Hi, everyone, we will be getting started shortly. We're going to give it a few minutes and let everyone log in. We have slated several participants today, so want to make sure that they get some time. So we will start in a couple of minutes. Hello again, everyone if you're just joining, we will be starting here shortly. We're giving people time to get logged on and probably about another minute. We'll get started. All right, well hello everyone and welcome to our vascular series number two. Today we are going to talk about EVARs, IBEs, FEVARs and TVARs. We're also going to cover a few open aneurysm procedures and I am joined today by my wonderful colleague Tammy Barron. She has lots of years experience in vascular coding so we were happy to have her join us a couple of years ago now. I'm going to hit some housekeeping things and then I'll turn it over to her and then she'll cover her portion and then I will take back over starting with TVARs. So before we begin, as always, to access the presentation slides you're going to click on the chat button and you can download the slides from there. We do ask that you only utilize the chat box for that as we do not monitor that. But if you have questions during the webcast then you're going to submit them through the Q&A button down here and we will try to answer as many as possible at the end of the webcast. We also ask that you do keep your questions on topic and then, as always, we will compile all of the questions and Tammy and I will put our heads together and get those answered and probably within a few weeks of this broadcast they'll be available on the Academy. Now you know next week's month end for all of us so it's going to take us a little bit to do that. All right, next to get your CEUs you can access those through the Academy. They're available to download in the transcript section of your MedAxium Academy account. Our team will get your certificate uploaded within one to two business days. Please note you do have to not only register but launch the webinar in order to obtain your CEU certificate. Now that you know you can also listen as a group but you still have to individually launch it and that is an AAPC requirement that we have proof that people actually attended not just register. And then this is a screenshot showing where you can you know click on the webcast that you attended and then this box will pop up and I'll say claim CEU. So that is where that you can do that and then once you claim it you can either view it, download it, print it, whatever you need to do. All right, well I am now going to turn this over to Tammy and she's going to get us started with aneurysms. Tammy, take it away. Okay, thank you, Jolene. So this is our slide. We're going to start out with the aneurysms and aneurysm is defined as a circumscribed dilation or outpouching of the wall of an artery often containing blood clots connecting directly with the lumen or the hollow passage through which blood flows of the artery. Today we're going to look at coding and billing opportunities regarding procedures that are related to aneurysms located in the aorta and the iliac arteries. Next. So an abdominal aortic aneurysm is located in the lower part of your aorta. Sometimes patients with AAAs will present with no symptoms initially and it's very typical to discover these aneurysms on an imaging scan performed for other reasons. Often symptoms aren't even present until there's a medical emergency involving the aneurysms. There are a couple of common ways to repair abdominal aneurysms and one of those is open wherein the patient has a long surgical incision and the grafts are placed to repair the aneurysm. This method typically requires a greater recovery time and it's also more painful for the patient. A more popular method of repair is endovascular repair which is better known as EVAR. Next. Iliac artery aneurysms may be present in conjunction with your AAAs or they may be present when no abdominal aneurysm is present at all. These may also be repaired by open or endovascular method. Next. As you can see, these pictures show different types of aneurysms based upon their location in the thoracic aorta. So you have aortic root, ascending aorta, aortic arch, and the descending aorta. The first three are actually repaired via open method but the descending aneurysm, however, may be repaired by endovascular or open method. Our focus today will be geared toward endovascular repair or TVAR for the descending aortic aneurysm. Next. So to get us rolling, we've made a list of the common acronyms associated with these procedures. If you're still wondering what the heck is the difference between these procedures ending in VAR, just remember that EVAR treats aneurysms in your belly, specifically in the lower abdominal aorta, just above the point where the femoral arteries branch off. TVAR treats aneurysms in your chest or thorax and it's especially suited to treat aneurysms in your descending aorta. That's the part that moves down through the chest towards your belly. And FEVAR is used in the upper abdominal aorta where the renal arteries branch off to the kidneys. Next. So there are just a few tips to be mindful of when reviewing your provider's documentation regarding these procedures. Number one, how was access obtained and how many accesses were there? Did they perform cutdowns or access percutaneously? It matters because that will change your coding options. What is your treatment zone? Providers should clearly identify that treatment zone, which is defined as the vessels that contain the graft. If extensions were placed, where are they? Are they included in your primary graft? Are they separately billable based upon their location? Regarding FEVAR, how many of those visceral vessels are involved? Your celiac, renals, and mesenteric arteries. Also does this graft involve the iliac arteries? It is imperative that you have this information in your note to be able to code this procedure properly. For TEVAR, you must know if the subclavian artery was covered. Code selection is based upon that documentation. And finally, be sure you're capturing all interventions performed outside your treatment zone. Not going to lie, coding for these complex procedures can be difficult. However, by learning the basics and using your CPT book as a guide, they will eventually become easier for you. Next. Okay, so let's dive into EVAR. So there are guidelines, of course, for coding these procedures, and they are very specific. First you need to know if the aneurysm is ruptured or non-ruptured. Then you'll need to look at the anatomical location of the graft. Where does it start? Where does it terminate? What vessels are involved? Is it a tube graft, or are there limbs extending to the iliac arteries? To code your EVAR procedures properly, all this information is pertinent. Most aneurysms are more difficult to deal with, as well as being higher risk. Therefore, your EVAR codes were split out into ruptured and non-ruptured status to capture that extra work, time, and complexity that's associated with these procedures. Decompression laparotomy may be reported, if applicable, with the codes for rupture. And I really can't stress enough the importance of your provider's concise documentation concerning these procedures. Next. So what is the treatment zone exactly? Well, I'm glad you asked. The treatment zone is identified by the vessels that contain the endograft. In this particular illustration, you see that the treatment zone involves not only the aorta, but the common iliacs as well. The limbs terminate in the common iliac arteries. Now sometimes, for any manner of reasons, the docking limbs may be very long and actually terminate in the external iliacs, for instance. In that particular case, the external iliac is now considered part of the treatment zone. So here's my broken record once again. It is imperative that your provider clearly document where the graft begins and where it terminates. That will determine all other decisions regarding which additional procedures may or may not be billable in conjunction with that primary EVAR code. Next. So sometimes, these procedures are performed by providers from two different specialties. And if that's the case, you're going to want to report modifier 62 on the appropriate codes for both providers. Both providers will need to dictate his or her own procedure note. If two providers of the same specialty, for example, two vascular surgeons are participating, it would not be appropriate to use that modifier 62. In this case, one physician would be primary, and the other would be an assistant, and you would bill the assistant's charge with modifier 80 or the appropriate assistant modifier if you're in a teaching facility. There are add-on codes. We have 34713 for a 12-french or larger sheath with percutaneous access. This does include ultrasound guidance, so you would not code 76937. But if you are using a smaller sheath than a 12-french, then you could indeed code that 76937 if all the requirements are met for the code. We have code 34715 for open axillary subclavian access, 34812 for femoral artery cut down, 34820 for open iliac access, and 34834 for open brachial access. All of these add-on codes have an MUE of 1, so be sure and pay attention to the parenthetical notes regarding the associated primary codes. This set of add-on codes describe open artery access with conduit creation. These add-on codes are available not only with the endographs, but also when establishing cardiopulmonary bypass with other procedures. Just note that a conduit must actually be created. If there's no conduit creation, then you don't want to code these for cardiopulmonary bypass. So just a word regarding bilateral modifier 50. Medicare does not always follow CPT guidance. As you can see, there is a conflict with the rules. CPT says report your add-on codes twice for bilateral procedures, but Medicare has an MUE of 1. So seemingly, Medicare will still allow the 50 modifier on these add-on codes. Having said that, always check with your local carrier for proper reporting. 34701 and 34702 define endovascular repair of the infrarenal aorta using an aortic-aortic tube graft. Choose your code based upon whether you have a rupture or not. I'll point out that if the provider performs a temporary aortic and or iliac balloon occlusion, that is included in all the codes for rupture. You would not code that separately. Also note in the description, extensions from the level of the renal arteries to the aortic bifurcation are included. Here are the codes for the aorto-uni-iliac graft. This graft covers the aorta and one iliac artery. Any extensions from the level of the renals in the aorta to the common iliac would be included in the primary code. Should the iliac limb actually be longer and terminate in the external iliac artery, then any extension would not be billable unless it terminated in the common femoral artery. Next, 34705 and 34706 are codes for aorto-bi-iliac bifurcated grafts. This graft has either a main body and one or two docking limbs or a one-piece bifurcated graft. The extensions related to these grafts also run from the level of the renals in the aorta to the iliac bifurcation. Just remember, docking limbs are not extensions. They are part of the main body. As we've talked about already, if the limbs are long and terminate in the external iliac, don't code for those extensions. Extensions would need to terminate in the femoral arteries to be coded appropriately. Basic procedures included with EVAR include imaging, non-selective cath placements, PTA, and stenting within the treatment zone. Next, 34709 is an add-on code that's available for placement of extension prosthesis distal to the common iliac arteries or proximal to the renal arteries. This add-on code is per vessel treated. For example, if your main body device terminates in the common iliac and an extension is placed in the external iliac and the internal iliac, you could report this code twice. It is per vessel, not per extension. Also keep in mind that a bifurcated graft includes the docking limb placement. These would not be coded as extensions. Docking limbs are an inherent part of the main body graft as we talked about earlier. Next, each primary CPT code is clear as to which vessels include the extensions. For example, CPT code 34703 states that extensions are included from the aorta at the label of the renal arteries to the iliac bifurcation. So if you extend proximally above the renals or distally to the external iliac arteries, you could bill an extension. Extensions do have an MUE of 3. Also note if the main body bifurcated graft has a docking limb that extends into the external iliac artery, you cannot bill that as an extension. Your extension would need to go into the femoral artery in order to be reported. This is why provider documentation is so very important. Have that discussion with your physicians and let them know it is critical that they document where that main body graft and the docking limbs begin and terminate. It is the only way these procedures can be coded properly. So these are the codes for delayed extensions, meaning that these are placed at a different session than when the primary device was placed. Code 34710 describes the initial vessel extension, and 34711 is an add-on code for each additional vessel. Next. Other add-on codes to be used with EVAR. 34808 is for an iliac occlusion device. Primary codes are listed there for you on the slide. 34813 for placement of a fem-fem graft during EVAR. Do not report the regular fem-fem bypass codes with your EVAR. This add-on code was created specifically for fem-fem bypasses. As an additional procedure to be used with your EVAR procedure codes. Every now and again, our providers need to anchor or secure that new graft to the vessel so that it doesn't slip. And for those instances, we have CPT code 34712. Transcatheter, excuse me, transcatheter delivery of enhanced fixation device to the endograft. This is the code for all the anchors, screws, and tacks the provider may use to actually set that graft. You're going to report this code only once, regardless of the number of anchors used. As I mentioned earlier, if decompression laparotomy is done in conjunction with a ruptured abdominal aneurysm repair, then you can report this 49000. Open access is separately reportable. We covered this in an earlier slide. As is extensive repair of an artery. And in this case, if the repair is done and you had coded 34812 for the open access, then you're going to drop that code and just apply the arterial repair code. And we'll note here, if that repair occurs on only one extremity, but open access code 34812 was utilized for bilateral extremities, then you would then use modifier 59 or excess for that other extremity. Cath placement, cath placements outside the treatment zone, IVUS and intervention outside the treatment zone are all additionally billable. So sometimes an endovascular repair is attempted, but it's a no-go, and it has to be converted to an open procedure. So for those cases, you would choose your code according to the type of procedure. You could also use these codes if the patient had a prior EVAR that failed, and then they had to be taken back for open repair. Okay, so we have a case example here. We have a 76-year-old male with greater than 9.3 centimeter infarenal abdominal aortic aneurysm with extreme pain. The appropriate lines were placed. The patient was intubated, prepped, draped. All this is pretty normal stuff. Ultrasound was used to percutaneously access the bilateral common femoral arteries. An eight French sheath was placed on the left and a ten French sheath was placed on the right. Then they did perclose. A calibrated pigtail catheter was placed via the left side into the abdominal aorta. Angioconfirmed the presence of that AAA. The renal arteries were patent and marked and then that eight French sheath was exchanged to a 12 French sheath on the left and the main body graft, which is a bifurcated graft, was placed via the left sheath and deployed below the lowest renal artery. Attempt is made at placing the contralateral docking limb on the right and the 10 French sheath is exchanged for a 14 French sheath on the right. Due to stenosis of the right common iliac artery, angioplasty is performed to 10 millimeters followed by placement of the right docking limb. We've got the measurements there and that is the end of that note. So for this first case example, excuse me, our codes would be 34705 for that EVAR by Iliac for other than rupture and 34713 with a 50 modifier for our large 12 French or greater sheath. Okay. Iliac aneurysms. CPT codes 34707 and 34708 describe endovascular repair of an iliac artery by deployment of an ilio- iliac tube endograft and following suit, following suit, these codes are dependent upon the presenting situation being other than rupture or rupture. IBE or iliac branch endoprosthesis describes a bifurcated graft that attaches to an aorto graft. The IBE has a main body in the common iliac and then it branches into the internal and the external iliac artery as you see here. IBE codes are defined as to whether they're placed at the time of an aorto iliac endograft. 34717 is an add-on code. This procedure is coded when it's performed at the same session as an EVAR placement. It includes your target zone angioplasty and stenting. All cath placements in the treatment zone are bundled as well as radiological supervision associated with placing this graft. It is a unilateral code so if it's performed bilaterally you want to report that code twice. It does have an MUE of 2 but if your payer wants modifier 50 again that's fine put it on there. 34718 is coded when the IBE graft is not placed at the same session as your aorto iliac endograft. Also this code is for other than rupture. Pay close attention to the parenthetical notes in CPT. If there is a rupture and you're placing an isolated IBE graft then you're going to report a listed code 37799. For fenestrated endovascular repair of the visceral and infrared aorta or fever. CPT clearly states do not report this code with 34841. Oh I'm so sorry I think I've skipped one Jolene. Let me go backwards. Okay. Okay sorry about that. So for fever the device is either in the visceral aorta alone or in combination with the inferrenal aorta. The fenestration or holes are within the fabric and allow placement of an endoprosthesis with either a bare metal or a covered stent to maintain flow to the particular visceral artery. These grafts are patient-specific and they're made to match their individual anatomy. 34839 is the physician planning code. This code is used to report physician planning and sizing for the fenestrated graft and the planning includes review of CT scans, CTA or MI scans. This information is vital to the provider of course. They use it to model the device for the patient with multi-planar views. CPT clearly states do not report this code with 34841 through 34848 when it's performed the day before or the day of the procedure. Next. So there are two groups of codes for fever that are based on how much of the aorta is involved. The first set 34841 through 34844 involves the visceral section of the abdominal aorta and these endografts terminate in the aorta. The second set 34845 through 34848 involves the visceral and inferrenal abdominal aorta and these grafts terminate in the common iliac arteries. The code structure is basically identical on both these sets of codes. Here's a closer look at the CPT codes available for fenestrated graft repair of the visceral aorta. Again these grafts do terminate in the aorta. 34841 describes repair of the visceral aorta with one visceral artery. 34842 is for two visceral arteries. 3 is for 3, 4 is for 4, and so on. These grafts include all imaging and all target zone angioplasty. Also if two providers from different specialties such as a CT surgeon and a vascular surgeon perform these procedures together, these codes will have to be billed with that modifier 62. CPT codes 34845 to 34848 describe endovascular repair of visceral and inferrenal aorta and these endografts terminate in the common iliac arteries. Your code choice will be based upon the number of visceral arteries involved as you can see here. For all FEVAR codes, imaging is included as well as your target zone angioplasty when performed and again if two surgeons of different specialties are involved in the procedure, that modifier 62 will be appropriate. Okay, do not code for extensions that terminate in the inferrenal aorta when billing 34841 through 34844 and do not code for extensions that terminate in the common iliac arteries when billing 34845 through 34848. And like EVAR, proximal extensions are not separately billable with FEVAR. So what is separately billable with FEVAR? Those are included here on this slide. Distal extensions that terminate in the internal iliac, external iliac or the femoral arteries. There's that code there for you 34709. Catheterization of the hypogastric arteries or arteries outside the target zone. Vessel access codes listed there for you. Extensive repair of an artery or other interventions outside the treatment zone. That would be your angioplasty, stents, embolizations, etc. Okay, so we have another case example here for FEVAR. We have an 80 year old male who presented to the hospital with abdominal aortic aneurysm measuring 10.5 centimeters and there's also severe renal artery stenosis. Patient was under general anesthesia. He was prepped and draped of course. Percutaneous access to the left and right common femoral arteries was performed. Sheaths were placed bilaterally. Patient was administered heparin and redosed throughout the case to keep the ACT greater than 300. Pretty standard stuff. Closure devices were deployed in each common femoral artery followed by placement of a 12 French sheath on the right and a 16 French sheath on the left. Tour guide was placed into the visceral aorta and selective cath of the left renal artery was performed. Selective angio confirmed left renal artery stenosis that was predilated and this was followed by placement of a stent. Next, the tour guide was used to selectively catheterize the right renal artery. An angio was performed and then a stent was placed in the right renal artery. Next, they did abdominal aortogram and then they deployed the graft with good positioning. The balloon was used to profile the newly placed graft and then they went in and aligned that graft to the left renal artery stent. A laser was used to create a fenestration in the graft and access to that left renal artery was successful. And I think he kind of repeats himself here. Predilatation was then performed of the balloon. Stent was positioned through the left renal artery deployed with good positioning. He extended that proximally so that it protruded into the aorta. Then he goes in, he aligns the right renal artery stent, goes in with the laser, creates the fenestration in the graft, does predilatation, does the stent in the right renal artery and deploys that without difficulty. Okay, then he goes down and he does pelvic angio, marks the right internal iliac artery on the screen. He selects a iliac limb and advanced into the ipsilateral gait and deploys that through the right common iliac to the right iliac bifurcation. Then he does the angio again, accesses the contralateral gait and deploys through the left common iliac artery to the left iliac bifurcation, profiles that whole graft, does bilateral intravascular ultrasound, demonstrated widely patent iliac limbs with good distal seal. Okay, that was a good one, long one. Next, your code for the second case is going to be 34846 for the fevar, visceral and infrarenal aorta including two endoprostheses. 34713 bilateral for that 12 French sheath or larger. 37252 for ibis and 37253 for your additional ibis. Okay, and having said that, that is going to do it for me and I'm going to turn this back over to my esteemed colleague Jolene Bruder. Take it away to finish up your part of the presentation. Thank you, Tammy. I really appreciate it. That's a lot of information and so I'm going to pick up with the TVARs and all these acronyms. So, when it comes to TVAR coding, we have, we basically have two choices. We either have that the subclavian artery was covered or it was not. So, as you can see, you know, in this picture, they've passed the subclavian. They're actually up to the carotid and that's been covered. There's actually been a graft here to keep blood flow to that part of the head. And then the other thing about the TVAR that makes them more unique than the EVAR and FEVAR is you can still bill for the radiological supervision and interpretation codes. And I've seen a lot of audits where that's getting dropped off. And so, be sure, you know, I always recommend, you know, have your CPT book open when you're coding these. There's so much information in the guidelines and in the parenthetical notes and all of that. So, for this one over here, the subclavian is not covered. Now, you do have to know your anatomy because sometimes, very rarely, are doctors going to use this language. They might, but usually they'll tell you where they terminate. So, you have to keep in mind, if it's actually terminating all the way by the inominant, then that means the subclavian is covered because you had to pass the subclavian to get to the inominant. So, keep that in mind. And I say that especially for newer coders because it, you know, if you're looking for that specific language, it's not always there. So, what else is billable? Well, with TVAR, we can code proximal extensions past the initial extension. It also has an SNI code of 75958. You have an initial extension and then you have each additional. And we're going to talk about more about these proximal extensions in the next slide as well, but keep in mind they do have the 33884 has an MUE of 2, so basically you can code up to three extensions. Now, so again, you can be working this way, but if you're going descending at the time of TVAR, you cannot code for those extensions. If, you know, that it's placed and then they decide they need to add one later at a different session, then you can bill the 33886 and that's for a delayed. So, that's after the initial TVAR was placed. It also has an SNI code and it does only have an MUE of 1, so it really doesn't matter how many distally they placed at a separate session. You can only bill it once. There's also a code for the open subclavian to carotid artery transposition that's performed in conjunction with the TVAR by neck incision. Sometimes these are actually done prior, but note that that's what they're doing it for, is for the TVAR. And then also you can have bypass graft other than vein with transcervical retropharyngeal carotid carotid that's performed in conjunction with the TVAR. Again, do not use any of the the regular carotid carotid bypass codes for that. This one is specific for TVAR. So, back to these proximal extensions. So, keep in mind, again, you're working towards the aortic valve, basically, if you're thinking you're coming up the arch with the extensions. And again, you can code up to three of them, but keep in mind, if those extensions end up covering the subclavian artery, then you're going to drop all those extensions and convert your code to the 33880. That's very important. So, again, and I know we stress this, we sound like broken records sometimes, your physicians have to be very clear on what's going on, and if they're not, then they could be losing out on, you know, because obviously the RVUs are higher for covering that subclavian than it is without. So, they need to be specific. So, things that are included in the TVAR is introduction, manipulation, deployment of the graft. That's pretty much the same as the other procedures. Any balloon angioplasty and or stent deployment within that target zone. So, again, wherever that graft is contained, whether it's before or after device deployment, that's included. And then, again, those distal extensions are not billable at the time of graft placement. So, what can you bill? Well, you can bill all the access codes that Tammy covered in great detail and with the EVARs and FEVARs. Also, we can code cath placements, including non-selective. So, the 36200 can be billed with the TVAR. Also, you can bill for IVAs. Extensive repair of the artery is also separately billable, but again, just like, you know, if they start off with that femoral cut down of the 34812, and then they end up doing an extensive repair, you're going to drop the 34812 and code the extensive repair. Also, other interventionals performed at the time of TVAR. So, if they happen to do an ominate, carotid, subclavian, visceral, or iliac artery angioplasty, or stenting, or embolization, that is separately billable. All right, so let's talk about this new guy. So, this is the thoracic branch endograft, or also known as a TBE. It is supposed to have a code next year. So, that'll be nice because it's, you know, there's been a lot of, by the way, this picture from Gore, there's been a lot of discussion about how to code these, and there are some school of thoughts out there from the vendors that say you should cover, you should code with the, cover in the subclavian, and then also code like the 37236 for the stent in the subclavian. Well the SBS which is Society of Vascular Surgeons, the STS which Society of Thoracic Surgeons, and the AMA recommend the unlisted code and crosswalk to the 33880. We at Medaxium follow the AMA guidelines. We don't follow vendors and so we you know and plus the two societies also believe it should be coded as unlisted. So that's what that is our recommendation. Now this does include placement of the graft, introduction, manipulation, positioning, again that balloon angioplasty, pre and post, anything that's done within that that treatment zone. But it is kind of a neat little gadget and again this stuff is you know it's still evolving and there's still a lot of new technology coming with us. So along with that unlisted code, you can still code the access, your cath placements, if they do any extensive repairs to the arteries, that transposition of the subclavian to carotid or the carotid carotid, that's all separately billable. Your proximal extensions again your proximal extensions again can be billed. Now keep in mind you're probably going to have to appeal because some of this you know a lot of the carriers are not going to consider your add-on codes to go with an unlisted. So that's just going to have to be something that's appealed and fought with. Also they recommend fluoro guidance of 75756. You know if we were billing just the subclavian it would be the 75956 but that only adds on to the 33880. So you can't use that SNI code with the unlisted. So this is the recommendation for that 75756 for that deployment of that graft. Also as always other interventions that are performed outside of the treatment zone are also separately billable. Okay so now I'm going to talk about open aneurysms as well. So again this is for the open repair of TAA which is your thoracic aortic aneurysms. Now they divide the aorta. You have your ascending area. This is the root the aortic root. This is your arch and then here's your head and neck vessels coming off of that. So here's your subclavian carotid anominate that breaks off into the carotid and the brachial spallum. And then we have oh I'm sorry the anominate and then the carotid and subclavian. Then you also have your descending thoracic aorta. So what we were talking about before and I did not have any cases to share with you or put in this but keep in mind sometimes you're going to have a whole bunch of people performing these procedures because you might have a vascular surgeon coming in here to do the tvar and then your CT surgeons could also possibly be doing um part of the arch or a hemi arch or the rest of the arch and the ascending. Sometimes you'll see it referred to as like elephant trunk procedures that type of thing. So and when that happens that's a person that has a lot going on obviously. So when you run into the biggest thing with coding all of these is if you if you stop and think about you just break down each section as it's going and um you know a lot of times if you have the capability print the op report off because it's you know they can get very detailed they can have a lot going on and you know a lot of time and I is you know I'm going on 25-30 years of doing this and there's times I still print off an op report and go line by line just to follow what's going on. And then you know then you plug it into your uh your coding um software and and find out you know what bundles what doesn't and all that good stuff. But again that's when I have my book open I'm looking at my parentethicals what can I build with this what bundles with that and all of that. So don't let them scare you just take it line by line. All right so first we're going to talk about the ascending aortic graft dissection and this is a fairly new code they split them out and there used to just be ascending aortic graft codes and now they split it out a dissection versus just an aneurysm. So a dissection is obviously very serious well they're both serious but a dissection is that aorta is actually starting to split and um you know and it'll start linking. So these are these are normally done emergent um because that's when you know as Tammy said a lot of this stuff there are no symptoms for you might have chest pain or some people might even think they're having heartburn or whatever the case might be but it's a lot of these are found because of something else. All right and then this one is just your standard ascending aortic graft replacement this does include valve suspension and this is performed for aortic disease other than a dissection. So you might see aorta ectasia as a diagnosis but this is just your standard aneurysm where it's not it's not dissecting itself. So then we have the bental and there's all kinds of things going on with the bental. So not only are they treating the aneurysm or dissection notice I said that it's not the picture but it could be either. So they put in this graft they sew buttons which um actually this is basically the coronary arteries is what they're sewing on here because you know your coronary artery run into your aorta. So uh what what happens is when they have to when they have to replace that root and then put in a valve so this is your new heart valve and it's sewn to that graft it's all one piece it's a conduit it's a valve conduit is what they call it. So once they place that in there they have to sew the arteries back on to this graft so that you know we can continue blood flow. Now keep in mind a bental is a bental is a bental. If it is done for dissection that well first off the description of this code does not separate between dissection or aneurysm. It just says ascending aortic graft with cardiopulmonary bypass with aortic root replacement using a valve conduit. So if that's what's being done that's what you have to code. Now if it is a dissection they do recommend that you add a 22 modifier because obviously a dissection is you know there's a lot more going on with the dissection than there is just a standard aneurysm. Okay now with the David or Yakub you sort of have the same scenario except for they're not actually replacing that valve. They're going to repair the valve as it's called a valve sparing aortic root remodeling. So what they do is they'll attach that conduit onto the valve. So again you know you'll you'll see where they they're sewing the arteries back on to it. So um the Yakub is actually A and B and then the David is on the right. And you might see it called I probably see more Davids than I see anything. But um just keep in mind if they're not replacing the aortic valve and they're doing a root um they call it that valve sparing root replacement then you're going to code the 33864 because they're actually using the patient's actual valve. And then in the Benthal they're putting in a prosthetic valve. So that that's the two big differences. All right so now we have the Hemiarch and the Hemiarch um has some rules with it. And um but basically it's replacing the underside I call the aorta those of you listen to my webinars for a long time um you know that I often refer things to food. So I look at the aorta as a candy cane because that's what it reminds me of. So if you're repairing the underside of the candy cane that's where your Hemiarch comes involved. A total arch has taken the whole thing off and we'll cover that in another slide. But um the Hemiarch is just going you have to go at least under the anominate. You have to go that far and um you either have to have um total circulatory arrest or isolated cerebral perfusion and then you cannot use a cross clamp. So and this is spelled out more on this slide here. So again they have to do a beveled anastomosis into the arch but if they use a cross clamp it's not a Hemiarch. Now sometimes in the dictation and again you have to pay close attention they'll start off with a cross clamp and they might do the ascending portion first. Then they'll remove the cross clamp do their beveled anastomosis and do that uh cerebral reperfusion or perfusion and and that can be retrograde or antigrade on that cerebral perfusion. Um and then they'll remove that clamp go ahead and do that beveled anastomosis and then um you know sew that all together and then it is a Hemiarch. But if they only leave the clamp on and then it's not and you cannot code for it. All right so now let's talk about the total arch. So this is where you have an arch aneurysm and um it can be done this way where they they just graft it's like one big piece or sometimes they'll cut off um they'll see a dictation such as like an island pedicle and they'll they'll separate the head and neck from the top of that aorta put in a graft and then sew it back together. So it just kind of depends on you know this is probably more popular now than this but um it is a total arch replacement. Now again a few years ago when these codes first came out they were not allowing us to code the ascending um aortic repair with the transverse arch which created a multitude of problems. But um the STS and and others went back and said hey that was not the intention of this you know these can all be performed at the same time. So now um they um because basically I think at the time there was confusion and you know the AMA and that was coming back well well you get the hemi arch and the STS was like well wait a minute we're doing more work than a hemi arch when we're replacing the total arch. So long story short they won their their case and now it can be coded. It does bundle however and does require that you um you know you have a modifier but just make sure you're not charging a total arch if they're only doing a hemi and for god's sake make sure that you know and vice versa make sure that you're billing the more extensive repair if that's what's being done versus just the hemi arch. And then this is the descending thoracic aorta um this really isn't done too much anymore because of the t-bar but um just note basically they they cut open the aneurysm they place that graft in and then they sew it all back up and they have that graft in there and which basically goes around the aneurysm well it goes through the aneurysm basically. So um but like I said those aren't really done as much anymore with the advent of the t-bar. And then we also have the um thoraco-abdominal aneurysm repair. Now this is major this is somebody that has a very diseased aorta so their aneurysm um runs all the way down to um through the the visceral area into the infernal abdominal aorta. So this is a obviously major incision um and a major graft. I honestly haven't seen these done in a long time either but um they are they can be done and it is a major and very dangerous operation. All right so let's talk about open uh triple A's and sometimes people don't qualify for the e-bar or the um fee bar you know and for whatever reason their anatomy is not going to be good for it or maybe they're conditioned um regardless um but they are they are still performed and basically again you know they've they've cut open the aneurysm placed in a tube graft sewn it back in and then closed everything back up. And as Tammy um noted earlier I just this is just a repeat slide if an attempted e-bar was followed by open repair then you're going to use these codes not the regular triple A codes. And this is the same if you know if they did an e-bar and six months later they come back and they're like hey this isn't working and and it's failing then and they decide to do that open repair then again you're going to use from this set of codes. So these are for people that have had an e-bar or at least an attempted e-bar. Now I did not list out every aneurysm um code I basically hit the the ones in the abdominal area because that's mainly what we're talking about here today. So um we have the direct repair of an aneurysm pseudoaneurysm so keep in mind it can be a false aneurysm or excision and graft insertion with or without patch graft for aneurysm and associated occlusive disease. So when they have an aneurysm and they also have occlusive disease and they're only working in the abdominal aorta your code will be the 35081. Now keep in mind those grafts you know that I think the one I just showed you was just a it was a tube back here right here um that was just the tube but they can actually have like a bifurcated graft um that's also placed and I'll tell you about what the kind of the difference is on whether or not your viscerals and and your iliacs are involved. Um what they're talking about when but for god's sake don't use the um what is it the aorta bifemoral graft and do not use that for open aneurysm repair because then again when you're talking about an aneurysm that's more difficult than just your standard occlusive disease. So make sure you're in the right area when you're when you're going to code these don't just look and go oh they put it in an aorta bifem graft so I should that's the one I should code but don't code these by the device type code them by where it is what it is and how they're fixing it. Um again these codes for years have been split out between ruptured and non-ruptured so again if it's ruptured um you would use this code. Now if it's involving the visceral vessels that means that you know there's uh the visceral vessels themselves are also aneurysmal. Um so that's when you would have the 35091 and then 35092 if it's ruptured. Then we have whether or not the iliacs are involved so again this is so if you think of the um the case that um or you know when Tammy was covering the the IVE graft with the EVAR it's the same situation the only difference is now we're doing this by open repair not the EVAR with the with IVE. So this would be a graft that where when when you're using this 35102 that's because the iliac vessels are also aneurysmal. And then again it's ruptured and non. All right so I have some cases here. So for our first case we have a 67 year old with aortic disruption. The plan is to repair with an endovascular graft. Notice that you know they're calling this a tag you'll see that sometimes they'll call them tag grafts or gorge or whatever but that will usually alert you to the fact that it is going to be a t-bar. So for this patient they have percutaneous access was obtained of the right femoral artery and then they secured that with a five front sheath and then percutaneous access was also secured with the left femoral artery and then they went on with um to an eight eight front sheath. All right so they brought up a Berenstein catheter from the left femoral approach so they were down here in the left femoral area and they're bringing that that graft up through here into the thoracic aorta and they're up here in the ascending. We are going to code the 36200 and then the catheter was exchanged out for a Lundquist DC wire. And then on the right side, they brought up a marker omni-flush catheter and connected that to a power injection. So again, we have another 36200 because we have two accesses and we have two cath placements that are in the aortic. Next, they brought in an 18-front sheath of the right femoral approach under fluoroscopic guidance. So we're gonna code that with the add-on code 34713. And then they did an angiogram centered on the arch and the LAO projection and brought that stent graft up. It was 21 millimeters by 10 centimeters long. And then they did a contrast angiogram and positioned the stent graft distal to the subclavian artery. So that means they're, so here's a subclavian and they're actually distal. They're distal from it, so they didn't cover it. It's a distal. So for that, our code would be the 33881. And then of course, don't forget your SNI code, the 75957. The graft was deployed without any shift and then they brought up a trilobe balloon and did angioplasty of the proximal and distal attachments. You do not code that because that's within that graft, that T-bar, I'm sorry, no. It is a T-bar, sorry. But it's included because you're in that graft, you're in that treatment zone is what I was trying to say. All right, so our final code is the 33881 because we have the stent graft that did not cover the subclavian. We have the 34713 with the percutaneous access with that 12 French or greater. And then we have the 36200 with a 50 because we have bilateral calf placements from the femorals to the aorta. And then we have our SNI code of the 75957. And again, 26 modifier because we don't own that equipment. So our next case example, we have an ascending and descending aortic dissection with aortic insufficiency. We have a repair of a type A aortic dissection, a BENTOL procedure using a 25 millimeter mechanical valve and a 26 millimeter VascuTech gel weave Valsalva graft. They did a right axillary cut down for the right axillary artery access. And then they did selective anti-grade cerebral perfusion with deep hypothermic circulatory arrest. So they did a cut down below the right clavicle followed by dissection of the pec major down to the pec minor, followed by identification of the axillary artery. Proximal and distal control was then achieved followed by administration of 3000 units of heparin. After the clamps were applied, an eight millimeter graft was then sutured in the side. The graft was de-aired and proximal and distal control was then released. The arterial line of the cardiopulmonary circuit was then connected to the graft followed by checking of the graft for arterial flows, which was noted to be adequate. So we're gonna have add-on code 34716. So then they went and made an incision over the sternum and prepped the patient, got them on bypass and all that good stuff. The dissection was then extended into the non-coronary cusp and into the right involving the right coronary as well. At this time, decision was made to perform a BENTOL procedure since re-approximation of the dissected layers was not feasible. And also the sinus of Valsalva was found to be aneurysmal and extremely thin. Once the coronary buttons were fashioned, the valve was then sized after the pledget sutures were put in place in the aortic annulus. The valve was sized to a 25 millimeter X-mechanical valve with an attached conduit of 26 millimeter Valsalva graft. So that's letting you know that it's a valve conduit, plus they called it a BENTOL, but sometimes you don't get that lucky. So these are terms you can look for. And keep in mind too, with the David and the BENTOL procedure, you don't code anything else with that aortic valve, it's included. So whether they're sparing it and repairing it, making it that route, which would be the David procedure, they're enlarging, they're doing that route remodeling with the David. With the BENTOL, they're actually replacing a valve, but with the other ascending aortic code or even the dissection, if they need to separately replace the valve, you can code for that separately. But if it's actually attached to the graft, then it's a BENTOL. So keep in mind that sometimes you will see where they may just put in a graft for the ascending aorta, and they might even do a hemiarche and then turn around and replace the valve separately. But if it's all together in one graft, then that's the BENTOL. All right. So then patient was returned back to the sinus rhythm. And... I'm sorry. It's like there's a page missing from my... From the slides. I'll have to get that added. Double-checking the next slide. Sorry. Oh, there it is. Sorry. All right. Chest tube was put in place. And at this time it was partially closed by removal of the graft on the right auxiliary, which was clipped and transected. Yeah, there's a whole slide missing. I apologize because they actually did a hemiarche with this as well. So I will get this fixed. And when we get that uploaded to the academy, we will have the correct, the full thing in there. But there was actually a hemiarche that was also done with those. So there should have been a slide in between. All right. So our answers for this is the ascending aortic graft with the aortic root replacement using the valve conduit. We also had an aortic hemiarche and then they did the open auxiliary subclavian artery exposure with creation for that conduit. And that was to establish cardiopulmonary bypass. Okay. So our final case example, we have an aberrant right retroesophageal subclavian artery aneurysm. And then this is all the big wishlist here. So they did an open right subclavian to right carotid artery transposition percutaneous access of the right femoral artery through a 20 front sheath, IVAS. They also inserted left arm brachial artery catheter, basically an art line, selective cath placement into the subclavian, TVR of the descending thoracic aorta, and then radiological supervision and interpretation, and then transcatheter placement of the left subclavian artery stent, that gore TBE. So this is an actual TBE case. And it's a 49 year old lady. Let's see, workup reveal compression on the esophagus due to aneurysmal aberrant right subclavian artery. She's brought to the OR for right subclavian carotid transposition and TVR to exclude the aberrant right subclavian artery. All right, so let's get into this. So right supraclavicular transverse incision was made, dissection was carried through the platysma. The scalene fat pad was divided and swept laterally. Hold on, sorry, I just lost my place. Anterior scalene muscle was divided using electrocarotid exposing the right subclavian artery. The left subclavian artery was dissected proximal to the internal mammary artery and vertebral artery and controlled. The carotid sheath was entered in between the heads of the sternocleoid mastoid muscle. Common carotid artery was dissected free of surrounding tissues and control. The patient was systematically heparinized. Subclavian artery was clamped and divided and about one and a half proximal to the vertebral artery. And the proximal subclavian stump was over sewn. And then the common carotid artery was clamped, arteriotomy was made and the subclavian artery was transposed to the carotid via an endocyte anastomosis. So they've transposed the carotid and the subclavian together. Next bilateral femoral access was obtained. Ultrasound guidance followed by a five front sheath on the left and seven on the right. Then they also came up with the IBIS catheter and additional heparin was administered. And then they did IBIS of the aorta was performed to assess the patency, integrity and extent of disease. IBIS measurement of the proximal landing zone between the left subclavian artery and the origin of the left carotid artery was 24 millimeters. IBIS measurement of the distal landing zone was three centimeters above the celiac trunk and that was 22 millimeters. So we have 37252 for the IBIS and 36200 for the right side of the access for the... I mean, you don't have it right and left aorta but this was talking about, I put that on there for the access. So pigtail catheter was inserted then through the left femoral access site and advanced to the ascending aorta. The aortagram was performed, arch vessels were marked. So again, now we're on the left side. So we have the 36200 from the left access. Left brachial access was obtained under ultrasound guidance with five French sheath. Wire selection of the left subclavian artery was performed and then a long five French sheath was placed in the subclavian artery reaching its origin. You do not get selective cath here because you're ipsilateral from the brachial artery. So that's not selective. So it basically came from the brachial right there. So that's ipsilateral side coming in. Okay, IBIS catheter was exchanged for a 24 or 20 French dry seal sheath over a curved lungwis. A long jag wire was inserted into the left subclavian via the brachial and then advanced into the descending thoracic aorta. So now it is actually in a non-selective part of the aorta. You know, the aorta itself is non-selective. So you do have an additional 36200 but you're probably gonna have to appeal that. It does have an MUA of two but it also has three for clinical date of service. So just note, you can code for it three times and then you're probably going to have to appeal and prove why. All right, so next they put in the Gore tag TBE graft and that was selected as a proximal endograft and deployed at the distal edge of the bovine trunk orifice via the lungwis and jag wire covering the origin of the left subclavian artery as well as the right apparent subclavian artery distally. So again, they're covering the subclavian and then that stent was advanced into the proximal left subclavian artery through the portal fenestration of the main body graft. So they come up through that main body and then place that stent. So again, because it's a TBE graft and then they did balloon angioplasty after and that's included. But since it's a TBE graft, we are going to code that with the unlisted code. So you're gonna probably have to appeal all of this anyway because you have, you got the unlisted code. So you're gonna have to send in the note the 36200 times three, the 37252 for the IVUS and then that 75756, which is a S&I per the AMA recommendation. All right, so a lot going on in that. I look forward and hope that they do have that new code in 2025. All right, so this is our disclaimer. Basically stating this webinar is not constitute legal reimbursement coding business or other advice. You always wanna check with your Medicare carrier and consult with your practice's legal counsel for coding and reimbursement. CPT disclaimer is that all these codes came from the 2024 AMA CPT book. And then here we are finally, we have some time for questions. Let's see. So one of them is 36245 renal cath placement is used for not jailing off. Can this be billed? I'm assuming that's what the EVAR. Yes, it is selected. That's outside of the zone. With an EVAR, yes. TVAR, no, or not TVAR, FEVAR, no. You don't bill the cath placements with a FEVAR. But with an EVAR, you do get that selective cath. Another question is what code do you recommend to use when a surgeon comes in to open femoral access for access repair after the EVAR is almost done? Little hard to answer this without seeing the full report, but keep in mind, EVARs themselves can be done percutaneously. But if for some reason they had to come in and do that femoral access, they had to cut them open, then that's fine. Then you're gonna code the cut down. Now, if you're talking to specialties, then again, they're each going to have to have their own note and that type of thing. But that does happen. Sometimes even they might even have to come in and do that conduit. For whatever reason, things weren't working well percutaneously, so then they had to do that cut down. And that's fine. You just have to code it appropriately. Now, if they had to end up doing extensive repair to that, let's say it's the femoral, oh, it is. That was your question, sorry. If they have to do extensive repair to that open femoral artery, then again, you won't code the cut down. You'll code for that repair. This code or this question is, and I don't know if they mean T-bar or EVAR. It says what code if the question has TAVR, but I don't think it was a TAVR. It was probably either, I'm assuming it's T-bar or it was converted to open. Then you're just going to code that open descending repair. There is no special codes broke out for that, like there is with the EVAR. But, and keep in mind too, you cannot code for both. You're only going to code what's successful. You're going to code the extensive procedure. You would not code a T-bar and then also code the open if that's what they had to convert to. But the recommendation is if they started off as one, you know, if they started off with a T-bar and that didn't work, so then they ended up doing that open descending repair, obviously that is a lot of work. So you're going to definitely want to put a 22 modifier on it. Well, that's saying too, if your carriers actually will pay, I know some of you out there, you have no success getting the 22 paid. Another question for delayed extension has to be on a different encounter or different day. It can be the same day, but it has to be a separate encounter. So if, when they do those delayed extensions, that basically they're bringing the patient back to the OR. It's not in the session of where the graft's being implanted. It's not that same initial. Question is of open subclaving to carotid, transposition is performed before the T-bar. Would you still code the 33889? I want to look at that for sure. Cause I can't remember off the top of my head and it's several slides back. I don't believe they're add-on codes. So you would just code them. If they are add-on, then you're going to want to probably go with unlisted. I don't think they are though, but I'll confirm that for sure when we compile the questions and give you a definite clear. Okay, good question. What's the difference between the TBE and the T-bar? Basically the TBE graft includes that stent. That stent, let me go back and show you the picture. Okay, so see how this all looks like it's one piece. The stent is inside and then they have to go in and unfurl it out. So where an actual T-bar graft itself doesn't involve anything going up into the subclavian. They might do that carotid to subclavian bypass, but there's nothing coming off that graft itself with the regular T-bar. That's the difference. It actually includes the subclavian stent. So that's what makes it different. Oh, here's a very good one. If they're doing BENTOL, but didn't document BENTOL on the report, any tips to look for to know that it's BENTOL? Well, again, because some of them won't tell you, they're not going to be that specific, but you need to hound them. But basically what you're going to look for is anything that talks about a valved conduit, because that valve is sewn to that conduit itself. Also you can look for coronary buttons, but keep in mind with the coronary buttons, it could be a David. So if they didn't actually replace the valve and they did valve resuspension, now you're looking at a David, not a BENTOL. That's probably the biggest tip with the BENTOL is looking for that wording that says valved conduit. And yes, you are correct. Thank you. One of our listeners, the 33889 is reported on case example five. So the final answers for that are, we'll go here. The final answers are 33889 and the unlisted, and the 36200, and the 37252, and the 75756. So also add that 33889. I'd left that off of there, but it was on the, I think the first slide for that case example number five. All right. I got time for one more. If a doc does a repair of the ascending aortic dissection and replaces the aortic valve, would that be coded as 33858 and 33405? That is correct if they do it separately. But if they do it as a BENTOL, then it has to be coded as a BENTOL. So watch out for that and definitely do not, don't break that out. I know some providers out there, they're very upset because a dissection is a higher RBU, but if they're using a BENTOL, they cannot code that out separately. It has to be the BENTOL. But if they didn't do a BENTOL and they just replaced the aortic valve and then did the graft for the ascending aorta, then by all means, yes, it should be coded separately like that. All right. So again, oh, final question here, they have, do we get to see the questions you'll answer after the webinar in the website? Yes. So once we get all the questions compiled and answered, what we'll do is we put that Q&A out there on the Academy. So it's there with the webinar itself and the recording of this. Now the recording will be up there prior to that. I have to fix the slides first and then our Academy team will get that uploaded because I have to get that one case in there. So we'll get that in there and I'll fix that case example five answer sheet. And then once I have those fixed, which I should have done by tomorrow, then the Academy will get the webcast uploaded. And then within a couple of weeks, we will get the questions compiled and answered. And then that will also be in the Academy. All right. Well, thank you all very much. And I hope you have a wonderful day and happy aneurysm coding.

endovascular repairs

open aneurysm repairs

grafts

stents

EVARs

FEVARs

TVARs

ascending aortic dissections

aberrant right subclavian artery aneurysm

billing

cath placements

delayed extensions