Cardiology Coding Alert

Question: The cardiologist successfully accessed the right common femoral vein using ultrasound and the modified Seldinger technique. They initially used a micropuncture 4-French sheath and upsized it to a 6-French sheath. Next, the cardiologist placed a pigtail catheter to the level of the IVC confluence via the right common femoral vein. They performed a selective ascending venogram using digital subtraction angiography to ensure there was no evidence of thrombus before placing a large bore sheath. Next, they placed a pigtail catheter in the right atrium and right ventricle pulmonary arteries to allow for hemodynamic measurements and oximetry of the right atrium and pulmonary artery. The cardiologist placed the pigtail catheter at the level of the main pulmonary artery with selective angiography followed by pigtail catheter placement into the right and left pulmonary arteries and their segmental branches to further visualize thrombus severity and distal runoff. Due to the significant thrombus burden, the cardiologist exchanged the pigtail catheter over a .035 super core wire, and the 6-French sheath was upsized to a 22-French sheath with the use of serial venous dilators. The cardiologist gave Heparin to the patient via the peripheral IV line and inserted the guide delivery sheath into the main pulmonary artery. This was followed by careful manipulation into the right and left pulmonary arteries and their segmental branches. The cardiologist also performed a selective angiogram via the guide delivery sheath to ensure appropriate positioning adjacent to the thrombus burden. Next, they performed mechanical aspiration with multiple passes and successful thrombus extraction. Approximately five minutes afterward, surveillance measurements of pulmonary artery pressures were obtained. The guide delivery sheath was then removed followed by manual hemostasis of the right common femoral venous site. How should I report this scenario?

Delaware Subscriber

Answer: Report the following codes on your claim:

• 37184 (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel) with modifier 50 (Bilateral procedure) appended. Never report 37184 in conjunction with 61645, 76000, or 96374, per CPT^®.
• 36015 (Selective catheter placement, segmental or subsegmental pulmonary artery) with modifier 50 appended.
• +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)). Never report +76937 in conjunction with 0505T or 0620T for ultrasound guidance for vascular access), per CPT^®. Also, if the radiologist uses ultrasound guidance when accessing a vessel for a catheter placement but doesn’t record the images, do not report +76937 because this code’s descriptor tells you it requires permanent recording.