# IVUS Coding guidelines



## kvo (Feb 25, 2016)

Our Physicians have started using the Intravascular Ultrasound more and the guidelines that I have found still leave me with questions.  Sometimes the physician will use IVUS bilaterally and usually includes the Inferior Vena Cava. 
For example the Physician will measure the IVC, Right Common Iliac Vein, Right External Iliac Vein, Left Common Iliac Vein, and Left External Iliac Vein. 
Since this is being used to measure each vessel should each vessel be reported?  I see that a 50 modifier is not allowed and I do not see an MUE limit posted anywhere.
Would the correct coding be:
37252 (IVC)
37253 (RCIV)
37253 (REIV)
37253 (LCIV)
37253 (LEIV)

Any clarification is GREATLY appreciated.


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## carelitz (Nov 17, 2020)

This looks correct to me. I have the same question as you and am coding it the same way. I am counting the number of vessels imaged within each territory. If anyone has any insights to help this would be apprecated!
For my report i have come up with: red is *Tib/Per*, green *Fem/Pop* and blue *Iliac* territory. Am i coding this accurately?

*37252 (posterior tibial ) LT
37253 (fem/pop) LT
37253 (common iliac) LT *
*37253 (external iliac) LT
37253 (common iliac) RT *
*37253 (external iliac) RT*

75625 59
75716 59


PERIPHERAL ANGIOGRAM/ INTRAVASCULAR ULTRASOUND REPORT

Procedure performed:
ABDOMINAL AORTOGRAM, BILATERAL LOWER EXTREMITY ANGIOGRAM
LEFT POSTERIOR TIBIAL ARTERY / TIBIOPERONEAL TRUNK, LEFT POPLITEAL/SUPERFICIAL FEMORAL ARTERY, LEFT ILIAC ARTERY, RIGHT ILIAC ARTERY INTRAVASCULAR ULTRASOUND.





INDICATION FOR PROCEDURE:
This is an gentleman with known history of coronary artery disease, and peripheral arterial disease with MILD left leg claudication, abnormal resting ABI, and high degree more than 50% left SFA stenosis on arterial duplex ultrasound. Pros and cons of procedure were discussed, consent was obtained.



TECHNIQUE:
Vascular access obtained with micropuncture kit, and modified Seldinger technique to the right common femoral artery, and 5 French sheath introduced.

Five French IM catheter was placed to descending aorta above the origin of renal arteries, and abdominal aortogram obtained in AP projection.

Left iliac angiogram obtained with the IM catheter position to the left proximal iliac artery, same IM catheter was used for the left lower extremity angiogram, and was advanced across the aortic bifurcation to the left common femoral artery.

Right iliac angiogram, and right lower extremity angiogram obtained through the 5 French sheath in the right femoral artery.

Six French 45 cm Destination sheath was placed across the aortic bifurcation over the regular J wire, and used for the intravascular ultrasound of the left lower extremity.

Perclose closure device successfully deployed to the right common femoral artery upon completion of the procedure.

Moderate sedation provided with IV Versed 1 mg, and fentanyl 50 mcg.

Local anesthesia to the right groin with 2% lidocaine -15 cc.

Blood loss was 10 cc.

Anticoagulation provided with IV heparin with ACT of 212.

There were no immediate complications.



ABDOMINAL AORTOGRAM:
Normal-sized descending aorta, with mild luminal irregularity due to atherosclerotic plaque, no protruding or mobile plaque, no stenosis, no dissection, no aneurysm.

Right renal artery is a medium-large vessel without significant stenosis.

Left renal artery is a medium-large vessel with 50% proximal stenosis.



RIGHT LOWER EXTREMITY AND ILIAC ANGIOGRAM:
Common iliac artery is a large vessel with mild -moderate luminal irregularities.

Hypogastric artery is patent medium -large size vessel without significant stenosis.

External iliac artery is a large vessel without significant stenosis.

Common femoral artery is a large vessel without significant stenosis.

Deep femoral artery is a medium -large size vessel without significant stenosis.

Superficial femoral artery is a large-sized vessel with mild luminal irregularities, not more than 20% stenosis in mid and distal portion.

Popliteal artery is a large vessel with minimal luminal irregularities without significant stenosis.

Anterior tibial artery is a medium-size vessel without stenosis.

Tibio-peroneal trunk is a medium-sized vessel without significant stenosis.

Posterior tibial artery is a medium-sized vessel without significant stenosis.

Peroneal artery is a medium-sized vessel without significant stenosis.



LEFT LOWER EXTREMITY AND ILIAC ANGIOGRAM:
Common iliac artery is a large vessel without significant stenosis.

Hypogastric artery is patent medium -large size vessel without significant stenosis.

External iliac artery is a large vessel without significant stenosis.

Common femoral artery is a large vessel without significant stenosis.

Deep femoral artery is a medium -large size vessel without significant stenosis.

Superficial femoral artery is a large-sized vessel with 50% stenosis in mid portion.

Popliteal artery is a large vessel with minimal luminal irregularities without significant stenosis.

Anterior tibial artery is a medium-size vessel without significant stenosis.

Tibio-peroneal trunk is a medium-sized vessel without significant stenosis.

Posterior tibial artery is a medium-sized vessel with mild-moderate luminal irregularities.

Peroneal artery is a medium-sized vessel without significant stenosis.



INTRAVASCULAR ULTRASOUND OF THE LEFT POSTERIOR TIBIAL ARTERY / TIBIOPERONEAL TRUNK, LEFT POPLITEAL/SUPERFICIAL FEMORAL ARTERY, LEFT ILIAC ARTERY, RIGHT ILIAC ARTERY
300 centimeter Phoenix extra-support wire was navigated to the distal left posterior tibial artery

Philips 0.014 intravascular ultrasound catheter was flushed, prepped, and advanced it over the Phoenix wire to the mid left posterior tibial artery, pullback was performed, and images recorded. for the iliac artery intravascular ultrasound, the sheath was respectively pulled back to allow ultrasound images.

Intravascular ultrasound findings:

Left posterior tibial artery is 4 x 4 mm vessel with mild plaque without significant stenosis.

Left tibioperoneal trunk is 4.5 x 4.4 mm vessel with mild plaque without significant stenosis.

Left popliteal artery is 5 x 5.5 mm vessel with mild plaque without significant stenosis.

Left superficial femoral artery is 5.5 x 6.0 mm vessel with evidence of segments of negative vessel remodeling, with the highest area stenosis of 52%.

Left external iliac artery is 7.5 x 8 mm vessel with mild nonobstructive plaque.

Left common iliac artery is 8 x 10 mm vessel with minimal nonobstructive plaque.

Right common iliac artery is 9 x 10 mm vessel with minimal nonobstructive plaque.

Right external iliac artery is 8 x 9 mm vessel with mild nonobstructive plaque.


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## Jim Pawloski (Nov 17, 2020)

Don't forget to code your catheter placement. 36247 for the Lt Posterior Tibial Artery.
Thanks,
Jim Pawloski, CIRCC


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## carelitz (Nov 17, 2020)

Jim Pawloski said:


> Don't forget to code your catheter placement. 36247 for the Lt Posterior Tibial Artery.
> Thanks,
> Jim Pawloski, CIRCC



Thank you! The doc that performed this told me that i can only bill out four (4) IVUS codes because the iliac IVUSs are “one vessel, one IVUS”  each for the LT and RT. I tend to disagree as i thought within the Iliac Artery “territory” there are three billable vessels that may have one intervention (or image) each?

I originally has six coded and ready to bill out but now i am questioning myself.


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## Jim Pawloski (Nov 17, 2020)

IMO, that is all the same vessel, but I can't find any documentation, so I am not sure about IVUS imaging. I will check on it more.  As to your question of carotid stents, in the green printing after the codes 37215 and 37216, it states "(37215 and 37216 include all ipsilateral selective carotid catheterization, ALL DIAGNOSTIC IMAGING FOR IPSILATERAL CERVICAL AND CEREBRAL CAROTID ARTERIOGRAPHY, and all related radiological supervision and interpretation)." You can code for non stented angiograms.

Thanks,
Jim


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