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34201

Hi, My Dr. performed open cutdown of left common femoral artery and left over the wire popliteal thrombectomy. How do I code the over wire thrombectomy. Should I use 34812 for cut down and 34203-22 for over wire thrombectoy? Please advise. Thanks, Renata

34502

Dr. Z I need help coding Innominate vein to right Atrium bypass with a spiral vein conduit

34800

In your book Vascular & Endovascular Surgery Coding Reference on page 240 example # 4 you use 35286 along with 34802 but when I put all the codes in I come up with that code as bundled. I thought you could not do anything else with the AAA repair. Can you help me to understand? Also can you do and endarterectomy of the common femoral when doing a AAA?

34800 aneurysm repair

Hello Dr Z, Is a percutaneous endovascular repair of the abdominal aortic dissection coded the same as open AAA repair (34800 & 75952)? We did a percutaneous mid abdominal aorta repair using 3 Gore Excluder as an outpatient procedure. CPT 34800 and 75952 require inpatient stay. How would I code this? Thank you in advance and see you in Nashville Melissa Russo

34802

Dr. Z..Please help. Endovascular repair. States caths, angios already in there then: following this, the device, 30 x 18 x 170 device was then placed via the right groin. It was advanced up to approximately the first lumbar vertebra, as well as the pigtail catheter. Then using a series of injections using 10 cc I was able to deploy the proximal portion of this endovascular prosthesis. It was deployed to the point that the figure of eight markers were seen on the gate. This was ballooned and inflated and pulled down into the prosthesis which appeared to be in good position. Next the retrograde injection was performed. The markers were counted out. It was felt that we could complete this procedure with a 14 x 16 x 105 prosthesis. This was deployed without difficulty. Next, the deployment on the right side was then completed. At this point the entire graft and distal fixation point were then angioplastied. Is this a 34802 or a 34803 or 34802 with a 34825 with the 75952 and/or 75953.

34802

Could I get your opinion on this one please? I just wanted to see how many extensions you come up with for this one...here's what i'm thinking 34802 34812-50 36200-59-51-rt. fem punc. 75952 75953 x3 34825-51 34826 x2 36246-51-int. iliac cath (I was thinking maybe 1st order?) Embo (75894/37204/75898) was done by cvir phys. do you agree with 3 extensions? thanks! OPERATIONS PERFORMED: 1. Endovascular repair of abdominal aortic aneurysm using a Gore excluder device. 2. Left side ipsilateral 28.5 x 14.5 x 180 mm main body device. 20 x 95 mm distal extension into left common iliac artery. 14.5 x 120 mm distal extension into left external iliac artery. 3. Right side contralateral 20 x 115 mm contralateral limb. 26 x 33 mm aortic cuff (distal extension into right common iliac artery). 28.5 x 33 mm aortic cuff (distal extension into right common iliac artery). 4. Bilateral femoral artery cutdowns for exposure. 5. Second order catheterization of branches of left internal iliac artery from left femoral approach. 6. Transcatheter embolization and occlusion of left internal iliac artery (performed by Dr. Peter Waybill). ANESTHESIA: General endotracheal with supplemental local. DRAINS: None. TOTAL CONTRAST USED: 144 mL. INDICATIONS: Mr. Kettering is a 79-year-old gentleman with a 6.1-cm abdominal aortic aneurysm, which has been growing. He is brought to the operating room for endovascular repair. The risks, goals, and alternatives were discussed with the patient who understood and gave consent to proceed. OPERATION: A time-out was performed, the patient identified and procedure verified. General endotracheal anesthesia was induced without incident. The abdomen and both groins were prepped and draped in the usual sterile fashion. The patient received preoperative antibiotics within 1 hour of incision time and preoperative steroid and Benadryl administration was performed given the patient's known history of intravenous contrast. The common femoral arteries were then exposed through bilateral oblique groin incisions. These were performed a little bit higher than usual because of the heavy calcification of the femoral bifurcations. The inguinal ligament was identified and elevated cephalad. The distal external iliac artery was prepared. The crossing circumflex iliac veins were divided bilaterally. Soft spots were identified bilaterally for use. Single wall puncture technique was used on both sides, and a Bentson wire was inserted up into the abdominal aorta. 7-French sheaths were placed on either side. On the right, a marker pigtail catheter was inserted up in the perirenal aorta. On the left, a Lunderquist wire was inserted and over this the 7-French sheath was up sized to an 18-French DrySeal sheath. An aortogram was then performed, demonstrating the location of the renal arteries with approximately 150 mm of distance from the renal arteries to the aortic bifurcation. Based on this, a 180 mm length device was chosen with the left side used as the ipsilateral side. It was oriented such that the contralateral gate would be anterior. The device was then passed up through the sheath and was deployed just below the renal arteries without any complication. The C3 deployment system was used and only the proximal portion of the device was deployed. With a series of wires and catheters eventually requiring a C2 catheter and an angled glide wire, the contralateral limb gate was engaged and a pigtail catheter inserted and spun within the graft to confirm intragraft positioning. The pigtail was then advanced up and given that the device had been in position but not anchored for quite some time while the contralateral gate was engaged, I shot another aortogram demonstrating that the graft is still in good position. The remainder of the graft was then deployed and via the left side a 32-mm Coda balloon was inserted and the proximal attachment site ballooned to profile. The pigtail catheter had been exchanged at this point for a Lunderquist wire on the right. This side was also up sized to an 18-French sheath. Prior to this, a sheathogram was performed locating the right iliac bifurcation. We knew we are going to have to place a larger cuff on this side and so a 20 x 115 mm device was chosen to land us just into the right common iliac artery and allow room for distal cuff. This was placed via the left-sided 18-French access and deployed uneventfully. Another injection via the right sheath was done to locate the iliac bifurcation and a 26 x 33 mm aortic cuff was used as a distal extension on this side to obtain seal. The Coda balloon was then inserted, and all junction points and the distal attachment site were ballooned to profile. Injection via the left sheath was then performed to identify the iliac bifurcation. Based on preoperative measurements, it appeared that a 20-mm device would obtain seal and so a 20 x 95 mm device was inserted up the left side access and deployed uneventfully. The Coda balloon was inserted here as well, and all junction and distal attachment sites were ballooned to profile. An aortogram at this point was obtained, which showed a fairly extensive type 1B endoleak from the left side. It did not appear that a further ballooning of the limb would achieve seal, and so I chose to extend. At this point, I had a choice of either extending into the external iliac artery or placing a larger cuff. There was not a lot of room here between the end of the extension piece and the iliac bifurcation and so I reviewed the films with Dr. Waybill from Interventional Radiology, and we agreed that embolization of left internal iliac would be appropriate. The left internal iliac artery was then accessed by inserting an angled glide wire and the C2 catheter up the left-sided 18 French sheath as a buddy wire type system, so that we did not lose access across the device. The left internal iliac artery was cannulated successfully and the wire was inserted into the distal branches of the internal iliac artery. The catheter was able to follow and a Rosen wire was inserted to achieve a little bit more stiffness of the wire into the internal iliac artery branches. The catheter was then removed and a 7-French sheath placed into the distal internal iliac artery branches. The embolization of the left internal iliac artery was performed by Dr. Waybill and is dictated separately by him. Briefly, an 18-mm Amplatzer device had been chosen and was placed under fluoroscopic guidance with additional injections of contrast to confirm placement at the left internal iliac artery origin. This was deployed uneventfully, and the 7-French sheath was then removed. A 14.5 x 120 mm length extension was then chosen and placed up the left side and deployed about 3 cm into the left external iliac artery uneventfully. The Coda balloon was used to balloon this to profile as well. Another completion arteriogram was performed revealing a type 1A and type 1B leak from the right iliac attachment site. The proximal endoleak was addressed by reinserting the Coda balloon and ballooning the proximal attachment site to profile. Several additional images were performed with various obliquities on the right side, and I chose to extend a little bit farther with a 28.5 x 33 mm cuff on the right. This was inserted uneventfully and ballooned to profile. A completion arteriogram at this point revealed resolution of the type 1A endoleak a much slower flow into what was thought to be a type 1B endoleak but on further review, it appeared that it may have been a type 2 endoleak causing this puddle of contrast at about the midportion of the infrarenal aorta on the right. At this point, I did not feel that further extension along the right would be appropriate given that I had already sacrificed the left internal iliac artery, and I chose to terminate the procedure. All wires and catheters were removed with a good pulsatile blood flow noted, and both arteriotomies were repaired with interrupted 5-0 Prolene suture. Backbleeding, forebleeding, and flushing maneuvers were performed prior to closure, and all wounds were checked and made hemostatic. The wounds were then closed with interrupted Vicryl with Monocryl for the skin. Dry sterile dressings were applied. The patient was awakened and extubated and taken to recovery room in stable condition and tolerated the procedure well without immediate complication. Intraoperative autotransfusion was not used.

34802

Please tell me how you would code this case? Is there a code for the contralateral limb? or is it included in the 34802. we placed 2 Perclose devices after accessing the right common femoral artery. We then placed a 7 French sheath in each common femoral artery and then advanced an angled guidewire into the right common femoral artery, up into the distal abdominal aorta. With this in place, we then used a 5 French pigtail to perform our first aortogram and runoff. With the first aortogram and runoff, we identified the takeoff of the right and left renals. We did have some overlapping on the left side with the inferior mesenteric artery. It required 2 extra aortograms with 1x magnification to fully delineate the takeoff of the left renal. Once we had this in place, we at this time changed our II to a craniocaudal angle of 15 degrees. With this positioning, we fixed the bed, fixed the II, and then introduced the main body device on the left side over a stiff Amplatz wire. With the main body device introduced, we selected out a 36 x 20 x 166 bifurcated main body device. We advanced this into the distal abdominal aorta just above the renal arteries. Once we were satisfied with this placement, we began the deployment. We deployed the device down to expose the contralateral limb and held it in place. We then took one more selective aortogram at the level of the renal arteries and noted that the device was in good position. We then removed our pigtail from behind the bifurcated device using an angled wire and then exchanged out the pigtail for an FR4 catheter. The FR4 catheter, however, with the angled glide could not be used to cannulate the contralateral gate. We therefore switched the FR4 to an MPA and with the MPA 5 French catheter, we were able to cannulate the contralateral gate with the stiff-angled glide. With this done, we then exchanged out the MPA for a 5 French pigtail. This was brought into what was seen to be the graft body. We were then able to spin the pigtail nicely and then injected approximately 10 cc of contrast. We could see very selective filling of the graft and then down the contralateral limb and then back up into the closed left iliac limb. Satisfied with the placement, we then brought in the contralateral limb. We selected out a 16 x 20 x 124 Endurant contralateral limb. This was positioned nicely over a stiff Amplatz wire and deployed. Once this was completed, we then released the proximal renal fixation and then withdrew our graft on the left side so as to complete the deployment. We then removed our MPA device and brought in a Reliant balloon from the right side. We ballooned proximally. We ballooned the gate and then we ballooned the distal iliac components on the right to obtain a good seal. We then brought the balloon to the left side and again ballooned proximally and distally on the left iliac limb. Once this was completed, we performed our aortogram with runoff. We noted that we had a good proximal seal initially but then had either late, Type 1-A endoleak or a Type 2 endoleak proximally. We had good sealing at the gate and good sealing at the distal iliac limbs. We then brought the balloon back in and inflated once more just above the graft sitting at the renals and then just below it so as to get a much better seal proximally. We felt that with this aggressive ballooning, we optimized our seal and then we repeated our aortogram. We noted a much better control and had a very tiny, Type 2 endoleak from the lumbar artery. With this completed, we then removed our devices, deployed our Perclose sutures, and got good hemostasis. We gave the patient a total of 80 mg of protamine. Of note, during the course of the procedure, we gave him a total of 14,000 units of heparin and had the ACT above 250 at all times. With the completion of the procedure and the administration of the protamine, we checked for pulses. We had good distal pulses. We had no bleeding at our access site.

34802 and stent placement at attachment site

Would surgeon get any credit for placement of Palmaz stent placement during a AAA repair see dictation below AAA repair proceedure, Unibody graft placed along with proximal aortic cuff. "Angiogram was performed and demonstrated small type I endoleak with the rest of the graft widely patent with good flow into both iliac arteries. Therefore the 10 mm x 40 mm Palmaz stent was placed onto the CODA balloon and advanced back up into the proximal portion of graft" Using cpt 37204, 34825 for graft placement, code 37205 bundles according to coding rules. I have not been giving credit for 37205 Palmaz stent placement. Is this correct? Surgeon would like confirmation.. Thanks for any insight... Julie Breedlove Surgical Care Associates 502-638-5115

34802, 34803, EVAR

"Example: Standard Seldinger technique under US bilateral CFA were accessed with different sheaths. Perclose suture mediated devices were deployed in both CFA and additional 3rd device also deployed in right CFA due to dense calcification even though vessels of decent size. 18 French sheaths placed bilaterally. Abdominal aortogram was obtained. Following review Gore excluded graft is deployed; this is a modular bifurcated graft. Following deployment in the infrarenal location, tapered catheter & Glidewire used to cannulate the gate. Bell bottom device used from the left side, which was placed through the cannulated gate with 3 cm iliac overlap. The proximal end of graft anchored with 30 mm compliant balloon. Right iliac limb is fully eployed with 14 mm balloon. Overlapping left iliaclimb and gate were anchored in place with compliant 30 mm balloon that slowly inflated. Same balloon used to anchor the left iliac vein. Hemostasis was obtained using percutaneous suture mediated device. Hemostasis obtained with no evidence for bleeding with no immediate complications." Is this reported with codes 34803, 36140-RT, and 75952-26LT?

34803

This patient was brought in for repair of iliac aneurysm and AAA. A bifurcated graft was placed and in addition, a stent was placed inside of the iliac limb of the graft due to vessel tortuosity. CPT book indicates that 37221 iliac stent is for occlusive disease. We have 34803, 75952, 36200 x2. Main body stent graft 32 x 96 was advanced from a right approach into the abdominal aorta. The contralateral limb was oriented anterolaterally. Proximal 2 stents were deployed and position adjusted to just below the level of the renal arteries. Contralateral limb was deployed. The suprarenal stent was deployed and catheter was pulled back to the distal abdominal aorta. Catheter was exchanged to a Kumpe catheter and later a Vanshee catheter. Contralateral gate was cannulated using the Vanshee catheter. Intraluminal position was confirmed by injecting a small amount of contrast within the graft. Lunderquist wire was advanced to the upper descending thoracic aorta. The catheter was removed. Left iliac arteriogram was performed to evaluate the common iliac bifurcation. A left limb 14 x 90 was advanced from a left approach to about 1-1/2 stent overlap. The stent was deployed proximal to the common iliac bifurcation. Due to tortuosity of the common iliac artery, it was decided to place a self expanding stent to increase radial force. A 14 mm x 60 mm SMART stent was deployed within the left iliac limb. The remaining 2 stents from the main body were deployed and nose cone was retrieved. Right iliac arteriogram was performed. Right limb 12 x 107 was advanced from a right approach to the right iliac limb. 2 stents overlap proximally and distally. The stent was deployed in the proximal right external iliac artery covering the origin of the right hypogastric. The infrarenal neck areas overlap and distal limbs were dilated using compliant balloons. The stent on the left was dilated using a 12 mm angioplasty balloon. Completion arteriogram was performed through a pigtail catheter from a left approach.

34805

Dr. Z. I need help...incision was made at the proximal thigh to expose the proximal sfa. After exposure needle was used to puncture the vessel and a quidewire was inserted. This was then followed sheath and dilator. An angiogram was then obtained with a hand injection of contrast through the side arm of the right sfa sheath. This redemonstrated the popliteal artery aneurysm. The measurements were taken and sheath changed to allow passage of the stent graft device. An 8 mm wide x 10 cm long graft was selected and was placed under fluoroscopic control. This was then postdilated using an 8 and 9 mm balloon. A completion angio was performed demonstrated a leak at the distal aspect of the stent graft. Therefore and additional endovascular stent graft was placed with a greater than 1 cm overlap. This stent graft was then ballooned with a 9 mm balloon. The stent graft extension was an 8 mm wide x 5t cm long device. After this was done a completion angio was obtained of the stent graft areas and of the entire right lower extremity. This anggio demonstrates resolution of the leak in the popliteal area. ....the rest is results of the angio and closure. I know there isn't an endo for popliteal but could we use 34805-22; 34825-51; 34812-51, 75952-26; 75953-26 and 36140? One coder thought 37207/37208 which isn't supported by 442.3 popliteal aneurysm. Can you please help??

34832, open repair of old, failed endovascular treatment of AAA

I am not sure how to code for the removal of an endograft (AAA, due to Type 2 endoleak). An aortobifemoral bypass was done, but I am not sure how to code the explant. 37799?? 22 modifier on the 35646? Something else? Since it was not infected, I hesitate using 35907.

34900

Dr. Z or Dr. D could you please help?? If you have a doctor take over from different practices. Dr H brought pt to angiogram suite and performed an aortogram with runoff. This demonstrated a large pseudoaneurysm within the left iliac area and with blood flow into the left pelvis. I was consulted at this point (Dr F). Access to the left common femoral was performed by Dr H. An 8-French sheath was placed. Subsequently, a Jwire was inserted into the aorta. Runoff demonstrated the pseudoaneurysms that appeared to be coming off the common iliac artery. It should be noted that a LIMA catheter was used to select the left internal iliac artery to make sure that this was not the source of aberrant blood flow to the pseudonaueyrsm. This was not the source. Subsequently, a stif Amplatz wire was placed within the iliac system into the aorta. Covered atrium stents were placed. The completion angiogram was performed with a balloon 12x40 and 10x40 distally. Completion angio deomonstrated a complete exclusion of this pseudoaneurysm. There was no leaking into that or into the pelvic area. There is a slight type 1 leak into the iliac artery in the region of the distal common iliac artery. This was angioplastied again with a 12x40 ballon. There was no evidence of type 1 leak into the stent area. Can Dr. F charge for the cath movement into the iliac? 36246, 37205 and the 35473? Could you please help? I can't find in search a change of doctor. Thank you!

34900 versus 37221

Pt is brought to IR lab for treatment of left common and external iliac artery stenosis with lifestyle limiting claudication. The patient was also noted on recent MRA to have left common iliac artery aneurysmal dilatation. He used a 8x100 mm Viabhan stent to dilate the stenosis and exclude the aneurysm. He notes excellent exclusion of the aneurysm and 0% residual stenosis following placement and dilatation of the Viabhan stent. What would you code for this procedure? 37221 LT or 34900

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

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

35013 35881 35621

Greetings, A patient had a axillary bifemoral graft. It develops a ruptured aneurysm at the axillary anastomosis. The physican removes the axillary graft from the right side and creates a new anastomosis on the left then takes the new graft across the chest wall and transects the distal rt femoral anastomosis and attaches a new graft to the end stump of the old graft. He also performs a bovine patch to the right axillay artery where the original graft was attached. The physicaian coded 35013 and 35881. Im thinking this should be a 35621 as it was moved to the left side, and 35013. What do you think? LW

35091

Patient has pararenal aortic aneurysm and due to the pararenal extension of the aneurysm and multiple accessory renal arteries, we felt the patient would need renal artery bypasses in addition to repair of his aortic aneurysm. A splenorenal bypass was performed to the mid left renal artery. A superior mesenteric artery to the renal artery bypass was performed to the most inferior left renal artery. This was performed with a ringed 6-mm Propaten bypass graft. Pararenal aortic aneurysm repair was performed with a 20mm x 10mm bifuracated Dacron graft. The right distal anastomosis was to the right common iliac artery and the left distal anastomosis was to the left common femoral artery. We have the following codes: 35091 35631 35636

35102

Greetings, A patient has a infected aortobifemoral bypass graft that is excised. They debbridement of the end of the aorta. A crypopreserved aorto illiac graft is placed. End to end anastomosis to the aorta,the right side was end to end anastomosed to the femoral bifurcation , on the left a end to side anastomosis was formed to the superficial femoral artery. Is this truly a bypass or a graft placement even though this was not completed for a aneurysm. Would you use 35646 or 35102. I was even looking at code 34832. Any help would be great. Thanks, LW

35141

Dr Z MD does AAA repair 34802,75952,34812/50 36200 after this is completed. He does repair of bilateral common femoral aneurysm he turned in 35141x2 but is that the code he should use? He placed graft on resected CFA and anastomosed to the PFA on the right side. He placed graft on resected CFA and anastomosed to PFA/SFA common origin. In reading the section before the AAA, I am wondering if he can bill 35141x2 or if he should use 35286 x 2. Should I bill what he used, not bill at all or use 35286 x 2? Would be nice if these were cut and dried, wouldn't it? Thank you,

35201

Greetings, Pt. has fem-peroneal bypass graft with spliced saphenous vein originating from the hood of aortobifemoral graft. At the hood connection of the vein a pseudoaneurysm develops. Pt taken back to the OR for repair. After draining partially thrombosed pseudoaneurysm he sutures the hole in the hood would you code this as 35141 or repair of a blood vessel Thanks, LW

35201

Please do NOT include any actual patient medical records with your question. Can you please clarify your Q&A 3525? Code 35141 does not fall into the range referred to in the answer. Can 35141 be reported for direct repair of pseudoaneurysm without insertion of graft? Date: Tuesday, February 28, 2012 Question: Greetings, Pt. has fem-peroneal bypass graft with spliced saphenous vein originating from the hood of aortobifemoral graft. At the hood connection of the vein a pseudoaneurysm develops. Pt taken back to the OR for repair. After draining partially thrombosed pseudoaneurysm he sutures the hole in the hood would you code this as 35141 or repair of a blood vessel Thanks, LW Answer: The note just prior to code 35001 states “For direct repairs associated with occlusive disease only, see 35201-35286”. Since this is a pseudoaneurysm I would not use the repair codes but stay with the aneurysm codes. Thanks, Dr. D

35206, 35761, 35860, 37799

Dr Z: My physician performed: Preoperative and Postoperative Diagnosis: Septic thrombophlebitis of the left cephalic and vasiic veins. Procedure: Excision of distal left cephalic vein at the wrist. and Excision of the left basilic vein at the antecubital fossa. Descrption: Following discussion with the patient regardig the risks, benefits, and expectations, signed consent was obtained. The patient was brought to the operating room, placed in supine position. His left arm was prepped and draped in sterile fashion. I made an incision over the cephalic vein of the wrist with a knife. Dissection was performed to free the vein proximally and distally in the zone of cellulitis. The ends were tied off with 3-0 vicryl sutures. The wound was irrigated and closed with nterrupted 3-0 vicryl followed by 4-0 Monocryl. The basilicc vein at the antecubital fossa was excised in a a similar fashion and closed. The ony CPT descrition I can fine is unlisted 37799. Is this correct. thanks for your help.

35221

Hello~ Can you tell me what the difference between codes 34502 and 35221 when coding the repair of an injury to the IVC? Brief summary for this procedure is....patient was undergoing a nephrectomy involving the right kidney and the IVC was injured, the vascular surgeon was called in to repair. The IVC was was directly repaired with suture also repaired was a branch that avulsed form the IVC which also required additional direct repair with suture. Would this be 35221? Can you give me an example of when I would use 34502? Thank you!! Joanne

35251, 37799

How do you report portal vein reconstruction with vein? "The mass was then excised along with this portion of vein, which included the level of the SMV up to the level of the junction of the splenic vein and portal vein. When the specimen was completely resected, we then turned our attention to our interposition graft. The length was not amenable to primary repair, so using our IJ vein graft, we performed first anastomosis from the level of the graft to the superior mesenteric vein using an end-to-end technique using 5-0 Prolene. When this was completed, we moved the clamp up to the level to include the graft and then cut the graft to length for the proximal anastomosis to the splenic and portal vein. This was performed in somewhat of a spatulated manner to incorporate both the large venotomy at this site."

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