Bilateral Straightforward: Angioplasty

Question:

What CPT codes would you use for bilateral straightforward angioplasty of the right and left external iliac arteries using one access site? Can you use 37254-50 or would it be 37254 for the initial vessel and 37255 for the vessel on the contralateral side?

Answer:

For bilateral straightforward angioplasty of the external iliac arteries (EIA) performed via a single access site, the correct coding approach in 2026 is to use the initial vessel code for each side, rather than using the "additional vessel" add-on code for the contralateral iliac artery.

Under current CPT guidelines for lower extremity revascularization procedures are reported based on anatomical vascular territories (Iliac, Femoral/Popliteal, Tibial/Peroneal, and Inframalleolar) and are typically unilateral.

The appropriate code for a "straightforward" angioplasty in the iliac territory is 37254 (initial vessel) and 37255 (each additional ipsilateral vessel). Because you are treating two different anatomical sides (Right and Left), both are considered "initial" vessels for their respective territories.

Primary Code: 37254 (Iliac territory angioplasty, straightforward, initial vessel)

Append Modifier 50 to the primary code (37254-50) or report as 37254-RT and 37254-LT, depending on payer preference.

*This response is based on the best information available as of 08/13/26.

Evaluation and Management Service in the Office - Based on Time

Question:

What should be documented when reporting an E/M service based on time in the office?

Answer:

When reporting an E/M (Evaluation and Management) service based on time, documentation must clearly support that time, not medical decision-making, is the controlling factor.

Key elements that must be documented:

• Total time spent

  • Document the total number of minutes personally spent by the provider on the date of the encounter.

  Documentation Example: “I spent a total of 45 minutes on this patient’s care today, including reviewing prior records, evaluating the patient, counseling on diabetes management, adjusting medications, and documenting the encounter.”

• Activities performed

  • You should indicate the types of activities included in that time, such as:

    • Reviewing tests/history before the visit.

    • Obtaining history and performing an exam.

    • Counseling and educating the patient/family.

    • Ordering medications, tests, or procedures.

    • Communicating with other healthcare professionals.

    • Documenting in the EHR.

    • Care coordination.

• Date specificity

  • Time must reflect work performed on the same calendar date as the encounter. Time spent on procedures must be excluded from the E/M time. Time spend on procedures must be excluded from the E/M time.

• Provider-specific time

  • Only include time personally spent by the billing provider (and qualified healthcare professionals if applicable per payer rules).

  • Exclude time spent by ancillary staff.

• Medical necessity

  • Documentation should still support why the visit was necessary (chief complaint, reason for care), and a medically appropriate history and/or examination.

  • A summary of counseling/topics discussed can strengthen the record.

Exact start/stop times are not required (total time is sufficient).

*This response is based on the best information available as of 06/04/26.

What’s Included and Excluded in an ALIF

Question:

Hi, I have a spine surgeon and vascular surgeon working together on an ALIF procedure, 2 level, which I have billed 22558/22585. The vascular surgeon is also repairing the sympathetic nerve, which i don't see a code for. He has input 64722 but I'm not quite sure that would be the correct code. Also, would that not be part of the ALIF procedure? He is also starting to bill and code the repair of the middle sacral vein, sacral artery, and iliolumbar vein. I looked at those codes at 35221, now I put those through the NCCI edits, and it seems that it can be billed. However, I read through another coding forum that a provider can’t bill those codes, as that is part of the ALIF procedure. I need clarification on whether repairing artery or veins are part of the ALIF procedure.

Answer:

The question you pose is a complicated one without reviewing the operative report, therefore, here are some general guidelines.

If the vascular surgeon is providing the approach and not there to treat a complication during the ALIF procedure, the approach may include access through the the iliac vessels, parasympathetic nerves, and middle sacral artery. If there are incisions through any of these structures, then they are included and would not be billed separately.

*This response is based on the best information available as of 05/07/26.

Transcarotid TAVR: Unlisted Code 33799

Question:

My hospital wants to pursue elective TAVR via carotid approach. Normally via percutaneous femoral approach, the Interventional Cardiologist and Cardiac Surgeon bill for the case. If they request me for open carotid artery exposure (as Vascular Surgeon), is there a way for me to bill as a third provider?

Answer:

There is currently no specific CPT code for transcarotid TAVR, so the entire procedure is reported using unlisted cardiac surgery code 33799. When submitting 33799, it is best practice to include a crosswalk to the comparable TAVR code range 33361–33366 to support valuation and reimbursement. Because all TAVR/TAVI codes include vascular access, exposure, and closure as bundled components, separately billing for access (e.g., carotid cutdown or repair) would not be appropriate. TAVR procedures are intended to be performed by two co-surgeons—a cardiothoracic surgeon and an interventional cardiologist, who each report the procedure using modifier 62 (co-surgery). If a vascular surgeon participates in the case for carotid exposure, the only potential billing pathway would be to attempt team-surgery reporting (modifier 66). However, this is not always accepted and would require that the payer recognizes the team-surgery model and that documentation supports the medical necessity of both the carotid approach and the involvement of all participating surgeons. Because the carotid approach remains an unlisted service, obtaining payer preauthorization or a pre-determination of coverage is strongly recommended to confirm acceptance of both the unlisted code (33799) and the team-surgery structure before scheduling an elective case.

*This response is based on the best information available as of 04/02/26.

Clarification on Consultation Codes

Question:

After reviewing the First Patient Encounter question and answer. Would this still be considered a consult since the problem is already established with the provider? "The admitting physician has asked me to see the patient again for that same condition" New vs established does not pertain to IP/Consult codes. However can they bill a consult on an established diagnosis?

Answer:

Consultation codes may be used for patients previously seen for the same condition, provided the provider did not assume ongoing care during prior encounters and is not assuming management in the current hospitalization. The key distinction lies in seeking an opinion or advice versus assuming care and management of the condition. To report a consultation, a formal physician request must be documented, a clinical evaluation and recommendations must be provided, and findings must be communicated back to the requesting provider. Previous encounters do not disqualify the use of consultation codes if these requirements are met and the current request genuinely seeks consultation rather than care management. However, if the provider is already treating and managing the condition, consultation codes are not appropriate when the requesting provider asks them to see a patient already under their active care.

*This response is based on the best information available as of 03/05/26.

Diagnosis Coding for Renal Angiography

Question:

What would be the appropriate ICD-10-CM code if the patient comes for renal artery bleeding and the physician studies renal angiogram and found no active extravasation? Diagnosis R58 is not payable diagnosis as per LCD policy for CPT 36253.  Can  you provide some guidance?

Answer:

When renal angiography is performed for suspected renal artery bleeding and no active extravasation is identified, the diagnosis must accurately reflect the clinical indication and intent of the study. Because nonspecific symptom codes such as diagnosis code R58 do not define an anatomical site or etiology, they often do not support the medical necessity of the procedure.

The order and final impression should clearly document the suspected or underlying cause prompting the angiogram (for example, postprocedural hemorrhage or renal injury). If documentation is unclear or a specific diagnosis cannot be identified, it is appropriate to query the provider to determine the most accurate diagnosis supporting medical necessity. When no suitable ICD-10 code can be established after clarification, append the appropriate G modifier based on ABN status to indicate that medical necessity may not be supported for the service.

*This response is based on the best information available as of 02/05/26.