Ask Dr. Z

"Procedures performed:

1) Bilateral common femoral endarterectomy with patch angioplasty.

2) Removal of obstructive stent over left profunda femoris artery necessitating additional 60 minutes of surgical time.

3) Heavy scarlike tissue around left common femoral artery necessitating additional 30 minutes of surgical time.

We then turned our attention to the left side. An arteriotomy using 11 blade and Potts scissors this was actually quite difficult as the stent was overriding so much and at the common femoral artery we were unable to actually identify the backwall of the common femoral artery. We were eventually able to get into the common femoral artery and had to remove the initial 2 cm of stent and an additional 1 cm of stent so that we would be able to close everything in the proximal superficial femoral artery. There was minimal blood flow able to get into the profunda femoris artery but we were able to remove all the plaquing as well as the stent that was causing the majority of the issue."

Is the stent removal included in code 35371?

Patient had stenosis in common femoral artery. MD performed angioplasty, and follow-up angiogram demonstrated dissection. Would you code for the intended procedure, which was angioplasty in the common femoral artery, or would you code for the stent placement for the non-occlusive dissection?

My physician did an aorto-bi-femoral bypass with aortic thromboendarterectomy, left common femoral endarterectomy with eversion endarterectomy of the profunda femoris, and endarterectomy of the proximal superficial femoral with tacking of the intima of the SFA and patch angioplasty of the CFA and SFA. It is my understanding that the thromboendarterectomy (both aortic and femoral) would be included in the bypass coding. He disagrees and says he does more work than just establishing inflow/outflow. Also, he wants to code for the profunda and superficial endarterectomy in addition to the CFA endarterectomy. I was under the impression that if it was one arteriotomy and one patch angioplasty you would use only one code (CFA, 35371). From what I can tell from his op note, only one arteriotomy was made and one patch angioplasty used. I guess my question is, when would it be appropriate to code separately for the endarterectomy with bypass and when would it be appropriate to code for more than just the CFA endarterectomy when the profunda and SFA are done as well?

Can we get clarification on when/when not to use 0715T when a coronary lithotripsy is performed? The CPT Codebook states the following: "Use 0715T in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975."  It looks like it can be used for angioplasty, atherectomy, or stent placement. Can we also use it with drug-eluting stent placement?

"The left radial to perforator arteriovenous fistula is patent.  There is early filling of the brachial vein. selection of the AV anastomosis and drug coated balloon angioplasty of the AV anastomosis and the perforator vein was done, Volume flows demonstrated adequate flow in the perforator vein and decreased insufficient flow in the cephalic vein.  Decision was made to coil the brachial veins-multiple Nester coils were deployed in brachial vein. Decision was to band the distal basilic vein.  0.018 wire was advanced into the basilic vein.  Over the wire, 2 mm balloon was inflated. silk suture used to band basilic vein."

Would this px be revision? 36832- angioplasty of the arteriovenous anastomosis, coiling of the brachial vein, and banding of the basilic vein were done.

I have a physician who would like to plasty AV graft mild stenosis and wants to bill for it. Rad states that this is his medical necessity: “A mild grade stenosis is present which could become severe and cause further complications if not treated at this time. For this reason, I believe it is medically necessary to treat the stenosis with angioplasty.” I am telling rad this is prophylactic and cannot be billed. Am I correct? Should he just be doing US until he does have a 50%> stenosis? 

"Left superficial femoral artery proximal, mid, and distal scattered 40 to 70% fibrocalcific stenoses. Right superficial femoral artery proximal, mid, and distal scattered 40 to 60% stenoses. Atherectomy of the left proximal, mid, and distal superficial femoral artery with a Hawk 1 atherectomy device; embolic protection with a EV 3 spider X 6.0 mm filter. Drug-coated balloon angioplasty to the left mid and distal superficial femoral artery with a Medtronic Inpact 6.0 x 150 mm, and proximal superficial femoral artery with a Medtronic Inpact 6.0 x 120 mm, in overlapping fashion. Ultrasound-guided access of right common femoral artery."

Can we report codes 37225, 75716-26, 76967-26?

Can you please help me figure out this case. How can I capture the work for the pediatric interventionist who is helping another provider during difficult cases of balloon angioplasty (92990) or pulmonary artery stent? Is it possible to report the service the main code with modifier -80 or -82?

Since the codes for Shockwave lithotripsy are for coronary arteries or lower extremity arteries, how would a facility code Shockwave lithotripsy and angioplasty to the left subclavian artery? Would we use an unlisted code to cover both procedures, 37246 with an unlisted, or would the angioplasty code (37246) be sufficient?

When coding angioplasty/stent in peripheral and central segments of AV, are codes assigned for both segments if there is one long lesion starting at the cephalic arch and then into the subclavian vein? The cephalic vein is widely patent except for the cephalic arch. At the distal aspect of the cephalic arch, there was an 80% stenosis with that lesion crossing into the subclavian vein. If stent inserted at stenosis in cephalic arch and stent into subclavian vein, are codes 36903 and 36908 reported? We know the cephalic arch is peripheral, and we think codes are assigned per segment even if one lesion crosses both segments and would like confirmation.

Can both billed together? 37241 and 37183

TIPS revision 12 mm balloon angioplasty of the TIPS was done with balloon sweep of thrombus (thrombectomy). Post intervention venogram demonstrated patency of the TIPS with an area of residual thrombus/occlusion at the superior portion. The portosystemic gradient measured approximately 25 mmHg. Subsequently, the superior portion of the TIPS was extended with 11 mm VBX stent Which was post-dilated to 12 mm.

EMBOLIZATION AND SCLEROTHERAPY: Through the retrograde groin accesses, the following interventions were done:

1.  Deployment of multiple detachable coils to occlude the renal venous communication to the shunt.

2.  Exchange to long 10 French sheath and subsequent deployment of 2 cm Amplatzer plug within the shunt in vicinity of the caval/lumbar communication

Should this be reported with 37215-78-52 or 37246-GZ?

"Poor expansion of the right internal carotid stent was likely an embolic event. After extensive workup and anticoagulation and antiplatelet regimen instituted, the consensus opinion was had, and repeat TCAR with ballooning of this poorly expanded stent would be immediately helpful as well as for long-range stent durability and patency. Left common femoral vein access had been obtained with ultrasound guidance, and this was upsized to 8 French silk sheath. We then initiated passive flow reversal checking for excellent flow, then clamped the common carotid artery proximal to the sheath to allow for active flow reversal. We performed angiography in two views, and stent was then decompressed and inadequately expanded, used first-day #5 and then a 6 x 40 mm balloon for re-angioplasty with full flow reversal." 

Can you give clarification for billing codes 37220-37230 for angioplasty/stent with thrombolysis (overnight lysis) when treating thromboembolic occlusion? I'd like to give my physicians some clear instructions for documentation guidelines on these interventions, and I have seen conflicting information and even some instruction that you cannot bill any intervention with thrombolysis since that is not for stenosis. Must there be the specific word "stenosis" used to bill for interventions with thrombolysis? What if just "occlusion" is used? Physicians use stenosis/occlusion interchangeably. If stenosis is not stated and they are treating thrombosis or thromboembolic occlusion, can intervention be billed with 37236-37246? Or do they just get nothing? 

If the doctor performs an angioplasty in the 1st diagonal branch and places a stent in the 2nd diagonal branch, would you code it as 92928-LD and 92921-LD?

Would this be considered congenital 33897, or would the scar tissue/cord lesion mean this was 37246?

"Patient was admitted for a cardiac cath for evaluation of CHD consisting of recurrent coarctation of the aorta. He was diagnosed with a discrete juxtaductal coarctation and ascending aorta hypoplasia. He underwent a surgical coarctation repair via extended end-to-end anastomosis. At recent cardiology visit, the velocity across the descending aorta had a large increase from his post op echo. He presents for cardiac cath balloon angioplasty of recurrent coarctation of the aorta. A pigtail catheter was inserted into the descending aorta. Angio and pressure gradients were obtained. We advanced a balloon over across the cord lesion. An inflation was performed by hand. There was a discrete post-surgical coarctation of the aorta just distal to the lower segment artery. Angiography demonstrated much improved angiographic appearance of the cord lesion. Patient had successful balloon angioplasty of recurrent coarctation of the aorta. An angiogram suggests that the scar tissue has been liberated." 

"PROCEDURE: Fistulogram and ligation of branch of the fistula as well as angioplasty of fistula.

We brought our attention to the right arm where we accessed the cephalic vein in the direction of the anastomosis. We did a fistulogram, which showed stenosis distal to the anastomosis. We also saw a large branch, in which we then made a small incision and dissected it out. We ligated that branch, and then balloon angioplastied the cephalic vein just past the anastomosis with a 6 mm balloon. Once we were done, there was better flow, and a palpable thrill could be now felt higher up in the arm. At this point, we felt that we had improved the flow through the fistula and then removed the sheath and closed the access site with the use of Prolene suture."

Under 36832 in the CPT Codebook it states to not report 36832 with 36902. Does that mean we only code 36832? We get an NCCI edit that 36832 bundles into 36902.

If an angioplasty is performed in three separate areas of the IVC ["suprarenal" inferior vena cava (60% stenosis), "infrarenal" inferior vena cava (50%), "retrohepatic" inferior vena cava (60%)], would it be appropriate to code three units? 37248, 37249 x 2.

I see this frequently from one of my clinics, and we are getting MUE edits for these codes. Typically during these types of cases, the surgeon is also doing venoplasties of the lower limbs. So, the codes I typically see are like: 37248-50, 37249-50, 37249-XS, 37249-XS, 37249-XS, 36011, 75822-XU.

What CPT codes are billable, and can you explain the logic?

Procedures to be performed: Left Heart Cath with intervention.

1.  Drug-eluting stent angioplasty of the ostial left circumflex in-stent restenosis, using the right femoral arterial access.  Radial access was attempted but was unable to pass wire due to radial artery obstruction-

Findings:

1.  Hemodynamics

AO:  160/78

CORONARY INTERVENTION:

LESION 1: 

Vessel: 90% ostial left circumflex in-stent restenosis-   

Anticoagulation: Heparin 80 units/kg guide catheter: 6 French EBU 3.5 from the right femoral approach.

Guide Wire: Fielder XT wire initially to cross the lesion for predilatation.

Pre-Dilation Balloon: 2.5 mm Abbott trek 15 mm PTCA balloon at up to 20 atm. Following predilatation, the Fielder XT wire was exchanged for a VersaTurn wire Intervention Device: 2.5 mm Abbott Xience Skypoint 12 mm drug-eluting stent delivered at 16 atm. Post Dilation: Stent delivery balloon at 16 atm.

Results: Reduction of initial 90% stenosis to less than 10% residual stenosis with no evidence of dissection, distal embolization or loss of side branch.

"Patient with hypoplastic left heart syndrome (mitral/aortic atresia). Patient underwent stage I palliation with Norwood, Sano conduit, PDA ligation and atrial septectomy as a neonate. He then underwent Sano takedown, creation of a right cavopulmonary anastomosis (bidirectional Glenn shunt) and intraoperative direct aortic balloon angioplasty. A 4 French was placed in the right femoral artery. Complete right heart and left heart catheterization via abnormal native connections was performed with oximetry, hemodynamics, and angiography in multiple planes." Would these cases be coded to 93597?

"Procedures: 1) Redo right femoral to anterior tibial artery bypass with 6 mm PTFE. 2) Cephalic vein patch angioplasty of anterior tibial artery. 3) Ligation left SFA. 4) Left common femoral artery thrombectomy/endarterectomy. 5) Left arm cephalic vein harvest.

Due to concerns about the thrombus in the SFA potentially washing out into the bypass or into the profundofemoral artery the SFA was then divided off of the common femoral artery at the level of the femoral bifurcation and ligated with a 3-0 Prolene suture. The arteriotomy on the common femoral artery was then debrided and shaped so that the bypass could lay very nicely with the heel of the graft just at the start of the profundofemoral artery coming off the femoral bifurcation."

I understand that the ligation is typically included in the bypass procedure. Would the ligation be billable in this instance?

Does the provider need to specify "angioplasty of the stent due to re-coarctation" to code 33897 for angioplasty of a previously placed coarctation stent? Would angioplasty of coarctation stent due to a patient growth or small stent size fall under coding as 33987?

"Patient called EMS for CP that woke him from sleep, along with diaphoresis and N/V. STEMI. No cardiac hx. Doctor arrives to bedside in the ED and requests Brilinta and heparin. Patient then goes into v fib arrest. ACLS protocol followed and patient goes into pulseless v tach. ROSC then achieved. Intubation noted to be difficult but pt has no periods of hypoxia. Levophed required after multiple doses of epinephrine. Pt taken to the cath lab for LHC, coronary angiogram, IABP placement, balloon angioplasty, and placement of one stent for a 100% wrap around LAD occlusion. Patient was then transferred to Hospital B for further care of cardiogenic shock.”

The patient had inpatient-only procedure 33967. Patient presented to ED, went to cath lab, and did not get admitted. The patient was then transferred out. How should this be billed?

Any updates on a procedure code for Shockwave balloon therapy during coronary angioplasty?

I was hoping you could help with how to code in the the tibial/peroneal area when shockwave lithoplasty is involved. Patient had diseases and stenosis in all three vessels. Angioplasty was performed of the posterior tibial artery and peroneal artery followed by shockwave lithoplasty of a particularly stubborn anterior tibial artery stenosis. Can we bill C9772 with 37228 and 37232 on the hospital side?

"On day 2 of thrombolysis to right leg from EIV to popliteal vein, the physician removed the EKOS catheter and performed inferior cavogram and right lower extremity venogram followed by mechanical thrombectomy to CFV, EIV and CIV. Venogram was repeated and showed minimal clot and stenosis in CIV, EIV, and CFV. Balloon angioplasty and stents were placed in the CFV and EIV. Repeat IVUS performed and showed stenosis in the EIV above the stent. A single 18 mm x 80 mm Wallstent was used to across CIV, EIV and CFV without any extension into IVC."

I have coded 37187, 37214, 37238, 37239 x2, 37252, 37253 x2, 75825, and 75820-RT. Are RLE venogram and inferior cavogram billable with the additional interventions?

Would I report 36901 and 36907 or 36902? "The right arm was prepped using ChloraPrep. Under ultrasound guidance, the right brachial basilic vein transposition fistula was accessed in antegrade fashion near the arterial anastomosis. A fistulogram was performed in stations to the chest. This demonstrated a recurrent, severe approximately 75% stenosis of the right brachiocephalic vein. Given the excellent palpable thrill of the fistula, assessment of the arterial anastomosis was deferred. Subsequently, the stenosis was angioplastied to 16 mm using a 16 mm x 4 cm Atlas Gold angioplasty balloon. Repeat fistulogram was performed. This demonstrated improvement in the brachiocephalic vein stenosis but with persistent moderate stenosis remaining. The stenosis was again angioplastied to 16 mm using the Atlas Gold balloon with prolonged angioplasty balloon inflation time utilized. Repeat fistulogram was performed, demonstrating mild less than 30% residual narrowing of the brachiocephalic vein."

"Case background: Right CFA accessed angio performed due to tortuosity hanged from short to long sheath during exchange pt became agitated and vascular access was compromised. Hematoma formation noted manual compression applied. Switch to LT CFA ,LT heart cath was done, afterwhich noticed pt became more hypotensive and actively bleeding fr RT CFA,distal aortogram w/bilateral runoff was done w/h showed active bleeding at the level of distal CFA and above SFA and profunda.Omni flush cath selec angio was done and confirmed the bleed , omni flush exchanged with 7x80mm armada balloon inflated nominal pressure fro approx 5 mins. Subsequent angio still showed active bleeding.Balloon re-inflated for prolonged time and vascular team were page. Subsequent balloon was removed; pt is having rapid expanding hematoma + hemorrhagic shock. Pt directly taken to OR for open repair of her RT CFA."

We got 37246 for the angioplasty fro the hematoma. MD thinks it should be 37224. Any suggestion?

"Patient came in, and vascular surgeon performed open thrombectomy of fem-pop above the knee PTFE bypass graft, and then angioplasty was performed in the native popliteal artery. They closed the graftotomy and performed angiogram, which showed there was still thrombus. They re-opened the graftotomy and further dissected the CFA, profunda, and SFA as well as the bypass graft and opened the anterior portion of the hood of the graft and found there was some dissection flap. Femoral endarterectomy was performed, a portion of the hood was excised, and pericardial patch was used to patch the graft. Angiogram showed flow through the graft to the posterior tibial artery on final angiography."

Would this be reported with codes 35376 (graft thrombectomy with revision of graft hood) and 37224 (native popliteal angioplasty)? And since the endarterectomy was performed in the area of the hood of the graft, endarterectomy (35371) that was performed to clear dissection flap can't be coded; is that correct?

A patient presents for diagnostic coronary angiography. Per the procedure report: "There was 100% occlusion in the proximal to mid left main coronary artery due to leaflet from a pre-existing surgical bioprosthetic valve after valve-in-valve TAVR with complete effacement of the sinuses by the transcatheter heart valve with no visible antegrade filling of the left main during this or by prior angiograms performed after TAVR. This lesion meets the definition of a chronic total occlusion, greater than three months old." A CTO device was used to facilitate crossing the chronic total occlusion prior to intervention, and balloon angioplasty was performed. Since the left main's occlusion was not caused by atherosclerosis, intimal hyperplasia, thrombus, inflammation, etc., but rather by an aortic valve leaflet, does revascularization code 92943 still apply? If not, what CPT code should be reported and why?

During dialysis graft angioplasty, we know that severity of stenosis has to be documented. For thrombectomy, does presence of thrombus alone allow for declot? Does it have to be "occlusive" thrombus? Does it have to be noted the thrombus is occluding the vessel ____ amount to support a declot? I've checked documentation from the NCCI Manual, SIR, CMS, and nothing conclusive is noted. Any input is much appreciated.

For physician billing of lithotripsy in 2022, has there been a change in the CPT codes used? We have been using the angioplasty codes 37220-37235. But our MDs would like to know if we should be using the atherectomy codes instead of the angioplasty code for our cases in 2022.

"Thrombosed LUE dialysis (carotid bovine graft): The SVC and brachiocephalic veins are patent. Pullback venography demonstrates thrombosis of the venous outflow to extend to the graft venous anastomosis. A total of 4 mg alteplase was injected through the Kumpe catheter into the clot burden. After approximately 5 minutes, an orbital thrombectomy device was used in the proximal venous outflow extending to the level of the intragraft stenosis. This was followed by a 6 mm mm balloon angioplasty of the throughout the mid and distal graft, as well as the venous anastomosis, covering the areas of known clot burden. Then, stent graft placement across the venous anastomosis to the irregular distal graft segment was performed with a 6 x 100 mm heparin-coated stent graft (Viabahn). This was then postdilated with a 6 mm balloon."

Per query reply: PTA/stent to distal & graft vein anast graft to L brach vein. What vein should be used for intragraft thrombectomy for ICD-10-PCS coding?

"Patient came to department as a code stroke. The cervical carotid artery was occluded at its origin without any antegrade flow intracranially. The catheter was repositioned into the left cervical internal carotid artery under roadmap guidance. The balloon was placed at the proximal cervical ICA and was inflated to its nominal pressure. Repeat angio demonstrated good antegrade flow within the left cervical ICA. At this point the microcatheter was inserted into the aspiration catheter and advanced to the occluded left MCA branch. The aspiration catheter was placed on continuous suction, and clot was removed." Is it appropriate to charge for carotid angioplasty in the ICA during mechanical thrombectomy (codes 61645 and 37246)?

In a brachial artery to jugular vein AVG, would angioplasty documented as venous outflow be considered central or peripheral for coding purposes?

Glad to see that CMS has updated its list of codes that are appropriate for use with C1761. However, we recently had a case where lithotripsy was performed and the vessel was then able to be opened with angioplasty (no stent, no atherectomy, and not a CTO). What do you suggest we report in this instance?

My physician performed a right anterior tibial artery atherectomy and angioplasty as well as a right posterior tibial artery angioplasty and stent. I reported code 37230 for the PTA stent/PTA and 37233 for the ATA atherectomy/PTA. The insurance (NY Empire Blue Shield) is denying the 37233 since it doesn't have a primary code assigned. Isn't 37230 the primary code? Am I assigning the incorrect codes for this procedure? Don't you assign the highest code first and then use the add-on code for the lesser procedure when the arteries are in the same territory?

Would this be coded as 36904 or 36905 or something else? From what we understand, "do not report removal of arterial plus during declot/thrombectomy as an angioplasty (36905) it's included in 36904, which includes balloon maceration. 1. u/s guided access LT thigh AVG directed towards venous outflow 2. inj. TPA into venous 1/2 of AVG 3. Balloon maceration & angioplasty of venous & AVG w/PTA balloon 4. 2nd U/S guided access of LT thigh AVG directed toward the arterial inflow. 5. Balloon sweep of arterial anastomosis of AVG w/Python balloon (to pull platelet plug of the AVG) 6. angioplasty of arterial end of AVG 7. completion venography w/cath parked in LT SFA FINDINGS: Initial AVG venogram = numerous filling defects along venous end of AVG consistent w/thrombus. 9mm graft aneurysm beyond apex of graft towards venous, fills upon inj. IMPRESSION: 1. Successful declot w/restoration of flow. entirety of graft angioplastied w/PTA balloon. 2. Viabahn stent-graft at venous anastomosis of AVG widely patent on completion image. Thank you.

I understand that in order to bill for angioplasty in a dialysis circuit the percentage of stenosis must be greater than 50%. The physician I code for uses the word "narrowing" instead of "stenosis." For example: "There is focal narrowing in the mid fistula where the lumen is compromised by 85%." It is my understanding that the word "narrowing" may not always equate to "stenosis", but maybe I am wrong. If I am not, can you send me any information that would help me make my case?

Day 1 patient comes in for venogram for leg swelling. tPA is infused via the catheter for 10 minutes and thombectomy done. Thrombus is chronic and adherent, so they do multiple venoplasties. More thrombectomy thrombus is still there. No lysis catheter left in. Patient is in a lot of pain, and they discontinue the procedure. Doc states that no stent placed due to bacteremia. Adherent thrombus still present. Two days later: Angioplasty is done multiple times with multiple balloons. Then stent was placed. So, on day one, would it be a thrombolysis and thrombectomy? Or just a thrombectomy (37187)? On next procedure, would we be at a thrombectomy for the angioplasty, or would we not code a thrombectomy, as angioplasty is included in stent placement? The patient clearly still had thrombus present, and nowhere was it documented underlying stenosis. 37188 or 37187 since "ongoing thrombolysis" not done? Or just code the stent placement?

I'm trying to determine if 36832 is used for the following, or if we should be using 37607, 36902 (36901?), 36909.

"Poorly maturing AV fistula: Physician performed fistulogram, coils in the cephalic vein, ballooned cephalic vein for spasm (not stenosis),  and ligated a cephalic vein branch near the antecubital fossa."   

Can do we code an ultrasound duplex venous with an AV fistulogram intervention? For the following example I'm thinking: 93971, 76937, and 36902. Is this correct?

"Ultrasound examination of the left upper extremity and intravenous fistula from the arterial anastomosis through the peripheral venous outflow demonstrated wide patency of the till anastomosis, juxta Esmarch segment, cannulation segment, and peripheral venous outflow. Prone images were saved. Using ultrasound guidance, needle was advanced antegrade into the cannulation segment. Sheath was used to perform outflow angiography through the central veins, which demonstrated multifocal stenosis within the cephalic arch. Angioplasty balloon was advanced, and prolonged balloon angioplasty of the cephalic arch was performed. Postplasty angiography demonstrated significant resolution of multifocal stenosis. Real-time concurrent ultrasound was used to visualize needle trajectory and a permanent image was stored in the medical record."

The patient had a brachiocephalic fistula for dialysis with stenosis in the distal subclavian vein. Two different access sites were used to treat the stenosis with angioplasty and stenting. One access site was in the femoral and the other in the basilic vein. The cephalic vein was also catheterized with imaging performed through the basilic access. I know the catheter placement from the femoral access site would be coded with 36012, but the basilic access is really throwing me off since it was not the outflow vein. What codes would you recommend for the rest of the procedure?

Can you explain how you would code the catheter placement if a case started with femoral arterial access but then ended up in the venous system and followed by vein angioplasty (37248)?

Our provider is using AGENT IDE - RESEARCH TRIAL balloon for his PCI procedure. I would like to know if there is any change for the balloon angioplasty code (92920). Or does it need to report with Q0 or Q1 modifier and Z00.6 Dx?

AGENT IDE: A Prospective, Randomized (2:1), Multicenter Trial to Assess the Safety and Effectiveness of the AgentTM Paclitaxel Coated PTCA Balloon Catheter for the Treatment of Subjects With In-Stent Restenosis (ISR)

We are not very familiar with this type of service.

Thank you..

Would this be reported with codes 33967 and 92941? "A BMW angioplasty guidewire was advanced into the LAD but would not cross the lesion. I placed a guide liner for additional support. A Choice PT wire was then used to cross the obstruction, and the lesion was dilated with a 2.5 mm balloon. I then deployed a 3.0 x 15 mm Xience drug-eluting stent. Repeat angiography was performed. During the follow-up imaging a small bubble was introduced into the circumflex, and the patient subsequently deteriorated rapidly. A code was called, and the patient was subsequently intubated and ACLS protocols initiated. I was able to exchange the sheath in the RFA for an 8 French balloon pump sheath and then placed a 40 cc intra-aortic balloon pump into the descending thoracic aorta."

I am unsure how to code this delayed endoleak repair. What codes would be best used for the Amplatzer plug and angioplasty?

"A J wire was advanced into the abdominal aorta, and a 5 French sheath was inserted. 2 perclose systems were deployed in the right femoral artery, and an 8 French sheath was advanced. A glide wire was used to get access in the arch, and a pigtail was advanced on it. Then the left brachial artery was percutaneously punctured and a 6 French sheath was inserted as above. Heparin was administered and ACT maintained at about 300 seconds. A glide wire was used on the left arm to get access to the left carotid artery. A 10 x 30 injection of the descending aorta was obtained and the endoleak seen. A 22 mm Amplatzer plug was advanced from the left arm and deployed in the false lumen and in the origin of the subclavian artery. A new angiogram showed no endoleak. Then a Coda balloon was advanced and the distal part of the stent was fully expand, and a completion angiogram showed a decrease of the type 1B endoleak."

Patient is ESRD and on HD. Right upper extremity AV graft with swollen arm. Patient had chronic occlusion in the right innominate (central segment) vein stent. Surgeon preformed balloon angioplasty of the stent without a hemodynamically significant residual stenosis. Can I still assign 36907 for it, and chronic occlusion is considered as stenosis?

Are we still able to charge for the diagnostic procedure, in the event that we find disease that we need to fix? So can we charge 93458 and C9600 when we do them in the same day, or does C9600 include the diagnostic procedure in the code with the angioplasty?

How would you code this case? 36221, 36902, 0237T?

"Pre/post op diagnosis: left AV fistula inflow stenosis. Description: The right common femoral artery was accessed using a micropuncture needle. This was exchanged for 5 French sheath using Seldinger technique. A pigtail catheter was advanced into the ascending aorta and arch angiogram was performed. Please see above findings for details. Next the left subclavian artery was selectively catheterized and a left upper extremity angiogram and left upper extremity fistulogram was performed. 5 French short sheath was exchanged for 5 French 90 cm sheath positioned in the left brachial artery. The proximal left brachial artery was subsequently balloon anigoplastied using a 4 x 60 drug coated ranger balloon. Completion angiogram and fistulogram revealed widely patent left radial artery without residual stenosis. Findings: high grade proximal left radial artery stenosis successfully treated with atherectomy and balloon angioplasty."

"Doctor removed infusaport, inserted AI pacemaker, angioplasty superior vena cava due to scar tissue. This was cut from the port body. Subsequently a Glidewire was advanced down through the port channel through the right atrium and into the inferior vena cava. Over the Supra core wire a 4.0 x 100 mm angioplasty balloon was used to perform angioplasty of the fibrotic scar bands which restricted passage of the sheath. Stenosis in the superior vena cava in this region of sheath was in excess of 90% though the majority of the superior vena cava likely remained patent."

Is 36590 the correct code for infusaport removal? Is this plus 37248 appropriate to be billed with PM insert?