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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 help with this case?? The Doctors notes a type 3 aortic arch. He punctures the right common femoral artery in a retrograde direction, he goes up and does an arch angiogram. He then selectively catheterizes the left sublclavian artery. Additional images of the left subclavian artery are obtained. He then selectively caths the left subclavian artery distally and was able to advance a sheath over a stiff wire into the left subclavian artery. The shuttle sheath was advanced distal to the left vertebral artery and a atrium stent was deployed in the distal subclavian lesion. This was post dialated with a balloon to a more acceptable caliber across the lesion. He then places a genesis stent within the sheath and pulls the sheath back to the origin of the left subclavian artery where another stent was deployed across the origin of the artery. He then removes the catheters and wires from the left subclavian position and pulled down to the abdominal aorta. Additional images of the right iliac system where obtained and this demonstrated a very significant external iliac artery lesion of approx. 70% and a common iliac artery multifocal calcified lesion. He then does an angioplasy of the external and common iliac arteries with significant recoil. A Smart stent was deployed across the lesion and this stent was postdilated with a balloon. He then goes on to deploy a closure device. Can you help me code this?? Thanks

Hello Dr. Dunn: What code(s) would be appropriate for a right external iliac artery to profunda and SFA bypass with a bifuracted dacron graft? I have 35665, however that just doesn't seem to be enough. Thank you, Jill

How do you code the following scenerio. The doctor tried to inject the right and left common iliac arteries for a bilateral runoff but he couldn't get access into the vessels. So he did a right brachial access and injected both right and left internal mammary arteries to visulize both right and left legs. I am not sure if what he wants to charge is correct. He wants to charge for injecting both RIMA (75756-RT) and LIMA (75756-LT) and bilat runoff (75716). I'm not sure if that is the correct thing to do. This sort of thing doesn't happen very often so I need some advice on this case. Thanks

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!

Hi, Very complex case and need help with modifiers...PLEASE HELP!!! Aortography with findings of bilateral renal arteries, infra renal abdominal findings and bilateral common iliac findings. Would you code 75630 or 75625 They then IVUS the left common iliac and proceed with stenting. Next they stent the right common iliac. Then they ivus the aorta and procede with a stent. they then stent both renal arteries. Should I append modifier 59 to the additional stent and S&I codes for the four additional stents placed?

A gray zone in my opinion. They definitely did not see enough to call this a bilateral lower extremity angiogram during a heart cath in my opinion. G0278 changed from iliac angiography to iliofemoral angiography at time of heart cath a year or two ago to prevent coding 75716 for obliques of the pelvis, so the proximal SFA and profunda femoral arteries are now clearly included in G0278 during a heart cath. Personally, if done during a heart cath and the catheter hooks the contralateral common iliac to visualize the iliofemoral on that side as a screening tool, then pull back into the ipsilateral for the same, I still just code G0278 and ignore the catheter placement. I suppose to be exacting per the codes, one should consider 36245-59, 75710-59 and G0278 for the ipsilateral side, however I think that 75710 is a zero edit with G0278 (so can’t be billed anyways) and the intent of the screening code G0278 is just that, screening. IF they look all the way down past the knees on both sides, then I switch to 75716-59. I remain conservative on these. Dr.z

hello dr z please help thanks,
Coronary artery anatomy showed left main normal, left anterior descending has mild diffuse disease. Left circumflex had mild diffuse disease. Right coronary artery, proximal 20% stenosis. Left ventriculogram: EF of 55%. LVEDP 9. A 3DRC catheter was used to take a picture of the left common iliac selectively with runoff, and it showed left common iliac mild disease, left external iliac with mild disease, left interior iliac mild disease, left common femoral mild disease, left superficial femoral artery with mild disease. The 3DRC catheter was pulled to the right common iliac, the right external iliac, and this showed right common iliac mild diffuse disease, right external iliac mild disease, right common femoral mild disease and right superficial femoral artery with mild diffuse disease. Hemostasis was by manual compression.

thanks
 

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.

Thank you for the time you undoubtedly spent reading through and analyzing this report. I see we were pretty close on the coding, except for the use of the additional 75710,26 and the use of 75774,26, RT. We did have 36246,RT coded, I just neglected to include it when I submitted the initial question. The reason I used the additional 75710,26 was because the initial one was retrograde and the one performed near the end of the session was antegrade, although from the same location. The reason I used 75774,26,RT was, because, after the initial bilateral lower extremity angiograms from the aortoiliac bifurcation (75716,26), another angiogram was performed after the catheter was advanced to the external iliac artery, and prior to what I thought were the supervision and interpretation related studies, for further, more detailed, diagnostic study of the leg. Could you, please, explain to me why you chose not to code those? I also noticed that you considered all of the additional views and projections a part of the other radiological procedure codes, which is the direction I was leaning in, and chose not to include ultrasonographic codes, which is what I was really stuck on. Could you walk me through your decision making process, as it pertains to those codes? My thinking is that the duplex wouldn't be coded, because the doctor just mentioned reference to it, as opposed to actually performing it. Even if she did perform it, it wasn't clear in the op report. On the other hand, although it's not flagged by NCCI edits, would you consider a duplex inclusive to the other procedures, even if it was clearly stated that it was performed intraoperatively? If you would code it separately, would you code it as a duplex (93925/93926) or as intraoperative ultrasound (76998/76937)? I imagine intravascular ultrasound (37250/37251) would only be used if ultrasonography was performed through an intravascular catheter, but I'm not sure. As you can see, I appreciate the guidance you've already provided, but I still have a lot of questions about these kinds of cases. I have a hard time differentiating between the different codes and when it's appropriate to use (or not use) each code. I want to fully understand the reasoning and logic behind your decisions so I can apply them to future cases. Thanks, again.
 

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

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

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

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

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!!!
 

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

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

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