Ask Dr. Z

Removal of FFBPG at Same Time as ABF

A patient has a fem-fem bypass graft that keeps clotting. Doctor wants to “take down” the fem-fem graft and put in an aorto-bi-femoral graft. I cannot find a code for the take-down of the graft other than removal of infected graft. This fem-fem graft is not infected. Is the take-down included in the aorto-bi-femoral graft, or would a -22 modifier be appropriate? Any suggestions?

Removal of fem-pop PTFE bypass grafts x 2

There is a code for removal of an infected graft in the lower extremity, but I can't seem to find the code for removal of a graft that is not infected. The patient had a removal of a fem-pop PTFE bypass graft x 2.

Removal of AV Graft

"Patient had a removal of an AV graft that was painful by taking the graft off the brachial artery just above elbow and suturing it. Incision was then made over the graft in loop-like fashion up the axillary vein, with graft removed from subcutaneous tissue. A large stent was removed as well, which was across the venous anastomosis, then the vein was sutured. Arm was then sutured." I thought 36815 included a revision or a closure, but it has a device-dependent edit. With removal there was no device placed. Is this code correct? If it is correct, how do we get this paid with the device-dependent edit? If not, what would be correct?

Removal of Graft

"Patient has thrombosis of aortofemoral bypass graft. Physician performed excision of PTFE femoral-femoral bypass graft with vein patch angioplasty and repair of right common femoral artery. Then he redid right to left femoral bypass graft using cryopreserved femoral vein. The patient does have some persistent drainage from the resent surgical wound in her right thigh, therefore a decision has been made to use cryopreserved femoral vein." Can I bill code 35903 for removal of infected graft with code 35661? Please advise.

Percutaneous Removal AV Graft Stent

What CPT code we would use for the removal of the AV graft stent? "1) Antegrade and retrograde ultrasound-guided access to the right forearm AV graft (image stored x2) with fistulogram and left brachial arteriogram. 2) Foreign body retrieval, arteriovenous graft covered stent removal. 3) Pharmaco-mechanical thrombolysis of AV graft. 4) Percutaneous transluminal angioplasty of arterial and venous anastomosis with completion fistulogram. PROCEDURE: Through the antegrade sheath, wire access was obtained through the arterial limb stent graft and into the venous limb of the graft. A 10 mm Gooseneck snare was advanced over the wire. The stent was constrained with manual compression on the skin and captured with the snare. The snare and sheath were removed as a unit over the wire. Covered stent graft was removed in its entirety. Successful retrieval of the constrained indwelling covered stent in the arterial limb of the graft. The previously noted iatrogenic graft-venous fistula is no longer present. Successful arteriovenous graft thrombolysis."

Hemodialysis Access

"Patient presents for removal of infected peritoneal dialysis catheter and creation of right axillary to right basilic vein AV graft. The next day patient returned to OR for removal of AV graft with patch repair due to arterial steal right hand. A new AV graft using PTFE from right subclavian artery to right basilic was performed." Would codes 36830-78 and 37799 be the correct codes for the return to the OR?

35881

My physician does the following on a previous common femoral to peroneal bypass using saphenous vein. Due to the vein graft stenosis a previous covered stent was placed in the distal portion of the bypass graft. The patient presented with exposure of the covered stent. My physician performed the following procedures: Revised the proximal saphenous vein anastomosis with interposition of a cryosaphenous vein graft at the anastomosis to upper thigh saphenous graft due to intimal hyperplasia of the proximal several inches of the saphenous vein graft. Revised the distal saphenous vein anastomosis with removal of the penetrating stent and interposition of cryosaphenous vein graft at the anastomosis up to the distal thigh saphenous vein graft with removal via catheter of thrombus from the peroneal down to the level of the ankle. I considered codes 35881 or 35876. Would I code it twice? Would I code removal of the stent separately and if so what code would I use? Since the thrombus removal was down to the ankle, would I code separately for that?

Partial Removal of AVG

Patient has an infected AVG. This required a partial explantation of the medial limb of the graft. Are we allowed to bill 35903 with or without a modifier for the first partial removal since the entire graft was not removed? The patient returned two weeks later, and the remainder of the AVG was removed.

36832 plus removal of old grafts

Should we also report the removal of the old grafts, or would this be included in 36832 since it was in the same area? "Once we had dissected out the Hero graft, and also dissected out the old graft that it was also in this area causing confusion for the technicians at the Dialysis Unit, we now brought an 8 mm PTFE graft on to the field and then tunneled medially between the 2 locations. We systemically heparinized the patient, clamped the patent graft and then opened it. We beveled both ends and created end-to-end anastomosis utilizing 6-0 Gore-Tex stitch. This was performed at both ends of the graft. We now released the clamps after flushing the system and they were rewarded with good flow through this. Now, we turned attention to resecting the previously placed grafts. The occluded graft was then removed utilizing electrocautery and blunt dissection. The stumps were oversewn. An additional graft was also noticed at this point and it was also removed utilizing electrocautery and blunt dissection. We copiously irrigated. We obtained hemostasis."

Vein Patch After Removal of AV Graft

Total excision of an infected left upper extremity AV graft was performed. Afterwards they harvested the distal brachial vein for a vein patch. The vein patch was sewn onto the brachial artery to repair the artery after the graft had been removed. I reported code 35903 for removal of the infected graft. Should a code also be assigned for the vein patch repair of the brachial artery?

Removal of Non-Infected AVG

I could use your input on the following scenario: The patient has a non-functional AV bovine graft in the left forearm, which our physician ligated and removed to prevent steal phenomenon in a new upper arm fistula, which he created in this same operative session. Normally, I would code for the ligation of the AV graft (37607) and the creation of the new upper arm direct type fistula (36821). Is there another code that could be used for the ligation and removal of the old forearm graft, which was not infected? The ligation was successful, but our physician was concerned that once he created the new AV upper arm fistula the patient would develop a steal phenomenon without removing the old forearm graft.

Placement Dialysis Graft-with removal of old graft

What would you think about the coding for placement of a new left arm prosthetic dialysis graft, excision of old prosthetic graft (different incision) and ligation of old left arm AV fistula with wound vac? Note said high potential that it was contaminated and possibly infected? I will query provider about that. But without, could you code 36830 LT, 37799, 37607, and 97605?

35011

Greetings, I have a repeat patient that I emailed for coding advice before. The pt had 3 grafts excised on one arm. The pt is back and now has a mycotic pseudoaneurysm at the repair. The brachial graft was infected. They removed the graft(35903). They also performed a axillary-brachal bypass (35522) and also removed the aneurysm when they removed the graft. Are these two codes that you would code? I would not code the aneurysm removal as it was removed with part of the infected graft. LW

Removal of an Infected Graft

Greetings, I have a physician coding both 36832 and 35903 for the following procedure procedure. I do not think I can bill these two codes together in the same area. Here is what the physician surgically completes: He opens at the site of the graft and drains the sinus tract. He transects the graft on the venous side. Then he make add'l incision and places a new peice of graft tunneled well away from the infected area and anastomosed to the remenent of the venous side of the graft then he transects the arterial side of the original graft and attaches the new graft to the remenent of the old graft. At the end of this the physicuan goes back to the original incision and removed the piece of infected graft. My thought is I can only code this as a revision using code 36832. Am I correct, or is the physician correct? 

Repair AV graft

Greetings, Pt had removal of infected AV graft 35903. He repairs the artery and vein with a bovine patch. Is this considered revascularization or repair. I'm checking to see if I can bypass edit. LW

conduit removal

Cardiac surgeon does a graft conduit of axillary for Impella placement, then a week later removes it. I went with unlisted code 33999 for implant of conduit, but I am not sure on the removal. I am thinking 13160 or 33999. thoughts?

Thrombectomy of AV graft with fistulogram and removal of AV graft

This patient had a thrombectomy of his AV graft with a fistulogram that showed an occlusion higher up in the arm at the axilla. Decision was made to take down the AV graft. Do you code this to a thrombectomy of the AV graft (36831)? Or is this an unlisted procedure of the vascular system (37799)? "Graftotomy was made in the arterial limb of the graft, and patient was given heparin. A thrombectomy was performed with a #4 Fogarty, clearing the graft material of clot. A fistulogram was performed, demonstrating a total occlusion higher up in the arm at the axilla. After multiple attempts, we still could not clear the total occlusion in the left upper extremity vein. At this point, because of the presumed contact in the outflow obstruction, it was elected to remove the graft material in the forearm loop. Next, a counter incision was made in the distal forearm, the graft material was dissected free of surrounding tissue with the scissors, and then the loop of the AV graft was removed."

Removal Hero Graft (non-infected)

"A patient with a recently placed Hero graft has developed a thrombosis from the graft through to the central venous catheter portion. Despite thrombectomy the surgeon determines that the patient is in a hypercoagulable state, and, because of variant anatomy of the right atrium, the graft (as well as the central venous portion) is removed in its entirety. The separate temporary dialysis line in the patient’s femoral vein is replaced OTW with a tunneled dialysis catheter." Since the graft is not removed due to infection, would this be reported with code 37799 rather than 35903?

TEVAR with cutdown and bypass

We had a TEVAR that had complications. Per procedure: "Upon removal of the stent graft, we encountered resistance. Reliant balloon was placed in infrarenal aorta to control bleeding." Quick summary: "Based on removal of external graft, there was injury to right external iliac, which ended up requiring stent grafting of the iliac artery and subsequent cutdown for ligation of right common iliac artery and fem-fem bypass." We coded as 33881, 75957. Would the extra work be considered billable as 37617, 34820, 34813?

LV Lead Removal/Multiple Lead Removal

We are seeking clarification on the correct coding of two scenarios: LV lead removal and multiple lead removal. After extensive research, we are finding conflicting guidelines from multiple reputable coding resources. For LV lead removal, some say the LV lead removal is included in the appropriate removal code, whereas others say report unlisted for LV lead removal. For multiple lead removal (more than two leads), we found three different coding suggestions: 1) append modifier -22 when more than two leads are removed to capture the additional work; 2) report unlisted for multiple lead removal, as the current CPT codes do not capture multiple lead removal; and 3) report the appropriate removal code even if more than two leads are removed, as these codes cover all leads. These two scenarios overlap in some cases, which adds an extra layer of confusion (e.g. RA, RV, and LV lead removal). Please provide your expert opinion and rationale.

Removal of venous component of thrombosed upper extremity HeRO graft

"One of our patients had a thrombosed HeRO graft of the left internal jugular. The procedure started with removal of the venous component by our vascular surgeon. It was replaced with 16 French peel-away sheath. The interventional radiologist then tunneled a hemodialysis catheter from the left anterior chest wall to the left neck incison. The tip was positioned in the superior vena cava under fluoroscopic guidance. Catheter was then flushed and secured to the skin." Is this a co-surgery, and what code should we use? Or are there two separate codes, one for the vascular surgeon's removal and one for the interventional radiologist's placement of a tunneled left internal jugular hemodialysis catheter? And what would those codes be?

Thigh dialysis graft

How would you code an AFV graft created in the thigh with removal of infected PTFE graft in opposite thigh? Documentation: "Dissected out the GSV and clipped the distal vein above the knee then transected and pulled through toward the groin. In the mid thigh we created a curved tunnel medially and laterally from the groin towards the counterincision. We clamped the SFA and created arteriotomy. We then spatulated our GSV and performed an end-to-side proximal anastomosis. Next we turned our direction to the opposite thigh and infected PTFE graft and dissected around the old exposed PTFE site from that thigh and removed it from surgical bed." 

Are these two separate procedures? I understand arm graft creation, but not sure if thigh AFV is treated the same.

Removal of an Occluded Lower Extremity Bypass Graft

One of our physicians removed an occluded lower extremity bypass graft. Would code 35903 be correct to use? If not, what would be the correct code? There was no revision performed or a new graft.

Removal of gastrostomy tube

We have a patient that came in for a gastrostomy tube removal and they used flouro.  We know that with chest tubes, gastrostomies there isn't a code for removal and they normally just pull these out. What if they use flouro, are we able to charge for these? Either with a low E&M or the flouro time? Below is the report that we have. Thank you so much for looking at this.

Thank you,


HISTORY: Removal of a percutaneous gastrostomy tube as it is no longer
required for feeding.

PROCEDURE: Fluoroscopic guided removal of the gastrostomy tube.

FLUORO TIME: 0.2 minutes.

PROCEDURE DESCRIPTION: The retention balloon was deflated and the
gastrostomy tube was removed. An image was obtained to document complete
removal.

IMPRESSION:

Fluoroscopic guided removal of the indwelling gastrostomy tube.
 

AVG Failure, AVF creation with same vein

"Patient has failed AVG in the forearm and presents for new AVF. The cephalic vein was identified, which had been part of the previous graft. The graft was dissected, and the segment connected to the cephalic vein was excised. The lateral branch of the cephalic vein through which the graft was connected was remodeled and oversewn with stitches. Brachial artery and cephalic vein were used to create the new AVF. Only the cephalic end of the AVG was removed."

Would this be considered a revision or removal with modifier -52 and new AVF code? (Brachial artery not used in the original AVG)

Takedown of infected axillary-fem-fem bypass; axillary only

"A patient has an infected left axillary-fem-fem bypass. The surgeon creates a right axillary PTFE graft and attaches it to the existing fem-fem bypass, thereby creating a new axillary-fem-fem bypass. Surgeon then proceeds to take down the left axillary bypass, which is infected. But, only the axillary graft is removed." Surgeon wants to report 35654 for new PTFE axil-fem-fem and 35907 for removal of axillary graft. Is this appropriate since the fem-fem portion was not removed, only a new anastomosis from the axillary to the right femoral graft was added?

Removal of Previously Placed Occluded Graft

We could use help on coding for the removal of the previous placed occluded graft. "Procedure: The common femoral, the superficial femoral, and profunda femoris arteries were dissected first on the right and then on the left. The femoral-femoral crossover bypass was dissected. The bypass was found occluded. The patient had an excellent pulse on the right side, but no palpable pulse on the left side. We cross-clamped first on the right side the distal external iliac artery, the profunda femoris, and the superficial femoral artery. We transected the femoral-femoral bypass that was occluded, and excised as much graft tissue as possible so that we had a good inflow through a wide opening in the right common femoral artery. On the left side, an identical procedure was performed of the occluded superficial femoral and profunda femoris artery. We transected the femoral-femoral crossover bypass. We almost completely excised the old graft that was well incorporated. It had no evidence of infection."

Graft Thrombecomy with revision

Hello, I need help :) The surgeon did a Graft Thrombecomy with revision (36833). He then did a fistula gram (36147) and because of stenosis in the venous outflow did an PTA (35476 & 75978-26). And a segmental incisiion of graft & overlying skin with primary closure??? Separate incision and closure.. Diag: End-stage renal disease, thrombosed graft fistula with recurrent bleeding from the false aneurysm of arterial limb of the graft with skin erosion. After revison/thrombecomy proc; The inflow was then tapered due to the incision..sheath removal of the graft was clamped proxiamally and distally, sheath withdrawn and sheath hole closed with sutures. Clamps released and palpable thrill was present along the graft, hemostasis was obtained. Counts ere correct x2. The wounds were closed in layers with Vicryl & Monocryl for teh skin Dermabond waa applied to seal wounds. This is what I am not sure about: Incision was then made to excise the sutured skin at the site of graft bleeding. The skin was excised as well as the underlying graft. No evidence of infection. The wound was reapproximated with nylon suture. Because this was a separate incision and it was done after the revision was completed, he feels he should get credit for the work. Since the graft was no infected, I am thinking this is still a part of the revision but not 100% sure. Your advice would be so appreciated! Thanks you!

Open thrombectomy of bypass with stent

I am trying to code this for physician. Would you report code only 35371 for this procedure? "Incision made below right knee artery in previous scar from prior bypass graft with dissection down to graft. A transverse arteriotomy was made on the graft, and a thrombectomy was performed of the distal graft into the pop and PTA arteries, using various Fogarty with removal of thrombus. I was unable to pass a catheter proximally, so an angiogram was done to check for proximal occlusion. A sheath was inserted with the bypass graft, and guidewire was able to traverse the proximal stenosis. Angiogram was done and angioplasty of proximal graft completed. Unfortunately, residual stenosis or thrombus was still present in stenosis, so a stent was placed. The graftotomy was closed. Then a micropucture was used to access the graft, and angiogram showed residual thrombus at distal anastomosis of the graft. Graftotomy was reopend and repeat thrombectomy performed on thrombus. The arteriotomy was closed, and completion angiogram showed flow through anastomosis into foot." 

Removal of Retained Filter Fragments

"Patient with prior IVC filter removal, now for removal of two retained filter fragments. Via right CFV, venacavogram and 3D rotational venography are performed to assess fragments. A sheath was passed and positioned in the infrarenal IVC. Alligator forceps were used to retrieve both fragments under biplane fluoroscopic guidance, with both fragments retrieved intact." We know 37193 is used for IVC filter removal, but question if the retained fragments should be reported as foreign body removal 37197 rather than 37193. What are your thoughts?

Transcaval Impella Removal

Can you advise what you would code for the removal of an Impella 5.0 that was placed in the left ventricle via transcaval access from right common femoral vein to IVC/Ao? We reported unlisted code 33999 for the placement, but not sure if coding the removal (33992) would be appropriate since they are placing an Amplatz ductal occluder to close the transcaval site in addition to the removal of the Impella.

Dear Dr. Z, we've got a case that's challenging my understanding of the new dialysis graft/fistula codes. Your comments & advice would be welcome. CLINICAL DATA: PT W/HX OF RT.FOREARM LOOP GRAFT AND RT. UPPER ARM AV GRAFT, REFERRED FOR EMBOLIZATION OF RT.FOREARM LOOP GRAFT AS WELL AS DIAGNOSTIC FISTULOGRAPHY OF RT.UPPER ARM AV GRAFT. Procedures performed: 1. Retrograde access of rt.forearm loop graft. 2. Diagnostic fistulogram. 3. Selection of axillary artery & performance of a rt. upper extremity arteriogram for eval. of brachial artery. 4. Amplatz embolization of arterial limb of rt. forearm loop graft. 5. Antegrade access of right upper arm AV graft. 6. Diagnostic fistulogram of rt. upper arm AV graft 7. PTA of venous anastomosis with an 8mm balloon. 8. Removal of sheath & catheters and hemostasis obtained w/manual compression. (Note:I have not typed out the body of the report because physician did such a good job in this procedure heading list, but if you need, will be glad to provide) I've arrived at these CPT codes: 37204 + 75894; 36147, 75658-59 for study/work on forearm graft. 36147(?-59) and 35476 + 75978 for study/work on upper arm graft. My question: 36147 did not edit out in our Encoder when coded x2; do you think it will be correct to submit x2 since pt has 2 different grafts in one arm? Also do you agree with 75658-59 for studying brachial artery? Did not code 36120 since brachial artery not directly punctured; axillary artery selected after retrograde access in rt forearm loop graft. Any suggestions you have would be appreciated. THANKS SO MUCH FOR YOUR HELP! :D

Removal of Infected Patch

My physician performed/coded a surgery and needed help with a code for the removal of the infected graft. The patch was placed 13 years prior by another physician. 1) Removal of infected Hemashield patch on carotid artery with a vein patch angioplasty (right proximal saphenous vein harvest). 2) Reoperative carotid artery operation greater than 1 month,  35390 (however, I'm not sure if 35390 is appropriate since he was not the surgeon who performed the original surgery). 3) Resection of carotid artery wall and partial endarterectomy for completion of procedure, 35301 (since this was partial should we add modifier reduced services?). Any help would be appreciated. 

Non-Infected AV Graft

Have they put out a new code for removal of a non-infected AV graft, or should we still be using the unlisted code?

Open small AAA repair w/aorto-bifemoral bypass graft

I coded: 35081, 35371-50. I feel like I am not accurately coding for the femoral graft procedures. Open aortic exposure performed w/vessel control. Aortotomy made w/removal of thrombus and plague. Dissection carried down to the aortic bifurcation and RT & LT CIA arteries. Blunt dissection used from femoral incision up to retroperitoneum. Dacron graft applied end graft to end aortic anastomosis. Left femoral arteriotomy made & extended in CFA down to SFA, 1-2 cm. Endarterectomy performed. Left limb of graft approximate to arteriotomy. Right femoral arteriotomy performed, extended 2-3 cm into SFA. Endarterectomy performed. Graft applied end to side. Fogarty embolectomy performed, 5 passes, due to no backbleed from SFA. Anastomosis completed, flow reestablished to femoral vessels. Fascia closed. Femoral incisions closed. Am I missing a code or is there a more appropriate code?

33241, 33244 LVL lead removal

A patient has a BiV ICD and it is being completely removed - nothing is being replaced. 33233 PM removal 33235 Remove leads dual system Can we charge for the LV (CS)lead removal? Unlisted code or is there something we aren't seeing in CPT book? Thanks, Lori Sprenger

jump graft common femoral to profunda artery

Would we code anything for profunda jump graft in addition to CPT code 35646?

"Procedure(s): Aorto to left iliac and right femoral bypass 18 x 9 and ligation of right femoral artery aneurysm, profunda bypass with 6 mm graft, profunda endarterectomy.

Dissection included dissecting out the femoral artery aneurysm, which was ligated, profunda bypass with a 6 mm graft. Aorta endarterectomy and stent removal were performed, and then an 18 x 9 Dacron graft was sewn into side. I then turned my attention to tunneling the right limb of the graft through the inguinal canal, and my assistant started the anastomosis to the common femoral after ligating proximal femoral aneurysm forming endarterectomy at the SFA and profunda and was performing common femoral anastomosis along with his profunda jump graft, I performed the left limb to the proximal common iliac artery end-to-side anastomosis."

Aborted vena cava filter removal

Dr. Z, In your online question (this is an old one OCt 13, 2005 )when filter removal attempted however unsuccessful your advice code only the completed procedures 36010 75825. The online book page # 197 Instruction # 6 if filter not removed, only code the catheter placement and cavagram. For our scenario patient schduled for filter removal after venogram no clot noticed proceeded to removal after an hour of multiple different maneuvers (snare) the decision was made that the filter was positioned such that removal would be very diffcult. Procedure abonded. Since hospital charged for snare not sure if we can also code 37204-74 to justify the attempted filter removal along with 36010 75825-59? please advice. Thanks

Open IVC Filter Removal

I have a patient who had a failed attempt at endovascular removal of the IVC filter. One month later the patient has developed abdominal and back pain and is deemed an appropriate candidate for exploratory laparotomy and open removal of the IVC filter. Would you code the open removal as 34502 or 35221? The filter penetrated through the IVC and duodenum, which another physician stepped in to repair (44602). Does 34502 or 35221 include removal of the filter with vessel repair, or should I look to using an unlisted code?

Graft/CFA thrombectomy & SFA/PFA dissection flap removal patch angioplasty

"Occluded right CFA limb of a right axillary-bifemoral bypass. Previous right groin incision reopened. Fresh inflammatory tissue surrounded the graft and femoral dissection. Dissection carried down to SFA and 2nd order branch of PFA. Graft removed from CFA and found with semi organized murky thrombus. Thrombectomy of the right limb of bypass graft with a forgarty to establish inflow, then from CFA, SFA, and PFA. Arteriotomy extended onto the SFA and PFA where occlusive dissection flaps were found, removed, and tacked down with prolene stitches. Arteriotomy was patched with bovine pericardium with extension of the patch onto both the SFA and PFA. Arteriotomy was made into the patch at the CFA, and the bypass was reanastomosed to the patch in an end to side manner." Is this coded with 35876 only? Or with 35302 and 35876?

Update Impella Device inserted through axillary artery conduit

Have there been any updates to the advice on coding open Impella insert through axillary conduit as 33990 and 34716? The manufacturer rep is stating coding should be 33975 34716 to the physician. Description of procedure as follows:

"Axillary artery clamped and incision created. A 10 mm Hemashield Dacron graft was cut with bevel and end to side anastomosis was created between graft and axillary artery. The graft was then tunneled and made inferior and lateral to axillary incision. Valve was placed on end of graft and wire was passed and manipulated across the aortic valve. Catheter advanced over wire and placed into ventricle. Impella device was advanced over wire and placed across aortic valve. Wire removed and device activated. Graft was cut back to skin level and introducer secured to graft and device secured to skin."

Would removal of same device through same access (axillary conduit) be coded as 33992 or use unlisted since the axillary has to be repaired from conduit? Or 33992 with a 22 for repair of axillary?

Biventricular ICD Removal

What codes would you bill for a complete biventricular ICD removal? Patient was having complications, so the physician removed the generator, RV ICD lead, RA ICD lead, and LV ICD lead without replacement of anything. Is the LV lead removal billable? If so, what code would you suggest?

Reboa removal

Trauma providers are asking if they can bill for a removal of a REBOA days after it was placed. They are asking if they can bill 33971. I don't feel this would be appropriate, but I would like to know your thoughts. Is there a code that can be billed for removal of REBOA?

Removal of Midline Catheter

Is the removal of the midline catheter included in the placement code 36410? So you don't report anything for the removal?

Wound Vac Removal and Hematoma removal for ICD pocket infection

An ICD generator and lead were removed due to a pocket infection and a wound vac was placed. The patient was brought back in 5 days. Local anesthetic was infiltrated, and moderate conscious sedation was administered. The wound vac sponge removed. The ICD was pocket irrigated with antibiotics solution and residual hematoma removed. The wound was inspected without signs of infection. The pocket was closed with sutures. The report calls this a successful CIED pocket/wound debridement, wound vac removal. Is the closure coded 12020 or 13160 or the hematoma removal 10140, no incision is mentioned? Is the wound vac removal included in the placement?

AV graft revision followed by graft relocation

Please do NOT include any actual patient medical records with your question. Dr.Z, We have a patient with upper extremity autogenous AV graft came with graft malfunction. open thrombectomy and open PTA performed then residual stenosis noted and decided the graft is not amenable to revision. So created new AV fistula in the same extremity basillic vein to brachial artery. My question since they are not using the graft can we still use 36833 and 75791 for the graft procedures along with 36821? Please advice. Thanks

IVC Filter Removal

Code 37193 is specific to endovascular removal of an IVC filter. What code should be used if the removal converts to an open approach? Would we use the unlisted code?

CPT code 35883 used alone or with other codes?

I am having trouble deciding when it's appropriate to use code 35883 alone or with other codes. What all does this code include? One case - previous iliofemoral bypass, which was aneurysmal. "After dissection and mobilization it avulsed off the proximal anastomosis. The entire graft was removed from operative field, and a new 8 mm graft was placed in the same location, distal external iliac to distal common femoral." Is this reported with code 35883 alone or just removal of graft (37799) and 35665? The other case was similar, ax-fem-fem bypass with aneursym on left femoral artery. "Patent ax-fem on the right, occluded fem/fem. Thrombectomy of right to left fem/fem. Aneursym of left femoral artery resected and interposition graft was placed left femoral artery to left profunda artery after it was thrombectomized." Is this codes 35883 and 35875-59 (for fem/fem thrombectomy)??? Also considered 35876. Can you please advise on these cases and how to determine when to use 35883 alone or with other codes.

Biliary drain removal

Does the patient have to have a biliary stent in order to code a removal of biliary drainage catheter? (They are using fluoro guidance.) The patient presents for tube check with possible removal of cholecystostomy and ultimately removed it... I would report code 47537 correct?

Direct punture into graft limb with imaging

Denial received for use of 36246, 75710. Please clarify is this is allowable. This is diagnostic, no recent studies billed with 35876 for primary procedure, notes states graft was punctured. The aortofemoral bypass graft could be seen coming down into the femoral level here. Next, the origin of the fem-pop bypass graft could be seen with a patch on this. A micropuncture was then placed above into the graft here, and a wire was placed. Then, an angiogram was performed of the left leg, which showed that the profunda had a significant stenosis where the patched area was, but that there was a patent fem-pop bypass graft with very slow flow due to distal occlusive disease in the graft.