Ask Dr. Z

Revision vs unlisted procedure for pacemaker pocket procedure

We are questioning if we should bill a revision or an unlisted code for the following pacemaker procedure. "A 4 cm incision was made on the skin overlying the infraclavicular fossa with a #15 blade. Dissection was carried down with electrocautery to the pre-pectoral fascia until his chronic DCPM was identified. Further dissection was performed and the device extracted from the body. Hemostasis was obtained as needed with electrocautery. The generator was seen in a vertical position. The generator was then removed, and a deeper caudal pocket was made using blunt dissection. Hemostasis was obtained with electrocautery. The lead and device were then placed in the pocket and sutures with 1-0 silk suture."

AV fistula case

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

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

35011

Greetings, A patient had a enlarging aneurysmal stump of a ligated BC fistula. It is starting to cause the pt pain. The physician excises the aneurysm and performs a patch to the artery. I think this would be coded as a 35011. Medical records is using a unlisted 37799. I do not think this would be a 36832 as the fistula was ligated over a year ago and is no longer functional. Do you agree with the 35001? Thanks, LW

Thigh AV Fistula

What code should we use when a doctor creates a thigh AV fistula using the saphenous vein (femoral-saphenous fistula)? When they state they "harvested the entire saphenous vein through the knee... tunneled and anastomosed to femoral artery", is this reported with code 36821 (possibly with -22 modifier), or is it reported with code 36825 (possibly with -52 modifier)? Or would it be unlisted?

Sigmoid Sinus Dural AV Fistula Embolization

I'm trying to discern between using codes 61624 and 61626. The patient has a sigmoid sinus dural AV fistula, which was embolized in two sessions. The arterial feeder is off the right occipital artery. The venous portion is the sigmoid sinus. Initial treatment/embolization of the fistula was performed solely via the right occipital artery feeder. The follow-up treatment involved embolization of the occipital artery feeder and sigmoid sinus. The fistula connects the extracranial vascular system to the intracranial vascular system, it seems. Would code 61624 be appropriate for both procedures regardless of the site of embolization (occipital artery feeder only vs. occipital artery feeder and sigmoid sinus)?

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!!!
 

av shunt embolization, two puncture with venoplasty

Please do NOT include any actual patient medical records with your question. question regarding AV fistula (forearm) accessory vein embolization. Fistula accessed and fistulogram findings demonstrated 2 accessory veins and high grade stenosis in the region of cephalic vein. Then with wire and catheter one of the large accessory vein was embolized with multiple coils. Follow up embolization run demonstrated successful occlusion.Next a second antegrade access of the fistula was obtained and PTA of cephalic vein performed. Can we code this 36147 36011 35476 75978 37204 75894 75898? Please explain. Thanks

Duplex mapping at the same setting as the creation of an AV fistula.

Is this enough documentation to bill 93986 performed during the same session as the creation of the AV fistula?

"Ultrasound was used to map out the superficial femoral artery, femoral vein, and great saphenous vein in the right groin. The site in which they were closely related was marked on the skin."

Fistula remote access 36901-52 and 36012

Could you please clarify if we can code 36901-52 and 36012? It seems like he moved the catheter back to stent the subclavian after he had accessed the fistula.

"Under sonographic guidance, right common femoral vein was accessed with a 21 gauge micropuncture needle. A 7 French sheath was inserted. Right cephalic AV fistula was catheterized with 5 French Kumple catheter and 0.35 guidewire. Right cephalic fistulogram and central venogram were performed. Right subclavian/innominate venous stenosis was angioplastied with a 12 x 60 mm balloon and stented with a 14 x 60 mm Cook Zilver Vena stent. The stent was dilated with a 12 mm balloon."

Fistulogram, Angioplasty, Embolization

I want to make sure this documentation is sufficient for billing the four 36011 codes. "Sedation was done. Access obtained in AVF in proximal aspect of the fistula close to the arterial anastomosis. Contrast was injected, and cephalic arch was angioplastied due to stenosis. Decision was made to approach branches from the other end of fistula. Sheath was removed, and fistula was accessed in proximal arm with the sheath towards arterial anastomosis. The side branches were selected. The selected side branches, 4 in total, were coil embolized using Cook Tornado coils. Result was acceptable and coils were in good position, and coil branches were totally occluded. Fistula was widely patent with no residual stenosis in cephalic arch. Procedure well tolerated." I would code 36147, 35476, 75978-26, 36011 (36148, deleted), 36011-XS x 3, and 37241. As always, I appreciate your input!

Ileal Conduit Dilation

I'm not sure how to code this. Would it be unlisted, urinary, or intestinal section? "PE: Abdomen/Flank: Soft, non-tender, non-distended. Positive for bowel sounds. No palpable masses or flank tenderness. Well-healing incisional wound. Ileal conduit with clear urine. Stoma somewhat retracted but reddish mucosa visible. The skin may have pulled away from the bowel mucosa. She was experiencing continuous urinary leakage due to a large vesicovaginal fistula at the trigone of her bladder. Patient is now s/p an ileal conduit urinary diversion and closure of VVF defect with democusalized detrussor flaps and concomitant ventral hernia repair. She had revision of her stoma for stenosis, and the stoma unfortunately re-stenosed. Has been staying relatively open - dilated to 28 French today without issues. Patient instructed on how to use self-dilator and will continue to do this several times per week."

Transposition of AV Fistula

A new AV fistula (brachial/cephalic) is created, and the cephalic is brought over and sewn end-to-side into brachial (I know this is 36821), but they then elevate the cephalic with sutures underneath to superficialize it during closing... would the procedure then become a transposition (36818)? 

renal stent at time of aortic stent graft

Greetings, I have three questions on two cases. 1. Patient has a AAA graft placed in placing the graft flow is diminished to the renal artery. A stent is placed in the renal artery after the deployment of the stent to fix the problem. Can we code the stent placement separate from the AAA graft or is it bundled. 2.A patient has a radial cephalic fistula and come in for arm swelling from the shoulder down. The patient has a stent occuluded in the braciocephalic artery. Would you code this as a 36147 or a 75710, for a diagnostic angiogram.I would code the interventions as well but I'm thinking I would not use the fistula thrombectomy code as thrombus was not removed from the fistula but from the bracialcephalic vein. Any help would be great Thanks, LW

Stenosis vs. Clotted AV Fistula

Coding guidelines state that when an intervention is performed on an AV Fistula, the arterial and venous sides are considered one vessel. It's understandable when a stenosis exists and requires just one wire to be placed, but I was wondering if there is an exception when a clot is encountered since two wires are placed and two sides are ballooned/stented?

Exploration/ Revision of LVAD outflow graft

I am tying to figure out a code for an exploration/revision of LVAD outflow graft. I am having trouble pinpointing a code, and I was thinking that unlisted code 33999 comparable to code 36832 would work best. Any guidance is greatly appreciated.

"Incision was extended medially and laterally until all bend relief was exposed, then it was cut open. Pressurized yellow pasty substance escaped through the opening. LVAD flows gradually improved to 4.5 LPM as all of the space was cleared. The whole outflow graft was cut longitudinally, and the space debrided, cleaned, and irrigated with antibacterial solutions. The OFG fully expanded. Hemostasis was assured, and the incision was closed over a #10 JP with running absorbable sutures in layers."

CVL with Redo Same Session

If a central line is placed (including a central venogram because of concerns that the left brachiocephalic might be occluded) and able to be placed "with its tip located in the mid superior vena cava even when the catheter was fully inserted. This high location and visualization of a kink in the neck suggested that this access would be problematic. It was felt that another puncture into the left internal jugular vein could be performed from a slightly lower location and using a different angle that would likely be less prone to create a kink in a catheter." So another access in the left jugular was used to replace the central line. Can the first access and venogram be placed in this situation in this situation in addition to the CVL placement or not?

AV Fistula Aneurysm Repair

We are receiving conflicting information on how to code AV fistula aneurysm repairs. Some coders are using code 35190, while some are using unlisted code 37799. What is the correct code for the following procedure? "The patient was taken to the OR. Left arm was prepped and draped in usual sterile fashion. A tourniquet was placed in the high arm. The aneurysm was appropriately marked with an indelible marker. An Esmarch was used to drain the arm, and the tourniquet was then insufflated to 250 mm of pressure. The anterior wall of the aneurysm was resected inclusive of the skin, subcutaneous tissue, and anterior wall of the vein. The vein wall was then reapproximated with running suture taken of 5-0 Prolene started at each end of the venotomy and tied at the midpoint of the venotomy. Antegrade flow was then restored by releasing the tourniquet. There was an immediate palpable thrill in the fistula. Hemostats were assured. The wounds were closed in layers with suture taken of 3-0 Vicryl at the subcutaneous tissue level. The skin was reapproximated with 4-0 Monocryl at the skin level."

Primary AV Fistulogram Left Upper Arm

"An 18 gauge angiocatheter was used to cannulate the AV access. Contrast was injected to perform diagnostic fistulogram of outflow tract... The more proximal stenosis was addressed by 'redirecting' the guidewire and sheath into the fistula in the opposite direction under fluoroscopic guidance. The stenosis was angioplastied." I know that I can code 36147 for the catheter placement in the AV fistula. Can I code 36148 (second cannulation of dialysis access) for the ‘redirecting’ or ‘redirection’ of the guidewire/sheath to perform a PTA?

36870 vs. 37187

Can you provide the correct procedure code(s) for the venous thrombectomies in this patient with a right upper arm AV fistula? Some like 36870 only, while others like 36870 and 37187 since they feel the subclavian is substantially away from the fistula. "We then percutaneously accessed the proximal venous outflow just past the anastomosis of the cephalic vein…noted a moderate stenosis just past the anastomosis. We then noted that the cephalic vein was patent for approximately 10 cm and then became completely occluded. There was no reconstitution of this until the superior vena cava, and the fistula was draining through small collaterals into the basilic system. AngioJet catheter was used to perform a mechanical thrombectomy over the cephalic, axillary, and subclavian veins on the right side for a total volume of 323 mL. Completion fistulography showed a patent lumen throughout the fistula with heavily diseased venous outflow for the majority of the cephalic, axillary, and subclavian veins. PTA of SVC was performed…”

Dual PPM to BIV ICD

Upgrade of left-sided dual chamber PPM to dual chamber biventricular ICD, US-guided vascular access, left upper extremity and coronary sinus venography, implantation of LV lead, pocket revision. Mixed cardiomyopathy EF 30-35%, NYHA class III heart failure, AVN ablation with DC PPM in-situ. Per the op report- the RA lead was re-used. The old RV was capped and a new RV lead placed in addition to the LV. 

Would this be coded as 33233, 33249, and 33225? Or 33231 and 33233?

36147

hello, if a patient has a brachial artery to cephalic vein hemodialysis fistula and the radiologist punctures the cephalic vein at the distal humerus level and advances centrally and performes a fistulogram would this be code 36147? is this punture concidered a fistula puncture or is it a remote access with 75791? please advice as the more i read it the more confused i get.. thank you for your help in advance...LR

ICD-10-CM code soft thrill AV fistula

My physician successfully placed an Ellipsys vascular access system. One month later the patient returned for a diagnostic duplex scan of the fistula (93990). The clinical indication was soft thrill, but the study was normal. What is the ICD-10-CM code for soft thrill?

Vein Ligation During AV Fistula Creation

During the creation of an AV fistula my provider ligated two veins off the cephalic vein to aide in maturation of the fistula. He used two separate incisions to do so; is this billable? Here is an excerpt from the operative note: "The cephalic vein appeared to split into two veins in the proximal forearm with one coursing laterally and not being fairly superficial of excellent size. There were two branches connected to this vein. In order to allow maturity of this branch as well, I proceeded to make a very small stab just proximal to the entry of this branches to the cephalic vein, and these veins were clipped. Each small stab was closed with 1 interrupted 4-0 Monocryl suture."

Femoral arteriovenous fistula for a pedicle free flap to lumbosacral area

Greetings, I have a physician completing a femoral arteriovenous fistula for a pedicle free flap to the lumbosacral area. They tried a iliac artry exposure first but due to scar tissue they had to expose the femoral vessels. The physician harvested the entire greater saphenous vein,then anastomosted the vessel to the common femoral artery. This was then tunneled to the lumbosacral area. While tunneling the illiac vein was injured. How would I code this? A fistula tranposition code with a 36818- 22. The unlisted code 37799. Do you have any advice? Thanks, LW

Ligated radiocephalic AVF causing hand symptoms

Coder used 36904 but I'm not seeing this. However, unsure what code should be used in this case ??

INDICATIONS: Patient had a Cimino fistula ligated due to successful kidney transplant. Now having symptoms in the hand and shown to have prominence over the left radial artery and acute thrombosis of the remaining portion of the fistula.

SURGERY: 15 blade for incision over old incision. Dissection down to the radial aneurysm. Scissors dissected the fistula from surrounding adhesions. Proximal and distal radial artery were isolated, and control achieved. Proximal artery was palpable but distal artery had no pulse and not even dopplerable. Heparin given and proximal radial artery clamped. Aneurysm was cut and thrombus cleared out. Balloon used to thrombectomize the distal radial at which point we noted backbleed. Aneurysm was excised. Arteriogram showed distal radial artery showed no significant supply for the hand and we decided to tie off the distal and proximal radial artery. Hemostasis verified and incision closed.

Mediport Revision

Physician states Mediport revision. Would unlisted code 37799 be appropriate? "The patient's neck and chest were prepped and draped in the usual sterile fashion. 15 cc of 1% lidocaine local anesthetic was infused. A small incision was made over the prior Mediport site, and the Mediport was dissected free. It was deep with a lot of fat overlying the Mediport, and it was non-functional, not sutured in place, and slightly kinked/facing inwards. The incision was extending 1 cm medially, and a new subcutaneous skin pocket was dissected free. The Mediport was secured in this new pocket with 3-0 prolene. Hemostasis was achieved and wound irrigated with antibiotic solution. The wound was closed in layers with 2-0 vicryl and 4-0 monocryl. Final x-ray confirmed that the catheter was in good position. The huber needle was used multiple times, and it flushed and aspirated well in the new position."

Vertebral Fistula

In question ID 5037 from the Ask Dr. Z Database, you suggested code 61624. Does the same hold true for this report? "The right vertebral artery was catheterized with a balloon microcatheter. Balloon was positioned in the high cervical vertebral artery segment. A microcatheter was introduced and navigated into the right vertebral artery and into the origin of the vessel dissection and into the fistulous pouch. Several attempts were made to deploy 3 x 6 mm helical and three-dimensional coil under continuous balloon inflation. Once the balloon was deflated it was noted that the coil was very unstable. The coil was removed. Several attempts were made to reposition the catheter more optimally within the fistulous pouch. When catheter was positioned within the origin of the fistulous pouch, injection was performed to confirm position of the catheter and to evaluate flow through the fistula. During the process of multiple attempts to the further coils within the fistula's pouch, it was noted that after last attempt the fistula was longer present and likely spontaneously thrombosed."

HERO

Hi Dr. Z, we appreciate your knowledge and expertise, and we can sure use it on the following scenerio. I think we are ok on how to code all the procedures here except for the removal of the HERO. It would stand to reason that if the insertion would be 36558 and 36830-52, then the removal would be 36589 and then a code for a revision/removal/ligation of the AV fistula graft, but I don't see this described here, are we missing something? Did he just simply disconnect the catheter portion from the fistula portion? Thank you so much for your help PREOPERATIVE DIAGNOSES: 1. Chronic kidney disease, stage V, presently dialyzing with dysfunctional right femoral TCC and thus for removal of the same: 2. Thrombosed left jugular HeRO device for removal of same. 3. No further need for IVC filter and thus for removal of same. POSTOPERATIVE DIAGNOSES: 1. Chronic kidney disease, stage V, presently dialyzing with dysfunctional right femoral TCC and thus for removal of the same: 2. Thrombosed left jugular HeRO device for removal of same. 3. No further need for IVC filter and thus for removal of same. NAME OF PROCEDURE: 1. Cutdown exposure of the HeRO catheter at the left jugular insertion site with removal of the HeRO catheter. 2. Removal of IVC filter through the left jugular approach. 3. Replacement of a left jugular tunneled cuffed catheter, 23-cm precurved Palindrome catheter. 4. Removal of right femoral TCC catheter. DESCRIPTION OF PROCEDURE: The patient's left neck and chest were prepped and draped in the usual sterile fashion after adequate satisfactory general endotracheal anesthesia was obtained. The left jugular HeRO catheter insertion site incision was reopened and the HeRO catheter isolated at this location. The catheter entrance tract was encircled with a 3-0 Prolene pursestring suture. The HeRO catheter was then divided and a guidewire passed down into the vena cava through the HeRO catheter followed by complete removal of the HeRO catheter and replacement with a 13-French sheath. The sheath was then replaced with a Cook IVC filter retrieval kit which was passed through the wire and used to remove the IVC filter without any difficulty. The filter retrieval kit was then exchanged once again for a 13-French sheath followed by placement of 22-cm precurved Palindrome catheter which was tunneled subcutaneously and delivered out over the course of the guidewire insertion site. The large dilator and introducer assembly were then passed over the guidewire after removal of the 13-French sheath and positioned in the right heart under fluoroscopic guidance. The guidewire and dilator were then removed and a 23-cm Palindrome catheter passed through the introducer and positioned in the right heart under fluoroscopic guidance. The peel-away introducer was then removed. The pursestring suture was then tied at the catheter insertion site and the catheter insertion incision was closed in layers using 3-0 and 4-0 suture. The catheter was then secured at the exit site to the chest wall using nylon suture. Sterile dressings were then applied. At this point, the patient's right femoral TCC catheter was prepped and draped and then removed. A sterile dressing was applied at the right groin. The procedure was then completed and the patient awakened, extubated and taken to the recovery room in stable condition.

Vein Mapping

What is the code for upper extremity vein mapping prior to the creation of a AV fistula? No Spectral was done. Does the code selection change if it's not done on the same day as the fistula creation and/or by a different physician?

Pocket revision at the time of generator change

Z-Health Diagnostic and Interventional Cardiovascular Coding Reference book, page 406 number 9, states "Do not code pocket revision during generator change to accommodate a different shaped or larger sized generator. This is considered part of the replacement, just like a pocket creation is considered part of an initial insertion of a new device". Per the above, codes 33262,33263 and 33264 should not be billed with 33223 if done only to change the size of the pocket. What if the physician had to remove scar tissue or debride the pocket at the time of ICD replacement, could we then bill for 33223? Per the CCI edits I can bill 33223 with the replacement codes and add a 59 modifier to 33223. Please help clarify this because the physicians want us to bill the 33223. Thank you

Venous Sampling

What code should we use for venous sampling? The provider only has 36500 and 75893. "Thereafter, I used high resolution real-time ultrasound, identified the right common femoral vein, infiltrated 1% lidocaine, and punctured into the vein under ultrasound guidance during a permanent image. I advanced a guidewire, then exchanged the puncture needle for a 6 French vascular sheath. I used a series of diagnostic catheters to sample multiple venous sites, including the right and left subclavian and brachiocephalic veins, right and left internal jugular veins, superior thyroidal veins, right and left vertebral plexus, azygos vein, left internal mammary vein, thymic vein, superior vena cava, and right atrium. All samples were sent to the lab for analysis, and the results were reported before the end of the day."

Open thrombectomy of AV graft

Greetings, This patient has a AV graft. The physician does a open thrombectomy of the arterial and venous sides of the graft. Following this a AV shuntogram is performed. This shows irregular calcifications in the graft. A curettage of the graft was performed to remove calcifications. Follow up angio showed a stenosis at the venous anastomosis which is ballon angioplastied. Due to pt history of strictureplasty a stent was placed. I think I can code 36831-59 thrombectomy / the shuntogram with code 75791-26-59/ Angioplasty is bundled with the stent placement / Stent codes 37207, 75960-26. What about the curettage? I'm not sure about the curettage. Would I code this as a 36833 and think of the curetage as a revision with thrombectomy along with code 75791-26-59 and then the angioplasy and stent are bundled as they are completed in the same zone as the revision. Any clarification would help. Thanks, LW

Coronary Artery Fistula Closure

I'm still pretty new in coding cath and want to make sure I'm on the right path. One of my providers performed a coronary artery fistula closure with a congenital cath plus coronary angiogram and supravavular aortography. This is what I'm coming up with so far: 37242, 93531, 93567, and 93563.

Can you please calrify the difference between dialysis fistulas and dialysis grafts. Reviewing your coding information, it seems as though you are only discussing coding rules for dialysis grafts. How do I code for an angioplasty at the anatomosis of a native fistula. Would it be correct to code 35476 since the artery and vein are directly anastomsed to form the fistula?

AV Fistula Open Thrombectomy and Angioplasty

If an open AV fistula thrombectomy is performed and a stenosis is then identified at the venous anastomosis and treated with angioplasty, are we able to submit codes 36831 and 35460?

Codes 33229, 33224

We need your help with this scenario. Outpatient comes in for biventricular pacemaker generator change. Lead testing for left ventricular lead was 5v. MD states that he "decided to proceed with PM generator change and bring her back for lead revision after proper consent was obtained for possible laser lead extraction." Generator was changed (33229), and the patient left the area only to return later that same day for replacement of the left ventricular lead. Later that day patient returned to cath lab and had a new left ventricular lead inserted (33224). Old lead was capped. Can we bill for each encounter? Can we use a modifier -59 on one of the procedures? What is the correct way to code these two procedures?

TPA, PTA & ligation of a collateral vein of a Radiocephalic Fistula

Pt w/radiocephalic fistula. A large collateral vein was cannulated with micropunture set. Dilator advanced in a retrograde toward the arteriovenous anastomosis. Arteriogram showed a severe stenosis of the proximal cephalic vein distal to the anastomosis. PTA of the stenosis was performed. In order to treat the thrombus within the access TPA was instilled within the access. The thrombus was also macerated percutaneously. Prior to the completion of the procedure a 2-1 Vicryl suture was inserted through the skin & subcutaneous tissue surrounding the collateral vein. The suture was tied so that the flow through the vein was disrupted. Findings: A critical stenosis of the proximal cephalic vein was dilated with 5mm balloon with improvement in caliber. A small volume of thrombus within the fistula at the level of the antecubital fossa was treated with TPA as well as maceration of the clot. The large competing collateral vein was ligated using 2-1 Vicryl. Would the codes be 36000 (access), 36905 (Fistula TPA & PTA) and 36909 (vein ligated)?

Repair of Two Arteriovenous Aneurysms

"A curvilinear incision was made over the aneurysm, and proximal and distal control were obtained without much difficulty. The aneurysm was rather eccentric. Skin flaps were elevated. The fistula was clamped, and the anterior wall was resected off of the aneurysm. Some of the lateral wall was then resected as well. There was a lot of laminated thrombus in the anterior saline, and then fistulotomy was closed longitudinally using 5-0 prolene. Flow was restored to the fistula, which obtained a good thrill. Additional sutures were applied to achieve good skin approximation. Light pressure dressing was applied." The physician called this an aneurysm repair (36832); however, I see thrombus was removed. Would we code this as 36831? I don't see that the fistula was revised.

High grade stenosis at cephalic/subclavian junction of AV fistula; atherectomy of stenosis using Diamondback device.Fluoroscopy used, cannulation of AV fistula on arterial site, fistulogram , patent arterial side anastomosis. On the venous side of the fistula, multiple areas of stenoses seen, especially 95% at cephalic/subclavian junction. Atherectomy performed using Diamondback device, total spin time was 1 minutes. Stenosis improved to 60%;decision to perform balloon angioplasty at the same site. Subsequent fistulogram performed revealing complete restoration of the caliber of the vessel. Please verify 36147, 36148, 35494, 35476.

lower extremity AV fistula peripheral segments

For lower extremity AV fistula peripheral segments, what is adjacent segment of native artery, peri-anastomotic region/arterial anastomosis? Does this mean only common femoral artery or iliac arteries also?

36820-53, 36821

LT wrist Radiobasilic transpo fully created due to concerns that the fistula would not develop it was taken down and revised to a non-transposed brachiobasilic AVF. Since the second attempt was successful and created through a separate incision would we be able to bill 36820-53 with the 36821?

Incision basilic vein to wrist. Basilic vein dissected & branches ligated/divided distally & proximately. RA was dissected. Vein was tunneled medial - lateral aspect of forearm bringing vein to RA. The vein was spatulated. Flow was established then through the fistula. The basilic vein harvest site was then closed. Noted to be no flow in the fistula. The anastomosis was then taken down and revised. Incision was made over the distal upper arm over the basilic vein made arteriotomy which was stented with Potts scissors. The vein was then spatulated using a running suture was sewn in there is a strong thrill in the fistula due to the larger size of the vein & artery. Hemostasis was confirmed. The radial artery incision and the upper arm incision were closed.

Pocket Relocation vs. Revision

During EOL generator change, a pocket revision procedure is noted in the operative report to reduce perioperative infection risk. Is debridement code 11042 for 14 sq cm appropriate to report? "A 10 blade was used to make an incision approximately 3 inches in length over the pre-existing scar. Blunt and sharp surgical dissection was carried down to the endothelialized capsule, which was incised. The pulse generator was removed from the capsule. Leads were removed from the head of the device. Chronic threshold testing and lead evaluation demonstrated all three leads to be adequate for utilization. A complete capsulectomy with excision of all devitalized tissue was performed at this time, with removal of approximately 14 cm tissue at this time. Hemostasis was assured with electrocoagulation. The pocket was copiously irrigated with Bacitracin solution. A new CRT-D pulse generator was brought on the field."

Peripheral Coding

Can you please clarify the appropriate CPT codes for these procedures? 1) Selective catheter placement in third order with selective placement in the left brachial, axillary, subclavian, and aorta with DSA imaging via left radial artery access. 2) Selective separate catheter placement in additional second order via right radial artery access in the right brachiocephalic and subclavian artery and DSA imaging. 3) Successful PTA and 8.0 x 37 and overlapping 8.0 x 57 stent to the left subclavian artery. 4) Successful PTA and 5.0 x 40 mm stent of the left brachial into the axillary artery in second arterial territory. 5) Thoracic aortogram.

Pleural Peritoneal Shunt

A patient was brought to the IR suite where they placed a pleural peritoneal shunt and also a peritoneal venous shunt using Denver shunts. We use code 49425 for the peritoneal venous shunt, but we're looking at an unlisted code for the pleural peritoneal shunt. I think code 32550 wouldn't be correct since this is a shunt and not a drainage catheter. "The venous end of the single valve shunt was trimmed and positioned within the peritoneal cavity... The peritoneal end was advanced into the pleural space." Would we use code 32999 or 49999? Also, the patient returned 8 days later for revision. The shunt was accessed with a Huber needle, and contrast injection showed occlusion of the shunt hub with debris. tPA injection failed to clear the debris. "Therefore I elected to place a new pleural to peritoneal shunt. Using blunt dissection the indwelling pleural to peritoneal shunt was removed, and a new shunt was placed under fluoroscopic guidance." What code would you recommend for the original placement and also the revision?

Follow-up on Carotid Cavernous Embolization

"Patient had right-sided carotid cavernous fistula and upon imaging before embolizing the right they discovered that a left carotid cavernous fistula was present, so they came back two days later to embolize the left. They performed a bilateral cerebral angiography from the common carotids prior to the embolization, which was performed from the left cavernous sinus via femoral vein access. After embolizing, the physician came back and performed cerebral angiography as a follow-up from the bilateral internal carotids, the bilateral external carotids, and the left vertebral." So my question is, can I code the extrernal carotids as angiography?  Or do I have to consider those a follow-up? Also since the catheter went further and since we code to the highest catheter placement, I am unsure if I should code the highest order and use the internal carotid code 36224 instead of the common carotid code 36223... or should it be 75898?

global period modifier use 58,78, 79

I'm needing some help with understanding proper coding and modifier use within a surgical global period.

Patient has fistula placed (36821) as well as tunneled catheter (36558) placed. Two months later, superfistulization (36832) is performed. Two weeks after that (still within 90-day global period) the tunneled catheter is removed in the office. What would be the proper modifier use in this scenario? Can catheter removal code 36589 be reported within this period in the office setting?

Or in the case where a fistula is placed in the LEFT arm, but fails in two months and a new one is placed in the RIGHT arm within the 90-day global period, would this be reported with modifier -79 because it's different arms or -78 because it's related, but not anticipated?

can a CARTO and TIPS revision be billed together? 37241 and 37183?

Can both billed together? 37241 and 37183

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

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

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

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

Code 36819

In the process of creating an AV fistula, the physician removes a thrombus from the basilic vein with a Fogarty balloon. He goes on to anastomose the basilic vein with the brachial artery. Would it be appropriate to report the thrombectomy with code 36831 and the creation of the fistula with code 36819-59?

Non-Maturing Fistula Takedown and new AVG Graft

Is it appropriate to report codes 37607 and 36830 in this case? Or is this revision? "There is an AVF in the antecubital space that never matured. An incision was made over the cephalic vein, and the cephalic vein was circumferentially dissected. Sutures were used to ligate the cephalic vein. Then a 3-inch longitudinal incision was created in the axilla overlying the brachial artery pulse, and the proximal brachial vein and artery were dissected free. The vein was ligated distally, clamped proximally, and transected. The artery was encircled with a vessel loop and dissected free. Accuseal PTFE graft was tunneled in a subcutaneous fashion forming an upper arm loop. This required a 1-inch counterincision a few fingerbreadths above the antecubital fossa. A 7 mm end of the graft was cut and anastomosed in an end-to-end to the draining brachial vein. The brachial artery was then controlled with clamps, and arteriotomy was performed with an 11 blade and a Potts scissors extending 4 mm. The end of the graft was then anastomosed in an end-to-side to the brachial artery."

Bilateral indirect carotid cavernous fistulae

From a RCFA access, the physician embolized R. sphenopalatine artery as an indirect embolization of the L. cavernous fistula. From a RCFV access, the physician embolized the R. cavernous sinus fistula.

Is this considered 1 or 2 operative fields?