterior superior iliac spine with the underlying inguinal ligament and iliac crest available for compression, using a micropuncture kit. This was exchanged for a 6 French sheath over a Bentson wire. A kumpe catheter and wire were advanced into the subclavian artery and angiogram images were obtained.

Angiographic Findings:

- successful access of the right axillofemoral graft with acute thrombus

- Patent right subclavian, axillary, and proximal brachial arteries and main branches

- Acute thrombus throughout axillary graft.

I found a similar case on question ID 4047 but it is outdated (2012) with now deleted codes. Thanks!

The innominate artery was selected, followed by the right common carotid artery. Biplane cervical and intracranial angiograms were performed from the right common carotid artery before stenting. Measurements were made from magnified oblique projections and an 8 mm x 2.5 cm GORE Viabahn covered stent was selected. This was prepped in the usual fashion with an Aristotle 18 microguidewire. The stent was attempted to advance through the Cerebase, but the sizes were not compatible.The Cerebase was fully removed from the body. Next, a 90cm BMX96 was advanced over the 130cm Berenstein selection catheter and Terumo Glidewire to the level of the aortic arch and the right common carotid artery was selected.  The 8 mm x 2.5 cm GORE Viabahn covered stent was then advanced over the Aristotle 18 microguidewire to the distal right common carotid artery. Next, the stent system was removed and we proceeded with balloon angioplasty to ensure good wall apposition. Would this qualify as 37215, EPD not specified?

"Limited incision was made thru subcutaneous tissue with cautery. The femoral sheath was sharply incised. A severely diseased artery was identified that was circumferentially severely calcified. Dissection extended under the inguinal ligament where the external iliac artery was controlled. Heparin was administered. Longitudinal arteriotomy was made with a #11 scalpel and then extended with a Potts scissors. Severe calcific and mixed plaque in the common femoral artery was identified. Endarterectomy was extended up into the distal external iliac artery. Separate endarterectomy profunda femoris artery was necessary due to the extent of the plaque. Good backbleeding was obtained. The SFA was endarterectomized as the saphenofemoral junction was noted to be relatively low. Primary closure of the endarterectomized vessels was undertaken with running 6-0 Prolene suture."

Would you code this as 35355 and 35372-- is "arteriotomy was extended" to bill both?

"The graft was accessed under ultrasound guidance. Contrast was injected, confirming a focal stenosis at the level of mid humerus. A 6 French sheath was placed and a Kumpe catheter advanced into the proximal graft where contrast was injected. This demonstrates a second more proximal stenosis near the graft/venous anastomosis. Angioplasty was performed of these stenoses. Contrast was then injected more centrally where prominent collaterals are present. These seem to be related to a recurrent stenosis in the subclavian vein. Angioplasty was performed with a 12 mm balloon. The balloon ruptured and would not fit in the 7 French sheath. Unable to remove the balloon through the sheath, access was achieved in the right common femoral vein and a 10 French sheath placed. A snare was used to capture the proximal end of the balloon."

Are codes 36902, 36907 and 37197 correct? Can we also code the catheter placement from the groin?

Is code 37243 appropriate for the following procedure?

"A 4 French Cobra catheter was advanced over the aortic bifurcation and the left internal iliac artery was selected. Angiography was performed-microcatheter was advanced into the left uterine artery. A small vessel travelling inferiorly, likely a vaginal artery, was identified and the microcatheter advanced beyond this point. Embolization was performed with 500-700 micrometer beads until there was sluggish flow. After some difficulty attempting to cannulate the ipsilateral, right internal iliac artery with a SOS catheter, Omni flush catheter was used to access the artery and then exchanged for angled glide catheter over the wire. Angiography was performed which showed a smaller right uterine artery which was quite tortuous. Numerous attempts to advance the microcatheter distally were unsuccessful. This site was abandoned. The catheters were removed and an angiogram of the right external iliac artery and common femoral artery was performed showing normal caliber and anatomy."

Indication: Polyclonal gammopathy, thrombocytopenia, and macrocytosis. Clinical concern for bone marrow disorder.

During fluoroscopic and cone beam CT guidance, right posterior iliac crest bone marrow aspiration and core biopsy was performed. "Cone beam CT was performed throughout this procedure and 3D advanced post-processing was performed using an independent workstation with active physician participation and supervision."

Is 76377 separately billable during CT-guided biopsy?

Patient presents for RHC (93451-26) & EMB (93505-26) s/p heart transplant w/possible re-intervention on pulmonary veins. Both right/left PA wedge angiography performed to eval pulmonary venous return on levophase. Hand injection done with catheters placed in left lower branch of LPA, main LPA to evaluate the LLPV, RLPV, RMPV, Left lingular pulmonary vein. Findings: right sided pressures were reasonable, PA wedge angiography showed mild-moderate stenosis in left lower and right lower pulmonary veins on levophase with PCWP being 16-17 mmHg. Stenosis appeared to be stable compared to post-angioplasty angiography at the last cath. Therefore, we decided to leave those alone.

I don't feel that billing 93568/93569 is appropriate since not looking at the pulmonary arteries. Can we bill for selective placement 36014 for placement in LPA and 75746 for the S&I to look at the veins? Thank you.

Hope you can help since we cant figure out what codes to use. Patient has abdominal aneurysm and iliac aneurysms. Vascular surgeon performed aorto-bi-femoral Dacron graft, bilateral common femoral and profunda endareterectomies and 6 mm Goretex common femoral to profunda jump graft and ligation of bilateral iliac arteries.

Should we go with 35102 for the Dacron graft? I am assuming that endarterectomies are not reported. Qhat about the jump graft? What code can we use and ligation of bilateral iliac arteries? Thanks!

Our physician completed an embolectomy through the RT CFA. He found significant atherosclerotic disease in the RT CFA and decided to treat with the Endarterectomy as well. There was only one arteriotomy we explained that only one would be billable. But in this case, he is questioning it since there was the finding of the significant atherosclerotic disease. Can you please let us know if both would be billable in this case?

"Arteriotomy in the CFA which was extended through the femoral bifurcation onto the SFA. Large amount of calcific plaque was identified in this area and an endarterectomy was performed. Embolectomy catheter passed retrograde, artery crossclamped. Embolectomy catheter passed down profundofemoral artery distance of about 20 cm with no return. Embolectomy catheter passed down SFA down popliteal and into the peroneal artery. It was passed to 65 cm. Thrombus was removed. Saphenous vein in the groin was then harvested spatulated reversed and using a running suture was sewn in a patch angioplasty type fashion to the arteriotomy on the CFA."

Please advise if documentation supports both 34201 & 35256 or 35302 only. Provider reported 34201 and 35256. 

Patient S/P TAVR w/occlusion of RT CFA/SFA @ site of closure device w/intimal disruption, dissection. Vertical incision made & closure device removed. Extended arterial puncture site w/Potts proximally then distally into the proximal SFA. Performed endarterectomy of CFA/SFA & tacked distal intimal edge w/multiple sutures w/sluggish backbleeding from SFA. Proceed w/FEM-POP catheter thrombectomy, #4 Fogarty thrombectomy, distally into SFA w/ retrieval of minimal thrombus. Segment not amenable to primary closure due to extent of arterial wall loss. Proceeded with harvesting of short segment of great saphenous vein. Vein graft sewn in place to the CFA/SFA in a patch angioplasty manner. Endarterectomized segment was flushed antegrade & retrograde prior to tying of our anastomosis. Closed the femoral sheath w/running 2/0 PDS. Closed the subcutaneous tissue in layers, closed the skin w/ running 4/0 Monocryl.

Would additional catheterizations and imaging (LT innominate, RT brachiocephalic) outside of the target treatment zone be separately reportable in the case below or is this included in 0644T?

"Right common femoral vein access. Catheterized Right external iliac vein. Venography was necessary due to questionable thrombus noted on ultrasound. Additionally, the patient has a left groin dialysis catheter which can make the patient more susceptible to thrombi. There is concern that the catheter may

either induce a scar, stenosis, or thrombotic event that would be worsened by advancement of large sheath.

Findings: Widely patent external and common iliac veins as well as the inferior vena cava. No evidence of high-grade stenosis, occlusion, or thrombus formation.

Catheterized Left innominate vein. Findings: Widely patent left innominate vein. With patent superior vena cava and right atrium. Suspicion for continued fibrin sheath within the superior vena cava. No evidence of complication such as active extravasation.

Catheterized Right brachiocephalic vein.

Findings: Patent right brachiocephalic vein and superior vena cava. Small residual fibrin sheath noted. No definite complication. No obvious large pulmonary thrombus.

Mechanical or aspiration thrombectomy Venous segment treated: Right atrium and superior vena cava

Transesophageal echocardiogram findings: TEE was performed by the anesthesiology service.

This was used to successfully advance the flush catheter to the fibrin sheath with subsequent aspiration of the vegetations. Selection and aspiration was performed under real-time TEE guidance. There was visualization of the thrombectomy. No evidence of embolization material by TEE."

Codes 35371 and 35875 (fem-pop bypass) do not bundle, but I believe since these are performed through one arteriotomy that only 35371 should be billed. Is this correct?

"At this point we placed profunda clamps on the profunda artery and cinched our vessel loops to obtain proximal control of the common femoral artery. We made an arteriotomy along the lateral aspect of the common femoral artery using 11 blade scalpel. Using Potts scissors we extended our arteriotomy proximally and distally onto the profunda artery. We performed endarterectomy of significant intimal hyperplasia using a freer elevator. At this point the two branches of the profunda artery appeared patent and healthy at this level as well as had good backbleeding. At this point we used a 4-0 Fogarty to perform thrombectomy of the right lower extremity graft. When we were no longer retrieving clot and had good backbleeding we stopped. At this point we performed a patch angioplasty of the femoral and profunda arteries using bovine pericardial patch with a 5-0 running Prolene suture."

What are the appropriate CPTs for this procedure performed? Left common femoral artery access. Catheter and wire were advanced to distal abdominal aorta where aortoiliac angiogram was performed. Catheter was pulled down to the aortailiac bifurcation and advanced over the wire to the contralateral common femoral artery and a right extremity runoff was performed. FINDINGS: patent distal abdominal aorta, bilateral common, external and internal iliac arteries. Right common, SFA and profunda arteries with mild plague, patent tibial peroneal trunk, patient peroneal with 100% stenosis anterior tibial and posterior tibial arteries.

"Left femoral artery was surveyed via ultrasound. A 22-gauge needle was used to access the apex of the left com fem artery over the femoral head. An .018 wire was then advanced into the ext iliac artery and confirmed with fluoroscopy. The 22-gauge needle was exchanged for a 4 french x 10 cm pinnacle sheath. A soft angle glide wire was then advanced into the infrarenal aorta and a 4 French Kumpe catheter was tracked over it. The infrarenal aorta, com iliac arteries, and the takeoff of the iliorenal bypass were imaged via DSA (all widely patent). We attempted to use the 4 French Kumpe catheter and a soft angle glide wire to access the iliorenal bypass but were unsuccessful. We exchanged the Kumpe catheter for an omni flush catheter which allowed us to gain access to the iliorenal bypass with the soft angle glide wire. A diagnostic angiogram was performed which revealed that the iliorenal bypass was widely patent, as was the anastomosis between the graft and the left renal artery."

Not sure on cath placement and S&I for this. Would this be 36245, 75625?

Patient has a tunneled central venous dialysis catheter in the left internal jugular as well as a functioning straight radio-brachial AVG in the left forearm. The physician removes the LIJ CVC and does central venography through the same access, and findings are documented as severe (50%) recurrent left innominate vein stenosis. Patient also has venous hypertension diagnosis and difficulty with accessing the AVG. He then angioplasties the innominate vein stenosis through the same access and does not replace the tunneled catheter. Would this be coded as 37248, 36589, and 77001?

DX : Severe SMA stenosis/abdominal pain. I was able to navigate into the SMA and placed a catheter in the distal portions performing an angiogram demonstrating the distal portions of the SMA. Placed a Rosen wire down and performed a 6x60 balloon angioplasty first, followed by a 7x60 shockwave (IVL) to the proximal and mid portions of the artery. Selected a 7x37 stent, landing this into the aorta itself and in a portion of the artery that appeared free from disease. How would this be coded and are there codes for shockwave in the SMA?

A SVC cavogram was performed through the catheter which showed a fibrin sheath in SVC. A 12 mm angioplasty balloon was advanced over the guide wire. The balloon was inflated in three different segments of SVC. A follow up cavogram showed widely patent SVC without any fibrin sheath. Subsequently a new tunnelled dialysis catheter was advanced over the guide wire. The 13.5F dialysis catheter wa tunneled under skin over right upper chest and then introduced over the guide wire with the tips positioned in right atrium under fluoroscopy guidance. The catheter was flushed with heparinized saline and sutured to skin with 2.0 Silk. IMPRESSION: 1.Successful replacement of a right jugular tunneled dialysis catheter. 2. Successful removal/disruption of fibrin sheath with angioplasty balloon. Is it appropriate to bill: 36581, 77001, 36595-52? Thank you.

Would there ever be a scenario where 75774 would apply when performing a diagnostic angiogram retrograde whether or not there is intervention? Typically our provider will access the DP and stay within the same extremity advancing to ipsilateral iliac and feels because he is advancing through each vessel on the way up he should get 75774 for those vessels. I have explained this is all non selective when staying in the ipsilateral extremity going retrograde but he feels this is not correct. Please advise, I would greatly appreciate any feedback on this.

INJECTIONS:

LEFT vertebral artery

RIGHT vertebral artery

RIGHT internal carotid artery

RIGHT external carotid artery

RIGHT external iliac artery

INTERVENTION:

Selective verapamil infusions into both vertebral arteries and both internal carotid arteries. Each vertebral artery infusion exceeded 10 minutes in duration. Each internal carotid artery infusion was less than 10 minutes in duration.

How would we code this? We were thinking 61650 and 61651.

RIA was cannulated a interlock detachable coil was advanced into RIA however, were unable to advance the full deployment mechanism around the curve of the cath attempted repositioning was, the coil itself began to unwind. Multiple wires were utilized to attempt advancement of the coil mechanism this was unsuccessful as the coils integrity had failed. To preserve access, a buddy wire was placed. The coil was removed with confirmation. No further attempts at coil embolization were made. Over a wire system Perclose technique was then performed to the RCFA access and following serial dilation that became difficult due to the degree of scar the sheath was eventually upsized to a 12 French which was advanced to the level of the endograft limb. A Gore excluder iliac limb was then deployed just distal to the flow divider followed by deployment of covered balloon expandable VBX stent spanning the distal aspect of the newly deployed endograft limb and into the native proximal external iliac artery with post dilation. 34718 vs 34710 with attempt coils?

I have a physician who wants me to bill for additional cath placement during fistulogram with angioplasty.

Physician documents first cannulation site near the distal end and pointed in an antegrade direction. Second cannulation of proximal end of fistula pointed in retrograde direction. (He thinks this second cannulation site is billable.)

After researching I feel this is included in the work done for 36902, since it was in the peripheral segment?

For thrombectomy/embolectomy of iliac stent, would I use 35875 or 34201?

During a CABG procedure the surgeon completes vein bypass to the first diagonal, artery bypass to the second diagonal, vein bypass to the RCA. The surgeons note there was an area of long soft plaque of the PDA (states significant finding) and completes a patch angioplasty. We know the bypass CPT codes, our question is can a patch angioplasty of the PDA be reported as well? What CPT would best capture this service?

Code for right femoral arteriography? Is it 36245 and 76937?

"Right femoral arteriography sono imaging LT groin demonstrated patency left common femoral artery. After local anesthetic administration, left common femoral artery was cannulated and retrograde fashion using real time US IMG guidance an 18-gauge access needle. Hardcopy US image documenting needle entry into artery was placed in patient's medical record. Using exchange technique, a 6 French sheath placed. A 5 French diagnostic catheter was then advanced over a floppy guidewire to the level of the distal abdominal aorta. The catheter was used to selectively catheterize the contralateral common iliac artery. The catheter was advanced over guidewire to the level of the right common femoral artery under fluoroscopic. With the catheter in this position multi planar MR angiography of the RT common femoral artery, right profunda femoris and RT superficial femoral artery was performed. Images reviewed. Catheter and sheath were removed and manual compression achieved hemostasis."

We are having a coding dilemma for the following case. Should this be reported as a creation (36830) with reduced/aborted modifier or as a repair (35206)? This was an initial graft placement. "Summary: Brachial artery too small for AVG, so AVG was connected to axillary artery and vein. Loss of pulse after AVG placement due to dissection of artery. Artery very friable and required repair with multiple tacking sutures and patch angioplasty anteriorly with bovine patch. Decision was made to remove graft after perfusion was restored to the hand because the risk of proceeding with reconnecting the AVG after arterial repair was felt to outweigh the potential benefit."

Main body was a 26 mm ALTO graft. Positioned and deployed just below the renal arteries with the covered portion of the graft. It was then per instructions filled with palmar. We then used a 3.0 x 140 mm with maximal overlap into the main body graft on the left side, we placed a 22 x 140 mm Ovation iliac extension limb, which was landed just proximal to the hypogastric excellent positioning and then mimicking the procedure on the right side with oblique imaging and iliac retrograde injection. We had trouble identifying the hypogastric takeoff, so I used an SOS Omni catheter to selectively cannulate the hypogastric perform injection and pelvic selective angiogram, and locate the position of the hypogastric. We then used a 3.0 x 140 mm with maximal overlap of the main body, positioned and landed just proximal to the hypogastric. We per instructions used 14 mm balloon to lock in iliac limb into the gate of the main body, we used a compliant balloon to iron out the proximal extent and overlap portions of the graft into the iliac vessels. 34705 with 34709 x 2?

Revision of right BKA to an above-knee amputation for necrosis and distal left SFA exposure with retrograde crossing of chronic total occlusion, angioplasty, and stenting. I believe correct codes would be 34812-LT, 37226-LT, and 27886-LT. What are your thoughts?

Patient had stent placed for CTO of LD and angioplasty for CTO of the diagonal.

Would I use 92943-LD and 92921-LD?

Or would I use 92943-LD and 92944-LD?

Physician is questioning.

Would it be appropriate to code 92920 with TAVR? Patient has a patent LM/LC stent protruding into aortic root.

"Via the right femoral artery, a 6F XB 3.5 guide catheter was advanced to the aortic root and BMW Universal 2 coronary guidewire was used to wire the LM stent into the distal LCx artery. A 3.5 x 20mm non-compliant balloon was then prepositioned into the LM/LCx artery stent. The aortic valve was crossed using a 6F AL-1 catheter. An Amplatz Extra Stiff wire with a broad distal curve was positioned in the left ventricle. A 23 mm Edwards Sapien 3 Ultra valve and Commander deployment system were prepared and inserted into the introducer sheath; final assembly was performed in the descending aorta; and the valve was advanced to the aortic annulus. After confirmation of valve positioning, the NC balloon was partially withdrawn with the proximal segment protruding into the aortic root and inflated to 18 ATM. The valve was then deployed in the aortic valve annulus under rapid ventricular pacing at 180 bpm."

Pt w/peritoneal carcinomatosis. With fluoro guidance, an angled glide catheter and stiff Glidewire were advanced thru the nose and into the stomach. A 24mm x 4cm angioplasty balloon was advanced into the esophagus over the guidewire. The balloon was inflated and US of the left neck showed a safe window of access for percutaneous transesophageal gastrostomy between the thyroid gland and LT carotid. With US guidance, an 18-g trocar needle was advanced between the thyroid gland and LT carotid. The needle was used to puncture the angioplasty balloon. Through the needle a J-wire was advanced/coiled within the angioplasty balloon. A 2nd operator then advanced the angioplasty balloon and wire into the stomach. Once in the stomach, the wire was separated from the angio balloon and the balloon was removed. Over the wire, after serial dilatation, a 12Fr x 60cm drainage catheter was advanced. The pigtail portion was formed within the stomach. Position was confirmed with contrast and catheter was secured to the skin. 

Would this be 49440 or unlisted 43999? 

I have a provider that performed an embolectomy of popliteal/tibia vessels with a vein patch (34203). Would you bill for the vein patch with a 35256 on top of the embolectomy 34203?

"We therefore elected to make an incision down in the distal calf overlying the posterior tibial artery after the gastroc muscle thinned out, identified the posterior tibial artery. It was soft. It was disease free, but was firm and hard with thrombus. Because of the size, we made a longitudinal arteriotomy with an 11 blade and a micro Potts scissors. We then passed a 2 Fogarty embolectomy catheter all the way down into the forefoot and were able to pull out a large amount of fresh and old thrombus. We then passed it proximally up to the popliteal artery and pulled it out and we were able to get good pulsatile flow now. Two more passes yielded no more thrombus. We were pleased with the result. We ossicles on the posterior tibial artery and then we splayed open the small vein that we had used and used that as a patch with 7-0 Prolene suture."

Sudden onset of pulsatile bleeding from rt groin pressure applied rt groin immediately. CT angiogram showed pseudoaneurysm & large hematoma in rt groin. external iliac artery stents. Iliac arteriogram revealed large common femoral patch & patent proximal anastomosis of bypass graft w/o evidence of active extravasation. A stiff Glidewire in aorta & brought over 7 mm balloon into external iliac artery and stent graft portion. Incision was made in the rt groin after staples removed. Immediately a hematoma was evacuated. Opened incision, to femoral artery. This is actually a large dacryon or interposition graft. We followed the graft distally until identified bovine pericardial patch on proximal anastomosis of the bypass graft. Immediately there was pulsatile bleeding from the patch. Proximal & distal control by inflating the balloon to 7 mm & clamping distal bypass graft with a straight PV clamp. This provided adequate control for repair. Two 5-0 Prolene sutures were used to repair bleeding from the patch using figure-of-eight sutures. 

Repair 35860 or 35142?

Femoral vein central venous line placement: Under ultrasound guidance, right femoral vein identified as being patent. Right groin prepped in sterile surgical fashion. Cannulated right femoral vein. Using a Seldinger technique, central venous line catheter was advanced. The cath was matured, dressing placed. Physician was queried for location of catheter tip and replied "No clinical reason to identify positioning of a femoral catheter. This is not standard of care." The CPT guideline, in part, states: "To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium.” This guideline also states that central insertion sites are “jugular, subclavian, femoral vein or inferior vena cava catheter entry site.” Is it necessary for the physician/HCP to also document where the catheter terminates when it is inserted via a central vein such as femoral, jugular, subclavian? Thank-you.

Provider states that the pre-interventional distal flow is decreased(TIMI 1). Interventional guide catheter was used to successfully engage the vessel. A straight tip pilot 50 was used to cross the lesion. A guidingguidezilla II 7FR guide liner catheter used for additional support. Angioplasty was don with sapphire ballon 1.0x8. multiple infations were performed. maxumum pressure: 20 atm. inflation time: 11 sec. The pos-interventional distal flow is decreased(TIMI 1). He then states that the RCA is 100% stenosed CTO. and was unable to cross the proximal RCA. He did a LHC and coronary angiogram. My question i coded it with 92943-RC and 93458-26-59.My clinic staff are wanting me to amend it with 53 for the professional and 74 for the hospital. My understanding is because he crossed the lesion with the wire it does not need the 53/74.

Is an AngioSculpt scoring balloon coded as angioplasty like a cutting balloon or atherectomy?

The description of code 50706 states it is for dilation of ureteral stricture. Can this code also be reported if angioplasty is used to dilate the ureter in order to push a catheter past a stone or stones to facilitate placement of an NU catheter or ureteral stent?

Patient had previous tube graft repair of AAA, now presents with infrarenal AAA and iliac aneurysm. Can this be coded as 34705, 34713-50, or 34710/34711?

"Subsequently a universal flush catheter with guidewire guidance was passed up from the left femoral access and bolus angiography was performed visualizing the level of the renal arteries the infrarenal aorta as well as the aortic bifurcation and iliac anatomy. With these landmarks identified a stiff wire was passed up from the right femoral access. The 11 French sheath on this I was now exchanged out with a 16 French sheath. This was passed up into the aorta. Through this sheath and over the stiff wire a Gore-Tex bifurcated IBE endograft was passed. This was specifically a 23 x 14 x 100 device. This was now deployed extending up into the previously placed aortic tube graft. The bifurcation of this device was placed just above the native aortic bifurcation and the right limb of the graft extended down into the distal right common iliac artery just prior to the origin of the internal iliac artery."

"Access into the endograft was established. Occlusion of the left graft limb within the aortic bifurcation. An aortogram was performed, demonstrating widely patent right side occluded left. Intravascular ultrasound was then undertaken to evaluate the CIA and EIA on the left side and aorta. This demonstrated compression of the graft with adjunctive presence of thrombus. Decision to proceed with intervention was made. Penumbra CATx catheter was used to undertake mechanical thrombectomy of the graft within the aorta and in the iliac artery. This significant amount of thrombus was removed. Revision of the endograft repair here was undertaken with VBX stent with deployment from the aortic bifurcation and reaching just close to the end of the graft. The contralateral limb was protected with a 10 mm balloon inflated opposing leg."

Provider wants to bill codes 37220, 34710, 37184, and 37185. Could you advise on correct coding for this scenario? I'm not sure about 37220 and 34710 together.

How should we code an AVG angiogram, balloon maceration with 8 x 40mm Conquest balloon, angioplasty of venous outflow anastomotic stent with 8 x 40 mm Conquest, Fogarty, angioplasty of inflow artery, arterial anastomosis and juxta-anastomotic segment with 6 x 40 mm Charger, 6 x 60 mm Lutonix balloon, and angioplasty of the intra-graft stenosis 6 x 40 mm Conquest balloon. The doctor reported codes 36905, 37246, 75710, and 36215. Is this correct coding?

I am really in need of help on this case. I was thinking of coding 35081 and 35646, but another coder said to just report 35102. Please let me know what you think is best in this case. 

"Patient has Ao aneurysm with Ao and iliac dx with rest pain of rt leg. There is atherosclerosis bil CFA. "We opened and controlled the bil CFA, then open abdomen and worked on the RT IIA as planned for anastomosis. Controlled the Lt CIA and then entered AO aneurysm infrarenal and bifurcation region. Repaired infrarenal aortic aneurysm with graft. This bifurcated graft was then anastomosis to the Lt CFA and Rt IIA. Due to Rt EXT iliac artery chronic occlusion a jump graft from the right limb of the Ao graft to the Rt CFA was completed with Dacron graft. " From the op report he states the bilateral CFA anasomosis where tunneled retroperitoneal. After completing we evaluated for signals in Bil CFA and they were excellent."