All right, well, I'm going to go ahead and kick this off. Welcome, everyone, to our boot camp session two. Today, my colleague, Tammy Barron, and I are going to cover the coding and documentation concepts for VENUS services. We're going to look a little at some diagnostic procedures as well as intervention. Before we get started, I do want to point out and go over some of our housekeeping items. So to access the slides, you're going to need to click on the chat box here, and you'll be able to download them. If you do have any issues with that, you can just put a message in that chat box, and my behind-the-scenes team, which we couldn't do these without those people, they will help you with that. As far as questions, we do need you to put those in the Q&A box. Do not put those in chat. We do ask that you keep your questions on topic, and we will answer as many of these as we can during the broadcast. And if not, we will compile all of them after, and they will be available on the website. Now, keep in mind, since this is boot camp week, it might take us a little longer than normal, and we may not get them all compiled until after the holidays. We will try our best, but you all know how it is for end of year trying to get everything done. So for claiming CEUs, you need to be aware that you have to access the MedAxium Academy, and you will have to click on the coding boot camp webinar that you attended. Again, keep in mind, you do have to launch the webcast from the Academy in order to get your CEUs. It's not enough to register. You do have to actually launch it. But once you're there, then you're, you know, once you're in the boot camp, or I'm sorry, once you're in the Academy, you can click claim CEU, and that will access your certificate. Once you claim your credits, they'll be available in the transcript. Now, keep in mind, too, and give us a couple of business days for sure to get these uploaded. And then, again, if you have any issues accessing this, you can let us know, and we will be more than happy to help you. Also note that the AAPC are the certificates that are in the Academy. For BMFC, you will need to email me personally or directly, and I will get you your copy for that. Now, we do have some changes coming up, and Nicole talked about them yesterday. But in case you weren't on that webcast, for 2023, we are going to look at four to six webinars that we will offer on demand. So what that means is if you can't attend our live session, you can get on demand. You can listen to it. You will have to access and answer a 15-question quiz, and then once that is done, you will be able to obtain your CEUs. We're going to try this out. That's why we're only going to do four to six next year, and we will let you know once we put that schedule together which particular webcasts of that on-demand certificates will be available for. Also, some exciting news for 2023. We have been an approved vendor for AHIMA, so we will be offering AHIMA CEUs. And, you know, as of right now, I know for the most part, they do accept the AAPC, but we've had a growing demand to actually become a vendor for AHIMA. So we've answered those demands, and we're happy to offer that. On that note, BMSC, we have less than three people that actually hold the certificate, and so we will no longer be offering those affected January of 2023. If you have any questions or concerns, you can certainly reach out to me, and we can just look, discuss those concerns. I do believe they will also accept the AAPC, but if you have questions, please just email me directly. All right. So I'm going to kick this over to, again, Tammy Barron. Welcome her. And she's one of our new specialty coders for this year, and I'm excited she's going to join us for this webcast, and I will pick up later, so I'm going to go off camera so I don't distract her. So, Tammy, go ahead and take it over. Okay. Thank you, Jolene. So we're going to begin today by covering the vein anatomy and some common conditions that are typically treated. Normal blood flow is essential for normal leg function. The heart pumps blood to the legs. The arteries deliver it, and veins in the leg return the blood back to the heart. The blood flow not only delivers essential nutrients, but also carries away toxic waste products. Next slide. Venous insufficiency is present when leg veins are no longer able to efficiently carry blood back to the heart. Now, this may be the result of blockage or obstruction, leakage of a valve, or a combination of both. The increase in venous pressure produces chronic inflammation, impaired tissue perfusion, ankle swelling, and often debilitating symptoms. Next. Here, you can see an illustration of spider veins. At the base of the skin, or dermis, is a microscopic venous plexus, which is merely a fancy word for a network of nerves or vessels in the body. This venous plexus drains into small dermal veins called venules, which in turn drain into subdermal veins. When the blood backs up in these microscopic venules, they become enlarged and filled with stagnant blood, which makes them visible to the eye. So, this is an illustration of the typical stages of varicose veins. Varicose veins are enlarged, twisted blue veins that are close to the surface of the skin. Because the valves in them are damaged, they hold more blood at higher pressures than normal, and that forces fluid into the surrounding tissue, making the affected legs swell and feel heavy, aching, tired, painful, and fatigued, generally. Skin symptoms include itching, burning, dryness, redness, and ulceration. Sometimes, these veins may be present without symptoms, but eventually, they will get worse and the symptoms will develop. So, now that we have a better understanding of the venous anatomy, let's look at some related non-invasive diagnostic testing. This is a common diagnostic study typically performed on the veins. CMS defines a duplex scan as an ultrasonic scanning procedure with a display of both 2D structure and motion with time and Doppler ultrasonic signal documentation with spectral analysis and or color flow velocity mapping or imaging, which is a mouthful. You'll need to check with your local Medicare contractor, as most do have a published LCD on this service. Just FYI, there are other codes available, which represent combo veins and arterial studies, but I'm not going to cover those today as our focus is on the venous system. Next, please. So, this is a Q&A from CPT assistant on the venous duplex services. The question was asked if it would be appropriate to report 93970, which is defined as a complete bilateral study. They can report that twice if both an upper and lower extremity venous study was performed. CPT assistant does state that it would indeed be appropriate to report this service twice. Modifier 59 or the X modifier, depending on carrier rules, must be added to this code if complete studies are performed on the upper and lower extremities. Next. So, here's a case example for a venous study. This patient is symptomatic with pain, edema, and discoloration of both lower extremities. Next. So, these next two slides will demonstrate what your report might actually look like. You can see your right and left Doppler measurements documented. Velocities are measured in centimeters per second. Diameters are measured in millimeters. And you can see if there is reflux, the reported reflux time in seconds, and the associated vein. Next. Here we continue with mapping and diameter measurements on your report. And next slide, please. Here you're going to see your final results. And this patient has reflux in both legs and the specific veins are documented. Next slide. So, for this procedure, the CPT code supported here is 93970. So, next we're going to talk about STAB phlebectomy. Phlebectomy, which is also known as microphlebectomy, ambulatory phlebectomy, or STAB phlebectomy, is a technique used to remove varicose veins. In this procedure, several tiny cuts or incisions are made in the skin through which that varicose vein is actually removed using a phlebectomy hook. Stitches usually are not required. This is an outpatient procedure that doesn't require an overnight stay in the hospital. And the areas of the veins that are not removed will close, preventing blood from flowing through them and thus eliminating the appearance of that condition and those painful symptoms. Next slide, please. So, for this case example, we have a unilateral right lower extremity microphlebectomy or STAB phlebectomy. This procedure is symptomatic, I'm sorry, the patient is symptomatic with very large bulging varicosities in the right leg. Consent is documented as well as anesthesia. Highlighted in blue, we see the veins are moderately enlarged. 22 incisions were made in the range of 1 to 3 millimeters using a 14-gauge needle. A large number of veins were removed and hemostasis was achieved and a dressing was applied. Next slide. CPT code for this case would be 37766. So, now we'll talk about sclerotherapy. Next slide. Sclerotherapy is a medical procedure used to eliminate varicose veins and spider veins. It involves an injection of a solution, typically a salt solution, directly into the vein. The solution irritates the lining of the blood vessel, causing it to collapse and stick together and the blood to clot. Medicare will not cover 36468 as it is considered cosmetic, but they may cover the codes for your larger varicosities, assuming it's medically necessary, of course, and all requirements of the LCD are met. CPT code 36470 is for injection of sclerosin in a single vein and 36471 is for injection of multiple veins in the same leg. Next, please. So, CPT code 36465 and 36466 describe injection of a non-compounded foam sclerosin into an extremity truncal vein. This sclerosin comes to the provider ready to use and does not need to be compounded, which simply means mixed or prepared by the provider. Please note here that these codes do include ultrasound-guided compression. So, CPT code 76942 for your ultrasound guidance, if used, would not be separately reported. Next slide, please. Here we have our next case example. This report lists microphylectomy of the left calf varicose veins times eight incisions and ultrasound-guided sclero of branching varicose veins in the left thigh. You can see that the report here is divided into two paragraphs for the procedures. In the left calf, the veins are marked. Tumescent anesthesia is documented. Staphylopectomy times eight incisions is carried out with removal of the veins. And next, the left lateral thigh vein is accessed using ultrasound guidance. The sclerosin agent is injected into multiple varicose or reticular veins in the left thigh and ultrasound confirms no thrombus in the deep veins and also appropriate filling of the superficial varicose veins. Next slide, please. So here, this code would be 37799. As in this case, there's only eight incisions documented for the phlebectomy. Documenting guidelines do state that if less than 10 incisions are performed, they were going to use the unlisted code 37799. Also, CPT code 36471 would be correct for the sclero on the left leg as multiple incompetent veins were treated. And ultrasound guidance is also billable with 36470 and 36471. So we're going to bill 76942 in addition to these codes supporting the documentation. Next slide, please. So another varicose vein treatment known as endovenous ablation uses different methods to cauterize and close the varicose veins in the leg. Endovenous ablation is safe and considered less invasive than conventional surgery and leaves virtually no scars. So today we're going to take a look at the different methods of this service. Next slide. Hey, Tammy. I hate to interrupt you. Do you have music playing in the background? Apparently it's picking up somewhat. Oh, one moment, I'll check. You may be coming from my TV downstairs. Give me one second. Sorry about that, everyone. My speakers actually aren't that great, and I didn't hear it, or I would have said something to her sooner, but I see all the comments about it coming through in the questions. While Tammy did step away, I do want to answer something real quick. We have the 93970. The question is whether or not the modifier 59 needs to be appended to both. No. You would only put it on the second one. And then as far as another question was, will we use XU or XS, or U as in uniform, S as in Sierra. More than likely I would go personally with the XS, X-ray Sierra. That way you're identifying that it's separate extremities. All right. I will stop talking now. Tammy, you can take it back over. Okay. I hope that's better. These must really be good speakers. Okay. So we are on vein ablations. Okay. So let's see. We're going to talk about the first type of ablation, which is mechanochemical ablation or the MOCA technique. This procedure combines mechanical endothelial damage using a rotating wire with the infusion of a liquid sclerosin. Heating in the vein is not required. And only local anesthesia is utilized at the insertion site. All imaging for this procedure is included. Once the system is in place, the ablation catheter is activated for approximately 10 seconds to create vasospasm. That's just a sudden constriction of a blood vessel. And then that catheter is slowly withdrawn with continuous infusion of the sclerosin agent. A compression stocking is applied for the immediate 24 hours after and then replaced daily for the following two weeks. The add-on code 36474 may only be reported one time per extremity. Next please. So next we're going to look at radiofrequency ablation. This process is used to heat and seal the incompetent vein closed. And this is an excellent illustration for this ablation. The most common site treated is the greater saphenous vein. Ultrasound guidance is included and is typically used to position the catheter tip at the level of the terminal valve. Catheter electrodes are deployed and radiofrequency energy is applied. Compression stockings are typically applied continuously for 24 hours and then daily for two weeks. Add-on code 36476 may only be billed one time per side. And I also want you to note the separate access site definition in this add-on code. Next please. So next we have endovenous laser ablation or ELA. This is a minimally invasive procedure used to correct venous insufficiency. This procedure is performed in the office under local anesthesia. Using ultrasound guidance, a laser fiber is inserted into the refluxing vein via small nick in the skin, and laser energy is applied along the length of the vein. This laser energy is used to heat the vein and seal it closed. And the most common site is the greater saphenous vein. Again, remember that the procedure includes any imaging guidance and monitoring, and it takes approximately 30 to 45 minutes. Patients are actually able to drive following the procedure. And once it's complete, the blood is rerouted to healthy veins. The leg is wrapped in an ace bandage for typically 48 hours, and then a compression stocking is worn for seven days afterwards. Also mentioned again for the add-on code 36479, a separate access is required. Next, please. So finally, we have ablation by transcatheter delivery of chemical adhesive, which is commonly called venous seal or superglue. This system uses an adhesive to close superficial veins in the lower extremities. It is FDA approved. The procedure is performed in the office setting and requires only one small needle prick. Unlike some of the other venous ablation techniques offered, there is no need for additional injections of local anesthetic around the vein, and there's no need to wear compression stockings after the procedure. Add-on code 36483 does require separate access. Next, please. So for this case example, we appear to have laser ablation of the right great saphenous vein. This is a 55-year-old symptomatic female with lower extremity varicosities and responsive to conservative medical therapy. She has undergone venous duplex study, which demonstrated severe reflux in the right great saphenous vein, and she was offered laser ablation. Ultrasound mapping was performed. Ultrasound guidance is documented. The great saphenous vein is cannulated. Guide wire is advanced, followed by the introducer, and then the laser fiber is advanced and positioned with the tip just proximal to the sapheno-femoral junction. Anesthesia is infiltrated along the course of the great saphenous vein, and the laser is activated. They give us the settings, and then the introducer and laser fiber were removed. Next slide, please. So for this case, CPT code 36478 is appropriate. So for our final case today, we have radiofrequency ablation of the right great saphenous vein and microphobectomy of the right thigh listed in our wish list. This patient has symptomatic varicose veins refractory to conservative medical therapy. The saphenous vein was mapped by ultrasound, marked on the skin. The limb was prepped and draped. The radiofrequency catheter was placed on the field. Skin incision was made. Mapping of the entry site was performed, and the vein was accessed using ultrasound guidance and cell dengue technique. Glybar was introduced. Next slide, please. The radiofrequency ablation catheter was placed, and energy was applied. The vein was ablated by heating a 7-centimeter segment and then indexing the catheter forward by 6.5 centimeters until the entire length was completed. Following the radiofrequency ablation, attention is directed to the varicose veins in the right thigh and calf, which had been previously marked. Tumescent anesthesia is documented, and then microphobectomy times 10 incisions is carried out. Documentation of the removal of veins is well documented in your report. Next slide. So for this case example, we have 36475 for the radiofrequency ablation and 37765 for the phlebectomy times 10 incisions in the right leg. Okay, so at this time, I'm going to turn the presentation over to my esteemed colleague, Jolene Bruder, to discuss the diagnostic vein procedures. Thank you, Tammy. That was fabulous. I really appreciate your help on this presentation today. So next, we're going to talk about some diagnostic vein procedures. And as most of you know, VEDAS procedures are a totally different animal than the arterial procedures. So you have to shut off your artery portion of your brain as far as what those coding rules are, because they're not the same when it comes to the venous side of the house. So the first thing we're going to talk about is venal cava or vena cava angiography. And as you can see here, the inferior vena cava travels, you know, this will travel right along the aorta. But it's, you know, from your diaphragm down to the bifurcation into the extremity vent. And then for the superior. Oops. Sorry. For the doing this to me. For the superior portion that's up closer to the heart. So we have 36010 is when we place that catheter into the vena cava, and whether it's the superior or the inferior. So this would be equivalent to the 36200, where that cath is placed in the aorta only now we're in the vena cava. We also have SNI codes the supervision and interpretation so when they do the angiography or the venography. See I have, I obviously didn't turn my brain off yet. When we do the venography, we're talking about. There's inferior, and then there's also superior. So depending on where they're at and what they're doing they may do both, but for in order to code the superior you have to have the entire vena cava. So keep that in mind. When you do the aorta on the arterial side, you can build renal vein imaging, along with your being a cabal imaging so that that's different from the arteries because as you know if we if we do an abdominal aortogram and then they do the renal arteries. The abdominal then becomes part of that it's what they call that flush aortography. Well that's not the case when it comes to the veins, you can bill for your renal separately from the vena cava. We have 75827 and 75825 are for the, the vena cava codes and then we have unilateral renal with 75831, and then bilateral with 75833. Now one thing about the vena cava codes, you are not going to report them if you're doing an IVC filter. That's that imaging is included when, when we're doing this, those filters and we'll talk a little bit about filter further in the broadcast. You also do not report any of the vena cava venography codes with any of the dialysis, the AV fistula dialysis codes the 36901-36908, or I'm sorry 36906, and you also do not report any of the vena cava venographies with sampling blood sampling. So let's do some diagnostic venous extremity coding. Now again we have, you know, the most of the veins mimic mimic the arteries so you know we have a basilic artery we also have a basilic veins, so like so on and so forth. And then in the leg you also have iliac veins, femoral veins, anterior lateral tributary lanes, and you also have greater saphenous. So that actually runs the total length of the leg and that's the greater saphenous is probably, well it is the biggest vein in the legs, and it's often used for cabbages. So if you have a coronary artery bypass graft often they are, they will take that greater saphenous vein, providing it suitable. So if we do. Sorry, this code should be 36005. If you have non selective injection procedure for the extremity venography. That should be this, this here should be 36005. When it comes to the first order venous cath that should be 36473. And then for the second. I don't know what happened to the slide the slide is not right. Can you go to the slide please for a moment and change your codes for 36005 36011 is first order and 36012 is second or higher. So, keep that in mind these, the slide is not correct, I will get this fixed before we put it up on the Academy. For the extremity venography we have 75820 which is unilateral and 75822 which is bilateral. So what do we do if we have, if we do both upper and lower venography on the same day so if they're looking at veins in the arms as well as the legs. If you have unilateral of both the upper and lower you would report the 75820 twice. Again, you're probably going to need a 59 or an X modifier. If bilateral, then you would do 75822 twice. And again, you're, you're going to need either the 59 or the XS. And that would indicate that you know you're looking at both the upper extremities and the lower. When it comes to the visceral system again we're talking about, you know, on the arterial side of the viscerals we have the superior mesenteric artery celiac artery all of that type of thing with the veins we have the inferior mesenteric superior the hepatic veins, all of that are considered your visceral vessels. So on that we have to have selective calf placement has to actually be in a vein that supplies a visceral organ. And the access has to be from a peripheral access so they're either going to come from the femoral vein brachial vein or the jugular vein. So when we have first order. The first order viscerals that are considered first order are unilateral and bilateral renal. If you, if they do bilateral you're going to use the 36011 with a 50 modifier. Also considered first order is rep right testicular, and that does that is without renals. And then we have right ovarian that is with or without renals. And then we have adrenal venography, and then hepatic venography, with or without hemodynamics, these are all considered first order calf placements when we're in the viscerals. Now for a second order we actually have additional selective renal venography, after the basic procedure. So again you're looking at, you're going further into the renal veins, not just the, the basic right and left renal veins. We also have left to testicular venography that again was without the renal. We have left ovarian venography, with or without renal. And then we have left adrenal venography and hepatic venography wedged with or without hemodynamics. So, most of your cardiologists are probably not going to get involved in the viscerals but your vascular surgeons would. So we're looking at imaging for this, just like, you know, again just like the arteries, the veins have their own imaging. So we have renal slash ovarian venography, and for 75831 that is a unilateral SNI code, and it does include the left gonadal vein or ovarian For 75833 we have bilateral renals or ovarian, and these also include any ovarian collateral 75820 is the. Now this is interesting because it is the extremity veins as well so keep that in mind we use the 75820 and the 75822 for the extremities, but you would also use it for testicular venography. If they're doing the right side, you would code the 75820 for that testicular venography. Selective iliac venography must also be performed. If they're doing bilateral testicular venography, then you would have the 75822 and again you have to have that selective venography and the iliacs. So I know you're going to ask me well what, what do we do if they don't go into those iliac veins selectively. Well, when that if that happens and they only do testicular venography, whether it be unilateral or bilateral, you will have to reduce your code with a 52 modifier, because they did not meet selecting those iliac and providing that imaging. So it's important that your doctors, you have these discussions with your providers and let them know it's fine if you know if they only want to do the testicular venography, that's fine but know that it has to be reduced. If they do actually selectively go into the iliacs. That's great. They need to document that and they also need to give findings, so keep that in mind. And for this again we're, you know, these are the adrenal venography unilateral bilateral, then we have the hepatics with hemodynamics and without the code 76496. 76496 is an unlisted fluoroscopic code. And this is again additional imaging after basic. This code is actually similar to the 75774 that we use on the arterial side, but 75774 is for arteries only and not veins. Now, 76496 is actually an unlisted code. So, you would have to have the documentation to support this more than likely you're going to have to send it in to get paid. And, you know, you have to meet medical necessity as to why you know so you have to have that basic exam so let's say we're even doing this in the legs. All the way down to the foot, just like the arterial side, and then if they do more selective calf placement and all of that, then you could code the 76496 but because it's unlisted, it's going to be up to your carriers as to whether or not they're going to cover that. So keep that in mind. For venous sampling we have 36500 is the calf placement for venous sampling. And then we also have the 75893 which is the SNI code that goes with this. Keep in mind this was coded per organ studied, not per vessel. So, they actually have to do being a sampling in an in an organ. And this does have an MUE of four so it could be reported up to four times but you have to be in four different organs, not just four different vessels. All right, so next we're going to talk about the head and neck veins and again they you know they follow their worded a little different than our arteries, other than the jugular. Well, I'm sorry. Anyway, they are worded different than the arteries but they, they, these are the veins that bring the blood from the head back to the heart. So, calf placement with this is pretty simple because if you come from a femoral approach. All of this is 36012. No matter what, once you hit the head and neck. Anything above, you know, your cervical here up is considered second order coming from a femoral approach. If they come from the jugular, then you have to code the unlisted code 36299 for that calf injection for that injection through that catheter. These are just the SNI codes for the, the Venus vessels in our head we have jugular superior sagittal sinus epidural orbital. And again we have that 76946 but you will need to check with your carrier. Just a note on 75872 this is rarely done as a separate study, but it can be but just so you know that it's kind of rare, this. A lot of the neural, neural providers are going to get more involved in the head and neck. But there are a few vascular surgeons I know for sure out there that will delve into it. All right, so now let's talk about angioplasty and stents. So again, this was just like one thing about intervention they all pretty much follow the same rules regardless of what type of vessel you're in. So, again, we have the balloon, and it's, you know, pushing against plaque, or we have a stent. If they do balloon with a stent, the balloon is included. You do not bill for that separately. And also, just like whether we're talking about heart or arteries or the veins, diagnostic venography does bundle with intervention, unless of course there was no prior study, or if there was a study, it has to be documented that for whatever reason they couldn't read it, or the patient's condition has changed since that study was performed, or the patient's condition changes during the current evaluation. Now, again, that has to be documented. You have to, you know, this should not be a guessing game. It should be very clear as to whether or not something is diagnostic, but the rules do not change with the veins. So, for venous interventions, again, I talked about balloons and stents. So, this is our coding. So, we have the 37248, which is the initial vein, and then 37249 is each additional. Again, this would not be the same vein. So, if they do, let's say they do balloon angioplasty in a renal vein, and then they do another one in the superior mesenteric vein, then you could code that. If they do two stents in the same vein, or two balloons, actually, we're talking about balloons right now, if they do two balloons in the same vessel, you only get to code it once. Keep in mind, too, those AV fistula dialysis vessels have their own set of intervention codes, and you would not use any of these codes with the dialysis circuit. For the stent, we have the 37238, and then additional vein 37239, if they do the stent in there. Again, balloons are included in the stent. So, that's nothing new. So, what is separately billable? Well, again, we can bill for the diagnostic venography if the requirements are met. Non-selective and or selective cath placements are separately reported, whether you're in the upper extremity veins, the lower extremity veins, or the visceral veins. So, keep that in mind, because, you know, like I said, when we're talking about arteries and the legs, cath placements bundle. When we're talking about the veins, they do not. So, that's why it's important you do not combine rules when you're talking about veins and arteries. Ivis is also separately billable, and that is, again, 37252 is your initial vessel, 37253 is each additional vessel. Keep in mind, too, if they're doing a pullback, just like in the arteries, you should not report each one. They should be selectively going in and looking at each vein and getting findings for that. Mechanical thrombectomy is also separately billable, and that is with the 37187 and the 37188. 188, I believe, is second day or subsequent day. You can also code for the 76937, the ultrasound guidance, if your requirements are met. So, again, you have to have, there has to be real-time imaging of accessing that vessel. There has to be permanent recordings, and there has to be findings of the vessel that was accessed. That is all clearly spelled out in our CPT books. So, if you're, you know, you have to meet that 76937 guidance. So, let's talk a little bit about embolization. So, just like arteries, you can do embolization procedures in the veins. These are the different styles. Sometimes they're called coils. They have actually a lot of different names, but keep in mind embolization is inclusive of all radiological supervision and interpretation, any intraprocedural road mapping, and any imaging guidance. So, you know, that's, you don't get to bill. There's no S&I codes that go along with the embolization. So, again, there are codes for the arteries. I'm only focusing on the veins today. So, we have 37241, which is vascular embolization or occlusion for the veins, and this would be other than hemorrhage. So, this could be a congenital or an acquired malformation, and they want to stop blood flow into that. So, that's coded with the 37241. 37244 is treatment for hemorrhaging. So, if we have a GI bleed or a vascular or lymphatic extravasation, you can report that with the code 37244. Keep in mind our embolizations are not coded per vessel, and that doesn't change whether we're in the arteries or the veins. They are coded per surgical area. So, you know, if they're treating the viscerals and then they're also treating an extremity, you could code two, but if not, then, you know, if they're only in the visceral, you only get to code it in one. So, what else can we build? Well, we can build diagnostic angiography, provided we've met the requirement. You'll hear me say that a lot, and then you can also build for those cath placements. So, again, you know, unless you really only have two choices, they're either going to be the 36011 or the 36012. They're either going to be, you know, first order or second order, so it just depends on where they're doing that embolization. Make sure you are coding to the highest cath placement that's available, where that cath lands. Stenting. You can build separately for stenting when doing an embolization, providing that stent is not being used to provide lattice work to deploy the coil. So, let's say they're going to put a coil in one of the renal veins. If they line that vessel with stents before they deploy the coils, you cannot code for that stent, but let's say they do a coil on the left renal vein and then they do a stent on the right renal vein, you could code for the stent on the right renal, but not the left, wherever those coils are. So, keep that in mind. All right, next we're going to talk a little bit about thrombectomy and thrombolysis. So, again, we have the 37187. This does not matter how many veins you're treating. It's vein or veins. Now, they do allow, and this is like per leg or per arm, they do allow you to build these bilaterally. You can, so if they do, you know, the right leg and the left leg, you can build this with a 50 or it depends. Again, this is carrier dependent. If your carrier prefers that you report this with LT or RT, then by all means, that's how you have to report it. So, please do not ever change how you're coding based on any of our webcasts without checking with your carrier. So, we always like to throw that little disclaimer in there too, and we say that a lot and it's because the rules vary across the country. For 37188, that is repeat thrombectomy, but that has to be a subsequent day. It's not the same day. And again, so what can we separately build with those thrombectomies? We can build for the non-selective and or selective cat placements. We can build for other interventions such as balloons or stents. We can also build for thrombolytic therapy, which we'll talk about here in a minute. And then diagnostic venography is separately billable if you meet those requirements. So, for transcatheter thrombolytic infusion, this is not injecting the vessel with TPA. This is actually, we're going to thread a catheter in. We're going, sometimes you'll see it reported as ECOS. You'll see it called an ECOS catheter. This is where they're going to thread a catheter to a vessel and they're going to, and usually they'll use heparin or whatever they need, whatever chemical they need to try to bust up those clots. So, we have 37212 is our initial treatment day, and that is for veins. Arteries, as you know, is 37211. The codes don't change as far as subsequent days or the cessation. So, you have 37213. You would code that each day that that catheter remains in place. Once they stop, then you're going to code the 37214. Now, if they start and stop the same day, you would only code the initial insertion. So, if they, you know, let's say they place that ECOS catheter at eight o'clock in the morning and four o'clock in the afternoon, they pull it out, you are only going to code the 37212. So, that cessation has to be a separate day. If they do multiple angiography or, well, sorry, I did it. If they do multiple venography that day, that is not separately coded because that's already included in whether you're doing the 37212 or the 37213. This is days, not sessions. If they do these therapies bilaterally, they do require separate access sites. So, if they place that ECOS catheter in the vena cava and then, you know, the thrombolytic agent drips down into both legs, you only get to code one. They would have to place that catheter in each leg or in each arm, wherever they're putting it, and then you can code that with the 50 modifier, but it does require separate accesses. You cannot do all this from one access. Cath placements are separately billable. Of course, diagnostic studies, providing you've met the requirements. Other interventions, such as stents and balloons. Ultrasound guidance is also separately billable, if the requirements are met. And then, finally, you can code E&Ms for the same days as these therapies, providing it's a separately identifiable service. So, it will require a 25 modifier. If the provider is just coming in and talking to them about, hey, you know, your clots haven't fully broke up. We're going to continue. Have a nice day. See you tomorrow. You cannot code that as a separate E&M. There has to be something else going on with the patient that has nothing to do with the thrombolytic. And you all should know that, you know, the 25 modifier has not changed as far as when we can and cannot use that. All right. So, now we're going to talk about the vena cava filter. And that's this little umbrella spider looking guy. And what they do with this is it is placed in the vena cava, and it is to help prevent clots from breaking loose and going to the heart and or the lungs. So, it can be placed. So, here's the deal with these. They can be removed. But keep in mind, when you put a foreign body into your body, your body fights that. So, your body's going to, you know, try to expel it, basically. So, you're going to have scar tissue growing around it. You're going to have, you know, fat will get in there. All kinds of things will attack this little filter. So, normally, if they have not removed it within six months of placement, they're probably not going to because it can be very dangerous to remove this filter. I'm sure you've all seen the lawyer ads for if you had a family that had a vena cava filter that went awry, you know. They're out there, and it is dangerous to remove them once they've been in a while. So, normally, they don't, after six months, they normally don't even attempt. But let's say it's, you know, within a few months and they don't need it anymore, then they'll go ahead and take it out. So, 37191 is the insertion. Again, that is an endovascular approach. It does include vascular access. It does include vessel selection, and it does include our supervision and interpretation. 37192 is repositioning. That cannot be the same session as placement. It can be the same day. So, you know, if they place it, and later on that day, it migrates or moves, and they happen to do an image, and they don't like where it's at, and they take the patient back to the cath lab or the procedure room, and they move it, then you can code for that repositioning. But if they move it around several times as they're inserting it, you only build an insertion. 37193 is the retrieval code. And again, this would have to be a separate session. All right. So, let's go over a couple of case examples. So, here we have a patient has a history of recurring facial and neck swelling and prior episodes of superior vena cava stenosis. They did superior vena cava venoplasty back in 2019. They also did a stent with venoplasty back in October of 2019, and patients returning again with signs and symptoms. This is our procedure wish list. Remember, we never code from these. We always have to code from the body of the report. But this will kind of guide you as to what the provider was going to do. But again, we do not code from that. It has to be supported in the body of the note. And then, of course, we have our findings documented here. So, what we have going on now is, and I'm not going to read the entire note. I will start with after achieving 1% lidocaine local anesthesia, the right basilic vein was accessed with a micropuncture needle. So, this is an access. So, we have the 36005. And that's in the right arm. And then, the venogram goes up to the level of the superior vena cava. So, the outer dilator was exchanged. Seven French PD sheath and stepped venograms were obtained to the level of the SVC. Stenosis was identified in the right subclavian vein as it crosses the clavicle at the brachial cephalic slash superior vena cava junction. It's also within superior aspect of the existing SVC step. So, right now, I have the 75820. But if you notice, I have it crossed out. And we'll talk about why in a little bit. But I have the 75820 for that extremity venography. Next, an MPA catheter was inserted into the sheath and utilized to direct the benston wire into the inferior vena cava. An MPA catheter was removed and a 10 millimeter by 60 millimeter balloon angioplastic catheter was inserted into the sheath and positioned over that right subclavian stenosis. Under fluoroscopic guidance, the balloon angioplastic catheter was inflated and remained inflated for approximately one minute. So, now we have the 37248 for that balloon. Next, they deflated the balloon and advanced into the right brachial cephalic SVC junction and into the superior aspect of the SVC stent. So, we have cath placement now of 36010. Again, the balloon was inflated under fluoroscopic guidance and remained inflated for one minute. And we are going to code the additional balloon because now we're in the superior vena cava. So, we're in a separate vessel. So, we get to code the 37249. Next, we have ultrasound guidance was used to evaluate the left forearm, which demonstrated a widely patent brachial vein. Micropuncture needle was visualized entering that vein and the image was stored for permanent record. We have ticked all the boxes that are required in order to code the 76937. So, again, I put that on there. Once the appropriate site was identified, lidocaine was injected subcutaneously for local anesthesia. 21 gauge micropuncture needle was then directed into the vessel and direct sonographic visualization of the needle entering the lumen of the left brachial vein was performed. And then they did venography was done on the left brachial cephalic vein with numerous left chest wall and mediastinal collaterals. So, again, instead of that 75820, we now have bilateral. So, we're going to code the 75822. Next, that MP catheter was advanced over the Benston wire into the subclavian brachial cephalic junction. And again, that dedicated venogram was performed. Following that, MPA catheter had an attempt to transverse the left brachial cephalic vein after several times. The left brachial cephalic vein was unable to successfully be crossed and the MPA catheter wire removed. We are not going to code an attempted intervention because they didn't do anything. They couldn't even cross it with the wire. All right. So, our codes, we have the balloon and the subclavian. So, we have the 37248. We have the balloon and the SVC, and that is 37249. We have the 36010, which is the right catheter in the superior vena cava. We have the 366005, and you're either going to use a 59 or an excess modifier because we have that left access injection for the extremity on the left side. Then we have 75822 with a 59 or possible XU, depending on your carrier, and that is for our bilateral venography that was done at the same time as our intervention. And then we have the 7693726 which is the ultrasound guidance on the left. All right, our next case. So this one patient had a insertion of an inferior vena cava filter, venogram and fusion cath placement peripheral thrombectomy. Notice that acute deep vein thrombus of the femoral vein of the right lower extremity was noted on a previous venogram. So since we had a previous study, it's clearly documented here. We're not going to code for another venogram unless something changes within the session. So let's drop down here to what we have going on. So using ultrasound guidance, left popliteal vein was mapped with an image obtained showing patent popliteal vein. This was accessed with a micropuncture needle and a five French sheet. Similarly, on the right popliteal vein was accessed with imaging and that showed minimal compressibility consistent with DVT. All images are retained as permanent recorded. So we have the 76937. Next, the wire was advanced to the inferior vena cava just at the iliac confluence from the omni flush catheter. And that was advanced into the vena cava. So we have 36010. And then the venogram was performed. This showed a very small caliber vena cava with inflow of the right and left renal veins, which were marked. So we have the 75825. Now I'm not coding for the left and right venal renal veins because they were not selected. Next, the filter was placed within the femoral with the arrow pointing towards the sheath and the catheter dilator was used as a pusher that should be to push the filter out over the wire. This was deployed in the appropriate location. So we have 37191. And then a focal venogram confirmed location in the popliteal vein. However, not a large amount of clot was present. Another venogram was performed from the common femoral into the iliacs, which was interesting. It's nice that he said that, but he didn't really tell me much. The common femoral head had a large amount of thrombus, appeared acute. There was very large collateral from external iliac, which crossed into the right iliac. They already knew there was clot, so we do not code for that venogram. The left common iliac had no flow at all. Again, this was already known, so we're not going to code for the bilateral venogram. Dropping down, angiojet was used to pulse tPA into the thrombus with fair results. With a mechanical thrombectomy, you would code that as 37187. And then they also decided to place an infusion catheter. Well, again, because we are looking at 36012, because we're in the vein, we would code that with that code, because they're going to put in that infusion catheter, that's another word, instead of the ECOS. And then finally, the infusion was set for the catheter and heparin at 500 units. This will be left overnight with a recheck tomorrow, so that's our 37212. So what is our final codes? Our final codes are 37191 for that vena cava filter. We have 37187 for the mechanical thrombectomy. We have 37212 with a 59, because there is a bundling issue, but it was separate, so it is separately billable. And then we have 36012, which is second order cath placement in the populate. All right, we got through it. So again, these are our disclaimers. Most of you have listened to us before, know that nothing that's put out in these webinars constitute legal billing advice. You should always check with your local Medicare carriers. And where your practice is legal counsel. These codes were actually taken from the CPT book, so that's our disclaimer for that. Again, we have our general case questions. You can send to the RCS at medoxin.com, and that will go to the entire team. And then that way we can, you know, look at your cases or address any of the questions that you have. Let's see, can you, I'm looking at some of your questions now, sorry. Tammy, if there's any that you wanted to answer, if you want to jump in here while I'm looking, you can do that. Somebody had typed, can you repeat? I'm not sure what they wanted me to repeat, so I can't talk to that. A question, can you code a venous angioplasty 37248 when performed after mechanical thrombectomy in the same vessel? The answer is yes, you can code for both. We already talked about the 93970. There's a couple other here, one of them wants to know if this is a TIPS procedure, the 36478. I've never heard it called that, but I'm not going to tell you that it's not. That is one of the ablation, the venous ablation codes, the 36478. I don't know which one right off the top of my head. Keep in mind with your venous ablations, you're going to look at the biggest thing with those, how many accesses are there, because you can only code for one if there's only one access. You have to have a separate access in order to code for an additional venous ablation. Then you have to know what type. Are they doing radio frequency? Are they doing laser? Are they doing the superglue? That's my favorite. Then there's that other one that I can't think of right off the top of my head either. It's been a long morning, so a lot of the stuff has gone out of my head at the moment. On pretty much everything else we have talked about, I'll repeat the code correction on slide 45. Slide 45, I apologize for that. I run through these, I swear we all do. We look at these, we show them to each other, and then inadvertently we'll be live and go, oh darn, that's wrong. So what should be on that slide is 36005 is your non-selected venous access. That's when they'll puncture the vein, and then they'll shoot that dye down the leg or the arm. That is your 36005. That's the injection for extremity venography. The first order cath placement for veins is 36011. Then your second and above, so we don't have third order with the veins like they do with arteries, is 36012. That slide should read 36005, 36011, and 36012. Let's see. Oh, here's a new question. If the patient comes in for planned RFAs prepped and draped and injected with lidocaine, but the RFA is aborted due to the complication, would billing the procedure with a 353 modifier, would that be appropriate? That's hard for me to say without actually looking at a report. It kind of depends on how far they got. Had they even started to access anything? Had they even started to thread the equipment? If there are situations, I know for whatever reason, patients, you start to do the prep and drape. They go into AFib and you abort. No, you're not going to code anything for that, or whatever your case may be. You're not going to code that. I would honestly have to see a report to give you a real fair answer on that. Would you submit 36012 if more than one venous vessel is entered? Yes, providing that you have separate accesses and that cath is going to go further. If you have two separate cath placements for the 36012, then you would report it twice. If you're just going down the same extremity further, once you get to that 36012, it's just 36012. You would have to go into a different family. Keep in mind each arm is a family, each leg is a family, your head and neck is a family, your viscerals are a family. I have another question here. What if it's a bilateral balloon? If each vessel is being treated, again, normally when we're talking about interventions, again, we're talking about separate families. Normally, if it's a bilateral balloon and you're treating, if they're ballooning the right iliac and their vein and they're ballooning the left iliac vein, then you're in two separate families. If they're ballooning the right common iliac vein and then they're ballooning the right femoral vein, then you would have your initial angioplasty and then your additional. It depends. Are we in separate families or are we in the same family? If it's the same family, you would bill your additional. If you're in a different family, then you would bill your primary, either with that RTLT or your 50 modifier. Can we bill IVUS for TP trunk vessel IVUS evaluation? Again, take off that artery hat. The artery hat, when it comes to the TP trunk, that is not considered a separate vessel for billing. When you're talking about IVUS evaluation, if they're truly selecting the TP trunk vein, I'm assuming we're talking about veins, but we're not talking about arteries here. You have the posterior tibial vein, the popliteal vein, and then they do the TP trunk. The TP trunk, if there's findings, they selectively go in there and they're looking at it, then yes, I would code multiple. If though, however, let's say they go down to the anterior vein and they pull that IVUS all the way back up to the iliac, that is a pullback. You should really only code one. Keep that in mind. Aspiration thrombectomy, okay, this gets confusing too because of the coronaries. The coronaries, they do not allow aspiration thrombectomy to be separately coded. It has to be mechanical. When it comes to the extremities, 37187 is treated, they don't care if it's aspiration or mechanical, you can bill that. It's not like the coronary in the heart. That's part of trying to keep all of these things straight in your head when it comes to what rules apply to what I'm doing. I'll tell you flat out, myself, everyone on my team, there's rarely a time that we code anything just strictly off. I know this. We always have our books open. We always look because again, it gets confusing. Especially if you're looking at, if you're doing 10 peripherals on the arteries and then a vein case pops up, well, then you have to go, oh, wait a minute. Now, I have to switch my thinking. Always keep your books open and your CPT book is your best friend. If you're great like Nicole, Nicole can do the online version. Jolene and Jamie do not and neither does really the rest of our team because we're old school even though I'm almost one of the oldest here. Jamie and Angie are our younger members, but they like the books. It just depends on what works for you, but my point is don't try to keep all this straight off the top of your head. Okay, next question. Regarding real time for 76937, if the MD just dictates needle entry, does that qualify or does real time have to be stated? Again, ideally, yes, they should state it, but if you can tell that if they're meeting the rest of the requirements, the biggest thing with that is did they visualize that needle going in? Did they document that vessel patency and did they keep that permanent copy? That's probably where we have the most problem is there's no documentation that that copy was kept. Pick your battles, but that is something you would want to use with your physicians as a teaching point that if you would dictate this way, it would make it very clear and very much easier on us. Let's see if mechanical thrombectomy is performed in two separate veins in one OR visit, can you bill for both? The answer to that is no, because the 37187 is vein or veins, it's plural. So now there might be an MUE that says clinical, you'd have to go and look. It's possibly something that could be appealed, but normally when that, you know, because they have the 37187 thrombectomy vein or veins, it doesn't matter how many you do. And then the 37188 would be for the next day. If 76937 is done on both legs, can it be billed twice or with a 50 modifier? Okay, again, this comes down to your carrier and it can come down to your commercials. Medicare does allow 50 sometimes depending on the carrier. Some want the RTLT, some want you to report it with two units. So you need to check with your particular carrier as to what they want you to do and follow that advice. I wouldn't, you know, if right now you're reporting it with 50 and they're not giving you any kickback on it, then I would keep doing what I was doing. But again, it just depends because some, it depends on what they want you to do. Commercials could be a totally different ball game. Let's see, some of these I'm going to have to go back and look up more. I want to clarify on the aspiration thrombectomy of the heart. We're not actually talking about the heart, so I'm not going to really get into that. Keep in mind aspiration thrombectomy is part really of if you're treating an acute MI and we're talking about veins today. So you could send that question to the RCS team and we can look at that later. Oh, IVUS pullback. The question is, can I expand on the IVUS pullback? It's generally used on all cases with separate documentation on each vessel. Can you code 37252 and 37253 with separate findings on each vessel? You need to discuss that with your physician. If everything is patent, I would only code one. But you need to have that conversation with your physician that, you know, again, are you actually going in looking at every vessel or are you just pulling that IVUS back and getting your findings along the way? If it's not clear, you know, we do not assume anything and we go and check with our providers on what exactly they're doing. Let's see. There's one more question about is that found under access of my academy? I'm not sure what we're talking about. Oh, you're probably talking about the questions themselves once we compile them all. I hope that's what you're asking me. Yes, once they compile them all and these will, you know, these presentations will be available for you to listen to. Again, give our team a few days to prep and get the stuff uploaded. Once the case questions are compiled and we've answered them all, we've researched them all, they will be available on the academy with the presentations themselves. Also keep in mind, I have, we did the November 8th webcast on the CABG open heart procedures. I have not gotten that Q&A session done yet. It will be done this week. I apologize. We've had a lot going on and, but most of that I had answered live. So, but I will get those on this week, but as far as the bootcamp, like I said, give us a couple of days or give us a couple of weeks. We will do our best to get everything compiled and uploaded before the holidays, but we're certainly not going to promise anything. Very well, maybe January before we get all of that done. We appreciate your patience with that. And there's a lot of work that goes into these bootcamps. So we appreciate all of you. We love doing these and sharing this with you and hoping to clear up some of the questions that you have when it comes to coding a lot of these more difficult cases. Again, we hope to see you tomorrow. Jamie and Nicole will be doing a deep dive on the E&M for 2023, and that's going to be an exciting presentation. And then again, Jamie and Nicole will be covering on Thursday, a lot of the ASC cases, which is the ambulatory surgery centers or the OBL cath, OBL procedures for those freestanding cath labs. So that will be on Thursday. And again, we appreciate all of your attendance and your questions. They were great questions. What we didn't answer, we will get compiled. And then finally, I'd like to thank again, my colleague, Tammy, for joining me today. And I hope you all have a wonderful day.

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