Ask Dr. Z

Pacemaker pocket revision

I have a patient who had a pacemaker pocket revision due to discomfort. No infection, relocation not done except for a slight move within the same pocket; I&D was not done. What code would be appropriate in this scenario?

"Blunt and Bovie dissection was carried out down to the level of the existing generator. The generator was removed from the pocket. Leads were dissected free of scar tissue. Dissection of the pocket was carried out in a superior medial direction extending over top of the transpectoral lead insertion position. The leads were coiled under the device in a more favorable anatomic location. The device was tacked to the prepectoral fascia as superior medially as could be obtained, just medial to the lead insertion positions. The pocket was irrigated with 180 cc of antibiotic irrigant solution on once again examined for bleeding. Both leads were pulled tested and remained fixed in place in the header. The wound was closed using a standard 3-layer closure technique."

Subclavian Vein Stenosis Treatment During AV Fistula Evaluation (36147)

If the subclavian vein is selected during an AV fistula exam evaluation of a brachial artery to axillary vein PTFE graft), and severe stenosis is found and treated with angioplasty, can you add selective code 36011 in addition to codes 36147, 35476, and 75978?

Bilateral Outflow Venograms

This one is confusing me. How should I code the following? "PROCEDURE: Outflow venograms of the upper extremities. TECHNIQUE: Using ultrasound guidance, superficial veins in the wrists bilaterally were accessed with 22 gauge Angiocath cannulas bilaterally. Segmental venograms were performed of each arm bilaterally, including forearm venograms with and without tourniquet placement cephalad to the elbow joints bilaterally. Additionally venograms were performed of the thoracic inlet during bilateral contrast injections for evaluation of the subclavian and brachiocephalic veins. On the left there is a mild to moderate small segmental narrowing underlying the left clavicle, most likely related to extrinsic compression by the overlying bone. No collateral vein formation is seen; however, minimal reflux into the left axillary veins is identified."

Palma Procedure

Patient underwent a right common VEIN to left common VEIN bypass with PTFE and a fistula creation with 6 mm graft right common femoral artery to the fem-fem vein bypass graft. Since this is a vein to vein bypass, is this an unlisted procedure (37799), as I was under the assumption that the bypass codes (35501-35671) are only used for artery bypasses. It's comparable to 35661. The fistula creation I was thinking 35686, but it is an add-on code, and neither 35661 or 37799 is an allowed primary code. What would be your advice on which codes to use?

Brain Death Study

Is there is a specific CPT code to use for a cerebral perfusion angiogram (brain death study)? The physician performs bilateral carotid angiogram catheter placement in common carotid (right, left). Righ vertebral imaged, catheter placement brachiocephalic, left vertebral selective cath placement. Is it appropriate to report codes 36223-50 or (36222-50) and 36225-RT/36226-LT, or are there codes specific for a brain death study?

36830 and 36903

Would you be able to code angioplasty of the central vein and stent of peripheral vein with the creation of this new graft? 36903-59, 36907-59, 36830? "Indications: The patient was evaluated with arterial studies that revealed adequate circulation of the upper extremities and also, with a venogram that showed that the superior vena cava was patent and that the left brachiocephalic vein had areas of occlusion as well as the left subclavian vein, and a preoperative venogram also showed that the axillary vein was occluded in the lateral and medial aspect, but there was a collateral that communicated with the subclavian vein. I recommended reconstruction of the central veins, and if successful, this will allow a placement of a new graft."

I&D with fistulogram

"Left forearm fistulogram performed for non-maturation of radial-cephalic AV fistula. Findings: patent anastomosis, only 2 mm cephalic vein directly adjacent to anastomosis. Cephalic vein essentially obliterates approx. 3 cm above the anastomosis site. No quality lumen to wire/angioplasty. No fistula maturation. Catheter related vein perforation treated with 1cm cut down to drain hematoma. No hematoma at end of procedure, silk suture to dermis." I reported code 36901 for the fistulogram. Is code 10140 appropriate for the cutdown/hematoma drainage, or would you not code it? Does code 36901 need modifier -74 since it appears that the complete dialysis circuit was not viewed? 

Suture repair of dehisced femoral bypass patch graft

Diagnosis - Pseudoaneurysm, left femoral artery /Dehiscence of the pericardial patch from femoral artery.

Dictation: I made a left flank incision to obtain retroperitoneal control of the left limb of an aortobifemoral graft. I dissected out the left limb of an aortobifemoral graft and was able to put a spring clamp on the left limb of the aortofemoral graft. I then proceeded to remove sutures from a left groin wound. I evacuated all the clots and there was a hemorrhage. On exploration, it appeared that about 25% the pericardial patch had dehisced from the left common femoral artery. I then proceeded to re-suture it with a 5-0 Prolene and ran several sutures along that anastomosis at the site where it had dehisced several interrupted sutures. After I placed the sutures and removed the clamps, it appeared that the bleeding was controlled.

Would this procedure be coded to revision of graft 35883 or would 35141 be more appropriate. Thanks for your help.

Venooplasty of AV Fistula

In your Interventional Radiology Coding Reference book (page 275) it states that if the stenosis is not hemodynamically significant to not code the venoplasty. What is considered hemodynamically significant? Our physicians frequently do venoplasty in the AV fistula for mild stenosis. What is considered "prophylactic"?

Revision of intrathecal drug pump

Procedure: Revision of intrathecal drug delivery pump. Indication: The patient currently has an intrathecal drug delivery pump in bad position, the pump has not been sutured down to the fascia so the pump has slipped and the pump is not usable and cannot be refilled. Description of Procedure: The area of the left lower quadrant of the abdomen was prepped and draped, surgical site was covered with ioban. An incision was made along the previous incision in the left lower corner of the abdomen which allowed exposrue of the intrathecal pump. the incision was carried down until the intrathecal pump was exposed and it was taken out of the pocket. Hemostasis was applied. then an incision was made about 1 1/2 inch anterior to the previous incision in the left lower quadrant of the abdomen. An appropriately sized pocket to implant the drug delivery pump was created using blunt dissection. Hemostasis was applied. the catheter was disconnected from the pump and it was passed to the new pocket. the catheter was reconnected to the pump. Aspiration was done through the side port of the pump. About 2.5 ml of CSF was aspirated. the pump was filled with preservative free morphine 10 mg per ml with 20 ml solution. Both pockets were irrigated with bacitracin solution. the pump implant was placed into the new pocket and was anchored down to the fascia using 5 ethibond sutures. both incisions were closed using 2.0 vicryl suture in the subcutaneous layer. the skin closure was done with staples. The surgeon describes the device as a pump and not a subcutaneous reservoir, the pump was sutured to fascia, so i did not feel CPT 62360 was correct. i get a device edit with CPT 62362 - the pump was not replaced with a new pump. 62350 appears to describe repositioning of the intrathecal portion of the device rather than the LLQ abdominal pump portion. Can you please advise? thank you. 62362

Arterial Anastomosis and Venous Outflow Intervention

"Left arm fistula was accessed and diagnostic fistulogram performed. Venous outflow stenosis was identified and angioplasty performed. The result was a focal rupture of the fistula requiring placement of a bare metal stent. Attention was then turned to the arterial anastomosis where a web-like stenosis was identified. Arterial anastomosis angioplasty was performed." I believe codes 37238 and 36147 would be correct, but I wondered about the PTA of the arterial anastomosis (35475, 75962). Is that considered inclusive to venous stent code 37238, or is it separately reported?

Bypass graft revision 35884 while performing CFA endarterectomy 35371

While performing a CFA endarterectomy the physician revises a fem-fem synthetic bypass graft with no mention of any prior patency issues with the graft. I have included a few excerpts from the documentation below. I am wondering if code 35884 is appropriate to code along with the endarterectomy code 35371 in this circumstance. "The proximal anastomosis of the femoral-femoral bypass graft was excised from the common femoral artery to enable endarterectomy of the entire common femoral artery. The arteriotomy was closed using the saphenous vein patch and running 6-0 Prolene suture. Revision of the proximal femoral-femoral bypass graft was performed by incorporating the anastomosis into the closure using 6-0 Prolene suture medially at the level of the mid common femoral artery."

Vessel repair hole in av fistula

Greetings, How would you code a(one)suture repair of a puncture hole of a AV fistula ? It doesn't seem complex enough to code repair of a blood vessel. thanks, LW

TAVR with Sentinel Device Embolic Protection

Our physicians have begun using a research device called Sentinel for embolic protection, placed in the right brachiocephalic and left carotid arteries during TAVR procedures. The use of embolic protection is not separately reportable with various other coronary and revascularization procedures, but would an additional code (93799) for the placement of the device be allowed when it is performed as part of a TAVR?

Right atrial thrombectomy

Physician removed a large vegetation from the right atrium due to an infected pacemaker lead. Diagnosis code is the root operation extirpation of matter or revision.

Which CPT to code 36832 or 36902 per CPT bundle issue?

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

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

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

CCI edits for lead repair

Hi, I have a Pacemaker at ERI with pocket revision and lead repair noticed during the PM Gen replacement. However CCI is saying that codes 33228 and 33218 can not be coded together even with a modifier because it is a component of column one. So I don't know how to code this lead repair with the new codes, please help. Below is part of the dictated report: Pre op: Pt pacemaker at ERI. In addition skin has been thinned over the pm superior aspect of the incision line. "The ventricular and atrial leads worked well. There was a crimp in the ventricular lead, although there was no alteration of functon and no palpation of any wire. The insulation was repaired in that location with medical adhesive and a silicon sleeve. It was tested again and worked well." Post op: Successful removal and insertion of dual PM. Repair with silicon sleeve and medical adhesive of crime in the venricular lead. Successful revision of the PM pocket to allow the PM to sit more deeply in the pocket and take pressure off the superior incision line.

New 2017 Dialysis Fistula Codes

"Patient has a DVT in the right AV fistula cephalic vein and subclavian/innominate areas. Two accesses were done with US guidance and image saved to PACS. Angioplasty of the partially occluded cephalic vein was successful, and subclavian vein was plastied with stent placement but clot still present. A lysis catheter was placed for overnight with the tip in the subcutaneous vein. The next morning a venogram was performed and a moderate amount of clot was still present in subcutaneous vein, so thrombectomy was performed with a second stent placement from the subclavian vein into the innominate vein. Lysis was ended, and the fistula is now ready for use." Would you report code 76937, or is that bundled? Should I report codes 36902 and 36908 for day 1? And code 36906 for day 2?

35475

Just when I think I get these I always question myself and get confused.  Would you consider this a venous or arterial angioplasty?  Is there an easy way to “get these”  no matter how much I read on these I still get confused.

Thanks!!

TECHNIQUE: The risks, benefits and goals of dialysis fistula/graft evaluation with possible stent placement and possible angioplasty under conscious sedation were discussed with the patient prior to the procedure. The patient desired to proceed and signed informed consent. The patient was placed supine on the angiography table. The right upper extremity was prepared and draped in the usual sterile fashion. 2% lidocaine with epinephrine was used as a local anesthetic. Access to the fistula was obtained using US guidance and micropuncture technique directed toward the arterial inflow. Evaluation of the fistula outflow was performed with digital subtraction venography to the level of the superior vena cava. A 6 Fr short sheath was inserted over a Bentson wire which was positioned into the brachial artery. Over the wire, a Bern catheter was inserted and positioned in the brachial artery. Digital subtraction angiography was performed to evaluate the arterial anastomosis and the perianastomotic region of the fistula.

Multiple segments of moderate-length narrowing were noted in the perianastomotic region.


A 5 x 4 angioplasty balloon was inserted and positioned such that multiple, overlapping angioplasties of the perianastomotic region were performed to treat the stenoses. The balloon was then positioned at the arterial anastomosis and angioplasty of the arterial anastomosis was performed. Post-angiography DSA was performed through a Bern catheter inserted into the brachial artery, demonstrating a good angiographic result with brisk flow centrally through this fistula. The catheter and wire were withdrawn. Hemostasis was obtained with manual compression. The patient tolerated the procedure well and exited the angiography suite in stable condition. FINDINGS: There is brisk flow through the fistula. There are multiple segments of 30-50 % narrowing in the perianastomotic region of the fistula, as well as at the arterial anastomosis. The outflow the brachio-cephalic fistula is otherwise unremarkable. IMPRESSION: Successful venous angioplasty of the peri-anastomotic region and arterial anastomosis of the right brachial artery-cephalic vein fistula. PLAN: The fistula can be used immediately.

36147

Please do NOT include any actual patient medical records with your question. Dr. Dunn, Open thrombectomy and open PTA- of AV graft performed. Then in a retrograde fashion, fistula accessed and fistulogram performed and stenosis at arterial anastomosis. PTA performed over a guidewire, my question - is it 36147 or 75791 since first fistulogram performed is not through direct fistula cannualtion. And my second question can we code only one PTA here 35475 along with 36831? Thanks

Central Venogram thru temporary hemodialysis catheter and removal

How would you code for the central venogram through the central venous catheter and then the removal of the catheter? I was thinking of only using code 36598.

"The left neck was prepped and draped, and the anchoring sutures were removed. The indwelling catheter was retracted into the peripheral aspect of the left brachiocephalic vein, from which a central venogram was performed. Imaging showed no central venous stenosis or central venous mural thrombus. It was felt that this patient would best be served by placing a Quinton catheter in a different location (reported separately). The Quinton catheter was then removed, and manual compression achieved hemostasis."

Parathyroid Venous Sampling

I received the following report, and I'm not sure if I should only report codes 36500 (x 2) and 75893 (x 2). "Technique: Right common femoral vein accessed under UL guidance. Using a combination of a glide cath and H1 cath, multiple bilateral veins were cannulated and blood was withdrawn in multiple locations and sent for PTH testing. Venography was performed at each location to confirm cath placement. Once the samples were obtained, the catheters were removed. Findings: Bilateral IJ, subclavian veins as well as the vena cava and azygos vein are widely patent. There is cross collateral filling from the external jugular vein to the contralateral side. Results: RT atrium 42.1, SVC 67.4, Azygos 40.2, distal left brachiocephal 42.5, cent left brachiocephalic 81.3, left subclavian vein 56.4, left IJ 56.4, right internal jugular 52.7, left superior intercostal 62.8, left inferior thyroid 57.8, etc… Impression: Uncomplicated parathyroid venous sampling. The results do not clearly localize to a specific site."

Resection of distal aortic graft and aortoenteric fistula

Our physician performed a resection of an aortoenteric fistula, removed the previous aortic graft, and performed an axillobifemoral bypass. My thought is to use 34832 for the latter and 37799 for the aortoenteric fisutla. Is the use of an unlisted code correct? I'm also at a loss for pricing this piece. The procedure was 6.5 hours of work. Another physician was brought in to repair the small bowel.

36870

If a mechanical thrombectomy of an AV fistula is done...right femoral vein punctured, cath. passed to the right upper arm access, not quite to the arterial anastomosis. Angiojet cath passed and TPA was pulse-sprayed for 20 min. Then a secondary puncture made on the venous side. this end was thrombectomized as well. would this be a 36870, 36147 (direct puncture of the fistula), and 36012 (access from femoral vein) thoughts? thanks!

Bronchial Artery Embolization

For the following, do you agree with codes G0269, 36217, 36218, 75726, 75774, 37242, and 37244? "Right CFA was accessed using a micropuncture needle. The right bronchial artery was catheterized, and angiogram was obtained. Subselective cath of a bronchial artery branch was then performed, and angiogram was obtained. The decision was made to perform embolization. The right bronchial artery was embolized until hemostasis was achieved. Post embolization angiogram right bronchial artery showed satisfactory hemostasis. Next right intercostal artery was catheterized, and angiogram was obtained. Subselective catheterization of a right intercostal artery branch was performed, and angiogram was obtained. The decision was made to perform embolization. The right intercostal artery was embolized. Post embolization angiogram of the right intercostal artery showed satisfactory hemostasis. The brachiocephalic artery was catheterized, and angiogram was performed. The angiogram demonstrated normal opacification of the brachiocephalic, right subclavian, and right common carotid arteries. Hemostasis was achieved with an Angioseal closure device."

Brachiobasilic Arteriovenous Fistula

"A site was selected just above the bifurcation of two joining basilic veins just a few cm above the elbow. The left basilic vein was identified during sharp dissection and mobilized circumferentially. The lateral most vein branch was divided with silk ties so that a tensionless anastomosis could be created. The vein was transected a few cm below the elbow for sufficient length. Sharp dissection with Bovie was used to circumferentially dissect the brachial artery and adjacent branchial veins. The left brachial artery was controlled with vessel loops and vascular clamps. The artery was opened with an 11 blade, and the arteriotomy was extended with Potts. The vein was spatulated and sewn in a 4 quadrant heel-to-toe anastomosis with Prolene in end-to-side fashion. The fistula was patent, but a sclerotic area was noted proximal. A Fogarty was passed, and this was ballooned several times until thrill and color flow duplex improved." 

Would this be reported with code 36821 or 36819? Would there be an additional code for the balloon?

Native arterial AV access

Since access has changed for 2017, I am not sure how AV fistula native arterial access and angioplasty should be coded when AV fistula is not used for access. "Left native artery cannulated. Access made of the native radial artery, J wire passed, retrograde brachial artery angio done. Ulnar artery patent-high grade native radial artery stenosis (60%) noted 6cm proximal to anastomosis. Angioplasty resolved native artery stenosis. Fistulogram showed forearm cephalic stenosis (70%) 4 and 6 cm from anastomosis. PTA successfully resolved stenosis. No central vein stenosis." I have chosen codes but would like clarification of this different type of access. 37246,36901-52?, 36120?, 75710, or 75658?

Angioplasty in a failed AV fistula

What is the appropriate ICD-10-PCS coding for an angioplasty in a failed AV fistula?

36831 vs. 36833

Regarding the previous Q&As about billing open thrombectomy with open angioplasty or open stent placement, the advice was to bill 36833 for revision. We have been using 36833 instead of 36831 for open thrombectomy with open stent or angioplasty in the dialysis circuit. We have received several denials from Humana and Healthsprings after they have requested and reviewed the procedure notes. They are stating that all angioplasty and or stent placement in the dialysis circuit is bundled and we are billing 36833 in error. The only guideline we can find in CPT states open dialysis circuit creation, revision, and or thrombectomy (36818-36833) bundles peripheral segment angioplasty and or stent placement (36901 36902 36903) However dialysis circuit central segment angioplasty or stent placement may be reported separately (36907 36908). Is there any CPT guidelines or any other references that we can use for the appeals to show that we are correct in using 36833 for open thrombectomy with open stent or open angioplasty in the dialysis circuit? 

Fistula Duplex Ultrasound

Patient comes to our office because he is having problems getting dialyzed. Patient is evaluated by the physician and sent for ultrasound imaging. After scanning the patient's fistula, the physician reads the ultrasound and determines that the patient will require an intervention. Can we still bill code 93990 for the scan as well as the intervention if performed on the same day or week? If so, what diagnosis code should we use with the 93990? We have not been billing them due to denials.

E&M for Purse-string Suture

Consultation was requested regarding patient with prolonged bleeding from AV fistula after dialysis. Patient was seen in the ED – persistent bleeding from fistula’s single puncture site. There was no ulceration or infection. Physician placed a single purse-string suture to control bleeding. Is there enough here to code a simple wound repair, or would you code an E&M visit?

Reposition PICC line during AV fistulogram

Please do NOT include any actual patient medical records with your question. I have a question about a internal reposition of a PICC line done during an AV fistulogram. The patient has a right forearm radial artery to cephalic vein fistula. The fistula is punctured, imaging done. Catheter is advanced across the right innominate vein, SVC, into the left innominate and subclavian vein and venogram done of the left arm to look at the possibility of creating an AV shunt on this side. Here is the part of the procedure I am questioning:..."The vertebral glide catheter was removed. We then partially inflated the 9 x 4 P3 balloon at the coil in the PICC line and gently pulled the balloon back in order to resolve the coil. The coil flipped as the balloon passed across this area and we then used the balloon to drag the tip back into the lower SVC. Postprocedure imaging showed the coil to be completely resolved and the PICC line tip was in the low SVC." Should I use 36597 for this reposition or the unlisted vascular 37799? Any guidance from you is appreciated. Thank you.

Fem-Fem Venous Bypass for Venous Occlusion

What CPT code(s) would be best for a left femoral vein to right femoral vein PTFE crossover bypass graft with construction of left SFA to saphenous branch AV fistula?

arterial catheter placements with AV shuntogram

Hi Dr. Z, We have a case here that we have not seen before and would like for you to take a look at it. We would appreciate your feedback on this one. When an AV shuntogram in the upper extremity is done from a lower extremity access location, the imaging code is 75791. The confusion comes in deciding the catheter tip location/coding. If the MD accesses a lower extremity VEIN, to the AV fistula, THROUGH the fistula, and INTO the radial or brachial ARTERY, is the code 36012 or third order vessel (artery) - 36217? Thanks in advance, Stephanie

Embolization right cavernous carotid fistula via SOV

"Dr. A performed a supraorbital cutdown and exposed the superior ophthalmic vein. From here Dr. B was able to puncture the vein using a 20 gauge AngioCath. A micropuncture kit was then used to puncture the right common femoral artery, and a modified Seldinger technique was used to introduce a 5 French sheath. The sheath was double flushed, and a groin was obtained. A 5 French Simmons 2 diagnostic catheter was advanced into the aortic arch and was used to select the left common carotid artery. Microcatheter was advanced over a Synchro 2 soft microwire through the right SOV into the right cavernous sinus. I was unable to catheterize the intercavernous sinus. From here I placed several coils into both the intercavernous sinus and right cavernous sinus with eventual occlusion of the fistula." We have coded 36011, 36215, 61624, 75894, and 75898. Do you agree? 

Remove of Skin Lesion

Patient scheduled for a pocket revision, but the day of the procedure only two superficial skin lesions near the pacemaker incision were removed and placed in Formalin. What should the hospital code?

Fem/Pop Bypass Graft AV Fistula

"Patient had a CTA with run-off showing AV fistula at the fem-pop bypass graft and came to IR. Bilateral run-off was done, catheter was placed in the graft, and embolization occurred with many coils. PTA was done in the popliteal artery at the anastomosis." I believe I should report code 37242 for the embolization and code 37224 for the PTA of the popliteal. The vascular surgeon wants to code the bilateral run-off plus catheter placements. Would you verify for me please?

Bypass graft revision

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

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

Code 36832

After my physician made an incision by the anastomosis, he placed a segment of PTFE graft around her fistula as a band (steal syn.). Then a separate long longitudinal incision was made, and this part of the fistula was mobilized.  Code 36832 is a separate procedure designation. So I do not think I can bill code 36832 with 37607. The patient has Medicare. Also when could I bill these two codes together? Any guidance is helpful.

AV Fistulogram with anigoplasty and basilic venogram

When an upper extremity brachial artery to cephalic vein fistulogram is performed with angioplasty of the cephalic arch followed by selective catheterization of the basilic vein with venogram of left upper arm to determine whether or not the patient is an adequate candidate for a surgical turndown revision, what would you code for the basilic venogram in addition to 36902?

36902 with 36833

The 2017 CPT guidelines indicate that if open dialysis circuit creation, revision, and/or thrombectomy (36818-36833) are performed, CPT codes 36901-36903 are not separately reportable. Am I understanding correctly that if an open revision with thrombectomy is performed in the AV graft body (36833), and an angioplasty is performed of a hemodynamically significant stenosis in the venous outflow through a separate puncture outside of the graft body and anastomoses, that code 36902 is still not separately reportable because it's still in the peripheral segment? My coding software shows that codes 36902 and 36833 are in a PTP edit, but the edit allows a modifier... Would the modifier allowance be for a separate practitioner or separate encounter only? Finally, code 36833 shows as the column 2 code and 36902 as column 1, even though 36833 has much higher RVUs and is more extensive, which is not adding up to me. I want to be sure we are coding hybrid procedures with combined open and percutaneous techniques appropriately, as the procedure seems to have taken a big revenue hit in 2017.

AV shunt interventions

Dr Z - Patient has a lower extremity AV fistula. The physician performs fistulogram (36147). He documents stenosis/occlusion in the common iliac artery (stents); external iliac (angioplasties); arterial portion of the graft (angioplasties). Here are my questions: 1. Would the new codes apply to the graft arteries or do the preexisting guidelines for AV fistula/grafts also apply to the lower extremities? 2. According to the "zones", the adjacent artery is included in the graft so both the external iliac artery and the arterial portion of the graft would be considered one vessel, correct? 3. If the new codes apply, how do we capture the fistula access and imaging? Would we then capture 75791 for the imaging since catheter placement is now included in the lower extremity interventions? Feel free to add any other advice you'd like to give! Thanks in advance.

93931, 93971, G0365

Can we bill codes 93931, 93971, and G0365 for these studies? If not, which codes we should bill? "Reason For Study: Failing left upper extremity fistula. History: Pre-operative mapping right upper extremity for dialysis access fistula placement. Patient states he is asymptomatic on todays exam. Conclusions: 1) Patent right upper extremity arterial inflow with complete Palmar arch. 2) Patent right cephalic vein measuring 5 mm in the upper arm and 2-3 mm in the wrist to forearm, respectively. 3) Patent right basilic vein but diminutive starting at the proximal biceps measuring 2 mm in diameter. Procedure: complete duplex scan was performed using B-mode gray scale imaging, Doppler spectral analysis, and color flow."

Radial artery PTA

"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?

Poorly Maturing AV fistula Coils Angioplasty and Ligation Venous Branch

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

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

Excision of AVF. Dx aneurysm of right arm dialysis AVF

How would you report this case (37607 or 35190)? "The patient was brought to the operating room and was placed in a comfortable supine position on the operating room table. The right upper extremity was sterilely prepped and draped. A longitudinal incision was made over the proximal portion of the arteriovenous fistula. This included an ellipse of skin that would also be excised with the fistula, removing redundant skin where the large aneurysmal segment was. Using a combination of electrocautery and scissor dissection, the cephalic vein was identified and dissected free. The vein was clamped and divided proximally, just beyond the arterial anastomosis. The proximal end was oversewn with a 2-layer running 5-0 Prolene closure. Distally, after excising approximately 10 cm of the fistula, the vein was clamped beyond the area of aneurysmal dilation and was divided. The distal end was suture ligated with a 2-0 silk suture. Wound was irrigated, and meticulous hemostasis was gained with electrocautery. The incision was then closed."

Aortic Arch Aortogram

I have an aortic arch aortogram that was done.  I have been coding 36221 and 75625, but my case was done from a left arm approach. Here is the report:

left: 30px;">Procedure Description: The right radial artery was cannulated. The right brachial artery is occluded. An attempt to traverse a large collateral branch was unsuccessful. The left radial artery was cannulated. Catheters and various guidewires could not be manipulated into the ascending aorta, although the guidewires readily prolapsed back up the innominate artery. Biplane aortic arch angiography was performed, and the procedure was then terminated. Aortic arch: The catheter enters the aortic arch from a left arm approach. There is a linear impediment to flow and passage of the catheter from the arch into the ascending aorta, except for a very small communication at the postero-medial edge of the barrier. With injection into the arch, there is excellent opacification of the three brachiocephalic vessels and RIMA, and only faint penetration of contrast down the descending thoracic aorta.

Pulmonary artery pulmonary vein fistula with shunting

Dr. Zielski,

Good afternoon it has been a while since I have sent you a question. I love the 2012 book by the way!

I have a question that I would like to ask as it is a rare situation that occurred and now I am trying to figure out how to code it.

A patient came to the ER hypoxic and not doing well, went to ICU and was there for several days.  The patient was found to have a right pulmonary artery/pulmonary vein fistula and was shunting past the left atrium.  The patient was not a surgical candidate and on high levels of oxygen. 
This case was a combined effort with the Interventional Radiologist and the Interventional Cardiologist (just like Amir Motarjeme once told me that it would be)
where the Radiologist did the diagnostic and filming via low resolution CT and the Cardiologist managed the intervention (has does the ASD/PFO closures in the Cardiac Cath Lab and is very familiar with the device)

The fistula was closed with an amplazter septal occluder (not vascular plug as there was no "tunnel/tube").
The patient's oxygen saturations immediately increased. The patient was returned to ICU and walked out of the hospital on room air a few days later.

Now my fun begins.  I was thinking of using the embolization codes of 37204/75894. The C code for the device is C1817.
There are no "procedure to device edits" per the Jan. CMS list for procedure 37204.

The patient was an inpatient but all of the charging of procedures are attached to CPT codes as per the chargemaster.

Thank you for your time and consideration.

36831 vs. 36833

"Patient had a thrombosed brachial-axillary AVG. We did an open thrombectomy (36831?) and closed. We then performed a fistulogram and a retrograde brachial arteriogram. It showed kinking and narrowing at the origin of venous end, subclavian, and SVC. Balloon angioplasty was done on both (36907 for the central segment?). As we were closing we could feel the flow turn very sluggish, and over the next 10 minutes had lost her flow completely. We felt we needed to re-evaluate. Therefore, we reopened and found the AVG was thrombosed again. Based on the previous fistulogram retrograde brachial arteriogram I felt we needed a larger arterial inflow and decided to revise and make this an axillary-axillary AVG. This was done utilizing a new graft (36832?). Flow was restored. Another fistulogram was performed and showed everything to be widely patent." Since the open thrombectomy was completed and closed up, would we be able to bill the open thrombectomy, angioplasty of the central segment, and then the new open revision? Or would we just bill the open revision with declot (36832)?

Hematoma AV Fistula

Hi! I'm hoping to get some insight on coding this procedure. Some think it could be a exploration, a repair of a vessel, or a revision.

left: 30px;">BRIEF HISTORY: The patient is a 42-year-old gentleman who has had multiple AV access operations performed on his right arm. He presently appears to have a hybrid access with a vein to artery anastomosis but a more distal graft. He came to the hospital with this access thrombosed. He underwent percutaneous intervention for opening of the access and this was successful; however, the procedure resulted in a large hematoma in the antecubital fossa. This has been painful. It has not shown any sign of resolution. We studied it in the vascular laboratory yesterday because it was pulsatile. We did not find a false aneurysm. However, I reasoned that the hematoma had sealed or at least was causing intermittent sealing of the puncture site. Given the size of the hematoma, the patient required evacuation and exploration. He comes to the operating room at this time for this purpose. DETAILS OF PROCEDURE: The patient was brought into the operating room and placed on the table in the supine position. His right arm was placed at his side on an armboard and was prepared with ChloraPrep and sterilely draped in the usual manner. Supplemental oxygen was given. Vital signs were monitored. Sedation was induced. Timeout was performed. Operation was initiated with the infiltration of 1% lidocaine and 0.5% Marcaine solution into the skin and subcutaneous tissues of the antecubital fossa. Then, a transverse incision was made incorporating the puncture site. Incision was carried into the subcutaneous tissues. The hematoma was encountered and there was some bright red blood within the hematoma. I evacuated the hematoma and as soon as I did, I was met with pulsatile bleeding. I put my finger on the source of bleeding and then opened the incision wide enough to gain access. At the depths of the hematoma, the AV fistula had a puncture site that appeared to be about 8 French in size. Suction was held to control the stream of blood flow and the puncture was closed with 4-0 Prolene suture. Approximately 200 milliliters of blood was lost during this maneuver. Once the puncture site had been sutured, the wound was irrigated and the hematoma and walls of the false aneurysm were further evacuated. Then bleeders were controlled with electrocautery. Subcutaneous tissues were closed in 2 layers of interrupted and then running 3-0 Vicryl. Skin was closed with a running 4-0 Monocryl suture reinforced with skin sealant. A sterile compression dressing was applied. The patient tolerated the procedure well. As noted, blood loss was about 200 milliliters. No blood replacement was required.