Ask Dr. Z

Ask Dr. Z Knowledge Base houses over 7,500 coding questions and answers dating back to 2013.

Ask Dr. Z Disclaimer

Please note this question was answered in 2023. The coding advice may or may not be outdated.

Payer not reimbursing 37228 d/t "significant residual stenosis"

Date: Jan 24, 2023


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

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

The payer is denying payment with these remarks:

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

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

Sign up for a membership to view the answer to this question.

Need to ask Dr.Z?

Don't see the answer you're looking for in the knowledge base? No problem. You can ask Dr. Z directly!
Ask Dr. Z a question now!