Hello, everyone, we will be getting started here shortly on our peripherally and geography and intervention webcast. We're going to wait a couple minutes just to give everybody time to log in. So if you're just joining us, we will be getting started here in about another minute. We just want to make sure everyone has time to log in and so that they can get all of this information that my colleague Tammy and I have put together. And we look forward to sharing that with you here in about another minute. All right, I think we can go ahead and get started. So welcome everyone to bootcamp session number three. My name is Joleen Bruder. I'm one of the managers with the Revenue Cycle Solutions at MedAxiom. And I'm joined today by my colleague, Tammy Barron. She's a specialty coder and is very well versed in vascular and peripheral services. So I was happy to have her join me today. I'm gonna go through some of our housekeeping slides and then turn it over to Tammy. And then I'll pick back up for intervention. So to begin with, this is our link to access the presentation. And then of course, the questions. Keep in mind, if you happen to do the chat, you can get the slides from the chat box. Do not put questions in that though, because we can't see them. And don't do any of the hand raising or anything like that because we're not interactive today with our meeting. So we ask that you type your questions into the question and answer box. We do ask that you keep your questions on topic and we will answer as many of those as possible during the webcast. Again, with this being bootcamp week and having so many presentations, we will be compiling all of the questions and then we will release those to the Academy. It probably will take us into next year before we can get all of that done and compiled. But it will be part of the Academy when they upload the presentations and everything that's recorded. Then we'll have them also add the Q&A session. So this is how to claim the CEUs. Note that you do have to go to the MedAxium Academy. You click on the webinar that you attended and then click claim CEU to access your certificate. For that too, just note, you have to be registered in the Academy and you do have to launch the webcast itself to get credit for it. And Jamie explained yesterday, this is now, it's a requirement with the AAPC that not only are you registered, we have to have proof that you actually attended. So that's how we can track that. And again, they will be available to view and download in the transcript section of your Academy account. Normally it takes us about one to two business days, but again, with it being bootcamp, there could be a slight delay. So if you don't have it, I would say by mid next week or end of next week, then just reach out to us and let us know. All right, so I am going to turn it over now to Tammy and she will take us through the angiography portion of our webcast today. So Tammy, welcome and go ahead and take it away. Okay, thank you, Jolene. So the first thing we're going to look at today is anatomy of the extremity arteries. To be successful in coding PV procedures, it is an absolute priority to be familiar with anatomy. We must be able to follow along with our provider's documentation, whether in our heads or by referring to the slew of charts and diagrams that are available to us. This slide defines the arteries in the upper and lower extremities, as well as those residing in the abdominal aorta. I would also refer you to Appendix L in CPT as it gives some nice branching models. Appendix L also instructs us that the subclavian and the axillary are considered one vessel for coding purposes. And this is also true for the external iliac and the common femoral artery, and true for the SFA and the popliteal. I'll mention here, please note, this does not apply when coding the lower extremity interventions, which are your codes 37220 through 37235, as these codes are based upon territories. Next. So let's review some angiography codes for the extremities. Most of us by now can recite this 76937 code in our sleep. It is the ultrasound guidance code for vascular access. It's available with many of our PV procedures. As is typical, there are guidelines concerning documentation required for billing this code. And those include documenting vessel patency of that selected vessel, documenting that real-time ultrasound visualization of the needle entry, and documentation of a permanent recording and reporting in the medical record. Next. This is a beautiful and simple example of proper documentation for 76937. Patient presents for lower extremity diagnostic NGO for bilateral claudication. Ultrasound is used to determine the suitability of the left femoral artery. Ultrasound is used as guidance for needle placement. The left femoral artery is deemed patent and suitable for use. Permanent images and reporting are documented and saved. Our non-selective calf placement codes are 36140, where we access the extremity directly, and 36200, where the calf is placed in the aorta. Here are some basic coding guidelines. Always code selective over non-selective. Code each vascular family to the highest order selected. Pay attention to the number of accesses, and remember to code separate vascular families that are imaged. Indications for diagnostic studies are for arm and hand symptoms, and not to image the carotids or the vertebrals. It's a whole different set of codes. Calf placements via a transfemoral approach are different for right and left upper extremities. Once you enter the right subclavian or the axillary artery, your calf placement would be second order. Third order vessels are your right brachial, ulnar, and radial, et cetera. Let's see, slide 13. For the left arm via transfemoral approach, the subclavian and axillary are first order. Once you hit the proximal brachial, you're in a second order artery, and then further placement into the ulnar, radial, and beyond are your third order vessels. Next. Now, if you access from an ipsilateral, anti-grade, or retrograde brachial approach, you would code the non-selective 36140 for the brachial artery itself, assuming no further advancement, as well as the subclavian or axillary arteries. The radial and ulnar are both first order arteries, and once you reach the common interosseous or palmar branches, you would be in a second order vessel. Next. So here are the commonly used SNI codes for diagnostic angio for unilateral, bilateral, and additional selective study. Make sure you're aware of the requirements per CPT regarding the additional study code 75774, which we have here on the screen. Next. Next. Imaging in the abdominal aorta is dependent upon cath placement, and what exactly is being imaged. I see this incorrectly billed more often than I would imagine, so I like to think of this code as going high and shooting low. You have one cath placement high in the infernal aorta, not down at the bifurcation, and contrast from there runs down through the abdomen and both legs to at least the level of the bilateral femoral arteries. Then findings from that infernal aorta through the iliofemoral arteries should be documented on your report. You can see that there on the slide. When you have two cath positions, the first one high in the infernal aorta, and then pulled down to the bifurcation, then you're looking at 75625 for the abdominal aorta, and either 75710 or 75716, depending on whether a unilateral or bilateral lower extremity study is performed. Again, findings must be documented on your report. Next. Here's a look at the lower extremity vessels. I'm sorry, each extremity is a separate vascular family branching from the aorta. Selective cath placements are coded per vascular family. We did include a slide for the lower extremity territories here as applies to interventions, and Jolene will discuss that more in depth during her portion of the presentation. If you're only coding for diagnostic studies, just remember that the external iliac and the ipsilateral common femoral artery are considered one vessel for coding purposes, and the SFA and ipsilateral popliteal are considered one vessel. Next. These are the selective cath placement codes for visceral arteries and the lower extremities, and these are fairly straightforward codes. I will mention here 36248 is coded for additional second or third order cath placement within a vascular family. Now we typically see this code used when the physician is down in the tibial area. For instance, if selective studies were performed on the contralateral anterior tibial, posterior tibial, and the perineal, you would code 36247 for the initial third order vessel, and then 36248 times two for your additional third order vessels. 36248 does have an MUE of six with an MUE adjudication indicator of three, which is your clinical adjudication indicator. Next. Next. This slide shows some common cath placement codes via contralateral common femoral retrograde axis, which means against the flow of blood, and ipsilateral common femoral antigrade axis, which means with the flow of blood. Again, here are the imaging code for the extremities. They're the same for the upper and the lower extremities, but we just wanted to stress for the lower extremities, in order to code that 75774, you would need imaging to the foot first before this code is billed. You also need additional cath placement with this code. Of course, make sure your medical necessity is supported. Next. Next. Further clarification when coding CPT code 75774, there is a true medical necessity for the additional imaging after that basic study has been completed. Catheter is moved to an additional selective position to image those vessels. You're not merely performing a completion runoff study or obtaining additional views of a particular vessel for billing this code. Next. Next. Lastly, we've included this one final slide regarding 75774. And I think we've included this in a prior presentation. Per the question, via a right groin access, an abdominal aortogram was performed with the catheter placed above the renals. Catheter is pulled down to the bifurcation with contrast injected. This revealed abnormality in the right palpateal. Catheter was then pulled back into the right femoral artery and an additional injection was performed. As you can see from the answer given, this procedure would be recorded with CPT code 36200, 75625, 75716. Read this slide thoroughly if you require further definition. So that will do it for me regarding the diagnostic portion of the presentation. And I'll turn it back over to my esteemed colleague, Jolene, and she will do a deep dive into the intervention portion. Thank you, Tammy. That was fabulous. Thank you. All right, so we're gonna talk about some interventions in the upper extremity. And as always, when it comes to diagnostic cath billable with intervention, there cannot be a prior catheter-based angiography that was done. If there had been one done, of course, if there's been a change to the patient's condition, or if that previous angiography had inadequate visualization, or if there's a clinical change during the procedure that requires a new evaluation outside of the target area of that intervention, then we can bill that cath. So just keep that in mind. And it has to be very clear, and it's important that your physicians document that. And it has to be in the, you know, they have to put that in the report, especially if, you know, there was a prior one within a week or two, they have to state why they need to do another one to justify billing for it. All right, some of our types of basic intervention in the upper extremities, we have balloons and stents. And this shows, you know, the balloon here, you have the plaque, and then they can inflate with the balloon, and then that pushes that plaque back up against the vessel walls. Sometimes if it's a lot of plaque, then they're going to have to do a stent. So usually your stent is loaded with a balloon. They enter that in that area of stenosis, inflate that balloon, and then remove the balloon, and then the stent is left. So normally when we're talking about the 37246 and the add-on code 37247, these are codes that are normally used in the upper extremities or the viscerals or the aorta. Now they can be used in the legs, providing you're not doing that for occlusive disease. 36246 is for the initial artery that's treated and then 36247 is for each additional artery. So again, these can be done by an open method or percutaneous. They do exclude the vessels that are in the nervous system, the coronaries, pulmonary arteries as well. The same rules apply for all interventions, multiple surgeries, and one vessel are only reported with a single code. If that lesion does extend from one vessel into another, but can be treated with a single therapy, then you would only report it once. So for example, if a lesion extends from the subclavian into the axillary, but one balloon opens them both up, you would code it once. If there are multiple lesions and you have to treat multiple lesions, and you have to do two different treatments, multiple lesions in two different vessels, and you have to use two methods to get them open back up, then you would report the balloon in one vessel and then the second balloon in a further vessel. So let's say we have axillary and then maybe down into the brachial bulb because you've left that particular territory and you're now in that other subsequent vessel, you can code for two. But if they have to do two balloons in the same vessel, or if it's the same lesion traversing into two vessels, if it can be opened up with one, then you only code one. So for these codes, the SNI is included. You cannot bill anything diagnostically from that. Cath placements are separately billable. So keep that in mind. And one of the things we always focus on is a lot of the rules are the same when it comes to peripheral, but then again, they're not. So you always have to pay attention to what part of the body you're in and what organ systems you're dealing with because the rules are not the same across the board. Also notice that or note that extensive repair or replacement of an artery is separately, billable. Ivis is also reported as well as mechanical thrombectomy or thrombolytic therapy. And I do want to say something about Ivis. You have to be very careful that it's not just a pullback. So if we're talking about the arms, if they take the Ivis down to the radial and then pull back through the arm into the subclavian and they just do that one pullback, you're only going to code for one Ivis. We'll talk about the legs, it's the same deal, but basically for them to have separate Ivis, you truly have to have medical necessity. There should be separate lesions. If it's the same lesion, then you would only code the one Ivis. All right, so let's talk about the stents. So for stent, same thing. We're talking about these are placed anywhere except for the lower extremity for occlusive disease. You do not use these codes for any of the coronaries or the intracranials or pulmonary arteries or your dialysis circuits. They all have their own separate codes for that. Again, these can be done open or percutaneously. They do include your radiological supervision and they also include all of your angioplasty. So 37236 is your initial artery and 37237 is each additional artery. So again, you're pretty much gonna follow the same rules as the angioplasty codes that we just covered note you can code for those separate cath placements and that is separately they are separately billable so don't forget that. All right so now let's move on to a little bit of the lower extremity interventions. Again same rule applies that diagnostic cath is billable with an intervention when you've met all of those rules. Now I do want to point out when it comes to CTA and MRA unlike the coronaries where you could still build your catheter you know your left heart cath right heart cath you cannot do that with the extremities. So if they have a previous based CTA or MRA study then again the documentation must state that for whatever reason it wasn't the images weren't readable or there's been a change in that patient's condition. So you know like for example let's say this that you know patient had a month ago they did a CTA discovered you know the patient has claudication they had claudication symptoms was confirmed by CTA. So you're bringing them in um you know there was already a schedule we're going to go ahead and and do an intervention. Well let's say in between that time um the patient now not only have they developed uh let's say rest pain but now they have a small ulcer developing well now they have a change in condition. So that would allow for that diagnostic cath to be billed again. So when it comes to coding interventions in the lower extremity keep in mind the cath placements now are bundled and again the imaging is bundled unless you've met that diagnosis criteria which I think we have beaten to death so far in this presentation. So some of again our basic interventions we have balloons and stents we also have atherectomy. Atherectomy actually is I kind of liken it to a plumber using you know like a rotary tool to to bust up your clots and your clogs and your pipes. This is the same principle only now we're talking about your blood vessels instead of plumbing in your house. But it's the same type but it's the same type of principle and that's you know and that can be followed with a stent or balloon either way. All right so let's talk about our territories and families and all of those things. So keep in mind each leg is considered a family and within that family there are territories. So a single primary code so we're talking about the iliac specifically you could have a single primary code for intervention to treat the initial iliac and then if the other iliac vessels are also treated you can build two add-on codes for the additional. So you know if they're treating the external iliac and the internal and the common iliac then you could you could build multiple interventions for those areas and we'll talk a little bit about lesions crossing into territories and all of that. But keep in mind if you have a single lesion that is let's say it takes up from the common iliac into the external if that can be treated with one intervention then it's going to follow the same rules you're only going to code one intervention and it would be for the external. Now when it comes to the femoral popliteal as you know Tammy pointed out this is all considered one vessel and it's all considered one vessel for intervention as well. So it doesn't matter what they use to treat any of this you can only build for one. So you want to make sure that the documentation is very clear and if you have any questions you should go back to your physicians because of the fact you want to make sure you're you're coding that highest level of intervention. So if it's an atherectomy with a stent you want to make sure that's coded and not just a stent or you know if they do balloons as well. Again it doesn't matter now you can build if that lesion comes out of the popliteal and into the tibial then you could you could code for the popliteal and the tibial if it requires two interventions. Same thing with with the iliac. Now if the iliac if it comes along the external over here if it comes out of the external into the common femoral but if it's treated with one intervention then you only code one and on that if it's from the iliac into the common femoral you would use your femoral codes because you're you're further down in the leg but if you have to put a stent in both areas that of course that you know you could code for both of those. For the tibial peroneal they are basically same rules as the iliacs as far as you can have you can treat each vessel separately you would have a primary and then you know if they go on the posterior and they treat a vessel there then you can code for that additional and then same with the peroneal. Again though well we'll talk about the tibial peroneal trunk here in a second on this next slide. All right so as far as billing purposes the tibial peroneal trunk is not considered a fourth vessel. So what that means is if they intervene in the trunk and then also the posterior tibial you only can code for one. Now if they happen to treat the trunk and then the anterior tibial that would be two separate vessels but you would if they treat all three and the trunk that trunk is included in the posterior tibial artery so you cannot code it separately. That's pretty much what all I wanted to really say about that is just keep in mind if it's the only vessel treated it can be coded if if it's treated along within the anterior tibial or the peroneal you could code it but you cannot code it with the posterior. Same when it comes to the dorsalis pedis that is part of the anterior tibial and then the medial malalar is part of the posterior so it's the same principle. So even if you know if they treat way up here in the anterior tibial and then come down into the dorsalis pedis you only get one intervention so keep that in mind. So I've kind of hit on some of this so the guidelines for treating multiple territories basically you know you have your one primary lower extremity revascularization code that you use for each territory. When you have those second or third vessels that are treated in the either the iliacs or the tibial peroneals then you can use those add-ons to treat those either the iliacs or the tibial peroneals then you can use those add-on codes providing that its actual require separate interventions. And then when more than one intervention is done in the same vessel you want to code that highest intervention once it's completed. And again we talked about it you know if that lesion crosses into two territories then you would code it with if it can be treated with one intervention you would code it as one intervention in the furthest vessel but if you need two interventions in each vessel then you can code both. Other than the femoral popliteal territory remember it doesn't matter how many interventions or where those lesions are or where they cross it's one vessel that can be intervened upon. And we pretty much talked about all this. All right so when it comes to treating both legs keep in mind your codes are chosen per territory per extremity. When the same territories of both legs are treated in the same sessions modifiers may be required to describe those interventions. Now we talk about this a lot. It depends on your carrier. Some carriers are going to want you to report it with a 50 modifier. Some carriers are going to want the RTLT. It just depends on what they want. Some will actually want 59 or X modifiers to denote that you're in separate legs. So you have to follow what your carrier wants you to do. All right so this slide lists the interventions. Remember you're going to want to bill by hierarchy per territory. So if a balloon was done in the anterior tibial and a stat was done in the peroneal where a separate lesion was found you would code the 37230 first. That's your highest. The 37230 first. That's your highest. Then you would code the additional um the 372228 for the uh I'm sorry that's not right the 37232 for your additional um treatment. All right. Also note that for atherectomy in the iliacs that is still a category three code that has not changed. Now we're going to talk about this a little more in depth. One other thing I want to talk about on this slide in particular is notice there are no add-ons for the femorals again and then and that's femoral popliteal. So you only have you have balloon only, atherectomy with balloon, stent only or stent with PTA or then your atherectomy with a stent with or without PTA. There's no additional um balloons or any additional atherectomies or any additional stents in that territory. All right so let's talk a little bit more about the iliac atherectomy code. So this one is a little bit different. It does have an MUE of two. Again it's carrier priced. It is proposed to sunset in 2026 but that doesn't mean it will. They could either continue it as a category three code or they can actually turn it into a category one code. It just depends. So it is important to report these category three codes. That's the only way we get them out of that status is the more that people are doing them and reporting them then uh you know medicare can say well you know obviously this is being done more than more often than it used to be so it deserves its own code. But here's the big caveat to this. So you can code cath placements if it's the only intervention that's done um in the leg. So if if they do an iliac atherectomy and um let's say in the external and that's the only intervention that's done then you would build a 0238T and then you would also build um the 36246 for second order cath placement in the external iliac. However once they start doing other interventions you do cannot code those cath placement. The other interesting thing with with this code is if they happen to do a balloon and or a stent then you would also code the balloon and stent separately. Well not both you would do one or the other sorry don't want to mislead you on that. So let's say they do a balloon and the atherectomy you could code for that balloon. So you could code the 37220 but you would have to drop your cath placement. If they happen to do the stent and an atherectomy you would code the 0238T and then you would code the stent with the 37221. Again as far as diagnostics you can only code that if you've met those requirements of it being a true diagnostic study. So again some more um additional procedures that are billable. We have the itis for each vessel imaged. Again this cannot be a pullback. This cannot be the same lesion. These codes do not allow for 50 modifiers. So don't think that you would bill the 37252 with a 50 if they did both right and left leg. That's not how these work. We have the 37252 is the first initial vessel that's done and then each additional after that. So you can do this and the MUE on that is five. So you could code these up to the 37252 would be once and then up to five times with the 37253 providing you've met the requirements for that and it's not just a pullback. If you are unsure you need to discuss that with your provider because you could be leaving a lot on the table if it truly was separate lesions and if it's not clear in their documentation then that's when you need to have those conversations. So let's talk a little bit about thrombectomies because this is always controversial as well. So the 37184 is for the initial vessel in each vascular family. Remember each leg is a family and then 37185 is each additional vessel within that family. Now the thing about the primary versus the secondary and this is what confuses everybody because secondary has in quotes with another intervention. That doesn't mean if they do an intervention it's automatically a 37186. It could actually be the 37184 and the 37185. So how you can distinguish that is it depends on what was known to begin with. So if there was a known thrombus and they knew they were going to do that thrombectomy then of course it's very easy you know that that's what was going to happen. It's a 37184 for that initial vessel and then the 37185 for the addition if that's the case. For the secondary thrombectomy what happens with that is so let's say the provider goes in does an atherectomy let's say an apoptotomy and a piece of thrombus breaks off or a piece of that plaque breaks off drops down into the tibial. Well now the physician is going to go oh we have to get that so they're going to reach down they're going to grab that they're going to perform that mechanical thrombectomy to get a hold of that clot and pull it back out and get rid of that. That's when you have that secondary intervention. That wasn't a planned we have a thrombus. Now if they're truly doing that initial diagnostic and they find that there's a thrombus when they're doing that initial diagnostic then you can still code that 37184. What I don't want you to get hung up on is just because it's an intervention does not mean it's automatically secondary. It just depends was the thrombus known before the intervention or did the intervention kind of cause that piece to to break off. So that's and that's how I tend to keep that straight is where was the thrombus and when did I know about it? Well not me personally but the provider. All right next uh obviously we can also build moderate sedation with all of these. Keep in mind that 99153 when you could code if you own your own cath lab but if all of these are being done in a hospital that you do not own then you don't code for it. The provider does not this is not a provider code the 99153 is a facility code so keep that in mind. All right embolizations is another variety of intervention. Usually these are done for they can be done for treating a congenital or an acquired malformation. They can be done for um if there's a tumor that's being fed by a vessel they can embolize and stop feeding that but that tumor because sometimes your you know your tumors are going to grow from blood flow so they can go in and do that. They can also perform these for arterial or venous hemorrhage. Um it could also be for um aneurysms to stop the growth of aneurysms things like that. Now there's a variety of ways they can do this. Coils is probably your most common but they can actually use um there's an injection that they can give that type of thing. If coil embolization is the only thing done you can report those cath placements. Um keep in mind though if they do an intervention if so interventions can be separately reported um but if they happen to do a stent that provides lattice for that coil then you're not going to code the stent. So it depends on what it's what it's being done for but if they you know if they put coils let's say in the internal iliac and then they stent the the femoral that's two different you know ball games and you can code for both. So thrombolysis I'm only covering our arteries for the uh for the thrombolysis. I'm not going to talk about the venous code that goes along with this. So we have the 3-7-2-11 which is your initial treatment day. Then we have 3-7-2-1-3 which is the follow-up day. These are by day not by session. So if they start the thrombolytic catheter and they bring the patient back in six hours later to do a recheck you can only code for one per day. Um so the 3-7-2-1-3 would be any subsequent day and that that might last a couple of days. And then our final code is the 3-7-2-1-4 which is the cessation of the thrombolysis which includes the removal of the catheter by any method and closure closure by any method. Now if they happen to do both on the same day so let's say they um they start um the initial treatment and then they uh ended on the same day you only code one. And um I would normally code the 3-7-2-11 because that's that's going to be you know, you had to start it before you could stop it, but if it's done on that next day or a few days later, then you would just code the cessation that day. You're not going to report any of your 7,000 codes when you're doing the subsequent or the day that it stops, unless they're, you know, if we're down here in the legs doing thrombolysis and they happen to have a reason to do an upper extremity angiography, you could possibly code that because that's a different ballgame. But again, it would probably bundle and you would need to check your CCI edits for all of that. So to talk a little more about moderate sedation, I think we're all getting used to the requirements for this. I do still see some questionable dictation from providers on it. It needs to be, the best case scenario for documentation is to have this as its own little separate paragraph. The doctor needs to dictate that moderate sedation is being used. They should call out who is actually doing that monitoring, and that's that person's only job, that trained observer who has no other duties. Also, there should be some documentation that, you know, their vitals are being checked throughout this. Also, we ask for, you know, when it comes to time, either do start or stop, or they can do total time, but they need to avoid words such as approximately 16 minutes of moderate sedation was given. We need exact numbers. Now, we get this asked a lot too. So what happens if they document all of this in their Hebo dynamic log? It can be used. I personally prefer everything to be in one document, because then it's all right there, nice and neat, and you don't have to worry about sending other copies of things. A lot of that depends on your practices, legal too, if they want it, if they allow it to be separate in that Hebo dynamic log. The biggest thing about that Hebo log is the only way it can be used is if the physician actually signs that log, because if you think about it, a lot of the cath lab staff, they're the ones filling out that log, not the physician. So if the physician actually comes back and says, you know, that this is what I did, and signs off on it, and documents in his procedure note that please see Hebo log for this, for the details of this, and, you know, something to that effect. But ideally, like I said, it'd be best to have it all in one document. It's cleaner that way. And again, these are our codes. Not too many of you are going to see the 99151, because that's for patients younger than five, and I would hope we're not doing any peripheral interventions on patients under five. But so normally it's going to be that 99152, and then as I said before, that 99153 is a facility code. Now also keep in mind, as far as what is considered intra-service time, everything on this slide is things that are not part of that intra-service time. So the assessment of the patient prior, reviewing the patient's previous anesthesia experience, any family history of sedation complications, drug tolerance, drug allergy, or intolerance, all of those things are outside of your sedation time. So the sedation time actually begins with the administration of the sedation, and it ends when the provider stops their face-to-face time with the patient. Anything that happens outside of once that physician leaves, that is no longer part of moderate sedation. So again, once that face-to-face time is ended, any post-service work, you know, that the facility staff is doing where they're assessing the vital signs after the patient's already left the cath lab and all of that type of thing, none of that counts in your time. And then this slide just, you know, reiterates that and what those requirements are. All right, so now we're going to get into some real-world case examples. And on this case, let me move my questions over here because they're in my way. So in this case we have a right and left angiogram with moderate sedation, closure of the right radial artery via a TR band. Note here we have this beautiful little paragraph that gives us the moderate sedation, and that the patient received one milligram of Versed with 50, I can never remember what the NCG stands for, I'm not clinical, I apologize. Anyway, they gave him Versed and fentanyl. His heart rate, blood pressure, O2 stats were continuously monitored by an independently trained observer as well as myself. Moderate sedation time for the procedure was 30 minutes, so I have coded the 99152. Dropping down into the next paragraph, after informed consent was obtained, they prepped the right wrist, so they went through the wrist and then brought their catheter down this way. And let's see, they used a Holy Wire and Navicross 150 and they did selective angiogram down the right common iliac. So we're here in the iliacs, well actually way up here, sorry. And we have 36245 for the right side, and then that imaging went all the way down to the ankle. Now I have these crossed out and you'll see why in in the next line, because not only did they they come from the wrist, come down through the aorta and went selectively into the right side, they also went over selectively in the left side. So now we have the 36245 with a 50 modifier, and then we have the 75716 with a 26 modifier, because you know that angiography went all the way down to the ankle. Now I get asked this a lot on angiography, and I know Tammy has as well, because people will say well do they have to go all the way to the femorals for angiography in the extremities with the 75716? No they don't. And keep in mind because this happens a lot too, especially when it comes to that 75630 and the 75625, we've seen a flurry of questions around this lately. The iliacs are part of the extremities. They have nothing to do with the abdominal aorta. So the 75625 should not be coded when they're only talking about the iliacs. So that's why, and I love Tammy's description, especially with the 75630 of what was that one high and shot low or something like that. It was great. I liked it. Anyway but keep that in mind. Those iliacs are part of the legs. They're not part of the 75625. They're not part of the 75630. So if they've not met those cath placement in the higher part of the aorta around that infernal area, then we're not going to code for those. So make sure your physicians understand that too, because to them this is all they're thinking well this is distal aorta. And quite frankly they're correct, but for billing purposes when you talk about distal aorta, then that signals to Medicare and the other carriers that you're talking here at the bifurcation. And that's not where they're at. So it's important that they document clearly where that is. And you can help your physicians out by talking to them about that. So anyway. All right so at the end of that case they did the sheath was removed and they did homostasis was obtained with a band. So basically they use the band instead of like an angiocele device or whatever for closure. Oh this gives the findings. I'm not going to read all these to you. But do note you do have to have findings when your physicians are doing these cases. So it's not enough to just say that you know they went in. They have to tell you what they found when when they went in there. All right so these are the final answers for case number one. We have the 3-6-2-4-5 with a 50 modifier and we have bilateral cath placement because the fact that came through the arm. We also have the 7-5-7-1-6 with the 26 modifier for that bilateral extremity angiography. And then again we have moderate sedation with 9-9-1-5-2. All right so our next case for the indications for this patient. So the patient was recently status post right SFA popliteal anterior tibial artery angioplasty with additional stenting in the anterior tibial and digital amputation of the right foot. She returned a few weeks post-op with failure of that amputation wound to heal and arterial ultrasound imaging suggests occlusion of that anterior tibial. So that statement right there gives us justification that we now the patient has a new problem. So now we can justify also coding that angiography if they happen to do intervention with us. I'll give you a side note they didn't but had they done intervention. I don't think they did. I shouldn't say that till I get through it. I was going through these cases the last few weeks and then they're all kind of running together. All right so let's get into the operative technique. We have the left common femoral artery was visualized under ultrasound was noted to be pulsatile and patent. Skin overlying was infiltrated with lidocaine and it was cannulated with a micropuncture needle under ultrasound guidance. Permanent image was captured. So again great great dictation there on for that ultrasound guidance with the 76937. And please note what these were taken from actual cases. So these these are physicians that have been well versed in how they're supposed to dictate to make the coders life easier. I know not everybody has that so that's why it's important to talk to your doctors and help them help you. Now I sound like Jerry Maguire. All right so next we have a rim catheter was advanced up into the aorta and aortogram with bilateral iliac runoff to the femoral level level was obtained. I have the 36200 and the 75716. The 36200 is scratched out and well because they do go more selectively because remember you do we do code selective over non-selective. So once they become selective we drop that 36200. All right this showed minimal disease in the distal aorta and iliac systems. So again he's talking about the distal aorta. He's not up here well the picture doesn't show it but he's not up in the infernal area. He's talking about that distal aorta and the iliacs. So we're not going to give him any abdominal angiography for that. He will get however the 75716 because he does talk about bilateral legs. So we're gonna give him that. Let's see then they like I said they talked about that minimal distal disease in the distal aorta. Glidewire was then advanced down the right iliac and femoral vessels and the catheter followed down to the common femoral level. So we have 36246 with the RT modifier. Again that is that's crossed out because it goes further down later. Additional image from the common femoral level showed the common superficial deep femoral arteries all to be patent. Recently angioplasty segments of the SFA and popliteal were widely patent below the knee and they start talking about the tibials and all the way you know further down. Now a lot of people I've seen before where they're gonna want to code that 75774 for this but this study or this shot here is actually just completing our basic study. So I you know he came down a little further and shot and and watched the end the dye run down into the tibials and peroneums. All right so continuing on. So now they put that stiff glidewire was then advanced into the SFA. So now they're here at the SFA and they did let's see rim catheter and short introducer sheath was removed. A 6 French by 70 introducer sheath was then advanced up and over and down to the distal SFA. A soft glidewire nanacross cath was used to attempt to cannulate the anterior tibial artery. Well we're already third order with this with the SFA. So now we have 36247. Dropping down a little bit I'm gonna pick back up where the anterior tibial seemed to come off somewhat high and was late and filling compared to the short segment of the tibial peroneal trunk. Given this difficulty performed a full strength contrast run from the popliteal to visualize the infrapopliteal vessels. Anterior tibial was noted above was occluded with a few centimeters and there was takeoff that and then was not visible again. They did not see any short segments or gross of it and the previously placed stents were visible. There's a short segment of peroneal in the mid leg just beyond this level where no name vessels were visible just a few corkscrew collaterals. So now we have justification for that 75774 on the right. So you know keep that in mind you you have to have to the foot to begin with but then once you've you know established that you have a reason to do that additional imaging you can. All right so our final answers on this we have our ultrasound guidance. Keep in mind too the ultrasound guidance usually does not require the RT LT. I don't know of any carriers that are making people do that but as a standard rule it's it usually doesn't show up as approved modifier. If your carrier however makes you do that then by all means please do. Then we have that's a typo that should be 36247 not 76. Sorry about that. So that should be 36247 with that RT modifier for that cath placement in the SFA but keep in mind you may or may not need that RT modifier. Next we have the 75716 with the 26 modifier and then finally we have the 75774 with the 26 and again if your carrier requires then you would add that RT modifier. All right a few more cases. So that kind of wraps up the angiography cases. So next we have an intervention so we have a selective right leg angiography. This was you know we call this the wish list so all this has to be supported within the body of the report. So stating that they're doing a right leg angiogram, angioplasty and stenting of the posterior tibial and then angioplasty and stenting of the distal right anterior tibial. Closure of the left common with the six French angiocele. So patient is 58 years old with mitral valve endocarditis end-stage renal disease. Had embolization to the right popliteal from the vegetation. Underwent right leg thrombectomy and angioplasty to the right popliteal. Also got a distal embolization to the right posterior. Did have collaterals and had Doppler pulses to the posterior. But now the patient continues to have pain as well as numbness and tingling. And so now they're being referred back for right leg intervention. So again we have a change in their, sorry, they had a change in their condition. All right so we have moderate sedation. We have the 99152 with that Versed fentanyl and all those things. So that's great dictation on that again. Actually we did not, I don't believe we did this one with, no we didn't. We did not do this one with angiography because of the fact, and I know this case personally, a different provider had done the follow-up angiography. So this is the interventionalist came in and performed this. So I apologize for misleading you on that. So on this one we have, I just showed the posterior tibial is a 3.5 vessel. Mid is a 3.0 vessel. So we have the 37252. They ballooned the posterior tibial. So again they're down here in the posterior tibial. And they ballooned that and then with a nano 3.0 by 40 nano cross balloon. I crossed that out because they've also stented. But had they just done the balloon we would have coded the 37228. So then they extended the proximal posterior tibial with that stent. And the stent was proximal to the ostium of the posterior tibial with a 3.5 by 3.8 millimeter drogolute stent. So we're gonna code that with a 37230. Then I'm gonna drop down again. Then they dilated with balloons. All of that's included. They also did subsequent angiography. And that's, you don't code for that because they're checking their work. And then I'm gonna drop down a little bit further. And then the anterior tibial distally is included. But there are collaterals going to the small branch that go to the toes. They went in with a choice PT and term pike LP. And they crossed through the distal lesion with a term pike and did a tip injection. Distally the dorsalis pedis with a 2.5 by 40 nano cross balloon. So again I had the 37232 for that additional balloon. But then they stent it. So I cross that off. And then we go with the 37234 for that additional stent in a separate bustle. So because we've treated the anterior and the posterior, you get your initial tibial and then whatever that additional is. They were both stents. So that is why we coded that that way. So I have 37230 for the posterior tibial, 37234 for the anterior, IVUS for the posterior, and then moderate sedation. Again, RTs may or may not be required by your carrier. All right, case number four. So now we have a patient is brought to the cath lab, prepped and draped. They had left leg pain, presents for diagnostic angiography with possible intervention. I love when providers document that line because that lets me know that their original intention is to do diagnostic, but if necessary and they have to do an intervention, they will. So for this one we have a five French pigtail catheter was positioned in the infernal aorta and abdominal aorta aortography performed and noted a patent aorta. Now we have the justification and the right documentation in order to code the 75625. Then that catheter was pulled down to the bifurcation, so again they were up here in the infernal area, they pulled down to the bifurcation, so we have two cath placements within the aorta. And then they did run off to the bilateral extremities and that was coded as 75716. There was severe stenosis noted in the iliacs and decision was made to intervene. The bilateral muscles from the femorals down to both feet were patent, so again all the problems are up here in the iliacs, not in the lower legs themselves. So then they positioned their catheter in the left common iliac, which would actually be over on this side, and they did a nano cross balloon, and then they also ballooned the left hypogastric vessel, which is the external. And so we finally have, and then they did the express stent also in that hypogastric. So we have the 37221 and then the add-on code 37222, and those are split out as we have the stent in the hypogastric iliac, and then we have the additional angioplasty in the common iliac, our abdominal aortography, and our bilateral extremity angiography. Now again we have to, because these bundle, the bilateral extremity angiography bundles with our two interventions, you're going to need either a 59 or an XU modifier, depending on if it's commercial or Medicare. And some of your Medicare's may or may not actually allow the X. I think most of them do now, but again it's up to what you've got going on. All right, so now we have an intervention in the upper extremity. So now we have right subclavian angiography with right upper extremity runoff, right subclavian covered stent placement, and ballooned. And the patient has right subclavian stenosis. So let's see, after safety pause lidocaine anesthesia was administered to the right femoral artery, a vertebral catheter was used to engage the right innominate, and cath was further advanced into the right subclavian. So again they're coming from the femoral, so they're coming up and over, and well actually up and then over to the right side. And so our cath placement here from this approach, because you have the innominate, your subclavian is actually second order. So that's why we have the 36216. They also did that extremity angiography, so we have the 75710. And then over a wire they placed a 50 millimeter stent at the location of the occlusion, which actually overlapped a previously placed stent. So now we have our code 37236. They also did that post dilation with a balloon, but as we all know, angioplasty is included in our stents, even when we're looking at the 37236, still includes angioplasty. So for our case here, we have the 37236 for the stent and the subclavian, the 36216 for that second order cath placement from the femoral approach, and then again we have the upper extremity angiography 75710. And you'll either need the 59 or the XU. All right, so some final thoughts. So again, and we cannot stress this enough, communication with your physicians is key for you to code correctly and for them to document correctly. If you don't have those relationships, you really do need to expand those because, you know, the definition of insanity is to keep doing the same thing over and over again and expect a different result. And, you know, if you think about it, if you don't inform your physicians that, you know, I don't know what you're doing, or this isn't clear, or, you know, if you don't talk to them about how they can improve their documentation, well, they're not just automatically going to improve. Next, you need to read the procedure reports thoroughly. Make sure you capture all the diagnosis and all of the billable procedures. A lot of times, you know, when I started out doing this, I would print the reports, I'd underline, I'd write all the codes and then go back and cross out the ones that, you know, as they changed as I did in the examples just to keep it all straight. Especially with peripheral, it can become a big ugly animal quickly if they're doing a lot of different things. Of course, you need to keep up with the ever-changing NCCI edits. And finally, communication with your physicians is the key to coding correctly so that that bears repeating. Also, we have part four of our boot camp series will actually wrap up on Monday, December 18th. Nicole will be handling that along with our longtime partner, Linda Gates. She'll be joining us, well, she'll be, not me, she'll be joining Nicole to go over some of this complex E&M coding and documentation. You definitely want to tune in for that. And now, let's see, we have, well, this is our Q&A session. Real quick, our disclaimer, I'm not a lawyer. None of the information contained in this constitutes legal billing advice. Always check with your Medicare carriers. And of course, your practice's legal counsel. And then finally, we have our AMA CPT disclaimer. We did go through the 2024 CPT book to get these codes to make sure that nothing had changed. So, all right. So there are several questions. I cannot promise I will get to all of these. Let's see. All right, if they're, so the question is, if they're treating both the left and right common iliac, is that still one code? If they put in a stent that goes into the other, but still only one stent? I'm pretty sure that's left. We haven't, I need new glasses too, by the way. If we're, if we're looking at left and right common iliac, that's actually, that's two separate families because each extremity is a family. And, and you know, that would, it would almost be impossible to treat that with one stent because of the fact stents don't usually go well around bifurcations. I'm not saying that it couldn't, but because you're in two separate families, I don't know how they would do that with one stent. If they put a stent in each one, then it would be coded, you know, with both stents. Okay, if the leg is accessed from the foot or below the knee, if it's a lateral intervention, the order of selectivity changes. Yes, if you're, if you're below the knee, then it's going to change. That doesn't happen too often. It kind of depends. Keep in mind, you know, if they're going antigrade, then wherever you access, so, um, you know, so if we take those femorals, so if we access from the common femoral and we're going in an antigrade direction, which means we're going towards the foot with the flow of blood. So that access on the common femoral is your access site. And then once you, once you move to the SFA, now you're at first order. So it's the same principle. So if they're, if they're below, then the popliteal or below knee and they access the popliteal, that's your access site, which would then make your tibial your first order. Um, but I don't see that done too often. I have seen where they've accessed the foot and gone up and then they're going in a retrograde. Well, when you're going retrograde until you actually cross that bifurcation, you're not selected and it doesn't, you know, you know, same thing with the arm. If they come through the wrist and they come up and over until, um, you know, they actually cross, you have to get across that aorta in order to become selected, unless you're going in an antigrade approach, then it's a different ballgame. Um, let's see. What documentation is needed to build the ibis? Is the size of the vessel or the finding needed to bill for it? Yes, they need to tell you exactly. Um, this is a, this is a great question. So this is a documentation that absolutely puts me over the edge. When a provider says I ibis, the tibial, um, popliteal SFA iliac and you know, they don't give you details and as coders, we are very detail oriented. We want the details, um, you know, details, details, details. So if they, if they give a documentation like that, I cannot justify saying, oh, sure you ibis each and every vessel. I don't know if the lesion is the same. I don't know, you know, so they have to be very specific on what they're looking at. And if there's any question at all, then you need to talk to them about that. So they need to have findings for each one of those vessels that they individually did it, or if they just did a pullback and maybe they just did the pullback. But if it's clear that it's the same contiguous lesion, then you're not going to do each vessel. You're not, you're not going to code that way. Um, let's see. Kind of the same question on the ibis. Um, lots on the island, like bouncing around on me now. Okay. Can you explain when it would be appropriate to code the catheter and diagnostic angio codes with the thrombolysis? I just lost it because you guys are all along, uh, with the thrombolysis code 37213 and 37214. This has been a point of confusion. All right. Um, when they have those thrombolytic catheters in there and the sheath in there, they may actually pull it out and do, um, the angiography through the sheath. You're not going to code the 7,000 code with those. You would have to actually have a totally separate access. You'd have to be looking at a totally separate set of vessels. So, um, in order to code that 7,000, otherwise it's just, you're going to, you know, that angiography is included with that 37213, um, or the 214 either way. Why aren't we using 36225 instead of 36216 for subclavian angio? Beautiful question. I love this question. And actually she went on and correct and say 36225. All right. The difference between the 36225 and the 36216 is what are we looking for? If the provider is actually looking at the extremities and they are concerned about what's going on in the arm, then we're going to have that, um, 36216 and then we'll have that angiography of arm itself, the 75710. The 36225, they might still be in the subclavian, but now they're interested in what's going on in the head and neck. So that's how you determine which set of codes you use, what is going on for your medical necessity. Are we looking at, um, you know, maybe a subclavian thoracic outlet syndrome? Do they have hand numbness or are we concerned about what's going on in the head and neck? I'll give you the hint for the 36225. You have to have vertebral findings. So if they only talk about the subclavian and they only talk about angiography going down that arm into the hand. Now you're in the arm. You're not worried about what's going on in the head and neck. So that's your key for 36225. Look for vertebral findings. And if you don't have that, then you cannot code that code. All right. Can you build the peroneal and the TP trunk separately? Now I have to go back and think about this. The posterior is what runs into the TP trunk. I'm actually going to skip that question and give you, we'll type that one up because I'm been talking so long now. I'm, I'm confusing myself, but, um, I'm, I want to say off the top of my head, no, because I think it goes part of the, or I'm going to say yes, because it goes off. The TP goes into the posterior, but, um, I will give you, uh, further clarification on that. Basically, though, keep in mind that, um, it's, it's not its own fourth separate vessel. All right. Next question. What is the difference between families and territories? Okay. So your families, and I apologize, um, FedEx just showed up and my hounds are barking. So if you hear them again, I apologize. Um, all right. So the difference between families and territories. So vascular families. So you have your head and neck. Um, that's a family. Your viscerals are family. Each extremity is a family, whether it be right arm, left arm, right leg, left leg. When we're talking about the lower extremities, then they split, um, those territories out. So you have your iliac territory, you have your femoral popliteal territory, and then you have your tibial territory. The rest of the extremities do not, um, um, have territories per se. That's mainly with the, uh, you hear about that with the lower extremities, and that's because of the amount of interventions and angiographies and all that. Especially if you think about if you have a really tall person, it's, it's very hard to see from their iliacs all the way to their foot without moving through all those different territories. Um, let's see. I'm trying to see if there's any more in here. Oh, here we go. If the physician views the abdominal aorta and the bilateral iliacs only, would that be coded as a 75625 and a 75716? The answer to that question is possible, is that it's possible. Depends on where that catheter was placed. If that catheter was placed in the infernal area, and they give you infernal findings, then absolutely yes, you can code both. Right. So there are still a lot, a lot of these, um, uh, uh, let's see. With the Q and A, somebody said they hope that my, they can't write down all my verbal answers. Absolutely. So even the ones that I've answered live, we will still compile all of that into the list and, and give you the full, um, definitions of those because we do get all of the questions. Um, those are all set. Um, let's see. Are you able to build, this is another good one. Are you able to build 37211 through 37214 with mechanical thrombectomy on the same day? Well, according to CPT, yes. Um, according to some carriers, no. So again, that's going to be dependent on the carrier. But according to the CPT book, it does allow for that, um, for you to code for both of those. Now I'm not going to tell you that you're not going to need a modifier to separate that out. But, um, I do know some carriers are adamant and will not, um, allow for that. All right. Well, I think we've covered as many as we can without going into a little bit further, um, explanation. We fully appreciate your time and attendance to these. Um, uh, they, they are definitely, uh, the heart and soul of, of, um, our education sessions. You know, I remember back in the days when we used to be able to be live and, and that's, um, you know, with the cost of everything. And then after the pandemic, it certainly made it harder and harder. So we appreciate you guys all attending these four separate days. Um, we put out a lot of information. Of course, if you have questions, always, uh, reach out to us. And we are asking, um, we're kind of telling people as they're asking questions to, it's better to ask, uh, to email us at the RCS at MedAxium. Um, as you know, on our team has grown quite extensively now, and there are so many of us, uh, available now to answer these. If you only send it to one of us individually, it, um, we may not get to it as fast as you would like. So if you send it to our group email, it goes out to all of us. And then, uh, you know, we can get your answer faster. Keep in mind, it might take us a couple of days to do the research and depending on what we got going on and things like that. But, um, on behalf of myself and Tammy Barron, my colleague, we really appreciate your time today. And again, we will compile all of these questions and we will have them all answered and they will be available. But like I said at the beginning, it's probably going to be closer to, um, I guarantee you it's going to be after the new year because there's, there's several questions and answers we have to do. So thank you again, and we hope you have a wonderful day.

coding guidelines

documentation guidelines

peripherally

geography

intervention procedures

vascular

interventional radiology

upper extremities

lower extremities

clear documentation

cath placements

thrombectomy procedures