# Celiac Stent Placement  meeting LCD Coverage



## Chlrtrep (Oct 17, 2016)

Question,

We recently placed a stent in a celiac artery due to a 85% stenosis.  We used CPT code 37236. Our revenue department has informed us that they are unable to bill this procedure because the diagnosis code is not listed in our LCD.  I was told the diagnosis code that was used for this procedure was i77.4 for celiac stenosis(stricture).

I know we have stented the celiac artery before but have never been told that this was not being covered. Has anyone else experience this before. Is there new information out that states the celiac stenting is non medically necessary.

Out Local MAC is WPS Indiana the LCD is L35998

I would appreciate any thoughts or recommendations


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## rlh27 (Oct 19, 2016)

Chlrtrep said:


> Question,
> 
> We recently placed a stent in a celiac artery due to a 85% stenosis.  We used CPT code 37236. Our revenue department has informed us that they are unable to bill this procedure because the diagnosis code is not listed in our LCD.  I was told the diagnosis code that was used for this procedure was i77.4 for celiac stenosis(stricture).
> 
> ...



Can you give additional information about the indications for the surgery...I didn't see i77.4 listed in the LCD, but I saw diagnosis codes for diseases that could be caused by the stricture.


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## Chlrtrep (Nov 10, 2016)

rlh27 said:


> Can you give additional information about the indications for the surgery...I didn't see i77.4 listed in the LCD, but I saw diagnosis codes for diseases that could be caused by the stricture.



PREOPERATIVE DIAGNOSIS: Mesenteric ischemia.
*
CLINICAL DATA: presents for further evaluation
and treatment of suspected celiac artery trunk stenosis. The patient has
been plagued with abdominal bloating and discomfort as well as post-
prandial pain for over the past several months. She underwent a CTA scan
of the mesentery circulation demonstrating a severe stenosis at the
origin of the celiac artery. She was referred for further evaluation and
treatment.
*
PROCEDURE
1. Retrograde access right brachial artery utilizing micropuncture
technique with ultrasound guidance.
2. Flush abdominal aortography in the lateral projection.
3. Selective superior mesenteric artery angiography.
4. Selective celiac artery angiography.
5. Intravascular ultrasound (IVUS) of the celiac artery pre and post
intervention.
6. Percutaneous transluminal angioplasty (PTA) with deployment of 2
overlapping stents in the celiac artery; the distal most stent was an
Express SD 6 x 14 mm balloon expandable stent which was overlapped
proximally at the origin of the celiac artery by a Synergy 4.0 x 8 mm
drug-eluting stents. The stents were then post-dilated utilizing a 6 x
14 mm PTA balloon.

*
FINDINGS
*
ULTRASOUND OF THE RIGHT BRACHIAL ARTERY: Ultrasound imaging was utilized
to assess the best access site. Concurrent real time ultrasound imaging
was utilized to visualize the micro needle entry into the vasculature;
this was permanently recorded and documented.
*
FLUSH ABDOMINAL AORTOGRAPHY: Flush abdominal aortography was performed
in the lateral projection to facilitate cannulation of the celiac
artery.
*
SELECTIVE ANGIOGRAPHY OF THE CELIAC ARTERY: Demonstrated severe ostial
stenosis of 98% with poststenotic dilatation which was confirmed by
intravascular ultrasound. There was collateral filling of the celiac
artery, from the mesenteric through the gastroduodenal arcade.
*
SUPERIOR MESENTERIC ARTERY: The superior mesenteric artery was widely
patent and free of disease; it was noted to give rise to collateral flow
to the hepatic artery and subsequently the celiac artery and its
branches through the gastroduodenal arcade.
*
SPLENIC ARTERY: The splenic artery was noted to have previous coil
embolization of 2 splenic artery aneurysms. The splenic artery aneurysms
were completely thrombosed.
*
POST-INTERVENTION: Successful PTA with deployment of 2 overlapping
stents in the origin of proximal celiac artery; completion angiography
demonstrated widely patent origin to the celiac artery with less than
10% residual stenosis and good antegrade flow; this was confirmed by
intravascular ultrasound.
*
RECOMMENDATIONS

4. Post procedure surveillance utilizing a CTA of the mesenteric
vessels.

Our Local MAC is WPS there is no specific dx codes for celiac. The LCD all covers mesenteric vessels. My understanding is the celiac artery is a mesenteric vessel.  the are the only dx codes covered by the LCD:

Group 4 Paragraph: Medicare is establishing the following limited coverage for CPT/HCPCS codes 37236, 37237, 37238, and 37239:
Covered for: Mesenteric vessels:
ICD-10 Codeescription
K55.011   Focal (segmental) acute (reversible) ischemia of small intestine
K55.012  Diffuse acute (reversible) ischemia of small intestine
K55.019  Acute (reversible) ischemia of small intestine, extent unspecified
K55.021 Focal (segmental) acute infarction of small intestine
K55.022 Diffuse acute infarction of small intestine
K55.029 Acute infarction of small intestine, extent unspecified
K55.031 Focal (segmental) acute (reversible) ischemia of large intestine
K55.032 Diffuse acute (reversible) ischemia of large intestine
K55.039 Acute (reversible) ischemia of large intestine, extent unspecified
K55.041 Focal (segmental) acute infarction of large intestine
K55.042 Diffuse acute infarction of large intestine
K55.049 Acute infarction of large intestine, extent unspecified
K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified
K55.052 Diffuse acute (reversible) ischemia of intestine, part unspecified
K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified
K55.061 Focal (segmental) acute infarction of intestine, part unspecified
K55.062 Diffuse acute infarction of intestine, part unspecified
K55.069 Acute infarction of intestine, part and extent unspecified
K55.1 Chronic vascular disorders of intestine
K55.8 Other vascular disorders of intestine
K55.9 Vascular disorder of intestine, unspecified


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