# Struggling with this case HELP



## ndriley10 (Oct 18, 2011)

As a new vascular coder i am struggling with this case and what is bundled.  There were three different days of serivce. I know this case is long but any help would be appreciated.
This is what I have so far:  76937, 36010, 75825, 37620, 75940 for IVC filter
36556, 37201, 75896 (for the last 3 items)

Day 1
POSTOPERATIVE DIAGNOSIS:  Large deep venous thrombosis of left lower extremity involving the popliteal, common femoral and common iliac veins.

PROCEDURES PERFORMED:
1.  Ultrasound-guided access right internal jugular.
2.  Catheter in inferior vena cava.
3.  Inferior vena cava venogram.
4.  Inferior vena cava filter placement.
5.  Ultrasound-guided access into the left gastroc vein.
6.  Left lower extremity venogram.
7.  Catheter placement into the left external iliac.
8.  Left external iliac and inferior vena cava venogram.
9.  Angioplasty of left femoral vein.
10.  Placement of a 5-French 90 cm length catheter, 50 cm infusion length Unifuse lysis catheter extending from the tip location in the common iliac vein on the left down to the popliteal vein on the left.
11.  Ultrasound-guided access into the gastroc vein on the left.
12.  Triple-lumen catheter placement right internal jugular.
13.  Initiation of lysis therapy via UniFuse lytic catheter.

DESCRIPTION OF PROCEDURE:    
Under ultrasound guidance an 18-gauge needle was placed into the right IJ.  The ultrasound was used to avoid injuring surrounding structures and image was saved in archives.  Under fluoroscopic guidance a Bentson wire was passed into the IVC and subsequently the tract was dilated with a 10 French sheath followed by the placement of the delivery sheath for the filter into the IVC.  An IVC venogram was then performed.

The right common iliac vein is widely patent with slow flow out of the left common iliac vein.  The IVC appears to be widely patent with no evidence of any thrombus and the renal veins enter the IVC at the bottom of L1.  At this time, a Cook Celect filter was advanced through the sheath and was deployed under fluoroscopic guidance with the tip of the filter located at the top of L1.  There was no tilt noted on the IVC filter after placement.

At this time a Bentson wire was advanced through the sheath followed by placement of a triple lumen catheter with the tip of the catheter located into the right atrium.  All three ports of the triple lumen catheter were flushed and withdrew easily and the catheter was then secured into position with 3-0 Ethilon sutures.  The patient was then taken off the table and then replaced onto the table in a supine position.  The left popliteal fossa was then prepped and draped in sterile fashion.  Timeout was once again performed identifying the patient's name, medical record number and the procedure to be performed.

Under ultrasound guidance a 21-gauge needle was placed into the left gastroc vein which rapidly entered into the popliteal vein.  Mandril wire was placed followed by a 5-French sheath and a Kumpe catheter was then used to enter into the popliteal vein.  A left lower extremity venogram was then performed showing a complete occlusion of the femoral vein as well as multiple collaterals throughout the left thigh.  The Kumpe catheter was used to try to cross the femoral vein, but it was noted to be very difficult and at this time I switched out to a Quick Cross catheter and a Glidewire to cross the femoral vein.  There was significant difficulty crossing the mid femoral vein and it was suspicious at this time that some of this thrombus could have been chronic in nature.  At this time an Amplatz wire was left in place and the mid femoral vein was then angioplastied with a 4 mm diameter x 4 cm P3 balloon.  This allowed for passage of UniFuse lytic catheter.  The Quick Cross catheter was then advanced into the external iliac artery and another venogram was performed to evaluate the left external and left common iliac veins.  These veins were noted to have significant acute thrombus.  At this time the 5 x 90 x 50 UniFuse catheter was advanced under fluoroscopic guidance with the tip located into the common iliac vein on the left and with the entire infusion length coat passing through the left external, left common, left femoral and left popliteal veins.  At this time, the catheters were secured and TPA lysis was initiated in through the sheath at 0.5 mg of TPA per hour.  The heparin was flushed through a 6-French sheath that is located through the gastroc vein entering into the popliteal vein at 1000 units per hour.  The patient will return in 24 hours to have a followup lysis venogram performed.

Day 2
ROCEDURES PERFORMED:  Follow up venogram at 24 hours status post 24 hours of tissue plasminogen activator lysis left lower extremity.

DESCRIPTION OF PROCEDURE:   the catheters located in the left popliteal fossa were then prepped and draped in sterile fashion.    At this time the injection of contrast first through the sheath was performed showing a significant collateralization throughout the left thigh.  There were some flow disturbances within some of the collaterals but the collaterals do fill rapidly into the common femoral vein which was now patent.  Subsequently another injection was performed through the indwelling lysis catheter.  This identified once again an evidence of chronic thrombus throughout the left femoral vein with approximately a 50% thrombus resolvement in the left common femoral vein, left external iliac vein and left common iliac veins.  At this time it was felt best to continue TPA lysis.  There was no manipulation of catheters and the sheaths and catheters were then flushed thoroughly and continuation of TPA lysis at 0.5 mg TPA per hour was continued through the lysis catheter and heparin was continued at 1000 units per hour through the sheath.  The patient was then taken back to the ICU in stable condition.

FINAL IMPRESSION:
1.  Evidence of chronic thrombus within the left femoral vein.
2.  Acute thrombus within the left common femoral vein, left external iliac vein and left common iliac veins have been reduced by approximately 50-60%.
3.  Continuation of tissue plasminogen activator lysis at 0.5 mg per hour of tissue plasminogen activator.

Day 3
PROCEDURES PERFORMED:
1.  Followup venogram status post 48 hours of tissue plasminogen activator lysis of left lower extremity.
2.  Angioplasty of left popliteal vein.
3.  Angioplasty left femoral vein.
4.  Angioplasty left common femoral vein.
5.  Angioplasty left external iliac vein.
6.  Stent left femoral vein using an 8 x 60 Smart and an 8 x 40 Smart.
7.  Repeat followup venogram.
8.  Placement of a new Unifuse 5 x 90 x 50 lytic catheter.
9.  Continuation of tissue plasminogen activator lysis.

DESCRIPTION OF PROCEDURE:    The left popliteal fossa was then prepped and draped in sterile fashion.  
Contrast was first injected through the sheath and subsequently the UniFuse catheter to identify once again multiple collaterals throughout the left thigh and still no opening of the left femoral vein.  However, collaterals rapidly filled into the common femoral vein which appeared to have resolvement of the acute thrombus.  There was, however, still a significant stenosis in the left common femoral, left and left external iliac veins at this time.

The catheter was then changed out for an Amplatz wire, and serial angioplasties were performed of the left external iliac, left common femoral, left femoral, left popliteal veins.  The first angioplasty series was run with a 5 x 100 P3 balloon, and subsequently by a 7 x 100 P3 balloon.  After the angioplasty with the 7 mm balloon, a repeat venogram was performed showing some decent flow through the femoral vein but a significant stenosis that is residual despite two angioplasties in the mid femoral vein.  At this time, a third angioplasty was then performed using a 10 mm x 6 cm P3 balloon.  This angioplasty was performed of the left external iliac, left common femoral, left femoral veins down to and including the left popliteal vein.  Upon completion, a repeat venogram was performed, and the central portion of the left femoral vein was still significantly stenosed and did not allow free flow of contrast.  At this time, an 8 x 60 and an 8 x 40 Smart stents were then deployed under fluoroscopic guidance and then angioplastied with the 10 mm balloon.  Contrast injection now showed acute thrombus within the left femoral vein.  However, there was significant improvement compared to the preangioplasty and pre-stenting.  A Unifuse lytic catheter measuring 50 x 90 x 5-French was then replaced into the left lower extremity venous system extending from the common iliac vein down to the popliteal, and lysis was continued for another 24 hours at 0.5 mg of t-PA per hour.

FINAL IMPRESSION:
1.  Chronic thrombus and severe stenosis of the left femoral vein that was angioplastied with serial balloons starting with a 5 mm, followed by a 7 mm, followed by a 10 mm balloon and subsequently placement of an 8 mm Smart stents.
2.  Repeat angioplasties and angiograms now identifies an acute thrombus within the left femoral vein and left common femoral vein.  Subsequently, t-PA lysis was continued by the placement of another UniFuse catheter and continued t-PA at 0.5 mg per hour.  She will return in 24 hours for her 72-hour followup.


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## chembree (Oct 19, 2011)

This is what I have so far: 76937, 36010, 75825, 37620, 75940 for IVC filter.

To be honest with you I have not read the report enough to give you all the codes… because of time restraints but for the IVC I wanted to comment….

I would not code 76937 because this is a guidance code and interpretation of the images are included in the S&I codes. Also, the 75825 is bundled and there is not enough documentation to support it. There was known thrombosis before the procedure began. 

This is an article released by SIR this year on coding IVC's… 
Placement of an inferior vena cava filter is usually done after
obtaining access to the inferior vena cava and performing an inferior
vena cavagram to assess the size of the inferior vena cava, the
presence of anomalous venous drainage, to look for the presence of
thrombus and to assess the location of the renal veins.
These indications are primarily for the benefit of the interventional
radiologist in order to provide the necessary information of where to
properly position the inferior vena cava filter. The inferior vena cavagram
is very seldom performed in order to assess the actual need for
the filter, as that has usually been predetermined on the basis of the
patient's clinical information.
The cavagram, therefore, is considered to be “roadmapping,” as it is
used to determine only where the filter will be placed and not usually
if the filter should be placed. The inferior vena cava filter gram is not
to be separately coded for inferior vena cava filter placement.
Certain scenarios may exist in which the inferior vena cavagram is
considered necessary for diagnosis. If the unexpected diagnosis of
thrombus is made, the procedure is then in fact diagnostic. If the
decision of whether or not to place the filter is made on the basis of
the findings, then the cavagram is diagnostic. These indications
should be clearly defined within the context of the radiology report.
If the cavagram is diagnostic, then the interpretation code for the
venogram (75825) may be used with the –59 modifier, indicating
that both a diagnostic and therapeutic procedure have been performed
on the same day. _


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## donnajrichmond (Oct 19, 2011)

(add modifier 26 to the 70000 codes if you are coding for the physician doing this at a hospital)

Day 1 - 
76937 - US for vascular access (not included in the S & I) 
36010-59, 37620, 75940 - IVC filter placement
36556 - triple lumen cath placement
36005-59, 75820 - venous angiogram, lower extremity
35476, 75978 - angioplasty femoral vein
37201, 75896 - initiation of thrombolysis

Day 2 - 
75898 - f/u angio

Day 3 - 
75898 - f/u angio
35476, 75978 - angioplasty (possibly x 4, if there were distinct lesions, but do not code bridging lesions separately)
37205, 75960 - stent 
37209, 75900 - exchange of thrombolysis catheter


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## chembree (Oct 20, 2011)

I strongly discourage the use of 76937 for coding IVC’s. I would research this to make sure you are not over charging. 76937 code was developed for the use of ultrasound guidance for vascular access in conjunction with any other surgical procedure in which the use of ultrasound guidance is NOT inherent to the procedure. When you bill a S&I code you are billing for the supervision and interpretation of the images!


I am going to try to attempt to attach the July/Aug 2010 Society of Interventional Radiology article for you so you can make an educated choice! It clearly lays out the correct codes for this procedure.


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## chembree (Oct 20, 2011)

I am not sure if you can see this SIR attachment but if you need me to I can email it to you so you can make sure your codes are correct.


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## donnajrichmond (Oct 21, 2011)

c422rad said:


> I am not sure if you can see this SIR attachment but if you need me to I can email it to you so you can make sure your codes are correct.



That article says nothing about 76937.  It is discussing intraprocedural fluoroscopic imaging.  Your own statement that  "76937 code was developed for the use of ultrasound guidance for vascular access in conjunction with any other surgical procedure in which the use of ultrasound guidance is NOT inherent to the procedure." - indicates that 76937 is appropriate in this case since US is not inherent in an angiogram or other catheter based procedure such as this.  There is no other ultrasound imaging involved in this procedure other than access, therefore, ultrasound is not inherent in the procedure.  

You might want to look at the SIR Interventional Radiology Coding User's Guide where it says "It may be necessary to utilize ultrasound guidance to achieve vascular access in performing interventional radiology procedures.  This service represents additional physician work, utilizing a different imaging modality, and is separately reportable.  Code 76937 was created to report this service when performed in conjunction with any other surgical or imaging service where the modality of ultrasound imaging is not inherent. " 

Or you may want to look at CPT Assistant January 2009 where a Q & A concerning IVC filter removal included this "If either an internal jugular vein or femoral vein approach is used, physicians may also use ultrasound guidance.  In this event, code 76937, Ultrasound guidance for ascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure), would be reported.  

There are several Clinical Examples in Radiology articles discussing this code.  Winter 2005 includes a sample case of an IVC filter placement that includes use of 76937.


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## chembree (Oct 21, 2011)

donnajrichmond said:


> That article says nothing about 76937.  It is discussing intraprocedural fluoroscopic imaging.  Your own statement that  "76937 code was developed for the use of ultrasound guidance for vascular access in conjunction with any other surgical procedure in which the use of ultrasound guidance is NOT inherent to the procedure." - indicates that 76937 is appropriate in this case since US is not inherent in an angiogram or other catheter based procedure such as this.  There is no other ultrasound imaging involved in this procedure other than access, therefore, ultrasound is not inherent in the procedure.
> 
> You might want to look at the SIR Interventional Radiology Coding User's Guide where it says "It may be necessary to utilize ultrasound guidance to achieve vascular access in performing interventional radiology procedures.  This service represents additional physician work, utilizing a different imaging modality, and is separately reportable.  Code 76937 was created to report this service when performed in conjunction with any other surgical or imaging service where the modality of ultrasound imaging is not inherent. "
> 
> ...





I also pulled my information from SIR althought I do see your point about the 76937 in CPT assistant 2009 although the question is geared toward retrieving a cath and not placing one. I can see where you are coming from and justifying this charge. Although, the codes are changing to be all inclusive in 2012 I can see where this could support it until then.


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## ndriley10 (Oct 27, 2011)

*Many Thanks!!*

BLESS YOU PEOPLE for all your help.  I can't thank you enough!  I've been avoiding this one for days.  Thanks for the guidance!!!!:


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## ndriley10 (Oct 27, 2011)

OH NO!  I found a day four!

PROCEDURES PERFORMED:
1.  Follow up lysis venogram status post 72 hours of tissue plasminogen activator.
2.  Balloon angioplasty of left common femoral vein.
3.  Angioplasty of left femoral vein.
4.  Balloon angioplasty of left popliteal vein.
5.  Mechanical thrombectomy using AngioJet of the left lower extremity.
6.  Follow up venogram status post mechanical thrombectomy.

DESCRIPTION OF PROCEDURE:  
The followup venogram was first performed through the indwelling sheath in the left gastroc vein and subsequently through the lysis catheter that was located positioned into the left femoral vein, left common femoral vein and left external iliac vein.  Upon completion of the venogram it was felt that there was still acute thrombus remaining within the pain and therefore AngioJet was performed.  I used the 6-French AngioJet and made three passes with heparinized saline.  Upon completion another venogram was performed showing now flow through the vein, left femoral vein with little collateralization.  At this time, it was felt that balloon angioplasty was necessary due to the residual stenosis just above the level of the stents that were placed into the left femoral vein.  Balloon angioplasty was then performed first with a 7 x 100 PowerFlex balloon and then subsequently with an 8 x 100 Advance 18 LP balloon.  Upon completion of the angioplasties a repeat venogram was performed showing now dominant flow through the left popliteal vein.  The balloon angioplasty was performed with those two balloons through the left common femoral vein, left femoral vein and left popliteal vein, left external iliac veins.  Upon completion of the angioplasties a repeat AngioJet was performed which made one pass using the 6-French AngioJet and then subsequent venogram was performed.  The venogram at this time showed a dominant flow through the popliteal vein continuing through the femoral vein with minimal collateralization with widely patent stents in the left femoral vein noted and then subsequently with good outflow into the common femoral vein and subsequently the external iliac and common iliac vein.  At this time, it was felt that no further interventions were necessary.  All lysis was discontinued.  The catheters and sheaths were removed.  Pressure was held on the left popliteal fossa until hemostatic.  The patient was then taken back to the post anesthesia care unit in stable condition.

LEFT LOWER EXTREMITY VENOGRAM FINDINGS:  The initial venogram after 72 hours of lysis showed fresh thrombus within the left popliteal and left femoral vein.  The stents that were placed yesterday are thrombosed.  The injection through the lysis catheter identifies acute thrombus throughout the entire femoral vein with collateralization through some large thigh veins.  The veins are reconstituted at the level of the common femoral vein with some stenosis noted in the common femoral vein, mild stenosis of the external iliac vein and a good flow through the common iliac vein and the IVC.  There is no thrombus within the IVC filter that is currently in position.

POST ANGIOJET FOLLOWUP ANGIOGRAM FINDINGS:  After AngioJet, three passes with a 6-French AngioJet, there is significant improvement of the acute thrombus load now resolved.  There was residual stenosis within the popliteal vein, a residual stenosis superior to the stents that were placed femoral vein, a stenosis noted in the common femoral vein and the proximal external iliac vein.  These were then subsequently angioplastied with the sequential ballooning of 7 followed by an 8 mm diameter balloon and follow up angiogram status post the angioplasty shows now good flow through the entire venous system.  There was still some acute clot noted that at the femoral stents on the left.

FOLLOWUP AFTER LAST ANGIOJET MECHANICAL THROMBECTOMY:  There is now dominant flow through the left popliteal vein, left femoral vein, left common femoral vein, left external iliac vein and left common iliac vein.  There was no collateralization visualized.  There was minimal thrombus load residual with less than 5% of residual thrombus noted.  There was no thrombus within the IVC filter.

FINAL IMPRESSION:  Successful mechanical thrombectomy and balloon angioplasty of the left lower extremity venous system now with dominant flow through the left femoral vein, left common femoral vein, external iliac vein and the common iliac vein.  There is no significant cauterization and thrombus reduction was approximately 95%.


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## endrest (Feb 25, 2013)

Okay sorry! - this is my first time using this forum. I don't see my original question: 

Central Venogram of IVC filter with hand injection noted the IVC was occluded. Probed the clot. The wire would not penetrate.

I'm looking at 36010, 75825-26, what about the hand injection would you use code 37211 (and not 75825?)

Thanks!


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## Jim Pawloski (Feb 28, 2013)

endrest said:


> Okay sorry! - this is my first time using this forum. I don't see my original question:
> 
> Central Venogram of IVC filter with hand injection noted the IVC was occluded. Probed the clot. The wire would not penetrate.
> 
> ...



Thrombolytic infustion over an hour is needed to bill 37211.  Hand injections do not count.
HTH,
Jim Pawloski, CIRCC


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