Ask Dr. Z

From H&P: "Woman with PMHx s/f PAH, pulmonary emboli (PAH thought to be out of proportion, Eliquis) here for PA angiogram." PMH lists CTEPH (chronic thromboembolic pulmonary hypertension) and pulmonary embolism. Cath report states: "Pulmonary artery angioplasty. Right heart catheterization. 60-year-old female with PMH of CTEPH referred for BPA #1. RHC performed with findings (93451). Sheath into right pulmonary artery. Selective angiography (93568). CTEPH treatment: Right lung A9 web lesion and A10 subtotal occlusion. Lesions in A9 subsegmental branch and A10 segmental branch were serially dilated with balloons, restoring flow distally with improved pulmonary venous drainage." How should this be coded: as a pulmonary angioplasty with 92997/92998 (LCD Article A56365 states I27.24 CTEPH is a covered diagnosis) or as thrombectomy with 37184? If patient's have CTEPH, would we code angioplasty because they have stenoses/narrowing of their pulmonary arteries as webs, bands, occlusions form, or would we code as maceration of clot/organized thrombus? (Patient not covered by Medicare.)

Would 36902 and 36907 be appropriate to code in this case?

"Patient brought back to the hybrid room and placed in supine position on the table. Right arm prepped and draped in sterile fashion. I accessed the AV fistula. A micropuncture needle and sheath were placed. A fistulogram was performed with retrograde filling into the artery. There was a severe stenosis in the right innominate vein into the SVC associated with the TDC. A stiff angled Glidewire was then brought in, and we brought in a 7 French sheath. The patient was systemically heparinized. I then used a Mustang 12 x 60 millimeter balloon angioplasty, which was performed multiple times. After the angioplasty, a repeat fistulogram showed good flow. At this point in time wires were removed. I used a pursestring 4-0 Monocryl stitch and more pressure. Occlusive dressings were placed. The patient tolerated the procedure well and was transferred to the recovery room."

Can you please elaborate on how to code for this (92997/92998)? We are specifically wondering how many times we should code 92998 in the following scenario: successful balloon pulmonary angioplasty in two subsegmental branches of the right A5 segment, one subsegmental branch of the right A4 segment, and two subsegmental branches in the right A3 segment.

We are also wondering if selective catheterization can be coded with the intervention?

When performing IVUS services, is the entire dialysis circuit considered one vessel? Can 37252 be billed for the peripheral dialysis segment and 37253 for the central segment?

When is it appropriate to bill codes 76377 for 3D and 93612 for ventricular pacing when performed during rotational angiography along with pulmonary artery angioplasty (92997)?

"Example: Patient presents for a diagnostic cardiac cath and possible intervention on the conduit. Complete right heart and retrograde left heart cath was performed. 6 French Berman angiographic cath was placed in the right ventricle. A 4 French pacing cath was inserted in the LFV sheath and placed in the right ventricle. Right ventricular pacing was performed at 180/min with breath hold, and rotational angiography was performed. Rendering and post-processing of the rotational images was performed. After post-processing, the image was used for overlay on the fluoroscopy. Angioplasty was then performed within the RV-PA conduit and the right pulmonary artery. There was adequate arborization bilaterally. Post angiography demonstrated adequate relief of the stenosis. Improved angiographic appearance of the RPA post balloon angioplasty with no evidence of vascular injury."

"A 5 x 40 mm Bard conquest balloon was then positioned across the arterial anastomosis and the proximal fistulous inflow and a prolonged and insufflation performed with balloon achieving profile. Kumpe catheters repositioned in the brachial artery angiography performed. 1.5 cm cleaner device was passed from the distal sheath and attempt to break up thrombus within the aneurysmal segment of the cannulation zones fistula without success. This appeared to be very mature thrombus. Despite further attempts at balloon angioplasty and balloon maceration never achieved beyond temporary patency with residual thrombus occlusive in nature unable to be removed. Selective left upper extremity angiography was performed via the fistula using Kumpe catheter positioned in the brachial artery proximal to the anastomosis. Serial dynamic imaging obtained from this location distally to the fingertips."

They want to bill 36905, but I would like your opinion of the failed thrombectomy.

"PROCEDURES:

1. Repair of left femoral to tibial bypass aneurysm with Gore-Tex interposition using hybrid graft.

2. Intraoperative arteriogram.

3. Balloon angioplasty to left femoral-tibial bypass.

INDICATIONS: The patient has a 7 cm aneurysmal dilatation to a left femoral to posterior tibial bypass that was felt to be in need of repair.

FINDINGS: The area of the aneurysm had significant inflammation that did not allow for good end point dissection. Because of this, the aneurysm was punctured for wire and balloon control and then an interposition graft was placed using hybrid grafts on the proximal and distal ends for control."

I'm confused with this one. I was thinking 35884, but they also placed a graft on the distal end of the bypass as well as the proximal end. Would we then code this with LE repair codes?

At the same time as common femoral artery endarterectomy is performed, balloon angioplasty is performed of the superficial femoral and popliteal arteries on the ipsilateral side. Is this reported separately or considered a way of establishing outflow? Establishing inflow and outflow is included in all of the lower extremity endarterectomy codes.

During a tunneled CVC, angioplasty was done of the right innominate vein. The catheter was then placed; however, the physician does not state that a final image was taken (CPT states radiographic documentation of final catheter position). He does state a fluoroscopic radiation summary in the report, so with all this work, can we report code 77001?

Can you tell me what CPT I would use for the aortic arch angiogram that is done with a congenital heart cath and balloon angioplasty of coarctation of the aorta? I am unsure if the 93567/75605 are the correct codes.

Our provider performed angioplasty to proximal to mid 1st septal perforator and 2nd septal perforator. Do we also code this with 92920?

"Wire placement was performed with a Runthrough NS Extra Floppy 300 cm guidewire, which was advanced through the vessel beyond the lesion. Angioplasty was performed with a RX Emerge 2.0 mm x 15 mm balloon at 4 ATM. Balloon used to block flow into LAD for possible alcohol septal ablation procedure. Injection of echo contrast through balloon shaft under TEE showed brisk contrast filling of the RV chamber as well as contrast staining of the RV side of the septum and moderator band. We decided against alcohol injection given these findings and the procedure was stopped. Final angiogram with the wire and balloon removed showed patent LAD and septal perforators without evidence of acute vessel closure, dissection or perforation."

When the MD accesses the brachial artery in a brachiocephalic fistula, is this always reported with 36140-XS? Or is the perianastomosis brachial artery included in 3690X? Example: "Real-time ultrasound guidance was used to access the brachial artery in retrograde fashion. Fistulogram was performed. Based on the findings, angioplasty of the cephalic vein was performed."

Would we use CPT code 37248 for the recanalization of the femoral vein performed here?

"We performed high pressure angioplasty up to 15 ATMs with a very tight waist that  resolved at full inflation. We performed three additional angioplasties up to 10 ATMs with no other waists noted. The balloon was deflated and removed and I performed a hand injection angiogram through the long sheath which showed further improvement in the patency of the femoral vein, although there was still an area of stenosis near the femoral head. We carefully prepared and de-aired a 7 mm Dorado balloon. This was advanced over the wire into the area of stenosis and multiple angioplasties performed. In the area of tough stenosis there was a waist seen that completely resolved at full inflation. The balloon was deflated and removed and I performed a hand injection angiogram through the long sheath which showed further improvement in the patency of the vessel."

My doctors are doing lithotripsy angioplasty. I am coding them as angioplasty, but they think there should be a new code for physicians to use to bill for this procedure (just like the atherectomy has one). Please clear this up for me.

When angioplasty is performed in the posterior tibial/ lateral plantar and dorsalis pedis arteries, would we code 37228 and 37232, or only 37228?

Patient has a LUE brachiocephalic AV fistula but due to repeated issues with subclavian vein stenosis a bypass graft was inserted that went from the cephalic vein to the internal jugular vein. Since the subclavian vein is completely occluded, would the peripheral portion of the dialysis graft be from the brachial artery anastomosis to the internal jugular anastomosis with the central portion being the left internal jugular vein through the superior vena cava? Reason being they performed an angioplasty and stenting of the left innominate vein from the AV graft access (36908) and internal jugular angioplasty via the femoral vein access (37248). I know the CPT Codebook 2021 page 309 states if angioplasty or stenosis is performed via a non-AV graft access it is coded with normal CPT, but what if both the stenting of the innominate and angioplasty of the internal jugular were performed via the AV graft micropuncture? Would it be just 36907? Or would it be treated as a regular bypass graft with 37248?

"An Angioseal was placed for arterial closure following a Y-90 embolization, but it became displaced. This resulted in distal embolism and thrombosis of the right lower extremity. The radiologist proceeded to snare and remove the Angioseal from the right profunda artery (37197), and then via a separate access proceeded to first inject tPA into the right anterior tibial artery and then perform angioplasties of both the right anterior tibial, the tibioperoneal trunk, and the posterior tibial arteries."  Since it sounds like the angioplasties were used in conjunction with the tPA injection to treat the iatrogenic occlusion, would this be considered secondary thrombectomies of the anterior and posterior tibial arteries (37186 x 2), or would we use the lower extremity revascularization angioplasty codes 37228 and 37232?

Is the arcuate artery a separate structure that you can bill for within the tibial/peroneal area? The doctors that I work for document atherectomy and/or angioplasty being performed in the arcuate artery. This is usually in addition to interventions also being performed in the dorsal pedal and plantar arteries.

"Patient's left upper extremity and indwelling sheath were prepped and draped. Fluoroscopic images demonstrated the Unifuse catheter tip to project in the axillary vein. Contrast Injection demonstrated short segment high-grade stenosis of left axillary vein. Angioplasty was performed of the stenosis of the axillary vein. Angioplasty was then performed throughout the venous outflow as well as balloon-assisted clot maceration. This resulted in significantly improved patency of the venous outflow however there was still no flow through the dialysis circuit as the inflow had not yet been addressed. Under US guidance, the graft was accessed in a retrograde fashion. The Kumpe was advanced beyond the arterial anastomosis into the radial artery. Fogarty balloon was advanced into the radial artery. Three sweeps were performed with Fogarty balloon to remove arterial plug across the anastomosis." Would the correct code be 76937, 36905, and 37214-XU?

"There is a short segment occlusion of the radial artery upstream to the AV fistula anastomosis. Via retrograde access of right common femoral artery, the catheter was advanced to the left subclavian artery, brachial artery then into the left radial artery where balloon angioplasty was performed." To code this, I'm thinking 36217-LT and 37246-LT. Is this correct?

Our vascular doc tried to place a carotid stent with DEP at the bifurcation of the common and internal carotid arteries. DEP was placed. Dissection occurred at the proximal carotid artery. He couldn't get past all the calcifications, so he angioplastied the bifurcation and placed a stent in the dissection. I'm not sure if the dissection occurred at the thoracic carotid or if it was considered cervical, just not at the bifurcation. (He's just calling it "proximal carotid".) What CPT codes would you report? Since he really didn't get the bifurcation stent in, can I report code 37215 since he did use the DEP and did place a carotid stent? Or am I at a stent and an angioplasty? What codes do you suggest?

Angiogram was performed, which showed distal right coronary artery 100% occlusion. Patient continued to have chest pain and therefore it was decided to intervene the left and descending artery, which had 90% stenosis. Angioplasty to both with placement of DES. In these instances and based on the information provided in your book 2017 Diagnostic and Interventional Cardiovascular Coding Reference, we code the highest level of intervention performed in each major coronary artery and branch separately, C9606 x 2? Is this correct?

My provider is doing balloon angioplasty for atherosclerotic disease in the left common artery (61630). He is also treating pre-existing vasospam in the left vertebral and left ICA. Would he be allowed to bill the left ICA 61650 when he has treated the left common with 61630 during the same session? With these being the same vascular family, I'm unsure if we can use modifier -59 to bypass the NCCI edit. The following is the proposed coding: Left common 61630, left ICA 61650, and left vertebral 61651.

Patient had very severe ICA stenosis and M2 occlusion initially. Planned for thrombectomy, but after primary angioplasty the thrombus was noted to have cleared. Further carotid angioplasty and stenosis was deferred, as well as intracranial exploration, because the patient was VERY sensitive to angioplasty, becoming asystolic instantly, requiring atropine resuscitation. Only cervical carotid angioplasty WITH protection device, but WITHOUT stenting was performed. Provider is asking if we can still bill 37236 on this one? Or should it now just be 37215-52? Please advise.

We are wanting to know if a catheter placement into the aorta from the SMA that was accessed with an arteriotomy by an abdominal incision is separately billable. The op note states in part: "An upper midline laparotomy incision is performed in the usual fashion… A small transverse arteriotomy was made on the anterior surface of the SMA. Next the micropuncture wire is inserted directly into the arteriotomy site followed by a micropuncture sheath… The SMA lesion was crossed retrograde. The sheath was upsized to a short 7 French sheath. Given the poor distal outflow is difficult to opacify the runoff however the heavily calcified ostial lesion is easily visible in a steep oblique angle. A flush catheter was placed into the aortic to confirm reentry into the true lumen. The SMA lesion was pre-dilated with a 5 x 40 mm angioplasty balloon over the stiff Glidewire. Next a 7 by 27mm VBX is deployed at the SMA origin with excellent angiographic result." Would the cath placement be billed with 36200 or be considered part of the primary procedure?

"Access was gained in both directions. Multiple injections of intravenous contrast were given, and a fistulogram was performed and evaluated. Arterial anastomosis and JA segment stenosis occluding more than 80% of the flow. 6 mm balloon angioplasty was performed. The flow was sluggish. Therefore, a catheter was introduced into the upstream radial artery than 10 cm away from the arterial anastomosis. Digital subtraction imaging revealed patent upstream and downstream radial artery with sluggish flow into the fistula. The more inferior collateral vessel was smaller and more tortuous. This vessel was then coil embolized. Follow-up imaging shows cessation of flow through this collateral vessel. The larger collateral vessel within the arterial limb of the fistula had more laminar and direct flow to the more central circulation and therefore required ligation. The skin anesthetized with lidocaine, and a 1 to 2 cm incision was made overlying this collateral vessel. The vessel was bluntly dissected/ligated." Can 36832, 36909, 36215, 75710 be coded?

I have a case where the physician is performing a thrombectomy (37184) with a Penumbra catheter as well as an atherectomy/balloon angioplasty (37229) in the right anterior tibial artery. Anterior tibial stenosis is documented as well as an "occlusion" in the same artery. Is it okay to capture the thrombectomy even though he is only naming it an occlusion?

Left vertebral artery DSA biplane, intracranial: left vertebral artery balloon angioplasty and stenting of the V4 segment for a medical refractory intracranial atherosclerotic disease. Can we use code 61635 for left vertebral artery balloon and stenting?

"1) Exploratory laparotomy. 2) Retrograde superior mesenteric artery recanalization, angioplasty, and stenting with 6 mm x 29 mm VBX stent graft. Yesterday, I performed a brachial artery attempt at mesenteric recanalization in an antegrade fashion, which was unsuccessful due to the dense calcification and occlusion of the origins of the vessels. Brought back for laparotomy and retrograde approach today. A longitudinal midline incision was made through skin and subcutaneous tissues. SMA was accessed retrograde with a micropuncture wire and needle, followed by a 4 French microcatheter. We were able to traverse the area of occlusion into the abdominal aorta. A 5 French sheath was then placed over the Glidewire into the SMA. We then were able to bring a 7 French sheath across the occlusion, then brought a 6 mm x 29 mm VBX stent graft and delivered it through the stent and pulled the stent back into the residual SMA."  Do I report code 37236 with modifier -22 or report an unlisted code?

Cardiac catheterization: If a balloon was inflated three times at a high pressure inflation and ruptured all three times, does this qualify as a successful balloon angioplasty or does it require a -52/-53 modifier?

Patient had atherectomy in AT, angioplasty in dorsalis pedis, arch and lateral plantar. In this situation, would we code an additional 37232 for the angioplasty below the ankle along with the 37229 for the AT?

What CPT code is used for the aspiration of thrombus along 36902/76937? "The 70% stenosis at the edge of the stent, as well as the intrastent stenosis, were maximally dilated using an 8 mm x 8 cm Gladiator angioplasty balloon. Prolonged balloon inflation was performed. Repeat angiography demonstrates wide patency at the treatment site with minimal recoiling. A non-pulsatile thrill was palpated within the graft at this time. In order to allow easier access to the venous graft limb, it was decided to aspirate thrombus from the thrombosed pseudoaneurysm of venous graft limb. After administering local anesthesia to the overlying skin using 1% Xylocaine solution, an 18-gauge needle was advance into the pseudoaneurysm. Approximately 15 mL of liquified thrombus was aspirated. Hemostasis was achieved using manual compression. The sheath was then removed and hemostasis was achieved using manual compression. Liquified thrombus was aspirated from thrombosed venous limb pseudoaneurysm in order to make it easier to access stents within the venous limb during hemodialysis."

When coding a TEVAR, is the Coda balloon also considered a balloon angioplasty?

"The ATA was selected with a glide wire and crossing cath and selective arteriogram performed of the distal ATA and DPA showing focal nearly occlusive filling defect in the very distal ATA and another high grade stenosis at the ankle joint in the proximal DPA. The distal DPA was surprisingly good caliber making 2.5mm angioplasty viable. 200 mcg of nitroglycerine was slowly instilled into the ATA through a cath. The 014 wire was advanced through the crossing cath into the distal ATA across the ankle into the DPA into the first dorsolateral DPA branch on the dorsum of the foot. The .035 crossing cath was removed and the .014 crossing cath advanced over the wire into the DPA . The wire was replaced into the the DPA and lateral branch crossing cath removed and the 2.5mm balloon was advanced over the wire and angioplasty performed of the diseased distal ATA segment and stenosed proximal DPA segment into the mid DPA where it was of good caliber." Is this 34203 and 37228, or 37229?

Is a cutdown procedure to basilic vein separately reportable following fistulogram and angioplasty? What code is appropriate? "... Subsequently, wire access was obtained into the basilic vein outflow region. This was confirmed with digital imaging and roadmapping techniques. Subsequently, cutdown was performed after initial mapping with ultrasound and fluoroscopy. The catheter was performed at the level of the basilic vein. Blunt dissection techniques were utilized. Once the vein was identified, dissection was performed underlying the basilic vein, which was subsequently banded with a 4-0 Prolene suture. Pressure was held at an adjacent branch component of this vein. Following this, digital images were obtained. The cutdown site was then closed with subcutaneous stitches and skin sutures. Subsequently, banding procedure was performed as described, which resulted in significant diminishment of flow into the basilic vein with direction of flow increasing into the cephalic outflow location."

Patient had a flow diverter placed for brain aneurysm. After placement of flow diverter, an endoleak was seen. Balloon angioplasty was indicated. Can we pick up any CPT codes for the endoleak?

If a cervical carotid stenosis is treated with angioplasty (Medicare) (37246-GZ), and an ipsilateral MCA is treated with thrombectomy (61645), are these okay to bill together, with -XS on 61645 per NCCI edits? I am finding that 61645 bundles intracranial angioplasty but not finding anything for cervical carotid. 

Should the carotid stent placement for this case be reported with 37215 or 61635? "Acculink stent was positioned across right carotid bulb stenosis. Angiography then performed after injection of right common carotid artery. Next, Xact stent was positioned from within the previously placed Acculink and into the distal common carotid artery. Angiogram performed and stent deployed. Angioplasty was then performed."

"Using US, I was able to visualize the left upper extremity AVG. Exchange was then made for wire and micropuncture sheath 035 wire was advanced into the central venous system. Exchange was then made for 7 French sheath. I did the same maneuver with cannulization into the arterial system. Exchange was made for stiff Glidewire Bernstein catheter, which was navigated into the brachiocephalic trunk. Angiogram was then completed, which demonstrated stenosis within brachial artery. I then exchanged this for a 6 mm balloon angioplasty of the brachial artery was then completed which promoted excellent inflow. Given the findings change was then made for a Trerotola which was utilized to clean the arterial limb and subsequently the venous limb. Stiff Guidewire was then navigated into the venous limb where balloon angioplasty of the AV graft was then completed along the venous outflow system. Complete angiogram showed excellent flow." What all can I code here? Brachial angioplasty also?

Ultrasound guidance is used frequently for access to dialysis AV fistulas/grafts. Coding 76937 is allowed if all the elements of the code are documented and only "when the AV graft or fistula is documented as either immature or failing". Immaturity is usually well documented. When would the AV graft or fistula be imaged and have some type of intervention performed if it is not failing? Is thrombus, stenosis, etc. found during the fistulogram treated with angioplasty, stent, thrombectomy enough to consider it failing? Is there specific documentation needed, or can 76937 be coded if an intervention is performed?

What documentation requirements are there to use these two modifiers? For instance, for modifier -52 does the physician need to state what percentage of a procedure was performed if attempting to angioplasty a coronary and cannot pass the wire after multiple attempts and much time has passed? Are there specific documentation requirements for -53?

If using the category III code for vertebral stent (0075T), can the angioplasty for that same artery be billed for, or is it inclusive like other stents?

My question concerns coding 35666 and 37228/37224 together when the same vessels are involved. My physician placed an SFA femoral-posterior tibial bypass graft (35666) in the lower extremity due to atherosclerosis, and then following this procedure he did a balloon angioplasty in the superficial femoral artery (37224) and posterior tibial artery (37228) at the anastomosis to optimize inflow to the bypass graft. Would the balloon angioplasties be billable, or are they considered establishing inflow and outflow and are not billable?

Starting to get these procedures and had a report that I charged C9765 with, and it edited wanting me to charge for closure device. Since per the description for these new codes they include the lower extremity procedures angioplasty, stent, and atherectomy, would the closure device not still be inclusive to the new codes C9764-C9767?

Is this reportable as AVF ligation or revision? "Post-op complication of AVF revision (aneurysm resection and angioplasty). Post-op diagnosis: Wound hematoma, ANASTOMOTIC BREAKDOWN. Clinical Indications: Bleeding fistula wound. Description of procedure: Prevail prep was used, and the right arm was isolated as a sterile field. The previous incision was opened by removing the staples and cutting the vicryl sutures. Blood immediately exploded out of the incision, and clot and blood were evacuated from the wound and control was obtained first by arterial pressure and then rapidly both the venous and arterial sides were controlled with vascular clamps. The arterial side was doubly ligated with silk and over sewn with a 4-0 prolene. The venous side was doubly ligated with silk. The wound was irrigated with the pulse irrigator and closed with nylon and staples. Findings: Completely disrupted anastomosis."

For the following should we report 35876 alone or with 35883? "I passed a 4 Fogarty catheter distally through the graft to thrombectomize the graft. I also was able to pass a 3 Fogarty catheter distally in its entirety into the tibial level vessels. Thrombectomy was performed until there was no residual thrombus removed. I did extend out onto the graft, and in this area, there was what appeared to be extensive intimal hyperplasia, which was all resected sharply. A Freer elevator was used to perform a thromboendarterectomy of the laminated thrombus and some pseudo-intima. A 3 Fogarty catheter was passed into the profunda femoral artery to thrombectomize this vessel. There was some moderate stenosis of the region of the distal anastomosis, therefore a Glidewire was placed, and then a 4 mm balloon was then utilized to perform angioplasty in this region with a satisfactory result. A bovine pericardial patch that had been brought out onto the field and prepared was then used for patch closure from the proximal portion of the graft and onto the common femoral artery with a 5-0 Prolene suture in a running continuous fashion."

If angioplasty is performed the venous anastomosis, would this be considered the central dialysis segment? Or peripheral?

My doctors have started performing percutaneous AV fistula creations with the new Ellipsys device. The patient was brought back a month later after this creation, and a percutaneous angioplasty was performed of the fistula for stenosis, but in addition to this they did ligation of the basilica vein to increase the flow. Can I bill 37606, or do you advise revision 36832 with the angioplasty 36902?

"Patient is status post stage II Glenn shunt and closure of the Sano conduit. There was anastomotic obstruction at the Glenn anastomosis. 018 guidewire was positioned in the RPA and balloon angioplasty of the SVC/Glenn anastomosis was done using 10-2 Tyshak 2 balloon." Would this angioplasty be captured with 92997 (pulmonary artery angioplasty)?

I had to do a balloon angioplasty but also had to ligate side branches of her saphenous vein bypass graft. How do I bill for the ligation of those side branches (which was the main part of that procedure since it created an AV fistula and was stealing flow from the bypass graft)?