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IVR (Intraventional Radiology)

What is IVR ?

Interventional radiology (IR) is the use of medical imaging techniques to guide doctors as they diagnose and treat certain problems with blood vessels and lymph vessels throughout the body. IR is also called image-guided therapy. 

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What are the medical condition where intraventional radiology procedure are performed ?

Interventional radiology (IR) procedures can be performed to diagnose and treat a wide variety of medical conditions.

  1. Atherosclerosis (blockages in arteries)

  2. Peripheral artery disease (PAD)

  3. Deep vein thrombosis (DVT) and other blood clots

  4. ​Aneurysms (especially aortic aneurysms)

  5. Tumor embolization ((blocking blood flow to tumors)

  6. Uterine fibroid embolization (for treating fibroids)

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What are the common interventional radiology procedure ?

Some common interventional radiology procedures include:

  1. Angioplasty and stenting – Used to treat narrowed or blocked blood vessels.

  2. Biopsy – Removing tissue samples from organs for diagnosis, often guided by imaging.

  3. Drainage procedures – Inserting a catheter to drain abscesses or fluid collections.

  4. Embolization – Blocking abnormal blood vessels to treat conditions like tumors or aneurysms.

  5. Varicose vein treatment – Minimally invasive treatments to treat enlarged veins.

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There are how many type of vascular system for IVR ?

There are Five vascular system for IVR

  1. Arterial

  2. Venous

  3. Pulmonary

  4. Portal

  5. Lymphatic

Each system is coded separately.

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Note: Document must have to code IVR:

  • Catheter insertion point

  • Catheter end position

  • Vessels catheterized

  • Vessels visualized

  • Abnormal anatomy if any, because the order will be changed.

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What are Vascular Family and order ?

Primary Branch Vessels: Vessels that arise from a single branch from the aorta or vena-cava

Vessels that arise from the access site - vascular order

  1. First Order: Vessel that arises off the aorta or vena cava

  2. Second Order: Vessel that branches off from a first order vessel

  3. Third-Order: Vessel branching off from a second order vessel


Example of First order arises off the aorta arch

  1. Left Subclavian artery

  2. Brachiocephalic 

  3. Left common carotid artery

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Example of Second order arises off the first order vessel-

  • Right subclavian

  • Right common carotid artery

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What are Selective and Non-Selective catherization?

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Non-Selective Catherization: the catheter is inserted directly into a vessel (aorta, vena cava, portal vein, etc.); no additional movement of the catheter is made; no advancement of the catheter further.

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Selective Catherization: the catheter is inserted into a vessel (aorta, vena cava, portal vein, etc.) (the main branch-vascular family) then manipulated into a branched vessel (off the main branch-vascular family).

Caution: Any vessels through which the catheter passes in order to be placed into the aorta, etc., and /or passed through in order to reach a higher degree of selectivity toward the final selective catheter position are included in the coding of the final selective catheterization. The vessel of a high vascular family must be purposefully selected for examination/treatment.

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Important Note:

  • Once a catheterization is "selective" the non-selective catheterization is inclusive (so once the catheter is manipulated; drop the non-selective code)

  • Code each access—bilateral access or upper/lower extremity access.

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For example:

  • A catheter is placed into the right upper extremity, and into the aorta. This is non-selective (we did not select a vessel off the aorta). - (36200)

  • We then manipulated the catheter into the right brachiocephalic (innominate)—this becomes selective and we omit the non-selective code. -(36215)

  • We then manipulated the catheter into the right subclavian -this is a second order and we want to capture each selection separately. -(36216)

  • We then manipulated the catheter into the right internal mammary (thoracic) -this is a third order and we want to capture each selection separately. (36217)

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In which scenario 75625 can be coded with 75710 and 75716 ?

75625 :Aortography, abdominal, by serialography, radiological supervision and interpretation

75710 :Angiography, extremity, unilateral, radiological supervision and interpretation

75716 :Angiography, extremity, bilateral, radiological supervision and interpretation

75630 : Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation

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CPT 75625 (Abdominal aortography, radiological supervision & interpretation) can be reported with CPT 75710 or 75716 only when two separate diagnostic imaging studies are performed from two different catheter positions.

If the catheter is not repositioned, you should report 75630 instead of combining 75625 with 75710/75716.

 

Scenario 1: Report 75625 + 75710 (Unilateral Extremity Angiography)

Requirements:

  • Diagnostic abdominal aortogram is performed.

  • Catheter is positioned high in the abdominal aorta (e.g., at or above the renal arteries).

  • Images of the abdominal aorta are obtained.

  • The catheter is then repositioned near the aortic bifurcation or common iliac artery.

  • A unilateral runoff angiogram of one leg is performed.

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Codes: 75625 – Abdominal aortogram

75710 – Unilateral extremity angiography

Appropriate catheter placement code (e.g., 36200/36245 as applicable)

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Scenario 2: Report 75625 + 75716 (Bilateral Extremity Angiography)

Requirements:

Diagnostic abdominal aortogram performed first.

Catheter positioned high in the abdominal aorta.

Abdominal aorta is imaged.

Catheter is then repositioned to the distal abdominal aorta/aortic bifurcation.

Bilateral lower extremity runoff angiography is performed.

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Codes: 75625 – Abdominal aortogram

75716 – Bilateral extremity angiography

Appropriate catheter placement code

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When NOT to Report 75625 + 75710/75716.

If the physician: Performs one contrast injection from one catheter position, and Images the abdominal aorta and bilateral iliofemoral runoff without moving the catheter, then report 75630 only.

Preoperative Diagnosis:
Renovascular hypertension with suspected right renal artery stenosis.

 

Postoperative Diagnosis:

  1. Severe stenosis of the right main renal artery.

  2. Severe stenosis of the right accessory renal artery.

  3. Renovascular hypertension.

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Procedure Performed:

  • Ultrasound-guided micropuncture access of the right common femoral artery.

  • Catheterization of the abdominal aorta.

  • Abdominal aortography.

  • Selective right main renal artery angiography.

  • Selective right accessory renal artery angiography.

  • Balloon angioplasty and stent placement of the right main renal artery.

  • Balloon angioplasty and stent placement of the right accessory renal artery.

  • Completion renal angiography.

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Procedure:

After informed consent was obtained, the patient was brought to the angiography suite and placed in the supine position. The right groin was prepped and draped in the usual sterile fashion. Local anesthesia was administered.

Using ultrasound guidance, the right common femoral artery was accessed with a micropuncture needle. A micropuncture wire was advanced, followed by placement of a micropuncture sheath, which was exchanged for a 6 French vascular sheath.

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A pigtail catheter was advanced over a guidewire into the abdominal aorta at the level of the renal arteries. Contrast was injected, and an abdominal aortogram was performed. Imaging demonstrated severe focal stenosis involving the ostium of the right main renal artery and an additional severe stenosis involving a right accessory renal artery supplying the lower pole of the kidney.

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The pigtail catheter was exchanged for a selective renal catheter. The right main renal artery was selectively catheterized, and selective angiography confirmed approximately 90% ostial stenosis. A guidewire was advanced across the lesion. Balloon predilation was performed, followed by deployment of an appropriately sized balloon-expandable renal artery stent. Post-deployment balloon angioplasty was performed with excellent expansion of the stent.

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The catheter was then redirected into the right accessory renal artery. Selective angiography demonstrated approximately 80% ostial stenosis. The lesion was crossed with a guidewire, balloon angioplasty was performed, and a balloon-expandable stent was successfully deployed. Post-stent balloon angioplasty was performed with complete expansion.

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Completion selective angiography of both the right main renal artery and the right accessory renal artery demonstrated excellent stent position, brisk antegrade flow, no significant residual stenosis, no evidence of dissection, perforation, distal embolization, or thrombosis. Both renal arteries remained widely patent.

All catheters and wires were removed. Hemostasis was achieved with an arterial closure device. The patient tolerated the procedure well and was transferred to the recovery area in stable condition.

Coding Tips:

Never code angioplasty along with stent placement for the same artery but if it is peformed in different artery then you can code seperately.

Completion angiography after intervention is generally included in the intervention and is not separately reportable.

When to code diagnostic Aortogram ?

  1. The diagnostic angiogram is medically necessary and separately reportable, provided the documentation supports that it was performed to establish the diagnosis before any intervention like in above case.

  2. The diagnostic angiogram would not be separately reportable if: Previous angiography had already fully defined the lesions, and The current angiography was performed only to guide the stent placement or to confirm the final result.

 

For example: "The patient had known severe right renal artery stenosis on prior CTA. Angiography was performed only to guide stent placement." In that case, the angiography is considered integral to the intervention.

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When to code Moderate Sedation ?

Moderate Sedation Coding Guidelines (CPT)

Documentation must support moderate sedation

1.The operative note should document:

  • Indication for moderate sedation

  • Sedation medications (e.g., Midazolam/Versed, Fentanyl)

The Provider must be present at th time of initial administration of the drugs. If the provider is not present, the service will not be billiable

2. Minimum time requirement

  • At least 10 minutes of intraservice moderate sedation is required to report the initial CPT code (99151, 99152, 99155, or 99156).

3. Independent trained observer is required

When the physician performing the procedure also provides the sedation, an independent trained observer (such as an RN) must continuously monitor the patient's level of consciousness and physiologic status and have no other duties during that monitoring.

4. Time starts and stops

Starts:

  • When the physician begins face-to-face moderate sedation and monitoring.

Ends:

  • When the physician completes personal face-to-face monitoring after the procedure.

Procedure time is not subtracted from the sedation time.

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Example 

Moderate conscious sedation was supervised by me using IV Fentanyl and Versed, administered by a registered nurse. Continuous monitoring of the patient's heart rate, blood pressure, oxygen saturation, respiratory status, and level of consciousness was performed throughout the procedure. Total intraservice moderate sedation time was 15 minutes. The patient tolerated the sedation well without any immediate complications.

Thrombectomy and its type in IVR ?

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Thrombectomy is a procedure performed to remove a thrombus (blood clot) from a blood vessel to restore normal blood flow. It may be performed using catheters, balloons, aspiration devices, mechanical thrombectomy devices, or surgery, depending on the location of the clot.

Common Indications

  • Acute limb ischemia

  • Deep vein thrombosis (DVT)

  • Arterial thrombosis

  • Thrombosed arteriovenous (AV) fistula or AV graft for dialysis

  • Pulmonary embolism (selected cases)

  • Acute ischemic stroke

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Types of Thrombectomy

  1. Surgical Thrombectomy – The surgeon makes an incision in the blood vessel and removes the clot, often using a Fogarty balloon catheter.

  2. Mechanical Thrombectomy – A catheter-based device breaks up and removes the clot. Commonly used device are AngioJet™,Penumbra Indigo® System,Rotarex® / Aspirex®

  3. Aspiration Thrombectomy – Suction is used to aspirate (remove) the clot.

  4. Pharmacomechanical Thrombectomy – Combines clot-dissolving medication (thrombolysis) with mechanical clot removal.

 

Common Thrombolytic Drugs

  • Alteplase (tPA)

  • Tissue Plasminogen Activator (tPA) - Very common

  • Urokinase

  • Tenecteplase (TNK)

  • Reteplase

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Thrombectomy CPT code selection depends on three main factors:

  1. Approach (Open vs. Percutaneous)

  2. Vessel or access treated (Artery, Vein, Dialysis AV fistula/graft)

  3. Technique used (Mechanical, Aspiration, Surgical, Pharmacomechanical)

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Thrombectomy Coding Rule by AAPC

​Step 1: Identify the Type of Thrombectomy - Percutaneous Mechanical

There are two types of mechanical thrombectomy:

  • Arterial Mechanical Thrombectomy (37184-37186 )

  • Venous Mechanical Thrombectomy (37187-37188 )

 

Arterial Mechanical Thrombectomy

For arterial thrombectomy, determine whether the procedure is Primary or Secondary.

 

Primary Arterial Mechanical Thrombectomy (CPT 37184 & +37185)

A primary mechanical thrombectomy is performed when the main purpose of the procedure is to remove the thrombus (blood clot). The physician diagnoses the clot before the procedure and plans the thrombectomy as the primary intervention.

37184 Initial vessel treated

+37185 Second and all additional vessels within the same vascular family

 

Note: Report +37185 only once, regardless of how many additional vessels are treated within the same vascular family.

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Example:A patient presents with an acute arterial thrombus. The physician's primary objective is to remove the clot.

Procedure Performed

  • Mechanical thrombectomy

  • Balloon angioplasty

Coding

  • 37184

  • Angioplasty CPT code (if performed)

Although angioplasty was performed, the thrombectomy remains primary because clot removal was the primary intent of the procedure.

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Separate Vascular Family

If thrombectomy is performed in another vascular family through a separate access site:

  • Report 37184-59

____________________________________________________________________________________________​

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Secondary Arterial Mechanical Thrombectomy (CPT +37186)

A secondary mechanical thrombectomy is performed when clot removal is not the primary purpose of the procedure.Instead, the physician is performing another intervention, such as:

  • Balloon angioplasty

  • Stent placement

  • Lower extremity revascularization

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During the procedure, a clot is encountered and must be removed to complete the intervention successfully.

This is commonly called a Rescue Thrombectomy.

+37186 : Secondary arterial mechanical thrombectomy

 

Example :The physician plans to perform:

  • Balloon angioplasty

During angioplasty, a thrombus blocks the artery. The clot is removed before completing the angioplasty.

Coding

  • Angioplasty CPT

  • +37186

Since angioplasty was the primary procedure, thrombectomy is considered secondary.

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Important Coding Rule

❌ Never report:

  • 37184

  • +37185

  • +37186

together during the same intervention.

These codes are bundled by the National Correct Coding Initiative (NCCI) because a thrombectomy cannot be both primary and secondary during the same procedure.

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Venous Mechanical Thrombectomy

Unlike arterial thrombectomy, venous thrombectomy does not require distinguishing between primary and secondary procedures.

Initial Venous Mechanical Thrombectomy : 37187

Use this code for mechanical thrombectomy involving one or more veins in the same extremity.

 

Repeat Venous Mechanical Thrombectomy : 37188

Report this code when thrombectomy is repeated on a subsequent day during an ongoing course of thrombolytic therapy.

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Bilateral Venous Procedure

If thrombectomy is performed on both extremities through separate access sites:

  • Report 37187-50

AV Fisutla Graft Thrombectomy 

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What is an AV Dialysis Circuit?

An AV dialysis circuit is created to provide vascular access for hemodialysis.

It may be:

  • AV Fistula – Native artery connected directly to a vein.

  • AV Graft – Synthetic graft connecting an artery to a vein.

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Dialysis Circuit

Includes:

  • Arterial anastomosis

  • AV fistula/graft

  • Venous outflow

  • Axillary vein

Does NOT include:

  • Subclavian vein

  • Brachiocephalic vein

  • Superior vena cava (Central veins)

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AV Fistula Codes

CPT 36901–36906 

36901 – Diagnostic Evaluation Only

  • Diagnostic fistulogram (angiography) only

  • No intervention performed

36902 – Balloon Angioplasty

  • Diagnostic evaluation

  • Balloon angioplasty within the dialysis circuit

36903 – Balloon Angioplasty + Stent

  • Diagnostic evaluation

  • Balloon angioplasty

  • Stent placement within the dialysis circuit

36904 – Thrombectomy + Balloon Angioplasty

  • Diagnostic evaluation

  • Mechanical thrombectomy (clot removal)

  • Balloon angioplasty

36905 – Thrombectomy + Balloon Angioplasty + Stent

  • Diagnostic evaluation

  • Mechanical thrombectomy

  • Balloon angioplasty

  • Stent placement

36906 – Thrombectomy + Central Vein Intervention

  • Diagnostic evaluation

  • Mechanical thrombectomy

  • Balloon angioplasty and/or stent placement

  • Treatment of central veins (Subclavian vein, Brachiocephalic vein, or Superior Vena Cava)

 

Q.Can we code Fistulogram code seperately ?

The fistulogram (dialysis circuit angiography) is included in CPT codes 36901–36906.

 

Q. Which central veins are outside the dialysis circuit?

Answer: Subclavian vein, brachiocephalic vein, and superior vena cava.

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Q.Which central veins are outside the dialysis circuit?

Answer: Subclavian vein, brachiocephalic vein, and superior vena cava.

Thrombectomy & Revascularization

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What is an Straight forward lesion ?

Whenever the stenosis is upto 99% then it is said to be straighforward lesion.

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What is an Complex lesion ?

Whenever the stenosis is 100% then it is said to be Complex lesion.

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Difference Between Thrombus and Embolus

  • Thrombus: A thrombus is a blood clot that forms inside a blood vessel and remains attached to the vessel wall at its site of formation.

  • Embolus: An embolus is a clot or other material (such as fat, air, or plaque) that travels through the bloodstream and can become lodged in a smaller blood vessel, blocking blood flow. It may affect the lungs, brain, heart, or other organs.

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When to Choose Angioplasty vs. Stent

  • Angioplasty is performed first to widen the narrowed artery using a balloon.

  • If there is good blood flow, minimal residual stenosis (<30%), and no dissection or recoil, angioplasty alone is sufficient.

  • A stent is placed if there is significant residual stenosis, vessel dissection, or elastic recoil after angioplasty.

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Atherectomy is a minimally invasive procedure used to remove atherosclerotic plaque (fat, calcium, and cholesterol buildup) from the inside of an artery to restore blood flow. Special devices such as rotational, orbital, directional, or laser atherectomy catheters are used.

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What is orbital atherectomy ?

Orbital atherectomy is a minimally invasive procedure that uses a diamond-coated rotating crown to sand and remove calcified (hard) plaque from the inside of an artery. As the crown rotates in an orbital motion, it modifies the calcium while helping preserve the healthy vessel wall.

When is it Used?

  • Severely calcified peripheral arteries (especially lower extremity PAD)

  • Before balloon angioplasty or stent placement to improve vessel expansion

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Transluminal Atherectomy

Transluminal atherectomy is a minimally invasive endovascular procedure in which a catheter is passed through the inside (lumen) of a blood vessel to remove atherosclerotic plaque, restoring blood flow.

  • "Transluminal" means through the lumen (inside) of the blood vessel.

  • "Atherectomy" means removal of plaque from the artery.

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Revascularization is any procedure performed to restore or improve blood flow to a tissue or organ when an artery is narrowed or blocked.

Common Revascularization Procedures

  • Balloon Angioplasty (PTA) – Opens a narrowed artery with a balloon.

  • Stent Placement – Keeps the artery open after angioplasty.

  • Atherectomy – Removes plaque from the artery.

  • Thrombectomy/Embolectomy – Removes a blood clot.

  • Bypass Surgery – Creates a new route for blood flow around a blocked artery.

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Lower Extremity Endovascular Revascularization CPT codes (37220–37235) are organized based on three key principles:

1. By Vascular Territory (Not by Individual Vessel)

Each vascular territory is coded separately:

  • Iliac

  • Femoropopliteal

  • Tibial/Peroneal

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2. By the Highest-Level Procedure Performed

Only one primary code per treated vascular territory is reported, based on the most extensive intervention:

  • Angioplasty (PTA)

  • Atherectomy

  • Stent placement

  • Atherectomy + Stent (highest level)

If multiple procedures are performed in the same territory, report only the highest-level code for that territory.

 

3. By Additional Treated Arteries

If additional arteries within the same vascular territory are treated, report the appropriate add-on code (when applicable). If a different vascular territory is treated, report a separate primary code for that territory.

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For Lower Extremity Endovascular Revascularization (CPT 37220–37235), the terms initial vessel and additional (secondary) vessel apply only within the same vascular territory.

Code the Initial Vessel when:

  • It is the first artery treated in a vascular territory (Iliac, Femoropopliteal, or Tibial/Peroneal).

  • Report one primary CPT code for that territory.

 

Code an Additional (Secondary) Vessel when:

  • Another artery in the same vascular territory is also treated.

  • Report the appropriate add-on CPT code for each additional treated artery (when allowed by CPT).

Example

Treated vessels:

  • Right Common Iliac Artery – Stent

  • Right External Iliac Artery – Stent

  • Common Iliac = Initial vessel (primary code)

  • External Iliac = Additional vessel (add-on code)

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Venous Studies—Vena Cava

Follow arterial non-selective / selective guidelines

  1. Code selective, inclusive of non-selective.

  2. Code each vascular family to the highest order selected.

  3. Each vascular access is coded separately.

  4. Additional vascular families that are catheterized; code separately.

  5. Add-on codes are assigned as indicated.

Diaphragm is the dividing line between Upper and Lower extremity Interventional radiology.


 

Example 1 with imaging 

Accessing the right common femoral, the catheter is advanced into the aorta and contrast is injected for bilateral lower extremity run off study. 

ANSWER: 

  • 36200 (non-selective - aorta)

  • 75630 (bilateral extremity; no movement of the catheter)

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Example 2 with imaging

Accessing the right common femoral, the catheter is advanced into the aorta and contrast is injected for an aortogram. The catheter is pulled down into the distal aorta, contrast injected for bilateral lower extremity run off study.

ANSWER:

  • 36200 (non-selective -aorta)

  • 75625 (aortogram)

  • 75716 (bilateral extremity; catheter is moved distally in the aorta)

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Example 3 with imaging

The right axillary artery was accessed, and the catheter advanced to the aorta; contrast injected with imaging. The catheter is advanced into the right common iliac, contrast injected with imaging of the right lower extremity and right internal iliac.

ANSWER:

  • 36200 (non-selective) is omitted when the right common iliac is selected 36245

  • 75625 (aortogram)

  • 75710 (right lower extremity)

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What are the therapeutic intervention in IVR ?

Therapeutic Interventions Include

  • Angioplasty

  • Stents

  • Atherectomy

  • Embolization

  • Thrombolysis

  • Thrombectomy

  • Dialysis graft declotting

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What are the common therapeutic interventions?

Angioplasty and Stent: Angioplasty, also called balloon angioplasty, is a procedure that

opens arteries to let blood go through more easily. Latest angioplasty procedures also

involve inserting a short wire mesh tube, called a stent, into the artery during the

procedure. The stent is left in place permanently to allow blood to flow more freely.

 

Atherectomy: Atherectomy is a minimally invasive procedure healthcare providers use to

remove plaque buildup and open narrow or blocked arteries.

Types of atherectomy:

  • Excisional atherectomy: A blade cuts plaque in one direction.

  • Laser ablation atherectomy: A laser destroys plaque.

  • Orbital atherectomy: A spinning tool works like sandpaper to remove plaque.

  • Rotational atherectomy: Tiny blades cut plaque in a circular motion.

 

Embolization: Embolization procedures stop blood flow to a specific blood vessel.

Treatment works by placing a substance in the vessel to prevent blood from flowing through it.

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Thrombosis: Thrombosis happens when a blood clot (thrombus) forms locally in a blood

vessel and slows or blocks the flow of blood. There are two types of thrombosis:

 

Venous thrombosis is when the blood clot blocks a vein. Veins carry blood from the body

back into your heart. Deep vein thrombosis (DVT) is the most common type. It usually forms

in the deep veins of your lower leg. But it can also form in the veins of your thigh, pelvis, or

Arm.

 

Arterial thrombosis is when the blood clot blocks an artery. The arteries carry oxygen-rich

blood from the heart to the rest of your body.

 

Thrombolysis: Thrombolysis, also known as thrombolytic therapy, is a treatment to dissolve

dangerous clots in blood vessels, improve blood flow, and prevent damage to tissues and organs. Thrombolysis may involve the injection of clot-busting drugs through an intravenous

(IV) line or through a long catheter that delivers drugs directly to the site of the blockage.

 

Thrombectomy: of surgery to remove a blood clot from inside an artery or vein.

 

Embolism: An embolus is any foreign substance that moves in your bloodstream until it

blocks a blood vessel. An embolism is often caused when a thrombus or a piece of thrombus

breaks off from where it formed and travels to another area of your body.

An embolism is a life-threatening condition and can cause serious complications such as

stroke (clot in the brain) and pulmonary embolism (clot or blockage in the lung).

 

Dialysis graft declotting: Declot is a common interventional procedure that occurs in

arteriovenous fistulae (fistula declot) and grafts. A declot is done to remove any clogging or

narrow passages in arteriovenous fistulas and grafts to improve blood flow.

 

Need to Know:

  1. Diagnostic angiography performed at a separate setting from any interventional radiology procedure is separately reported.

  2. Diagnostic angiography performed at the time of any interventional radiology procedure is not separately reportable if it is specifically included in the interventional code descriptor.

  3. Modifiers may be appended when appropriate; watch edits!

  4. Whenever catheters are placed and then a decision is made to do an intervention on the same vessels, the catheter placement (selective and non-selective) are not coded separately, as they are bundled with the intervention CPTcode(s).

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Note: Ipsilateral means the same side of the body, Contralateral means opposite side of the body.

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Case Study 1 (Catheter placement only)

The left common femoral artery was accessed percutaneously, and a catheter placed in the aorta. Aortogram was obtained with an injection of contrast. The catheter was then cannulated in the left common iliac and a left lower extremity angiogram was performed. The angiogram showed a 60% stenosis in the superficial femoral artery (SFA). 

The catheter was then changed and parked in the SFA contrast was injected; angiogram performed; showing 85% stenosis in the anterior tibial artery. The decision was made at this time to perform stent placement/angioplasty in the SFA and atherectomy/stent/angioplasty in the anterior tibial artery.

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Answer : 

  • Access is ipsilateral...work was performed on the same side as the access (left)

  • Catheter placed in the aorta (36200)

  • Catheter went into the left common iliac (delete 36200 add 36245-LT)

  • Catheter went into the left SFA (delete 36245-LT, add 36247-LT, 36248-LT)

Code all selective catheterizations; if two third order, 36248 is coded for the 2nd 3rd order)

  • Atherectomy/DE stent/angioplasty left anterior tibial artery (delete 36247-LT, 36248-LT as the diagnostic is bundled into the intervention of the same artery(ies) 37231 -LT is added, 37226-LT is added for the SFA DE stent/angioplasty

Correct response: 37231-LT, 37226-LT
 

Case Study 2 

Endovascular laser ablation of three incompetent perforator vein(s), RT and LT,LE 

The patient was placed in reverse-Trendelenburg position and local anesthesia was instilled in the skin overlying the access site. The vein was accessed using ultrasound guidance. The laser catheter was prepped according to the IFU. The 21 g access needle was placed into the vein and positioned at a point at the layer of fascia and at least 1 cm from the deep venous system confirmed utilizing ultrasound guidance. 

After the laser catheter position was verified by ultrasound, local anesthesia was infiltrated into the tissue surrounding the treatment site. Laser energy was applied at 7W. Repeat ultrasound of the perforator vein was performed, confirming successful closure of the perforator vein with no extension of the thrombus into the deep venous system. The laser and needle were withdrawn, and hemostasis established with direct pressure. 

Answer: Right and left endovenous laser ablation

Correct Response: 

  • 36478-50—endovenous ablation therapy…first vein treated (1 RT, 1 LT) 

  • 36479 --subsequent vein(s) treated in a single extremity (third vein) 

Chart 1 : Angiogram & Angioplasty

 

PREOPERATIVE DIAGNOSES:

1. Left superficial femoral artery subtotal stenosis.

2. Arterial insufficiency, left lower extremity.

 

POSTOPERATIVE DIAGNOSES:

1. Left superficial femoral artery subtotal stenosis.

2. Arterial insufficiency, left lower extremity.

 

OPERATIONS PERFORMED:

1. Left lower extremity angiogram.

2. Left superficial femoral artery laser atherectomy.

3. Left superficial femoral artery percutaneous transluminal balloon angioplasty.

4. Left external iliac artery angioplasty.

5. Left external iliac artery stent placement.

6. Completion angiogram.

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FINDINGS: This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh. He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.

 

Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary. However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery. The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament. Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area. Ultimately, this wound up being a much more complex case than initially anticipated.

 

Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result. The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity. We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.

 

The left superficial femoral artery was dilated with a 6-mm balloon.

The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.

A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh. After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.

The patient had good dorsalis pedis pulses bilaterally upon completion.

The right common femoral artery was used for access in an up-and-over technique.

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PROCEDURE: With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.

 

The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed. We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery. We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire. A selective left lower extremity angiogram was then done with the above-noted findings.

 

We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery. Because of the findings as noted above, this became more involved than initially hoped for. Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area. Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.

 

Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.

Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.

 

Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery. Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.

 

The patient tolerated the procedure well throughout. He had good palpable dorsalis pedis pulses bilaterally on completion. He was taken to the recovery room in satisfactory condition. Protamine was given to partially reverse the heparin.

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Chart 2 : Angiography & Catheterization - 1

INDICATION: Acute coronary syndrome.

CONSENT FORM: The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. He understands. All questions answered and is willing to sign consent.

PROCEDURE PERFORMED: Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.

NARRATIVE: The patient was brought to the cardiac catheterization laboratory in a fasting state. Both groins were draped and sterilized in the usual fashion. Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery. Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery. Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.

FINDINGS
1. Hemodynamics systemic blood pressure 140/70 mmHg. LVEDP at the end of the procedure was 13 mmHg.

​2. The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.

The LAD is calcified and diffusely disease in the proximal and mid portion. There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.

3. The right coronary artery is dominant. It is septal to be occluded in the mid portion.

The findings were discussed with the patient and she opted for PCI. Angiomax bolus was started. The ACT was checked. It was higher in 300. I have given the patient 600 mg of oral Plavix.

The right coronary artery was engaged using a #6-French JR4 guide catheter. I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support. I was unable to cross with this lesion using a whisper wire. I was unable to cross with this lesion using Cross-IT 100 wire. I have also used second #6-French Amplatz right I guide catheter. At one time, I have lost flow in the distal vessel. The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.

Dr. X was notified.

Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel. I have performed careful balloon angioplasty of the mid RCA. I have given nitroglycerin under the nursing several times during the procedure.

I then performed arthrectomy using #5-French export catheter.

I performed more balloon predilation using a 3.0 x16 mm Voyager balloon. I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result. Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.

Left ventricular catheterization was performed with #6-French angle pigtail catheter. The left ventricle is rather smaller in size. The mid inferior wall is minimally hypokinetic, ejection fraction is 70%. There is no evidence of aortic wall stenosis or mitral regurgitation.

Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.

CONCLUSIONS
1. Normal left ventricular size and function. Ejection fraction is 65% to 70%. No MR.
2. Successful angioplasty and stenting of the subtotally closed mid RCA. This was hard, organized thrombus, very difficult to penetrate. I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. The RCA is dominant.
3. No moderate disease in the distal left main. Moderate disease in the ostium of the left circumflex artery. Mild disease in the proximal LAD.

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Chart 3 : Aortogram - Leg claudication.

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PREPROCEDURE DIAGNOSIS: Left leg claudication.
POSTPROCEDURE DIAGNOSIS: Left leg claudication.

OPERATION PERFORMED: Aortogram with bilateral, segmental lower extremity run off.

ANESTHESIA: Conscious sedation.

INDICATION FOR PROCEDURE: The patient presents with lower extremity claudication. She is a 68-year-old woman, who is very fearful of the aforementioned procedures. Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence. She appears to understand and agrees to proceed.

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​DESCRIPTION OF PROCEDURE: The patient was taken to the Angio Suite, placed in a supine position. After adequate conscious sedation, both groins were prepped with Chloraseptic prep. Cloth towels and paper drapes were placed. Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed. Guidewire was threaded followed by a
4-French sheath. Through the 4-French sheath a 4-French Omni flush catheter was placed. The glidewire was removed and contrast administered to identify the level of the renal artery. Using power injector an aortogram proceeded.

The catheter was then pulled down to the aortic bifurcation. A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach. The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery. The Omni flush catheter was advanced to the left distal external iliac artery. The glidewire rather exchanged for an Amplatz stiff wire. This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath. This was advanced into the proximal superficial femoral artery and an angiogram performed. I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.

The patient was given 5000 units of heparin and this was allowed to circulate. A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels. A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.

Final views after dilatation revealed a dissection. A search for a 5-mm stent was performed, but none of this was available. For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery. Post dilatation was performed with a 4-mm angioplasty balloon. Further views of the left lower extremity showed irregular change in the popliteal artery. No significant stenosis could be identified in the left popliteal artery and noninvasive scan. For this reason, I chose not to treat any further areas in the left leg.

I then performed closure of the right femoral artery with a 6-French Angio-Seal device. Attention was turned to the left femoral artery and local anesthesia administered. Access was obtained with the ultrasound and the femoral artery identified. Guidewire was threaded followed by a 4-French sheath. This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery. The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath. The destination was placed in the proximal superficial femoral artery and angiogram obtained. Initial views had been obtained from the right femoral sheath before removal.

Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery. For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon. A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation. No further significant abnormality was identified. To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery. A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis. Reasonable use were obtained and possibly a 4-mm balloon could have been used. However, due to her propensity for dissection I opted not to. I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length. This was placed into the left posterior tibial artery. A 2-mm balloon was used to dilate the orifice of the posterior tibial artery. I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel. Final images showed improved run-off to the right calf. The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.

FINDINGS: Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma. No evidence of renal artery stenosis is noted bilaterally. There is a single left renal artery. The infrarenal aorta, both common iliac and the external iliac arteries are normal. On the right, a superficial femoral artery is widely patent and normal proximally. At the distal third of the thigh there is diffuse disease with moderate stenosis noted. Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted. The perineal artery is functionally occluded at the midcalf. The dorsal pedal artery filled by collateral at the high ankle level.

On the left, the proximal superficial femoral artery is patent. Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery. This was successfully treated with angioplasty and a stent placement. The popliteal artery is diffusely diseased without focal stenosis. The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.

IMPRESSION
1. Normal bilateral renal arteries with a small accessory right renal artery.
2. Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.
3. The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries. Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.
4. Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement. Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.​

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