Interventional Part

should use code 37799 for the intracranial angioplasty and stent placement. This should be
discussed with your payer.

13) 28-year-old with recent subarachnoid hemorrhage, now with decreasing mental status. Via
right femoral puncture, a catheter is advanced into the right and left internal carotid and both
vertebral arteries (catheter placements in the carotid arteries are bundled into the vasospasm
angioplasty and diagnostic imaging codes). Diagnostic angiography is performed (36226-50;
imaging of the carotid arteries is bundled into the vasospasm treatment). Vasospasm is seen in
the carotid/cerebral arteries. Nicardipine is infused in both internal carotid arteries for 30
minutes each (61650, 61651). Follow-up angiography in both vessels (bundled) shows vertebral
flow to be improved, but intracranial angioplasty for vasospasm is required in both the right and
left supraclinoid internal carotid arteries and additionally of the right middle cerebral artery
superior and inferior M-2 branches (bundled with 61650 and 61651). This is performed without
complication. Follow-up angiography at 10 and 20 minutes shows excellent perfusion of distal
carotid and cerebral vasculature (bundled).

14) 70-year-old with right ICA aneurysm seen on MRA. The physician indicates it is medically
necessary to perform catheter-based angiography prior to consideration for therapy. Arch,
bilateral cervical, bilateral cerebral (36224-50), and bilateral vertebral (36226-50) angiography
are performed by selective catheterization of the vertebral and internal carotid arteries
(catheter placements are bundled). Images demonstrate a wide-mouthed aneurysm requiring
use of a scaffolding type stent (Enterprise or Neuroform) to safely perform the coil embolization
procedure. This is placed, followed by microcatheter placement across the stent struts into the
aneurysm. Five coils are subsequently placed with complete thrombosis of the aneurysm on
completion angiography (61624, 75894, 75898). A total of six additional follow-up studies were
performed during the intervention to ensure patient safety (add 75898-59 x 6 for medically
necessary intracranial embolization follow-up angiography). The stent placement is bundled into
the embolization procedure when done at the same setting. Final study shows vasospasm in the
M-1 segment, which is treated by a 10 minute infusion of verapamil (iatrogenic vasospasm is
bundled). Follow-up imaging (bundled with vasospasm therapy) shows patency of the M-1
segment.

Note: Had there been an embolus to M1 segment treated with a Penumbra System for clot
extraction, it would be appropriate to submit code 61645. Additionally, MUEs currently limit
the use of code 75898 to two times per date of service.

15) 30-year-old for petrosal vein sampling of the pituitary gland bilaterally. From a bilateral
femoral venous approach, two catheters are placed up the jugular veins and into the petrosal
sinus bilaterally. Venography along the route documents anatomy for localization. Venous blood
samples are obtained and sent to the lab (36500-50, 75893, 75893-59). (All venography and
catheter placements are bundled with venous sampling codes 75893 and 36500 respectively.)

16) 30-year-old status-post MVA with bulging exophthalmos. Via right femoral approach, an
arch, bilateral cervical, and bilateral cerebral angiograms (36223-50) are performed after
selecting the right and left common carotid arteries in this patient with bovine arch. A
carotid-cavernous fistula is seen via the right carotid injection. Cerebral flow is maintained. Via
a femoral venous puncture, a catheter is advanced into the right and then left jugular veins, and

venography (36012, 36012-59, 75860, 75860-59) shows rapid flow due to the fistula. Catheters
are advanced into the cavernous sinus on the right, and coils are tightly packed to occlude the
fistula (61624, 75894). Follow-up angiography via the right carotid injection shows complete
occlusion of the fistula (75898) and good cerebral flow without embolus.

17) 78-year-old with TIAs and 95% left common carotid origin stenosis and separate 95%
proximal internal carotid stenosis on recent angiogram. Surgical approach for endarterectomy is
performed with proximal and distal control. Access to the common carotid is via a direct left
carotid puncture via the cutdown, followed by placement of a wire and sheath. This is advanced
caudally. The patient is given 6,000 units IV heparin. Angiography shows the severe origin
stenosis (bundled). The lesion is crossed with guidewire. Pre-dilation with a 4 mm balloon
(angioplasty and catheter placement are bundled) followed by placement of a balloon
deployable stent (37217) across the stenosis. The stent is then flared slightly in the aorta. The
surgeon proceeds with the endarterectomy (billed separately). (Note: Use code 37218 if
performed via antegrade transfemoral approach.)

18) Patient with hypervascular vertebral body tumor compressing the spinal cord at T-11. Via
transfemoral approach, catheter placements into the T-9, T-10, T-11, T-12 intercostal, and L1
lumbar arteries are performed bilaterally (36215, 36215-59 x 7, 36245-50) with spinal imaging
(75705, 75705-59 x 9), demonstrating enlarged arteries at T-10 and T-11 bilaterally supplying
the hypervascular T-11 vertebral body. All four vessels are selected with advancement of a
microcatheter to a second order branch in each vessel (add 36216, 36216-59 x 3; delete 36215,
36215-59 x 3) and embolization with embospheres performed (37243). Follow-up angiography
of all four vessels (bundled) shows marked stasis of flow to the mass. Catheter is removed and
hemostasis obtained.

Note: Embolization of a vertebral body is a non-CNS, non-head and neck procedure. Use
embolization code 37243 to describe the procedure when the etiology is tumor and code 37242
when the etiology is a non-CNS vascular malformation. The MUE for spinal angiography code
75705 is 20.

19) Same case as example #18, except the pathology is suspected spinal cord (CNS)
arteriovenous malformation (AVM). Following catheterization and imaging of T9-L1 bilaterally
(36215, 36215-59 x 7, 36245-50, 75705, 75705-59 x 9), selection of the artery of Adamkiewicz
arising off the T-12 intercostal artery (add 36216, delete 36215) with imaging (75774) shows
supply to a thoraco-lumbar spinal AVM. Third order catheterization (add 36217, delete 36216) is
necessary to safely treat the AVM. This AVM is embolized (61624, 75894), requiring four
follow-up angiograms during the procedure (75898, 75898-59 x 3). Closure device is placed
(G0269).

Note: This is a CNS (spinal cord) embolization. Use code 61624 to describe the procedure.
Additionally, MUEs currently limit the use of code 75898 to two times per date of service.

20) Dehydrated child presents with severe headache, decreased level of consciousness, and
superior sagittal vein thrombosis on MRI. Via a femoral vein approach, a base catheter is
advanced to the left jugular vein (36012) and venography performed (75860), showing patent
vessel with slow flow. Microcatheter is advanced into the transverse, then superior sagittal sinus
with venography, showing thrombosis (75870). Thrombolytic infusion is started (37212). Patient

returns the next day for follow-up imaging, which demonstrates patency. The catheter is
removed (37214).
Note: If a venous angioplasty is used to treat underlying stenosis as the cause of thrombosis,
use code 37248. If a venous stent is placed to treat underlying stenosis as the cause of
thrombosis, use code 37238. The stenosis should be documented in the report.

21) Patient with dural AV fistula. Via a transfemoral approach, selective bilateral vertebral
(36226-50) and bilateral CCA injections with cervical and cerebral imaging (36223-50) are
performed. A catheter is advanced into the meningohypophyseal trunk off the left ICA (36228)
and left (PCOM) posterior communicating artery (36228) with imaging. The left thyrocervical
trunk (36218, 75774), two branches off this vessel (36218,
75774 x 2), and the left costocervical trunk (36218, 75774) are selected with imaging to further
evaluate the fistula. The fistula is then embolized with coils and glue (61624, 75894). Follow-up
shows occlusion (75898).

Transjugular Intrahepatic Portosystemic Shunt (TIPS)



7 Vascular Interventional Coding
Transjugular Intrahepatic Portosystemic Shunt (TIPS) Pages: 316-322

Procedure Coding Instructions
Physiology Example(s)
Clinical Indications References
Codes

PROCEDURE:
TIPS procedures usually require puncture of the jugular vein and placement of a catheter into
the hepatic vein with venography and pressure determinations. A metal needle is then
introduced through a long sheath to create a tract from the hepatic vein to the portal vein.
Once access to the portal vein is secured with a catheter and stiff wire, the tract through the
liver is first balloon dilated, then a stent or covered stent is placed to keep the tract open.
Diagnostic portography and pressures are obtained before and after this tract creation.
Embolization of varices is occasionally performed at this setting. Embolization is coded
separately. After an initial TIPS procedure, blockages or stenoses can occur along the shunt
resulting in a non-functioning shunt and recurrent symptoms. This usually occurs within six
months. A TIPS revision, which is similar to the initial shunt placement, can be performed to
remedy this problem. It is usually easier to traverse the stenosed or occluded shunt with a wire
than to create a new tract, so a different CPT code is used for a revision. A second TIPS is
occasionally necessary to successfully decompress the portal system and lower the
porto-systemic gradient to a level that prevents variceal bleeding (usually below 12 mmHg).

PHYSIOLOGY:
The portal system is a separate venous system in the abdomen. After arterial blood goes to the
abdominal viscera (liver, spleen, stomach, small and large bowel) it returns by venous drainage
through the portal system (splenic, portal, superior, and inferior mesenteric veins) to the liver
where nutrients are processed and toxins are removed. When a disease process in the liver
results in cirrhosis, causing the flow through the liver to slow down, the blood pressure (portal
pressure) in the portal system increases (portal hypertension) and blood is diverted through
pre-existing non-used venous communications (varices) to return to the heart. These varices, or
abnormally enlarged veins, may occur in the esophageal region (esophageal varices), in the
rectum (hemorrhoids), in the abdomen about the umbilicus (caput medusa), and near the
"ostomy" of a colostomy or ileostomy. When these varices ulcerate, bleeding complications
occur. These patients also tend to have difficulty processing and making proteins such as
albumin in the liver, resulting in hypoproteinemia and ascites (large collections of fluid in the

abdominal cavity). They also tend to develop encephalopathy related to the liver's inability to
break down some of the toxins in the body. This usually worsens after a TIPS procedure, but can
be controlled medically by ingesting lactulose, a medication that binds ammonia in the body
(which is responsible for the encephalopathy).

CLINICAL INDICATIONS:
The TIPS procedure is usually performed in individuals with severe portal hypertension and
symptomatology that is unresponsive to medical therapy. The procedure may help reduce
ascites in patients with massive recurrent ascites not responding to medical therapy. It also
can be used to dramatically reduce active esophageal variceal hemorrhage. There is an
approximate 50% mortality with each massive gastroesophageal variceal hemorrhage.
Processes that can damage the liver resulting in portal hypertension include cirrhosis
(secondary to hepatitis and ethanol abuse), hemosiderosis, hemochromatosis, and certain
congenital hepatic deposition diseases. The TIPS procedure is a mechanism to divert blood
flow and lower portal vein pressure. It does not cure or improve the underlying disease
process in the liver. TIPS may be performed prior to liver transplantation.

CODES: PROC CODE TS T
PROCEDURE DESCRIPTION 37248 O& O
Transluminal balloon angioplasty (except dialysis circuit), AT I AT
open or percutaneous, including all imaging and P AL C P AL
radiological supervision and interpretation necessary to CR O CR
perform the angioplasty within the same vein; initial vein VD V
UE U

5 B
1 8. u
9 68 n
2 dl
e
d

Transluminal balloon angioplasty (except dialysis circuit), N 4. B
open or percutaneous, including all imaging and / 22 u
radiological supervision and interpretation necessary to A n
perform the angioplasty within the same vein; each dl
additional vein (List separately in addition to code for 37249 e
primary procedure) ♦ 37182 d
Insertion of transvenous intrahepatic portosystemic
shunt(s) (TIPS) (includes venous access, hepatic and portal N 23 B
vein catheterization, portography with hemodynamic / .9 u
evaluation, intrahepatic tract formation/dilatation, stent A0 n
placement and all associated imaging guidance and dl
documentation) e
d

Direct intrahepatic portosystemic shunt (DIP) ♦ 37182 N 23 B
/ .9 u
A0 n
dl
e
d

Percutaneous mesocaval shunt ♦ 37182 N 23 B
/ .9 u
A0 n
dl
e
d

Revision of transvenous intrahepatic portosystemic 37183 5 10 B
shunt(s) (TIPS) (includes venous access, hepatic and portal 1 .9 u
vein catheterization, portography with hemodynamic 9 0 n
evaluation, intrahepatic tract recanulization/dilatation, 2 dl
stent placement and all associated imaging guidance and e
documentation) d

Percutaneous transluminal mechanical thrombectomy, 37187 5 11 B
vein(s), including intraprocedural pharmacological 1 .4 u
thrombolytic injections and fluoroscopic guidance 9 2 n
2 dl
e
d

Transcatheter therapy, venous infusion for thrombolysis, 37212 5 9. B
any method, including radiological supervision and 1 82 u
interpretation, initial treatment day 8 n

3 dl
e
d

Transcatheter therapy, arterial or venous infusion for 37213 5 B
thrombolysis other than coronary, any method, including 1 6. u
radiological supervision and interpretation, continued 8 79 n
treatment on subsequent day during course of 2 dl
thrombolytic therapy, including follow-up catheter e
contrast injection, position change, or exchange, when d
performed;

Transcatheter therapy, arterial or venous infusion for 37214 5 B
thrombolysis other than coronary, any method, including 1 3. u
radiological supervision and interpretation, continued 8 56 n
treatment on subsequent day during course of 2 dl
thrombolytic therapy, including follow-up catheter e
contrast injection, position change, or exchange, when d
performed; cessation of thrombolysis including removal of
catheter and vessel closure by any method

Transcatheter placement of an intravascular stent(s), open 37238 5 B
or percutaneous, including radiological supervision and 1 8. u
interpretation and including angioplasty within the same 9 73 n
vessel, when performed; initial vein 3 dl
e
d

Transcatheter placement of an intravascular stent(s), open N 4. B
or percutaneous, including radiological supervision and / 43 u
interpretation and including angioplasty within the same A n
vessel, when performed; each additional vein (List dl
separately in addition to code for primary procedure) 37239 e
d

Vascular embolization or occlusion, inclusive of all 37241 5 12 B
radiological supervision and interpretation, 1 .9 u
intraprocedural roadmapping, and imaging guidance 9 1 n
necessary to complete the intervention; venous, other 3 dl
than hemorrhage (eg, congenital or acquired venous e
malformations, venous and capillary hemangiomas, d
varices, varicoceles)

Vascular embolization or occlusion, inclusive of all 37244 5 19 B
radiological supervision and interpretation, 1 .3 u
intraprocedural roadmapping, and imaging guidance 9 n

necessary to complete the intervention; for arterial or 3 7 dl
venous hemorrhage or lymphatic extravasation e
d

1st or 2nd order selective venous catheter placement 36011 N
or 36012 / 4.
A 56
N 5.
/ 04
A

Percutaneous portal vein catheterization by any method 36481 N 9. 7 5
(with hemodynamics) / 74 5 1 1.
A 8 8 94
8 3
5

Percutaneous portal vein catheterization by any method 36481 N 9. 7 5
(without hemodynamics) / 74 5 1 1.
A 8 8 94
8 2
7

Selective catheter placement, venous system; first order 36011 N 4. 7 5
branch (eg, renal vein, jugular vein) (with hemodynamics) / 56 5 1 1.
A 8 8 55
8 3
9

Selective catheter placement, venous system; second 36012 N 5. 7 5
order, or more selective, branch (eg, left adrenal vein, / 04 5 1 1.
petrosal sinus) (with hemodynamics) A 8 8 55
8 3
9

Selective catheter placement, venous system; first order 36011 N 4. 7 5
branch (eg, renal vein, jugular vein) (without / 56 5 1 1.
hemodynamics) A 8 8 57
9 3
1

Selective catheter placement, venous system; second 36012 N 5. 7 5
order, or more selective, branch (eg, left adrenal vein, / 04 5 1 1.
petrosal sinus) (without hemodynamics) A 8 8 57
9 3
1

♦ Inpatient-Only Procedure Add-on Code>

CODING INSTRUCTIONS:
426. Codes 37182 and 37183 include imaging guidance, vascular access to the peripheral
venous system (jugular) as well as the portal venous system, hepatic and portal
diagnostic venography and pressures, venoplasty, and stent placement. Any additional
intervention outside of the liver (such as embolization, thrombectomy, or thrombolysis)
can be separately coded. Code 37182 is an inpatient-only procedure (status indicator C)
for Medicare patients. Code 37183 is a status indicator T procedure and may be
performed on an outpatient basis.
427. Use codes 75885, 75887, 75889, 75891, and 36481 (as appropriate) if the exam was for
diagnostic purposes without TIPS or TIPS revision.
428. Do not use code 75885 with 75887. Portography with hemodynamics (75885) includes
portography without hemodynamics (75887). Do not use code 75889 with 75891.
Hepatic venography with hemodynamics (75889) includes hepatic venography without
hemodynamics (75891). These codes are also not submitted with TIPS or TIPS revisions.
These codes are only used when the study is diagnostic in nature and there is no TIPS or
TIPS revision performed.
429. Do not report code 36481 if portography without pressures (75887) is performed via
an SMA arterial injection. Use code 36245 for the superior mesenteric arterial
catheterization instead. If done via a selective splenic injection, use code 36246 for the
arterial injection.
430. Treatment of thrombus, stenoses, occlusions, and varices outside the liver "TIPS zone"
is separately reported with codes 37187, 37212, 37238, 37239, 37241, 37244, 37248,
and 37249 as appropriate. Catheter placement in the splenic, mesenteric, or non-portal
venous branches and varices is separately coded.
431. Use code 37241 for embolization of non-bleeding varices.
432. Use code 37244 for embolization of actively bleeding varices.
433. Use code 37238 or 37248 for venoplasty or stent placement in the splenic or
mesenteric veins. Stent placement includes venoplasty here. All venoplasties, stents,
and embolizations in the TIPS and portal (intrahepatic) veins are considered part of TIPS
placement and revision codes 37182 and 37183, respectively.
434. Do not use codes 37238, 37239, 37248, and 37249 in the "TIPS treatment zone", as
venoplasty and stent placement in the TIPS zone are bundled with codes 37182 and
37183,

435. Use TIPS revision code 37183 to purposefully narrow or occlude the TIPS shunt with a
constricted stent or embolic material. This may occur when encephalopathic
complications make the TIPS undesirable. Occasionally we see this in the elderly when
TIPS is initially done for intractable ascites.

436. Use code 37182 to describe direct intrahepatic portacaval shunt (DIPS) with creation of
a channel between the portal vein via the caudate lobe of the liver and the inferior vena
cava. This procedure bundles the venography, catheter placement, venoplasty, tract
creation, and covered stent placement (similar to TIPS). We also recommend using code
37182 for percutaneous mesocaval shunt creation (in patients with portal vein
occlusion). This procedure is performed via an anterior abdominal approach. A needle is
advanced through the SMV and into the IVC, followed by covered stent graft placement
between these two vessels. You should discuss this with your payer.

437. Transhepatic portal vein embolization for treatment of neoplasm is described by codes
37243 and 36481.

438. Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices is
coded as a venous embolization (37241 and venous catheter placement - e.g., 36011,
36012) and may use a combination of sclerosing agent and coils at time of TIPS
placement or TIPS revision. Other methods of variceal treatment include BATO
(antegrade), CARTO (coil-assisted), and PARTO (vascular plug-assisted) transvenous
obliteration.

439. Portal vein branch embolization to stimulate hypertrophy of the opposite lobe of the
liver is reported with code 36481 once for venous access to all selected intrahepatic
portal vein branches and code 37243 for embolization of this side of the liver to shrink it
and cause hypertrophy of the opposite lobe.

EXAMPLE(S):

1) 38-year-old male with ethanol induced cirrhosis presents with massive recurrent variceal
hemorrhaging after failure of multiple sclerotherapy attempts. The right jugular vein is accessed,
and a 10 French sheath is advanced to the right hepatic vein. Venography with wedge and free
hepatic vein pressures are obtained. Using a Colapinto needle, puncture of the right portal vein
is successful. A wire followed by a catheter is advanced into the splenic vein. Imaging and
pressures are obtained. The tract is dilated with a high pressure 8 mm balloon, followed by
placement of a 10 mm self-expanding stent that covers the tract (37182). Portosystemic
gradient is now less than 12 mmHg, so no further therapy will be done.

2) Same patient as in above example returns three months later with recurrent active
esophageal variceal bleeding. The right basilic vein is accessed, followed by placement of a
catheter into the portal vein via the shunt. Shuntogram shows stenosis of the mid shunt and
massive varices. A new covered stent is placed across the stenosis and dilated (37183). Because
of the varices and recurrent active bleeding, a large gastroesophageal varix arising from the
splenic vein is selectively catheterized (36012) and embolized with eight coils (37244). Follow-up
angiography (bundled) shows complete occlusion of the varix and a patent shunt.

3) Same patient returns three months later with thrombosed splenic vein and occlusion of the
shunt. TIPS revision with balloon venoplasty is performed (37183) along with thrombectomy of
the splenic vein with a Trerotola catheter (36011, 37187). Follow-up angiography (bundled with
thrombectomy) shows residual clot. Three-hour continuous thrombolysis is required to resolve
all thrombus (37212). Follow-up angiography shows patency (bundled).
4) Same patient returns three months later. Portography with pressures (36481, 75885) shows
no evidence of stenosis or varices.

AV FISTULA

7 Vascular Interventional Coding
Arteriovenous Shunt Interventions Pages: 323-335

Procedure Coding Instructions
Physiology Example(s)
Clinical Indications References
Codes

PROCEDURE:
When an arteriovenous (AV) fistula or graft is not working properly, diagnostic imaging is
performed and interventions are attempted to correct the underlying cause. Interventions
include thrombectomy to remove clot, angioplasty to dilate blockages, placement of stents to

help maintain patency in resistant lesions or at sites of rupture, and embolization to exclude
venous branches that prevent maturation of an arteriovenous fistula.

PHYSIOLOGY:
Patients who have chronic renal failure often require dialysis. This may initially be performed
through temporary or permanent dialysis catheters; however, long-term dialysis patients
require the use of an AV fistula or graft. High flow access to the veins is necessary for dialysis to
purify the blood (remove waste). Dialysis is usually performed every two or three days. The
rapid blood flow required for dialysis may cause blockages to develop, resulting in shunt
stenosis, occlusion, and failure, requiring intervention to improve graft function. These
blockages tend to recur, eventually resulting in the need for a new shunt and placement of
central venous access catheters for temporary or permanent dialysis.

CLINICAL INDICATIONS:
Poor flow, abnormal dialysis parameters, clotted shunt, abnormal ultrasound of shunt, or
non-maturation of AV fistula.

CODES: TS T
PROCEDURE DESCRIPTION O& O
Introduction of needle(s) and/or catheter(s), dialysis AT I AT
circuit, with diagnostic angiography of the dialysis circuit, PROC CODE P AL C P AL
including all direct puncture(s) and catheter placement(s), 36901 CR O CR
injection(s) of contrast, all necessary imaging from the VD V
UE U

5 N
1 4. /
8 90 A
1

arterial anastomosis and adjacent artery through entire
venous outflow including the inferior or superior vena
cava, fluoroscopic guidance, radiological supervision and
interpretation and image documentation and report;

Introduction of needle(s) and/or catheter(s), dialysis 36902 5 N
circuit, with diagnostic angiography of the dialysis circuit, 1 6. /
including all direct puncture(s) and catheter placement(s), 9 98 A
injection(s) of contrast, all necessary imaging from the 2
arterial anastomosis and adjacent artery through entire
venous outflow including the inferior or superior vena
cava, fluoroscopic guidance, radiological supervision and
interpretation and image documentation and report; with
transluminal balloon angioplasty, peripheral dialysis
segment, including all imaging and radiological supervision
and interpretation necessary to perform the angioplasty

Introduction of needle(s) and/or catheter(s), dialysis 36903 5 N
circuit, with diagnostic angiography of the dialysis circuit, 1 9. /
including all direct puncture(s) and catheter placement(s), 9 24 A
injection(s) of contrast, all necessary imaging from the 3
arterial anastomosis and adjacent artery through entire
venous outflow including the inferior or superior vena
cava, fluoroscopic guidance, radiological supervision and
interpretation and image documentation and report; with
transcatheter placement of intravascular stent(s),
peripheral dialysis segment, including all imaging and
radiological supervision and interpretation necessary to
perform the stenting, and all angioplasty within the
peripheral dialysis segment

Percutaneous transluminal mechanical thrombectomy 36904 5 10 N
and/or infusion for thrombolysis, dialysis circuit, any 1 .7 /
method, including all imaging and radiological supervision 9 8 A
and interpretation, diagnostic angiography, fluoroscopic 2
guidance, catheter placement(s), and intraprocedural
pharmacological thrombolytic injection(s);

Percutaneous transluminal mechanical thrombectomy 36905 5 12 N
and/or infusion for thrombolysis, dialysis circuit, any 1 .9 /
method, including all imaging and radiological supervision 9 4 A
and interpretation, diagnostic angiography, fluoroscopic 3
guidance, catheter placement(s), and intraprocedural
pharmacological thrombolytic injection(s); with
transluminal balloon angioplasty, peripheral dialysis

segment, including all imaging and radiological supervision
and interpretation necessary to perform the angioplasty

Percutaneous transluminal mechanical thrombectomy 36906 5 14 N
and/or infusion for thrombolysis, dialysis circuit, any 1 .9 /
method, including all imaging and radiological supervision 9 5 A
and interpretation, diagnostic angiography, fluoroscopic 4
guidance, catheter placement(s), and intraprocedural
pharmacological thrombolytic injection(s); with
transcatheter placement of intravascular stent(s),
peripheral dialysis segment, including all imaging and
radiological supervision and interpretation necessary to
perform the stenting, and all angioplasty within the
peripheral dialysis circuit

Transluminal balloon angioplasty, central dialysis segment, N 4. N
performed through dialysis circuit, including all imaging / 28 /
and radiological supervision and interpretation required to A A
perform the angioplasty (List separately in addition to
code for primary procedure) 36907

Transcatheter placement of intravascular stent(s), central N 6. N
dialysis segment, performed through dialysis circuit, / 10 /
including all imaging and radiological supervision and A A
interpretation required to perform the stenting, and all
angioplasty in the central dialysis segment (List separately 36908
in addition to code for primary procedure)

Dialysis circuit permanent vascular embolization or N 6. N
occlusion (including main circuit or any accessory veins), / 04 /
endovascular, including all imaging and radiological A A
supervision and interpretation necessary to complete the
intervention (List separately in addition to code for 36909
primary procedure)

Selective catheter placement, arterial system; each first N 6. N
order thoracic or brachiocephalic branch, within a vascular 36215 / 18 /
family A A

Transcatheter placement of an intravascular stent(s) 37236 5 13 N
(except lower extremity artery(s) for occlusive disease, 1 .0 /
cervical carotid, extracranial vertebral or intrathoracic 9 0 A
carotid, intracranial, or coronary), open or percutaneous, 3
including radiological supervision and interpretation and
including all angioplasty within the same vessel, when

performed; initial artery

Transcatheter placement of an intravascular stent(s), open 37238 5 N
or percutaneous, including radiological supervision and 1 8. /
interpretation and including angioplasty within the same 9 73 A
vessel, when performed; initial vein 3

Transluminal balloon angioplasty (except lower extremity 37246 5 10 N
artery(ies) for occlusive disease, intracranial, coronary, 1 .1 /
pulmonary, or dialysis circuit), open or percutaneous, 9 4 A
including all imaging and radiological supervision and 2
interpretation necessary to perform the angioplasty within
the same artery; initial artery (central to upper extremity
shunt)

Transluminal balloon angioplasty (except dialysis circuit), 37248 5 N
open or percutaneous, including all imaging and 1 8. /
radiological supervision and interpretation necessary to 9 68 A
perform the angioplasty within the same vein; initial vein 2
(central segment venoplasty when not accessed via the
dialysis circuit)

Revascularization, endovascular, open or percutaneous, 37220 5 11 N
iliac artery, unilateral, initial vessel; with transluminal 1 .7 /
angioplasty (central to lower extremity shunt) 9 2 A
2

Revascularization, endovascular, open or percutaneous, 37224 5 12 N
femoral, popliteal artery(s), unilateral; with transluminal 1 .9 /
angioplasty (distal to shunt) 9 7 A
2

Secondary percutaneous transluminal thrombectomy (eg, N 7. N
nonprimary mechanical, snare basket, suction technique), / 14 /
noncoronary, non-intracranial, arterial or arterial bypass A A
graft, including fluoroscopic guidance and intraprocedural
pharmacological thrombolytic injections, provided in 37186
conjunction with another percutaneous intervention other
than primary mechanical thrombectomy (List separately in
addition to code for primary procedure)

Selective catheter placement, venous system; first order 36011 N 4. N
branch (eg, renal vein, jugular vein) / 56 /
A A

Selective catheter placement, venous system; second 36012 N 5. N

order, or more selective, branch (eg, left adrenal vein, / 04 /
petrosal sinus) AA
Introduction of needle or intracatheter, upper or lower
extremity artery 36140 N 2. N
/ 63 /
A A

Angiography, extremity, unilateral, radiological supervision 7 5
and interpretation 5 1 2.
7 8 45
1 3
0

Add-on Code

CODING INSTRUCTIONS:
440. Codes 36901-36909 describe the current practices for diagnosing and managing
dialysis shunts. The concept of the "dialysis circuit" is introduced and utilized within the
code descriptions.
441. The dialysis circuit (AV shunt) is currently surgically created (percutaneous shunt
creation is in development) either by directly anastomosing an artery to a vein (Cimino
shunt or AV fistula) or by placing a prosthetic graft in the extremity (straight or
U-shaped) with arterial and venous anastomoses. The AV fistula tends to last longer and
have fewer complications; however, it requires time to "mature" and enlarge to a usable
size. A tunneled dialysis catheter is often necessary for six weeks to support dialysis in
the interim. Occasionally these fistulae have branches that divert blood from the central
channel, preventing maturation, which may require vascular occlusion techniques
(percutaneous or open) to obtain a functional fistula. The AV graft is available for
immediate use (due to its 6 mm diameter); however, these shunts tend to have higher
re-stenosis rates, pseudoaneurysm development, and infection due to the repetitive
access of a prosthetic material. Both types of shunts will be referred to as the "dialysis
circuit".
442. The dialysis circuit includes the immediate arterial inflow, peri-anastomotic region,
arterial anastomosis, the limbs of the graft (if AV graft), venous anastomosis, and veins
of the extremity, including venous outflow through the central veins to the right atrium.
443. For interventional coding purposes, the dialysis circuit has been divided into two
segments: the peripheral segment and the central segment. These are described as
follows:

Upper Extremity
Peripheral Segment-Adjacent segment of native artery, peri-anastomotic
region/arterial anastomosis, fistula or graft, venous graft anastomosis,
and outflow veins up to and including the axillary vein (peripheral veins)
This also includes the basilic, brachial, and the entire cephalic vein. The
"central" cephalic vein is still in the peripheral segment.)
Central Segment-Subclavian vein, brachiocephalic vein, and superior vena
cava (central veins)

Lower Extremity
Peripheral Segment-Adjacent segment of native artery, peri-anastomotic
region/arterial anastomosis, fistula or graft, venous graft anastomosis,
and outflow veins up to and including the common femoral veins
(peripheral veins)
Central Segment-External iliac vein, common iliac vein, and inferior vena cava
(central veins)

444. Codes 36901-36908 describe procedures performed through a direct percutaneous
access or a puncture of the dialysis circuit. These codes include all accesses; catheter
movements within the circuit; contrast injections; imaging for diagnosis, guidance, and
follow-up S&I of the circuit; and access closure. Conscious sedation (99151-99153,
99155-99157) and ultrasound guidance for vascular access (76937) are separately
billable (however, code 76937 is only reported when the AV graft or fistula is
documented as either immature or failing). Catheter placement across the arterial
anastomosis up the proximal arterial inflow vessel substantially away from the
peri-anastomotic region (to evaluate the possibility of central native arterial inflow
disease) is separately reported with selective catheter placement code 36215 or 36245,
along with extremity arterial imaging code 75710. Routine crossing of the arterial
anastomosis with imaging of necessary parent artery is included in code 36901 and is
not separately billed. When imaging of the dialysis circuit is performed from a remote
access (not via direct access of the circuit), use code 36901-52 (or -74 for hospital billing)
as well as the remote arterial access catheter placement code (e.g., 36217 for right
brachial artery injection of fistula when access is via the common femoral artery). When
imaging is performed via pre-existing shunt access, only report code 36901-52 (or -74
for hospital billing).

445. Codes 36902-36909 do not require imaging of the dialysis circuit when imaging is not
necessary. If imaging is done, it is bundled.

446. Dialysis circuit intervention is based on which segment an intervention is performed in.
For the peripheral segment, a progressive hierarchy of codes is available: 36901 < 36902
< 36903 < 36904 <36905 < 36906. Only one code from 36901-36906 can be submitted
per session, with code 36906 being the highest level intervention.

447. The peripheral segment procedures include:

Angioplasty of one or more vessels for hemodynamically significant stenoses (36902)
(includes imaging);

Stent placement of one or more vessels for hemodynamically significant stenoses
(36903) (includes any angioplasty);

Thrombectomy of the dialysis circuit by any method [includes infusion thrombolysis,
percutaneous thrombectomy (including balloon maceration) of any involved
vessels in the peripheral and central segments (the entire circuit), as well as
imaging of the circuit (36904)]; and

Thrombectomy with peripheral segment angioplasty (36905) or stent placement
(36906).

All peripheral segment interventions include dialysis circuit access(es), imaging, and
catheter placements. Stent placements always include angioplasty anywhere in
the same segment.

448. Codes 36901-36909 include all catheter placements and imaging.
449. Codes 36901, 36907, and 36908 specifically require performance via a direct puncture

of the dialysis circuit.
450. For central segment angioplasty and/or stent placement, add-on codes 36907 and

36908 are used once per session, with angioplasty anywhere in the central segment
bundled with stent placement in the central segment. These two codes require the
procedure to be performed via direct access to the dialysis circuit.
Embolization/occlusion of branches or the entire dialysis circuit is described by add-on
code 36909, which includes all catheter placements, imaging, and embolization
necessary to occlude the branch(es) and/or entire dialysis circuit. Add-on codes 36907,
36908, and 36909 can be used with 36901 as the base code.
451. Occasionally a central segment angioplasty or stent placement is performed via a
remote access (e.g., femoral vein), and the catheter is advanced retrograde across the
SVC into the subclavian vein. When angioplasty or stent placement is performed via this
approach (and not via direct access to the dialysis circuit), submit code 37248 or 37238
respectively along with the appropriate selective catheter placement code (e.g., 36012).
452. If a separate upper extremity native artery stenosis (substantially away from the
dialysis circuit) is treated, submit code 37246 (angioplasty) or 37236 (stent placement)
along with the appropriate selective catheter placement code (e.g., 36215).
453. Do not use codes 37241 and 37244 for embolization of dialysis circuit vessels. This
procedure is described by add-on code 36909, which includes the catheter placement
and embolization of one or more venous branches.
454. Do not use codes 36901-36903 with open procedures described by codes 36818-36833.
Codes 36904-36906 also would not be used, as they describe thrombectomy, which is
inherent to codes 36831 and 36833.
455. When open surgical creation, revision, and/or thrombectomy is performed, do not
report code 36901 for angiography of the shunt. Any angioplasty, stent placement, or

thrombectomy within the peripheral segment is bundled with the open procedure. Do
not submit codes 36901-36906. When central angioplasty or stent placement is
performed at the same session due to significant stenoses, report add-on code 36907 or
36908 as appropriate.
456. Use codes 36904-36906 for percutaneous thrombectomy procedures in the peripheral
segment.
457. Use code 36831 or 36833 for open thrombectomy procedures in the peripheral
segment (36833 includes any angioplasty or stent placement in the peripheral segment).
Central segment angioplasty or stent placement is separately reported with code 36907
or 36908.
458. Use code 36832 for open revision in the peripheral segment (without thrombectomy).
This includes angioplasty or stent placement in the same segment.
459. Central venoplasty or stent placement (36907 or 36908) can be reported with open
revision/thrombectomy codes 36831-36833 and creation codes 36818-36830.
460. Code 36901 describes initial puncture and includes any eventual catheter placement
via this access site. This includes placement of the catheter into the superior or inferior
vena cava and across the arterial anastomosis. Code 36215 may be additionally reported
if the catheter must be moved further into the native upper extremity artery
(substantially beyond the peri-anastomotic region). If the catheter is advanced centrally
into the aorta, keep code 36215, as this is a higher level catheter placement than code
36200. Report code 75710 for imaging of these native upper extremity arteries.
461. To perform invasive diagnostic shunt/fistula studies (36901), the medical necessity
must be documented in the medical record as to what the medical necessity is. Routine
surveillance does not meet medical necessity requirements and may lead to payer
audits with potential compliance implications.
462. Code 36901 is an all-inclusive code describing imaging before, during, and after
intervention. This includes all necessary imaging of the arterial inflow, the shunt itself,
venous outflow, and central venography up to the level of the right atrium. Code 36901
includes all necessary accesses and catheter movements within the AV fistula/graft.
Code 36901-52 (or -74 for hospital billing) is for evaluation performed via a pre-existing
AV graft catheter or from a remote access. If angioplasty or stent placement is
performed of the peripheral segment of the dialysis circuit via a remote access, use code
36902-52 or 36903-52 (or -74 for hospital billing) respectively (also submit the
appropriate selective catheter placement code when via remote access).
463. If a diagnostic dialysis circuit study is performed via a brachial artery access, report
catheter placement code 36140 and 36901-52 (or -74).
464. Use code 36904 for thrombectomy of clotted AV shunts anywhere in the dialysis circuit
(including the central segment up to the right atrium). Code 36904 includes mechanical
methods such as thrombectomy devices and Fogarty balloon extractions as well as
pharmacological methods such as dissolving the clot with thrombolytic agents, including
"lyse and wait" procedure. Utilization of one or multiple methods is included in the

single code 36904.
465. If angioplasty or stent placement in the peripheral segment is performed at the time of

thrombectomy, use code 36905 or 36906 respectively. These codes include dialysis
circuit thrombectomy and/or infusion thrombolysis, catheter placements, and
diagnostic imaging.
466. Codes 36904, 36905, and 36906 include a catheter-directed prolonged (usually
overnight) continuous infusion for venous thrombolysis performed anywhere in the
dialysis circuit, including the central segment (e.g., for treatment of superior vena cava
syndrome due to SVC occlusion and thrombosis in patients with ipsilateral AV shunts).
467. Code 36902 applies to the entire peripheral segment, including the arterial
anastomosis and peri-anastomotic region. If the only stenosis treated with venoplasty is
in the native cephalic or basilic vein, code 36902 still applies.
468. Use codes 37220, 37224, and 37246 as appropriate to describe angioplasty of the
native artery separate from the peri-anastomotic region. Use code 36902 for
angioplasty of the peri-anastomotic region, an arterial anastomosis, or within the
peripheral segment of a fistula/graft in the lower or upper extremities as appropriate.
Use codes 36903, 37221, 37226, and 37236 as appropriate to describe stent placement
at the same locations as above.
469. Use code 37246 for angioplasty of the upper extremity native brachial, radial, ulnar,
subclavian, or brachiocephalic artery stenosis significantly away from the arterial
anastomosis. Use code 37236 if a stent placement is necessary at this site (angioplasty is
bundled).
470. Only code one angioplasty procedure per treatment segment, no matter how many
"lesions" are dilated in each segment. Do not code for multiple angioplasties when
several different dialysis circuit structures in one "segment" are treated.
471. Only code one stent placement procedure per treatment segment, no matter how
many "lesions" are stented in each segment. Do not code multiple stent placements
when several different dialysis circuit structures in one "segment" are treated. Stent
placement in a segment includes any angioplasties in the same segment.
472. Code one angioplasty or stent placement for contiguous or bridging lesions.
473. Angioplasty performed at the arterial anastomosis (or perianastomotic region) is
reported with code 36902 for this upper extremity intervention if it is the only stenosis
treated. Code 36902 includes an upper extremity venous angioplasty (in the same
peripheral segment) when performed. If a stent is also placed anywhere in the same
peripheral segment, only the stent is coded (36903), as the angioplasty/venoplasty is
bundled. If a separate "native" upper extremity arterial angioplasty is performed (and it
is separate from the peri-anastomotic region), then code 37246-59 may additionally be
submitted.
474. Stenoses treated must be "hemodynamically significant" and must be considered
medically necessary to code for angioplasty or stent placement. Prophylactic angioplasty

is not considered medically necessary and should not be billed. Balloon maturation of a
fistula is not reportable. Balloon maceration of thrombus is considered part of
thrombectomy (36904).
475. Do not code venoplasty if a stenosis is not documented. The stenosis must be
hemodynamically significant to submit venoplasty codes (at least 50% diameter stenosis
per recent OIG settlements). Medicare does not reimburse for "prophylactic"
angioplasty.
476. Hemodynamically significant stenoses usually need to be documented as greater than
or equal to 50% diameter stenosis. Do not use terms such as mild, moderate, and severe
to describe stenoses.
477. Only bill one "balloon treatment" code per extremity from the peri-anastomotic region
up to and including the axillary vein. Dialysis circuit angioplasty (36902) should be billed
once for all angioplasties in the peripheral segment of the dialysis circuit.
478. Code stent placements by segments (peripheral or central) following the same rules
that govern venoplasties; however, venoplasty is bundled with stent placement when
done anywhere in the same segment.
479. All catheter accesses and placements (via a circuit access) within the dialysis circuit are
included with codes 36901-36909.
480. Report embolization of collateral or branch vein(s) (e.g., with coils) as one surgical site
with add-on code 36909. Selective venous catheter placements are bundled. Diagnostic
shunt study (36901) can be a base code for add-on code 36909. If you place a catheter
into the upper extremity native artery substantially away from the peri-anastomic
region, report code 36215 in addition to 36901. Imaging of the native extremity arteries
is reported with code 75710. (If the catheter is advanced further centrally into the aorta,
catheter placement code 36215 remains the same and does not change to 36200.) All
venous branch selections are included in codes 36901-36909.
481. For coding purposes, any graft is considered one vessel, so you cannot code for
interventions of both arterial anastomotic and venous anastomotic stenoses. Only code
for the dialysis circuit peripheral segment angioplasty in this circumstance.
482. If two different percutaneous interventions (angioplasty and stent placement) are
performed at two separate stenoses in one segment, only submit the code for the stent.
Use code 36903 or 36906 for stent placement with or without thrombectomy in the
peripheral segment of the dialysis circuit respectively. Use code 36908 for stent
placement in the central segment of the dialysis circuit.
483. Do not use code 36904 more than once regardless of the number of methods used to
remove the clot from the dialysis circuit and immediate inflow and outflow regions.
484. Use code 36904 for declotting by thrombolysis or thrombectomy substantially away
from the the actual graft, but within the dialysis circuit.
485. Do not use code 36904 for thrombectomy of grafts or vessels unrelated to dialysis (e.g.,
femoral/popliteal bypass graft). Codes 37184-37188 are described in the "Percutaneous

Thrombectomy" section and are specific to percutaneous arterial and venous
thrombectomy procedures unrelated to the dialysis circuit.
486. Do not code a venoplasty (36902) for "balloon maturation" of a fistula. There is no
actual stenosis in this case, and the use of a balloon to dilate a normal small vein
(non-stenotic) is not reportable.
487. Do not code the use of a balloon catheter to macerate clot as a venoplasty. It is
included in thrombectomy code 36904.
488. Balloon maceration of thrombus is part of dialysis circuit thrombectomy code 36904.
Peripheral segment balloon dilation of underlying venous anastomotic stenosis
associated with thrombectomy (must be documented) is reported as a thrombectomy
with venoplasty with code 36905 (code 36904 would not be reported).
489. Do not code angioplasty for use of a balloon to "pull the arterial plug". This is part of
thrombectomy code 36904.
490. Do not code separately for inferior vena cavagram (75825), superior vena cavagram
(75827), extremity venogram (75820), or follow-up angiography (75898) with dialysis
circuit venography. These are all included in code 36901.
491. Do not code follow-up angiography (75898) with dialysis circuit thrombectomy. This is
included in code 36904.
492. Use unlisted vascular code 37799 for use of atherectomy device to remove stenosis
caused by "intimal hyperplasia" in the dialysis circuit. The Diamondback Orbital
atherectomy device is FDA-approved for use in dialysis grafts. Use code 0237T to
describe native brachiocephalic arterial atherectomy. Atherectomy is coded in addition
to angioplasty or stent in the same vessel.
493. Do not code percutaneous stent placement (37238) for venous stent or stent graft
placed via the dialysis circuit for graft or vein rupture, stenosis, or pseudoaneurysm in
the dialysis circuit. Use code 36903, 36906, or 36908 as appropriate. Code 37238 is
appropriate when the stent is placed via a remote access (not via the dialysis circuit
access) for central venous stenosis treatment.
494. Report only the stent placement code (36903 or 36906) if an initial venoplasty is
performed in the same segment, or add-on code 36908 depending on the segment
treated and whether concurrent thrombectomy is done. This may be due to significant
residual stenosis, acute occlusion, or vessel rupture after venoplasty. This rule applies to
all angioplasties and stent placements performed in the same vessel (vein or artery) and
for dialysis circuit interventions in the same peripheral or central "segment".
495. Ultrasound guidance for vascular access (76937) may be reported with AV access
procedures if indicated and documented appropriately. There should be documentation
that the fistula is immature or the dialysis circuit is failing.
496. If an arterial anastomotic stent and a central venous stent are placed via the dialysis
circuit, use peripheral segment stent code 36903 and central segment stent add-on
code 36908.

EXAMPLE(S):

1) Patient presents with a clotted left forearm AV dialysis graft. The graft is accessed from both
the arterial and venous sides (one for diagnosis, the other for therapeutic reasons) (36901).
Images are performed of the graft followed by imaging of the arm veins, central veins, and
superior vena cava (included in 36901). Stenoses of the arterial anastomosis, venous
anastomosis, basilic vein, and subclavian vein are identified. A mechanical thrombectomy with
balloon extraction as well as administration of a thrombolytic agent is performed (add 36904,
delete 36901) of the clotted graft. The two venous stenoses in the arm are angioplastied (add
36905, delete 36904). The arterial anastomosis is also angioplastied due to stenosis (no
change).

Note: Only one angioplasty is billed for the arm because the stenoses are in the same segment.
A separate central venoplasty (via the dialysis circuit direct access) of the subclavian vein would
be reported with add-on code 36907.

2) Patient with clotted left leg dialysis graft undergoes cross catheter technique (36901) with
shuntogram (included) and declot utilizing a thrombectomy catheter (add 36904, delete 36901).
An arterial inflow stenosis in the native iliac artery 8 cm proximal to the arterial anastomosis is
ballooned (37220), as is a common iliac vein stenosis (36907).

3) Same as case #2, but the inferior vena cava is also thrombosed. An Oasis catheter is used to
perform percutaneous thrombectomy of this central vessel (included in 36905, as the IVC is part
of the dialysis circuit). Residual clot is seen and treated with a four-hour catheter infusion of tPA
(no change). Follow-up angiography (bundled) shows underlying 80% IVC stenosis and complete
clearance of clot. Stent placement (36908) results in excellent flow on follow-up exam (no code).

Note: Central venoplasty (36907) would not be reported.

4) Patient with slow maturation of an AV fistula. Single wall puncture of the venous outflow
near the anastomosis is performed (36901). Fistulogram shows three collateral channels,
preventing enlargement of the primary venous outflow. An 80% stenosis is seen in the basillac
vein. Each collateral is selected (bundled) and embolized with a combination of 4-6 mm fiber
coils (36909). Follow-up angiography (bundled) shows occlusion of the collaterals. Basilic
venoplasty (add 36902, delete 36901) with a 6 mm balloon gives a good result. The existing
tunneled central dialysis catheter is exchanged over a guide wire (36581) using fluoroscopic
guidance (77001).

Note: This is one venous surgical site, so only one embolization/occlusion procedure is coded.

5) Transfemoral approach to the brachial artery (36217), followed by an AV graft/fistula
evaluation [36901-52 (or -74 for hospital billing)].

6) Direct access via brachial artery puncture (36140), followed by an AV graft/fistula evaluation
[36901-52 (or -74 for hospital billing)].

7) Direct access is obtained to an upper extremity forearm AV fistula. Complete imaging is
performed (36901). Balloon venoplasty of a 90% venous anastomotic stenosis is performed (add
36902, delete 36901). Slow inflow remains despite a normal peri-anastomotic region. The

catheter is advanced across the arterial anastomosis up to the proximal subclavian artery
(36215), and upper extremity angiography is performed (75710-59). 80% mid subclavian artery
stenosis is treated with stent placement (37236).

IVUS

7 Vascular Interventional Coding
Intravascular Ultrasound Pages: 336-338

Procedure Example(s)
Clinical Indications References
Codes
Coding Instructions

PROCEDURE:
Intravascular ultrasound (IVUS) utilizes an over-the-wire vascular catheter with ultrasound
capabilities to record ultrasound pictures of the vessels evaluated. The procedure requires
special equipment, monitors, expertise, and personnel to perform. It is an adjunct to
angiography and may be used to help plan, evaluate, and determine success of vascular
interventions (e.g., angioplasty, stents, or stent grafts). Coding is per vessel evaluated; however,
contiguous vessel abnormalities (e.g., DVT, diffuse atherosclerotic disease) are described by a
single code. Check your LCD closely, as there may be limitations for the use of these codes.

CLINICAL INDICATIONS:
To characterize vascular stenosis for subsequent intervention (e.g., accurately size a vessel,
determine degree of stenosis and plaque morphology, evaluate eccentricity, calcification, and
dissection) and to evaluate the results of the intervention (e.g., determine the need for
stenting after angioplasty).

CODES: PROC TO S
PROCEDURE DESCRIPTION CODE A TA &I
PL C
C RV O
D
U E

Intravascular ultrasound (noncoronary vessel) during diagnostic N 2. B
evaluation and/or therapeutic intervention, including radiological / 66 u
supervision and interpretation; initial noncoronary vessel (List A n
separately in addition to code for primary procedure) dl
37252 ed

Intravascular ultrasound (noncoronary vessel) during diagnostic N 2. B
evaluation and/or therapeutic intervention, including radiological / 14 u
supervision and interpretation; each additional noncoronary vessel A n
(List separately in addition to code for primary procedure) dl
37253 ed

Add-on Code

CODING INSTRUCTIONS:
497. Codes 37252 and 37253 are add-on codes and must be reported with a base code
(diagnostic imaging or intervention).
498. In 2018, 183 base codes have been added to the parentheticals for clarification as to
appropriate procedures that non-coronary IVUS codes can be billed with.
499. IVUS codes 37252 and 37253 should not be billed with vena cava filter procedures
described by codes 37191-37193 or intravascular foreign body retrieval procedures
described code 37197, as IVUS is bundled with these procedures.
500. Codes 37252 and 37253 apply to non-coronary arterial, venous, and portal venous
IVUS procedures.
501. Code separately for selective catheter placement.
502. Code separately for any diagnostic angiography performed.
503. Code per vessel evaluated. Only submit one IVUS code for evaluation of a bridging
lesion extending from one vessel into another. If diffuse vessel involvement is evaluated
(e.g., IVUS evaluation of DVT extending from the popliteal vein up to and including the
IVC), only submit one IVUS code (37252).
504. There is no code for non-coronary intravascular Doppler for flow measurements. This
procedure is considered part of renal angiography codes 36251-36254.
505. Report peripheral IVUS codes for carotid or vertebral evaluation.
506. IVUS may be reported at the same setting as carotid or vertebral stent placement.

Although imaging of the carotid or vertebral is bundled at the same session and in the
same vessel as stent placement, CPT parentheticals for code 37252 allow reporting with
codes 37215, 37216, 37218, 0075T, and 0076T.
507. Codes 37252 and 37253 include IVUS before, during, and after a single vessel
intervention. Only submit once per vessel.
508. Do not use coronary IVUS codes (92978, 92979) for peripheral or visceral IVUS.
509. Do not use peripheral IVUS codes for coronary IVUS.
510. Do not use peripheral IVUS codes for peripheral optical coherence tomography (OCT).
511. Do not use code 37252 for IVUS performed and documented with the Pioneer catheter
during subintimal recanalization procedures (usually for re-entry into the patent distal
peripheral vessel). The lower extremity endovascular revascularization codes include the
work of accessing vessels and traversing lesions, which are subsequently treated with
angioplasty, atherectomy, or stent placement. The Outback catheter is similar to the
Pioneer catheter, but does not utilize IVUS. The Pantheris is an atherectomy catheter
with built-in OCT to guide the procedure. Do not code IVUS here either.
512. Do code for IVUS when performed for diagnostic purpose before, during, or after lower
extremity endovascular revascularization.

EXAMPLE(S):

1) 70-year-old male with an abdominal aortic aneurysm presents for evaluation.
Aorto-iliofemoral angiography (75630) is initially performed. An IVUS catheter is advanced into
the aorta, and aortic IVUS is performed (36200, 37252), as well as IVUS of the entire ipsilateral
common iliac artery (37253).
Note: Some carrier and FI LCDs may limit the use of IVUS. Please refer to your local policies
prior to use of these codes.

2) 50-year-old smoker with recent angio showing 26 cm occlusion of the mid and distal SFA
(TASC 4 lesion) here for therapy. Via an antegrade approach, a 6 French sheath is placed, and
angio is obtained, confirming mid SFA occlusion (no code for guiding shots). Probing with a
Bentson wire is unsuccessful. A Lumend catheter is advanced to the occlusion, but due to
calcification, we are unable to advance this catheter. The site is then probed with a stiff
glidewire; however, a subintimal channel is created. An Outback catheter is then advanced over
a .018 wire to a level of patent popliteal artery (no code). We are unable to access the arterial
lumen, so a Pioneer catheter is utilized. Under ultrasound guidance (included in SFA stent code),
we enter the proximal popliteal artery (catheter placement is bundled). The entire length of
subintimal passage and re-entry are pre-dilated with a 4 mm balloon. Three 6 mm x 10 cm
nitinol covered stents are then placed along this region and post dilated to 5 mm (37226).
Follow-up angio shows patency and good distal run-off. Closure device is placed (bundled) at the
access site.
Note: Had diagnostic IVUS in the SFA been performed prior to or after stent placement, it
would be separately reported with code 37252.

Endovascular Thoracic and Abdominal Aortic Stent
Grafts

7 Vascular Interventional Coding
Endovascular Thoracic and Abdominal Aortic Stent Grafts Pages: 339-358

Procedure Example(s)
Clinical Indications References
Codes
Coding Instructions

PROCEDURE:
Abdominal aortic stent grafts involve a combination of minimally invasive techniques and
surgical skills for the repair of abdominal aortic aneurysms. Typically, the procedure is
performed by two physicians: a combination of an interventional radiologist, cardiologist,
vascular surgeon, and/or cardiothoracic surgeon. The procedure can be performed either in the
operating room or in an endovascular suite in the imaging department. Moderately rigid criteria
need to be met in order to qualify for this type of repair as opposed to open surgical repair.
Criteria are met through pre-procedural imaging that may involve a combination of CTA of the
chest, abdomen, and pelvis; thoracic and abdominal aortography; and intravascular ultrasound.
Measurements are made from these studies to determine if the currently available stent grafts
will work and what array of components will be needed. Patient hospital stay is reduced from
seven to two days on average. Current FDA-approved abdominal and thoracic aortic endografts
include AFX, AneuRx, Aorfix, Endurant II, Excluder, Ovation, Powerlink, Talent, Ventana, Zenith
Fenestrated, and Zenith Flex. The AneuRx, Endurant, Excluder, and Talent grafts are modular
bifurcated devices with one docking limb. The Zenith Flex, Endologix TriVascular, Ovation, and
Endurant IIS stent grafts have two docking limbs. The Powerlink and AFX stent grafts are
unibody devices. Ventana and Zenith Fenestrated devices are for use as fenestrated grafts
(FEVAR). Other EVAR devices in the FDA approval process include Anaconda, InCraft, Nellix, and
Treovance. Others are sure to be developed as well.
A typical procedure involves general anesthesia and a wide surgical prep of the abdomen and
groins. Most EVAR procedures can be performed percutaneously; however, femoral cutdowns
may be necessary in some patients. Bilateral access is gained with placement of wires and large
sheaths into the aorta, followed by component device placement under fluoroscopy and
roadmapping. Placement of the main stent graft body below the renal arteries is critical;

however, device improvements allow suprarenal attachments in some "short-necked"
aneurysms. Fenestrated devices are available for treatment of aneurysms involving the visceral
vessel origins. Docking limb components may be added to complete the graft into the iliac
arteries. Balloon inflation may be needed to seat the graft or seal an endoleak. Extensions may
be placed as necessary proximally in the aorta or distally into the iliacs. Embolization may be
needed prior to graft placement to prevent endoleak. Less than 1% of the cases must be
converted to an open conventional procedure during the attempted stent graft placement. This
usually occurs due to complete coverage of the renal arteries during stent graft placement,
aneurysm or access vessel rupture, stent graft malfunction, or migration. For 2018, a new set of
EVAR codes is established, with new guidelines and bundling.
Endovascular repair of thoracic aortic aneurysms involves placement of a main body device that
covers the left subclavian artery or is just distal to the left subclavian artery origin. Distal
extensions are bundled at the time of initial placement. Proximal extension placements are
additionally coded, as well as any bypass graft surgery related to the procedure (e.g., when the
left subclavian is covered by the stent graft, a carotid to subclavian artery bypass may need to
be performed to maintain blood flow down the left arm). FDA-approved devices include the
C-TAG, Relay, TX2 ProForm, and Valiant. Others are in development, including fenestrated
thoracic endografts.

CLINICAL INDICATIONS:
Thoracic or abdominal aortic aneurysm greater than 50% size of the normal aorta (usually at
least 4 cm in the abdomen, larger in the thoracic aorta), enlarging aneurysm (more than 5
mmgrowth in 6 months), thoracic or abdominal pain related to aneurysm rupture or
dissection, pseudoaneurysm, penetrating ulcer, or AVM.

CODES: T S T
PROCEDURE DESCRIPTION O & O
Endovascular repair of infrarenal aorta by deployment of an T I T
PROC A A C A A
CODE P L O P L
C R D C R
E
V V
U U

♦ 34701 N 35 B

aorto-aortic tube endograft including pre-procedure sizing and / .7 u
device selection, all nonselective catheterization(s), all A2 n
associated radiological supervision and interpretation, all
endograft extension(s) placed in the aorta from the level of the dl
renal arteries to the aortic bifurcation, and all e
angioplasty/stenting performed from the level of the renal d
arteries to the aortic bifurcation; for other than rupture (eg, for
aneurysm, pseudoaneurysm, dissection, penetrating ulcer)

Endovascular repair of infrarenal aorta by deployment of an ♦ 34702 N 53 B
aorto-aortic tube endograft including pre-procedure sizing and / .3 u
device selection, all nonselective catheterization(s), all A6 n
associated radiological supervision and interpretation, all dl
endograft extension(s) placed in the aorta from the level of the e
renal arteries to the aortic bifurcation, and all d
angioplasty/stenting performed from the level of the renal
arteries to the aortic bifurcation; for rupture including
temporary aortic and/or iliac balloon occlusion, when
performed (eg, for aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, traumatic disruption)

Endovascular repair of infrarenal aorta and/or iliac artery(ies) ♦ 34703 N 40 B
by deployment of an aorto-uni-iliac endograft including / .2 u
pre-procedure sizing and device selection, all nonselective A5 n
catheterization(s), all associated radiological supervision and dl
interpretation, all endograft extension(s) placed in the aorta e
from the level of the renal arteries to the iliac bifurcation, and d
all angioplasty/stenting performed from the level of the renal
arteries to the iliac bifurcation; for other than rupture (eg, for
aneurysm, pseudoaneurysm, dissection, penetrating ulcer)

Endovascular repair of infrarenal aorta and/or iliac artery(ies) ♦ 34704 N 66 B
by deployment of an aorto-uni-iliac endograft including / .9 u
pre-procedure sizing and device selection, all nonselective A5 n
catheterization(s), all associated radiological supervision and dl
interpretation, all endograft extension(s) placed in the aorta e
from the level of the renal arteries to the iliac bifurcation, and d
all angioplasty/stenting performed from the level of the renal
arteries to the iliac bifurcation; for rupture including temporary
aortic and/or iliac balloon occlusion, when performed (eg, for
aneurysm, pseudoaneurysm, dissection, penetrating ulcer,
traumatic disruption)

Endovascular repair of infrarenal aorta and/or iliac artery(ies) ♦ 34705 N 44 B
by deployment of an aorto-bi-iliac endograft including / .3 u

pre-procedure sizing and device selection, all nonselective A4 n
catheterization(s), all associated radiological supervision and dl
interpretation, all endograft extension(s) placed in the aorta e
from the level of the renal arteries to the iliac bifurcation, and d
all angioplasty/stenting performed from the level of the renal
arteries to the iliac bifurcation; for other than rupture (eg, for
aneurysm, pseudoaneurysm, dissection, penetrating ulcer)

Endovascular repair of infrarenal aorta and/or iliac artery(ies) ♦ 34706 N 66 B
by deployment of an aorto-bi-iliac endograft including / .7 u
pre-procedure sizing and device selection, all nonselective A4 n
catheterization(s), all associated radiological supervision and dl
interpretation, all endograft extension(s) placed in the aorta e
from the level of the renal arteries to the iliac bifurcation, and d
all angioplasty/stenting performed from the level of the renal
arteries to the iliac bifurcation; for rupture including temporary
aortic and/or iliac balloon occlusion, when performed (eg, for
aneurysm, pseudoaneurysm, dissection, penetrating ulcer,
traumatic disruption)

Placement of extension prosthesis(es) distal to the common N 9. B
iliac artery(ies) or proximal to the renal artery(ies) for / 38 u
endovascular repair of infrarenal abdominal aortic or iliac A n
aneurysm, false aneurysm, dissection, penetrating ulcer, dl
including pre-procedure sizing and device selection, all ♦ 34709 e
nonselective catheterization(s), all associated radiological d
supervision and interpretation, and treatment zone
angioplasty/stenting, when performed, per vessel treated (List
separately in addition to code for primary procedure)

Delayed placement of distal or proximal extension prosthesis ♦ 34710 N 23 B
for endovascular repair of infrarenal abdominal aortic or iliac / .2 u
aneurysm, false aneurysm, dissection, endoleak, or endograft A5 n
migration, including pre-procedure sizing and device selection, dl
all nonselective catheterization(s), all associated radiological e
supervision and interpretation, and treatment zone d
angioplasty/stenting, when performed; initial vessel treated

Delayed placement of distal or proximal extension prosthesis N 8. B
for endovascular repair of infrarenal abdominal aortic or iliac / 66 u
aneurysm, false aneurysm, dissection, endoleak, or endograft A n
migration, including pre-procedure sizing and device selection, dl
all nonselective catheterization(s), all associated radiological ♦ 34711 e
supervision and interpretation, and treatment zone d
angioplasty/stenting, when performed; each additional vessel

treated (List separately in addition to code for primary ♦ 34712 N 19 B
procedure) 34713 / .8 u
Transcatheter delivery of enhanced fixation device(s) to the A7 n
endograft (eg, anchor, screw, tack) and all associated dl
radiological supervision and interpretation e
Percutaneous access and closure of femoral artery for delivery d
of endograft through a large sheath (12 French or larger),
including ultrasound guidance, when performed, unilateral N 3. B
(List separately in addition to code for primary procedure) / 74 u
A n
dl
e
d

Endovascular placement of iliac artery occlusion device (List N 6. N
separately in addition to code for primary procedure) / 06 /
A A
Endovascular repair of descending thoracic aorta (eg,
aneurysm, pseudoaneurysm, dissection, penetrating ulcer, ♦ 34808
intramural hematoma, or traumatic disruption); involving
coverage of left subclavian artery origin, initial endoprosthesis ♦ 33880 N 52 ♦ N 9.
plus descending thoracic aortic extension(s), if required, to / .1 7 / 87
level of celiac artery origin A7 5 A
Endovascular repair of descending thoracic aorta (eg, 9
aneurysm, pseudoaneurysm, dissection, penetrating ulcer, 5
intramural hematoma, or traumatic disruption); not involving 6
coverage of left subclavian artery origin, initial endoprosthesis
plus descending thoracic aortic extension(s), if required, to ♦ 33881 N 44 ♦ N 8.
level of celiac artery origin / .8 7 / 46
A1 5 A
9
5
7

Placement of proximal extension prosthesis for endovascular ♦ 33883 N 32 ♦ N 5.
repair of descending thoracic aorta (eg, aneurysm, / .5 7 / 63
pseudoaneurysm, dissection, penetrating ulcer, intramural A3 5 A
hematoma, or traumatic disruption); initial extension 9
5
8

Placement of proximal extension prosthesis for endovascular N 12 ♦ N 5.
repair of descending thoracic aorta (eg, aneurysm, / .0 7 / 63
pseudoaneurysm, dissection, penetrating ulcer, intramural A8 5 A
hematoma, or traumatic disruption); each additional proximal 9
extension (List separately in addition to code for primary ♦ 33884 5
procedure) 8

Placement of distal extension prosthesis(s) delayed after ♦ 33886 N 28 ♦ N 4.
endovascular repair of descending thoracic aorta / .2 7 / 94
A1 5 A
Physician planning of a patient-specific fenestrated visceral 9
aortic endograft requiring a minimum of 90 minutes of 5
physician time 9
Endovascular repair of visceral aorta (eg, aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, intramural 34839 N 0. N
hematoma, or traumatic disruption) by deployment of a / 00 /
fenestrated visceral aortic endograft and all associated A A
radiological supervision and interpretation, including target
zone angioplasty, when performed; including one visceral ♦ 34841 N 0. N
artery endoprosthesis (superior mesenteric, celiac or renal / 00 /
artery) A A
Endovascular repair of visceral aorta (eg, aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, intramural ♦ 34842 N 0. N
hematoma, or traumatic disruption) by deployment of a / 00 /
fenestrated visceral aortic endograft and all associated A A
radiological supervision and interpretation, including target
zone angioplasty, when performed; including two visceral ♦ 34843 N 0. N
artery endoprostheses (superior mesenteric, celiac and/or / 00 /
renal artery[s]) A A
Endovascular repair of visceral aorta (eg, aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, intramural
hematoma, or traumatic disruption) by deployment of a
fenestrated visceral aortic endograft and all associated
radiological supervision and interpretation, including target
zone angioplasty, when performed; including three visceral
artery endoprostheses (superior mesenteric, celiac and/or
renal artery[s])

Endovascular repair of visceral aorta (eg, aneurysm, ♦ 34844 N 0. N
pseudoaneurysm, dissection, penetrating ulcer, intramural / 00 /
hematoma, or traumatic disruption) by deployment of a A A
fenestrated visceral aortic endograft and all associated
radiological supervision and interpretation, including target
zone angioplasty, when performed; including four or more
visceral artery endoprostheses (superior mesenteric, celiac
and/or renal artery[s])

Endovascular repair of visceral aorta and infrarenal abdominal ♦ 34845 N 0. N
aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating / 00 /
ulcer, intramural hematoma, or traumatic disruption) with a A A
fenestrated visceral aortic endograft and concomitant unibody
or modular infrarenal aortic endograft and all associated
radiological supervision and interpretation, including target
zone angioplasty, when performed; including one visceral
artery endoprosthesis (superior mesenteric, celiac or renal
artery)

Endovascular repair of visceral aorta and infrarenal abdominal ♦ 34846 N 0. N
aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating / 00 /
ulcer, intramural hematoma, or traumatic disruption) with a A A
fenestrated visceral aortic endograft and concomitant unibody
or modular infrarenal aortic endograft and all associated
radiological supervision and interpretation, including target
zone angioplasty, when performed; including two visceral
artery endoprostheses (superior mesenteric, celiac and/or
renal artery[s])

Endovascular repair of visceral aorta and infrarenal abdominal ♦ 34847 N 0. N
aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating / 00 /
ulcer, intramural hematoma, or traumatic disruption) with a A A
fenestrated visceral aortic endograft and concomitant unibody
or modular infrarenal aortic endograft and all associated
radiological supervision and interpretation, including target
zone angioplasty, when performed; including three visceral
artery endoprostheses (superior mesenteric, celiac and/or
renal artery[s])

Endovascular repair of visceral aorta and infrarenal abdominal ♦ 34848 N 0. N
aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating / 00 /
ulcer, intramural hematoma, or traumatic disruption) with a A A
fenestrated visceral aortic endograft and concomitant unibody
or modular infrarenal aortic endograft and all associated
radiological supervision and interpretation, including target

zone angioplasty, when performed; including four or more
visceral artery endoprostheses (superior mesenteric, celiac
and/or renal artery[s])

Introduction of catheter, aorta (non-selective) (add-50 modifier 36200 N 4. N
for bilateral) / 06 /
A A

Open femoral artery exposure for delivery of endovascular N 6. N
prosthesis, by groin incision, unilateral (List separately in / 02 /
addition to code for primary procedure) A A
Open femoral artery exposure with creation of conduit for
delivery of endovascular prosthesis or for establishment of ♦ 34812
cardiopulmonary bypass, by groin incision, unilateral (List
separately in addition to code for primary procedure) N 7. B
/ 85 u
A n
dl
34714 e
d

Open iliac artery exposure for delivery of endovascular N 10 N
prosthesis or iliac occlusion during endovascular therapy, by / .2 /
abdominal or retroperitoneal incision, unilateral (List A7 A
separately in addition to code for primary procedure)
♦ 34820

Open iliac artery exposure with creation of conduit for delivery N 11 N
of endovascular prosthesis or for establishment of / .7 /
cardiopulmonary bypass, by abdominal or retroperitoneal A8 A
incision, unilateral (List separately in addition to code for
primary procedure) ♦ 34833

Open axillary/subclavian artery exposure for delivery of N 8. B
endovascular prosthesis by infraclavicular or supraclavicular / 77 u
incision, unilateral (List separately in addition to code for A n
primary procedure) dl
34715 e
d

Open axillary/subclavian artery exposure with creation of N 10 B
conduit for delivery of endovascular prosthesis or for / .8 u
establishment of cardiopulmonary bypass, by infraclavicular or A9 n
supraclavicular incision, unilateral (List separately in addition to dl
code for primary procedure) 34716 e
d

Open brachial artery exposure for delivery of endovascular N 3. N
prosthesis, unilateral (List separately in addition to code for / 79 /
primary procedure) A A

♦ 34834

Open subclavian to carotid artery transposition performed in N 23 N
conjunction with endovascular repair of descending thoracic ♦ 33889 / .0 /
aorta, by neck incision, unilateral
A6 A

Bypass graft, with other than vein, transcervical ♦ 33891 N 28 N
retropharyngeal carotid-carotid, performed in conjunction with / .0 /
endovascular repair of descending thoracic aorta, by neck A4 A
incision

Repair blood vessel, direct; lower extremity 35226 5 24 N
0 .2 /
7 6 A
1

Repair blood vessel with vein graft; lower extremity 35256 5 29 N
1 .7 /
8 7 A
4

Repair blood vessel with graft other than vein; lower extremity 35286 5 27 N
1 .1 /
8 0 A
4

Open repair of infrarenal aortic aneurysm or dissection, plus N 51 N
repair of associated arterial trauma, following unsuccessful ♦ 34830 / .1 /
endovascular repair; tube prosthesis
A6 A

Open repair of infrarenal aortic aneurysm or dissection, plus N 56 N
repair of associated arterial trauma, following unsuccessful ♦ 34831 / .1 /
endovascular repair; aorto-bi-iliac prosthesis
A3 A

Open repair of infrarenal aortic aneurysm or dissection, plus N 55 N
repair of associated arterial trauma, following unsuccessful ♦ 34832 / .0 /
endovascular repair; aorto-bifemoral prosthesis
A2 A

Placement of femoral-femoral prosthetic graft during N 6. N
endovascular aortic aneurysm repair (List separately in / 88 /
addition to code for primary procedure) A A

♦ 34813

Bypass graft, with vein; femoral-popliteal N 40 N
♦ 35556 / .7 /

A8 A

Bypass graft, with vein; femoral-femoral N 35 N
♦ 35558 / .8 /

A6 A

Femoral distal bypass graft - vein N 48 N
♦ 35566 / .6 /

A7 A

In-situ vein bypass; femoral-popliteal N 42 N
♦ 35583 / .1 /

A3 A

In-situ vein bypass; femoral-anterior tibial, posterior tibial, or N 48 N
peroneal artery ♦ 35585 / .7 /

A9 A

Bypass graft, with other than vein; femoral-popliteal N 31 N
♦ 35656 / .5 /

A5 A

Bypass graft, with vein; femoral-anterior tibial, posterior tibial, ♦ 35666 N 36 N
peroneal artery or other distal vessels / .8 /
A6 A

Endovascular repair of iliac artery by deployment of an ilio-iliac ♦ 34707 N 33 B
tube endograft including pre-procedure sizing and device / .3 u
selection, all nonselective catheterization(s), all associated A1 n
radiological supervision and interpretation, and all endograft dl
extension(s) proximally to the aortic bifurcation and distally to e
the iliac bifurcation, and treatment zone angioplasty/stenting, d
when performed, unilateral; for other than rupture (eg, for

aneurysm, pseudoaneurysm, dissection, arteriovenous
malformation)

Endovascular repair of iliac artery by deployment of an ilio-iliac ♦ 34708 N 53 B
tube endograft including pre-procedure sizing and device / .6 u
selection, all nonselective catheterization(s), all associated A1 n
radiological supervision and interpretation, and all endograft dl
extension(s) proximally to the aortic bifurcation and distally to e
the iliac bifurcation, and treatment zone angioplasty/stenting, d
when performed, unilateral; for rupture including temporary
aortic and/or iliac balloon occlusion, when performed (eg, for
aneurysm, pseudoaneurysm, dissection, arteriovenous
malformation, traumatic disruption)

Endovascular repair of iliac artery bifurcation (eg, aneurysm, ♦ 0254T N 0. B
pseudoaneurysm, arteriovenous malformation, trauma) using / 00 u
bifurcated endoprosthesis from the common iliac artery into A n
both the external and internal iliac artery, unilateral; dl
e
d

Transcatheter placement of an intravascular stent(s) (except 37236 5 13 N
lower extremity artery(s) for occlusive disease, cervical carotid, 1 .0 /
extracranial vertebral or intrathoracic carotid, intracranial, or 9 0 A
coronary), open or percutaneous, including radiological 3
supervision and interpretation and including all angioplasty
within the same vessel, when performed; initial artery

Transcatheter placement of an intravascular stent(s) (except N 6. N
lower extremity artery(s) for occlusive disease, cervical carotid, / 22 /
extracranial vertebral or intrathoracic carotid, intracranial, or A A
coronary), open or percutaneous, including radiological
supervision and interpretation and including all angioplasty 37237
within the same vessel, when performed; each additional
artery (List separately in addition to code for primary
procedure)

Transluminal balloon angioplasty (except lower extremity 37246 5 10 N
artery(ies) for occlusive disease, intracranial, coronary, 1 .1 /
pulmonary, or dialysis circuit), open or percutaneous, including 9 4 A
all imaging and radiological supervision and interpretation 2
necessary to perform the angioplasty within the same artery;
initial artery

Transluminal balloon angioplasty (except lower extremity N 4. N
artery(ies) for occlusive disease, intracranial, coronary, / 98 /
pulmonary, or dialysis circuit), open or percutaneous, including A A
all imaging and radiological supervision and interpretation
necessary to perform the angioplasty within the same artery; 37247
each additional artery (List separately in addition to code for
primary procedure)

Vascular embolization or occlusion, inclusive of all radiological 37242 5 13 N
supervision and interpretation, intraprocedural roadmapping, 1 .9 /
and imaging guidance necessary to complete the intervention; 9 5 A
arterial, other than hemorrhage or tumor (eg, congenital or 3
acquired arterial malformations, arteriovenous malformations,
arteriovenous fistulas, aneurysms, pseudoaneurysms)

Ultrasound, abdominal aorta, real time with image 7 5
documentation, screening study for abdominal aortic 6 5 0.
aneurysm (AAA) 7 2 79
0 2
6

♦ Inpatient-Only Procedure Add-on Code

CODING INSTRUCTIONS:
EVAR Guidelines

513. There are new codes describing EVAR and iliac aneurysm endograft procedures for
2018. There are no changes to the existing FEVAR or TEVAR base codes.

514. Surgical codes 34800-34806, 34825, 34826, and 34900, along with S&I codes 0255T,
75952, 75953, 75954, and 93982, are deleted in 2018. There are sixteen new CPT codes
(34701-34716) to describe EVAR and iliac endograft procedures.

515. The term "endograft" is interchangeable with stent graft, endovascular graft, covered
stent, and endoprosthesis. An "extension" can be any covered stent.

516. Extensions, fixation devices, percutaneous access and closure of femoral artery for
large sheaths (12 French or larger), and some surgical access codes are new for 2018
and apply to all endovascular stent graft procedures (including existing FEVAR and
TEVAR).

517. New for 2018, non-selective catheter placements are bundled with EVAR and iliac
endograft codes 34701-34712. Non-selective and selective catheter placements are
bundled with code 0254T for bifurcated iliac endograft.

518. Access codes 34812, 34820, 34833, and 34834 are revised in 2018 and are now add-on
codes. Report the code twice if done bilaterally (do not append a -50 modifier, as these
are add-on codes).

519. EVAR refers to abdominal aortic endovascular aneurysm repair. TEVAR refers to
thoracic aortic endovascular aneurysm repair, which may involve the abdominal aorta
and several branches. FEVAR refers to fenestrated endovascular aneurysm repair. EVAR,
TEVAR, and FEVAR all apply to endovascular treatment of aortic aneurysms with stent
graft technology.

520. EVAR codes are used for treatment of all aortic and/or iliac pathology other than
atherosclerotic occlusive disease. For treatment of occlusive disease, use codes 37221
and 37223 for iliac endograft placement and code 37236 for aortic endograft
placement.

521. EVAR codes are based on general device type placed (aorto-aortic, aorto-uni-iliac, and
aorto-bi-iliac). The number of docking limbs (zero, one, or two) does not matter in 2018,
so unibody devices (e.g., AFX) and modular bifurcated devices with one (e.g., AneuRx) or
two (e.g., Ovation) docking limbs are coded the same.

522. Iliac aneurysm repair codes 34707 and 34708 describe treatment with stent grafts that
start and end in the iliac artery. If an aorto-bi-iliac bifurcated endograft is placed to treat
bilateral iliac aneurysms, use code 34705 or 34706 instead. These codes are based on
the general type of device placed.

523. Each general type is further broken into procedures that are stable repairs vs.
emergent repairs for aneurysm rupture. Procedure codes for rupture (34702, 34704,
34706, and 34708) include use of a temporary occlusion balloon to stabilize the patient.

524. Code 34709 can only be reported for extensions placed at the time of initial
implantation and only for those placed in the internal iliac, external iliac, and suprarenal
abdominal aorta. Extensions placed in the common iliacs and infrarenal aorta are
bundled. Code 34709 is an add-on code to codes 34701-34708. It can only be reported
once for each iliac system and once in the aorta (maximum of three times). If three
extensions are placed in one iliac, only submit code 34709 once. Do not use code 34709
for placement of docking limbs.

525. Code 34710 and add-on code 34711 describe delayed placement of extensions. These
codes cannot be submitted at the time of initial implantation (do not report with codes
34701-34708).

526. Code 34712 describes placement of endoanchors, tacks, screws, or other enhanced
fixation devices. This code includes all devices placed, all imaging related to the
procedure, and catheter placements. Fixation devices can be placed at the time of initial
implantation or at another session (delayed implantation). This code may only be
reported once per encounter.

527. Code 34713 describes percutaneous access and closure when using a 12 French or
larger sheath. This code is reported once per side and bundles ultrasound guidance
(76937). Code 34713 is only reported with TEVAR, EVAR, and FEVAR procedures
described by codes 33880-33886, 34701-34708, 34710, and 34841-34848. Do not report
code 34713 for sheaths less than 12 French. Use code 34812 for open femoral exposure
for these procedures.

528. Code 34710 may hit an add-on code edit with code 34713, as it is not listed in the
parenthetical. This issue is being addressed by the AMA.

529. "Rupture" is defined as an acute hemorrhage related to the aneurysm. This is
diagnosed clinically or radiographically (e.g., on a CT scan). The patient will most likely
be hemodynamically unstable and must be emergently treated. A pseudoaneurysm or
chronic "contained" rupture is not reported with code 34702, 34704, 34706, or 34708,
as the patient can be treated non-emergently. RVUs are higher for the "rupture" codes.

530. If a docking limb terminates in the external iliac artery, other ipsilateral external iliac
artery interventions (e.g., angioplasty, stent placement, extensions) are bundled.

531. Selective catheter placements, IVUS, and non-target vessel embolization are separately
reported. Angioplasty and stent placement in vessels other than the stent graft
deployment vessel(s) are also separately reported.

532. Non-selective catheter placements are bundled. Angioplasty and stent placement
performed in the same vessel as the main graft, docking limb(s), or extension(s) are
bundled.

533. All imaging of the aorta and its branches is bundled, including angiography, 3D CT
reconstructions (DynaCT), follow-up imaging, and complete lower extremity run-off.
Fluoroscopy and supervision/interpretation are also bundled.

534. Code 34714 describes creation of a conduit (via an open femoral arterial approach) for
delivery of an endograft or to establish cardiopulmonary bypass. If the conduit is
converted to a vascular bypass graft, code the bypass graft (not 34714).

535. Code 34715 describes open subclavian or axillary arterial exposure for delivery of an
endograft.

536. Code 34716 describes creation of a conduit (via an open subclavian or axillary arterial
approach) for delivery of an endograft or to establish cardiopulmonary bypass.

537. Code 34820 describes open iliac arterial exposure for delivery of an endograft.
538. Code 34833 describes creation of a conduit (via an open iliac arterial approach) for

delivery of an endograft or to establish cardiopulmonary bypass.
539. The delivery of the initial contralateral limb (also known as the "docking limb') of the

AneuRx, Endurant, Talent, or Excluder device is not an "extension device" - it completes
the graft. Delivery of both docking limbs completes the Zenith and Trivascular Ovation
grafts - these are not extensions and are not separately coded. Discuss appropriate
documentation with your physicians, as sometimes this can be an area of confusion for
coders.

540. Any addition beyond the initial docking limb's landing site vessel is called an extension
limb or cuff, and regardless of the number of extension devices delivered in a single
vessel, rules allow only one extension code per side. For EVAR procedures, there are five
vessels possible: the right and left internal and external iliac arteries and the aorta
proximal to the renal arteries. Extensions into the common iliac arteries and infrarenal
aorta are bundled. For fenestrated grafts, extensions are only coded when the extension
is placed into the internal iliac, external iliac, or common femoral arteries. Extensions
into the common iliacs and proximally in the aorta are bundled with FEVAR.

541. All work to place the stent graft in the target vessel is included in the EVAR code. This
includes all angiography of the aorta and its branches. It also includes any angioplasty or
stent placement in the stent graft deployment vessel, whether before or after the stent
graft deployment.

542. Non-selective catheter placement codes (36140, 36200) are bundled with FEVAR, EVAR,
and iliac endovascular stent graft codes. FEVAR graft placements and bifurcated iliac
stent grafts also bundle selective catheter placement off the aorta and any visceral
vessels.

543. Diagnostic angiography of the aorta or its branches prior to stent graft intervention is
bundled and should not be coded, even if there has never been a diagnostic study. This
includes the renal, visceral, and extremity arteries, as they are "branches" of the aorta.
Imaging to reconfirm a known lesion, to size the vessel, to confirm catheter placement,
or to guide the placement of the stent graft is bundled in the stent graft imaging codes
as well.

544. Do code for intravascular ultrasound performed at the time of endovascular aneurysm
repair (before or after deployment of the stent graft) with codes 37252 and 37253.

545. Do code for angioplasty or stent placement to treat a stenotic or dissected segment of
vessel not in the same vessel treated by the stent graft (e.g., outside the stent graft
deployment vessel). If the stent graft extends into the external iliac, do not code for
angioplasty or stent placement in a more distal segment of the external iliac artery,
even if for dissection; it is bundled.

546. Do code for angioplasty or stent placement to treat a complication of a stent graft
placement (e.g., dissection or displaced plaque above or below stent graft deployment
vessel). Lower extremity revascularization codes 37220-37235, peripheral angioplasty
codes 37246-37247, and stent placement codes 37236-37237 include both open and
percutaneous approaches.

547. Do not code for angioplasty or stent placement to prepare the vessel for the stent graft,
to fully deploy the stent graft, to seal a stent graft leak, or to straighten out a "kink" in
the stent graft.

548. Iliac occlusion device placement code (34808) is an add-on code only to be used with
codes 34701-34704, 34707-34710, 34813, and 34841-34844. An add-on code edit
between codes 34703/34704 and 34808 may occur due to missing codes in the
parentheticals. This is being addressed by the AMA.

549. Code 34812 describes femoral artery cutdown when necessary for access to perform
EVAR, TEVAR, FEVAR, iliac stent graft placement, and percutaneous LVAD placement. If
done bilaterally, report code 34812 twice.

550. Code 34813 (fem-fem bypass) is an add-on code for use during endograft insertion,
usually when an aorto-uni-iliac device and a contralateral iliac occlusion device are
placed.

551. All angiography used to localize placement of the graft components as well as any post
placement angiography is included (bundled) into the primary endograft procedure
codes.

552. Different codes are used for different stent grafts/techniques.
553. In general, the main graft body and docking limbs are coded separately, with one set of

device placement codes. Additional code sets are submitted for placement of extension
cuffs beyond the common iliac arteries or above the renal arteries (in the aorta). FEVAR
bundles placement of extension cuffs in any aortic location and in the common iliac
arteries.
554. Use code 34705 or 34706 for placement of the AneuRx, Excluder, Endurant II, Talent,
Cook Zenith, Endurant IIS, Trivascular Ovation, Lombard Aorfix, Powerlink, and AFX
aortic stent grafts. All of these are aorti-bi-iliac endografts.
555. Codes 34806 and 93982 for wireless AAA pressure sensor procedures are deleted in
2018.
556. Do not code for roadmapping, guiding shots, or other contrast injection during
intervention.
557. Do not code for follow-up angiography post intervention, as it is included in the
endovascular S&I codes.
558. Do not code angioplasty to deploy a stent or stent graft.
559. Do not code angioplasty to further dilate or completely deploy a newly placed stent or
stent graft.
560. Do not code angioplasty if the intent of the procedure was to place a stent or stent
graft.
561. Do not code for any balloon angioplasty treatment within the zone of aortic or iliac
stent graft placement. This includes the situation where the intent was an iliac
angioplasty for treatment of stenosis; however, the vessel ruptured and required an iliac
stent graft placement. Since the initial angioplasty is within the iliac stent graft
deployment zone, the angioplasty is no longer reportable. The iliac stent graft in this
case is reported with code 34708 for iliac rupture. This is a new guideline for 2018.
562. Codes 34830, 34831, and 34832 can be used to describe open repair of a previously
placed percutaneous abdominal aortic stent graft whether at the same setting as initial
placement or on a later date of service. If at the same setting, do not code the
percutaneous aortic stent graft placement codes (34701-34706).

563. Stent graft placements for aneurysm, pseudoaneurysm, dissection, penetrating ulcer,
trauma, or AVM of the aorta or iliac vessels are inpatient-only status indicator C
procedures for Medicare.

564. Use stent graft extension codes 34710 and 34711 for the delayed (at a later date)
deployment of extension device(s) at the site of iliac limb(s) and/or aortic endoleak.
Placement of the Zenith "Renu" device is an example of this. This is an inpatient-only
status indicator C procedure for hospital billing to Medicare. Report code 34713 for
percutaneous placement and closure of a 12 French or greater sheath.

565. If an arterial exposure is performed to create a conduit for delivery of an endovascular
prosthesis, it may be additionally reported with code 34714 (femoral), 34716 (iliac), or
34833 (axillary/subclavian). These codes may be reported with codes 33880-33886,
34701-34708, 34841-34848, and 0254T (EVAR, FEVAR, TEVAR, and iliac endograft
procedures).

566. Report code 37242 once for embolization of one or more non-target vessels (accessory
lower pole renal artery, IMA, internal iliac artery), as this embolization is of one surgical
site (e.g., the aortic aneurysm). Also submit the appropriate selective catheter
placement codes.

567. Use of "Aptus" clips (or other transcatheter fixation devices, anchors, screws, tacks, or
clips) to secure an endoleak at either end of the endograft is separately reported with
code 34712. Only report one time per operative session regardless of the number of
fixation devices placed, whether performed for sealing an endoleak at the initial EVAR
deployment or at a later date (separate session). Catheter placement is bundled.

568. Placement of a chimney, snorkel, or periscope is described by codes 37236 and 37237.
These are placed in renal, visceral, or internal iliac arteries with regular EVARs. It is more
common to see these complex aneurysms treated with FEVARs.

569. Report code 49000 for decompressive laparotomy for compartment syndrome when
performed at the same time as EVAR for rupture.

570. Temporary occlusion balloon to tamponade a stop active vascular hemorrhage in a
patient with aneurysm rupture is bundled.

571. A device that has an aortic component, a unilateral single iliac limb, and a contralateral
"double" iliac limb (that extends into both the external and internal iliac arteries) is
reported with the combination of codes 34705 and 0254T for non-ruptured aneurysm.

572. Updates to these codes will be posted on our website at ZHealthPublishing.com.
FEVAR Guidelines

37. Codes 34839 and 34841-34848 are for fenestrated endovascular repair of the visceral
aorta (with or without the infrarenal aorta) (FEVAR).

38. Codes 34841-34848 are for use with aortic stent grafts with fenestrations that allow
placement of the visceral endoprostheses through the endograft fenestrations.

39. If the FEVAR placement is for the visceral aorta (for treatment of aneurysm,

pseudoaneurysm, dissection, trauma, penetrating ulcer, or intramural hematoma), use
codes 34841-34844 based on the number of visceral extensions placed (one, two, three,
four, or more). These devices terminate in the distal aorta.
40. For FEVARs, extensions in the aorta are not reported; they are bundled with codes
34841-34844. Extensions into the internal iliac, external iliac, or common femoral
arteries are described by codes 34709-34711.
41. If the FEVAR also involves the infrarenal abdominal aorta, codes 34845-34848 describe
placement of this larger device to cover the entire abdominal aorta with one, two, three,
four, or more visceral extensions, respectively. These devices terminate in the common
iliac arteries.
42. Physician planning and sizing of patient-specific FEVAR include review of patient images
(CTA, MRA, 3D reconstructions, etc.) to determine the best approach and device
selection. Code 34839 is submitted by the physician when at least 90 minutes of
planning is documented. This must be done at least two days prior to the actual FEVAR
and requires documentation of cumulative time spent doing planning. This is routinely
done a couple weeks prior to FEVAR.
43. Code 34839 cannot be submitted for work performed on the day of or day before the
actual FEVAR procedure.
44. All angiography, sizing, guiding images, final images, and catheter placements are
included in the fenestrated stent graft codes in the deployment zone. Embolizations are
coded separately. Catheter placements outside the FEVAR zone are separately coded.
45. All FEVAR procedures include imaging of the aorta and its branches, along with catheter
placements in the aorta, and branches related to visceral endoprosthesis placement
through the main body graft fenestrations.
46. Catheter placements in vessels other than those related to the FEVAR (e.g., internal iliac
arteries, inferior mesenteric artery, SMA via a "Scallop") are separately coded.
47. "Scallops" are cutouts at the proximal end of a FEVAR to gain access to the SMA or celiac
artery not via a fenestration.
48. Catheter placement and interventions (stent placement or angioplasty) into a vessel via
a "Scallop" are separately reported (e.g., 36245, 37236, 37246).
49. If an arterial exposure is performed to create a conduit for delivery of an endovascular
prosthesis, it may be additionally reported with code 34714 (femoral), 34716 (iliac), or
34833 (axillary/subclavian). These codes may be reported with codes 33880-33886,
34701-34708, 34841-34848, and 0254T (EVAR, FEVAR, TEVAR, and iliac endograft
procedures).
50. Stent graft extensions in the aorta or common iliac arteries are bundled at the time of
FEVAR.
51. Stent graft extensions into the internal iliac, external iliac, or common femoral arteries
during FEVAR are reported with code 34709 once per side. Codes 34710 and 34711 are
used for delayed extension graft placement.

52. Delayed stent graft extensions in the proximal aorta after FEVAR are coded with thoracic
stent graft codes.

53. Codes 34841-34848 address fenestrated stent graft procedures. These codes decribe
percutaneous treatment of AAAs that involve the origins of renal or visceral arteries
with treatment requiring fenestrated stent grafts with visceral extensions. The
deployment of chimneys, periscopes, or snorkels (stent grafts) are described by codes
37236 and 37237. Catheter placements are additionally reported. Code 0254T addresses
the use of a specific bifurcated iliac stent graft for treatment of iliac aneurysm with iliac
bifurcation stent grafts.

54. The use of stent grafts (periscope in the internal iliac with extension placement across
the common iliac into the external iliac) is reported with codes 37236 and 34709 at time
of EVAR, respectively.

55. Code 0254T describes placement of a bifurcated iliac stent graft for treatment of iliac
bifurcation aneurysm, pseudoaneurysm, AVM, or trauma. Code 0254T bundles the S&I
and all selective catheter placements in 2018. This requires placement of the stent graft
device from the common iliac artery into both the internal and external iliac arteries.
This code can also be reported with EVAR and FEVAR procedures. S&I code 0255T is
deleted in 2018.

TEVAR Guidelines
1. Thoracic endovascular aortic repair (TEVAR) is described by codes 33880-33886 and
75956-75959.
2. Unlike endograft repair of abdominal aortic aneurysms where only one extension code
is permitted per vessel despite the number of devices placed, thoracic endograft repair
allows coding for each additional proximal extension with codes 33884 and 75958.
Again, if this additional proximal extension results in coverage of the left subclavian
artery, delete prior codes (33881/75957, 33883/75958, and 33884/75958), and replace
with codes 33880/75956.
3. If in the process of deploying an extension proximal to the initial thoracic component
the origin of the left subclavian artery is covered, the coding changes. Do not report
codes 33881/75957 and 33883/75958, but rather report codes 33880/75956 with
regard to this complex procedure.
4. Report codes 33886/75959 only once, no matter how many delayed distal extensions
are placed at the same subsequent session.
5. Do not code for distal extensions placed concurrently with an initial thoracic endograft
placement. These distal extensions are bundled.
6. If an arterial exposure is performed to create a conduit for delivery of an endovascular
prosthesis, it may be additionally reported with code 34714 (femoral), 34716 (iliac), or
34833 (axillary/subclavian). These codes may be reported with codes 33880-33886,
34701-34708, 34841-34848, and 0254T (EVAR, FEVAR, TEVAR, and iliac endograft
procedures).

7. The following codes may require co-surgeons and are applicable for modifier -62: 33880,
33881, 33883, 33884, 33886, 33889, 33891, 34701-34716, 34808, 34812, 34813, 34820,
and 34830-34834.

8. The following procedures do not qualify for use of modifier -62: catheter placement,
cutdown, imaging, angioplasty, atherectomy, stent placement, embolization,
thrombolysis, thrombectomy, and FEVAR codes 34841-34848 (as these are
carrier-priced).

EXAMPLE(S):

1) 8 cm AAA for elective endovascular treatment. Bilateral groin cutdowns (34812 x 2) are
performed under general anesthesia. Bilateral aortic access (bundled) is achieved under
fluoroscopic guidance with placement of a percutaneous right 22 French and a percutaneous
left 18 French sheath. An Excluder main endograft device is placed from the right side and
deployed with fluoroscopic guidance. From the left sheath, the contralateral docking limb is
deployed (34705). Graft angioplasties at the proximal aspect and at the flow divider are
performed (bundled). Follow-up angiography does not reveal an endoleak. Groins closed
(included with 34812 x 2 for open access).

2) Patient with 6 cm AAA with near occlusion of the right common iliac artery. Left groin
cutdown is performed (see below) with placement of aortic wire and sheath (bundled) under
general anesthesia. Aorto-uni-iliac stent graft is deployed (34703) to cover the aneurysm using
fluoroscopic guidance. Right groin cutdown (34812 x 2) is then performed. A right iliac occluder
is placed (34808, 36140-59) in the right common iliac artery. A 6 mm PTFE graft is tunneled
from the right to the left femoral region, and the anastomosis of the fem-fem graft is completed
bilaterally (34813). Angiography is performed and reveals a proximal endoleak. An aortic cuff is
guided into place below the renal arteries with fluoroscopy and deployed (bundled). A 30 mm
occlusion balloon is inflated to achieve proximal seal. Final angiography shows proper proximal
seal, no endoleak, and excellent flow through the fem-fem graft to each SFA. Groins closed.

3) Patient with a 7 cm AAA for endovascular treatment. Bilateral groin cutdowns (34812 x 2) are
performed under general anesthesia. Bilateral aortic access is achieved (bundled) under
fluoroscopic guidance with placement of a right 22 French sheath. The left external iliac artery
stenosis is crossed with a wire, and a 10 French sheath is placed. A 12 mm Wall stent is
delivered and dilated to 12 mm (37221-59; this is outside the stent graft deployment zone).
Subsequently, an 18 French sheath is placed through the stent. AneuRx main endograft device is
placed from the right and deployed with fluoroscopic guidance. From the left sheath, gate
access is achieved, and the contralateral docking limb is deployed in the right common iliac
artery (34705). Follow-up angiography reveals an endoleak, which is treated with two Aptus
clips in the common iliac artery (34712). Groins closed.

4) 6 cm AAA for endovascular treatment, as the patient is not a good surgical candidate.
Bilateral groin cutdowns are performed (34812 x 2) under general anesthesia. Bilateral aortic
access is achieved (bundled) under fluoroscopic guidance with placement of a left 22 French and
a right 16 French sheath. The AneuRx main endograft device is placed from the left and

deployed with fluoroscopic guidance. From the right sheath, gate access is achieved and the
contralateral docking limb deployed (34705). Graft is angioplastied at its proximal aspect and at
the flow divider (no code). Follow-up angiography reveals a poor distal seal with Type 1
endoleak in the left common iliac artery. An iliac extension device is deployed into the external
iliac artery and dilated to 10 mm (34709). Repeat angiography reveals an endoleak at the distal
aspect of the right limb. Retrograde fill of the iliac component of the aneurysm is noted. An
extension device is placed into the right external iliac artery using an aortic cuff component to
"bell bottom" into the aneurysm stent graft and gain good seal (34709-59). Final angiography
demonstrates excellent seal. Direct repair of the right common femoral artery with a bovine
patch (35286) is required secondary to atherosclerotic disease. Groins closed.

5) Patient with an 8 cm abdominal aortic aneurysm, clinical and CT evidence of acute rupture,
and left iliac involvement. Under general anesthesia, bilateral percutaneous access to the
femoral arteries is achieved. Bilateral aortic access with wires is followed by placement of a
right 10 French sheath (no code) and a left 18 French sheath (34713-59). A tapered tip modular
bifurcated main body device with two docking limbs (the Zenith device) is placed from the right
(34706) and deployed under fluoroscopy with repeated injections to confirm position. The left
sheath is then retracted, and selective catheterization (36245) of the left internal iliac artery is
performed. Subsequent fluoroscopic guided delivery of numerous embolization coils to
completely occlude the left internal iliac artery is performed (37242), confirmed by follow-up
angiography demonstrating stasis of flow (bundled). Two limbs are then placed through the left
sheath: first the docking limb to complete the graft at the left side (included in the main graft
code) and then a second long limb extending into the left external iliac artery to fully exclude the
internal iliac artery (34709). The separate right docking limb of the Zenith device is placed
(included in the main graft code). Follow-up angiography reveals excellent seal. Groins are pre-
and perclosed.

Note: Code 34713-59 describes the left 18 French percutaneous access and closure. No code is
submitted for the 10 French right percutaneous access and closure.

6) Patient with a descending thoracic aortic aneurysm, 5 cm in size. Under general anesthesia, a
right femoral cutdown is performed (34812). Aortic access is achieved (36200) and a 24 French
sheath placed. Under fluoroscopic guidance, the stent graft is deployed across the aneurysm
and tacked proximally and distally with a 30 mm balloon. This covers the left subclavian artery
(33880, 75956). Subclavian-carotid transposition by neck incision is performed by the vascular
surgeon (33889). Angiography reveals a distal endoleak, requiring placement of a distal
extension with repeat angioplasty (no code, bundled at the time of initial thoracic stent graft
placement). Proximal extension is also placed (33883/75958). Final imaging reveals excellent
seal.

7) Patient with a saccular mid thoracic aortic aneurysm. Unilateral femoral cutdown (34812)
and dissection is performed with placement of a vascular sheath into the aorta (36200). Brachial
cutdown to assist with thoracic stent graft deployment (34834) is achieved and flush catheters
are placed into the proximal descending thoracic aorta (36200-59). Fluoroscopically-guided
delivery of a mid thoracic aortic endograft covering the aneurysm (33881, 75957) is performed.
This is below the take off of the left subclavian artery. A 30 mm PTA balloon is utilized to tack

down the proximal and distal aspects to ensure proper seal (no code). Final thoracic angiogram
reveals exclusion of the aneurysm and no evidence of endoleak (no code).

8) Patient with large abdominal aneurysm, short proximal neck and bilateral renal and superior
mesenteric artery involvement. CTA with specific measurements was obtained six weeks prior in
order to obtain a customized fenestrated stent graft system. Via bilateral external iliac artery
cutdowns (34820 x 2), a fenestrated modular aortic device is placed carefully in the proximal
aorta with multiple repositionings required to accurately deploy this with the fenestrations
(holes) in the device lined up with the renal vessel origins. This is deployed, followed by both
extremity docking limbs that are secured in place with balloons in the common iliac arteries.
Bilateral renal endoprostheses are placed in the right and left renal arteries via fenestrations,
and a fenestrated endoprosthesis is placed in the superior mesenteric artery (34847) via open
brachial approach (34834). These are secured with full balloon deployment. An extension is
required on the left side extending into the external iliac (34709). Prior to placement, coil
embolization of the left internal iliac is required via the brachial approach (37242, 36246-59).
Final imaging (bundled) shows excellent positioning of all devices without endoleak.