# Endovascular AAA repair



## R1CPC (Jan 12, 2015)

My physician repaired the renal artery with a modular bifurcated prosthesis (1 docking limb) 34802, added and extender 34825 in the iliac artery, and added a stent to the iliac artery. My questions is the physician is coding 37223 for stenting the iliac artery is that correct? If it's not what code should we use?


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## lkfloyd (Jan 13, 2015)

37223 is an add on code to be used with additional stenting after initial vessel (iliac). 
37221 is the iliac stent placement code you need. hope this helped


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## R1CPC (Jan 13, 2015)

Yes that makes sense, I just had one more questions CPT says to use this code only when the stent is placed outside the target zone of the endoprosthesis, so for the scenario above would that mean if the physician had placed a stent inside the renal artery then we wouldnt be able to bill an additional code, is that correct?


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## lkfloyd (Jan 13, 2015)

of course without reading the actual op-report I can not be certain , but reading the CPT it says  that other interventional procedures performed at time of endovascular repair (34802) should be additionally reported., check your NCCI edits for proper modifier use (if any).


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## R1CPC (Jan 13, 2015)

After administration of general anesthesia and 2
grams of Ancef, the abdomen, groins and thighs were prepped with chlorhexidine
based soap prep followed by ChloraPrep.  He was draped with Ioban.  Transverse
incisions were made over both groins.  The common femoral arteries were quite
large, but not frankly aneurysmal.  They were controlled with vessel loops.  On
the right, micropuncture technique was used to cannulate the vessel and on the
left a Cook needle and Bentson wire was used.  As expected, the right iliac
system was much more tortuous than the left and took a little more time to get
up into it, but overall access was uneventful.  On the right side, a 16 sheath
was advanced.  Again, because of tortuosity, the Amplatz wire had to be
exchanged for a stiffer Lunderquist wire.  Once the tip of the sheath was in the
sac, a pigtail catheter was inserted to the renal level and on the left side,
the bifurcated 28 x 16 x 166 Endurant stent graft device was advanced also
proximally to the renal level.  Selective aortogram was performed delineating
the takeoff of the left, i.e. the lower of the two renal arteries.  The stent
graft was allowed to flower open and another angiogram was performed.  The
proximal portion of the stent graft was then seated just below the left renal
orifice.  The bare metal was released and then the device was opened up to
release the contralateral gate.  The gate was captured without too much
difficulty by Dr. Park and the pigtail wire was spun in the body of the graft to
confirm intraluminal placement.
At this point, an attempt was made to perform a retrograde angiogram through the
right iliac sheath to delineate the location of the external iliac artery.
Unfortunately, the artery was accordioned over the sheath and the anatomy could
not be determined.  An 8-French sheath was inserted through the 16-French sheath
and through this a second pigtail catheter was placed within the common iliac
aneurysm.  An injection here was able to determine the takeoff of the
hypogastric artery and the location of the proximal portion of the external
iliac artery.  A 13 x 13 x 82 extender limb was then inserted into the right
side, focusing placement of the distal portion at 3 cm beyond the external flush
hypogastric bifurcation.  Once this was deployed, a 16 x 13 x 199 limb was
advanced.  There was resistance in the 13 x 13 x 82 extender, so this was
ballooned.  Then, the 16 x 13 x 199 was advanced, but felt to be overall too
long.  Therefore, a 16 x 13 x 136 limb was used to finish the repair of the
common iliac aneurysm.
Attention was turned to the left side.  A pigtail marker catheter was inserted
and then a retrograde angiogram was performed.  The 16 x 13 x 199 left extender
device was then inserted.
Kissing balloon technique was used to iron out and seal the stent graft.  There
appeared to still be stenosis and pinching off of the distal aspect of the right
iliac limb, so a 10 x 40 balloon expandable stent was placed across the overlap
site of the two extender limbs.  A retrograde injection showed much more
satisfactory appearance of the right iliac system.
Finally, a completion angiogram was performed, which showed good opacification
of the renal arteries and no evidence of type 1 or type 2 endoleak and no
stenoses.
Wires and catheters removed.  The sheaths were removed, starting with the right
side and closing the arteriotomies with 5-0 Prolene.  After the left femoral
artery had been closed, the feet were checked and found to be warm and well
perfused.  The wounds were irrigated with bacitracin irrigation and closed with
3-0 Vicryl followed by 4-0 Monocryl subcuticular suture, Dermabond and
Steri-Strips.
Estimated blood loss for the entire procedure was about 200 mL due to issues
with a dislodged sheath, some difficulty clamping the huge femoral arteries, and
general leaking around the valves.  Floor time was 29.58 minutes.  Contrast used
was 80 mL.  The patient tolerated surgery well and was sent to recovery room in
stable condition.
The physician coded as followed:
34802-62
34812
34825
36200
37223
I'm new with this specialty and just want to make sure I'm not overcoding or missing a procedure. I think were I was confused was the CPT guideline said 37221 ok to bill with 34802 or 34825 as long as it's out of the treatment zone of the endoprosthesis so seeing that the physician added and extended cuff the iliac artery I wasnt sure if it would be appropriate to bill 37221 or 37223. 
Your help would be greately appreciated.


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## lkfloyd (Jan 13, 2015)

after reading the report, my thoughts are:
34802
34812
34825
36200
no justification for the additional 37221(37223)


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## R1CPC (Jan 14, 2015)

Hi there thanks for reviewing the report but I was wondering if you could explain why there is no justification for reporting CPT 37221.


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## lkfloyd (Jan 14, 2015)

there are CCI edits that come into play 
34812 Misuse of column two code with column one code to 37221
36200 Misuse of column two code with column one code to 37221
37221 is column 2 code to 34825

 modifiers are allowed in order to differentiate between the services provided.

the right side work is very well documented, however the left side is not, and the work seems to be in the same area therefore the XS mod (my opinion) would not apply either.


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## R1CPC (Jan 14, 2015)

I think where I'm getting confused is that CPT guidelines say* Code also only when transluminal angioplasty is performed outside the treatment target zone of (34802-34805, 34825-34826, 34845-34848, 34900, 0254T) * woldnt that mean it's ok if done during the primary procedure? The other confusion is that the dictation says the additional stent was placed because stenosis was founf in the iliac artery wouldnt that qualify as a separate structure since the endoprosthesis was placed in the renal artery? When would it be appropriate to code the above together?


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## lkfloyd (Jan 15, 2015)

"stent graft device was advanced also *proximally* to the *renal level* The proximal portion of the stent graft was then seated just below the left *renal orifice"* :The primary procedure is *"infrarenal" *(aka visceral aorta) and the extender limb was advanced into the iliac, 
CPT states if lesion/treatment extends across the margins of one vascular territory into another but can be opened with a single therapy, this intervention should be reported with a single code despite treating more than one vessel. 
This is where the hierarchy guidelines come into play with the CCI edits.


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## R1CPC (Jan 15, 2015)

Ah okay yes that makes sense I just needed that last info to explain to the physician. I appreciate you taking your time in getting back to me on this case. Thanks for your help


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## lkfloyd (Jan 15, 2015)

I'm glad I could help!


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