2025 CPT code 75827
Venography, caval, superior, with serialography, radiological supervision and interpretation.
Modifiers 26 (Professional Component) and TC (Technical Component) can be used to report the professional and technical components of the procedure separately. Modifiers 51 (Multiple Procedures), 52 (Reduced Services), 59 (Distinct Procedural Service) may be applicable in certain circumstances.
Medical necessity should be established by documenting clinical signs and symptoms suggestive of superior vena cava pathology, such as swelling in the upper extremities, face, or neck, shortness of breath, or other relevant indications. Pre-existing conditions and prior imaging results that support the need for the procedure should also be documented.
The physician performs the procedure under local anesthesia, inserts the catheter, injects the contrast, and interprets the images. Clinical responsibility includes the entire process of obtaining the diagnostic images necessary to determine the patient's condition.
In simple words: This procedure uses x-rays and dye to create a detailed picture of the large vein that carries blood from your upper body to your heart (superior vena cava). The doctor uses a small tube (catheter) to inject dye and a special x-ray machine to take rapid pictures of the vein, which helps them find and assess blood clots.
This code represents the physician's supervision and interpretation of a superior vena cava venography, including serialography (rapid sequence imaging). This is an invasive diagnostic procedure where x-rays of the superior vena cava are taken after injecting contrast dye. The procedure helps identify the location and extent of any blood clots. It involves puncturing a distal vein, inserting a guidewire and catheter to the superior vena cava, removing the guidewire and injecting contrast dye. Serial images are then taken and interpreted by the physician.
Example 1: A patient presents with swelling in the neck and face. A superior vena cava venography with serialography is performed to evaluate for potential thrombosis in the superior vena cava., A patient with a known central venous catheter has new onset shortness of breath. A superior vena cava venography with serialography is performed to rule out a thrombus related to the catheter., A patient undergoing chemotherapy treatment experiences swelling in the arm and chest. A superior vena cava venography with serialography is used to assess for stenosis (narrowing) or thrombosis in the superior vena cava that may be impacting venous drainage.
Documentation should include the medical necessity for the procedure, the site of access, details of the procedure (including confirmation of the catheter tip placement, contrast agent used, and imaging technique), and the physician's interpretation of the images, including the findings and any associated diagnoses.
- Revenue Code: I4B – IMAGING/PROCEDURE - OTHER
- Specialties:Radiology, Interventional Radiology, Vascular Surgery, Cardiology (in some cases)
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, and other facilities where imaging services are provided.