Ask Dr. Z

Hi Dr Z,

Which CPT code can be billed for following procedure.

This is facility billing

Left forearm arteriovenous graft declot

Fistulogram and central venogram

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

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

Thank you in advance

Successful IVUS-guided PTCA and recannulization of LAD CTO performed due to under-expanded stents. I spoke with the physician, and there was no intention of placing a new stent, just wanted to recannulate/open and expand existing stents in the artery. Would code 92920-22LD be appropriate? I'm trying to cover for the time spent on the CTO piece.

If a doctor documents high-grade stenosis or subtotal occlusion when an angioplasty is performed for a dialysis fistulogram, is this enough to code for the angioplasty? I know that the percent of stenosis is required, but I am not sure if those terms are acceptable as well.

Physician states he utilized a 6 French cath for engagement of the RCA. It was difficult to engage the ostium and he attempted to use side holes. More stable support was achieved with AL 0.75 cath. Engaged without difficulty. Lesion was crossed utilizing 014 Prowater guidance. At this point after crossing the lesion attempted to cross the severe stenosis in the proximal RCA. He was unable to cross. Subsequently exchanged for 1.2 x 12 threader dilation sys. and PTCA was performed in the mid lesion with some improvement. Then attemped to dilate with 2.0 x 6 sprinter dilation sys. and was unable to cross utilizing the 2.25 x 12 resolute onyx stent. What is the correct way to code this? Code the attempted RCA stent with modifier 74? The angioplasty was successful but if you go with charging the PTA instead of the stent to the RCA, can you still change the supply charge for the stent? I understand you should charge was actually done, but how does your facility not lose the cost of stent that was attempted.

Our hospital is using a new device called the Reflow Temporary Spur stent. After performing an angioplasty, they insert the Temporary Spur Stent and inflate it which causes the drug-coated spurs to create channels in the vessel lining and the physician leaves it in place for a period of time to allow the drug to be deposited into the vessel lining to prevent recoiling after angioplasty.

Please note we code for pro-fee and facility. Would this procedure be coded as an angioplasty procedure with use of the reflow system included? Would this be an unlisted code? For pro-fee, if we can code the angioplasty code, would we also assign a -22 modifier for the extra work? 

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

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

I have an appeal denial from UHC stating that cpt code 37233-59-LT (1 Unit) remains not supported. As per the Society of Interventional Radiology Coding Manual, if an angioplasty or atherectomy of an occlusion is unsuccessful because the lesion cannot be crossed, then the appropriate access and/or selection only should be coded. As such, the request for CPT code 37233 is denied as "Not Documented."

I don't understand this - our provider documented atherectomy/PTA in left AT, and a partially successful atherectomy and PTA of the left PT (residual stenosis). Are we not able to bill for code 37233 for the second vessel because it was partially successful?

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

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

When an angioplasty is performed only in a coronary SVG, do we report code 92920 or 92937? Code 92937 says a "combination of", so I'm not sure if it would be appropriate to report 92937. Please advise.

Code 92972 has replaced 0715T in 2024 for percutaneous transluminal coronary lithotripsy. If atherectomy and/or angioplasty with stent is performed as well, should the C9600-C9608 series be coded or in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975?

1. RT brachial artery open exposure. 2. RUE angiogram. 3. RT subclavian artery pseudoaneurysm repair with a covered Viabahn stent. Incision made on medial aspect of RT arm. RT brachial artery dissected out and encircled with vessel loops. Direct needle access gained into the RT brachial artery with placement of a sheath. Kumpe catheter was advanced to the level of the RT subclavian artery where angiogram was performed and confirmed CT findings of RT subclavian artery pseudoaneurysm. There appeared to be a 3-4 cm segment proximal to the pseudoaneurysm as well as a landing zone proximal to the RT vertebral artery. I passed a 11 x 5 cm Viabahn covered stent and deployed this just distal to the origin of the RT common carotid within the RT subclavian artery. Angioplasty was performed and imaging demonstrated no endoleak. 

Is this considered an open procedure and coded with 37799 (with comparable code 35011 since there is no CPT code for open subclavian artery aneurysm repair via brachial incision) OR an endovascular procedure with 37236 and 36140? Thank you!

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

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

Operative findings:

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

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

An AVF angioplasty and embolization was performed and provider queried because stenosis percentage was missing for intervention. The provider responded that the stenosis was greater than 50% but angioplasty was performed for low flow volume due to failure of maturation and treated with assisted maturation (angioplasty) to increase the diameter of the AV fistula to allow for access in dialysis and adequate flow volumes to achieve dialysis. The patient also underwent coil embolization to redirect outflow of the fistula at the same time to increase flow volumes in the distribution of access in the cephalic vein. When angioplasty is performed for this reason, is stenosis percentage still required in the documentation?

The patient came in for AV graft(36830) along with basilic vein graft after a diminished distal brachial pulse. Would there be a separate code for the vein patch angioplasty?

"Following initial construction of a brachial–axillary left upper arm AV graft, there was a complete loss of left radial pulse and Doppler signal, as well as a diminished pulse in the distal brachial artery. Due to significant concern for ischemic steal, I elected to revise the graft with more proximal looped inflow. The arterial anastomosis was taken down and the brachial artery was repaired with a patch of neighboring basilic vein. New inflow was constructed onto the axillary artery adjacent to our venous outflow anastomosis and a second graft segment was tunneled in the more medial upper arm. The 2 grafts were anastomosed to 1 another, creating a looped upper arm axillary–axillary AV graft. Upon completion, there was a palpable thrill in the graft, an ongoing faintly palpable radial pulse, and a multiphasic radial Doppler signal."

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

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

I know these two codes bundle, but are they billable together same side when cervical and cerebral artery stents are placed?

Angioplasty and stenting of left internal carotid artery origin with distal embolic protection

Angioplasty and stenting of the intracranial left internal carotid artery petrous/lacerum segment

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

If a patient has a stenosis in a lower extremity bypass, fem-pop for instance, and it is treated with stent or angioplasty would you code from 37236-37246 since it is not an 'artery' of the lower extremity? Or is the bypass now considered an artery of the appropriate territory and would be coded with 37224-37226? Thank you.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Would I use 92943-LD and 92921-LD?

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

Physician is questioning.

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

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

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

Would this be 49440 or unlisted 43999? 

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

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

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

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

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

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

Can you assist whether 37229 would be appropriate for this procedure?

"The patient was systemically anticoagulated. A 018 wire and catheter were used to recanalize the total occlusion of the anterior tibial artery with re-entry at the dpa in the foot. A 014 wire was then exchanged for the 018 wire in preparation for atherectomy. IVUS was used over the wire for vessel sizing in the vessel. This was used in the anterior tibial artery, superficial femoral artery, and popliteal artery. SFA and popliteal artery had minimal disease. The ATA was occluded with a native vessel size of 2.5 - 3 mm. The segment was treated with CSI atherectomy throughout. Angioplasty with a 3x0 x 220 mm balloon was performed. There was recoil of the vessel with incomplete revascularization. The patient had a labile blood pressure during the CSI, likely secondary to the low dose vasodilator. This returned to normal with additional IV fluids. At this point, the case was completed. The wire and catheter were removed."

When performing angioplasty of the right posterior tibial, common plantar and lateral plantar arteries, are all arteries included in CPT 37228 or is it appropriate to add 37232 x 2 as well? Thank you.

Hi Dr. Z. Besides 93458, can we bill 92920-74 (hospital) for the attempted intervention? The doctor spent 35 minutes on the attempt, no balloons, just wires and microcatheter. “I used a 6 French EBU 3.75 guide catheter and selectively engaged the left main. I then attempted to cross into the 1st diagonal (culprit vessel) which is a small caliber that is less than 2 mm in diameter with a 95% stenosis and reduced TIMI 2 flow. The 1st diagonal branch has an extremely angulated takeoff. Essentially it goes backward 180° and then turns another 180° in an S shaped with extreme acute angulation that makes wiring essentially impossible. I could not wire with a run-through. I attempted wiring with a different wire she is a choice PT floppy wire crossed into the proximal diagonal but with an S shaped that prevented it from further advancing across the lesion (any time I would advance it it would flop back into the LAD). After a prolonged attempt I elected not to proceed ...” Thanks in advance!

50 year patient. Malfunctioning tunneled CVC was removed, after angioplasty of the right IJ with 12 x 40 mm balloon, there was resolution of stenosis to less than 10% residual stenosis. After angioplasty of the SVC with 12 x 60 mm balloon, there was resolution of stenosis. A 23 cm DuraMax catheter was placed over a guidewire with its tip in the atriocaval junction in good position. The catheter was functioning with good blood return and flushed without difficulty.

What would be the correct code(s) for this removal of tunneled CVC, angioplasty of IJ and SVC, and new tunneled catheter on over the same guidewire?

Our physician performed Shock Wave balloon lithotripsy of the Lt SFA (6x60 mm) along with Drug coated balloon angioplasty LT SFA (6X40mm). We are trying to determine if this is 37224 angioplasty or 37225 atherectomy which includes angioplasty and not billing both CPT codes. Our department feels we are not coding this correctly. Does Shockwave balloon lithotripsy mean an atherectomy was performed? If you need any additional information, please let me know. Please advise since Dr. Z is the Expert to clear this up. Just waiting for an answer.

Question 18154

Percutaneous access via outflow vein close to the antecubital fossa with fistulogram + central venogram.Angioplasty along entire length of the peripheral outflow vein, however, vein was still clearly somewhat diseased.Separate percutaneous access via outflow vein closer to the shoulder with fistulogram and angioplasty of the anastomosis. Repeat fistulogram showed extravasation. Balloon was reinflated, no change on repeat fistulogram which told me that the rupture was at the anastomosis directly. Longitudinal incision was made overlying the AV anastomosis w/blunt dissection of brachial artery. No backbleeding from the outflow vein. Brachial artery was fully mobilized w/creation of end-to-end anastomosis resulting in excellent pulse in the brachial artery. I then ligated the open end of the outflow vein using medium clips. There was a seroma at the basilic vein harvest site with was drained w/needle (100ml). Provider wants to bill 36902,35206,37607. Would this be a revision, 36832-22 (for conversion to open)? Your guidance is apprecicated. Thank you.

A provider performed angioplasty of the tibioperoneal trunk. Pre-treatment stenosis was 100%, post-treatment stenosis is documented as 50%, and is documented as follows in the report:

"We balloon dilated the right tibioperoneal trunk to 6 Atm for 2 min with a 2.5 mm by 100 mm Coyote balloon from Boston Scientific. Pre-treatment stenosis was 100%. Post-treatment stenosis was 50%. The distal most peroneal artery could not be traversed but there appeared to be improvement of flow into collaterals."

The payer is denying payment with these remarks:

"Per CPT, the clinical documentation provided in the narrative operative report does not sufficiently describe or support the requisite criteria for approval of the requested CPT code. As such, CPT 37228 is denied as "not documented." A significant residual stenosis is documented."

So, basically, they're denying payment of revascularization because he could only open this completely occluded vessel to 50%. Is there some definition of technical success that must be met in order to bill a revascularization?

Right femoral endarterectomy and thromboembolectomy with patch angioplasty. Is this reported with code 35141?

Since we have two separate accesses, should we code this as 37224, 37220, and 35371? Or only report code 35371?

"The physician completes right SFA and right EIA angioplasty through an ultrasound-guided left common femoral access. After the SFA/EIA procedure is completed, the physician makes a right groin incision, exposes right femoral artery, dissects 3 cm of the PFA and SFA, clamps the CFA/SFA/PFA, and opens the atriotomy. The physician then completes a common femoral endarterectomy/profundoplasty and extends the arteriotomy down the SFA for 2 cm. He pulls plaque from EIA and then uses 6-0 prolenes at the distal profunda endarterectomy and origin of SFA and then places patch."