Endovascular Aortic Aneurysm Repair (EVAR)
3470534709wRVU: 6.34 — Placement of extension prosthesis at same session as primary EVAR (add-on per primary, 6.34 wRVU; report once per vessel treated regardless of number of extension modules — NOT once per module)34812wRVU: 4.03 — Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (add-on per primary, 4.03 wRVU; separately reportable for each cutdown; bilateral cutdowns = 2 units or modifier -50)34713wRVU: 2.44 — Percutaneous access and closure of femoral artery for delivery of endograft through large sheath (≥12 Fr), including ultrasound guidance when performed, unilateral (add-on per primary, 2.44 wRVU; separately billable per side for PEVAR; NOT bundled)
Abdominal aortic aneurysm, [X] cm maximum diameter, anatomically suitable for EVAR
Same
Endovascular abdominal aortic aneurysm repair (EVAR), [device: Endurant / Excluder / Zenith]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal [/ spinal / MAC with local]
The patient is a [age]-year-old [male/female] with a [X]-cm abdominal aortic aneurysm with anatomy suitable for endovascular repair (infrarenal neck [X] mm diameter, [X] mm length, angulation <60°). EVAR was selected over open repair given [patient comorbidities / patient preference / favorable anatomy]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
Both common femoral arteries were accessed without difficulty. The aortic neck measured [X] mm in diameter with [X] mm length and [X°] angulation. Bilateral iliac fixation zones were adequate. The [Endurant / Excluder / Zenith] endograft was deployed with [no / type I / type II] endoleak on completion angiography.
The patient was positioned supine on the angiography table. Bilateral groin [cutdowns were performed through longitudinal incisions / access was obtained percutaneously]. The common femoral arteries were dissected and controlled with vessel loops [or accessed percutaneously under ultrasound guidance]. Systemic heparin [100 units/kg] was administered and ACT confirmed >250 seconds.
Access was obtained bilaterally and stiff wires [Lunderquist] were positioned in the descending thoracic aorta under fluoroscopic guidance. Sheaths were upsized to accommodate the delivery system [14-22 Fr depending on device]. A [Lunderquist] stiff wire was positioned in the descending thoracic aorta under fluoroscopic guidance. The main body of the [device] endograft was introduced via the [right / left] femoral sheath and advanced to the level of the renal arteries under fluoroscopic guidance. The renal arteries were marked using contrast angiography with a pigtail catheter positioned at the level of the renal ostia.
The main body was deployed with the proximal fixation zone [X] mm below the lowest renal artery. The contralateral limb gate was cannulated from the [left] femoral access, a stiff wire positioned, and the contralateral limb advanced and deployed. The ipsilateral limb was then deployed to the [common iliac / external iliac] artery. Overlap between the main body and limbs was confirmed [≥3 cm].
Completion angiography was performed in [AP / oblique] projection confirming [no endoleak / adequate seal zones / patent renal and hypogastric arteries]. [A type II endoleak from [IMA / lumbar artery] was identified and [embolized / observed].] Sheaths and wires were removed. [Common femoral arteriotomies were repaired with running 5-0 Prolene / Percutaneous closure devices (Perclose ProGlide) were deployed.] Femoral pulses were confirmed. Wounds were closed in layers.
None
None
[X] mL
None
The patient tolerated the procedure well and was taken to the PACU in stable condition. Follow-up CTA scheduled at 1 month and 12 months per SVS EVAR surveillance protocol, then annually thereafter.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: AAA, *** cm, EVAR suitable
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: EVAR, *** device
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: .PTAGE-year-old .PTSEX with *** cm AAA. Neck *** mm × *** mm, *** angulation. EVAR selected given ***. Consent obtained.
FINDINGS: Bilateral CFA access obtained. Neck *** mm, iliac fixation adequate. Completion angio: no endoleak / type *** endoleak.
PROCEDURE:
Supine on angio table. Bilateral femoral [cutdowns / percutaneous access]. Heparin *** units/kg, ACT >250. Stiff wires in descending thoracic aorta. Sheaths upsized to *** Fr. *** device main body deployed *** mm below lowest renal artery. Renal arteries marked with pigtail catheter. Contralateral limb gate cannulated, limb deployed. Ipsilateral limb to ***. Overlap ≥3 cm confirmed. Completion angio: ***. Sheaths removed. [Arteriotomies repaired with 5-0 Prolene / closure devices deployed]. Pulses confirmed. Wounds closed.
EBL: *** mL
COMPLICATIONS: None
DISPOSITION: PACU stable. CTA at 1 month and 12 months scheduled.
Signed: .ME, .MYDEGREE
.TODAYVariants
Type II Endoleak: Embolization vs. Observation
A type II endoleak originating from the [inferior mesenteric artery / lumbar artery] was identified on completion angiography. The aneurysm sac pressure was assessed as low-flow. Option A (embolization): the IMA was cannulated via the SMA collateral pathway and coil-embolized. Option B (observation): the type II endoleak was observed given low-flow character and will be reassessed on 1-month CTA. Type II endoleaks not associated with sac enlargement are observed; those with sac growth at 6-12 months require intervention.
Charting Tips
- Document the proximal seal zone distance from the lowest renal artery. Inadequate neck seal is the most common cause of type I endoleak and late aneurysm rupture. The distance to the renal arteries must be explicitly recorded.
- Document completion angiography findings specifically: endoleak type, renal patency, hypogastric patency, and iliac limb positions. A generic 'no endoleak' statement without documenting renal/hypogastric assessment is insufficient.
- EVAR requires lifelong surveillance. Document the follow-up imaging plan in the operative note per SVS 2018 guidelines: CTA at 1 month, 12 months, then annually. This establishes the surveillance protocol and is a quality metric.
- For open cutdown: document 34812 separately per side. For percutaneous access: document sheath size (≥12 Fr triggers 34713) and closure device used — both required to support the 34713 add-on. If rib or costal cartilage was resected for access (rare in standard EVAR), document separately.
- ICD-10: I71.43 (infrarenal AAA without rupture, most common elective EVAR indication), I71.33 (infrarenal AAA, ruptured), I72.3 (iliac artery aneurysm). I71.41/I71.42 for pararenal/juxtarenal without rupture.
Billing Tips
- 34705 (EVAR aorto-biiliac, 28.84 wRVU, 90-day global) is the standard code for bifurcated endograft repair of infrarenal AAA. Code family: 34701 (aorto-aortic tube graft, 23.12 wRVU), 34703 (aorto-uniiliac, 25.86 wRVU), 34705 (aorto-biiliac, 28.84 wRVU), 34707 (ilio-iliac, 21.72 wRVU). These are mutually exclusive standalone primary codes — select based on graft configuration.
- 34703 (aorto-uniiliac, 25.86 wRVU) applies when a uniiliac device is used (e.g., with contralateral iliac occlusion and femoral-femoral bypass using 35661); 34707 (ilio-iliac, 21.72 wRVU) for isolated iliac aneurysm repair. 34710 (delayed extension, first vessel, 14.63 wRVU) and 34711 (add-on, 5.85 wRVU) are used when extension limb placement occurs at a separate session.
- 34704 (aorto-uniiliac, 43.88 wRVU) and 34706 (aorto-biiliac, 43.88 wRVU) are the RUPTURE variants — they apply when temporary aortic and/or iliac balloon occlusion is performed, as in emergency EVAR for rupture. These are NOT revision or redo codes. Do NOT use 34704/34706 for elective revision of a prior endograft — that is a compliance violation. There is no dedicated revision EVAR code; elective reintervention is coded with the relevant intervention code for the work performed.
- Extension limb placement at the same session: 34709 (add-on, 6.34 wRVU) reported once per vessel treated, regardless of the number of extension modules required. If two extensions are deployed into the same iliac vessel, bill 34709 once. Delayed extension placement (separate session) uses 34710/34711.
- Femoral access add-ons: open cutdown (34812, 4.03 wRVU) IS separately billable — report once per groin; bilateral cutdowns = 2 units. Percutaneous large-sheath closure (34713, 2.44 wRVU) IS separately billable when a ≥12 Fr sheath is used with a closure device — report once per side. These are among the most commonly missed revenue items in EVAR. Only the arteriotomy closure repair code 35226 is bundled.
- Radiological supervision and interpretation (formerly coded as 75952/75953/75954, deleted January 2018) is bundled into the current 34701-34708 code family. Do not separately bill for intraoperative completion angiography. Diagnostic aortography performed at a prior separate session is separately reportable.
- Global period is 90 days. Post-op CT surveillance for endoleak, routine follow-up, and routine contrast studies are bundled. Endoleak embolization requires modifier -78 (unplanned return for complication) within the global. Planned staged procedures (e.g., scheduled contralateral limb extension at a second session) use modifier -58.
General coding reference. Verify with your institution’s billing department before submitting claims.