Hello, and welcome to the MedAxiom Academy. In this session, we will be covering Peripheral Vascular Basics. My name is Jolene Bruder, and I'm a Revenue Cycle Solutions Consultant for MedAxiom, an ACC company. Before we actually get started, I'd like to go over a couple of things. This slide is our disclaimer, and it basically states that this is for informational purposes only and does not constitute legal reimbursement, coding, business, or other advice. You should always check with your local Medicare carrier and consult with your practice's legal counsel for coding and reimbursement advice. This disclaimer is for the CPT. All codes from this content are from the American Medical Association's CPT book. All right. So before we actually get into the coding of peripheral, I'd like to go over some basic documentation guidelines. These are things that should actually be in the procedure note. They are key elements. So a procedure report must be written or dictated after the procedure was performed, and it must contain a detailed summary of the findings throughout the procedure. The procedure that was performed, any specimens that are removed, the pre- and post-op diagnosis, indications for the procedure should also be documented. You should also see any patient demographics, such as their name and date of birth. The date of the procedure should also be easy to find. On the indication section of the op note, we need to know what is the primary reason that prompted the order for this procedure. Was it a known diagnosis or was it merely signs and symptoms? Final diagnosis should always include the principal diagnosis, as well as any comorbidities or impacting conditions that may exist for the patient. For example, does the patient have diabetes or chronic kidney disease? This could pose an added risk for infection or delay the healing of the patient. Any adverse events that have occurred during the procedure should also be documented. What are the recommendations for further treatment plans? And also the physician's signature should be easily identifiable. Some additional information that you may see documented in the note, there should be obtaining informed consent from the patient, and that should always be documented. Any anesthesia services should be documented as well, whether it be general or conscious sedation. If conscious sedation is given, does the documentation support billing that service under the physician? Another one we could possibly see is, was there a co-surgeon or an assistant involved? If so, are the guidelines being met in the documentation to support that billing? There are specific modifiers for these assistant services, so if documentation meets that, you want to be sure to report those. Documentation of medical necessity and coverage guidance. We all know that detailed documentation is key to correct code assignment and appropriate reimbursement. It is recommended that you check with your local Medicare contractor for any guidance that they may have posted for a particular procedure or a CPT code. These are commonly called national coverage determinations, or there might have local coverage determinations. Remember, only documented services may be coded. Make sure covered indications are clearly documented so the correct diagnosis are also being reported. Any prior testing that was performed, such as diagnostic studies, and any findings of those studies should also be documented. Okay, so now we're going to jump into the diagnostic head and neck studies. This is a picture of your head and neck arteries. And as you can see, this is actually the aorta, and it's referred to as the aortic arch. And then the branches of the head and bustle arteries come off of that arch. So we have the left carotid is here, the right carotid is on this side, and then of course you have the brachial cephalic, and that actually branches off into the anominate and the right carotid. So those will be key, and I will have diagrams through this when we get into these procedures. So the first thing we're going to talk about is codes for the arch, which is the aortic arch, and the carotids. You will see that 36221 is for a non-selective cath placement. So what that means is that catheter is still placed in the aorta. This code also is for unilateral or bilateral. It doesn't matter if they run two caths up, if they do this procedure and they're only doing this arch aortography, that catheter is not selectively leaving the aorta. The imaging that is done from this point should contain the findings of the arch and the bustle origins. So basically what happens is they thread that catheter up into the aortic arch, they shoot their dye, and from that they can image lots of things, including the head and neck bustles. Now when it comes to code 36222, that is when the cath is actually selectively placed inside either the anominate or the common carotid, and then imaging is performed. You should see findings documented of that carotid circulation. You may also see extracranial carotid circulation documented. In code 36223, again we have that selective catheter placement in the common carotid or the anominate artery. The difference between this code and the previous code is this one will look at intracranial carotid circulation. For 36224, the catheter is placed all the way up into the internal carotid artery. You probably won't see this a lot with cardiology. This would be something more an interventional radiologist would do, possible vascular surgeon or a neurologist. So for the coding guidelines on these codes, only one code can actually be selected. Code number 36221 is the non-selective service and it applies to a unilateral or bilateral service. So it would only be reported once. When it comes to 36222 through 36224, these would be reported once per side. So if they look at the carotid artery, the common carotid artery on the right side, and then they move that catheter back into the aorta and then select the left side, you would code those twice. These codes are also reported based on hierarchy performed. So for example, if 36224 is the highest service, it would also include everything from 36223, 222, and 221. When we talk about the subclavian and vertebrals arteries, they also have their own code selection. So these services are also unilateral and only one code from 36225 and 36226 can be used for each side. So if that selected cath placement that's in the subclavian, if it's placed in the subclavian and they see that vertebral circulation, you would code the 36225. For 36226, that actually requires that catheter go further up into the head and neck vessels and to the vertebral artery. So that vertebral artery, you would also have vertebral circulation and then all of the other that's included in the cervical-cerebral arch. Again, this is a hierarchy code. We also have add-on services for the additional imaging performed. So for 36227, this will specify that you have selected catheter placement in the external carotid artery and then guidelines state that this service would be reported with the 36222 through the 36224. When it comes to add-on code 36228, this specifies that the catheter is placed in an intracranial branch of the internal carotid or vertebral artery. Again, you're probably not going to see a lot of this in cardiology. The guidelines also state that code 36228 would be used in conjunction with 36223 through 36226. It can be reported on both of these codes, can be reported twice if they're done on each slide. For bilateral imaging, so on here, let's say they selectively go into the anominate and up to that right carotid artery, they pull that catheter back into the aortic arch and then they select the left common carotid artery, you would code that procedure twice with a 50 modifier. So the example that's shown here, we have bilateral extracranial carotid angiography with selective cath of each common carotid, which is what I showed you, that code would be 36222 with the 50 modifier. Now, if they had gone further, let's say on the right-hand side, they did the right common carotid, but then they also looked at imaging up here higher and into the intracerebral area on this side, you would code the 36223. But if then on the left, they still only stayed in the left common carotid, that code would be 36222. You will have to distinguish out those codes either with a 59 modifier, some payers do like the right and left modifier, but it would not be the 50 modifier because the imaging that you've seen on the right is totally different than what was documented on the left. So next, we're going to talk a little bit about intervention of the head and neck. So when stenting in the carotids, you need to pay attention to the approaches and where that stent is actually being placed. For example, are you in the cervical carotid or the infrathoracic common carotid? Was the approach open or was it percutaneous? Did they go retrograde or did they go anterograde? For code 37215, it's probably the most popular procedure when it comes to stenting. This is done in the cervical carotid and can be done either open or percutaneously. It does use distal embolic protection. Code 37216 is without protection. There will not cover the 37216. And to be quite honest, I don't know of anybody performing these carotid stents without that embolic protection. For 37217, the stent can be placed in either the innominate artery or in the infrathoracic common carotid. This is done by a retrograde, open, if it's a lateral cervical carotid exposure. For 37218, that's for stents that are placed in the common or an inominate artery. And this is either an open or percutaneous anterograde approach. If you keep in mind, retrograde is against the flow of blood and anterograde is with the flow of blood. So some CPT guidance and inclusions on these procedures. So cath placement is always included as well as diagnostic imaging for that side. So if they're stenting on the right side and they did that angiography and they did that selective cath placement, you would not code, for example, the 36222, which is your imaging, because that is all included in that stent code. Now if they happen to do that imaging, place that stent on the right, but then also do imaging on the left side, providing there's medical necessity to support that left angiography, then you could bill for the left side. Again, you will need either a 59 or one of the X modifiers so that that doesn't bundle. Otherwise, the claim will get kicked out if it doesn't have that modifier stating that this was a separate procedure from that stent. Also like with all stents, if they do balloon angioplasty first, that is not separately reportable. Some of the guidance for the 37217, it does include vessel exposure and access. Again, all of that imaging that is done on that same side will be included. Then again, if they do balloon angioplasty prior to that stent, that angioplasty would be included. For the most part, the rules for all of these interventions in the carotids is the same. So again, for 37218, we include that cath placement as well as that diagnostic imaging. Even if they perform that carotid diagnostic angiography and decide to perform a stent that day, you still do not get to bill for that imaging. So that's separate from some of our other procedures that are done in the legs or even if you look at the coronary angiography with coronary intervention, you are allowed to bill for those diagnostic studies. With the carotid arteries, you are not. Some of miscellaneous billable services that are also done, we can do moderate sedation. It is separately reported with the 37215, 216, and 218. Now keep in mind, carotid services that are done with the 37217, that's actually done with anesthesia. So that one would not have moderate sedation. In this one, you can bill these, with the 37217, you can bill these additional procedures. But again, this probably would not be a cardiologist doing this because I don't believe they do any carotid endarterectomies. This would be more for your vascular surgeons. There are Category 3 codes in place for vertebral stenting. For vertebral stenting, and if you keep in mind, your Category 3 codes are carrier priced. So what that means is your individual Medicare carrier will decide how much they're going to pay on that. They will also decide whether or not they're even going to approve the procedure and reimbursement. Included in these codes, again, we have all of that ipsilateral extracranial catheterization, all of that imaging. So again, no matter where we're stenting in the head and neck, it's going to include all of that imaging. Now for subclavian intervention, that's a little different. The subclavian intervention is actually split out by codes 37246 for balloon. And then there's an additional code for each additional artery. And then for stenting, we have the 37236 and an add-on code for each additional artery. Imaging is included in this, so unlike the other with the carotids where all that imaging is included and never separately billable, you can make the case for if you're in the subclavian. And the reason why is the subclavian artery actually runs into our extremities, our upper extremities. So you could have diagnostic study, and then based on that study, go ahead and do that intervention. Cath placements are also separately billable with the subclavian intervention. So that's a little different than the carotids and the vertebrals. So some general catheter coding guidelines. You're always going to want to code selective over non-selective. So keep in mind, non-selective is wherever that catheter, if it entered the vessel, and they did imaging from that placement, that is considered non-selective. If that catheter's actually placed into the aorta, that's also considered non-selective, because the aorta itself is what they call zero order. From zero order, then you can go selectively off the aorta into your other vessels. Each vascular family should be coded to the highest order selected. Each vascular access is coded separately. Additional vascular families that are catheterized are also coded separately. So again, here are some codes for the non-selective catheterization. So for 36140, this is what I was talking about. You enter that vessel either in the arm or the leg, and then you do imaging. This would be done in an antigrade, so this would be with the flow of blood. And then again, 36200 is that catheter placement in the aorta. So from here, we're gonna talk about selective catheterization that is done above the diaphragm. We have above the diaphragm and below the diaphragm codes. So remember that aorta is zero order. 36215 would be first order, 36216 is second order, 217 is third, and 36218 is an add-on code for either any additional second order or third order and beyond. So these would be codes that you would mainly use in the upper extremities. And the reason why is they used to be with the carotids and all that, but when they came out and bundled the carotid cath placement with imaging, they changed all those code numbers. So you would never use these codes in any of the carotid or vertebral areas. This would basically be upper extremity. For the catheterization below the diaphragm, again, you have 36245 as your first order, 246 is second, 247 is third, and then 248 is your additional second or third order. Now, these would be used in the areas of the visceral arteries, which are around your renal around your renal. It doesn't actually include the renal because they have their own code, but this would be like your celiac arteries, your mesenteric arteries, things like that. And then also for the lower extremities, these would be your iliac, your femoral, and your popliteal and your tibial arteries. Ultrasound guidance for vascular access can be separately billed if it meets these following requirements. You have to have documentation of the selected vessel patency. So what that means is if they go into the femoral artery and that's where they access, and they want to get a good look at how that, if that access is going to work, if that access is going to work, then they do imaging. They do, well, they do ultrasound imaging and they have to document whether or not that vessel was patent. Patent means it was open and able to accept blood flow. They also have to document real-time ultrasound visualization of that vascular needle entry. And then finally, and this is the biggest piece that we probably have the most problems with, there needs to be documentation that a permanent recording was kept. Now, it can be kept in different systems, but there does need to be documentation that it truly was kept. There's not a lot of leeway on this code. It's very specific, and Medicare wants all three of these things documented. So some examples of that documentation for the 76937, you would see, you know, patient presents for lower extremity diagnostic angiography for bilateral claudication. So that would be your indication for the procedure. Ultrasound is used to determine the suitability of the left femoral artery. Ultrasound is used as guidance for needle placement. And then it goes on to say that the left femoral artery is actually deemed patent and suitable for use. And then finally, hard copy images and reporting are documented. So next, I'm gonna talk about the upper extremity angiography. So for the upper extremity, see, this is where I was talking about your subclavian. It starts here in the head and neck, but it goes into actually the arm before it returns into the axillary artery. Then you have what's called your brachial arteries. And then that splits down to your radial and ulnar arteries. So indications for these studies mean that there should be some arm or hand symptoms that prompted the physician to do imaging. The intent of these studies is not to image the carotids or the vertebral. Calf placements that are from a transfemoral approach. So that means they were down in the femoral artery from the leg, they threaded that calf. Let me get my mouse over here. They threaded that calf up from the leg, up into the aorta and they come out here and now they're in that subclavian artery and they move on down. So for that case, that is considered that transfemoral approach. The calf placement codes are actually different depending on if you're in the right extremity or the left upper extremity. So that's gonna be different, especially when we talk about the legs. So this is kind of unique to the arms themselves. So for the right side, we are going to have calf placements from the transfemoral approach. Once they hit that right subclavian and axillary artery, they're actually in what's called second order. And then once they came down to the brachial and then or further down into the ulnar or radial arteries, those would be third order. Now on the left-hand side, so this is a picture. Now remember, when you look at these anatomical pictures, even though this looks like this was the right side, it's always by which side is the patient. So this would be the patient's left extremity. So that's what we're talking about. So that's why it looks backwards. It looks like, well, wait a minute, this should be on the right side and this should be on the left. But you're always looking at this from the patient's anatomical position and perspective. So anyway, so back to, so we're running our catheter up through the aorta and now they come into that subclavian. Now on the left side, it's actually considered first order, the left subclavian and axillary arteries. Then when you move down into the left brachial, those would be considered your third order. And then I skipped the left lateral thoracic. I don't believe it's on this picture. Oh no, here it is. So as they hit the subclavian axillary, once this branch is off, this internal thoracic artery is actually second order. Then they move on and then once they get to the brachials, that would be third order. So the brachials are third order. And of course the ulnar and radial because now we're going farther down. Now, remember there's also that add-on code, that 36218. So if your physician actually brings that catheter up through, if he takes off here to the second order and then he goes back into the subclavian through the axillary and comes down here and hits this bifurcation, he could build this additional cath placement. And if he comes back to the axillary down into the, well, we're actually into the brachial, but once he hits these bifurcations and selectively goes off the main running artery, then those would be considered additional selective or additional selective second or third order branches. Again, that's probably gonna be rare with cardiology, but I just want to describe what they mean by the first, second, third order. So now if we come from an antergrade or retrograde approach from the brachial, our codes change again. So if they approach antergrade, so I'm just, I still have the left picture up, but this will be the same whether it's left or right. If they access, let's say here in the subclavian and they place that sheath in there and they shoot dye, you're going with the blood flow. So the access is from this artery, not down here from the legs, we're not threading the catheter up through the arch, we're actually right here, accessed here and then shoot the dye. That's an antergrade approach. Once you get past the subclavians and the auxiliaries, now your right and left radial ulnar arteries are gonna be considered first order because we actually started up here. We didn't start down in the leg and come all the way through. And then once you get into the deep palmar arch arteries and superficial palmar arch and all of that, those would be considered second order. So you always wanna make sure that you're paying attention to where they access and how that catheter travels. All right, now our imaging for the upper extremity, if they only do one arm, it would be unilateral, so that would be your 75710, 75716 is bilateral, the 75774 is an add-on code. Now it is different for each, it is different whether we're talking arms, legs or the visceral arteries, the 75774. For the arm, it means once they did this imaging and they have to document that that imaging went all the way down to the hand, then if they came in and selectively did another cath placement and did more imaging, then you could build a 75774. However, there has to be medical necessity for that. So if they come in here and we're in the auxiliary and they shoot and it runs down to the hand and they see that there's something going on in this deep palmar arch and they wanna get a better look at it because there might be collaterals coming off that arch and it's not flowing like it should, then if they selectively come down here and do another shot, then you could build for that. But if they just came in and did the auxiliary and let's say imaging only came down to the radials and then it kind of faded off, so they moved the catheter down farther and did more imaging so they could see the whole hand, that's just your basic exam. You have to have hand documentation in order to build that additional. And again, it's gonna be rare. All right, so next we're gonna talk about diagnostic aortography. For diagnostic aortography, we have that cath placement again in the abdominal aorta or it's in the aorta period. This is showing kind of your diagram here. So we have the ones, this is the vessels going to the head and neck and then these all actually branch off into the arms. But right now we're talking about this area. So for here, once that catheter is threaded and they can come from the arm or they can come from the leg. Basically, once that catheter is in the aorta, this is where you have that non-selective 36200 code. For thoracic aortography, so this will be up here more in the chest. You have 75600, which was aortography of the thoracic without seriolography. Or you have the 75605, which again, you're up here looking at the thoracic arteries coming off. Those would be the ones that are in the chest coming off. Those would be with seriography, then it would be 75605. Remember the difference is one has it and one doesn't for the seriography. So make sure your physicians are giving you clear documentation on that. So for abdominal aortography, there's always a lot of controversy with these codes. Basically, we need to know how many injections were done and where did those injections occur? And then what exactly was imaged from each injection? So for the 75630, this is where you have one catheter placement. So again, I'm just gonna use the leg. So they came through the leg and they came up here. You have to be in at least this renal artery area. You might see it documented as end for renal. They might talk about which lumbar they were near and that has to do with your spine segments. So if they're talking about lumbar one and two, they're up higher in your spine. But anyway, so they'll have this catheter, they'll place it in this area and they do one imaging shot. From that shot, they can see all of this and then also it'll run off and it'll run off into each leg and you have to have imaging at least to the femoral arteries along with findings. So if this case, we have this one catheter placement, we're gonna have abdominal angiography. So they're looking at this down here too. And then you have both legs at least to the femoral arteries. Now, here's where it gets sticky. So for the abdomen with runoff, with two cath positions, so in this area, so not only do we have that catheter up here in the end for renal area, then they'll also pull that catheter down to the bifurcation and do an additional image. So this is two cath placements and two shots basically. For both codes, whether it's the 75630 or the 75625, you have to have more than just the distal abdominal aorta imaged. So if they come up through that leg, because I'll see this a lot in documentation, they'll come up to that leg and say they placed in the distal aorta and they did a shot and then they move on down to the next leg. You cannot build a 75630 or the 75625 because we don't have enough image. So what you have to do is determine were they in that new perennial area and then did they move that catheter within the aorta? That's how you determine the difference between the 75630 and the 75625. Now, once they do this other shot down here, not only are they seeing the lower abdomen, but as long as there's documentation of imaging to the femorals, then you can also build that 75716, which is the bilateral extremities. You do need documentation results in both legs. Also keep in mind, even if they do both, you still have to have the medical necessity. So if the patient has all kinds of complications on this leg, but nothing really is going on to indicate that anything's happening in the other leg, then you would change that to the 75710. Okay, so next I'm gonna get into more of the diagnostic of the visceral and renal arteries. So again, earlier I said the renal arteries have their own imaging and cath placement code. So this shows you a picture here. So you have your kidneys out here and then your renal arteries branch off of that aorta. And then there's also accessory arteries. Not everyone has the accessory. Some do, some have a couple of them. It just depends on the anatomy. But for this one, so if we selectively go into this renal artery, we would code the 36251. This is considered first order, and it includes the main renal artery and any accessory renal arteries for that son. This code also includes arterial puncture, fluoroscopy, it includes all of the imaging, and it also includes flush aortogram. So what that means, remember in the previous slides we were talking about the abdominal aortogram, and we had the code 75630 and 75625. If they go into selectively into the renal artery and they do any imaging, you can no longer code that 75630 or the 75625, because that aortography is included in this code. So next we have bilateral renal. So this would mean you went into both the left, yeah, this would be the left. You would go into both the left and the right side. Again, this is going to include any of your accessory arteries, and it includes that abdominal aortic flush angiogram. For 36253, you're actually getting into higher orders off of the renal arteries. So as they come in farther through here, if they're starting to look at things like this that are branching off, this picture doesn't show everything that branches off, but there are arteries that come off of the renal. Those would be more of your super selective, and again, cardiovascular docs and cardiologists are probably not going to venture into this area. Next I want to talk about the imaging code for the visceral arteries. So the visceral arteries contain the celiac, the superior mesenteric, and the inferior mesenteric, and additional vessels off of both. When you're doing any imaging for the visceral arteries, now these would not include the renals. These are, this is separate from the renal. We have the imaging code 75726, and that is for that visceral vessel. It also includes that abdominal angiography. So you would not know the 75630 and the 75625. You can also code for the 75774, which is for each selective additional vessel that is done after that basic exam. I'm not going to get too deep into this because cardiologists don't really do this part. And this would be more of your vascular surgeon. So here we have the cath placement. So again, we have the celiac, superior mesenteric, and inferior mesenteric. They all include that flush aortagram. They come off of here. So this is your aorta, and then these are all the visceral vessels coming off here. So right here, you have the celiac trunk, which is very hard to see in this picture. Down here, you have the mesenteric artery, and then even farther down, you have the inferior mesenteric artery. Now here's what makes this different. So all of our other codes, you know, we were talking about in the arm, we had first order, second order, third order. That's because they were all coming off that same main vessel. Here, you're actually selectively going into the celiac, then you come back into the aorta, and then you selectively go off into the superior mesenteric, you come back into the aorta, and then you selectively go down into the inferior mesenteric, so you had to go back into the aorta. So all of these little branches off of the aorta would be considered first order. It's as you get farther into these vessels that you start hitting your second and third order. So keep that in mind, because that's a little different than what we're used to with the arms and legs. The inferior phrenic artery, which is up here, this would also be considered first order. So now we're going to get into interventions of the arteries of the upper extremities, the abdominal, and the renals, and the viscerals. So with this, and this same rule applies to a lot of things other than the carotids. So in order to bill a diagnostic cath with intervention, there cannot be a prior angio-based study that includes CTAs and MRAs. If there is a prior study that was done, but the patient's condition has changed since that study, then you could justify billing another diagnostic cath. Or if there's inadequate visualization of the anatomy or the pathology. The big key on this is it needs to be documented that the imaging was not good enough, and the physician couldn't read it, so therefore he had to do another study. The other reason you could do another angiography would be if there's a clinical change in that patient during the procedure, and it requires a new evaluation, but that would have to be outside the target area of where they're intervening. So next I want to talk about some basic interventions. So right now we're going to talk about balloons and stents, and angioplasty is a balloon. So you might, you could see different words such as cutting balloons, anything, anything that has the word balloon in it means angioplasty. So this shows an artery that has a lot of plaque buildup, and as you can see, as it's building up, it narrows and it doesn't allow the maximum blood flow to go through. So and this can be caused from several things, poor diet, smoking, hypercholesterolemia, hereditary actually plays into it. So anyway, these things happen and the vessels start to narrow. So what they can do, they can run that balloon through that, with the catheter, they run that balloon into that vessel, and they place it around this in between these lesions, and then they inflate that balloon. Once that balloon's inflated, it pushes those vessel walls back, and then as you can see, your artery is much more open than it was when we started. Now all that plaque didn't go away, but it is open more. Now usually it depends on how bad that plaque is, on whether or not they decide, okay, we did an angioplasty and that's enough. But sometimes if you have a lot of plaque buildup, like over here in this picture of a stent, you have all this plaque built up, well, a balloon's probably not going to do enough to keep that vessel open. So what they do is they thread that balloon inside the stent, and then they run all of this up into the vessel. Now keep in mind, when you're coding for stents, angioplasty is included, and the reason why is most of the time they're going to inflate that stent with a balloon. So they run this through, then they inflate that balloon, that stent, which is that little wire, it looks like a little fencing. That stent will stay in place, and it pushes those walls back, and it'll hold those walls back, and then they pull that balloon out, and then your stent is left in place. So this also helps bridge this opening. So when there's a lot more plaque, a balloon angioplasty is not going to be enough because eventually that plaque will just rebuild up, whereas a stent, that'll help keep that vessel open longer. So our guidelines for angioplasty codes, so that balloon coding, they can be done either open, which means they actually cut into the vessel, or they can be done percutaneously, which means they puncture the vessel and then run those catheters through. Again, as I was talking about, you might see some different names. You'll see low-profile, a cutting balloon, or a drug-coated balloon. Again, keep in mind, if you see the word balloon, it means angioplasty. It does exclude any vessels of the central nervous system, the coronary arteries, the pulmonary arteries, and the lower extremity arteries when we're talking about occlusive disease. So this 37246 and 37247 would not be built in the leg if you're talking about occlusive disease for the patient. All angioplasties that are performed in a single vessel are still only billed as one. Even if they're separate and distinct lesions within that same vessel, you still can only bill a single code. So if we have a lesion that extends across the margins of one vessel into another that can be treated with a single therapy, then that intervention should only be reported once. When you have additional separate and distinct ipsilateral or contralateral vessels that are treated in the same session, then you can bill your add-on code as appropriate. So the 37246 is your initial balloon, and the 37247 is your additional. Okay, these codes do include all radiological supervision and interpretation for that, you know, because they have to image when they open those balloons and they have to go back in and image. That imaging is all included. We're not talking about diagnostic here. We're talking about road mapping to make sure that their intervention worked. Replacement is separately reportable for these codes. If they have to do extensive repair or replacement of an artery, that is also separately billable. This would be usually done by a vascular surgeon, could be a CT surgeon. But this means that the artery itself, when they opened it, it may have got tore up. So they have to be able to go back and fix that. So that can be separately reported. If they do intravascular ultrasound, which is also known as IVAS, IVAS is separately reported. And then if they have to do any mechanical thrombectomy or thrombolytic therapy, that is also separately reported. So again, this is a full description of the codes 37246. And again, that's initial artery, and then 37247 would be each additional. So for example, let's say we're in a visceral area and they put a balloon in the celiac artery. You would code that with the 37246. So next they come out and they have to put a balloon in the superior mesenteric artery. Then you would use this additional 37247. Same thing if they're doing the renal. So whichever renal they do first is the initial artery, and then the add-on code would be for the other side. So if they did the left renal artery first and then did the right renal artery, you would code the 37246 and then this add-on code. When we talk about stents, this was from the CPT introductory language, and this has to do with our stenting codes 37236 and 37237. Again, multiple stents that are placed in a single vessel can only be reported with a single code. If that lesion extends across the margins of one vessel into another, but can be treated with a single therapy, that intervention should only be reported once. So if we take the renals and they're in the main renal and then they have to selectively go into an additional artery off that renal, but it can be done with one treatment, one stent, then you would only code that once. If additional different vessels are treated in the same session, you would report that 37237. And then this code series includes any balloon angioplasty, as well as treatment of a lesion the stented segment, but in the same vessel. So even if we have a lesion at the very beginning of the renal, and then it's farther down in the distal area of the renal, you still only get to code one stent because you're in that same vessel. And always keep in mind with the 37236 and 37237, just like the balloons, you are allowed to bill non-selective and or selective cath. And again, this is a full description of these codes. We have the initial artery and then each additional. Now I want to talk about studies in the legs. So the legs is a little bit of a different animal. We have vascular families of the lower extremities. Each extremity is actually considered a family. So you have your right side of your family and the left side of your family. Groups of vessels within that, within those extremities, they arise off of a primary branch, and then there's a network of vessels. You know, they come out, they start off from the aorta, which is where your iliacs are. So you have this. And then there's a network of vessels that arise from the access site. So if they access here from the femoral, the common femoral, all these things branch off of there. Selective cath placements are coded per vascular family. So you have anything that's selective on this side is coded, and then anything that's selective on the right side. And I'm going to talk about that a little bit more. Okay, so next I want to talk about the arterial territories of the lower extremity. Now keep in mind, all of these vessels are on both legs. But to make the picture more clear, they only pointed them out. So even though it says external iliac artery over here on the right leg, there is one on the left leg as well. So we have your arteries, we have the common iliac, the internal iliac, and then of course this is the external. So this is your iliac territory. Next we go into the femoral, which goes all the way from the femoral down to the popliteal. This is all considered one territory. They don't count any of these bifurcations or any of this branch. There's no, this territory is not split out between femoral or popliteal. And then finally we have our tibial and peroneal. So we have here, we have the anterior tibial, the peroneal artery, and then the posterior, which actually runs down the back of your leg. So again, we have three vessels within that territory. So again, the rules are the same. You're going to code selective over non. You're going to code each vascular family to the highest order. Each vascular access code is coded separately. And then additional families that are cath are also coded separately. I've already went over this, so I'm not going to talk about this a whole lot, but again, we have our anterograde where they puncture that vessel and then shoot that dye down. Or we have non-selective where they actually put that catheter into the aorta. And again, we have our cath placements that are below the diaphragm. This is a repeat, so I'm not going to spend a lot of time on that. This would be more important for you. So for the cath placement for the leg, again, we have that first, second, and third order. So our first order is our common iliac. And then second order is the external iliac as well as the common femoral. And then third order is your superficial femoral artery, or better known as SFA. And anything past that is considered third order. Now if we do that puncture where I was talking about that 36140, so if they puncture in the common femoral and then they selectively go down that same leg, they don't cross the aorta, then you would have your superficial femoral artery now becomes first order. Second order would be popliteal. And then third is your anterior tibial and posterior tibial and your peroneal. So for extremity angiography, again, this mimics just like the upper extremities. You have unilateral, bilateral, and then the 75774. Now notice this is highlighted after that basic exam. So what we need in the legs is we have to have imaging down to the foot first. Then anything selective, and there has to be medical necessity, if they do additional selective angiography further down from where they originally were, then you can build the 75774, but you have to have that imaging to the foot first. So we'll talk about this a little more extensively because this is probably the most, where the most confusion is for use of this code is in the legs. So again, we have to have true need, there has to be medical necessity. It is not done to just look at additional lateral or oblique views or rotational views, anything like that. The additional vessel has to be imaged after that basic exam. So remember that basic exam is down to the foot and some of the need would be if they're smaller vessels that have no imaging codes and the above is met. So again, you have that true need, you have that additional vessel examined. You're not going to use it when you're completing a runoff exam. So what that means, so let's say we started in the abdominal aorta. Let's say they pulled, they were up by the renals, they pulled down to that bifurcation, they did imaging down to the femoral. Then they selectively placed that catheter in the common femoral and then they do more imaging down to the foot. Now you have completed your basic exam. So let's say that there's collaterals coming off of the anterior tibial and there's not real good blood flow through that anterior tibial. So now they selectively go further down the leg, let's say to the popliteal, and they do that additional imaging of that tibial, then you can build a 75774. This was from CPT Assist. This was a question and answer. I'm not going to read all of this to you, but basically it's, you know, it says it is appropriate to report the code when additional selective cath after that basic study is performed and it should not just be reported for extra views or additional imaging. You have to have a medical necessity. So next we're going to talk about interventions in the lower extremity. The method of intervention is going to be the same, it's just your codes are going to be different. Again, we had that same rule that diagnostic cath is bundled with intervention unless it meets this criteria. Now this is different. Catheter placements are bundled when we're talking about the lower extremity. Imaging is also bundled, and again that's that diagnostic. So if there's a true need and they haven't imaged before, or if they did image before, but the images aren't very clear, or if the patient's condition has changed, then you can build that imaging. Now in this one, again, we have this basic intervention with the balloons, the stents, and then we also have atherectomy. Atherectomy is a device that's used, I kind of relate it to Roto-Rooter. So, you know, if you have plumbing problems in your house and they send the plumber out and he runs that snake down into the pipes and it turns on this machine and it traps all the stuff that's in your pipes, this was basically what this was like. This was atherectomy for your blood vessels. So again, we have, these are CPT guidelines for the ILLIAC territory. So if we're here in the ILLIAC, we have a primary code that's used for the initial ILLIAC that's treated, and then if other ILLIAC vessels are treated and it's appropriate, then we can build those extra codes. If other ILLIAC vessels are treated and it's appropriate, then we can build those extra codes. So if we do, let's say for argument's sake, they come in here from the right side and they cross over and they look at the common ILLIAC artery here and they place a stent there and then they're looking at the imaging and by gollies, they need to put one in the internal and then they also want to put one in the external, you can build for each one of those vessels. You're going to build a primary code and then you would build the additional vessels and we'll get into those codes here in a minute. I'm more concerned here about the concept versus what the actual code is. So in this case, you can build for each one of those vessels that are treated. Now remember, these add-on codes, again, are for additional vessels, not additional lesions. So if there's three lesions in the common ILLIAC and they treat all three of them and they put in three stents, you still only get to code that once. Now if they have that lesion that's in the common ILLIAC and then it's also in the internal ILLIAC, then you can code both of those. For the femoral popliteal territory, so remember I told you that, you know, it starts here at the common femoral and goes all the way down here to the popliteal. This is what's called a single intervention vessel in this territory. So it doesn't matter, they could stent in a common femoral, they could stent here in the SFA, they could also stent here in the popliteal artery. Even though they are considered separate vessels anatomically, for billing purposes, this is all considered the same territory and there are no additional codes. And, which this is the area that's probably treated the most, but it doesn't matter what they do, you can only code one. Now keep in mind, there is a hierarchy. So you have atherectomy with stent, you have atherectomy only, you have stent only, and you have balloon. So if they would happen to do a balloon, a stent, and an atherectomy, you want to be sure that you would code the atherectomy with stent versus just picking the balloon, because the balloon is not going to be the highest procedure that is done. Next, we're going to talk about the tibial peroneal territory. So again, you're going to have that single code for the initial tibial treated, so if they treat the anterior, you would code that as your initial, and then if they happen to go into the posterior, and then also the peroneal, those could be billed as separate vessels. Same rules apply. It doesn't matter how many, if they put, you know, 15 stents in the anterior artery, you're still only going to get to bill for that once. They have to be distinct vessels, not distinct lesions. For the tibial peroneal trunk, in this case, we have, so here's the deal with this little guy. So this, but this is the popliteal artery. This is where your knee creases. So the popliteal turns into the tibial peroneal trunk, and then it starts branching off. So we have the branch off at the anterior tibial, we have the branch off of the peroneal, and we also have the branch off of the posterior. So while it is, again, anatomically, it's a vessel, for reporting purposes, it is not considered a fourth vessel for reporting. So if they treat the tibial peroneal trunk, and then they also treat the posterior tibial, you're not going to count that as two separate vessels. That's all going to be included as one. If they only treat in the trunk, then you can bill for that. But you can't look at this as, well, they put a stent in the tibial, they put a stent in peroneal, they put one in the posterior, and they put one here, you only get to bill for the three. Dorsalis pedis, now we're getting down here into the foot. The dorsalis pedis is actually considered part of the anterior tibial artery. So again, if we stent in the anterior and we stent in the dorsalis pedis, we still only get to code one, because that's all considered the same vessel. And then if you have the medial malalar artery, that would be considered part of the posterior tibial. So when you come down here, and again, this is in the back of your leg and your foot, that is part of the posterior artery, so you would not code that separate. So the rules for multiple territories. So you can have one primary lower extremity revascularization code is used for each territory. When second or third vessels are treated in the iliac or the tibial peroneal, then you can use those add-on codes. When more than intervention is done in the same vessel, the highest intervention is the one that's coded. So again, that's what I was talking about. If they happen to do that atherectomy and the stent, you're going to choose the atherectomy stent code versus just the stent. So what do we do if our lesions cross into additional territories? I'm going to use this example here. So if we have stenosis extends from the common iliac into, I'm going to use this slide. So this is a common iliac and extends into the external, but it can be treated with one stent, one balloon, one atherectomy, whatever that case may be. But it can be treated with one stent, one balloon, one atherectomy, whatever that case may be. You only code it once. But if they have to stent in the common iliac and then they also have to stent in the external iliac, then you could code that initial and the additional. So for bifurcation lesions, so what this means, so again, your bifurcation, so you have the aorta and then you have, this is where this is considered a bifurcation where it splits off to the leg. You also have one here. Actually, let's drop down further into the tibials because I think it's shown more clearly. So you have a bifurcation. So you have a bifurcation more clearly. So again, this is your popliteal, then you hit your trunk and then your arteries for the tibial and the peroneal start branching off. So if you have a lesion that not only hits the anterior tibial, but also involves a peroneal where it's hitting that bifurcation, you would code each one of those because your stents are not going to be able to cross, you know, like even up in here in the iliac. Your stents aren't going to go around corners and split off. So you're going to have to use two stents here, but you're in two separate vessels, so therefore you can treat that. You can bill for those each. Now keep in mind with the whole femoral and popliteal area, even though we got all these bifurcations and all these treatments, it doesn't matter. Let me back that up. So when we're talking about the femoral popliteal area, remember, even though you've got all these bifurcations and all these vessels coming off, this is still only considered one territory. So it doesn't matter. You can only bill it as one, one intervention. So for bilateral legs, codes are chosen per territory per extremity. When the same territories of both legs are treated in the same session, modifiers may be used to describe those interventions. You're going to use a 59 or an X modifier to denote the different legs are being treated, even if the mode of therapy is different. So if we have a stent in the right leg and an atherectomy in the left leg, you're still going to have to use that 59 or X modifier. So these are our codes for these. So we have this whole chart is split out by description. So this is the type of treatment and then it's split out by your vessel. So for your iliac, we have balloon only. We do have an atherectomy code that's done with an iliac, but it is a category three code. So again, that's going to be carrier priced. Then we also have stent with or without balloon. We have each additional balloon, and then we have each additional stent with or without balloon. So those are all of your codes for the femoral or for the iliac. For the femorals now, we only have balloon, atherectomy with balloon, stent, and stent with atherectomy. We don't get any of these each additional codes because we can only bill the highest intervention that's done. So again, if they do that stent with atherectomy, that's your highest procedure that would be done in that territory. Now don't get me wrong, if they treat the iliac and the femoral and the tibial, you can bill for all three of those territories. But if they're only treating the femoral popliteal area, you only get that one code. And then here for the tibials, we have balloon only, atherectomy with balloon, we have stent with or without balloon, and then stent and atherectomy with or without balloon, and then all of our additional codes. So the atherectomy for the tibials actually has a category one code. Additional billable procedures, we have the IVUS again, that intravascular ultrasound, and that is coded with initial vessel and then each additional. We can also bill for primary thrombectomies, and that would be the initial vessel and then the additional vessel. Now again, your femoral popliteal is only going to be considered one vessel. You can also have secondary thrombectomy, and then of course our moderate sedation. The things I want to talk to you about the primary thrombectomies too that I want to really mention. So the difference between a primary thrombectomy and a secondary thrombectomy has to do with the intention of the physician and what they knew. So if they already suspect that the patient has thrombus and they planned on doing a thrombectomy, that is when you're going to use your primary code, that 37184. If however, they do, they go in to do just a stent or a balloon, they don't know anything about this thrombectomy, or they, while they're in there, because a lot of times what will happen when they place that stent, some of that plaque, remember that picture with the stent pushing the plaque against the vessel wall, some of that or the lesion might break off and travel further down. Let's say the leg, for instance. In that case, that is where you would be a secondary thrombectomy because that piece broke off. This was not planned. They did not, you know, this was something that was actually, you know, created after the intervention. So in that case, you're going to use that secondary code. Now this trips people up because it says secondary thrombectomy with another intervention. That's not to say you can't have an intervention with the primary. They could have planned, hey, not only are we going to go in there and get that thrombus out, we're also going to stent in the tibial and we might do a balloon in the iliac, that type of thing. So don't get that confused that, oh, well, it's automatically secondary because they did another intervention. That has nothing to do with it. That has nothing to do with it. It all has to do with the intent of what that physician was going to do. All right, some final thoughts. Be sure you apply the correct rules for each vascular family that you are coding. Ensure you capture all of the billable services. If imaging is done with intervention, make sure it's truly diagnostic before you bill it separately. Keep in mind too, the carotids, it doesn't matter if it was diagnostic or not. If you do intervention, all that imaging is included. And then as you've seen, some rules across the vascular families are the same. For instance, angioplasty is included with stenting and atherectomy. Lesion rules are pretty much the same and multiple interventions in one vessel are not separately billable. If you should happen to have any final thoughts, this does conclude our presentation today. If you have additional thoughts, be sure and email us or questions, be sure and email us at therevenucyclesolutions at medaxeum.com and either myself or my two colleagues, Nicole Knight and Jamie Coynbee, we'll be happy to answer your questions. Thank you for your time.

peripheral vascular interventions

coding

accurate documentation

procedure notes

diagnostic studies

selective catheter placement

upper extremities

lower extremities

balloon angioplasty

stents

medical necessity

coding guidelines

billing guidelines

interventions

cardiovascular procedures

iliac arteries

femoral arteries

tibial arteries

peroneal arteries

balloon procedures

stent procedures

thrombectomy procedures