Hi, everyone, we will get started here in a couple of minutes. I'm going to give everyone time to get signed on. So just bear with us here for a couple more minutes and we'll get started. Hello again, everyone. If you're just joining us, we're going to get started here in about another minute, and I'm just giving people time. We have quite a few people signed up for this webcast today, so I'm going to give them time to log in. All right well hello everyone and welcome to our first webcast of 2024. I can't believe that February is almost over and we're getting ready to start March soon but welcome to the webcast today. We are going to discuss vein procedures and AV fistulas. I'm going to cover the vein procedures like the ablations and things like that as well as some venography and then Tammy Barron my esteemed colleague she will take over with some vein intervention cases and codes and then she's also going to cover the arteriovenous fistulas which we'll talk about creation of them and then also intervention. Note this is the first in our vascular coding series. We're going to do two more surrounding vascular series this year and then also we're going to have a series on electrophysiology which Jamie will be covering and then my other colleagues Cassie Dill and Michelle Platt and myself will also be doing some CT surgery series and then of course we'll have our standard ICD-10 and all of those good things but it should be an exciting year and we're happy to get started with this. So before we get fully going on the presentation we got some housekeeping so remember that we have a button for the link for the act to access the presentation that's over on the chat box and then we have the question box so keep in mind that we have I'm sorry I just lost my train of thought. Anyway questions are submitted through the Q&A box keep in mind that we do want you to keep your questions on topic and then if we have time we will get we'll answer the questions at the end and if not then and whether we get to all of them or not we will always combine the questions and then we'll answer them offline and then we'll put them on the Academy website so that everyone can see what the Q&A is. So also for CEUs keep in mind that you now we've done this for a couple years now you do have to go into the MedAxium Academy and click on the it says coding boot camp webinar but it doesn't have to be the boot camp any of our webinars you will click on that and then claim your CEE now keep in mind in order to do that not only do you have to be registered but you do have to launch the presentation so if you don't do that then you won't get the CEU and that is because the AAPC has gotten very strict and on this and we have to have proof that not only did people register but that they actually listened. So now it's okay I know some of you listen to these as a group and that's fine but just make sure you individually launch so you can get your CEU credit. We also ask for one to two business days to allow time for those certificates to get uploaded. I know our team is pretty much Johnny on the spot with that but if you know they should be there within two days if not then reach out and let us know because there could be could possibly have an issue. All right so we're going to begin by covering some of the venous conditions that exist. So in this picture here this shows the normal blood flow and I remember veins bring the blood back to the heart so it travels this way and what happens is there's a series of little valves and as you know your calf contracts it pushes the blood back up to the heart through those valves and normally those valves should close and not have any backflow in them. Well as you're as some people develop some venous insufficiency means those valves aren't working like they're supposed to anymore so you get all kinds of blood will pool in there sometimes you'll see like people with puffy veins and you know different conditions can happen because of that and I got another picture on the next slide to talk a little bit more about that and then again like I said the valves are supposed to close and then after the blood goes through and it shouldn't be coming back. So these are some different stages of varicose veins and they can be enlarged twisted they you know they're they're blue veins that are close to the surface and the reason why they appear blue is because they're not they don't have as much oxygen in them but once the valves are damaged and they hold more blood at a higher pressure than normal so that'll force that fluid in the surrounding tissue and it'll make the affected leg it could be swell it can feel heavy achy tired painful fatigue there can be skin symptoms as well such as itching especially when you're getting into the stage here there can be some itching and ulceration and dryness so a bottom line the worse these get then you know physicians have to go in and treat them. Now reticular veins and the spider veins that's where they're they're like in clumps and then you can see a lot of these these are where they're getting puffy and all those types of conditions now keep in mind until there's actually symptomatic it's considered uh cosmetic so medicare won't cover anything that's uh cosmetic most of your insurance companies won't either and usually you have to go through some type of treatment prior to a procedure so a lot of times the physicians will prescribe compression stockings and things like that to try to help with that but if the you know if that doesn't end up helping or curing and and they still have symptoms then obviously they have to go in and do some type of treatment of it so one of the things we're going to talk about next is stab phlebectomies and actually what they do is they make these little incisions and they'll take a hook and they'll pull kind of like if any of you ever did latch hook that's what it reminds me of um they'll pull that vein up and then cut it off tie it off and that's what they're called phlebectomies now the phlebectomy codes are broke up into uh you have the actual cpt codes you have 10 to 20 incisions and then your next option is more than 20 well so now you're going to say what do we do if there's less than 10 well if there's less than 10 then you have to code an unlisted code um and that is because um medicare will when they approve these codes they wanted them to start at at least 10 so um you you know a lot of places are successful with that enlisted code for the under 10 incisions it is important that when you have these discussions with your physicians that they actually that they're very specific on how many they did and how many on each leg if they treat both legs so you don't ever want a case where they'll say i did i did um 15 incisions and you know basically where you don't want them to document i treated both the right and left leg and there was 15 incisions well was there 15 incisions total was there 15 per leg and because you know then how do you break that up did that you know because one is 10 and one is five or whatever so it's important that they are specific um on how many incisions they did in which extremity also note that um hospitalization is not required for this this is normally an outpatient procedure that does not require an overnight stay a lot of times they're even done in office so keep that in mind so i do have a case example here so for this case we have a unilateral left lower extremity micro phlebectomy the patient is symptomatic with very large bulging variscosities in the left leg um it is documented um quite well in the in the patient's chart that they've done you know that's one of the things you need to look for um i know on this one because i've taken it from a particular case that we have coded ourselves but um that's important especially for those insurance carriers that want proof that other methods were tried prior to doing any of these procedures you need to make sure that's clearly in documented in the patient's chart so they also documented consent as well as what anesthesia was done so here we see that the veins are moderately enlarged 26 incisions were made in the range of one to three millimeters using a 14 gauge needle a large number of the veins were removed homostasis was achieved and addressing was applied so for this case we have the 37766 which is the stab phlebectomy of the varicose veins for um 20 or more incisions and again um we only did one side now your carrier may require that you add the lt or for this case it'd be lt um lt or rt modifier depending on which leg you're doing or both so um if they require that be sure that you add that all right so next we're going to talk a little bit about sclerotherapy so sclerotherapy is actually a medical procedure that is used to eliminate varicose veins and spider veins it involves an injection of a solution typically it's it's a saline type solution and they inject that directly into the vein and then what happens is that solution will irritate the lining of the blood vessel and it causes it to collapse so this kind of shows you when they inject it and then it collapses and then it looks more normal again um and then it'll it'll cause that vein to collapse stick together the blood will clot now this is where i'm talking about so uh if we're doing it for spider veins in a limb or trunk that is not covered by medicare because it is considered cosmetic um it may cover the code for larger varicosities assuming that the medical necessity is met and all requirements of the lcd or ncd are met so you always want to make sure if your carrier has an lcd on any of these procedures that um you know you're following that so cpt code 36470 is for injection in a single vein and 36471 is for multiple veins in the same leg so again these are coded per laterality so for cpt codes 36465 and 66 they describe the injection of a non-compounded foam sclerosin um that is injected into a truncal vein the sclerosin comes to the provider ready to use so it doesn't need to be mixed or compounded the physician does not have to do anything to prepare it so um that's what they mean by a non-compounded foam uh please note also that these codes do not include ultrasound guided compression you may code 76942 um uh wait a minute they do include sorry and these do include so you would not report the 76942 for the ultrasound guidance you would not report that for these sorry about that all right so our next case example that we're going to talk about so reportless micro phlebectomy of the left cap varicose veins eight incisions and ultrasound guided sclerotherapy um um of branching varicose veins in the left thigh you see that the report is separated into two paragraphs so we have our indications phlebectomy and then the ultrasound guided sclerotherapy so in the left calf the veins are marked anesthesia is documented micro phlebectomy times eight incisions is carried out with removal of those veins next the left lateral thigh is accessed using ultrasound guidance the sclerosing agent is then injected into multiple recticular veins in the left thigh ultrasound confirms no thrombus and also appropriate filling of the superficial varicose veins so for this case we actually we're going to have to use that unlisted code for the phlebectomy because we're less than 10 incisions so basically you know they accessed that left leg and did their eight incisions then they also injected the vein with sclerotherapy and then they did use that ultrasound guidance of the 76942 now note that is billable with the 36470 and the 36471 so um we were able to report that but um in this case we did the 36471 because we had multiple there was multiple veins that they treated in this leg i kind of went through that next we're going to talk about vein ablations so there's a lot of different ways they can ablate the veins and um i do want to point out for all of the ablations you have a primary code and then you have an add-on code for the subsequent vein treated note that for all of those i don't care what if you're doing it mechanical chemical i don't care if you're doing radio frequency i don't care if you're doing laser whatever the case may be in order to code that um add-on code for those subsequent veins you do have to have a separate access into the leg so keep that in mind they they might treat several veins under one access then you only get to code the primary code so the first type of ablation that we're going to look at is a mechanical chemical ablation sometimes you'll see it referred to as mocha technique this procedure combines medic mechanical and lethal damage using a rotating wire with the infusion of a liquid sclerosant heating on the vein is not required in this case and only local anesthesia is utilized at the insertion site all imaging is included for that um again once that system's in place the ablation catheter is activated for about 10 seconds and it creates a vasospasm which is a sudden constriction of your blood vessel then i'll slowly withdraw that catheter with continuous infusion of the sclerosing agent and then a compression stocking is applied for the immediate 24 hours after and then it it can be replaced daily for the following two weeks just kind of depends on on how well they you know recover for that for radio frequency ablation this is probably the most common right now that we see done the most i would say at one time it was a laser but then the they've kind of went with a radio frequency um all right so this process is used to heat and seal the incompetent vein and you can see that they run that catheter in the vein then they um they heat it up and then they'll uh as they withdraw that catheter catheter that vein collapses and closes so um this is ultrasound guidance is included with with this procedure so you do not code that separately and then um also note again that you're gonna once they do that they're gonna probably place the compression stockings and again you know keep them on for 24 hours and then probably change them out for a couple weeks and again note that add-on code you have to have a separate access for the endovenous laser ablation or better known as ela this is also minimally invasive and it is used to correct venous insufficiency this is performed normally in the office under a local anesthesia using ultrasound guidance a laser fiber is inserted into the refluxing vein and they make a small nick of the skin in order to do that and then they put in a laser and that energy is applied along the length of the vein again that laser energy is used to heat the vein and then seal it closed most common site for this is the greater saphenous vein that's where they're going to use it the most and then remember procedure does include any imaging guidance and this one takes a little and this one takes a little longer this this procedure takes 30 to 45 minutes do note that you can drive after they don't necessarily need a driver because it's local anesthesia and then once the procedure is completed the blood is rerouted to healthy veins and then that again they're gonna wrap that leg and ace bandage and again that compression sock but notice they usually keep the for the laser they keep them wrapped for about 48 hours versus 24 and then finally we have ablation by transcatheter delivery of a chemical adhesive it's commonly called venous seal and it's glorified superglue is what it is so in this uh procedure the system uses an adhesive to close the superficial veins that are in the lower extremity this is an FDA approved system procedure again is probably uh commonly performed in the office it does require just one small needle prick and then unlike some of the other venous ablation there's no need for additional injections or any local anesthetic around the vein they also do not have to wear compression stock stockings after this procedure and again just that final thought um that add-on code is only used if there's a separate incision all right so i have a case example of this as well so this one we have endovascular or endovenous radiofrequency ablation so this is the rfa and that's going to be the great saphenous vein and they're also going to do 12 incisions so here we have symptomatic varicose veins and i would probably also go back to the physician and go what exactly are their symptoms because it's it's not enough again if it's just if it's just varicose veins then you're not going to be able to code for that well i'm not going to say you can't code for it but it won't be paid because it would be considered cosmetic so they do have to have they should your physician should be listing what that symptom is. All right, so the insufficient saphenous vein was mapped and depth and diameter of the vein to be treated was documented. Then they go on to say the affected limb was prepped and draped in the usual sterile fashion and the RF catheter was placed on the sterile field. I'm gonna go ahead and jump forward. That was just more of the indications continued. It's kind of strange because they combine a lot of things in this one, but they call it indication. So be careful with your provider and make sure they're documenting this very clear. All right, let's see. After radiofrequency cath was positioned was verified by ultrasound, the transmucent anesthesia was infiltrated. Let's see, go on down. I'm gonna drop down a little bit. So the RF energy was applied. The vein was segmentally ablated by heating a seven centimeter segment and then indexing that catheter forward by 6.5 centimeters until the treatment length was completed. The device temperature was maintained at 120 Celsius with initial power level of 40 Watts dropping to 20 Watts for each treatment. Total vein length treated was 12 centimeters. So following that ablation, then they also went on to do a stab phlebectomies in the right thigh and calf. Again, they use a transmucent anesthesia and that's documented. And then they did micro phlebectomy times 12 incisions is carried out. And then documentation of the removal of the veins as well documented. So again, we have our endovenous radiofrequency ablation. And then because we were more than 10 incisions, but less than 20, we will code the 37765 for that stab phlebectomy. All right, now we're going to move on into some diagnostic vein procedures. Now keep in mind when we're talking veins and arteries, they do have some rules that are similar, but they have a lot that are different. So do not automatically apply the arterial rules with the vein venous rules because they are different. So the first thing I want to talk about is vena cavale angiography. So you have code 36010 and that is your zero order calf placement. So it mimics the 36200. And as you see, this is your vena cava and it's right next to your aorta. So for the non-selective area here, we have the 36010 that can go all the way up into the superior vena cava. Superior vena cava is up closer to the heart and the inferior is down from the diaphragm around the abdominal. And like I said, it mimics the aorta. The only difference is the aorta is pushing the blood out to the body and the vena cava is bringing it back to the heart. So then the other things, so we have two separate CPT codes for the venography. And so we have 75825, which was venography of the inferior cavale, which again is down here, we're in the inferior vena cava. Or you have 75827, which is superior. Now keep in mind, you need to know where they're at. Superior vena cava includes inferior. So if they do superior, you're just, you code the one. All right. So some other things that are billed with the vena cava. So if you think about, go back to our arteries. When we do, when they place that cath in the abdominal aorta, and they do an abdominal aortagram, we're talking the aorta, and then they see the renals, that's coded, you know, with one code. Now, if you separately select the renals or any of the other visceral arteries, so like your celiac, your SMA, your IMA, those things that you do that imaging, well, as you know, those include that flush aortagram. So you wouldn't bill like the 75625 or the 75630 with the selective renal or any of the viscerals, because it would already include that. When it comes to the vena side, that is not how that works. You can code the inferior and or superior vena cava along with your renal venography. Now, the renal codes are split out by either unilateral or bilateral, but do keep in mind, you can bill for them. So this is one of those instances where the arterial rules do not mimic the venous rules. Now, there are some things that the 75825 and the 75827 do bundle with. You do not report them if you're also performing an IVC filter, the inferior vena cava filter. These bundle with these codes here. You also would not report it with any of your dialysis circuit codes, and you would not report it if you're doing a venous sampling procedure, which is coded with the 75893. All right, so let's look at some diagnostic venous extremity coding. So again, we have the veins of the arms and the legs, and keep in mind, again, they're gonna mimic. So we have the bacillic vein, along with the bacillic artery, that type thing. You have the cephalic vein, which is with the cephalic artery. But again, cath placements change here, and things are coded a lot different with these. So for the venous side, we have 36005, which is your non-selective injection for your extremity venography. This is a unilateral code. So if they access one leg, and basically they access and they shoot that dye, they don't move the catheter at all, then you have the 36005. And that can be done bilaterally, again, if they access both legs. You would code that with a 50 modifier. If they only do one leg, then you may have to use your RTLT with that as well. So when we start talking about first-order venous cath placements, and again, I'm gonna talk about the lower extremities right now, they have to cross the vena cava in order to be selective. So if they access on the right femoral vein, and they cross the vena cava, and they go over into the left iliac vein, or into the left femoral vein, then that would be, now you're looking at your first order. As you get down further, then it goes to second order. They do only have, they're basically non-selective, and then first order or second. There's no third order when it comes to the veins. But you do have to cross that vena cava in order to bill selectively. And then again, we have our venography, and this is for extremity or pelvic veins. We have bilateral and unilateral for those. And again, these are the same whether we're doing the upper extremities or the lower extremities. So keep in mind if you, if they do both the upper and the lower, you would report, if it's unilateral, so if they do the left side, the left upper extremity and the left lower extremity, you would report the 75820 twice. If they do both upper and lower bilateral, then you would report the 75822 twice. Now, obviously you're probably going to have to use a 59 or an XS modifier. Let's see. Yeah, that's all I wanted to say about that. Excuse me. So next we have the visceral area. So again, this is down in your abdomen by your inferior vena cava. You have the splenic veins, inferior mesenteric veins, superior mesenteric vein, your hepatic veins. All of those things are here in the visceral area. Some guidelines for that. So the selective calf placement needs to be in a vein that supplies a visceral organ, and then it also must be from a peripheral access. So they either have to come from the femoral, the brachial, or the jugular. So again, so for first order, and now again, we're talking viscerals, so we're not down in the legs. So 36011 is first order, and that is unilateral and bilateral selective renal. You have to use the 50 if we're doing it bilateral, or if they're doing right testicular venography without renal, right ovarian venography with or without renal, and then we have the right adrenal venography, and then hepatic venography with or without hemodynamics. These are all considered your first order calf placements. Questions out of the way. All right, so for second order, now we're looking at, this would be additional selective renal angiography after the basic exam. Again, we're talking calf placements here. And we have, then you have your left testicular, again, without renals, left ovarian with or without renal, left adrenal, and then hepatic venography wedged with or without hemodynamics. So for CPT code 75831, now we're gonna look at the venography of those. It's used for either a renal or ovarian venography, or left gonadal venography, and again, that's unilateral. You would use 75833 for bilateral, and then you only code these once per session. So if you do renal and ovarian, you only code it once. Extremity venography is used for testicular, either unilateral or bilateral, and then the unilateral code also includes the right gonadal vein. Now, most of you on this call are probably not gonna be doing a lot of this unless you have vascular surgeons. Not too many cardiologists or interventionists get involved in this, but they might. It just depends on how, how aggressive and how much they wanna get involved in other things. All right. So also note, if they do not mention selective venography, you have to use selective iliac venography. If they do not mention that on the 75820, then you have to reduce that with a 52 modifier. So keep that in mind with both of these. They have to mention iliacs, otherwise you have to reduce it. All right. Here are some more of the visceral imaging continued. So we have adrenal venography, unilateral and bilateral. And then we also have the hepatic venography with hemodynamics and then without. Now, let's talk about 76496, because I see I actually had a question about should we use the 75774 like we do with the, additional artery imaging, but that is specifically for arteries and not veins. For veins, it would be the 76496, but keep in mind that is an unlisted code and your carriers may or may not cover it. They're probably going to request the documentation to show that. So keep that in mind too. And you will have to meet medical necessity for doing those additional codes, but the venous codes do not have that separate imaging code like the arteries do and do not use 75774 for that. All right. So next I'm going to talk a little bit about the 36500, which is venous catheterization for selective organ blood sampling. This is coded per organ, not per vessel. So you have to be talking about something that's feeding an organ. So if one's feeding the kidneys and one's feeding the spleen, that type of thing. So it wouldn't be, you know, just more of the renal veins or whatever. It's per organ, not vessel. It does have an MUE of four. So now, interestingly enough, you would code the 75893 for the venous sampling through the catheter with or without angiography, but it only has an MUE of two, but it does have an adjudication indicator of three. So you could bill three of them, but again, you're going to have to have documentation and proving. And again, most of this is going to be done by your vascular surgeons, not too many interventionalists will get involved in this, or if any of you are billing for interventional radiology, they would probably venture into this more than a cardiologist as well. All right, so now let's talk about veins of the head and neck. And this just kind of shows a picture of most of the common, not all of them, obviously, but the common veins of the head and neck. Now, this can get a little tricky too. So if we're coming from the upper extremity ipsilateral approach, so if you're coming from the brachiocephalic or the subclavian, and keep in mind the brachiocephalic and the indominant are interchangeable word, you would use the 36005 if you're coming from an upper extremity ipsilateral approach. For the external internal jugular, that is first order. So you don't get to first order till you hit the external or internal jugular, and you don't achieve second or greater order, which is the 36012 until you've actually reached the anterior jugular veins. So keep this in mind, and unless they get up into, you know, if they're just here at the subclavian or brachiocephalic area, and they do that injection, then you're going to code it with the 36005. But if they start moving the catheter more selectively, your external and internal jugulars are the 36011, which is first order. And then once you get into anterior jugular, then you're in second or greater. Now, if you're coming from the transfemoral approach, so all veins of the head and neck are second order from a transfemoral, so you're coming from the leg, coming from the veins in the femoral vein, once you get past the anominant and brachiocephalic. So once, it doesn't matter, you don't have to wait till you get to the anterior jugular. You're actually second order once you're past that anominant brachiocephalic. Now, if they do a direct puncture into the jugular, then you have to code the enlisted code. So keep that in mind. And then again, these are all of our venography codes that go with this. And, you know, you have the suprasagittal sinus, the jugular, epidural, orbital. And then again, if your carrier allows, you can code the 76946 after your basic exam is complete. So now I do have one example of just a venography. It's kind of rare. Usually they're done in conjunction with some type of intervention. But, all right. So on this one, on this particular procedure, and I don't think, one of the things on this that I would go back to the provider is he or she did not give any indication of why we're doing this. So this is an actual note. So this is one of those things that, you know, this would be something that you would need to talk to your providers about and say, you know, we have to know. All right. So I have moderate sedation was started 1144, ended at 1225. I did not code that. It should be. It's the 99152 for the moderate sedation because Minnie Mouse was the RN who administered the sedation and monitored the patient's vitals and was given direct supervision by the provider. It is best if your physicians do document who actually did that monitoring. It just makes things more clear when it comes to the carrier and that, you know, they can see that this was an independent person. Again, keep in mind, anybody that's doing that moderate sedation has no other duties other than monitoring that patient. So you, you know, especially with your vascular surgeons, a PA is not gonna come in and assist with anything and then also do moderate sedation. This person is standalone. That's their only job at that time. All right. So they did go over. So again, we had the procedure details, the wishlist type thing. They did tell me where they accessed. They did talk about and get the patient's consent. All of that is very good documentation that you have the consent, but again, I don't have why we're doing this. So the next slide, this is the meat of what's going on here. So again, we have venogram was performed through the left sheath and I coded the 36005. And I also coded the 75820 with the 26 modifier. Now notice this has a strikethrough because that code's gonna change. It's gonna go away. But right now we did a venogram on the left through the left sheath. There was no significance stenosis noted of the left common femoral vein, left external or the left common iliac vein. Next, they performed a right venogram through the right sheath. So again, we're gonna have the 36005 with a 50 modifier. And then I changed my venography code to bilateral with the 75822 with the 26 modifier. Next, the provider performed IBIS of the left common iliac vein. We coded that with 37252. Provider noted that there was diffuse fibrotic stenosis of the left common iliac vein, as well as significant compression of the left common iliac vein with measurements of 77 millimeters at the compressed segment. Then the provider, now this dictation is very good and this one's kind of lucky because you don't normally get this good of dictation, but next the ivus was performed from the right common femoral vein with pull back to the right common iliac. So measurements for femoral vein was 104, external was 144, and the right common was 135.3. So again the provider was very clear that it was a pullback so we would only code the 37253 for the additional. Then they pulled the sheath and applied manual pressure. Based on the findings they decided they will bring the patient back later for intervention on that left common iliac vein. All right so this is kind of showing so what they did and granted this picture is the back of the legs but they went in um through the uh they did injections through sheaths down both legs. So they did not cross, which it's not pictured, but they did not cross the IVC, they didn't go up and over, they just injected each leg. So that's why I have 36005 with a 50 modifier for those bilateral injections. Then I also coded the 75822 because we have venography on both legs. And then I did one IVUS the 37252 or I should say the initial IVUS uh 37252 which that one was done on the left. Now remember IVUS you don't use LT and RTs on those. And then they also did so they did the left side he did the iliac and then on the right he went from which they don't have the femoral noted but he went from the femoral and pulled back into the iliac. So that's why they got the additional IVUS for the other side with the 37253. Again please make a note I forgot to put the moderate sedation so I apologize for that and that code is 99152 because they didn't meet the requirements for that. Now I am actually going to turn this over to my colleague Tammy Barron and she's going to take us through interventions and the AB fistula coding. So Tammy take it away. Okay thank you Jolene that was awesome. Good afternoon everyone. I'll be taking the reins and talk a little about venous interventions. It is probably one of my favorite areas of coding because it's quite challenging most of the time and also quite rewarding when you make it to the end of one of those challenging cases. You definitely need to put out your special venous hat when you're coding these procedures because though it may appear they're likened to arterial procedures I can assure you they are there are distinct differences in the guidelines. As more and more codes are being impacted by bundling your component codes back into a single code, venography coding has not yet been affected by this trend. Next. So before you begin coding vein procedures make sure you are familiar with Appendix L which clarifies that the inferior vena cava from the iliac vein confluence to the right atrium is considered one vessel for reporting purposes. Each of the common iliac veins are independent separate vessels. The external iliac vein and ipsilateral common femoral vein are considered one continuous vessel for reporting purposes. Just like all other interventions the same rules apply for the venous system when you're coding diagnostic venography. These are available here for you on the slides. Next. The angioplasty codes for veins include imaging and they are not to be used for dialysis circuit procedures. These codes are used for both open and percutaneous procedures. Balloon angioplasty is included with stenting so it would not be billed separately. Likewise multiple angioplasties and or stents in the same vessel would be coded as one intervention. Per CPT if a lesion extends from one vessel into another it is treated with a single interventional therapy. Then only one intervention code would be reported. It further states separate and distinct ipsilateral or contralateral lesions would be coded with the appropriate add-on codes. So what is separately billable? Imaging that is inherent to the balloon or stent procedure is included. However a true diagnostic study is indeed separately billable assuming the requirements are met. Non-selective and selective cath placements are billable as is IVUS and mechanical thrombectomy. And as of January 1st ultrasound guidance which is CPT code 76937 as we know is bundled with several procedures that we currently code. Per chapter 9 of the NCCI manual radiological supervision and interp codes include all radiological services necessary to complete that service. CPT codes for fluoro, fluoroscopic guidance, or ultrasound or ultrasound guidance shall not be reported separately. Next vascular embolization or occlusion procedures are inclusive of all radiological supervision and interp interprocedural road mapping and imaging guidance. CPT code 37241 describes coiling for venous conditions that are not related to hemorrhage or hemodialysis access. While CPT code 37244 is for treatment of arterial or venous hemorrhage. Now this may be GI bleed or a vascular or lymphatic extravasation. You want to remember with these codes you may only report one code per surgical field not per vessel. That surgical field is the area immediately surrounding and involved in the treatment procedure. Again what are you allowed to bill with these embolization codes? Well you may bill your diagnostic venography or angiography. You get your selective cath placements and you get to bill for any stents placed. One thing to remember on that is if your provider is placing those stents to provide lattice work for deployment of the coil or coils it would not be appropriate to bill for that stent. I would urge you to read that parenthetical in CPT regarding stent placement with your embolization codes. Next, thrombectomy and thrombolysis or thrombolysis however you want to say that. For mechanical thrombectomy of the veins we have CPT code 37187 for the initial date of treatment and 37188 for the repeat treatment on a subsequent day. If both legs are being treated you would of course use modifier 50 or the LTRT depending on your individual carrier. Now as is typical with these procedures imaging that is inherent to the intervention is included. However a true diagnostic study is indeed separately billable. Now I'll tell you I code a ton of these procedures and most not all but most of these patients come into the cath lab for the purpose of intervention based upon a confirmed diagnosis that has been determined already by a CT scan. Usually the providers are pretty good about documenting that on their procedure notes. Non-selective and or selective cath placement is separately reportable. IVUS as well as other interventions such as PTA, stent and thrombolytic therapy are all separately billable. Next, thrombolytic infusion codes are fairly straightforward. You have your code for the initial treatment day 37212 and a separate code for your subsequent treatment day 37213 and then the final day when the thrombolysis is completed and the catheter is removed and it's 37214. Modifier 50 may be used with CPT code 37212 when it's performed bilaterally. Cath placement, diagnostic studies and any other percutaneous interventions performed are separately reportable. An E&M service that is significant and separately identifiable may be reported with modifier 25. However, E&M services on the day and related to the thrombolysis are included. Fluoroscopic guidance and radiological supervision and interp are included in 37211 through 37214. These codes should only be reported once per treatment day. I'll also mention here that 37213 for your subsequent day of therapy and 37214 for the last day thrombolysis is administered, which includes the removal of the catheter, are not modifier 50 eligible. They each have an MUE of 1 and an MUE adjudication indicator of 2. So even if you did place those initial catheters bilaterally, you would only submit 37213 or 37214 one time. That's applicable. Next, we have intravascular vena cava filter. Now these filters are commonly placed for refractory DVT and pulmonary embolism or when there is a contraindication to anticoagulation therapy. The codes for the filter are fairly straightforward. 37191 is your initial insertion code. If repositioning is required, then that code is 37192 and finally retrieval of your filter is 37193. Be aware of the code description with these filter placements as it does state vascular access, vessel selection, and SNI are all included services. Also, you would not report the repositioning code for the filter. Also, you would not report the repositioning code 37192 with your initial insertion code 37191 on any given day. Next, so now we can look at a couple actual case examples on these. On this first case, we have a clinical concern for a left subclavian vein stenosis and they're telling us the procedure is going to be ultrasound guided access in the left brachial vein, left brachial venogram, left subclavian venogram, and left subclavian vein angioplasty. and left subclavian vein angioplasty. Next, so we have our basic consent. They're at the top, our timeout, and they're identifying the laterality, left arm was prepped and draped, and then after achieving lidocaine, the left brachial vein is accessed. A micro wire was inserted into the needle and the needle was exchanged for a coaxial dilator. The dilator was removed and a Benson wire was inserted. A venogram is performed of the left brachial vein. Catheter is advanced into the left subclavian vein and venography is performed and it's demonstrated a stenosis. So the sheath was placed and angioplasty was performed on that left subclavian vein with a balloon. Then they repeated the venogram and this showed wide patency with improved flow and reflux into the superior vena cava. And a final impression, successful balloon dilation of a significant left subclavian vein stenosis. Next slide. So for this case, angioplasty of the left subclavian vein is reported with CPT code 37248. I've got the LT modifier on there. The injection and cath placement is reported once with 36005. Since there is an NCCI edit with the intervention code, we'll need to append modifier 59 or the X modifier. Diagnostic procedure is distinct and diagnosed the lesion that was subsequently treated. Imaging of all the veins in the left upper extremity would be reported one time with 75820. And again, you're going to need that modifier 59 or X to indicate that it is a true diagnostic imaging procedure. Next. Case number two, we have a transcatheter venous infusion. Indications, left leg DVT identified on Doppler study. Patient presents for assessment of the extent of the disease. So via right brachial access, the catheter is advanced into the superior vena cava and positioned at the proximal inferior vena cava. No clot is seen in the vena cava. Catheter is then advanced into the left external iliac vein and into the left popliteal vein where contrast is injected and imaging is performed of the lower leg. A blockage is visualized in that popliteal vein. I advance the catheter further into the popliteal vein and do additional contrast injection. Imaging shows significant thrombus with total occlusion and thrombolysis is initiated. Next. So for this case, you have 37212 for the transcatheter venous infusion. Catheter placements in the vena cava is bundled with the popliteal vein cath placement. So 36012 is your only cath placement code. Then imaging of the unilateral extremity and the inferior vena cava is reported separately and there's no code submitted for the additional second shot in that popliteal vein. Okay, so now we're going to talk about hemodialysis access and AV fistulas. Next, here's a lovely diagram. The purpose of the hemodialysis is to filter waste, salts, and fluid from your blood when your kidneys can no longer perform this function. With AV fistula or graft, your blood flows from the artery directly into the vein. This increases the blood pressure and amount of blood flow through the vein and this causes those veins to enlarge, thus providing high blood flow rate sufficient for the hemodialysis treatments. Next. So here's a nice compact slide defining the available codes for open AV fistula creation and revision. And you can see that these are in a nice order in CPT beginning with 36818 through 36820 wherein the veins are transposed to create the fistula. Then 36821 describes direct anastomosis any site. This is by far the most common method wherein they sew that artery and vein together at one area from a single access. Then 36825 and 36830 are used when creation of the fistula is other than direct AV anastomosis. And these are dependent upon whether an autogenous or non-autogenous or synthetic graft is used. And lastly, we have 36831, 2, and 3 which are our thrombectomy and revision codes. So what is a dialysis circuit? It is a surgically creative structure for long-term hemodialysis access in patients with end-stage renal disease. It involves creating an artificial communication between an artery and a vein. It begins at the arterial anastomosis and it extends to the right atrium. There are two types of creations. One is an arterial venous anastomosis referred to as AVF and the other involves a prosthetic graft placed between an artery and a vein. And this is your arterial venous graft or AVG. The circuit is comprised of two segments, the peripheral and the central dialysis segment. Next. Now the peripheral segment begins at the arterial anastomosis and extends to the central dialysis segment. In the upper extremity, it extends through the axillary vein or the entire cephalic vein if the outflow is the cephalic vein. If there's a lower extremity fistula, that begins at the arterial anastomosis, excuse me, through the common femoral vein. The peripheral dialysis segment includes the perianostomatic region which is defined as that region near the arterial anastomosis encompassing a short segment of your parent artery, anastomosis itself, and a short segment of the dialysis circuit immediately adjacent to the anastomosis. That's a mouthful. Next. So the central dialysis segment includes all draining veins central to the peripheral dialysis segment. This is pretty explanatory, pretty self-explanatory here. In the upper extremity, this includes the veins central to the axillary and cephalic veins including the subclavian and inominate through the superior vena cava. And in the lower extremity, that includes the veins central to the common femoral vein including the external iliac and common iliac veins through the inferior vena cava. So here are a couple more definition slides, the perianostomatic region, which we talked about previously. We also wanted to mention that when we're talking about diagnostic studies or interventions performed through the circuit, we're talking about performing those procedures via direct percutaneous access of that dialysis circuit. Next. So, the codes for dialysis circuit are in typical hierarchy fashion. 36901 describes accessing the circuit percutaneously, of course, and performing the angio of the fistula or the graft. All imaging of axillary or cephalic veins in the upper arm or the common femoral vein in the leg are considered that peripheral imaging. If there is an indication and they performed angioplasty following the fistulogram, then your code changes to 36902. Likewise, if a stent is placed, then that code changes again to 36903. Next. 36901 through 36906 are your base codes. You only submit one of these codes based upon the procedure that you've performed. Remember, they are hierarchy codes, so each one merely progresses with complexity of the procedure. So, 36904 is the code for mechanical thrombectomy. And if they additionally perform angioplasty, that code changes to 36905. And if a stent is placed, then 36906 is the code you're going to use. 36907 through 36909 are add-on codes, which may be billed with your 36901 through 36906, as well as your open codes, 36818, 36833. 36907 and 36908 define angioplasty or stent of the central dialysis segment. And 36909 defines embolization or occlusion of the dialysis circuit. And this particular code I'll mention is only applicable to your base codes, 36901 through 36906. Remember our previous slide defining your peripheral and central segment. You must understand your definitions thoroughly to be able to code these dialysis procedures appropriately. Next slide. I have another case example. This one is for AV fistula malfunction in stage renal dialysis. Or in stage renal disease, I'm sorry, on hemodialysis. And our procedure is ultrasound guided access of the left radiocephalic fistula times two. We have a fistulogram of the left upper extremity. A venogram of the central venous system. Planoballoon angioplasty. And radiologic supervision and interp. Next slide. So after informed consent was obtained, the patient was brought to the hybrid room. Basically, that's our basic information placed in supine position. Sedated the patient. The left upper extremity was prepped and draped. Timeout was conducted. The fistula was palpated. And under ultrasound guidance, a micropuncture needle was used to gain access. Next, the wire was threaded up the outflow vein for which the needle was removed and the sheath was advanced. Images were obtained of the venous outflow including the central system. And this appeared patent without significant areas of stenosis or large collaterals. The flow did seem sluggish though, relating more to an inflow issue. And additionally, there were large branches coming off the cephalic vein near the anastomosis, stealing some of that flow. Including one that had become aneurysmal. Where dialysis was probably sticking and finding prolonged bleeding. Therefore, we elected to access the fistula more proximally on the arm in a retrograde fashion. This was performed in similar fashion using ultrasound guidance with the micropuncture kit. The sheath was exchanged. Catheter was used to cannulate through the anastomosis and into the proximal radial artery. And there was some difficulty traversing this area in the perianastomotic region. Next, an image was taken through the catheter positioned in the radial artery in several views. And this demonstrated a focal area of stenosis. Patient was given heparin. Angioplasty of this segment was performed with a plain balloon for two minutes. And this demonstrated resolution of the stenosis. Repeat fistula gram was performed evaluating the outflow vein and central stenosis, which again demonstrated no areas of stenosis and much more brisk flow. And this concluded our procedure. Next. So for this case, we have 36902 fistula gram with angioplasty. Okay. Next, we have another case example. And this is a brachiocephalic fistula creation. The operative sites were prepped and draped. Patient had a regional block. Prior to incision, she had a dilated cephalic vein in her right arm, despite ultrasound showing a smaller-than-normal vein. So we made an initial skin incision in the extremity, and the artery and vein were dissected freely from the surrounding tissues, controlled with vessel loops. Upon inspection, I see that the vein had flow, was not scarred, and was of adequate size. So the vein was clamped approximately and transected distally, with the distal end tied with suture. The vein was distended with heparinized saline, and it distended well. Clamp was removed, and the vein flushed easily. The vein was re-clamped along with the proximal and distal brachial artery, and the anastomosis was performed end-to-side with proline. Prior to completion, the system was briefly bled and flushed. The anastomosis was completed, and clamps were removed. There was a good thrill, and this was confirmed with handheld Doppler, which also revealed good biphasic distal brachial artery flow. Next. So for this case, you have 36821 for the direct AV anastomosis. And next slide. Oh, gosh, that went fast. So this is our disclaimer, stating that it is for informational purposes only and doesn't constitute legal reimbursement, coding, business, or other advice. You should always check with your local medical carrier and consult with your practice's legal counsel for coding and reimbursement advice. And this next slide is our CPT disclaimer. And that is going to do it for me, and I'm going to turn it back over to Jolene, who will take us down the final home stretch. Thank you, Tammy. That was wonderful. So I've answered some of these questions online. One of the things that has come up is the 76937. So at the beginning of the year, they did say they put it in the manual, the NCCI manual, but then it was, well, people are going to argue this. Well, there has been an errata, I think, that came out in February 14th that states that they're going to change that in the NCCI manual. So unfortunately, because there is so much controversy, I'm not sure how fast – first off, I'm not sure how many carriers even caught it to begin with to deny it. And then two, how many of them, if they did catch it and were denying it, now how fast will it be that they reverse that? So just keep in mind, as long as you're meeting that documentation, and again, that errata did come out that they were going to reverse that, but I'm not sure if the effective date was – I know it says February 14th, but sometimes those erratas don't actually hit until the next quarter, which would be April 1st. So you're just going to have to kind of play the game with your carriers on whether or not they're going to pay for that. Some may allow you to back code that if you weren't coding it. If some of you have been holding on to claims, waiting to see what would happen, that's up to your administration if you want to start sending them out now or wait until April, whatever the case may be. But they did – the ultimate goal is they are removing that from the NCCI edit. So apparently they didn't mean to put that in. But again, keep in mind with that ultrasound guidance, you have to have – there has to be clear documentation of needle entry, and there has to be documentation of that vessel patency, and there has to be permanent recording. That all has to be documented. So make sure that would be the case too. All right. It looks like if only a non-invasive – so here's another question. If only a non-invasive diagnostic imaging study was done, so say a Doppler, is it okay to code a diagnostic venogram despite there being a known diagnosis to perform an intervention? Documentation is not always clear as to whether a true catheter-based diagnostic venogram was performed prior. So that's the case with all diagnostics, whether they be coronary, whether they be angiograms, whether they be venograms. They do bundle with intervention. So it does have to be a true diagnostic. Now, a Doppler study itself would not qualify as a previous study. So – but, you know, it's not so much about the diagnosis. It's about whether or not there's been a study. Now, keep in mind, unlike the coronaries, when it comes to the peripheral, if they do a CT, if they do a CT angiography or venography, that's out the window unless there's been a change in that patient's condition or if the provider documents that, you know, for whatever reason he couldn't read those images, that type of thing. So that one rule applies for everybody, you know, regardless of what we're talking about, whether it's veins or arteries or even in the coronaries. So keep that in mind when it comes to that diagnostic study. But a Doppler enough would not be considered because that's – a Doppler is basically like an echo. So that is not true imaging. Someone else asked if an IVC filter is placed and then they do mechanical thrombectomy and or stents or all cath placements and diagnostics bundled if no study was performed. Well, it kind of depends on where all these stents and thrombuses are being done. So it's hard to give a blanket statement. But, for example, if they're placing that filter, now you cannot code the vena – the cavale, the vena cavale. You cannot perform any of those vena grans. You can't code for that with that filter. That bundles, period. But if they're doing extremity and they're placing those stents in the extremity and that type of thing, those do not bundle with an IVC filter. But, you know, if they're doing it all in the vena cava, then, you know, there probably are. You're going to have to run it through, I don't know, all the bundles right off the top of my head. So it's always best no matter what, especially if you're billing a bunch of codes. And those of you that have been doing vascular a while know that peripheral can get ugly. The venous studies get ugly. The venous intervention, all of that gets ugly. So it's always best if you're billing a bunch of codes to always run them through some type of NCCI edit and, you know, make sure that you've got modifiers and that it's appropriate. You know, make sure it's an appropriate modifier to add, not just add it. There's some, somebody brought up that the 75774 is, they're citing a CPT assist article from 2022. I have not specifically seen that. We will go and look. But to my knowledge, that 75774 is for angiography only, not venography. It adds on to codes that are arterial studies, not venous studies. So most of your venous studies start 758, you know, whatever it be, 7582022 and so on and so forth. That is not listed in the CPT book with that. So I will have to go and look at that article specifically. And when we do our final compilation of the questions, we will let you know for sure on that, what that determination is. Let's see. Again, one of the questions is in this kind of same theme, if MD states diagnostic venogram and dictation, but it's a known diagnosis with a prior CT, how do we determine if it's truly diagnostic? Again, and we cannot stress enough, you have to have these conversations with your providers. If it's not clear, then that CT imaging is going to override any venography that you're doing. You know, a lot of times, unless there's been a change in that actual patient's condition, you know, and now if it's during, then you can, you know, if they're doing an intervention and the patient starts complaining of something else and they go do a different denography, then you could, you know, code for that. Or again, if there's been that documented change in condition from the last time they had that CT. Let's see. Oh, here's a good one, but I can't answer it. So the question is, we have a hard time discerning how many vessels to code venoplasty when the patient has multiple vessel DVT and the report documentation does not specifically state separate thrombus are treated. For example, patient has a venumplasty and common iliac vein, external iliac vein and common femoral vein. Would this be three separate venoplasties, which they have coded as 37248 and 37249 times two, or would it be one venoplasty? So again, that comes down to, first off, is that a contiguous lesion? If it's the same lesion, then you're only going to code one. So again, these are things you truly need to have these discussions with your physicians and say, you know, if it looks like it's just one lesion, then that's how you have to code it. And if it's truly isn't, then they're obviously leaving money on the table by not being more clear in their documentation. Gosh, I wrote a blog on this. Jamie and I did a webcast one year about that relationship with your providers. And it's very important. And I know some of you don't have, some of you are like with a common billing office and you may not have that, that daily interaction with providers, but this is stuff I would be emailing. If you're using Epic and you're doing in basket messages, whatever the case may be, you need to communicate back with that provider to say, you know, I'm not understanding what you did here. And, you know, I can't based on what you've documented, this was all I can code. And if it, if it truly was separate, then, you know, you need to be stating that because if we never go back and tell them how to improve their documentation, they're never going to improve it. You can't fix what you don't know. So, okay. I've been on my soap box on that long enough. Let's see. Physician is doing Cavall, venography and lower extremity venography. How would you code the cath placements? Would it be two codes? Well, it depends if, if they're actually doing selective cath placement, then that's going to trump the three six Oh one Oh, because that is a non-selective. It's just like the aorta. You wouldn't code the 36, 200 with like the three, six, two, four, five. So, but if they're all non-selective, if they do that three, six, zero, zero, five, that injection for venography in, in the extremity and then they also selective or won't wouldn't be selective, but if they place that cath in the vena cave and then you could code both, you may or may not need a modifier. Again, I don't know that for sure right off the top of my head, I'd have to look. That would be rare that that would be done, but you know, not saying that it can't happen. Someone also asked us three, six, zero, zero, five, use this placement for an introducer sheath. If venography is not performed that code three, six, zero, zero five specifically states injection for venography is why you're doing that. So I would say, no, I don't know why they'd put in an introducer or sheath if if they're not going to, you know, it's not like the vessel access code if that's what you're thinking of with the, with the arteries. And actually some of these are a little bit more in depth. So we will, again, we'll compile all of them and that will be available on our, on the Academy with give us, well, it's end of month. So give us a few, give us a couple of weeks on that, but we'll get that compiled and it will be available on the Academy with a recording. They always put the Q and a there too. And please don't forget, check back in a couple of days for your CEUs. And we are going to go ahead and wrap this up. So thank you very much for your attendance and patience and great questions. And Tammy, thank you so much for helping me out with this. It's so nice to not have to do these lengthy mind-boggling procedures, procedure coding all by myself. So I appreciate that and I hope you all have a wonderful day. Thank you.

vascular procedures

vein procedures

AV fistulas

accurate coding

diagnostic studies

interventions

embolization

thrombectomy

CPT codes

venography

angioplasty

dialysis circuits