Hello everyone and welcome to the webcast will get started here in a few minutes so people have time to log on. Hello again, everyone. If you're just logging on, I'm going to give it about another 30 seconds and we'll get started. All right, so we will go ahead and get this kicked off, welcome, and this will be, let's see, we have this webcast and then we have a couple in November, I will be doing one on lungs and then we'll have our boot camp in December and of course we'll have our final rule. So as we approach midway of fall, I can't hardly believe it, we'll get going here on vascular surgery. So to access the presentation slides, you can click in the chat box, which is over here, and that'll give you the slides so you can obtain them, download them that way. If you're having any issues, just put a note in the question box and we can get them to you. For actual questions, we do need you to click the Q&A. We do not answer any questions out of the chat box. We do ask that you keep your questions on topic and if there's time at the end of the presentation, I will go ahead and answer as many as I can and then whatever I don't get to or if there's not enough time for all of them, and actually regardless, we do still compile them and then put them on the website and you'll be able to get them in the academy. Probably within a month being next week, it's going to be a couple weeks before I get those up and posted. For the CEU certificate, those will be available to view and download in the transcript section on your MedAxium Academy account. Our team will get your certificate uploaded within one to two business days and I do want to make this clear, you not only have to register for the webcast, you do have to launch it in order for us to give you that certificate. So that is an AAPC rule and we can lose our vendor status if we do not follow that rule. So it's fine if you all get together and listen as one, but you have to launch it individually or we cannot give you the CEU. And then this is a screenshot of how you would download your CEU certificate from the MedAxium Academy. Once you log in, you'll click on the presentation and then click on claim CEU, it's right here. And then it will give you a PDF that you can print or download to your computer. And then of course you can upload it to your tracking log on the AAPC website. So today we're going to cover vascular bypass and endarterectomies. We're also going to cover open aneurysms of the lower extremity. We will also be looking at AV fistula creation and then some other miscellaneous procedures that I didn't put on here. And then we'll be diving into some case studies. These are real world and we'll dissect them down and go through that. So let's first talk about vascular bypass graphs and procedures. So when you're billing the bypass procedure, you have to determine where the inflow artery is so that, so that's how you know where you're starting. So if you're starting with a common femoral, that's your inflow artery. And then if the graph goes to the popliteal, for example, that would be your outflow artery. And the next thing you need to know is what type of conduit is used. And we'll get into that specifically in the next few slides. Note that other interventions are reported, but they are only reported if they're done at a different site than the bypass. Because bypasses do include establishing inflow and outflow. So for example, if they do a femoral and arterectomy with your FEMPOP bypass, that is not separately billable. That is included. And I do still see that on audits where sometimes groups will code for both and you can't do that. Okay, so some of our conduit options, we have a vein bypass. So when it's done with a vein, they're talking about the patient's native vein. And usually what they'll do is they'll cut a portion out, tie that off, and then sew it around the blockage in the artery. Now keep in mind, they either have to reverse it, because as you know, with veins, the little valves are, they either have to render them incompetent, or they have to reverse the vein. And the reason why is the vein's job is to bring the blood back up to the heart. While you don't want that happening, you don't want to put it in, you know, where it's in its native state, because then it's going to fight with the artery and you're still not going to have blood flow down to the foot. Note that if saphenous vein is used, it is included, but if they do harvest from other sites, then those may be separately reportable. When we're talking about in situ, that means the patient's vein remains in its native bed. So again, they have to go in and render those valves inside the vein incompetent, so that they won't push the blood back up to the heart. And basically, then they'll just sew that vein in its native bed, they'll cut it off and then sew it to the artery at the spots in order to go past the occlusion. So they don't actually remove it, they don't reverse it, they don't do anything like that, it stays in its native bed. Now there's not a lot of areas that you do that, it's mainly the femoral that you would see that. If they use other than vein, that would be, they could use artery, or if they use a Dacron or Petfi, which is that polytetrafluoroethylene graft, that would be other than vein. Also if they use that cryogenic vein, that's actually coded as other than vein, because that's not the patient's native vessel. So those are usually taken from a cadaver, and so it's not the patient's native vein, so you would not use with vein when they're using that cryogenic. So when a physician's actually doing a bypass, the arteries that are being bypassed are isolated and dissected from their adjacent structures. And then the physician creates that bypass around a section of the artery that's either damaged or blocked, and again when we're talking with vein, we're using the patient's vein, and they can do one of two methods of repair, so again they're either going to reverse it, or they'll render those valves inside the vein incompetent. So they'll put vessel clamps on either side of that blockage, and then they will affix the vein to either in an end-to-side or end-to-end, it just depends on how they're going to do that. But they suture that vein into the artery on the inflow, and then they bypass through a tunnel down to the outflow arteries. So when we're talking about inflow and outflow of the artery, so this first one, we have axillary femoral, so your inflow is the axillary artery, and your outflow is the femoral. So just keep that in mind, that that's what they mean by this. So we have, you know, axillary femoral, femoral, which means they go into both the right and the left legs, and then you have aorta iliac, bialiac femoral, bifemoral, and so on and so forth. And again, these codes continue, I'm not going to, you know, read you all of this on the slide. Biggest thing to note is on the femoral, femoral, that can either be ipsilateral, meaning the same side, so it could be common femoral to the SFA on the right side, or the left, or they're actually going to do a crossover, where they're going to attach, they're going to bypass from the left leg to the right leg, and they'll do a fem-fem, so that's what's meant by the crossover. The other place this can happen is the ilio-iliacs, so keep in mind that that is either ipsilateral or crossover. All right, so next we're going to talk about that in situ, again, we don't have a lot of codes for this because it's really only done in the femoral popliteal area or the femoral tibial area. Again, they're using the patient's vein, its own vein, but it's not excised, it's kept in its native bed, basically. And then if you have an aorta bifemoral bypass using synthetic material, and then if you do one in situ, you have to report two codes. So keep that in mind, you know, because you're, you have to accommodate, you have to account for if they're doing both, it wouldn't be one code. So that, these would be your combination codes, and then they are, you'd have that, like I said, you have that synthetic graft and then an in situ. So the 33539 would represent the aorta femoral vein bypass, and then the 35583 would be for the in situ. And then again, these go on with your, other than, or with vein, sorry about that, with vein. So again, you have the axillary femoral, the graft is coming from the axillary, which is up in your, you know, up in your clavicle area, going into your arm, and then they'll run that graft all the way down to the femoral. 35623 is if they do to the popliteal or tibial, and again, then, you know, these just follow from the aorta to the iliac or biiliac, femoral or bifemoral. So now when we're doing other than vein, again, we have that axillary to femoral, or axillary femoral femoral, femoral popliteal, and again, the femoral femoral can be either ipsilateral or crossover when you're doing other than vein. And then same with the iliacs, they can either be the ipsilateral side or actually crossover. And again, these are just all the codes, I just listed them, but I'm not going to spend time on each one of them. Now we do have an add-on code for reoperation of the femoral popliteal, or femoral tibial, or the popliteal tibial. Keep in mind, this has to be at least 30 days from the first operation, and you know, you can code that with whatever they're doing after that, whether it be if they're using a vein now, or if they're using a pet feed, whatever type of graft they're doing, as long as you're more than 30 days past that, and you're in the same area. These are the codes that you can use that in conjunction with. So again, it's an add-on code, so you have to report it with one of these primary codes here. All right, so now on this 35685, the provider actually will harvest part of a vein, and they'll use it as a patch, and they'll position it and sew it between the distal portion of a synthetic graft, and then also the native artery. Again, this is an add-on code, so you would use it with the 35656, the 35666, or the 35671. For 35686 code, the physician actually creates a fistula during a lower extremity bypass procedure, and then they harvest the vein and sew it between the tibial or the peroneal, and then the vein at a distal bypass from the anastomosis site. That's not done a whole lot. The vein patch and cuff is done probably more often than creating that fistula. So next we're going to talk about upper extremity bypass grafts. Again, with your axillary axillary, it can be the same side or crossover, and then all the rules pretty much remain the same as far as, you know, it's your inflow artery, your outflow artery, your endarterectomies, anything like that is all included. Keep in mind that all of that establishing inflow outflow is included in the bypass. And then we have codes for upper extremity with other than vein, and then this group is with the abdominal group and your viscerals. So you have your hepatorenal, aortosiliac, or mesenteric, and then splenorenal. Again, same rules apply as the others, and then the other side. Then this is the group of codes that are other than vein. And if you don't actually have a code for this, if they're bypassing to a vessel that there isn't actually a code, then it is recommended to use unlisted. Don't try to, you know, some ways like with the axillary and subclavian, those are close enough together, but don't try to use a code that's not actually there. Um, you know, don't try to substitute something that's not exact. So with the carotids, so now we're up in the head and neck area. On the 35501, this is common carotid to internal carotid on the same side. For 35506, it's for carotid to subclavian or subclavian to carotid. So this one can go either way, because usually this is your inflow and that's your outflow. And, but this, this code can be for either one. And this one is ipsilateral only, so you're not going to do this for a crossover. And then we have the code for carotid vertebral. And then, uh, we do have a code for carotid contralateral carotid. So unlike the femorals where you have that crossover and the iliacs, this one actually has its own code for contralateral. So that's if they're sewing from right to left or left to right. And then, um, again, we have subclavian, subclavian, and that one is actually, uh, subclavian, and that one is actually, uh, ipsilateral or crossover. Then again, more codes with vein. Um, and you know, it's just basically breaking that out. And then we have again, other than vein. So, um, the biggest thing about all of the bypasses are, so let's talk about what we can add on. So these are the approved add-on codes. So if you harvest from an upper extremity vein, um, you need to read the parenthetical notes to make sure that you can use that code with your primary code. And then, um, keep in mind, again, saphenous vein is included. And I've seen on some of my audits where, uh, some groups have been billing the 3-3-5-0-8, which is for the endoscopic saphenous vein harvest for a cabbage. Do not use that with our bypass codes. That's a totally different, um, situation. That is only allowed to be used with the, uh, cabbage and not your regular, um, and I don't care how they harvest it. You cannot bill for that with the vascular bypass. Um, again, like I said, make sure that it does add on to the procedure you're doing. And then basically what they do, um, with these is, uh, they'll harvest the vein and they'll split it lengthwise. And then, uh, they'll kind of wrap it in a spiral and suture it around a large, uh, synthetic graft. That's with that composite. And then, uh, if they're doing autogenous composite grafts, they're used to, uh, these codes are to report the harvest and anastomosis of multiple vein segments from distant sites. So that would be your 3-5-6-8-2 and 3-5-6-8-3. So the 3-5-6-8-2 is they're taking two segments from two locations. And then for, uh, 3-5-6-8-3, they're taking three segments of vein from two or more locations. And I do actually have a case example for this. So we'll, um, I'll show you again, or, you know, we'll get into that in detail on, on how that works. All right, so some more add-on codes for the bypass. Again, we have, um, um, you know, these, these upper, or I'm sorry, these add-on codes for harvesting of the upper extremity if they use the femoral popliteal. And again, uh, bypass and all of that. Now what's included? All right, now keep in mind that endarterectomies, thrombectomies, stents, anything like that, that is being done in that vessel that you're bypassing, that's all included in that bypass. If you look at appendix L in the CPT book, and especially if you look at the, the iliac femoral area, the external iliac and the common femoral are actually considered one vessel for billing purposes. Also the SFA and the popliteal are considered the same vessel for billing purposes. Now, when we're talking about interventions themselves, so if, if we're doing, you know, our peripheral, the stents or balloons with the iliacs and the femoral, that's a different, that's a different ball game, because now you're talking where you're billing territories. And the iliac, the external iliac is allowed to be coded as well as the femoral because those are split out by territories. But when you're talking about actual bypass grafts or thrombectomies, endarterectomies, things like that, that is actually considered the external iliac and the external, or the common femoral are considered the same vessel. So you do not code both of them. And I got another example of that later as well. So these are our excision, exploration, repair, and replacement codes. So this group of codes are not done a whole lot. This would probably be somebody coming in the ER and they suspect there may be something wrong and that they open up the vessel and then find out nothing's wrong, so then they sew them back up. They're not done, like I said, they're not coded very often. This set of codes are specifically for post-op hemorrhage, thrombosis, or infection. And then they're split out by whether or not you were in the neck, the chest, the abdomen, or the extremities. Now, usually your chest, your CT surgeons are going to take care of that, but sometimes the vascular surgeons can as well. But again, you have to meet, they have to meet this criteria. So if they're not hemorrhaging, they don't have thrombosis or infection, you cannot build these coats. If they are still within that 90 day global, so keep in mind these are post-op codes. If they're still within that 90 day global, you will probably have to affix the 78 modifier. I do know some carriers don't like the 78 and they want the 58, which personally I don't agree with because I don't feel that it's, you know, they're not normally planned. You don't plan on having hemorrhage or thrombosis or infection. And it's I certainly don't consider it a more extensive version of the original procedure, but you have to follow what your carriers want you to do. So if your carrier allows the 78, great. If they don't, then more than likely they will accept the 58. Okay, so now here we're talking about if the patient has a thrombus of their arterial or venous graft, then you would use the 35875 for removing that thrombus. Now again, we're talking our bypass grafts. We're not talking about the hemodialysis, the AV fistulas. They have their own set of codes, so you would not use these if you're dealing with an AV fistula for hemodialysis. In 35876, now we now we're doing a revision of that graft and that would also include if they, so if they sew on a new piece of graft to the original, and maybe they'll balloon it, all of that is considered revising that graft. Maybe they don't even sew anything and they just put in a stent or a balloon, whatever the case may be. If they open that up, then that would be part of the revision. As far as 35879, that's when you're going to have bypass without thrombectomy, and then they do some type of vein angioplasty, and then 35881 is a segmental vein interposition technique. For 35883, this is revision of the femoral anastomosis of the synthetic arterial graft. Again, we're talking the Dacron, Petfi. It's a synthetic graft, not your vein. For 35884, that would be an autogenous vein patch. This group of codes is specific as well. Keep in mind, you cannot code for excision of a graft unless it's infected. You can possibly add a 22 if your doctor dictates that way and gives you enough information and talks about extra time and things like that, but do not use these excision codes if the graft is not actually infected. If they have to go in and replace an original graft and they take that graft out and it's not infected, that's just considered as part of establishing, preparing the vessels to be grafted. If it's infected, that's a different ballgame. Again, you have a graft for your neck, extremities, thorax, and abdomen. For thromboendarterectomy and thrombectomy, basically the difference is on this one, they're going to cut open the vessel and then they'll use a spatula and clean out all that plaque. When it comes to thrombectomy, they'll usually, they'll cut open the vessel again and then they'll run a catheter and run it through that clot and try to pull that clot out. So that is the biggest difference between the two. So when, again, when you're performing that thromboendarterectomy, they open the vessel, they use a blunt-like spatula tool to clean that out, and then they'll re-sew the artery back together. Now sometimes they have to use a patch to make sure that it closes okay, and that can be a vein patch, you'll see anything that's a patch graft, that's what they mean by that. So once it's removed, patch grafts are performed, they can either take those patch grafts from another part of the body or a cadaver, or they can use synthetic, and then it's sutured to the vessel, and that will enlarge the diameter of that artery. There is a re-operation carotid thromboendarterectomy code, and that is for one month after the original procedure, so the carotid has one specifically for it. And let's see, what else do I want to say about this? Oh, and then there is an add-on code for each additional tibial or peroneal artery that's done. So you have your tibial or peroneal, which is your initial vessel, and then if they treat, so let's say they do the anterior tibial, and then they do the posterior tibial, and the peroneal, you would code the 35305, and then that add-on code twice. So it is important that your physicians are very clear when they do that. When it comes to, I do want to talk a little bit about the SFA, because this comes up a lot too. So when you go in order in the book, the SFA and arterectomy is well above the common femoral, as far as the listing in the book. So here's the deal about the SFA, the common femoral, and the profunda. Unless they do an extensive portion of the SFA or of the profunda, you do not bill these additional endarterectomies. They would all be included in the common femoral. Now, so if they do extensive, they should have a separate incision as well. So if you think about the, if you're looking at the common femoral artery, and you know that it runs into the SFA, if they only go to the orifice of the SFA or very, the proximal, very proximal portion of it, that's not extensive. So you need to have a discussion with your providers that they really need to give you specific details about how extensive, they need to use words, extensive, things like that to help you out. And it should involve a significant length of that superficial femoral artery in order to code it. Otherwise it's, it's counted as a common femoral. And I know they get upset about that. And I know they want to argue with you about that, but unfortunately that's, that's the way that goes. So again, the codes continue. I do want to point out on the iliofemoral. So remember I was talking to you about appendix L. Well, if they do an endarterectomy of the external iliac and the common femoral, that is not coded as iliofemoral. It's only coded as common femoral. And the reason why again is for billing purposes, that external iliac is considered part of the femoral. So unless they're actually in the common iliac and the common femoral, then you could code the iliofemoral. Or of course, if they go into the internal iliac, that would count as well. But if they're in the external, especially if they say distal external and two common femoral, you cannot code the 35355. And again, you know, I pretty much talked about with the deep profunda as well, there has to be significant extensive portion of that deep profunda in order to code it separately. And then of course, you got the aorta iliac and then the aorta iliofemoral. So that one, you would have to have at least the aorta in there in order to code that code. So again, what's included? So if they're doing a thromboendarterectomy, it includes thrombectomy, so you would not report that separately. Patch closure is included, so they don't get anything extra if they harvest a piece of vein for that. And again, remember, endarterectomies cannot be coded for the vessels that you're bypassing. And then embolectomies or thrombectomies, again, that's done with or without a catheter. It is cut cutting open into the vessel. And then these are the codes for carotid by neck incision, subclavian by thoracic incision. Then you have your upper extremity vessels by arm incision. They do all have an MUE of one. So if the physician does an embolectomy, the carotid and the subclavian and the anominate, you would only report that once per side. One thing I want to point out, too, on these embolectomy thrombectomy codes, do not confuse these codes with your peripheral percutaneous interventions of the 37184, the 185 and the 186, because that's percutaneous. These are actually cutting open the vessel. I've seen that done in audits, too, where they'll code the mechanical thrombectomy instead of the open. So make sure that you're paying attention to that. And again, these are, you know, the rest of the other codes, only these are done in the veins. And again, you're not going to use the 37187 in place of these codes because it's actually cutting the vessel open. All right, so now we have repair blood vessel other than fistula. And then again, this is with or without patch angioplasty. Most of these would be considered trauma codes. Um, so you know, something's happened that the patient comes in and they have to have their vessel repaired, whether it be, it can be stabbing, gunshot wounds, it could be car accidents, it could be I fell off a ladder and impaled myself, you know, whatever the case may be. Just keep in mind, this first group is for direct, that means they're just selling the vessel. That's it. No, no graphs, no. You know, whether they be vein or other than vein, those are just a direct repair. Then we have with a vein graft. So we have our code split up here. Now remember back when we were talking about the bypass codes, there is a situation if you don't have if your inflow and your outflow codes are not represented by a CPT code, the Society of vascular surgeons have stated you should either report an unlisted code or you could report, you know, if they're doing the vein graft, then you can say it's an arm and you don't have that inflow outflow vessel code, then you could use this one, same with lower extremity, anything like that. But that kind of depends on how your doctors want you to go about it. And I would have that discussion with them because RVU is probably going to be a little bit lower on this than it is for occlusive. So they may want you to go with the unlisted code. But again, that's a discussion you need to have with your provider. And then of course, we have repair a blood vessel other than fistula with other than veins. So again, they'd be using a synthetic, some type of synthetic graft with that. All right, so now let's talk about some arterial transposition. And basically, this is simply, they're either transposing the vessels or the re-implanting them, but basically, they're simply, you know, cutting off these two vessels and sewing them together. No graft is actually used. So they'll make a small arteriatomy in one vessel and then attach it to the other vessel. It's usually done in an end-to-side method, you know, like this is the side of one vessel and this is the end of the other, and then they're sewing them together. So the first four codes are for the head and neck vessels. Note for the 35694, that's subclavian to carotid transposition, do not use this code with a T-bar. T-bar has its own code for that, so that would be the 33889. I didn't put it here on the slide, but just note, do not use this code with T-bar. And then if they happen to do a re-implantation visceral artery to infernal aortic prosthetic, each artery, you're not going to report that with the 33877. But this would be your add-on code for that. So back in, I think, the spring of this year, Tammy and I covered open aneurysms that involve the aorta and the iliacs. So I'm not going to talk about them today because we covered that with that EVAR, FEVAR, and T-VAR, and then we did other open aneurysms. So this is basically what I'm focusing on is most common for viscerals and then the extremity. So again, this is a saccular aneurysm, this is what they look like, or this can be a fusiform or ruptured. We'll talk about ruptured quite a bit because there's some confusion sometimes with that. So for your visceral arteries, so you have your splenic here, your celiac, and then I can't find it right off the top. Oh, here, here's the SMA. So these are, if you're going to do a direct repair of the aneurysm, they can use a graft. It can be done with or without a patch. Note also the code includes any occlusive disease. So if they happen, if they happen to do a graft of some sort, you know, whether it be aorta splenic, you're not going to use the aorta splenic bypass graft. You're going to use the aneurysm repair because of the fact aneurysm is a much more extensive procedure, much more dangerous procedure. So this has a higher RVU. So, and I probably see this more with the aorta, like the aorta bifem graft. I've seen that build instead of the aorta involving the femorals or iliacs, things like that. So just watch that. Make sure if, if your doctors are documenting an aneurysm, that's what you want to code. This is where you're going to want to choose your codes from. So now let's talk about rupture. So rupture, obviously, if it's a free flowing rupture, then unless that happens in the hospital and depending on which vessel, you know, the patient may or may not make it because they, you know, they're, they're going to bleed out pretty fast if it's a free flowing rupture. Now, then you'll see where your providers will document contained rupture. Well, here's the thing about contained. Is it contained within, you know, like, is it contained within the peritoneal area? If so, um, it's still a rupture, even though it's not free flowing out of that. What you do have to keep in mind contained itself is not enough to call it a rupture. There has to be some type of active bleeding that is seen on a CTA, for example. So again, that free flowing obviously is a rupture, but that's normally going to happen. Um, the repair of that is going to happen if the patient's already in the hospital, um, just because, you know, they're, they'll probably bleed out if it happens outside, not always, but again, it depends on the size of a vessel. So keep that in mind just to see contained ruptures, not enough. A contained pseudoaneurysm is not considered a ruptured aneurysm at all. And remember these codes are used for pseudo, which is false. It's a false aneurysm. And then you, your regular aneurysm. So keep that in mind. Um, let's see what else, anything else I'm going to say about that? No, not really. Other than these are, you know, these are your codes for, we have the splenic, then we have the hepatic, celiac, renal, or mesenteric. And then, um, you also have the code for ruptured. When we talk about the lower extremity, same thing you're going to have, whether it's in the, um, uh, femoral superficial femoral or the profunda, and then whether or not it's in the popliteal and then is it ruptured or not ruptured. So you're, you know, it'd be these vessels here in the leg. All right. So let's move on to hemodialysis access and AV fistula. Now note, um, I'm not getting into the percutaneous, uh, repairs of those with the balloons and stents and everything else, because again, that was covered earlier this year, by the way, just on a side note, you can always go on to our website and into the academy and access previous webcast. And we do highly recommend you do that. Um, if, if they're getting to be older than a year, um, eh, year or two, um, they're still pretty relevant unless there's been a major overhaul in codes, then of course it would be, but, um, you know, you can always go back and, and, uh, listen to our other webcasts too, but anyway, back to this one. And I apologize. This is a blurry picture. So this is showing, um, an AV fistula graft. Now this is being created for hemodialysis. So this is a patient with, um, normally in stage renal disease. And if it's not in stage, it's pretty close, uh, but they are dialysis dependent. So what they do is they go in and they create a graft and they have, um, you know, the blood from the dialysis machine comes into the artery and then it goes through the fistula. And then it goes back out to the machine where it's, you know, um, filtered and then sent back to the bot. Now these grafts can be made of, um, they can either be direct transposed or they can actually use an artificial, um, they'll call them art grafts sometimes, um, that can be used. So all of the codes for creating the fistula, um, I basically have on this slide and the revisions. So when we're talking about, um, uh, the codes three, six, eight, one, eight through three, six, eight, two, zero, these are when the veins are actually transposed to create the fistula. So what they do is they'll, uh, take the symbolic vein, transpose it, which means they flip it. Um, and then they'll run it through a tunnel and then sew it to the artery. You have two incisions with this. So you have the incision where the cephalic vein is, or if you're doing the basilic, or a forearm vein, you're gonna have that incision, and then you'll have the incision for the artery that you're sewing it to. 36821 is direct, and that's any site, and that's where they just simply sew the artery to the vein next to it. That's probably the most common that's done, although I do see transpositions as well. And then we have creation of AV fistula with an autogenous graft, which means it's natural as part of the body, or a non-autogenous, which is, you know, you'll see that art graft. As far as thrombectomies, so remember earlier when I was on the thrombectomy for the upper extremities and the legs, and I said, don't use those codes for the AV fistula, that's because they have their own codes. So you have thrombectomy, which is open without revision, so that's when they just go into the graft, it doesn't matter if it's an autogenous or non-autogenous, they'll do that thrombectomy and nothing else. If they do a revision, they can revise the graft without a thrombectomy, so, you know, they may go in and add to it, maybe cut a portion off, reroute it, whatever they need to do to revise it, maybe they'll do a balloon with that. Again, that's open, that's not your, from the like 36902 codes, none of those, that's all peripheral, this is actually cutting open the graft. Then you have revision of the graft with thrombectomy, so you have thrombectomy only, revision only, or the combination of both. So these AV fistulas that we're gonna talk about for repair, these are either acquired traumatic, acquired traumatic is kind of the same thing, or they're congenital. So this is where, unlike our, let me back up here a little bit, unlike this nice, clean, you know, graft that's here, this is, you know, a big mess. And sometimes as far as congenital, there's an abnormal connection between artery and vein, and this happens with some of the babies in the womb for whatever reason, these vessels do not form the way they're supposed to. Nobody really knows why it happens, but it does happen. And then for acquired, those are normally in the lower extremity, but they can occur anywhere, but a lot of times it has to do with varicose veins, and sometimes you'll develop that AV fistula, or then in traumatic, that's usually caused by some type of piercing of the skin, again, stabbings, gunshot wounds, where the vein and the arteries are side by side, and then they heal together. So again, this set of codes will not be used for your AV fistulas that are created for hemodialysis. So this is other than hemodialysis. Again, we have, they're broke out by congenital, and the acquired or traumatic, and then we have a set of codes for head and neck, thorax and abdomen, and then extremities. And then for this one, we actually have, again, these are the acquired or traumatic, and it's just a matter of same type of repair that's being done. And again, split out by head and neck, thorax and abdomen, or extremities. So now I'm gonna get into some of our case examples. So for this patient, we have end-stage renal disease, that's on hemodialysis. They're doing a left upper extremity arteriovenous graft with a pet fee, or that polytetra, you know, that mile long word. So for this one, we have a 46-year-old gentleman that was recently initiated on hemodialysis. He has a history of IV drug abuse, and is scheduled for placement of an arteriovenous graft of the left upper extremity for permanent hemodialysis. Then we have the description of the procedure. So this right here is kind of our, setting the stage of why we're doing this. And then this, the procedure, and then down here too, in the indications, what they're planning on doing. Now, this is, again, we refer to that as the wish list. And basically what you want is the body of the report should support the list wish. Now, a couple of things I wanna say about that. If it does not, then obviously you're going to code what's documented. That being said, you also need to go back and talk to your provider and say, this is what you actually told me you were going to do in your procedure list wish, or wish list, but the body of the report supports, you know, something else, or it doesn't support everything you listed. You need to have those conversations, because sometimes maybe they left something out, or, you know, they got in there and the procedure totally was different than what they had planned. Whatever the case may be, you need to have that open dialogue with your providers, and you need to be, you really need to let them know how they can improve their documentation, because otherwise they're just gonna keep documenting the way they always have. And I'm not sure if it was Mark Twain, or either Mark Twain or Albert Einstein, I'm not sure which one. I don't think they'll come back and sue me, but basically the definition of insanity is to keep doing the same thing over and over again, and expect a different result. Well, if you're not letting them know that their documentation is not meeting what you need to code, then they're not gonna change. So always keep that in mind. But anyway, back to our case. So this is the hemodialysis with the pet feed graft. So again, this is showing the fistula graft and that it is artificial. This is not a direct, this is not a transposition. This is an artificial graft that is being done. So we have a transverse skin incision was made through the left antecubital fossa, and then dissection was carried down to the subcutaneous tissues. Cephalic and bacillic veins were explored, but they were thickened and chronically occluded and small in caliber. So then they did a deep dissection down to expose the brachial artery, which was four millimeter vessel, kind of strong poles. So then they did a second incision in the left axilla, and a longitudinal skin incision was made through the skin and the subcutaneous tissue. And it was carried down to expose the left axillary vein, which was four millimeters. The vein was freed and encircled with a vessel loop. A curved tunnel was then made between the two incisions and a four by seven millimeter pet feed graft was placed through that tunnel. The four millimeter end approximated to the artery and the seven millimeter end approximated to the vein. Brachial artery was then controlled proximally and distally with bulldog clamps. Longitudinal arteriotomy was made. The graft was bubbled and anastomosed to the brachial artery. And then the axillary vein was controlled proximally and distally. Again, they did that venotomy. Graft was bubbled and anastomosed into side of the axillary vein. So finally, our code is that 36830. I did put the LT modifier. Most of the carriers now want laterality modifiers on any of your vascular procedures. If your carrier does not though, do not start adding them because of this webcast. Do not change anything in that regard, because again, a lot of this stuff is carrier specific. And what happens with one carrier is not necessarily going to be the same with another. So our final code again on this is the 36830 LT, which was a creation of the AV fistula graft non-autogenous. And again, that means it's synthetic. It's not the native vessel. All right. So on case number two, we have abdominal to right profundus artery, left common femoral artery with a 16 by eight Dacron bifurcated graft. And then we have a left common femoral SFA profundus artery endarterectomy with a bovine patch angioplasty. And then finally we have a right femoral to above knee bypass with that six millimeter ring distal flow gore graft. Again, this is the wishlist. And you should also see where, you know, they have estimated blood loss. All of that is standard in your dictation and it should be listed. It doesn't affect you for billing, but it should be in that. And again, you always need a good indication of what we're doing, why we're doing it. If it's not clear, again, that's something you need to go back and discuss with your providers. Because everything that we do that is done to a patient should have medical necessity. All right. So I highlighted kind of what we needed to look for in the procedure notes just to make it faster so I'm not reading everything. So on this one, we had the midline abdominal incision was carried out from the xiphoid down to the pubis. The incision was carried out from the skin down to the subcutaneous tissue through the abdominal fascia. The abdomen was entered. And then the rest of this is just talking about how they're setting the stage and retracting the small bowel and all of that prepping for that graft. So then they did bilateral vertical incisions on the right and left groin. So they're going to, you know, cut into the femorals on both sides. Actually, they're down here. I was up in the Iliacs. So down on, you know, your femoral arteries. Out from the skin through the subcutaneous tissue, the right common femoral artery was exposed from the level of the inguinal ligament and extended down past the SFA. Profundus was exposed for a length of approximately four centimeters. Proximal distal control of the vessels then carried out. Then they performed a left common femoral artery exposure. And that was from the level of the inguinal extended four centimeters past the SFA. Dropping down, the provider then performed an aortotomy between the clamps. And then they use a 16 by nine millimeter Dacron was sized. Proximal anastomosis of the Dacron graft to the abdominal aorta. So they sewed up here to the aorta. That's where they started in this area. And then the proximal anastomosis was carried out. And then prior to completion, the clamps were removed and de-airing maneuver was carried out. And then they brought the limbs through the retroperitoneal into the right and left groin incision site. So they have, so it's basically the graft is going to follow the aorta and then bifurcate into both legs. So then they brought the graft down on each side into the femoral artery. Let's see. Then the right common femoral artery SFA was completely occluded. The distal anastomosis of the Dacron graft to the right profundus was carried out. And then dropping down to the left side, the small arteriotomy was made in the left superficial femoral artery. And at the bifurcation, they extended more cephalon to the left common femoral. Then they perform an endarterectomy of the distal left common femoral artery, proximal profundus, proximal SFA. So for one minute, I want you to think that this was all they did, that they're not doing the bypass. So if that was the case and we were just building the endarterectomy, we would still only code the 35371, which would be for that common femoral endarterectomy because nowhere did the provider say he did multiple incisions in these areas, nor did he state that the endarterectomy was extensive. But now back to this actual case, since we're not doing just an endarterectomy, we're doing a bypass. Yes, I coded it, but I also struck it out because it's included as part of establishing that inflow and outflow for that graft. So dropping down from there, the left Dacron limb was anastomosed to the left common femoral artery. And then prior to the completion of the anastomosis, the bustle loop was removed and de-airing of that graft and also from the femoral bustles. So our code is 35646, which is for that bifurcated aorta bifemoral graft. But also not only did they do the aorta bifem, they also did a femoral to popliteal. So now we have an additional graft. So in this case, they went ahead and did a six centimeter distal medial right thigh incision was carried out. And then the incision was carried from the skin along the vastus medialis muscle. Popliteal artery was exposed from the Hunter's canal to the knee for a length of six centimeters. Again, they did that proximal distal control of the bustles. They sewed in a six millimeter cortex graft, and that was also tunneled sub-saturously between the two incisions. And then distal anastomosis of the femoral to above knee bypass was carried out. And then the proximal anastomosis to the cortex graft from the right femoral. So they're basically, you have your bifurcated graft, which was here, and then they're also adding on from femoral to popliteal. But because that was a separate graft, you're going to code that three, five, six, five, six. And not just the aorta bifemoral, because you have separate incisions, you have another additional piece of graft. So you do get the two codes for that. And then the rest of this is just closing the incisions and everything else. So on this one, I have the three, five, six, four, six. Now, obviously we're not going to use laterality on this because it is a bifemoral bypass. So it means it's going into both legs. And then you'll have that three, five, six, five, six for the right, for the femoral popliteal bypass. And again, these are other than vein. So that's why we use that synthetic code or other than vein code. All right. So case number three, this one we have a patient that is 77. He's had a previous right fempop bypass. He's had two previous thrombectomies. The bypass is threatened. Indication for repeat bypass identified. And then after describing all risks and benefits, incent was given and obtained. Now we're going to code the REopt code, that add on three, five, 700. I know it's not dictated in here. I prefer that it would be, but I do know this is a doctor we actually provide services for. We do his coding and the patient actually had the bypass, the previous bypass was about four months ago. So I know that. And if you can defend that in your medical record, if you can go show, I'll know that the bypass was done more than 30 days, then go ahead and bill it. Keep in mind, if it gets audited, you're going to have to prove that it was done. So if you don't have that proof, then you can't code for that REopt because it has to be more than 30 days. All right. So the full description is under ultrasound guidance and access right internal jugular access wire was placed, CVL placed, secured and sterile addressed. This is all part of setting up for lines and all of that things are included. Next on our ultrasound guidance, microneedle right radial artery was accessed, wire placed, angio cath placed and secured. And then bilateral upper extremity and right legs are confidentially prepped and draped. And then next using a two team approach. I want to talk about this for a minute. I didn't actually, when you get the final answers on this, I did not give the codes for the assistant, but they do have an assistant. And if it's a physician assistant, you would use the AS modifier. If it's an actual surgeon, then you would use the 80 if you're in a non-teaching facility. If you're in a teaching facility, then you would have to use the 82. Keep in mind when it comes to co-surgeries, which would be the 62 modifier, Medicare requires that those co-surgeons are of different specialty. So if you have two vascular surgeons in your practice together under the same tax ID, they have the same taxonomy, you cannot code for both of them as co-surgeon. There is some wiggle room exception to that. And the only thing would really be if, for example, let's say you're doing a bilateral leg amputation, they're doing right and left, and one provider's doing the right and the other's doing the left, then you could have that with both specialties. I probably would just code one under one doctor and one under the other. Commercial, they'll give you a little more wiggle room, but a lot of them do follow Medicare guidance on that. So do not under any circumstance, well, I shouldn't say under any, but unless you have those rare occurrences, you do not code co-surgery with a 62 modifier with the same specialty. So keep that in mind. I didn't put any slides up on that, but I just thought I'd talk to you about it off to the side. All right, so here we go back to our case. So the right bacillic vein was harvested by open approach. Separately, a series of skip incisions were made in the left arm along the course of the cephalic vein, and the cephalic vein was harvested from the elbow to the delta pectoral groove. Next, two encounter incisions were made in the leg, and then a distal incision was made four centimeters above the medial malus. All right, so this is where they're harvesting from two sites. We have bacillic and cephalic, so that's why we have the add-on code, the 35682, because this is going to add on to our actual graft. So this is a good example of when you would code that, but you have, remember you have to have two vessels from two locations or three segments from at least two locations. All right, so then they did dissection down through the fascia. Fascia was incised and the posterior tibial artery was isolated and encircled with vessel loops. Next, a second counter incision was made in the above knee popliteal region. Dissection was carried down to the pet fee bypass, again encircled with vessel loops. Next, tunneling was performed from the SFA to the subfacial from the posterior tibial to the above knee popliteal incision. Systematic heparin was given at that point. Both veins were transected and proximal and distal portions were ligated. Next, the graft bypass was clamped and the graftotomy was made. Bacillic vein was spatulated and the anastomosis was created. Next, they released those clamps. Debris clot was removed from the vein graft. Again, that would be included. That's all part of prepping your outflow vessel. Cephalic vein was spatulated as well as a distal aspect of the bacillic vein. Anastomosis was then created, and again we have some more debris clot removal. That's all part of the inflow outflow. Vein was marked and tunneled. And then next, the posterior tibial artery was clamped, arteriotomy was made, vein was spatulated, and then the anastomosis was created. Prior to completing this anastomosis, they did the back bleeding and forward bleeding to make sure that the graft was working as it should. So now we have the 35571 on the right side. So again, our final codes are the 35571 popliteal to posterior tibial vein bypass. We also had two segments of veins from two locations. They took it from the cephalic and the bacillic, and then we have our redo fempop or pop tibial. So on this one, it was actually the popliteal to tibial, but this code can be used for redo femoral popliteal as well. Case number four. This is going to break a lot of surgeons hearts, and I'm sorry, but it is what it is. So we have a left iliofemoral SFA endarterectomy with patch angioplasty. We have a left external iliac thrombectomy. We have a right iliofemoral endarterectomy SFA endarterectomy with patch angioplasty, and then we have a right to left femfem bypass using an eight millimeter ring propaten, propaten graft, and then again they put in some art lines and all those good things. So the provider began with a longitudinal incision in the left groin. Dissection was carried down to the distal external iliac artery. By the way, if you're new to coding these, you're going to need to learn the the abbreviations for all of this and the acronyms to help you get through these dictations. Due to previous stents and access, patient has significant scar adhesions. Dissection was continued distally to the SFA and profunda. Systemic heparin was given. Each vessel was clamped. A longitudinal arteriotomy was made. Extensive endarterectomy from the distal external iliac to the SFA was performed with feathered endpoints distally in the SFA. Proximal endarterectomy was performed to the previously placed stent. Again, we're going to lose our endarterectomy because it's we're doing a bypass and it is part of establishing that inflow outflow. At this point, an attempt was made to place Fogarty catheters number three, four, and five through the arteriotomy. They would only pass approximately 10 centimeters or so and they did remove chronic clot plaque and all of that. The Fogarty's would not easily pass and because of that decision was made to do a right side fem fem bypass. So again, we're going to lose that 34201 which is a thrombectomies because we're doing a bypass. And again, we're you know they're in this area. They're from the external actually external iliac down into the femorals. At this point, endarterectomy site was patched using bovine pericardium prior to completing the anastomosis. Back bleeding, forward bleeding, and heparinized saline was used. At this point, then they did a longitudinal incision in the right groin. Dissection was carried down to the external iliac common femoral SFA profunda. Clamping was performed. Again, they did extensive endarterectomy from distal iliac to the SFA. Good endpoints were noted. We're going to lose that endarterectomy as well. And then finally, they did an eight millimeter ring. PEPFE was selected. Soaked in antibiotics. Subcutaneous tunneling was performed. So they're going to they're basically going to do a fem fem bypass is what they're going to do. So they're they're going to connect both legs. Femorals are going to bypass this other stuff so that patient can get blood flow down to the legs. Now, because of all of that endarterectomy, and here's where here's where I would break also the surgeon's heart due to the fact I could have possibly given him a 22 because he did back in here state that the patient had extra extensive scar tissue and all of that and then doing all of these endarterectomies, but he didn't give me any extra time. He actually didn't request the 22. So and here's the thing about the 22 modifier. If you're successful in getting those covered and reimbursed and paid, then by all means keep doing it. If you do if you are not successful, then your administration needs to make a decision as to whether or not you're going to continue to pursue these. And the reason why is once these are once you place that 22 modifier, it holds up the entire claim until it's educated or adjudicated. So once that's done, you know, you might have to wait five, six months before they'll actually pay or even determine if they're going to pay. So that entire claim sits there until they've decided whether or not the documentation supports the 22 modifier. Our recommendation at MedAxiom is to have a separate paragraph where the provider states their case as to why they feel the 22 modifier is supported. So again, you know, the patient's had previous bypass or had previous work that got a lot of scar tissue, that type of thing. You're going to want to document that or if it's or the provider is going to want to document it. Or if the patient has aberrant anatomy, if the patient's extremely obese, whatever the case may be, doesn't have to be big, lengthy, you know, statements, anything like that, just clear and concise and separate. And then the biggest thing is to document the extra time. Now some providers will say, you know, this case normally would have taken me an hour and a half, but this case took me three and a half hours due to the fact, you know, and then state their case. What, what was wrong with the patient? What was going on? Why did it take that extra time? Something, time is part of that modifier. So they have to document something about that time. So after all of that wonderful work that the provider did, he gets this code. Bypass graft other than vein, femoral, femoral. So the right side's included, the left side's included, the endarterectomies are included, the thrombectomies are included, all that is included. All right. So case number five, we have a right groin wound dehiscence. Notice on a post-op diagnosis, this is always, you always want to pay attention to this too, because of, you know, your pre-op was right groin wound dehiscence, but in the post-op, it had the infected right femoral bovine pericardial patch. Now note that patch is not a graft. So even though they remove it, don't code a removal of a graft because they're not the same thing. But we have a 58 year old man who presented in the hospital with non-healing right foot wound. He underwent an attempt at limb salvage with a right femoral endarterectomy and a right femoral posterior tibial artery bypass with cephalic vein. Unfortunately, the bypass failed. He was seen in the office today and was found to have dehiscence of his incision on the right side. So they sent him emergently to the OR. And all right, I'm going to drop down here. So they excised the bovine pericardial, or they transected the occluded bypass. They excised the bovine pericardial patch from the femoral artery and then concerned that further dissection of the profunda femoris artery wouldn't lead to injury given inflammation and significant amount of bleeding. So upon removing the patch, they were able to see the two profundas. They inserted Fogarty catheters in each of the distal ostia and inflated them to control the back bleeding. Next, they made an oblique incision in the left groin. Um, I just noticed. Let's see. So they did an incision in the left groin and then they did dissection carried through the subcutaneous tissue to his residual saphenous vein. Then they dissected a length long enough to serve as a patch. It was ligated proximally and distally and excised. It was then open longitudinally and performed patch angioplasty to the right femoral artery. And then, uh, they removed, prior to completing that, they removed the Fogarty catheter. On this one, we coded the 35860 because this is post-op infection and whatever repair is done is included in this code. Uh, dropping down, they did the distal thigh incision was reopened and then they dissected, uh, down to the gracilious muscle, which is over here. So they're doing a muscle flap. Again, remember that we're doing the, uh, wound dehiscence and, uh, I lost my spot here. Sorry. Okay. All right. So they carried down to the gracilious, they dissected it, circum circum for entry. You know what they did? They dissected the muscle out within his wound and divided his tendons segment near the knee, freed it. And then perforators were clipped and divided. Then they made a second counter incision between the groin and the distal thigh over the muscle. And then they were able to pull the gracilious up into the wound. Um, they performed additional dissection. And then once they had the muscle completely mobilized, it created a tunnel between the groin incision and the counter incision and secured that muscle flap in place. So with that, you're also going to have the code 15738 for the muscle flap. And then, so our final code is exploration for post-op hemorrhage, thrombus or infection. And then I also have the muscle flap code, the 15738. All right. So that was our last case. This was our disclaimer, basically stating that the information contained in this webcast is for informational purposes only. It does not constitute legal advice. Um, keep in mind, you always want to check with your particular carrier on how they want things coded. And then, um, also your practice's legal counsel for, um, other reimbursement advice. Copyright for this came out of the 2024 American Medical Association CPT book. And now we will go to questions. Um, I have to, I can't find my questions at the moment. Hold on. There they are. Okay. Sorry about that. All right. Let's see what we have. Oops. I don't want that either. Um, okay. 35820. I'm getting rejections with the 78 and the 59. Jeez. I know that they typed that. I didn't just say that. Uh, I try the 58. I have found that there are some carriers that that's what that's what they're wanting. Again, I don't understand why I've even had, um, they want the 58 for balloon pumps, um, and things like that. So again, um, I recommend trying the 58 and then see if that works. If not, you definitely want to appeal. I mean, when, when you're bringing the patient back, uh, reopening, um, you know, the chest or the leg or whatever you're doing, you should be paid with that. Um, if it's same day, I recommend, um, if you do the 58, maybe also add, uh, I think, what is it? The X X E for the separate encounter, if it's Medicare. Oh, all right. Question. Then what procedures are included in the exploration excision repair revision? Is debris been included? Um, yes. So when you're, when they're opening up that, when they're reopening an incision and they're repairing it, anything that's being done in that area is going to be included. Um, now if they have ulcers at different sites and you're, and then you do the separate debridement with that, then you could, um, um, you could code that. Another question. Do you have inclusive arteries that you mentioned in the slides? I miss what you said about the SFA. So basically when we're talking about the femoral arteries, the, uh, the SFA, which is a superficial, the common femoral and the profunda that is all part of, um, when it comes to endarterectomy, they don't want to build for those separately unless it's extensively done. Because if you think about it, you have to get into the common femoral to get to the SFA or the profunda. So if they're not actually, if they're only going to the orifice or the, or, you know, very proximal portion of those vessels, that's all going to be included in the common femoral. So they have to do extensive, um, extensive endarterectomies in those areas. And they need to be very clear about it. Now, some carriers will allow you to build, um, the additional, if you have separate, uh, incisions. Now let's say, let's say though that you only have the one incision, the common femoral, but then they did extensive and they document extensive SFA endarterectomy, then I would code the SFA and not the common femoral. Um, if you're wanting to do all three, you know, if, if the documentation is there, you do have to have separate, or you're going to have to pick whichever one is the most extensive. Um, if you don't have separate incisions, you can't build for all three of them. I hope that helped clear that up. Um, let's see. This one's a little off topic, not completely, but I'm going to go ahead and answer it. When repairing an aortic aneurysm, which that code is the 35081, and if they remove an infected aortic graft, is it appropriate to report the repair as well as the removal? Yes, it would be. Now, if you're in one of those, uh, carrier groups that they want 51 modifiers appended to your additional, um, uh, procedures, you'll have to put the 51. If you don't have to put the 51, they're going to do it for you automatically. Uh, I think, you know, this has kind of given you my age. Back in the day, we used to have to list properly, you know, in proper order, what was the primary procedure, then what was the next and so on and so forth. Now, most of your, billing software is smart enough to, to put them in the correct order, but just always make sure, um, that your primary is first and then, you know, your, your lesser procedures are after that. If you do have to put 51s, make sure you're not putting it on the primary, uh, procedure, because they'll reduce it at 50%. If you're not required to put the 51, don't put 51s, because then they're going to reduce it twice. So, um, oddly enough, there are still several of you out there where, um, you know, you have to add those, but, um, let's see, that's a very extensive, uh, question. Oh, somebody told me it was Einstein. Thank you. That was on the definition of insanity. Um, all right. All right. Most of these are going to be pretty in-depth and I'm going to have to go back and look at, um, these in further, further due. I know we are coming up, coming up on time. I'm seeing if there's any others I can, um, let's see. Good questions, by the way, though, but some of them, like I said, I just, I'm not going to be able to answer right off the top of my head. I think that is going to go ahead and do it for today. So like I said, next week being end of month, look for probably the first week in November, and I'll have all of, uh, those questions compiled and answered for you. And then my fabulous team, uh, that does all of our webcast support, uh, the MedAxium Academy, they will actually, uh, get those uploaded and posted. And if you, if you do have any, um, uh, I didn't include the RCS, uh, email on here, but if you have any problems with your, uh, CEU certificates, or you can't find the questions, or you can't access the webcast again, um, just reach out either to the RCS email, which is just RCS at MedAxium.com, or you can email me directly. And, uh, but we appreciate all of you joining and, um, I, yeah, I'll be talking to you before Thanksgiving. So our next webinar, I believe it's November 20th, we'll be on, uh, open lung procedures and, um, we'll probably throw through a few VATS procedures in with that as well. So thank you and have a wonderful day.

vascular surgery coding

bypass grafts

hemodialysis access

AV fistulas

aneurysm repair

inflow arteries

outflow arteries

endarterectomies

thrombectomies

modifiers

CPT codes

medical necessity