Wiki IVUS Coding guidelines

kvo

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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.
 
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.
 
Last edited:
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.
 
Last edited:
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
 
Hi any help as how to bill this would be very much appreciated.

Pre-op. Diagnosis:
1.Chronic embolism and thrombosis of inferior vena cava - I82.221
Post-op. Diagnosis:
1.Chronically occluded bilateral iliac veins and IVC
Operation:
1.Ultrasound-guided access into the bilateral greater saphenous veins and the right internal jugular vein with permanent recording and reporting
2.Pelvic venogram and inferior vena cavogram
3.Intravascular ultrasound of bilateral iliac veins and inferior vena cava
4.Endovascular retrieval of inferior vena cava filter
5.Stent placement within the infrarenal IVC, left common iliac vein, right common iliac vein, right external iliac vein, and right common femoral vein
Anesthesia:
Local anesthesia with 1% lidocaine was administered at the access site. Anesthesia was provided by anesthesiologist Dr. Nguyen.
Indications:
Post-thrombotic syndrome. History of 3 year old IVC filter. Known occlusion of IVC and bilateral iliac veins.
Details of Procedure:
Informed consent for the procedure including risks, benefits and alternatives was obtained and time-out was performed prior to the procedure. The site was prepared and draped using maximal sterile barrier technique including cutaneous antisepsis.

Initial scout images showed a tilted Celect IVC filter.

The patient was positioned supine on the angiography table. Using ultrasound guidance, the patent bilateral greater saphenous veins were percutaneously accessed using a micropuncture needle. Permanent images were stored. 10 French sheaths were introduced at each access site. Contrast was injected and pelvic venogram performed. This revealed complete chronic occlusion of the right external and common iliac veins. The left external iliac vein was patent, without stenosis. Numerous pelvic, paravertebral, and abdominal wall collaterals were present. There was chronic occlusion of the infrarenal IVC at the level of the filter and extending caudally. The nose and hook of the filter was embedded within the right lateral caval wall. The struts extended outside of the cava. The inferior vena cava cephalad to the filter was patent.

Using ultrasound guidance, the patent right internal jugular vein was percutaneously accessed using a micropuncture needle. A permanent image was stored. Using this access, a 16 French sheath was placed. The tip of the sheath was placed at the level of the nose of the IVC filter. An endobronchial forceps device was then used to free the nose and hook of the filter from the caval wall. The nose of the filter was then grabbed with the forceps and the filter freed from the cava by advancing the sheath over the filter. The filter was then pulled out of the sheath. Examination of the filter revealed it to be intact.

Next, using a wire and catheter, the right iliac vein and IVC occlusion was crossed. Contrast injection in the IVC confirmed successful crossing. The left external iliac vein occlusion was then crossed via the left groin access with a wire and catheter. Contrast injection in the IVC confirmed successful crossing.

Parallel balloon angioplasty of the infrarenal IVC was then performed using 12 mm balloons. 12 mm balloon angioplasty of the left common iliac vein and right common iliac, external iliac, and common femoral veins was next performed.

Next, double barrel 14 mm Zilver Vena stents were deployed within the infrarenal IVC with extension across each common iliac vein. An additional 14 mm Zilver Vena stent was deployed within the right external iliac and common femoral veins. All stents were profiled with the 12 mm balloons.

Post stent reconstruction venograms showed excellent brisk flow throughout both iliac veins and within the IVC, without residual stenosis and with resolution of collateral filling.

Sheaths and wires were removed and hemostasis achieved using manual compression. Sterile dressings were applied.
Specimens:
None.
Complications:
None.
Findings:
Summary:

Chronic infrarenal IVC and bilateral iliac venous occlusions secondary to indwelling IVC filter. The IVC filter was successfully retrieved and iliocaval stent reconstruction performed, as described above.

Plan:

Start Eliquis 2.5 mg BID and aspirin 81 mg daily. Follow up in 2 weeks.
Notes:
Total fluoroscopy time: 15 minutes
Procedure Codes:
1.76937 US GUIDE, VASCULAR ACCESS. Units: 3.00. Modifiers: 26, 59
2.37193 REM ENDOVAS VENA CAVA FILTER. Modifiers: 22
3.37238 OPEN/PERQ PLACE STENT SAME, Inferior vena cava.
4.37239 OPEN/PERQ PLACE STENT EA ADD, Left common iliac vein.
5.37239 OPEN/PERQ PLACE STENT EA ADD, Right common iliac vein.
6.37239 OPEN/PERQ PLACE STENT EA ADD, Right external iliac vein.
7.37239 OPEN/PERQ PLACE STENT EA ADD, Right common femoral vein.
8.G9500 RADIATION EXPOSURE INDICES DOC.
9.36005 INJECTION EXT VENOGRAPHY.
10.75820 VEIN X-RAY, ARM/LEG.
11.37252 INTRVASC US NONCORONARY 1ST.
12.37253 INTRVASC US NONCORONARY ADDL.
 
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