# Carotid stent placement & diagnostic carotid angio



## endrest (Apr 18, 2013)

Can you bill for diagnostic arch angiogram and diagnostic angio of carotid during the same operative session upon placing a Carotid Stent (37215) what codes would you use?
Description of procedure is below.
THANK YOU!

NAME OF OPERATION/PROCEDURE:
1. Diagnostic arch angiogram.
2. Selective cannulation of the innominate artery and the right common
carotid artery.
3. Diagnostic angio of the carotid, as well as the cerebral right hemisphere.
4. Balloon angioplasty and stent of the right internal carotid artery using a
10 x 40-mm stent, there is pre dilatation with a 4 x 2 balloon followed by a
5 x 4 balloon post stent deployment angioplasty.

 used an ultrasound for micropuncture
technique in the right groin.  We then went up with a JB 2 catheter and
selective the innominate artery.  Diagnostic angiograms were performed
showing the right common carotid artery with a severe stenosis of 85% distal
to the patch.  We then placed a Magic Torque wire into the external carotid
artery.  The patient was heparinized with 2000 units of heparin.  A working
shuttle sheath was placed into the common carotid artery, this was then
followed by 4000 units of heparin.  ACT was performed and found to be greater
than 250.  At this time there was then use of a Cordis embolic protection
device which was able to cross the lesion.  This was a 6-mm device and was
deployed without difficulty.  Following this, based on the severity of the
stenosis,  there was a preballoon dilatation with a 4 x 2 balloon.  After
predilatation, there was then placement of the stent.  The stent was a 10 x
10 in diameter x 40-mm stent.  This was deployed and flared into the proximal
portion of the common carotid artery.  Status post this there was then
balloon angioplasty with a 5 x 4 balloon.  Status post balloon angioplasty
and stent, there was now minimal residual stenosis.  Diagnostic cerebral
angiogram preprocedure and postprocedure showed no evidence of significant
malformation, no change preprocedure and postprocedure, as well as no
evidence of significant AV malformation.


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## Jmate (Apr 18, 2013)

Assuming this is indeed the initial diagnostic arch angio and no prior diagnostic angio was done prior to this intervention I'd code 36222 with 37215.


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## endrest (Apr 18, 2013)

Thank you!


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## endrest (Apr 18, 2013)

3-6 months ago evaluation with CTA showed severe stenosis, does that qualify for pryor diagnostic?

Also, what clued you into to use 36222 (extracranial) vs 36223 (intracranial) these two confuse me?


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## Jim Pawloski (Apr 18, 2013)

endrest said:


> 3-6 months ago evaluation with CTA showed severe stenosis, does that qualify for pryor diagnostic?
> 
> Also, what clued you into to use 36222 (extracranial) vs 36223 (intracranial) these two confuse me?



For 36222 Catheter is in the common catotid and the carotid bifurcation is imaged, for 36223, the catheter is in the common carotid, and the intracrainal circulation is imaged.
HTH,
Jim Pawloski, CIRCC


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## dpeoples (Apr 19, 2013)

endrest said:


> Can you bill for diagnostic arch angiogram and diagnostic angio of carotid during the same operative session upon placing a Carotid Stent (37215) what codes would you use?
> Description of procedure is below.
> THANK YOU!
> 
> ...



Don't mean to confuse, you can (at least you could before the new codes) bill for the arch study, but *not *for the carotid study on the side being treated. If the opposide is imaged, you will need to add modifer 59 to that code.

37215 and 36221 are the codes I would code.



HTH


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## suela923@aol.com (Apr 19, 2013)

I have a couple of questions...
1) why wouldn't 36223 be used, wasn't the innominate selected?
2) is the angioplasty not billable because the stent is more comprehensive?

I am new to interventional radiology and I love this forum, I try to figure out what I would bill and then compare it to the answers...it's great practice for me.

Does anyone know of any kind of workbook I could get that would help me practice coding...especially catheter placement.

Thanks,
Sue


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## endrest (Apr 19, 2013)

Thank You Danny! The diagnostic arch 36221makes sense to me now. Appreciate it!


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## Jim Pawloski (Apr 23, 2013)

suela923@aol.com said:


> I have a couple of questions...
> 1) why wouldn't 36223 be used, wasn't the innominate selected?
> 2) is the angioplasty not billable because the stent is more comprehensive?
> 
> ...



To answer your questions, 36223 is part of the right carotid family, so it is bundled into the carotid stent, and bundled into any the the carotid codes on the right.  For the second question, stent placement supersedes atherectomy which supersedes angioplasty.
HTH,
Jim Pawloski, CIRCC


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## amneske (Apr 23, 2013)

Jim Pawloski said:


> For 36222 Catheter is in the common catotid and the carotid bifurcation is imaged, for 36223, the catheter is in the common carotid, and the intracrainal circulation is imaged.
> HTH,
> Jim Pawloski, CIRCC



can someone give me their definition of the intracranial circulation? i was under the impression that if anything beyond the skull base was imaged that was intracranial. Between the aortic arch and skull base was extracranial?


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## Jim Pawloski (Apr 23, 2013)

amcarter82 said:


> can someone give me their definition of the intracranial circulation? i was under the impression that if anything beyond the skull base was imaged that was intracranial. Between the aortic arch and skull base was extracranial?



You got it!  Common Carotids and bifurcations and the external carotids are extracrainal.
Thanks,
Jim Pawloski, CIRCC


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## carelitz (Nov 12, 2020)

Jim Pawloski said:


> To answer your questions, 36223 is part of the right carotid family, so it is bundled into the carotid stent, and bundled into any the the carotid codes on the right.  For the second question, stent placement supersedes atherectomy which supersedes angioplasty.
> HTH,
> Jim Pawloski, CIRCC



I have a report that states doc stented the RT common/internal carotid artery. The also did an angiogram of the carotid and cerebral arteries.

I saw in the CPT book under diagnostic studies of cerviocerebral arteries that, _*"diagnostic angiography of the cerviocerebral vessels may be followed by an interventional procedure at the same session. Interventional procedures may be separately reportable using the standard coding conventions."*_

I also found online this reference that seems to state both angiography and intervention can be billed together as the stented area is distinct from additional angiography. See Scenario One.


			https://evtoday.com/articles/2013-aug/bundled-cervicocerebral-angiography-and-intervention-codes
		


So am I correct in thinking I can bill 36223 59 (for the cerebral portion of angio) and 37215  for the stent to the carotid artery?

Thanks for any insight.


PROCEDURE PERFORMED:

   1. Selective right carotid cervical and cerebral angiogram.
   2. Right carotid artery stent 8-10 x 40 Xact stent with distal embolic 
      protection.

INDICATIONS FOR PROCEDURE:  This is a  gentleman who was found 
to have severe symptomatic bilateral carotid stenosis.  He underwent a 
very complex carotid endarterectomy on the left side by Dr. J and 
difficulty was related to the anatomically high location of the stenosis. 
Considering that the right carotid artery appeared even anatomically 
higher in the neck compared to the left, he was referred for carotid 
stenting because of high anatomical risk features.  Pros and cons of 
procedure were discussed, the CTA of the carotid was personally reviewed, 
consent was obtained.

TECHNIQUE:  Initial access obtained to the right radial artery via the 
modified Seldinger technique and 6-French glide sheath introduced.  
Verapamil 2.5 mg and heparin 4000 units given intraarterial upon sheath 
insertion.

A 5-French HH1 catheter was used to selectively engage the proximal right 
common carotid artery from the right radial approach and angiogram was 
obtained including cerebral Townes and lateral views.  Second arterial 
access was obtained to the right common femoral artery with micropuncture 
kit and modified Seldinger technique and initially 6-French sheath was 
introduced and 6-French 90 cm Cook shuttle sheath was used for the 
interventional part of the procedure.

The patient is on dual antiplatelet therapy with aspirin and Plavix and IV
heparin was used for anticoagulation during the procedure with therapeutic
ACT.

At the end of the procedure, the Angio-Seal closure device was 
successfully deployed to the right common femoral artery, and wrist band 
applied to the right wrist.

Blood loss was overall 70-80 mL.

The local anesthesia with 2 percent lidocaine, 2 mL to the right wrist and
15 mL to the right groin.

Procedure was performed otherwise without moderate sedation.

HEMODYNAMICS:  Initial blood pressure was 145/80 mmHg.

After the stent placement, there was hypotension with the lowest blood 
pressure of 85/45 mmHg, the patient received 50 mcg of phenylephrine, as a
part of protocol he received 2 mg of atropine and was started on IV 
dopamine at 4 mcg/kg/minute and received IV bolus of saline at 500 mL. 
Closing blood pressure was 100/50 mmHg.

RIGHT CAROTID AND CEREBRAL ANGIOGRAM:

   1. Right common carotid artery is a large, slightly tortuous vessel in 
      the proximal portion, taking off large innominate artery.  The 
      proximal and mid portion has no significant stenosis.
   2. The distal portion including bifurcation has 70 percent stenosis.
   3. Right internal carotid artery has an 80 percent ostial calcific 
      stenosis as continuation of the bifurcation stenosis.  This was 
      followed by large and normal-appearing carotid bulb and otherwise 
      patent cervical internal carotid artery.
   4. The intracranial portion of the right internal carotid artery has no
      evidence of significant stenosis, no aneurysm.  It gives rise to the
      right, so it gives rise to unremarkable right anterior and mid 
      cerebral artery without significant stenosis.
   5. Right external carotid artery is a medium-sized vessel with moderate
      luminal irregularities, no evidence of any significant stenosis.

Angioplasty and Xact stent of right carotid artery with distal embolic 
protection:  Initially, we placed the 260 cm Versacore wire from the 
radial approach to the proximal-mid right external carotid artery; 
however, I was unable to advance the HH1 catheter to the external carotid 
artery due to tortuosity of the bifurcation with right subclavian and 
right common carotid artery.  After several attempts, we switched to the 
femoral access.

From the femoral access, we were able to advance HH1 catheter to the 
proximal right carotid artery, then I was able to advance the Versacore 
wire to the mid right external carotid artery, but again HH1 catheter 
would not follow the wire and it would prolapse from the aortic root.

We then used a stiff angled Glidewire, which was successfully navigated to
the occipital branch of the right external carotid artery under 
control, then we were able to advance the HH1 catheter to the midportion 
of the right external carotid artery, the stiff Glidewire was removed and 
300 cm SupraCore wire was positioned. This allowed us to successfully 
navigate the 6-French 90 cm Cook sheath to the distal right common carotid
artery.

We crossed the lesion in the distal common carotid artery and ostial 
internal carotid artery with a 190 cm bare wire, which was navigated to 
the most distal portion of the cervical internal carotid artery and placed
the large NAV6 Emboshield filter to the mid straight portion of the right 
internal carotid artery.  Then, initial predilatation was performed with 4
x 30 mm balloon of the lesion up to 8 atmospheres for 20 seconds, atropine
1 mg was given prior to the inflation, then I attempted to position the 
stent, but it would not cross the lesion and we performed second 
predilatation with a 5 x 20 mm balloon, inflated up to 8 atmospheres for 
another 20 seconds, that allowed us successfully place the stent across 
the lesion from distal common carotid artery into the proximal internal 
carotid artery and deployed.  Then, we performed post-dilatation with a 6 
x 20 mm balloon, inflated up to 10 atmospheres for 20 seconds, and another
1 mg of atropine IV was given prior to inflation.

Final angiogram was obtained showed excellent procedural result, full 
stent expansion and apposition, no any significant residual stenosis, no 
extravasation, no dissection, no visible material in the filter with 
excellent flow.  The cerebral angiogram in Townes view was unchanged.  The
filter was removed, the filter time was 11 minutes.

The patient tolerated the procedure well.  There were no immediate 
vascular or neurological complications.

CONCLUSIONS:

   1. Severe symptomatic 80 percent right carotid artery stenosis in 
      patient with high anatomical risk for CEA as defined by Vascular 
      Surgery.
   2. Successful angioplasty at 8-10 x 40 mm Xact stent to the right 
      common/internal carotid artery with distal embolic protection.


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## carelitz (Nov 12, 2020)

mk2001 said:


> In scenario 1 they performed a bilateral angiogram so 37215 was for the right stent and 36223,59 was for the left angiogram.




Makes perfect sense! So the right side carotid and cerebral angiogram work is included in the right side carotid stent code! Thanks so much for your help.


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## Jim Pawloski (Nov 15, 2020)

Any images taken on the same side of the carotid stent placement is bundled into the carotid stent code - 37215.
HTH,
Jim Pawloski, CIRCC


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## carelitz (Nov 15, 2020)

Jim Pawloski said:


> Any images taken on the same side of the carotid stent placement is bundled into the carotid stent code - 37215.
> HTH,
> Jim Pawloski, CIRCC



Thanks, Jim!


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