Hello everyone and welcome to our webcast. My name is Jolene Bruder and I'm a Senior Coding Consultant with Metaxeum. I am joined today by one of our specialty coders, Michelle Platt, and we are going to talk about coding for head and neck vessels. We're going to cover angiography and also touch a little bit on upper extremity angiography and how you can tell the difference for which service is being provided. Michelle will then take over and discuss interventions as well as a few open procedures that involve these vessels. Before we do start getting into housekeeping and all of that, I do want to begin by letting you know that we realize we have not hosted a webinar in a while and part of that is because of our new platform through the Metaxeum Academy. There's going to be some growing pains with it, but I do feel, we all feel, that this is going to be a much better platform for all of you. We will also host two webcasts in September and actually next month, Nicole and Jamie will be hosting a webcast on the proposed rule and some of the proposed E&M changes that are coming out for next year. So again, we appreciate your patience with this. We also are trying to avoid the end of the month, I know this is a bad timing, but unfortunately for this month, it's the only way that it worked out. So our control panel is a little different than what we were used to with GoToMeeting and GoToWebinar. To access the slides for today's presentation, you're going to need to click on the chat box. That's the only thing we really want you to use that chat box for, is for the link to the slides. Questions will be answered in the Q&A box. We will also be able to answer any that we do not get to during the webcast, you know, we'll compile them like we always do. They will also be out on the Academy, but we will try to answer as many as we can. As always, we ask that you do keep your questions on topic. And like I said, we will try to do as many as we can. So CEUs, this one, now this is going to be for this webcast and all the ones going forward. The coding CEUs for the AAPC will be available to view and download. And you will access that with the transcript button that's on your Academy when you log in. Now I do want to talk about something that's a little bit different. You can listen as a group, as you always have. However, you do have to be registered through the Academy, and you should go ahead and launch the webcast through your own individual computers. It's fine if you all want to get together as a group, but you will have to actually launch it or you will not get your CEU. We are asking for one to two business days to make sure that those are uploaded and available on the Academy. But this will be nice for, you know, a few months from now, you're like, hey, I don't think I uploaded that AAPC CEU to my tracker. You can go back on your own dashboard, and you can pull up any webcasts that you have attended. Now, again, that's only for the ones going forward. Anything you listened to prior to today's webcast, those, you know, if you lose them, you will have to notify us. As far as the BMSC holders, nothing is changing for you. You will email me directly to request those. I'm going to pull in my support team here. There's people stating that the link is not working to get the slides, so if you guys can check that out for me. We're working on those, Jolene. Thank you. Perfect. All right. Next, I want to welcome, our team is expanding again. We have a new specialty coder, Cassie Dill. She started with us, I think, gosh, I'm losing track of time. I think she started in June. But anyway, we welcome her. She has had seven years of coding cardiothoracic and cardiology procedures. She also does some E&M and diagnostic. She worked for the University of Iowa and the Mayo Clinic. She also does have a clinical background in echocardiography, so that's great. And her passion is basically cardiovascular thoracic surgery, but she is well-versed in the others. All right. All right. Now, to our disclaimers, again, keep in mind, we are not lawyers. This information is, the webcast is for informational purposes only. This does not constitute any legal reimbursement, coding, business, or other advice. As always, you should check with your own local Medicare carrier, and then consult with your practice's legal counsel for any coding and reimbursement advice. Next is our AMA disclaimer, and of course, this is for the CPT codes, and that all codes from this content are from the current year, American Medical Association CPT Book 2022. All right. So for our agenda, we're going to cover, like I said, we're going to do a little bit of a brief recap on upper extremity diagnostics, and this came up because when we did our boot camp in December, we were covering this area, and there were several questions that came up about, well, wait a minute, why aren't you using the subclavian vertebral code from the head and neck vessel? Why are you using, you know, the regular extremity cath placement? So we're going to cover that a little bit. We're going to get into depth of the head and neck vessel angiography. I'm going to cover a few cases of upper extremity head and neck angiography. Then Michelle's going to take over with interventions, and then she's also going to follow up with some open carotid procedures, some bypasses and arterectomies, embolectomies, those type of thing, and then she's going to cover some open cases as well. So we're going to talk about some general cath coding guidelines. So if you, you know, and these rules are pretty much the same no matter where we're talking. You always want to code selective cath placement over non-selective. You're going to code each vascular family to the highest order selected. Each vascular access is coded separately if there is, and then additional vascular families that are catheterized are also coded separately. That's just in general. So next we're going to talk about ultrasound guidance. Now this is kind of, this is one of those codes that this really is dependent upon your carrier. It is an add-on code. They do not list what this code adds on to. They have left that up to the individual MAC carriers. Some of them apparently only allow it to be used with vein procedures. Some do allow with peripheral. It just depends on what your carrier has decided to do. There are some rules surrounding this. You do have to meet all of the requirements, and the fact that there has to be documentation of the selected vessel patency, whether or not it was patent. You have to have that real-time ultrasound visualization of needle entry, and you must maintain a permanent record of that. So first and foremost, you have to meet those requirements. After that, then it's up to your actual carrier as to whether or not they're going to allow it. Now some procedures do not allow it at all. EP procedures, one off the top of my head, they do not allow you to use ultrasound guidance for an EP procedure, but again, check with your carrier. This is example of proper documentation, and it shows that, you know, this patient presented for carotid artery diagnostic angiography. Ultrasound was used to determine the suitability of the left femoral artery. It was also used as guidance for needle placement. The left femoral artery is deemed patent and suitable for use, and then hard copied images are documented. It can also say something about permanent images were stored in packs, something to that effect. All right, so let's again, like I said, we're only briefly going to talk about those upper extremity cath placements and such. So we have our first, second, third order, and then additional order within this vascular family. These all start with the, you know, the 3, 6, 2, 1, 5 is your first order, 2, 1, 6 is second, then 2, 1, 7 is third, 2, 1, 8 is for anything additional. You're probably not going to run into this with cardiology. Vascular surgeons don't normally do a whole lot in the hand and the arm, but this would be again, you know, additional third order placement. Your first or second order, depending on which arm, and it depends on your approach, and we're going to get into that here next. So again, when we're doing upper extremity, arm and hand symptoms are what we're looking for. We're not looking for any indication that has to do with the carotids or the vertebrals. So keep that in mind, you're looking for hand and arm symptoms. That's how you know the difference. Once you start venturing up into the head and neck, then you no longer use the cath placements that I had on the previous slide. There is some rules with that, and we'll talk about that. Cath placements from a transfemoral approach are different for right and left upper extremity. And of course, you always want to watch for any variation in anatomy, no matter what your patient is. So if we're coming from a transfemoral approach and we're going to the right side of the body, now keep in mind, this is for the patient's right, not ours as we're looking at it. So it'd be the patient's right side. When you come up from the femoral and they come up through the aorta, you first hit the brachial cephalic or the anomaly. So that's actually your first order, because now you're out of the aorta. Once you hit the subclavian, now you're in a second order. So that starts at the right subclavian, goes through the axillary. And then once you get into the brachial, radial, ulnar, et cetera, now you're in third order cath placement. On the left side, when you come up through the aorta, you go directly into the subclavian. So that's why 36215 on the left side from a transfemoral approach is always first order because you didn't have to cross the anominate. It's on this side, but not on the left, the left, you go directly into the subclavian. So that's what makes them different. Then your second order would be left lateral thoracic artery. And then third order is always your brachial, ulnar, radials, et cetera, and then down even into the hand. And again, if they, you know, once they start hitting these bifurcations and they get further in the hand, that's when you would have the additional selective cath. But I honestly, I've never really seen cardiologists or even vascular surgeons get in that area. Not saying that they can't, but they normally don't. If you're coming from an anterograde retrograde brachial approach, then your right and left subclavian, if that's your access site from your brachial. That is three, six, one, four, zero. That is a non-selective code. You don't actually hit first order until you get to the radial. And then second order would be the superficial deep palmar arteries. So keep that in mind, it's kind of just like the legs. If you know, if you, if you think about the access, the right femoral artery, and then you go in an anterograde approach, that common femoral artery is your three, six, one, four, zero. It's the same principle. Right. Now the imaging for the upper extremity, again, we have the seven, five, seven, one, zero for one arm, seven, five, seven, one, six for both. You can also have the seven, five, seven, seven, four. Again, that's going to be rare. And you must have the complete basic exam done, which would mean all the way down to the hand. In the legs, we talk about, you have to have all the way down to the foot, for the arm, you have to have all the way to the hand and you have to have a more selective calf placement as well. Plus you'd have to meet those medical necessity requirements. It's not just to complete that imaging to the hand. So now let's look at the head and neck. So of course you have the aortic arch here, and then you have your subclavian coming off the left side. You have your left common carotid, your brachial cephalic or nominant, same thing that comes off the aorta and then it splits to your carotid and then also goes up to your end of the vertebral. So when we talk about coding for the arch and the carotids, the first thing, the first level of code is the 36221. And what we're talking about here, I don't care if they come from the arm or the leg or wherever, basically that calf is being left in the aortic arch, they're doing a shot and it's, that dye runs up into the head and they can look at, they can pretty much look at everything from that shot. But this will be considered a non-selective visualization of all of these vessels because the calf is not leaving the aorta. Once that calf leaves the aorta and either goes into the left common or into the nominant or if it goes up into the left subclavian, and we're not talking arm and hand here, we're talking head and neck issues, you would lose that 36221. You're not going to code for that anymore because that's non-selective, that's kind of a one and done shot. But once they select, then you have to, then you start looking at these other codes. So the first one in this hierarchy is the 36222, and this is when the calf is actually selectively placed into the anominate or either common carotid, and then they do imaging. Here you're looking for findings of the extracranial carotid circulation, so everything that's on the outside, all those vessels on the outside. So you're going to see internal carotids, external carotids, all of that is what you're imaging here. So this is our basic example. Probably this code and then on the next slide, the 36223, these are going to be probably your most common that you're going to be coding from this group of codes. Now in this one, in the 36223, again, you have a selective calf placements of either the common carotid or the anominate, but now we're looking at intracerebral vessels. So here you should be looking for any mention of middle cerebral, anterior cerebral artery, you might see circle of Willis, anything in that area, et cetera. There's a lot of vessels in there. Once they start talking about that intracranial, not only does this code include the intracranial, it also includes everything from the previous. So it's going to have all of this imaging, all of this imaging, that's all included. So these are, again, these are hierarchy. So we start with non-selective, then this is our first selective code. And then this one, and basically the difference is what we're imaging. So on this one, we're looking at intracranial carotid circulation and the 36222, you're looking at extracranial. Keep that in mind. For 36224, this is actually where they're going to selectively place that catheter into the internal carotid. Again, most of your cardiologists and vascular surgeons are not going to venture this high. They're going to be more or less in the neurology is going to handle most of those, not cardiologists and usually not your vascular surgeons. But again, once they're up into this internal, now it includes everything, you know, it includes the 36223, the 222, and the 221. So for our coding guidelines, we're only going to pick one code from the 36221 through the 36224. You only report them once per side. These are specifically unilateral. Now, if they happen to perform selective cath on both the right and left side, if they keep the same, if they do the same on both, so if both the right and the left side, they perform the extracranial, you would bill the 36222 with a 50 modifier. If they happen to do extracranial on the left side, that would be 36222. And then they happen to do intracranial on the right side, that would be 36223. Now you because you got two separate sides, you're going to have to put a 59 on that 36222 or an X modifier, depending on if you're on the right, or I'm sorry, the X modifier if you're using your Medicare versus commercial. Again, the codes are inclusive, meaning the more extensive service includes everything from the lesser service. For 36225 and 226, now we're looking at placing that cath in the subclavian. Remember though, we're not looking for hand and arm symptoms. You need to know your anatomy well enough and prefer to make sure you're referring to proper diagram. When it's arm or hand symptoms, you're going to look at the upper extremity codes and 36215 through 217. When it's head and neck, you're going to look at the 36225 or the 36226. Now here's the biggest thing that will alert you. With the 36225 and or the 36226, the difference between the two codes are the cath placement. For 36225, you're only in the subclavian. 226, you're actually placing that cath in the vertebra. If you do not have vertebral findings in either one of these cases, you cannot use this code. So if they place that cath in the subclavian and say you're looking at a report, you're really not sure what your physician was trying to do. Was he looking at arm or hand or was he looking at head and neck? It should be very clear. If not, you need to go back and have conversations with your physicians and tell them that this needs to be very clear because it totally changes what you're coding, what you're looking at, the RVUs, everything else. But there has to be mention of vertebral findings. If there's no mention of vertebral findings, you cannot use either one of these codes. So keep that in mind. There are some add-on codes for additional imaging if that's supported. So 36227 specifies select cath placement in the external carotid artery and the guidelines state that this is reported with the 36222 through the 36224. Again, you're probably not going to see a whole lot, but you might. You might see the add-on code with this. 36228 does specify selective cath placement of an intracranial branch of the internal carotid or the vertebral artery. So again, this is above and beyond that 36225. So this would actually add on to 223 because you have to have at least the intracranial imaging through 36226. 36228 is reported up to two times per side, regardless of the number of additional vessels. So if they keep going up higher and further, you only get to report it up to twice per side. This code does include, these codes do include the accessing of the additional vessels, all the cath placements, your imaging, your SNI, fluoroscopy, all of that. Right. again, I kind of already touched on the bilateral, but just to make sure, if you're visualizing the same thing at each level, it's a 50. If one side is different than the other, then you're going to need to report the appropriate code that was done and then use a 59 or an X modifier. So next I'm gonna cover a couple of cases. So for our first case, we have right subclavian angiography with right upper extremity runoff. Well, it's kind of letting you know right here, we're looking at the arm, not the neck. Indications are right subclavian stenosis with hand numbness. Again, you know, we're talking about the hand. We're not talking about the head and neck. So I shouldn't even see any vertebral finding on this either. This is, you know, we're worried about what's going on in the extremity. So for this one, after safety pause, 2% lidocaine anesthesia was administered to the left femoral artery after using a micropuncture kit. Now, it's called a vertebral catheter. That does not mean they're in the vertebral artery. So watch for that too. And I know some of you are like, really, Jolene? There are newer people that don't fully understand all this and haven't been doing this for a long time. So this is things that, you know, as you're training some of your newer staff, you need to point out to them, don't get catheter names confused with actual vessels. Anyway, so it was using a vertebral catheter and it engaged the right innominate, which is here. And then the cath was further advanced into the subclavian artery. This revealed mild stenosis of 20%. So our cath placement is 36216 because we came from the femoral artery. And we're up here into the right innominate. And then second order is that subclavian. And then we have the 75710 for our final angiography and our diagnostic. The findings are without significant stenosis in the innominate, mild stenosis in the subclavian. And then the axillary brachial, there was no stenosis with good flow. So our answer on this, we have the 36216 for that second order cath placement in the right subclavian. And then we have the 75710 with the 26 modifier. If you own your cath lab, you will not bill it with that. This is mainly looking at, you know, people that are going to facility. You know, if they're going to the hospital, outpatient, either in or outpatient, you will need that 26 modifier. All right, so case number two. On this one, we have a 69-year-old patient with a past medical history of chronic vertigo for the last year with no improvement. Patient was diagnosed with vertigo and because of continuous dizziness and lightheadedness. They have had her on medical therapy for the last two months. Sorry, that's a typo, scratch out that word, year. With minimal to no improvement at all. Patient possessed to the clinic for further evaluation. They did do a CT scan to rule out subclavian stenosis. Patient came back and said, hey, I already had one. The doctor looked at it, but because of the benefit or given the benefit of the doubt that there might be some subclavian seal syndrome causing that dizziness and lightheadedness. With some of her severe symptoms, they're going to go ahead and do angiography with possible intervention. All right, so they accessed the right common femoral under fluoroscopic guidance. They placed a five-fret sheath into the right common femoral. Pigtail catheter was placed over the guide wire into the ascending aorta. So they're up here in the, well, actually it was in the, ascending, but he also did an arch shot. And then went ahead and talked about the patient possibly had a bovine arch. Common origin of the left parotid artery with brachial cephalic. There was no significant stenosis in the brachial cephalic, right common, right subclavian. There was some stenosis in the left subclavian. So right now I have coded that 36221 because this was all done from that arch shot. However, the physician decided to selectively engage that left subclavian artery. So now we're out of the arch and we're into that left subclavian. They performed angiography of the proximal artery and mid artery that contains stenosis. While stenosis was present, I did not feel it was enough to intervene at this time. There was still good flow from the subclavian into the left vertebral artery. So we've got documentation of vertebral flow. We've got documentation of that subclavian. Patient was dizzy, lightheaded. So we're looking at the head and neck muscles again here. And our code now will be the 36225 because we have that selective cath placement in the subclavian or anonymous. And then with our imaging. All right. And then I have one more case. Case number three. We have a patient that has right internal carotid artery stenosis. Status post previous stenting from 10 years ago. Recent CTA revealed stenosis in the right internal carotid artery at the distal aspect of the previously placed stent and revealed stenosis of the left intern. One thing I want to point out here too, because this is going to come up when Michelle starts talking about interventions. You can do a diagnostic study even if there's a previous CT. What you can't do is a diagnostic study and intervention if there's a previous CT. So it's fine that he wants to get better look at this. But so keep that in mind. Because as you know, and Michelle will talk about it. I'm not trying to steal her thunder here. All right. Patient had conscious sedation was administered by a dedicated interventional radiology nurse. Patient's cardiopulmonary status was monitored throughout face-to-face sedation was 60 minutes. We're actually looking at right and left carotid angiography in this study. So here they access from the right common femoral and let's see, they used anatomic landmarks, palpation. Drop down here for five French vertebral catheter was advanced into the thoracic aorta and used to access the left common carotid. So again, they came up through the aorta or here in the left common carotid. Left common carotid arteriogram was performed in various obliquities. This demonstrated known high grade, approximately 60% stenosis of the proximal left internal carotid. So he's still imaging from the left common but he's looking at the internal. There's otherwise wide patency of the left common carotid, left external carotid and more distal left internal carotid. Biplane intracerebral angiograms were then performed and the catheter was in the left common carotid. And this demonstrated widely patent left internal common, or I'm sorry, left internal carotid artery, left middle cerebral artery. And that also did not have any aneurysm or inclusions on the left anterior cerebral was not actually visualized. And they're thinking that represents an A1 bearing. So for here, I have the 36223. And again, I have it lined out. You'll see why in a minute. But I did that with the left side. Now, again, you may or may not need right and left. It depends on your Medicare carriers. I know some are adamant they want that and some will do not. So you have to do whatever your carrier tells you to as far as that RTLT modifiers. So then next they went in through the brachial cephalic arteries. So they came here and then up into the right common carotid. So again, they came out of the left, went over to the anominate brachial cephalic. Now they're up here in the right. Again, they have right common carotid angiography. They have shown severe stenosis at the distal end of the internal carotid stent. Selective right cerebral angiogram was performed. There are straightening, patent, intracranial, internal common or carotid artery, and then ossification of branches in the right middle cerebral distribution. So now we have the same imaging done on both the left and the right-hand side. So we are at 36223, and then we will use a 50 modifier because we have the same level of imaging for both the right and the left. And I actually left out the 99152 in this by accident. I apologize for that. We should have 36223 with a 50 and then the 99152 for the moderate sedation. So next, I'm gonna turn this over to Michelle and she's gonna cover the intervention of head and neck. And then she's also going to, like I said, get into some of the open procedures for us. Take it away, Michelle. Thank you, Jolene. Now let's take a look at some head and neck intervention in the carotids. So when standing in the carotids, you need to pay attention to, oops, wait a minute. My screen's just switched. Sorry. You're good. We're looking at your clean version. Yep, here we go. Okay. Nope, now you're back to the other version. So you can do it that way. Just hit stop share. I'm sorry? And then you'll share the other screen. So screen one. Screen two. There. Now that's that, right? There. Now that's that, right? So stop share and share screen one. I'm sorry? It's all good. There we go. Perfect. Okay. Correct. Sorry about that. Okay, so when standing in the carotids, you need to pay attention to the approaches and where the stent is being placed. So for example, are you in the cervical carotid or the interthoracic common carotid? Was the approach open or percutaneous, retrograde or antegrade? With 37215 is probably the most popular procedure when it comes to stenting the carotids. This is done in the cervical carotid and can be done open or percutaneously and distal embolic protection is used. 37216 is without protection and Medicare won't usually pay for the, or won't pay for these procedures. 37217, the stent can be placed in either the anominate artery or in an interthoracic common carotid. This is done by retrograde, open ipsilateral cervical carotid exposure. 37218 is for stents placed in the common carotid or the anominate with either an open or percutaneous antegrade approach. So for some guidelines, cath placements are included with these two codes as well as the diagnostic imaging. So if they perform a carotid diagnostic angiography and then decide to perform a stent, then you can't bill for the imaging on that same day. If they do the diagnostic and determine the stent is not warranted, then you would bill for the diagnostic imaging and then angioplasty is also included. For 37217, vessel exposure and vascular access, cath placement, imaging and angiography are all included in the 37217. For 37218, cath placement is included as well as diagnostic imaging and the angioplasty. So you can bill moderate sedation with the 37215, the 37216 and 218. Listed on the right are services that you can bill with the 37217. Okay, so these are the basic interventions. Okay, so these are the basic interventions. We have angioplasty and stent and angioplasty is a procedure used to open narrow and blocked arteries. When the balloon is inflated, it compresses the plaque against the wall, restoring blood flow. A stent is a tiny lattice shaped metal tube that expands to compress the plaque and keep the artery open. So these are the angioplasty codes, 37246 is for the initial artery treated and 37247 is for each additional artery. And you are allowed to bill cath placements with these codes. So some guidelines for the angioplasty codes, they can be done open or percutaneously. These codes are to be used in the aorta, the upper extremities or the viscerals. They can be used in the legs providing it's not for occlusive disease. When multiple angioplasties are done in a single vessel, it would be reported with a single code. Separate and distinct ipsilateral or contralateral vessels treated in the same session may be reported with code 37247. So for example, angioplasty done in the left subclavian then angioplasty done in the right brachial, we would code 37246 for the left subclavian and then 37247 for the right brachial. So imaging directly related to the angioplasty is also included. Cath placements can be reported. Extensive repair or replacement of an artery may be reported. If IVUS is done, it can be reported and as well as mechanical thrombectomy and or thrombolectomy therapy. So these are the stent codes. 37236 is the initial artery and 37237 is each additional artery. Same rules apply for the stent codes as they do for the angioplasty codes. They're used in the aorta, the upper extremities and the viscerals and they can be used in the legs providing it's not for occlusive disease. So guidelines for stents, multiple stents. So let's say three stents are placed in a single vessel, only one single code is reported. If treating a lesion that extends across the margin of one vessel into another, but can be treated with a single stent, you should only report it one time. 37237 is appropriate to report to treat different vessels in the same session. Balloon angioplasty is included in the treated vessel and any lesion outside the stented segment in the same vessel. And calf placements, non-selective or selective are reported separately. So vertebral stenting. The vertebral stenting, these are category three codes. So included in these codes are the ipsilateral extracranial vertebral catheterization, all diagnostic imaging for ipsilateral extracranial vertebral artery stenting and all related radiological supervision and interp. If stenting is not warranted, then you would not build, oh, then you would build a selective calf placed for the imaging, sorry. Got a little tongue tied there. For subclavian intervention, if an angioplasty is done, you code the 37246 and 37236 would be coded for a stent placement. Again, imaging is included, but calf placements are separately billable. So as I mentioned earlier, all of the diagnostic calves are included with the carotids and the vertebrals. However, a diagnostic calf is billable with the subclavian intervention as long as no prior calf study is available and a full study is done. And based on those findings, they decide to intervene. Or if they have a prior study, the imaging is, and the imaging is inadequate or the patient's condition has changed or there's a change during the procedure, then you would be able to bill. So coil embolizations can be done for a variety of reasons, hemorrhage, malformation, tumors. The two codes are divided by whether it's an artery or vein being treated. The third code is for tumors and the fourth is for hemorrhage. Only one code per surgical field is reported. There are not, they're not per vessel. These calves, I'm sorry, calf placements may be reported separately and our physicians may not, may not say embolization. They may refer to like Nestor coils or helical coils. So let's move on to the open procedures. When billing bypass procedure codes, you must determine whether inflow artery, where the inflow artery is. So where we start, such as the carotid followed by where the outflow is, such as the subclavian and where the, and what conduit is used. Other interventions are reported only if done at another site. Also establishing inflow and outflow is included in all bypass procedures. For example, a carotid endarterectomy would not be reported separately for a carotid subclavian bypass. So the conduit options. So the patient's own vein is used when we do the with vein. It is excised or cut out and moved to a different location and it may be reversed or orthograde. If the staphonous vein is used, it is included in the code, but if veins are harvested from another site, they may be reportable. So conduit options. These are other than vein. So they are other than vein, it includes artery or prosthetics, such as Dacron or PEPFE. So cerebral bypass. Cerebral with vein bypass. Notice on 35501, this is the common carotid to the internal carotid on the same side. 35506 is carotid to subclavian or subclavian to carotid. And 33508 is carotid to vertebral. 35509 is bypass from one carotid to the contralateral opposite side carotid. Also 35510 carotid brachial and 35511 subclavian to subclavian. Remember I mentioned earlier, the first vessel was inflow and the second was outflow. These are the codes for the subclavian bypass to the brachial, the vertebral, the axillary and the with vein. These are bypass with other than vein. So 35601 common carotid, ipsilateral same side, internal carotid. 35606 is carotid subclavian. 35612 subclavian to subclavian. Just a side note, if a common carotid to common carotid is done in conjunction with a T-bar, do not report the 35601, you would use the 33891. Also if a carotid to subclavian is done in conjunction with a T-bar, do not report 35606, use 33889. Okay, so these codes cover subclavian axillary 35616 carotid vertebral 35642 and 35645 subclavian vertebral and with other than vein bypass. However, inflow and outflow is included, so these services would not be reported separately when you're doing the bypass. So thromboendarterectomy, when performing a thromboendarterectomy, the vessels are incised and using a blunt spatula like tool, the plaque and the vessel lining are separated from the arteries and removed. After this is removed, patch grafts is performed and taken from another portion of the patient's body, a cadaver or synthetic sorts, and is sutured to the vessel. This enlarges the diameter of the artery. There is a reoperation code for a carotid artery and more than one month after the original procedure. 35301 thromboendarterectomy by neck incision, carotid vertebral subclavian, and then 35311 is done by thoracic incision. So what's included in these? We have the patch closure and the thrombectomy. These codes have an MUE of one. For instance, if the physician does an embolectomy of the carotid and the subclavian and the nominant, you can only report this once per side. Okay, so let's look at some cases. Our first case is the patient had an acute cerebral accident. We have left neck exposure with thrombectomy of the left internal carotid artery. So we have a 76-year-old male with left carotid stenosis. He developed a CVA two hours ago. CT angio demonstrated a small left MCA stroke and stenosis in the left internal carotid and just distal to the previous endarterectomy site six months ago. So the left internal carotid, left external carotid, and the left superior thyroidal of the common carotid were encircled with vessel loops. The internal carotid was snared past the area of concern. The rest of the snares were all tightened. A small debaking vascular clamp was placed on the common carotid. A stitch closing the patch was incised with a number 11 blade. A focal decatheter was used to pass distally to the S snare and then inflated and pulled back, removing all thrombus from the left internal carotid. So that's the 34001. And then they had excellent backflow from the internal carotid. And then the vascular clamps were placed and carefully inspected. I did not appreciate any flaps or stenosis. The previous endarterectomy site was inspected. The patch was sewn back first and third interrupted proline to the internal carotid. And then he did the stitching on both sides of the patch. So our answer for number four is the 34001, the embolectomy or thrombectomy, with or without catheter, carotid, subclavian, or nominate by neck incision. So case number five, we have right carotid stenosis, a 62-year-old male with right carotid artery stenosis, and he's going to do a thromboendarterectomy. So he makes an incision over the anterior border of the sternomastoidal. The carotid sheath was entered. The middle facial veins were identified and dissected free, ligated, and transected. He gets, see, the internal jugular vein was then retracted laterally. See, I'll jump down. The internal carotid and external carotid arteries were dissected free and controlled with vessel loops. At this point, the patient was systematically heparinized. Clamping was performed, followed by common carotid, the transected off, I'm sorry, plaque in this internal carotid was inverted with feather point ends, and inversion endarterectomy was performed to remove plaque. So we have the 35301. Our final answer for that is the 35301 thromboendarterectomy, including the patch graph, if performed. So case number six, we have a severe cerebrovascular disease with a cerebrovascular accident. They did sedation, so the 99152. His findings are left subclavian vertebral artery angiography, left vertebral artery with a mild 30% disease approximately. The left vertebral artery was 95% stenosed. So using a French short sheath was introduced in the right femoral. Catheter was placed selectively in the left subclavian artery and selective angiography was performed. After diagnostic angiography, the six French sheath was exchanged to the six French 95 centimeter sheath. Ivis examination of the left vertebral artery. So his findings on that, he had 95% stenosis and the wire was placed in the distal portion. Using the volcano Ivis system is the 37252. There was severe greater than 90% stenosis. So intervention was then performed, percutaneous transluminal angioplasty of the vertebral. Then he did percutaneous transluminal stent implantation of the vertebral. So this was the 0075T. So our final answers on that one is the stent placement of the extracranial vertebral stent, the 0075T, which is the category three codes that I talked about earlier. The 37252 for the Ivis and then 99152 for the moderate sedation. Okay, so we have last one is a TCAR. So it's a trans carotid artery revascularization. So they did a left common carotid artery cut down was performed and visualized. The left common carotid axis was obtained and a micropuncture was then inserted in advanced. The controller high flow line was in prepped and connected to the artery and venous and root extracranial neuro protection system. So that was their, the protection, I just lost my train of thought. The protection device. A left common carotid angiography under fluoroscopic guidance was done, contrast injection by hand, reverse flow was performed, timeout was performed, the interventional devices, blood pressure and heart rate verified. The proximal carotid artery was then clamped and confirmed by saline injection. Intervention was then performed on a 99% stenosis of the left common carotid artery. The balloon angioplasty, they did balloon angioplasty with a five by 40 by 80 balloon. The balloon was in placed across the lesion given a single inflation and a maximum inflation pressure of 14 ATM. Intervention was then performed on the 99% stenosis of the left internal carotid artery. Then they placed a nine by 40 trans carotid self-expanding stent and advanced across the lesion and deployed. So our final answer for this would be the 37215 and the LT and then note, you know, use the anatomical modifier if required by the Medicare carrier. Thank you, Michelle. So I'm going to go over some of the questions here. A couple of things, too, I want to point out. And so on this slide, I have my email and I have Michelle's email because she and I are the ones that presented this. We do want you to know and we've actually started, you know, since our team has expanded so much, if you have general case questions that you're wanting to send to get our opinion on for coding and things like that, you can send it to our RCS at MedOxium.com. And it goes to all of us because sometimes, you know, oh, my gosh, especially Nicole travels so much that she's in and out of the office a lot. And, you know, just with the amount of work and auditing and things that we're doing, if it's only going to us three, you know, you're not going to get a timely answer a lot of times just because of what we have going on and what our workflow is. So please just be sure and use that. Now, of course, you can still contact us individually. I'm not trying to discourage from that. And, you know, it just kind of depends. But if it's a case study or something that you want to answer, just send it to that RCS address. And like I said, it goes to everybody and you can get a much faster answer that way. So a few questions. I'm going to go over a couple of things. There are several questions about dialysis circuits and when you can actually code the 36215 and the 75710. I'm not going to answer that. We didn't actually cover dialysis circuit today. So we're not going to cover those. You know, I'm sure we'll do another webcast on the dialysis circuit and then we can kind of get into it there. But I would point out your CPT book in the introductory language does talk a lot about if you have to use those, if you're outside of that circuit, when it would be appropriate to code the actual extremity angiogram, things like that. There was a couple of other questions on vein, not like vein for the bypass, but actual venous system. We're not going to get into that either because today we were talking mainly the arteries. But as always, you can send if you have a specific case. Some of those are very hard to answer without actually looking at a case. So if you have a specific case you'd like us to take a look at, then you can send that. But in the meantime, I do have a few here. So one of the questions was bypass other than vein. Does that mean cryo vein? It does. It also means the polytetrafluoroethylene graft, the PETV graft. The thing I want to point out about the cryo vein, because I get this asked a lot, do we use the vein codes or do we use other than vein? When they're talking about the vein codes for bypass, they're talking about the patient's actual vein. Cryo veins are usually taken from a cadaver and they're kept on a shelf. So that is not native to that patient. So when we're talking about using the vein bypass codes, we are talking about the patient's native anatomy. Let's see, I have another question here. CVS often reports other arterial interventions at the site of bypass and specifies a different location, but work is done through the same access site. Again, I'm going to have to kind of give a generic answer here. If that work is done to establish inflow or outflow for that bypass itself, then it's included because it's any, no matter what the method is, when they're putting in a bypass, if they have to clean up the inflow artery. So let's say we're doing a fem pop bypass just for argument's sake, to make it easier for me to answer. If we're doing a fem pop bypass and they have to put a stent in that common femoral and they put in a balloon in that popliteal, that's all included because you're in that vessel. That's establishing inflow outflow of that bypass graft. Now, if they get out of that inflow outflow vessel, then normally, yes, those interventions would be separately billable. They don't necessarily require a separate incision. What's the difference between 37215 and 37218? So now we're talking about our carotid intervention code. So the 37215 is opener percutaneous. It's a cervical carotid stent placement. Biggest difference between the 37215 and the 218 is it's an anti-grade approach and it can be opener percutaneous as well. But the biggest thing about the 37218, of course, they're talking about the common carotid or the nominate carotid, but again, it's an anti-grade approach. Not a retrograde. Oh, what is the calf placement when coding 37218? Calf placements and all imaging, ipsilateral with carotid intervention, that's all included in that 37218. There's nothing separate to report on that. Now you can bill if they're doing a stent and subclavian for an arm and hand problem. You can use that if they're, you can, you know, then you can code your calf placement. But anything to do with that carotid intervention with stents, all of that is included, ipsilateral side. If they do go to the other side, then you are allowed to bill. So let's say they stent on the right and they just do angiography on the left. You can bill for that angiography on the left separately from everything that went on on the right. You will need a 59 or an X modifier when it comes to that. Oh, here's a good one. And this is kind of a, this is a general thing. So if an MD does not dictate protection, but there is neural protection device in the supplies, which I'm assuming is being found in the hemodynamic log, is it compliant to code with that embolic protection device? Should the MD amend his dictation? Well, there's a couple of things. First off, it depends on what your administrative policy is. If they allow the physician to do that addendum, then by all means, I would do it. Keep in mind, Medicare will not cover crowded stents if they're not done with protection. In fact, I don't think anybody does. I don't quote me on that, but I know for a fact, Medicare does not. So there's a couple of other things, you know, you got the argument, it's in the chart. It happened. Well, the hemodynamic log, that's not filled out normally by a physician. That's filled out by a tech. If the physician signs that and dates it, then you have a better leg to stand on. But in all honesty, I prefer, when I was in a practice, I talked to my physicians until I was blue in the face about the importance of having a standalone document. Because if you think about it, Medicare send a request, we want to look at this procedure. This procedure is your staff is, you know, the whoever's pulling the record, whether it be a coder, whether it be medical records, whoever, whoever's pulling that, or they're going to think, oh, gee, I better pull that hemodynamic log too. Probably not. So they're going to send in the OR report, and the OR report is going to be sitting there without that protection documented. It's not a good thing. So again, the importance would be educate your physicians and make sure that they're giving you the, you know, the best amount of details that they can. Okay. This one had carotid thrombectomy and bilateral vertebral angiogram is the ipsilateral. Vertebral angiography consider the same territory as a carotid thrombectomy and bundled with the intervention. Um, when you're doing intervention, that angiography on that ipsilateral side is included. The contralateral side, you can separately bill for, but again, you're going to need that 59 X modifier. You're also going to need, you know, medical necessity. Always keep that in mind. Whenever we're doing any of this, you have to have that medical necessity. There's a few more questions I did not get to. A couple of them are going to require a little bit more research. And I don't want to, you know, just give you stuff off the top of my head without making sure that I have all the ducks in a row for that. Oh, this one, I can answer them real quick. How to differentiate between a thrombectomy and embolectomy versus a thromboendarterectomy. That's a very good question. So thrombectomy, embolectomy are kind of interchangeable. And if you think about that, so whether we're doing an open approach or a percutaneous approach, normally what happens is open. They're going to cut open that artery. Percutaneous, they'll puncture and then they'll run. They'll run a catheter in there and they'll grab that and might see pronto. You might see fetch. Um, something to that effect when they're going to grab that thrombus and they're going to pull it out. Endarterectomy, they're actually cutting open, um, the artery itself and they're scraping all of that plaque up. So, um, if you think about, I always liken things to plumbers, if you think of it, you know, like a plumber would cut open your, your sick drain and then clean all that gunk out of it, that is, um, that would be like an endarterectomy. If they're just running a snake down your drain and they're grabbing that, you know, blob of hair or whatever, and they pull that out, that's what a thrombectomy is like. So, um, that is the biggest difference. Now, um, the RVUs are slightly different on each one. If they do both at the same, on the same artery, you're going to need to pick whichever one is the most extensive procedure because I normally, you do not get to go for both, um, in the same vessel if they go out. So if they did, um, you know, um, they did a thrombectomy in the subclavian and then turn around and maybe did a, um, endarterectomy in the brachial, you could bill for both. Um, but if they're, you know, in that same vessel, you're not going to bill for both. So, all right. Well, we really appreciate all of your time. Again, we will, um, a lot of the questions I did get to, um, some of them are kind of repeat. I just set the highlights, but we will compile all of those. Again, give us a couple of days to make sure that, um, you can access your CEU through your transcript button, um, in the Academy. And again, going forward, this is going to be a lot better, um, for everyone involved. Um, and it will probably be, you know, more timely as far as getting your CEUs. You're not going to have to wait that three to five business days. We don't have to send out mass emails. So, it's all going to be right there. And, um, and like I said, from this webcast moving forward, so, you know, six months from now, if you're like, oh gosh, you know, it's next February and you're like, oh, I forgot to get one of them CEUs from, you know, in September. You can go on the Academy and grab that CEU. Everything prior to today though, that's, that's not going to be on there. This is just from today moving forward. So, thank all of, um, thanks again to all of you for listening to our webcast. And again, we will see you next month. I believe it's August 18th, but be watching the listserv and that for, uh, we'll be sending out information on that and, uh, hope you all have a wonderful day. Thank you.

coding

head and neck vessels

angiography

upper extremity angiography

interventions

open procedures

specific coding scenarios

dialysis circuits

bypass procedures

thromboendarterectomy

medical coders