and welcome to our webcast today. My name is Jolene Bruder, and I'm going to be joined by my colleague, Tammy Barron, and we're going to talk about coding for endovascular and open aneurysm repair. Before we get to that though, of course we have our disclaimers and all that housekeeping stuff. So to access the slides for today's presentation, you need to click on the chat box and there'll be a link there. And then we do ask that you don't use the chat box for anything else. If you have questions, you can click on the Q&A box, and then that way you can type your question in there. As always, we will try to answer as many as we can at the end of the webcast. Whatever we don't get to, we will compile and get those answered. And those will be put on the website later. I would say within a couple of weeks. For CEUs, you will claim those in the MedAx Academy, and you'll click on, I know it says coding bootcamp, but I'm sorry, I didn't see that before. It is still the same process. So you're going to click on this webcast and claim your CEU. Also note that this particular webcast is on demand. So therefore, if you have colleagues that are unable to attend today, they can go back and listen, and they can get CEUs after they answer the quiz. Those of you that are listening live, you do not have to take the quiz. We do want to note with these on demands, they take a little longer to upload onto the Academy. So give us probably at least a week before that will be on there and available. Also note for the AAPC CEUs, in order for you to not have to take the quiz for this one, you do have to register, and you do have to launch the course. So just keep that in mind. All right, so our objectives today is we're going to talk about the different types of aneurysms, and we're also going to note some of the common acronyms. We're going to discuss endovascular repairs of aortic and iliac aneurysms. And then we're also going to discuss open repairs. And then we do have case studies for both types. So Tammy is actually going to kick us off now, and she's going to cover the EVAR-FEVAR portion, and then I will be back with you later. Thanks, Jolene. Good afternoon, everyone. Today we'll be discussing the types of aneurysms and also some helpful tips when coding these procedures. So let's begin with a few definitions, which are critical to understanding these procedures. The aorta is the main vessel in the body that takes oxygen-rich blood from the heart to the rest of the body. The aortic wall consists of three layers, the intima, the media, and the adventitia. An aortic aneurysm is defined as weakness in all three layers of a vessel. A pseudoaneurysm is defined as a hole or tear in these three layers of the arterial wall, which results in an aneurysm like expansion of blood around the vessel. Maybe this is from a wound like a gunshot or stabbing or even an iatrogenic cause at a sheath or central venous cath placement site. An aortic dissection is a tear of the intima layer of the aortic wall that results in a true and false lumen. Type A involves the ascending aorta, plus or minus a distal extension, while type B involves only the descending aorta and the distal extension. With a dissection, you may see expansion of the false lumen with compression and compromise of the true lumen, rupture of the aorta and or major arterial branch occlusions such as your SMA, celiac, renals, or iliac arteries. So I'll be talking about abdominal aortic aneurysm repair today. There are a couple of ways to repair these aneurysms. Open method, which is more painful and results in greater recovery time or endovascular repair or EVAR, which is becoming a more popular method of treatment. Next, please. My colleague, Jolene, will be covering the thoracic aortic aneurysms today. So I'll just quickly say, as you can see from the illustrations, you may have aneurysms of the root, ascending arch, and or descending aorta. The first three are repaired by open method. The descending aneurysm, however, may be repaired by open or endovascular method or TVAR. This slide contains most of the common acronyms associated with endovascular aneurysm repair that you'll see in your procedure notes. You can look over those. So some things you definitely want to be mindful of when you're reviewing your physician's documentation are how was access obtained for the graft? Were cutdowns performed or was it percutaneous? What was the treatment zone? Your docs need to clearly identify the vessels that contain the graft. If extensions are placed, where are they? For fenestrated grafts or FEVAR, your docs should clearly identify the visceral vessels involved in the graft. For example, your celiac, your renals, and or mesenteric arteries. TVAR coding requires specific documentation as to coverage or non-coverage of your seclavian artery. And finally, be sure you capture all interventions outside the treatment zone. Although coding for these procedures may be difficult, your CPT book will be very useful when you're reviewing this documentation. Next slide. With that, we're ready to dive into EVAR. So in order to code these procedures properly, we absolutely must know where the graft starts, where it terminates, and which vessels are involved. Also, the codes reflect whether or not the aneurysm was ruptured. Ruptured aneurysms are much more complex, so the CPT codes were split out in order to capture the extra work time and difficulty associated with these procedures. If decompression laparotomy is performed, it may be reported with your ruptured aneurysm codes. Again, I can't stress this enough. Physicians must clearly document the treatment zone in order to capture all the correct codes. In this slide, we see an illustration of the treatment zone definition. It's fairly straightforward in that it's identified by the vessels that contain the endograft. This particular illustration shows the treatment zone involves not only the aorta, but also the common iliacs. Limbs terminate in the common iliacs. Note that sometimes the docking limbs will be long and actually terminate in the external iliacs. And in that case, the external iliac is now considered part of your treatment zone. So this is another reason it's so important for your physicians to clearly document where that graft begins and where it terminates, because that's gonna determine what other procedures can or cannot be billed in conjunction with your primary code. Next slide. So these add-on codes represent open artery access with conduit creation. They may be billed with, did I miss a slide? Yeah, Tammy, hang on, let's, it is the co- Let me go back. Post-surgeon slide. Sorry about that. 16. Oh, you're on 15. I must be going too fast here. Okay, so we're on 15, right? Okay. Sorry about that. These procedures are often done with two types of specialties. When that happens, be sure to report the procedure with modifier 62 on the appropriate codes. Do not use 62 when the physicians are in the same specialty, for example, two vascular surgeons. In this scenario, one would be primary and the other would be an assistant. So in those cases, you would wanna use your AD modifier or the assistant modifier if it's a teaching facility. So this slide represents available add-on codes for vessel access with our endovascular procedures. We have 34713 for 12 French or larger sheath with percutaneous access. And this does include ultrasound guidance. So you absolutely would not be able to code this with 76937. Having said that, if you are using less than a 12 French sheath, ultrasound guidance may be used in build, providing all the requirements are met for the code. We have code 34715 for open axillary, subclavian access, 34812 for femoral cut down, 34820 for open iliac access, and 34834 for open brachial access. Note that all of these codes have a unilateral MUE of one. You wanna be sure you pay attention to the parenthetical notes as to which primary codes these add on to. I mentioned this because I sometimes see these build when performing various audits. And these specific femoral cut downs are only for the endovascular repair codes. So if a provider is performing an open stamp, for example, cuts down into the femoral artery, it's not appropriate to code the 34812 with a 37236, for instance, as the description of CPT code 37236, states open or percutaneous. So on 17, these add on codes represent open artery access with conduit creation. They can be built with the endographs and also when establishing cardiopulmonary bypass with other procedures. Please note that it's absolutely necessary that a conduit is actually created. There's no conduit, then don't use these codes for cardiopulmonary bypass. Next. We added this slide to affirm that Medicare does not always follow CPT guidance. As you can see, there is a conflict with the rules of figure. For AMA, report the codes twice or two units if it's bilateral. For CMS, you may append a 50 modifier if it's bilateral. Bottom line, of course, check with your local carrier. Next slide. So we're getting into the EVAR placement codes. Please note the diagnoses, aneurysm, pseudoaneurysm, dissection, penetrating ulcer. CPT codes 34701 and 34702 define an aortic tube graft. Choose the code based upon ruptured versus non-ruptured aneurysm. And please note the description of these two codes. If the physician performs a temporary aortic and or iliac balloon occlusion, that's included in all the rupture codes and it wouldn't be reported separately. Any extensions from the level of the renal arteries to the aortic bifurcation are also included. Next. Aortouni iliac grafts cover the aorta and one iliac artery. Included extensions for these codes run from the level of the renals in the aorta to the common iliacs. Please note, should the iliac limb actually be longer and terminate in the external iliac, then extensions would not be billable unless they terminate in the common femoral artery. Next. Next we have the aortobiiliac graft codes. And this is typically the scenario we see more often, or at least I do. This graft consists of the main body and one or two docking limbs or a one piece bifurcated graft. The extensions in these grafts also run from the level of the renals in the aorta to the iliac bifurcation. Remember, docking limbs are not extensions. They are part of the main body. And also, as I mentioned before, if they're super long and they terminate in the external iliac artery, don't code for those extensions. Again, you will only code for extensions if they terminate in the femoral arteries. Next. So what is included with EVAR? Well, imaging is included in the codes. Also non-selective cath placements are included. PTA and stenting in the treatment zone, spondyl. All stent grafts that terminate in the common iliacs or in the aorta, below the lowest renal artery, are included. Next. So what about extension add-on codes? If the extension is distal to the common iliac arteries or proximal to the renal arteries, then these can be reported. This add-on code is per vessel treated. So for example, if your main body device terminates in the common iliac and an extension needs to be placed in the external iliac and the internal iliac, you could report this code twice. But remember, it's per vessel, not per extension. Also keep in mind that a bifurcated graft includes the docking limb placement. So these would not be coded as extension. Docking limbs are an inherent part of the main body, as I mentioned earlier. Next. Please note that each CPT code states which vessels include extensions. For example, 34703 states that extensions are included from the aorta at the level of the renals to the iliac bifurcation. So if you extend proximally above the renal arteries or distal to the external iliac arteries, you could build an extension. Extensions do have an MUE of three, by the way. So also note if the main body bifurcated graft has a docking limb that extends into the external iliac artery, then you may not build that as an extension. Again, that would have to go into the femoral artery to be able to report that. And again, it's vital to remind your physicians that they must specifically document where that main body and docking limb start and terminate. Otherwise, we cannot present a true and concise picture to the payer. Next. There are codes for delayed extensions, meaning that these are placed at a different session than where the primary device was placed. Code 34710 for the initial vessel extension and 34711 is an add-on code for each additional vessel up to two. Both of these codes represent delayed placement of distal or proximal extension prosthesis. CPT 34710 is the initial vessel, 34711 is for each additional vessel treated. Next. CPT code 34808 is for an iliac occlusion device. We're given the primary codes with which it may be reported here. 34813 is for placement of a fem-fem graft during EVAR. Do not report the regular fem-fem bypass codes with an EVAR. Want to make sure you submit this add-on code with EVAR. Next. Occasionally, there is a need to deliver anchors or taps or screws to assist in anchoring that graft to the vessel and lessen the chance of graft slippage. So for these fixation devices, we would use CPT code 34712. These are reported once, regardless of how many anchors are used. If a decompression laparotomy is done in conjunction with a ruptured abdominal aneurysm repair, you may report this 49000 code. Next. So some additional billable services we want to mention. Access is separately reportable, which we covered in earlier slides. Cath placements outside the treatment zone. IVUS, extensive repair of an artery. Note, if the repair is performed and you had coded 34812, you would drop that code and just bill for the arterial repair. If it's only one extremity that's repaired, you would drop one side and you could bill the 34812 with a 59 or an excess modifier to represent the opposite extremity. If an endovascular repair was attempted and it was reverted to an open procedure, you would build these codes depending on what type of prosthesis was used. These are also used if the patient had a prior EVAR that failed and they had to go back and perform one of these procedures. Okay, so now we'll talk a little bit about ILLIAC aneurysms. CPT codes 34707 and 34708 are used for ILLIO ILLIAC endograft dependent again on rupture versus non ruptured vessel. Please pay attention to the diagnoses for both these codes. An ILLIAC branch endoprosthesis or IBE as we call it is a device that isolates the common ILLIAC artery from systemic blood flow and preserves the blood flow in the external and internal ILLIAC arteries in patients with a common ILLIAC or aorto ILLIAC aneurysm. The IBE has a main body in the common ILLIAC and then it branches into the internal and external ILLIAC arteries. Codes for IBE are now split according to whether or not they're placed at the time of an aorto ILLIAC endograft. 34717 is an add-on code and this procedure is coded when performed at the same session as an EVAR placement. It includes your target zone angioplasty and stenting. All cath placements in the treatment zone are bundled as well as all radiological and supervision codes associated with placing this graft. This is a unilateral code. So if it's performed on both the right and the left sides then you would report that accordingly. Next, CPT code 34718 is coded when an IBE graft is not placed at the same time as your aorto ILLIAC artery endograft at the same session. Indications for 34718, aneurysm, pseudoaneurysm, dissection, arteriovenous malfunction, penetrating ulcer. If your note supports a traumatic disruption and you're placing an oscillated IBE graft then you must report an unlisted code 37799. If it's a bilateral procedure, you'll be reported with modifier 50. You may report IBIS as documented, cath placements and interventions outside the IBE zone. Otherwise do not report your cath placements within the IBE deployment zone. Imaging of aorta and its branches including your runoff vessels post-deployment, embolization within any of the vessels treated with IBE. 34709, 34710, 34711 extension codes with ipsilateral IBE, extensions from the aorta through the common femoral artery, big list there. Next, we're gonna talk about fenestrated grafts. So fenestrated aortic grafts or FEVAR involve the visceral abdominal aorta and the graft will terminate in the aorta or it may involve the visceral and infernal abdominal aorta and the graft will terminate in the common iliacs. There are CPT codes for both types of these endografts. And the important thing about these grafts is that they are patient-specific and they are made to match the patient's anatomy. Fenestrations are holes within the fabric and allows placements of an endoprosthesis with either a bare metal or a covered stent to maintain flow to your visceral arteries. Artery or arteries, next please. Now, as you can imagine, there is insane amount of planning that goes into these grafts. So we do have a specific CPT code available to report the physician's time and effort. Just note that the 90 minute requirement in this code description is there. Next. This slide gives you more guidelines for billing 34839. Note the date of service guideline. You cannot include time spent the day before or the day of placement of your FEVAR graft. Next. As I mentioned earlier, there are two sets of FEVAR codes available. These are based on where the graft terminates and how many visceral arteries are involved. The first set is for the visceral aorta and the second is for the infernal aorta into the common iliac arteries. Next. So here are your first set of codes for the grafts that terminate in the aorta. As you can see, they're based upon the number of visceral artery endoprosthesis required. These codes do include all imaging, fluoroscopic guidance, non-selective and selective cath placements via the fenestration, extensions in the aorta, extensions in the common iliacs or the vessel in which the graft terminates, docking limbs, PTA, stent within the endograft zone. Also, if two providers from different specialties such as a CT surgeon and a vascular surgeon perform these procedures, you're gonna wanna add modifier 62 appropriately. Here's the second set of CPT codes that set up exactly the same. However, these codes represent the grafts that terminate in the common iliacs. You also have the exact same bundles as the prior slide. So we won't go over those again. Next. Next. We do wanna stress that you will not code for extensions that terminate in the aorta. And this does include the suprarenal extensions and do not code for extensions that terminate in the common iliacs. So what is separately available with FIVAR? Well, distal extensions that terminate outside the common iliacs, such as your internal, external iliac or femoral arteries, cath placements outside the target zone, vessel access codes, extensive repair of an artery, other interventions outside the target zone are all separately billable. Okay. So we are ready to look at some live cases. Bring this home. Case example number one, I always like to look at just the top of the procedure and sort of get an idea of what the physician says he did. And then I'll move on to what he actually did. So this first page just kind of covers the technique. And we'll go on to the next slide. And we'll read a little bit of this. Over the wire, an eight French vascular sheath was placed into the right common femoral artery through which an angio was performed that demonstrates the ostema of the hypertrophied right internal iliac artery. Although no definitive type 1b endoleak was identified. Omni was advanced and formed in the iliac limb. This was then used to select the right internal iliac artery. Angiogram was performed to confirm the position and then multiple coils were deployed under careful fluoroscopic guidance. Repeat angio demonstrated no flow through the right internal iliac artery. So there we have an embolization, which is 37242 and our selected first order path, 36245 in the right internal iliac artery. Attention was directed to the right iliac limb of the EVAR. A myo-wire was advanced into the aorta. Catheter was advanced over the wire. Aortogram was performed, which was used to measure the length of the limb extension over the wire under careful fluoroscopic guidance. The stent graph system was advanced to the appropriate level at the flow divider. The right iliac limb was positioned appropriately and deployed under fluoroscopic guidance. Completion angio through the sheath was performed that demonstrated no evidence for endoleak. Next slide. Case one answers, we have 37242, which is arterial embolization, 36245 for our cath placement and 34710 for the delayed extension. Second case example. I am still, I'm still showing mine off center. We may have to come back to that one, Jolene. Actually, it looks okay on my end. You want me to go ahead and read through it? Would you mind? Sure. Okay, so for this case example, I guess I can put myself back on camera too. For this case example, we have, and it depends on your doctor. Some will give you the full procedure list and some do not. On this one, they did not. So we had the patient under general anesthesia. I'm going to drop down. So they did a stiff wire on the left and placed a 16th French sheath and a 12th French sheath on the right. So notice we have 34713. It says times two, that actually should be slash 50, depending if it's Medicare, it'd be 50, but also note it's struck through and we'll get into why later on. But if, you know, if they stopped right here and didn't do other things, we would code that. Dropping down, they place an ILLIAC branch device up the left side. So in this picture, it's actually the right side, but just so you can see. And that was a 23 by 14 by 10 device. It was partially deployed with the gate overlying the internal ILLIAC aneurysm and using a through and through wire, they directed the 12 French sheath from the right into the ILLIAC system on the left. We then cannulated the internal ILLIAC aneurysm, did imaging, treated the hypogastric aneurysm initially with an eight millimeter lung by 79 millimeter VIABON, that's what VBX stands for, VIABON covered stent. To increase the seal zone, they used a 10 millimeter by seven centimeter internal ILLIAC branch device. So this is going to be coded with 34717 due to the fact that they're also going to do an actual EVAR. So sometimes they'll do the EVAR first and sometimes they'll do the IBE first, that really doesn't matter. Dropping down, they cannulated the right internal ILLIAC, kind of talks about those quite a bit. They did some balloonings and some stents all in the internal, all of that's included because it's in our treatment zone of the IBE and of course the main body that we're going to get to. Then they switched to a 16th French sheath on the right, place the main body bifurcated gore. So now we're looking at the main body graph up here in the aneurysm in the A order. And for that code, we are going to use the 34705 due to the fact this is not a ruptured aneurysm. They go on and did angiography, showed renals, all of that's included now. That's all included in that 34705. Again, they did some more stenting in the contralateral limbs, all of that stuff. Again, that's all in that treatment zone. And let's see what else we got. Okay. So continuing on, he thought there was a problem with the closure device. So then he made a cut down on the left groin. So notice we have 34812 with LT. Again, that struck out because they ended up doing something else. The artery was quite calcified. They did do a limited endarterectomy. The closure device, and notice I coded the endarterectomy, but then we actually struck through that too. And again, I'll explain why. The closure device had functioned appropriately. The artery more proximal had a weak pulse, placed a sheath after closing the arteriotomy. I'm gonna drop down some more. Let's see. Then they attempted to get a wire through the stent and despite significant trial, could not get the wire to pass. For that reason, they did a fem-fem graft. And that was necessary, particularly since the patient had bilateral prosthetic popliteal aneurysm repairs in the past. So now we have this fem-fem bypass on top of everything else. All right. So for that, now keep in mind, we went to cut down. So that's why we have the 34812 with a 50. And that's again, assuming it's Medicare. And we are going to lose this endarterectomy up here. Why? You might all ask. Because that's part of establishing inflow and outflow of this fem-fem graft. So they don't get that anymore. So that fem-fem graft is a 34813 code, which is an add-on code. And it adds on to the 34812. So that's why we did this this way. So our final answers on this, we have the 34705 for the EVAR. We have the 34717 for the IVE or that iliac branched endograft. And then we have the 34812 with a 50. If it's commercial, then report it the way the CPT book states. Or if your Medicare carrier accepts what the CPT book states. But for the most part, from what I'm seeing across the country, Medicare wants this reported with a 50 because they do show it with an MUE of one and it's a unilateral code. So that's the only way they can get around it. So again, when in Rome, do what the Romans do and you have to go by what your carriers, whether they be commercial or Medicare want you to do. And then finally we have the 34813, which is that fem-fem bypass during EVAR. We would not code the actual, and I don't know the code off the top of my head, but we would not look in the bypass area of the CPT book because this was being done in conjunction with that EVAR. All right, Tammy, I'm gonna turn it back over to you. Is everything looking okay on your side now? Yes, this one's fine, yes. Thank you so much. You're welcome. Okay, so for case example number three, we have a perirenal abdominal aortic aneurysm. And I'll skip down to the OP report so Jillian can have plenty of time. Patient was taken to the hybrid room, blah, blah, blah. The chest, abdomen, bilateral groins, and lower extremities are prepped and draped. Bilateral ultrasound guided retrograde femoral access is obtained followed by deployment of our pre-closed devices. Bilateral retrograde 12 French sheets were situated. So we're looking at the 34713 codes there. Next page. The main body delivery system for the fenestrated component was delivered over a heavy wire up to the level of L1. Aortography was performed to delineate the precise position. A device was then deployed in its first stage so as to expose the fenestrations. Then he goes on to advance a dry seal sheath, maneuvered into the fenestrated device, proceeded with selective cath through the appropriate fenestrations into the left and right renals, proceeded with bare stents into their positions. Bilaterally, this was followed by deployment of the proximal and the fenestrated component and ballooning the interest stent components to essentially rivet the stent grafts in place. Once both these grafts were successfully deployed, then proceeded with the distal stage of the bifurcated stent positioning. He did retrograde iliac angio bilaterally to determine the precise length of the iliac components. Angioplasty was done and everything looks complete. There we have 34846, which leads us to our final answers on the next slide. We have a fevar inferrenal and two visceral fenestrations, and that code is 34846. And then you have your 34713. With the 50 for your greater than 12 French sheath. Again, note the CMS states that a unilateral code is performed bilaterally. You're gonna append the 50 modifier and this code only has an immunity of one, so you can't report it with units, which as Jolene mentioned is contradictory with the CPT book. So that's my portion. And at this time, I'm gonna turn it over to Jolene and she'll guide you through T-VAR and open repair. Thank you so much, Tammy, great job. And I appreciate you getting through that one funky slide. All right, so now we're gonna talk about T-VARs. And these are my favorite thing. I don't know, I just love all of these endovascular things. I'm strange, I know. But, so as Tammy was pointing out earlier, when you're talking about ascending and most of your arch, that is done open. The descending is rarely done open anymore. It's mainly the T-VARs. It just kind of depends on what's going on with the patient. Keep in mind though, sometimes in some of you, I know Minnesota is one of the places, some of you get into all these, this elephant branch thing and you got all kinds of people getting involved. So you'll have CT surgeons and vascular surgeons. And some of the vascular surgeons are doing the T-VAR while the CT surgeon are doing the ascending aorta and the arch. And so those are exciting cases too, but I didn't throw anything that difficult at you today. All right, so like we said, T-VARs is the repair of the descending thoracic aorta. The approved FDA devices, most of them are, you hear Gore, Medtronic, Cooke, you might see TAG. So you could see these devices listed in the physician documentation. And then when it comes to coding these, it's extremely important. Did they cover the subclavian like in this picture here, or did they not? Because your code is going to be determined by whether or not that's covered. Now, keep in mind, and this is where your anatomy comes in and is important. If they're talking about going up to the left carotid, then they've covered the left subclavian. So keep in mind too, they may not say the word subclavian. They may say that they deployed it at the left carotid, or they might even say they've deployed it at the right brachiocephalic. So keep in mind, when they're talking about it starts here, then obviously they've covered the subclavian over here. And then you got, sometimes people have those bovine arches and different anatomy. So you have to keep in mind, and if you're unclear, always check with your physician. All right. Okay, so other billable codes that we have with this group, we have the placement of proximal extensions, which I'll get into a lot of that here in a minute. But, and that is per extension. They're not counted per vessels because they're all done here in the aorta itself. You have each additional proximal extension, which has an MUE of two. So you can build up to three extensions. Notice too, one thing about the TVARs, we still have SNI codes for these. I don't know for how much longer, but they are the only group in the endovascular aortic repair that still allows the SNI codes to be built. Then we also have placement of distal extension that's delayed. So basically what they're saying is during a TVAR, you can code extensions going towards the heart itself. Anything going distally during that initial TVAR placement is included. You can't code for that. So the only way you can code for these is if it's done at a separate session. So it's delayed. It's after that initial TVAR has been placed. We also have codes for open subclavian to carotid artery transposition that's performed in conjunction, which means at the same time with the TVAR. And that is done by neck incision. And then we also have bypass graft with other than vein of carotid performed in conjunction. That's also done at the time the TVAR is placed and it's also with a neck incision. All right. So let's talk a little bit more about these extensions because this is important. So let's say the actual graft terminates right here. Well, if they say, oh geez, we need to go a little higher and they start putting those proximal extensions in. Once they've covered the subclavian, you no longer code the non-covered subclavian and all those extensions. You drop all of that and convert to the 33880 that includes covering that subclavian. That's very important. And then if they end up extending approximately after you've converted to the 33880, then by all means you can start coding those extensions again. So that's stuff that trips people up, I know. And it gets a little confusing. Again, your CPT book is your friend and a lot of this information is in there in the parenthetical notes and things like that. So what's included? Most of this is the same that Tammy already eloquently covered with the EVAR and FEVAR, but just note the one, the big difference here is distal extensions are not billable at the time of the TVAR. If they're done in a separate session, then you would code that delayed extension with the 33866. Also note balloon angioplasty, stent, all that within the target zone is always included. So what is separately billable? So this is kind of strange too. And this is where you have to take off that EVAR, FEVAR hat because calf placements are separately billable with the TVAR. Again, for how much longer? Hard to say. But I would venture there's going to be a time when they start bundling all of this. The access codes are the same and those were covered in depth along, we also have the greater than 12 French sheath and all of that. I do see going back to this calf placement that I see this missed a lot in audits. I also see the 7,000 codes missed a lot. So keep in mind that that is stuff that is still billable. As always though, interventions that are outside of the target area. So if they happen to be in the anominate, the carotid, the subclavian, you can bill for those. Arterial repair is also billable and IVUS is also billable. All right, so now let's talk about some open aneurysms. And to be honest, I'm not gonna read you all of this stuff. You're all capable of reading it, but there's some things I wanna point out. Of course, one thing I wanna talk about for sure is aneurysms trump occlusive disease. So if a patient has an aneurysm and they also have occlusive disease, you're going to code for repair of that aneurysm, which is not only aneurysm, but it's pseudoaneurysm. And then it also includes any associated occlusive disease. Cause I've seen where, you know, and of course with the advance of the EVAR and FEVAR, a lot of this isn't done really anymore, but it is still done depending on the patient and their anatomy and what's best for them. But I have seen where people have coded the aorta bifemoral bypass code instead of the open aneurysm repair. So keep that in mind that aneurysms always trump the regular occlusive disease bypass codes. These codes again are split out between ruptured and non-ruptured. And of course, ruptured aneurysm is much more dangerous for the patient, obviously, because that's a major vessel to be rupturing. And there's a lot more work involved. We also have the codes, whether or not the visceral vessels are involved. So again, we're talking our celiacs, our renals, our SMAs. If the aneurysm happens to go into that or they need to do a graft, you know, so that doesn't cut off the renals and all that, and they're not doing a FEVR, then, and they're doing this open, then you need to be billing with the 35091 and not the 81. Again, we have whether or not it's ruptured. And then we also have whether or not the iliac vessels are involved. So again, now we've got this, you know, aorta biiliac graft. You're not going to code the occlusive disease graft. You're going to code the open aneurysm repair if that's what's going on first. So always keep that in mind. There's also codes for carotid. Most of them, again, are designated whether they're ruptured or not. So we have carotid vertebral. It doesn't state. And then you have axillary brachial artery. And those are all done by, you know, they're up in the neck. That's a neck incision. If they're in the extremity, then it's going to be an arm excision for these upper extremity vessels. And again, these are going to trump, if they have an aneurysm, these are going to trump your regular bypass codes. We also have, you know, there's some thoracic incisions with these. So if we do an ominous clavian through a chest incision, and then that's split out between whether or not it's ruptured. And then we have a code for radial ulnar artery aneurysm. And then we go on with the splenic. Now this would be splenic artery only. So, and same with the hepatic celiac renals. If it's in conjunction with an abdominal aneurysm as well, then you're going to choose those other codes on the previous slide. You're not going to choose that for these. This would be if it's in the celiac, the hepatic renal only, and then whether or not it's ruptured, same with the iliacs. If the aorta is not involved and it's only the iliac, and they're doing an open repair, then you're going to choose from this group of codes. All right. And we've also got codes for femoral arteries, ruptured femoral arteries, popliteal, ruptured popliteal. Keep in mind, again, these are also for pseudoaneurysms. Now, one thing I want to talk about with these groins, the femorals, because a lot of times you'll see it as a groin, make sure the actual artery is involved and that it's not just like a hematoma in the skin. You know, sometimes you'll get those. It has to be a true aneurysm. It can be a pseudoaneurysm, but it has to truly involve that artery, not just a superficial in the, you know, underlying the skin type of thing. All right. Okay. So we're going to get into some case examples here. So for case example number four, and I'm going to be looking over at the screen so I can point stuff out. So I'm not rolling my eyes at you, I don't think that. All right. So this patient has a large thoracodominal aneurysm requiring a thoracic stent grip. So they're not doing this open. They're going to do this with a T-bar, but that's not what they're doing today. Today, they're actually preparing the patient because, all right, keep in mind. So if you have that T-bar and you block off the blood flow to the subclavian, well, now you've just cut, you know, this side of the body, you've cut off the vertebrals, you've cut off the left arm, all that blood flow to there. So sometimes they'll do this in conjunction with the T-bar and sometimes they'll do it prior. So it just kind of depends on what, you know, what's best for the patient. Just keep that in mind. So this particular today, they're going to do a left subclavian carotid transposition. And then they're going to do a left vertebral artery re-implantation into the common carotid. So these are two different vessels being involved here. So for this case, we have, I'm going to drop down. Well, I'll give you the indication. So it's a 74-year-old woman with a large thoraco-abdominal aneurysm. They're anticipating endovascular repair. Her vertebral artery rose from the arch of her subclavian and would require coverage of both to allow for an adequate seal. So therefore, they're going to do a carotid subclavian transposition with re-implantation of the vertebral artery. So that's what's going on here. So I'm going to drop down. So a small puncture was made in the, trying to move stuff around here. All right. A small puncture was made in the medial aspect. Vertebral artery was clipped approximately and divided. And then an endocyte anastomosis was carried out between the vertebral artery to the common carotid. So it's kind of hard. This picture is not the best, but so you have your vertebral here and they're sewing to the common carotid. They're going to implant that into the common carotid. All right. That's my spot. So we are going to code that with a 35691. Then they did two additional sutures were necessary for the suture line homostasis. The artery was allowed to flow for several minutes before again, the common carotid then was reclamped. Then the subclavian artery was transposed and then an endocyte anastomosis was carried out more approximately on the common carotid. So now we're hooking the subclavian up to the common carotid. And that is going to be reported with 35694. And again, the reason why I'm using the 35694 and not the other code that's done in conjunction with the T-bar is because this is not all being done at the same session or the same day. So that's why I coded this this way. So our final answers, we have the 35691, which is a transposition and or re-implantation of the vertebral to carotid. And then 35694, which is a subclavian to carotid. All right. So case example number five, moving right along. So this one, this one's a mess. This one, we have a 73-year-old who was admitted to the hospital and actually transferred. The workup showed a large aortic arch aneurysm, his chest pain resolved with pain control. He was worked up for an aortic arch aneurysm. They offered him a reduced sternotomy and complete debranching and endovascular endograph placement. So we're doing several things at this time. So they brought him to the OR and he underwent general anesthesia. And this physician did the initial ascending aorta to right subclavian and right common carotid artery bypass with a 20 by 10 bifurcated background graft. So what they've done is he has a branch graft, but we're going to count this as the 35626 because we're going from the aorta to the right subclavian, which is actually up here. And then, because this is the abnominate. And then we have also the aorta too. And even though it's a bifurcated graft, this is how it's coded. So let's see what I got the first one, the right subclavian and then the right common carotid. So you know how the abnominate breaks off here. So this is the right common and this is a subclavian. So we have this one branch or a bifurcated graft. And so we're going to have aorta to subclavian and then aorta to right carotid. Then they go over to the left-hand side and do the aorta to the left subclavian. So that's why we have the 35626. This does have an MUE of three and we can code this three times. So you're going to use that with three units. More than likely, I'll tell you flat out, you're probably going to have to send in a note because they're going to come back and want to look. And again, report it how your carrier wants. Some of them may want you to list it three times and then do an XE, or they're gonna want you, or an XU, or an XS, or a 59. Just do what you normally do. Don't change anything that you code just because of what's on this graph, because we speak in general terms because it's different for everybody across the country. And I know we're kind of like a broken record with that, but it truly does differ. All right, so then after they did all this, they proceeded to make an incision in the left neck above the clavicle in transverse fashion, dissected down to the plastema, and he's doing a bunch of stuff, getting things right. So then, let's see, they did a dissection onto the subclavian and placed vessel loops around it, was given additional bolus of heparin, and then proceeded to clamp the right common carotid and did an arteriotomy, and then opened and did an eight millimeter pet feed graft sewn into side to left common carotid. So not only did we do all this debranching of the aorta, now we're doing a carotid to carotid in conjunction with the T-bar. So now we're gonna code the 33891. All right, used ultrasound guidance, visualize the femoral arteries, and access the micropuncture sheath and place the sheath in. I noted here, ultrasound guidance requirements were not met. Why? There was no mention of vessel patency, and there was no mention of real-time needle visualization, and there's no documentation of permanent images of those. So just keep that in mind. All right, let's see. It's just going on about the femorals. So on the right side, the physician proceeded to place a pigtail catheter in the ascending arch. So remember, because we're in the aorta, and we're up here in the ascending arch and all of that, and we're doing a T-bar, cath placement is coded. So we're going to code the 36200 with that. They did an aortagram, which that's all covered in those 7,000 codes. We're not gonna code the other thoracic aorta, SNI with this. All right, the aortagram was done, which showed patent bypass with patent right subclavian vertebral and right common carotid. Left common carotid artery was also patent, and the left carotid subclavian bypass was patent. And prior to doing the aortagram, they advanced the main body of the endograft, which was 37 by 31 by 207 Navion via the left side successfully. After marking the origin of the bypass graph, I proceeded to deploy the endograft in excellent position, successfully covering the subclavian artery. So he's not this far. It's hard to get pictures all the time exactly what's going on. So just note that the graft actually starts here. So they cover the subclavian. So we're gonna code that with the 33880. And then we're gonna have our SNI code of the 75956 with the 26 modifier. And, nope, I need my mouse to work. Uh-oh. Mm, ah, oh, went too fast. Okay. All right. So we have the 35626 times three. We have the carotid-carotid bypass with the 33891. We have the cath placement in the aorta with the 36200. That may bundle with this. So you may need a 59. We have the 33880 for the T-bar, and we have the 75956 for the SNI for the T-bar placement. Make sure you're picking the right SNI code too, because there's one that goes for covering the subclavian, and there's one for non-coverage of the subclavian. Right. So now we're gonna move to case example number six. So now we're gonna talk about the open aneurysm repair. So we're not doing T-bar. We're not doing E-bar or Phe-bar. This is actually the old-fashioned way. So this patient has a juxtarenal abdominal aortic aneurysm with a penetrating ulcer at the level of the renal arteries. They're actually going to do an open AAA repair with a 20-millimeter hemoshield graft, tube graft. The abdominal aortic aneurysm was unsuitable for an E-bar, so that's why they're doing open. So they did a midline incision from the xiphoid to several centimeters below the umbilicus. And keep in mind, this is a large, large incision. This is going straight down the center of the body, basically, and those incisions are very painful. They're hard to recover from. They are more likely for infection and issues and things like that. That's why they try to do the less invasive, but not always does it work out that way. All right, so again, he's pulling stuff aside, moving the bowel out of the way, the peritoneum, all that good stuff. So they expose the aorta above the level of the renal arteries for several centimeters. So they basically were up in this area above the renals. Then the common iliac were exposed for a few centimeters on each side, and the patient was then heparinized. So then the aorta was clamped above the renals, but below the SMA. Common iliacs were clamped. The aneurysm was entered and opened up to the point just below the renal arteries, and the aorta was transected at that level. This gave us exposure to the aortic wall above the penetrating ulcer posteriorly. Aneurysm was then opened caudally down to just above the aortic iliac bifurcation. Now, keep in mind, so on these, what they do is they actually were the less invasive. They actually, you know, they launched those through the vessel. Here, they actually have to cut open the aneurysm, place the graft, and then sew the aneurysm back over that graft. So that's why it's a lot different than our, you know, endovascular, because they're actually cutting into that aneurysm. All right, so this, you know, this graft then is inside the aneurysm itself. Okay, so let's see. A 20-millimeter hemoshield tube graft was selected. It was spatulated mildly, and proximal anastomosis was performed. Once the suture line was completed, a hydrograph clamp was placed on the graft beyond the proximal anastomosis, and it was tested. They had to put a couple of additional repair sutures for bleeding points along that back wall. And then once the anastomosis was hemostatic, the clamp was permanently removed down below the anastomosis on the graft. The renal arteries were then reperfused. Then they cut that graft to the appropriate length and sutured to the distal cuff of the aorta. And just prior to completing the suture line, the iliac vessels were back-blood, and the graft was flushed. So for this one, our code is 35081, because it was not actually ruptured. And that's our open repair code. So we only have one code for this. So we have that direct repair of the aneurysm with a graft. So that actually concludes our presentation. I do want to point out, this is our disclaimer. Note that we are not lawyers. This does not constitute any legal advice, billing advice. You always need to check with your carrier and or your practice's legal counsel. That's who you should get your guidance with. Here's our CPT disclaimer. This did all come from the CPT book, 2023. And then, and I put our individual emails on here, but also note that we do have the MedAxiom RCS email. We do prefer that you use that due to the fact that it goes to all of us then, and we can, depending on who's on the office or who's got what going on, it reaches more of us, and we can answer those faster. We will cover a couple of questions here. So let's see. So one of the first questions was, for the add-on code 34812, MUEs are one, 50 modifier is not allowed, but it says to bill once per site. Okay, well, and I know we talked about this, but I do want to drive this home because the CPT book and Medicare, most of the time they do a line, but not always. So in this instance, CMS has come out and said, no, this is a unilateral code. We're still going to accept the 50, and CPT says not report it twice. So again, you're gonna have to do what your carrier wants. If it's a Medicare, I'd use the 50. And if those of you, and I'm not touting anyone, a lot of your, whether it be ENCODE or PRO, I'm trying to think of some of the other software out there, usually they'll show that Medicare's still allowing a 50, and then the commercials, they have like the 50 with the circle through it, or the line through it. So it just depends on what your commercials want you to do versus Medicare. Medicare does still want it reported with the 50. There's one on here too about the embolization coils in the internal iliac during an EVAR, if that's coded with embolization, the 37242, or if it's that 34808 iliac artery occlusion, it kind of depends on what's going on. Usually if it's done at the time of the EVAR, they do consider that the occlusion device. But in our example that we did, it was after the EVAR was done. So this was done, cause they were putting a distal extension. So on that one, we did code it with the embolization coils. If you ever get stuck with that, you can always, if you have a specific case that you would like us to look at, you can go ahead and send that one in. Let's see. So, so this is a case I'd like to actually probably see the dictation to, but I think I can answer it. I think I know what's going on. If I'm wrong, then email me and call me out. But this one looks like the patient had a ruptured EVAR, or they did a 34706 for a ruptured AAA. The EVAR didn't rupture, the aneurysm ruptured. And then the following day, the same physician had to do an open repair. Is this 34831? Well, I don't know the codes right off the top of my head, but I'm assuming that's the one with the failed EVAR attempt and then bringing them back for that open repair. I think, I believe that's the code. I don't, like I said, I don't have my book open in front of me, but yes, in that case, since it was an attempted EVAR, even though it failed, I would then code that with attempted and then converted. That does not have to be the same bit. If they attempted that EVAR and, you know, like in this scenario, patient left, even if they come back a month later and it failed and they convert it to that open repair, then you use those codes. You don't just go resort back to the regular aneurysm codes. I hope that makes sense. And like I said, if I'm offline, the person that asked that question, email me. And if I'm not talking about what, if I did not answer your question, then email me. All right. This is always, oh, thank you. Somebody said vital wear. That's the other one. Yep. Okay. This question comes up a lot and there's always controversy with it, but it says when an aneurysm is contained rupture, is this billed as a ruptured aneurysm? Most school of thought is if it's contained, it's not truly ruptured. So, but that is a conversation I would definitely have with your physician because RVUs are a lot different. But for the rule of thumb, usually though, is a contained rupture is not truly ruptured. Ruptured means it's, you're bleeding to death, basically. Oh, can you explain what you meant when you said we can bill ultrasound guidance during the percutaneous access enclosure? Okay. If they do not do a cut down, whether it be the femoral, the brachial, whatever they do, if they don't do that cut down and they don't use a greater than 12 French sheath, if they use ultrasound guidance, you can bill that 76937 with Azure access, but you have to meet the guidelines of that. So they have to have that vessel patency, has to be documented. They have to document that there was real-time visualization and they have to document that they are keeping permanent records. Now at one time, and it's been a few years, at one time, if they did ultrasound on one side and they did the 12 French or greater sheath on the other, you could bill for both. You could bill the 76937 for the one side and then the other side, you bill the sheath. Well, now they don't, it bundles no modifiers allowed. So once they do that 12 French sheath or greater, or once they do a cut down, you lose ultrasound. So, all right. When is calf placement separately billable with aneurysm repairs? The only time calf placement, all right. The only time the aortic calf placement is billable, the 36200 is with the T-bar. With the others, you have to be outside the treatments up. So if we're doing a fevar, so we're getting into those visceral vessels. So mostly that's the 36245, whether it be the renal, the mesenteric or the celiac, you cannot code those, that 36245 with that because you're in, that's the treatments up. If they're doing a fevar that goes down into the iliac, you can't code that calf placement until you're outside it, the area that contains the graft. So if we're talking a straight E-bar, for example, and let's say they, so that, let's say they put a calf placement in the femoral or they put a calf placement in that external iliac, you can code for that calf placement, but you cannot code for any calf placement within that treatment zone. The only exception is T-bar. Well, that looks like I hit the majority of them, I think. I appreciate all of your time. Again, give us some patience on uploading this stuff to our academy because of the fact this is an on-demand. We did promise we would try to do some of these this year so that people could get the CEUs if they weren't able to attend the live. Just a side note on that, part of the reason why we don't do it for all of them is we have to have everything written prior to applying for CEUs. So, you know, like for example, Jamie, our wonderful Jamie, my colleague, she always does our ICD-10 presentation, what the new codes are gonna be, she usually does that in September. Well, it's too hard to try to get the CEUs applied for in a timely fashion with a quiz. So there's some certain circumstances and just like at the end of the year with the new CPT codes, we just don't have time to do that on-demand and have that quiz. We don't have the time to do it prior, but we are trying it out. I know the first one, the format didn't go through real well, so we appreciated your patience on that. And so this is our second attempt at a different format, but it is gonna take them a little longer to upload those questions and get this all on the site. So please be patient with that. Again, the CEUs for listening live, they should be within three to five business days. Again, I will compile, Tammy and I will compile all these questions and get them answered and uploaded, even though we did open or I'm sorry, we did answer everything that came through live, but I know sometimes it's nice to go back and see that printed out in writing, and especially for those that aren't able to attend the live presentation. So again, we appreciate all of you. I'm gonna give you back about 11 minutes of your time. Have a great day. And we will, I think we have one in August, if not, we're doing two in September or something like that. So gosh, where's the year going? But thank all of you, have a great day.

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