# Volcano Procedure



## Jane5711 (Feb 26, 2018)

Hi!!!  (Jim-long time no speak, happy New year all!!)

Regarding the below procedure, we seem to be having some coding differences.  This is a Volcano procedure and an insurance company is denying the 37238RT and 37238LT.  We believe that these codes should be 37221RT and 37223LT.  Here is the procedure:

PROCEDURES PERFORMED:
Ultrasound Guided Vascular Access
IVUS-Inferior Vena Cava
IVUS - Lower Extremity venous system - Left
IVUS Lower extremity venous system – Right
Venography of IVC
Venography Unilateral LLE
Venography Unilateral RLE
Venous Stenting/PTA Lower Extremity

INDICATIONS
Venous Right lower extremity VCS score: 20
Venous Left Lower extremity VCS pain score: 20
Venous CEAP disability score 3 – Unable to work even with supportive device
Venous Insufficiency CEAP classification State Right Lower Extremity: C6- Active Venous Ulcer
Venous Left lower extremity VCS pain score: 10
Venous Right Lower VCS pain score: 10

INTRAVASCULAR ULTRASOUND FINDINGS:
 Inferior vena cava – Reference area 263 mm2

  On the right side: right common iliac vein reference area 104 mm2 the compression or 70 millimeter squared given a 32 percent stenosis.  Anatomic norm for the right iliac vein is 200 mm2.  Right external iliac vein reference area 105 mm2 with compression area of 75 mm2 given a 28 percent stenosis. Anatomical norm for the external iliac vein is 150 millimeter squared.
Right common femoral vein reference area 91 mm2 with compression area of 81 millimeter squared given 11 percent stenosis.

  On the left side:  The right common iliac vein reference area 139 mm2 compression over 74 millimeter squared given a 46 percent stenosis.  The left external iliac vein reference a 100 millimeter squared with compression of 92 millimeter squared given an 80 percent stenosis.  The left common femoral vein reference area 97 mm2 decompression a 46 millimeter squared given a 51 percent stenosis.  

We ended up doing bilateral common and external ilac vein stenting after pre-dilated both sides with a 16x40 balloon.  We then placed a 16 x 90 self expanding wall stents across both right and left common and external iliac veins deployed simultaneously.  We then post dilated the left common iliac vein.

The right common iliac vein post stenting area 128 mm2.  The right external iliac vein post stenting area 130 millimeter squared. The left common iliac vein post stenting area 156 mm2.  The left external iliac vein post stenting area 145 mm2.

PROCEDURE NOTES
The patient was brought to the cath lab in resting and fasted state.   Both the patient’s upper thigh area’s were prepped and draped in the usual sterile fashion.  Initially, local anesthesia was achieved with 1% lidocaine solution in the right upper thigh area.  Under ultrasound guidance, the right femoral vein was entered below the level of the deep femoral confluence and then a J-tip guidewire was advanced and a 8-French sheath was advanced over the wire.  Using similar technique, a 8-French sheath was placed in the proximal segment of the left femoral vein under ultrasound guidance with the entry point being just below the level of the deep femoral vein confluence.  Venography was performed by simultaneous injection of dye via both side ports and venogram of the lower segment of the inferior vena cava, both common iliac veins, both external iliac veins, both common femoral veins, also the proximal segment of both femoral veins were obtained.  Then an 8Fr Volcano intravascular ultrasound imaging catheter was advanced over the J-tip guidewire to the lower segment of the inferior vena cava and then by slow manual pullback, intravascular ultrasound images of the lower segment of the inferior vena cava, the right common iliac vein, the right external iliac vein, and the right common femoral vein, and proximal segments of the right femoral vein were obtained.  Similar images of the left common iliac vein, the left external iliac vein, and the left common femoral vein, and proximal segment of the left femoral vein were obtained.  The images were reviewed, analyzed, and measurements were made.  We then placed a 10 french sheaths in both right and left common femoral veins.  We gave patient heparinization and then did angioplasty of the left and right pelvic veins.  This was then follow-up with simultaneously placement of 2 16x90 self-expanding Wall stents.    

The patient tolerated the procedure well and it was performed without any complications.  The patient will return to the post cath recovery area for sheath pull and hemostasis via manual compression.


Sedation start time 13:00
Narcotics/Sedation Fentanyl 50 mcg IV
Narcotics/Sedation Versed 1 mg IV
Narcotics/Sedation Versed 1 mg IV
Narcotics/Sedation Fentanyl 50 mcg IV
Narcotics/Sedation Versed 1 mg IV
Oxygen:  3 L/min via nasal cannula
Sedation End Time 13:47

CONCLUSIONS

Successful bilateral ultrasound-guided vascular access of the left right common iliac veins.

Successful intravascular ultrasound bilaterally the deep pelvic veins.

The codes used were:
76937RT, 76937RT, 36005RT59, 36006LT59, 37328RT, 37238LT, 37252RT, 37253LT, 37253RT, 37253LT, 75825,59, 75822,59, 99152, 99153.  Should 37238RT, 37238LT, be 37221RT, 37223LT??

Successful venography left and right deep pelvic vein showing significant collateralization.

Successful bilateral PTA with follow-up stenting of the left and right common and external iliac veins due to the bilateral disease at the confluence and congenitally small vessels.


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## Jim Pawloski (Feb 27, 2018)

Jane5711 said:


> Hi!!!  (Jim-long time no speak, happy New year all!!)
> 
> Regarding the below procedure, we seem to be having some coding differences.  This is a Volcano procedure and an insurance company is denying the 37238RT and 37238LT.  We believe that these codes should be 37221RT and 37223LT.  Here is the procedure:
> 
> ...



Hi Jane,
Belated Happy New Year to you!  I think you may have made the third party payor a little upset at you. You may have too many codes for the payer.  Lets try it this way with different modifiers:
76937-50 for bilateral vascular access. Not RT and LT.
36005-50 for bilateral injection procedure for extremity venography (includes introduction of needle or intracatheter.
37238-50,59 for bilateral venous stent placement. The stenosis was one long lesion, so you cannot code for 37239. (See CPT guidance before code 37236)
37252-50-59 for IVUS of bilateral extremity. The IVUS was done in a specific vessel, so the add-on charge cannot be used.
75822-59 bilateral extremity venogram.  IVC cannot be billed as it was end part of the extremity venogram and not separately injected.

When you can, I think it is better to use the modifier -50 instead of coding each side separately. 
I hope this helps you out.
Thanks for the interesting case,
Jim


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## Jane5711 (Feb 28, 2018)

*Thank you!!!!!*

Thank you for your prompt response!!!!  I guess modifier 50 is better!!!!  I really appreciate your response and will use it wisely


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