DRIL Procedure

Question:

The surgeon said he did a DRIL procedure on an AC fistula. I’m not sure how to code this. Is it an unlisted code?

Answer:

The DRIL procedure (Distal Revascularization with Interval Ligation) is a surgical intervention to treat complications related to hemodialysis access. It is performed to address complications arising from hemodialysis access, such as ischemia (reduced blood flow) or steal syndrome (where blood flow is diverted away from the limb) in the affected extremity. It involves restoring blood flow to a limb while also addressing issues like high flow or steal syndrome by ligating (tying off) a portion of the access. This procedure aims to reduce pain, improve tissue viability, and prevent further complications in the affected limb. This procedure has an existing CPT code and is reported as 36838. 

*This response is based on the best information available as of 7/31/25.

Thrombolytic Infusion

Question:

If a thrombolytic infusion catheter is placed and later in the day it is removed for an interventional procedure and then replaced after the procedure, what is the correct code to report?

Answer:

CPT code 37211 is for the entire day of initial thrombolytic therapy. No additional code would be billed for catheter replacement on the same day.

*This response is based on the best information available as of 7/17/25.

Same Group Coding

Question:

If an Electrophysiologist performs a 90-day procedure and an Interventional Cardiologist in the same group sees the patient mostly for the reason for procedure, can he bill an EM, if yes, would a modifier be necessary?

Answer:

The Interventional Cardiologist can generally bill an E/M (Evaluation and Management) service during the 90-day global period of a procedure performed by the Electrophysiologist in the same group — but only if certain conditions are met and modifier 24 is applied correctly.

Since both physicians are in the same group, they're typically considered the same provider for billing purposes. The key is demonstrating that the Interventional Cardiologist's service was separate, medically necessary, and not just a routine post-procedural visit that would normally be included in the global surgical package.

The documentation should clearly support why this additional E/M service was necessary and distinct from the typical care associated with the procedure.

*This response is based on the best information available as of 7/03/25.

Selective or Non-Selective Catheterization

Question:

If we access the dorsalis pedis artery with a catheter and go up into the anterior tibial for arteriogram, is this selective or non-selective?

Answer:

This would be a non-selective catheterization; the access was made and did not cross into the aorta or into another territory for selective catheterization.

*This response is based on the best information available as of 6/19/25.

E/M for Worsening Chronic Condition

Question:

I have a patient with end stage renal disease who I saw yesterday in follow-up in the clinic. His ESRD is not at treatment goal, I recommended a fistula procedure and discussed specific risks and benefits of the procedure with the patient. What E/M level should I bill?

Answer:

ESRD is a chronic condition. If the patient is not at treatment goal as you stated, the complexity of the problem addressed is moderate. When recommending a major procedure if you discuss patient and procedure risks in detail and document this information in the note, the risk of mortality and/or morbidity of patient management is high. Based on these factors, the level of service would be moderate. Two elements must be met from the Medical Decision Making table for the level of service. Since this is an established patient, I would report 99214 (established patient office or other outpatient).

*This response is based on the best information available as of 6/05/25.

First Patient Encounter

Question:

I saw a new patient in the outpatient clinic several weeks ago. Now, the patient has been admitted to the hospital. The admitting physician has asked me to see the patient again for that same condition. This is my first time seeing them in the hospital for an inpatient visit. What EM code do I bill for this visit?

Answer:

The E/M code for an initial inpatient visit, regardless of whether the patient was new or established to you, would be billed with either an inpatient consultation code (99252-99255) or an initial hospital code (99221, 99222, 99223 ) with the appropriate level based on MDM or Time.

*This response is based on the best information available as of 5/22/25.