Knowledge Base

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Midline Catheter Insertion

I code for a hospital. We have a Vascular Access Team that performs many midline catheter procedures using a Powerwand. The physician's order is specifically for a midline catheter. The intent is to place a midline catheter, NOT a PICC line. The procedure is performed with the catheter tip in the axillary vein. I code these procedures with 36000, but this code is not authorized by insurance. Many coding authorities suggest coding these midline catheter insertion procedures with 36569 with a modifier -52 for reduced services. I do not feel this is appropriate/compliant since this is not a central venous catheter insertion, nor was that the intent. Your clarification will be greatly appreciated.

G0278

To follow up on a previous question regarding denials on G0278, iliofemoral run-off during cardiac cath... In many cases, the iliofemoral vessels are being assessed because the cardiac cath is being done prior to a TAVR procedure and the doctors want to assess, along with the cardiac cath, if the iliofemoral vessels are suitable for a TAVR procedure. If the patient does not have peripheral disease, the G0278 is being denied. Should I just write off the G0278, or should I be using the pre-procedural examination diagnosis codes such as Z01.810?

Renal Vessels and IVC

For the following, would you use 37799? "Incision was made and vena cava exposed. Right renal vessels were explored. The right renal artery was dissected free for adequate length, doubly ligated, clipped and divided for reduction of inflow. The vena cava was the uncontrolled and tumor was noted to be localized to the segment just above the renal vein. The clamp was able to be manipulated around this area and the tumor milked back into the renal vein. The clamp was secured so no tumor movement was possible. The proximal vein was then readied for control. The right renal vein was divided right at its origin into the cava and the tumor was milked out of the IVC in continuity. The renal vein was then fully divided and the side wall of the vena cava repaired with running prolene suture. Prior to completing the final suture, proximal and distal flush maneuvers were performed. No significant narrowing of the cava was noted. The renal vein was then isolated slightly farther with the tumor intact and the case turned back over to Dr. X for dissection and removal of the kidney."

CT

Can you please provide some guidance on how to charge for this scenario? "A CT urogram was done. A CT lumbar was ordered the same day, but after the CT urogram was completed. They were able to take the data from the CT urogram and reconstruct the data for the CT lumbar." How would you code for this? 

Celiac Stenosis vs Compression

I know you don't usually do a lot of diagnosis information, but I have a question on celiac. When you go to stenosis in the ICD-10 book it takes you to I77.4 for celiac. I don't agree with coding this when we are doing an angio and it is confirmed stenosis and not compression. Is it appropriate to code to mesenteric (K55.1)? I know in a previous question it was stated that it would be considered mesenteric for stent placement, but we wanted to verify that it means to code diagnosis to K55 and not I77. 

CPT code for preplanning artery mapping

My provider is trying to determine donor graft candidacy after a Moyamoya craniotomy. He has ordered a preplanning artery mapping. Is there a CPT code for this?

APUS Tack

Is there a code for placement of Aptus tacks? We have been using an unlisted code (37799) for this procedure. It is for repair of aortic aneurysm attachment using Aptus tacks.

AV Fistulogram, Central Venogram, and Cephalic Vein Angioplasty and Stent

These are so confusing with the new codes. Please help. 1) Initial left upper extremity diagnostic fistulogram reveals a widely patent left cephalic vein except for a 99% stenosis due to a kink at the peripheral side of a previous cephalic vein stent. This is severely limiting outflow from the upper arm cephalic vein AV fistula. 2) Cephalic vein kinked stenosis is crossed with mild difficulty and subsequently plastied to 7 mm diameter and then stented with a 10 x 6 mm Absolute Pro Self-Expanding bare metal stent dilated to 10 mm with an excellent end result and no residual stenosis. 3) Central venogram revealed no central venous stenosis.

Retinoblastoma via extended ophthalmoscopy and fluorescein angiography, etc

"Selective catheter placements and angiographies of the patient's left internal carotid artery, external carotid artery, and ophthalmic artery via a right CFA access. Angiography reveals both extracranial and intracranial internal and external carotid arteries and their branches are of normal course and caliber without atherosclerotic disease, aneurysm, focal area of stenosis, or early draining vein. Ophthalmic artery and its branches reveal a chorodial blush. No significant washout of contrast is noted into the supraclinoid internal carotid artery. 1 mg of topotecan was injected into the ophthalmic artery with follow-up angiography performed with no changes from initial angiogram. 5 mg of melphalan was injected into the ophthalmic artery with follow-up angiography demonstrating no change from initial angiogram. Follow-up internal carotid artery angiography was performed with no changed from initial angiogram. No branch occlusions are seen." Is this coded 61624, 36217, 36218, 75898 x 3, 75894, and 96420 (hospital only)? There is no example of this in your database.

LHC with OPEN aortic pressures

When documentation only supports OPEN aortic pressures, does this equal a LEFT heart cath? My coders are wanting to code a LHC, as they indicate the left heart chamber is accessed for OPEN aortic pressures. Below is an example of what is found in the documentation. "Hemodynamics: Body mass index is 28.7 kg/(m^2).; Body surface area is 2.59 meters squared.; Opening aortic pressure is 124/41 mmHg; mean 70 mmHg."

93571-74, FFR without adenosine

Left heart catheter was done with coronary angiography. FFR on LAD without adenosine was also done during the LHC. How should I code this case for the hospital outpatient facility coding? Should I code 93458 and 93571-74? I am not sure if I can add the fully completed procedure and the procedure with -74.

36593 for thombectomy of vena cava filter?

Could I use code 36593 for the following? "Given thrombus detected on intravascular ultrasound, rheolytic thrombectomy was done with the AngioJet device within the basket of the inferior vena cava filter for 20 seconds. Final intravascular ultrasound was performed, demonstrating marked improvement in volume of thrombus within the filter. Therefore, decision was made to remove the filter in the same setting."

Vertebral Stent Code

I just wanted to verify which code is correct for vertebral stenting: 0075T or an unlisted code? The patient has severe peripheral arterial disease, with occlusion of common carotid arteries, as well as the left vertebral artery. He has had prior left subclavian artery stenting and has intermittent episodes of near syncope and drop attacks. The entire cerebral circulation is supplied by the right vertebral artery, which has a critical proximal stenosis of approximately 80%. He now presents for angiography and possible vertebral stenting. The physician proceeded to do angiography and placed a stent in the right vertebral artery after deploying an Emboshield distal embolic protective device. They PTA'd the stent and removed the filter.

Ablation of Parathyroid Glands

How would either an alcohol or RF ablation of three independent parathyroid glands under ultrasound guidance be coded if performed in a single session? Would 60699 x 1 and 76942 be the correct codes?

Dual chamber PM upgrade to Bi-V ICD using existing leads

Patient with a dual chamber pacemaker is being upgraded to a biventricular ICD. Existing RA and RV leads are functioning properly and will not need replacing. Pacemaker is removed and replaced with a new ICD, and a new LV lead is attached. Should we report codes 33233, 33230, and 33225?

Bilateral Arthrogram

Bilateral shoulder arthrogram done with fluoroscopic guidance and only spot film. I know I can bill for 23350-RT and 23350-LT, but can code 77002 only be billed once per encounter? Or can I bill for each side with an -XS modifier on the second 77002? 

US Guidance with Embolization

Can ultrasound guidance for vascular access (76937) be coded separately with vascular embolization (37241-37244)? The code descriptor states “and imaging guidance necessary to complete the intervention”; however, CPT Assistant, Nov 2013, pg 6-8, states: "US guidance for vascular access is NOT included and separately coded." Also, MedAssets (Code Correct) does not provide bundling issues between the two codes. Is this different from TIPS or IVC filter where the code descriptor states “all associated imaging guidance”?

Angiogram of Fontan Conduit

I understand that contrast injection for atrial and ventricular angiograms is included in 93580, but how can we report contrast injections of the conduit from a previous Fontan procedure when performed at the same session as 93580? Would code 93564 be appropriate?

Angiogram after Bypass Surgery

When a patient has a fem-pop bypass performed, for example, and the surgeon does a completion angiogram and notices stenosis further down the leg and decides to put in a stent based on the completions angiogram, would this be billable with 75710?

93621 Documentation

This is an old question, but I wanted to check again with you. What documentation must be present in order to bill code 93621 (left atrial pacing and recording from coronary sinus or left atrium)? Is a sole statement at the top of the report indicating "comprehensive electrophysiologic studies with coronary sinus mapping and pacing" sufficient? I'm under the impression the CS catheter can be used for multiple different pacing maneuvers for multiple locations, and its presence cannot necessarily be solely equated with left atrial pacing and recording. Is that correct?

36005 and 36011

Can you please explain when it is appropriate to use codes 36005 and 36011? The physician performed a right and left congenital heart cath through existing septal defect, did angiograms, and then did a pulmonary valvuloplasty. Per report: "A hand injection angiogram in the left innominate vein and SVC demonstrates normal venous anatomy and return to the right atrium." Is that statement enough to report codes 75827/36011? I am confused when I can add code 36005 or 36011 and what documentation needs to be in the report. 

Diagnostic angiogram vs. road mapping

If the physician documents the following, would you consider it selective catheter placement with diagnostic angiogram or roadmapping? "A 5 French EnvoyO.056 inch, 90 cm guide catheter was prepared, advanced over a Terumo glidewire (.035in) to the descending aorta, double flushed, and used to select the following vessels: The catheter was then repositioned into the left common carotid artery, and selective angiogram was performed in the cranial views. The catheter was then repositioned into the left external carotid artery, and selective angiogram was performed." Later on in the operative report, physician dictates: "Microwire was inserted into a Prowler select plus, 150 cm, 450 microcatheter, and this system was advanced under roadmap fluoroscopic guidance into left sphenopalatine artery. An angiogram was then performed." I think it should be coded as 36223 and 36227. I would not code the catheterization and angiogram for left sphenopalatine artery. What is the difference between diagnostic angiogram and roadmapping?

Mapping with VT Ablation

Can you bill code 93613 with 93654? I was told this is bundling, but 93613 can be billed with 93656. Is this true? We are billing physician charges not hospital. Also do any modifiers have to go on any of the codes?

36227 without 36222, 36223, or 36224

We have a patient whereby the doctor only did a 36227 (50). In the AMA/CPT book it says this code cannot be used without a 36222, 36223, or 36224, but the doctors are insisting that they were able to look at the externals without having to go into the internals, and because this patient has kidney issues, the internals were looked at during the previous diagnostic angiogram around 10 days ago. The physician could not do the full diagnostic in one day because the contrast is very dangerous for patients with kidney problems, so it needs to be limited and done in pieces. How do I code this then?

32557

For the following, is code 32557 appropriate? "Informed consent was obtained prior to the exam after discussion of risk and benefits of the procedure. No sedation was administered during the exam. CT demonstrated a small hydropneumothorax within the right hemothorax. The skin was prepped and draped under sterile conditions, and 1% lidocaine was used for local anesthesia. A 19 gauge needle was used to access the fluid collection. There was return of a small amount of fluid, which was serous to serosanguineous. A wire was advanced. The tract was dilated to 8 French, and an 8 French APD drainage catheter was placed and connected to a pleuro-vac. The patient tolerated the procedure."

3D Cerebral Embolization

I have a 3D cerebral embolization case, 61624, 75894, with multiple follow-up angios 75898, and I need clarification regarding your instructions on codes 75898 and 76377. Per your 2017 Interventional Radiology Coding Reference, regarding follow-up angiography code 75898, the manual states: "Intracranially, code 75898 may be used as often as medically necessary and requires excellent documentation." Also, page 297, #49 states: "Documentation must support these separate and distinct follow-up angiograms." Could you elaborate further on this type of documentation and what is required? There were also two Q&As from March 3rd and March 9th, 2017 that state 3D reconstruction (76377) should not be reported separately when performed during intracranial embolization with or without imaging. Since there are no NCCI edits on these code combinations can you explain why the 3D imaging is inclusive and should not be billed?

AV Fistula

Can you please advise what CPT codes would be appropriate for the following procedure report? The main question we have is: do we code the PTA of the central subclavian vein, or is it included in 36907? "Procedure report: 1) Ultrasound access to the outflow limb initially with a 5 French, then upsized to an 8 French for Angio-Jet suction. 2) Ultrasound access to the inflow with an 8 French. 3) Balloon angioplasty of the outflow using an 8 x 80 using up to 10 ATM. 4) Angio-Jet suction to the inflow. 5) The inflow 8 French was pulled out and hemostasis obtained with a Z-stitch. 6) Angio-Jet suction of the outflow. 7) Balloon angioplasty of the graft using a 7 x 60 to 10 ATM. 8) Balloon angioplasty of the central subclavian vein using a 12 x 6 initially, and then 14 x 6 up to 6 ATM. 9) Z-stitch to the outflow 8 French catheter." I tried sending the entire procedure note, but it will not allow me to send the complete note.

Unsuccessful attempt to recanalize CTO of RCA

"The patient is with recent cath found to have CTO of the RCA, and is scheduled for attempt to recanalize this occlusion. Access was gained into the right CFA, and a sheath was placed. Through this sheath, an attempt was made to advance a guide catheter, but it was too large for the ostium of the right coronary artery. Eventually, a smaller guide catheter was advanced and selectively engaged the ostium of the RCA. Repeated attempts were made to recanalize the CTO in the distal RCA, but were unsuccessful, as different wires were going subintimal into the distal vessel. The procedure was aborted, and the patient will be considered for medical management versus re-attempt through retrograde access at CTO occlusion dedicated stent there. Conclusion: Unsuccessful attempt to recanlize CTO of the RCA." Would this be considered 92943-53RC? If not, what would it be considered? 93454-53? These unsuccessful attempts really confuse me.

Conventional Myelogram vs. Digital Subtraction Myelogram

"First day, spinal needle was placed in thecal sac under fluoroscopic at L2-L3. A needle was placed over left pedicle of T10 vertebra. Omnipaque was injected to confirm subarachnoid position. 12 mL intrathecal Omnipaque was administered for biplane digital subtraction myelography centered at the thoracic level. Normal saline was then administered. Cervical, thoracic, and lumbar conventional myelographic images were then obtained. FINDINGS: Biplane fluoroscopy confirms appropriate position of the needle at the L2-L3 level. Digital subtraction myelography of the thoracic spine demonstrates no findings specific for CSF leak. Conventional myelographic images of the cervical, thoracic, and lumbar spine exhibit no findings specific for CSF leak (62305). CT post myelogram follows. Next day, repeat complete spinal myelogram (62305)." The conventional myelogram is documented as complete for both days, but the digital subtraction myelogram is thoracic (on first day), then cervical (on second day). Does this documentation warrant coding two complete myelograms for two sequence days?

75710 or 75716 and/or 75774

Can you help some newbies code this procedure? We are in conflict with the pro coders and can’t agree on a correct set of codes. We are unsure if 75716 is appropriate or if 75710 and 75774 work. "Patient has right iliac stent and left-sided sx with probable dz in the left iliac now. Access to right CFA. Abdominal aortogram done. Left LE runoff through the catheter. With the sheath in the right EIA, the right CIA and EIA were ballooned. Then a stent was deployed in the right CIA and in the right EIA in an overlapping fashion. Repeat retrograde angiogram. Advanced sheath over the aortic bifurcation into the left CIA. Angiogram through the sheath. PTA of the left common/external iliac artery high-grade short length stenosis with a balloon. The sheath was withdrawn to the right EIA and then repeated a retrograde angio, then closure."

How to bill 37187 and 37252?

Venous thombectomy was done on right external iliac, right common iliac, right tibial, and IVC. How many times can we bill code 37187 on the same leg? How would we bill an IVUS done on right common femoral, right superficial femoral, and right popliteal femoral? 37252, 37253 x 2?

Venous Malformation of Head and Neck

For performing percutaneous sclerotherapy of a venous malformation in the head and neck, if a digital subtraction venogram is performed through the needle, to confirm the diagnosis prior to sclerotherapy, is there a procedure code that can be billed separately from 37241?

Moderate sedation 99153 as a technical only service

I have a physician who is asking for clarification on where this code is listed as a technical only code and why he can not bill this when he is doing the time at the hospital. Where can I find the guidance on this being only billed by the facility and not the physician when it is an facility setting?

Nuclear Medicine Imaging with Mapping and Y90

The IR physicians are nuclear medicine imaging twice in NM: once for the mapping study with Tc-99m MAA (they charge a liver SPECT) and once after treatment Y90 (they charge a liver SPECT). They charge 78205 and for the SPECT. (It's a zero charge?) I have always used the 78xxx codes for tumor localization, 78801 for multi, and 78803 for SPECT. Which NM code should I be using?

Stand-alone Vascular Lab

I was wondering if you could refer me to where I can get information about coding for the stand-alone vascular lab. Such as what we can bill out over and above the procedure code? We will be billing out in POS 11. Can we bill for supplies, drugs, injections? Will you have a session on this at your seminar, or will you be addressing this in one of your webinars? With these being more common, I need help in making sure that I am billing out everything that I can for our company.

93650 with 93609

I am getting some conflicting information that I was hoping you could clarify. If mapping is performed/documented at the time of an AV node ablation, is it acceptable to report code 93609 with 93650? I am being informed that it is not bundled into 93650 and can be separately coded, but the coding guidelines make no mention of 93650 as a code 93609 can be used in conjunction with, even though it is an ablation procedure.

LINQ procedure provided at the same session of an Ablation procedure

Our providers are performing an ablation (zero global days) during the same session as the LINQ (90-day global) in the hospital outpatient area. What advice can you provide regarding performing and reporting together in the indicated setting?

93325 billed without 93320 or 93321

A few things in Dr. Z’s Diagnostic & Interventional Cardiovascular Coding Reference lead me to believe that 93325 should not be reported without 93320 or 93321. Like on page 579, #11, it says: “Color flow velocity mapping is an add-on code and, if documented, should be reported in addition to Doppler code.” And page 585, #9, says: “ Add-on code 93325 (color flow velocity mapping) should be reported in addition to the Doppler code (do not use with 93306 and C8929)." And on page 571 towards the bottom, in describing Doppler, he says: “Doppler is displayed in black and white. Color flow may be added to enhance the image by assigning colors to differentiate the direction of blood flow." I am being told that 93325 can be reported alone with its primary code. Can you please clarify the statements from the reference book, and if it's true, in what circumstance does color flow not have to be reported with 93320 or 93321?

Sclerotherapy at the same time as RF or ELVS

Additional coding of sclerotherapy at the same time as an RF or ELVS procedure must be in a separate or additional vein that was not treated or it is included. Is this correct?

Left Heart Catheterization with Stent

"Left heart catherization, coronary angiography and left ventriculography. Percutaneous transluminal angioplasty with coronary stent placement in the mid LAD. Percutaneous transluminal angioplasty of the diagonal branch of the LAD. Femoral angiography and placement of the 8 French Angio-seal. Fractional flow reserve study of the LAD." Please tell me if the coding is correct. I have coded: 93458- 2659, 92941-LD, 36245-59, 36140-59, 75710-2659, and 93571-26LD.

Diagnostic VATS 32601

"Decision for VATS for decortication in ER day prior. On insertion of thoracoscope, it was noted that there were significant adhesions with purulence throughout the chest cavity and a trapped right lower lobe and right middle lobe. Based on this, it proved to be difficult to do a decortication through a VATS approach. It was decided to perform a posterolateral thoracotomy. A posterolateral thoracotomy was performed." The provider wants to bill the VATS in addition to the open procedure. Referring to Chapter 5 of NCCI: "However, a diagnostic thoracoscopy is separately reportable with an open thoracotomy, thoracostomy, or mediastinal procedure if the findings of the diagnostic thoracoscopy lead to the decision to perform an open thoracotomy, thoracostomy, or mediastinal procedure, ...with modifier 58."

Cryo Amputation

"Patient came in with infected amputation stump. Physician took patient to OR to debride amputation, but he became unstable and they decided to do a cryo amputation. Stump was packed with dry ice and then wrapped in towels. Patient was taken back to the ICU to see if he would stabilize so that they could then go back to OR for a higher formal amputation." I was planning on coding the debridement, but I'm not sure if we can bill for the cryo. I have researched and can't find anything about billing for this. Any suggestions?

Brugada Procainide Challenge

I know you have answered several questions on this subject before, but, now for 2017.... The coding desk reference for 93024 says: "The purpose of the study is to evaluate for coronary artery spasm. If ergonovine is not available, certain other ergot medications may be infused for the same purpose." So, can I now use 93024 instead of the unlisted code?

Diagnostic Cerebral Angiogram

My physicians often do a bilateral ICA, vert, and ECA with right and left thyrocervcial trunk and right and left costocervical trunk. Is it correct to code 36224-50, 36226-50, 36227-50, and 36218 x 4 with 75774 x 4?

Injection for Pain after Myelogram

I have a patient who was in the hospital (outpatient) for a lumbar myelogram. The procedure was performed and also the post CT scan. Lately I've noticed that I'm getting a report (usually several hours later) for a CT-guided translaminar epidural lumbar spine steroid injection for chronic pain. I billed 62323 for the steroid injection, 62304 for the myelogram, and 72132 for the post CT L spine. I am getting edits between codes 62323 and 62304. NCCI says, "No modifier allowed." My first question is, did I use the correct codes? Is this normal that the radiologist who performed the myelogram would go back and do a spine injection for pain? Like I've said, I've never seen it before, but we do have a newer doctor in the group, and it seems to be his reports. Can you give me any insight on this? 

Ablation not completed

Can you let me know if 93654-52 is the correct way to code this report? "Mapping and ablation of PVC/VT frequent PVC was seen at baseline. 3D mapping in the the RVOT area showed earlier activation in the high septal sit but only had 10-15 ms before the onset of QRS. Ablation at this sirte was not effective. Mapping was then performed in the the LVOT area using retrograde approach. The early site was mapped to the aortic valve area, next to RVOT early site. But the activation time was 10-15 ms before the onset of QRS, suspected on the epicardial site. This sit is also close to the LAD, ablation was not performed. It was determined to treat with bb. Summary: The results of the EP study showed that patient had LVOT PVC near the aortic cup and likely on the epicardial side. It will treated by bb."

2 First-Order Upper Extremity Artery Selections in Same Vascular Family

We have an interesting scenario and are seeking guidance on the correct way to code. If a patient is accessed via the right brachial artery, and the right radial and right ulnar arteries are selected, would that be coded as 36215-RT and 36215-RT for two first order selections in the same vascular family (since 36218 is for additional selections of the second and third order and beyond selections)?

Separate SVC injection/access site from PM upgrade to BiVen ICD

If there is a separate access site/injection for imaging of the SVC and coronary sinus to evaluate the placement of an LV lead during a dual pacemaker upgrade to a biventricular ICD (with LV port capped), can we code separately for the SVC imaging/catheter placement? Ordinarily we know this is included with lead placements, but if the lead was not placed via this injection site, can we code 36010/75827 along with the dual pacemaker upgrade to biventricular ICD (LV port capped) with replacement of right ventricular lead (33249, 33233, and 33235)?

Resection of aneurysmal AV fistula

"We proceeded to dissect down to the brachial anastomosis. We used the same 1.5 cm incision that was placed originally. We dissected down to the aneurysmal portion of the anastomotic region, and the brachial artery was sharply dissected free in addition to the proximal end of the vein, proximally and distally. We transected the venous outflow off the arterial end. We left the cuff and over-sewed. We turned our attention to the venous portions of the vein graft, which is causing symptoms. We incised over the aneurysmal portions and created flaps around the vein since it was fairly superficialized to the skin for multiple areas. There was a thin plane in which we maintained all compromising skin. We dissected down the flaps to create the flaps circumferentially, and the vein was mobilized towards the distal anastomosis. We dissected this free and sharply ligated with sutures. We then removed all the aneurysmal venous portions en bloc." Code 36832 doesn't apply since AV was removed. CPT 37607 or 35011?

Epicardial Leads

I am unable to find anything. For unlisted codes my organization requires a code to compare price to. "INDICATIONS FOR PROCEDURE: Pocket erosion with ICD exposed and infected. The epicardial leads were placed in 2004. FINDINGS AT THE TIME OF SURGERY: No evidence for infection at entry site into chest cavity of epicardial leads. They were divided as the entered the chest cavity to avoid performing thoracotomy and risk of unscrewing leads off the surface of the heart. DESCRIPTION OF PROCEDURE: After successful induction of GETA, sterile prep and drape was performed. She was already on antibiotics. A small incision was made superficially in the area of the previous mini-thoractomy back in 2004. The two epicardial wires were easily identified. No fluid or purulence was noted. Under gentle tension, each wire was cut as proximal to the heart as possible and allowed to retract back into the chest cavity. EP physician will pull out the wires from the pocket. A 2-0 Vicryl, 3-0 vicryl and 4-0 Vicryl were used for closure."

Provider billing 93531, 36299, 93565, 92997 & 92998 is this accurate?

"TAPVR patient, catheter through left jugular vein into innominate vein, angiogram performed, catheter advanced to left lower pulmonary vein & angiogram performed. Catheter withdrawn into left pulmonary venous confluence & angiogram performed. Catheter exchanged for mini-trek balloon & advanced into left pulmonary confluence & inflated two times. Balloon exchanged for larger balloon & inflated two times. NTAG reinserted & advanced to left pulmonary confluence, pressure measurements recorded in LPV & LA. An attempt to advance NTGA was unsuccessful. Catheter exchanged to 4 French Cobra & advanced into RUPV and angiograms performed. Cobra exchanged for Mini-Trek balloon & advanced to right pulmonary confluence and inflated, balloon removed. Cobra cath reinserted & pressures obtained in RLPV & LA." I'm at a loss, as I don't see any documentation for the codes the provider wants to bill. Please help.

Gore-Tex Acuseal Patch Angioplasty

What CPT code would I use for Gore-Tex Acuseal patch angioplasty done at the same time as an AV graft?

LIMA Steal Syndrome s/p CABG

The LIMA to the LAD is noted to have large branches with significant steal. Would you code LIMA steal syndrome to T82.898A?

Secondary Prevention, sequence of codes

I am having a dispute with an auditor regarding the sequencing of codes on an ICD device installed for secondary prevention. Patient suffered an acute MI followed by sudden cardiac death six days prior to the device install. I remembered a CMS rule stating that Z86.74 is a status code that is unacceptable as a principal diagnosis, so I coded I21.4, Z86.74. The auditor coded Z86.74, I21.4. This despite a company policy of "always coding to CMS rules". Does Z86.74 have to be in the principal position for the claim to be paid? Does the CMS "unacceptable" rule apply equally to IP and OP claims? See Definitions of Medicare Code Edits, ICD-10 Version, v 33 October 2015, page 217.

Breast cyst aspiration with catheter left in for drainage

Do I code 19000/76942 for an ultrasound -guided breast cyst aspiration if they leave the catheter in the breast for continued drainage, or do I use code 10030?

36590 with Hematoma Removal

Would you report codes 36590 and 10140 for this? "Patient with port has a growing hematoma. Decision was made to remove the port because of the small number of chemotherapy sessions prior to anticipated transplant. Pocket was opened, and port and catheter were removed. Extensive chronic hematoma/clot was manually removed from the port pocket. Pocket flushed and packed with Gelfoam."

93931, 93971, G0365

Can we bill codes 93931, 93971, and G0365 for these studies? If not, which codes we should bill? "Reason For Study: Failing left upper extremity fistula. History: Pre-operative mapping right upper extremity for dialysis access fistula placement. Patient states he is asymptomatic on todays exam. Conclusions: 1) Patent right upper extremity arterial inflow with complete Palmar arch. 2) Patent right cephalic vein measuring 5 mm in the upper arm and 2-3 mm in the wrist to forearm, respectively. 3) Patent right basilic vein but diminutive starting at the proximal biceps measuring 2 mm in diameter. Procedure: complete duplex scan was performed using B-mode gray scale imaging, Doppler spectral analysis, and color flow."

Cardiomems Insertion- new updates for 2017?

In reference to question ID# 6772, have there been any changes in the coding and billing procedures in respect to 93799 and C9741 where 93451 and 93568 are now additionally billable? Physician coding being 93799 and hospital C9741.

CS Venoplasty with failed Bi-V uprgrade

During an attempted upgrade to an existing dual chamber ICD, the CS was accessed, and the LV lead was inserted, but our EP physician could not get it past a very tight stenosis. One of our interventional cardiologists scrubbed in and performed multiple venoplasties on the very tight CS lesion. The LV lead was reinserted and advanced, but still could not pass the stenosis. The attempt was aborted. My thought is to bill code 33224-74. I normally would not bill for the venoplasty, as it would be included in the lead placement, but since the lead attempt was aborted, would it be appropriate to bill it in this case?

AV Shunt Inflow Artery Imaging

Do you have specific criteria/documentation suggestions we can use to help us determine when arterial inflow imaging codes 36215 and 75710 are allowed to be used in addition to 36901-36906?

Puncture AV Fistula Outflow Vein w/ Cath of Native Brachial Artery

Puncture of AVF basilic outflow vein with selective catheterization of the native brachial artery. LUE arteriogram performed, and then angioplasty of the brachial artery and mechanical thrombolysis of the brachial, ulnar, and interosseous arteries. Infusion catheter placed in the ulnar artery for overnight thrombolysis. Is it appropriate to bill 36901-52 for the initial puncture in the graft, along with 36215 for the catheter placement in the brachial (and subsequently the ulnar and interosseous arteries)? We believe the correct codes for the procedure are 36901-52, 36215, 75710, 37246, 37184, 37185, 37211. Please confirm. 

Does seperate incision allow 36833 and 36902?

For the following, is it appropriate to report codes 36833 and 36902? "Using #4 Fogarty catheter, outflow thrombectomized, flushed, clamped. Then, the arterial plug was removed using again the Fogarty catheter. Graftotomy repaired with interrupted sutures. Upon restoration of the flow, patient had pulsatile flow within the graft. Graft was cannulated through separate skin incision using entry needle. It was upsized to 7-French sheath and a fistulogram was performed, which revealed patent graft. There was high-grade stenosis in the venous anastomosis. Subclavian, axillary vein, brachiocephalic vein was widely patent all the way to the right atrium. Glidewire was introduced, parked in the right atrium and high-grade stenosis within in-stent was angioplastied using 8 x 200 angioplasty balloon catheter. During inflation of balloon, contrast was refluxed in the arterial system, which revealed absence of any hemodynamically significant stenosis of arterial anastomosis. Balloon was deflated and another fistulogram was performed, which revealed excellent flow through the angioplastied area." 

Mediastinal Abscess

"Cervical abscess extending down into the posterior mediastinum: LT lateral thoracotomy performed - there was a walled off process at he apex as predicted and with dissection of the lung the purulent pleural process was encountered just above the arch posteriorly. Cultures were taken and irrigation of the thoracic cavity performed. lung reinflated and no visceral pleural air leak noted. Three chest tubes left in pleural space, one posterior apical tube into the abscess cavity." Would code 39010 be appropriate for this case?

Endarterectomy bundling question

Would an endarterectomy of the femoral artery be separately billable during a fem-pop bypass if the endarterectomy was performed to improve flow to the profunda rather than being performed for inflow to the bypass?

Tunneled catheter vs VAD

I see a new Coding Clinic as of May for the tunneled catheter and how to code. It seems to me the VAD would be for ports that are placed in a pocket, and the tunneled line would be coded the same as the non-tunneled line. It says the revised codes will become effective October of this year. Will you send out updates to membership holders?

Fistula Duplex Ultrasound

Patient comes to our office because he is having problems getting dialyzed. Patient is evaluated by the physician and sent for ultrasound imaging. After scanning the patient's fistula, the physician reads the ultrasound and determines that the patient will require an intervention. Can we still bill code 93990 for the scan as well as the intervention if performed on the same day or week? If so, what diagnosis code should we use with the 93990? We have not been billing them due to denials.

Vasodilator or catheter placement for acute mi treatment

Our doctor is wanting to charge an acute MI intervention (92941), but the following text is from the report and this was all that was performed. "Placement of Pronto catheter intracoronary in the ramus intermedius with direct delivery of vasodilators including nitroglycerin, veramil, and nipride with improvement of vasospasm. Intervention on the ramus intermedius was performed as detailed above with no balloon angioplasty or stent placement." Would any of this warrant the billing of 92941?

CPT/HCPS for sacroiliac injection with US guidance

Can you please provide us with information regarding CPT/HCPCS code(s) for the hospital side and MD side for sacroiliac injection with ultrasound guidance for the purpose of a pain injection with lidocaine and steroids?

20610 with 20605

If the provider injects the right glenohumeral joint and right acromioclavicular space or bursa under fluoroscopic guidance, can we report codes 20610 and 20605? Or can we only report code 20610 once for the shoulder joint?

Posterior Auricular Artery Catheterization with Angiogram

Would you report code 36228 or 36226 for superselective catheterization with angiogram of the left posterior auricular artery at the origin of the transosseous branches? Here is what the physician documented: "There was successful embolization of large segment of the dural arteriovenous fistula and the tentorial sinus from this pedicle. We then prepared another scepter 4 mm x 11 mm balloon catheter and used the mirage wire to position the balloon catheter in the distal left posterior auricular artery at the origin of the transosseous branches. Superselective angiogram was then performed."

Breast Biopsies performed at IDTF

The facility my radiologists contract with just changed their accreditation at one location, from an outpatient hospital department to an IDTF. Breast biopsies are being performed at the “new” facility. We are having trouble getting reimbursed for the surgical codes of the breast biopsy. The remit states: “Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.” From what I have read, only the physician performing the biopsy can bill for the surgical codes for a breast biopsy. This is split billing of course, not global. Can you please give information and guidance on this situation?

His lead Pacemaker

Our cath lab department is now inserting His leads when performing pacemaker insertion. "Operative note: Through this sheath, a 5 French His bundle catheter was placed in the bundle of His. The left pectoral region was prepped and draped in the standard fashion. The skin and periclavicular region were anesthetized with 1% lidocaine. An infraclavicular incision was made and carried down to the prepectoral fascia using electrocautery. Using blunt dissection and electrocautery, the generator pocket was created and hemostasis assured. Micropuncture needle was used for axillary vein access x 1. A 7 French safe sheath was placed. Via this sheath, a His bundle introducer sheath was placed in the right atrium. Using the His bundle lead, the His bundle was mapped. The lead was secured to the His bundle tissue, and pacing characteristics were reevaluated. Under fluoroscopic guidance, the guiding sheath and safe sheath were removed." Would we code this as 33206, or are these procedures reported with unlisted code 33999?

Soft Tissue Cryoablation

What code would you recommend for cryoablation of soft tissue mesenteric mass? Access organ: soft tissue. Additional access organ information: mid-line mesenteric mass. Access side: right and left.

Minimally invasive valve replacement w/bypass and femoral vein repair

Can you code for the repair of the femoral vein (35226) with primary procedure of mini sternotomy approach-minimally invasive aortic valve replacement (CPT 33405)? Since this was a minimally invasive procedure and bypass was performed (the femoral vein was repaired due to the cannulation of the vein for bypass), I wanted clarification whether the femoral vein repair could be reported.

Modifier -52 vs. -74

In your 2017 Interventional Radiology Coding Reference, you stated: "In 2017, the S&I code (75791) is deleted, so 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)." My question is, why change the modifier for the hospital when both modifiers are valid for hospital use?

Fluoroscopic evaluation of NG tube

How would you suggest to code a fluoroscopic evaluation of an NG tube? "PROCEDURE: Fluoroscopic evaluation of NG tube. FLUOROSCOPY TIME: 0.6 minutes. FINDINGS: No contrast was able to be instilled via the NG tube. Visualization of the upper portion of the tube reveals there was a kink in the oral pharynx. This was removed under direct fluoroscopic visualization. The tube was resecured with tape. Instillation of contrast revealed filling of the stomach. IMPRESSION: Initially malpositioned NG tube with kink. This was repositioned. Functioning NG tube."

Removal and replacement of existing right ventricle lead for ICD

"Relocated pocket and ICD from the right to left side of the chest using the same generator and same RV lead. After this, I proceeded to the right side where I reopened the previous incision going through the same scar. The device was delivered out of the pocket. The pulse generator was disconnected and washed with antibiotics. The old lead was freed of any of the stitches around it, and, under fluoroscopic guidance, I unscrewed it and then pulled the lead out. It came out in its entirety. The lead was visually intact. I irrigated it also and cleaned it completely with antibiotic solution. The same lead was now already introduced through the introducer sheath that is in the left subclavian vein. I navigated that lead under fluoroscopic guidance into the apex of the right ventricle cavity. I actively fixated it. Pacing and sensing functions were assessed and were adequate. I thus fixed that lead to the fascia of the first and second ribs with multiple stitches of 2-0 silk." Would the lead relocation be 33215, or removal 33244 and replacement 33216, and 33223?

36831 and 36907

"Micropuncture technique was used to cannulate the fistula above the antecubital level. Fistulogram was performed, which showed a patent fistula of the cephalic arch where there were two tandem stenoses. The one at the very top of the cephalic vein was nearly occlusive. There was a second approximately 80% stenosis a few centimeters peripheral to this. The micropuncture was exchanged for a 7 French sheath. A 0.035 guidewire was advanced easily through both stenoses and into the central veins. Adorado balloon was then across more central of the two stenoses and inflated. The balloon fully inflated at 18 atmospheres. The second stenosis was then addressed and the balloon fully inflated. Fistulogram showed no residual stenosis. Partial central venogram was performed through the innominate level, which showed no stenosis. Fistula was clamped and was entered through third incision right between venous and arterial cannulation site. Kelly clamp was used to milk out thrombosis. The fistulotomy was closed and flow restored. Cannulation site was closed." Should this be reported with codes 36831 and 36907? If not, what codes are appropriate?

Coarctation of aorta and bicuspid aorta valve

I have a provider that is trying to tell us that if a patient has a coarctation of the aorta and a bicuspid valve then we need to bill the congenital CPT codes. I noticed that you answered a similar question in March, but I was wondering where you got your information so I can provide that information to my provider.

Excision of AV Fistula

"Our patient had an infected chronic thrombus and aneurysm in her left upper extremity AV fistula. She was taken to the OR for excision. A duplex Doppler was used to measure the brachial artery flow and to check the outflow vein to decide on the area of disconnection and division. Images were retained. The fistula was excised by disconnecting it from the brachial artery, followed by anastomosis and repair of the brachial artery. The aneurysm, chronic thrombus, and overlying skin were excised in the needle access segment of the fistula. The cut end of the outflow vein was repaired at the level of the shoulder. The 6 x 4 cm skin defect was closed with flaps." Can any imaging be billed? How do we code for the excision of the fistula?

Tunneled cvc with port insertion using same pocket

Can I charge for a removal and an insertion on the following dictation?? Do I need a modifier for the use of existing pocket? "A single incision was made over the reservoir with a 15 blade. The port was removed in its entirety. The pocket was flushed thoroughly. No drainage was noted from the pocket. Under ultrasound guidance, access into the left internal jugular vein was obtained using a 5 French micropuncture system. A permanent sonographic image of the vein was obtained to document patency. An Amplatz wire was then advanced into the inferior vena cava under fluoroscopic guidance with the utilization of a Kumpe catheter. A tunneling device was utilized to bring the catheter from the port site utilizing existing pocket to the jugular vein. CONCLUSION: Successful placement of left internal jugular Bard single lumen PowerPort catheter and removal of left subclavian Infuse-a-Port."

75625 and 75716 with no findings

The physician would like to have 36246, 75625, and 75716 billed. However, the report states the wire was advanced from radial, after left and right femoral would not allow wire to cross, and into the aorta. Abdominal aorta performed, showing severe occlusion with no collateral flow on long leg runoff bilaterally. Would it be more appropriate to report codes 36200 and 75625 only?

FFR performed with Medicare drug-eluting stent

If patient has FFR only, then a drug-eluting stent is inserted, would we report code 93799 for the FFR where C9600 is not listed under the codes that you would apply for the add-on 93571 FFR code? I see 92928, but not C9600, and we have had denials when charged with C9600. In this case, would we treat it like the FFR is performed alone and charge the unlisted as well as C9600?

Non-tunneled cath placement for CT contrast administration

Our IR department places a non-tunneled cath for CT or MRI exams on patients who no longer have access available. These lines are placed in the internal jugular vein as described here: "Under real-time ultrasound guidance, the IJV vein was accessed with a micropuncture kit, and an image documenting patency was recorded to PACS. The 5 French microcatheter was left in the right IJV. It was capped and covered with a tegaderm." We have reported codes 36556 and 77001. From other questions listed, we should be adding modifier -52 to 36556. Another suggestion is to use code 36011. What is/are the correct CPT(s) for this exam?

75630 vs. 75716

"Catheter placed just above the renals. An aortorenal angiogram was obtained, showing patency of the renal arteries and infrarental aorta with excellent flow through the iliacs on either side." Would you go with 75630 or 75716?

Aortogram with lower extremity studies

I still get quite confused with coding abdominal aortogram and lower extremity angiograms. Here is my current scenario. Abdominal aortogram and bilateral lower extremity study from one cath position; findings are of infrarenal AA, BCIA, BEIA, and BCFA. Then the physician moves the cath to the left popliteal artery and completes the left leg run-off with further detailed imaging down to the foot. Should I report code 75630? Or codes 75625 and 75710-LT? Or codes 75630 and 75774?

93655

Patient is scheduled for an ablation for PVI, but was in atrial flutter when he arrived in the lab, so the atrial flutter was ablated before the PVI. Can we bill for code 93655 when it is performed before the primary PVI? The physician's documentation is as follows: "The patient arrived at the clinical electrophysiology laboratory in atrial flutter with a ventricular rate of 85 beats per minute. The QRS width was measured at 90 milliseconds, and a QT interval was measured at 320 milliseconds. The HV interval was measured at 52 milliseconds. The attrial flutter showed concentric left atrial activation and counterclockwise rotation of the right atrium, negative sawtooth waves in leads II and III, and a VF and positive in lead V1. Utilizing Carto 3-dimensional mapping as a guide, energy was then targeted in a linear fashion from the tricuspid, mid isthmus to the inferior vena cava. This resulted in termination of the tachycardia. We then turned our attention to the primary arrhythmia, which was the atrial fibrillation and proceeded with the pulmonary vein ablation."

33210 with AICD generator replacement

Can a temporary pacemaker (33210) be reported with an AICD generator replacement (33263) if done during the same encounter?

Pacemaker moved from the left to right side

My physician moved a patient's entire pacemaker implant from the left side to the right for chemotherapy purposes. He wants me to bill the removal of the leads (33234) and insertion of a device (33207). Would this be the correct coding for what he did? Since he moved the entire implant to the other side of the body, I am tempted to use the repositioning code (33215) and not the new and replaced pacemaker code, but I am still unsure. 

Generator Evaluation

When a patient has electrodes changed for a pacemaker, but the generator is not changed, would it be appropriate to charge for a generator evaluation since only the leads were changed (33216 and 33235, RV lead replaced and removed)? Or would code 93280 or 93288 (evaluation) be included in the CPT codes for RV lead removal and replacement?

Attempt type I endoleak repair

"PT presents to undergo repair of type I endoleak. Bilateral femoral access with left subclavian cutdown was performed to accommodate large french sheath. From subclavian access with great effort 12 french catheter advanced into descending aorta. Noticed was significant bleeding at the left subclavian cutdown site. Conduit separated from the artery tearing the artery. Covered stent from right femoral approach encountered difficulty advancing across arterial tear due to kinked wire. Stent was pulled back, however unable to remove from right femoral decision was made to deploy in external iliac. Once again through the wire access of the subclavian a stent was successfully deployed across the area of arterial damage in the mid left subclavian. A complete thoracic & abdominal aortogram was performed confirming large type I endoleak. Decision to reexplore alternative treatment option for type I endoleak." Code selection 36200 left subclavian, 36215 right femoral, 36140 left femoral approach, and 37236 stent placement of arterial tear. Recommendations?

Modifier for C2616 for Y-90 Case

For Y-90 treatment cases, we are noticing that a modifier needs to be added to code C2616 when billed with 78205 (liver spect scan). Is -XU the correct modifier to add and why?

Sternoclavicular joint Injection

Can you tell me how to code a sternoclavicular joint injection? I am unable to find any documentation to guide me to the correct code.

Endomyocardial Biopsy

I need help coding the following procedure. Is it coded the same as 93505? "TIA PROCEDURE: She was brought to the lab and prepped in the usual sterile fashion. Vascular access was obtained with ultrasound-guided punctures of the right femoral vein with 14 French and 10 French sheaths. Intracardiac echo was used to guide the procedure. Images of the RV, septal masses were incorporated to the 3D CARTO map. A robotic Hansen catheter was used to guide an ablation catheter and create a CARTO 3D map of the RV and direct the robot into the septal mass. Then, the ablation catheter was removed and a bioptome was inserted. The robot was used to direct the bioptome to the masses in the distal septum. Multiple specimens were collected of the mass and the inside cystic core. The patient tolerated the procedure well. ICE showed no effusions. The sheaths were pulled, and Proglide sutures were deployed to achieve hemostasis and allow rapid ambulation. CONCLUSION: Successful robotically guided biopsies."

Fistula stenosis, proximal and sublcavian, with balloon rupture

"Patient comes in for a fistulogram. Stenosis is found in both the proximal fistula and the subclavian innominate junction. The proximal fistula stenosis is angioplastied and has excellent results. The subclavian stenosis is angioplastied and the balloon bursts. The physician is unable to retrieve the balloon without doing an open cutdown. He then makes an incision, ligates the fistula, removes the balloon, and ligates the fistula in the mid arm as well. The patient will now have to come back and get a PermCath placed." Do we only report code 37607, or would the angioplasties be billable as well (36902, 36907)?

Discharge summary

Will there be a discharge summary for elective procedures with no complication? Should the Dr's bill for them if they stay over night? Can an E/M be billed with venous ablation or is it consider global? What is the global period for a Venous ablation post-procedure? Hospital release angiogram? lower extremity PVI?

99152 bundled with New AV Shunt Codes

We continue to get edits on our accounts with the new AV shunt codes 36901-36909 when billed with code 99152 for MD billing. Per your email, these edits were to be removed April 1, 2017. Do you have any updates on this or links to CMS where this was completed?

Balloon Assessment of RVOT

I need help with a heart cath where the physician did a balloon assessment of the RVOT. It appears they were sizing for a pulmonary valve. What CPT code would be used for the following? "Intervention – Balloon assessment of the RVOT: An 0.035" Amplatzer super stiff wire was positioned in the distal left pulmonary artery, lower lobe brach. A 30 mm x 4cm sizing balloon was prepped and advanced over the wire and positioned across the right ventricular outflow tract. The first inflation was slightly distal and had no waist on the 30 mm balloon, with to-fro movement of the balloon in the RVOT. A second inflation was done with the balloon positioned more proximally, and again there was no waist on the 30 mm balloon with a to-fro motion of the balloon on the wire, suggesting that the balloon was not occlusive in the RVOT."

99152 as a stand-alone code

Can we bill moderate sedation if no other billable procedure codes? I am wondering if the moderate sedation codes (99152, 99153) can be billed as the only service for a physician? For instance, on day 2 of BRTO when balloon is removed after venogram verifies occlusion of varices, and no CPTs can be billed for this portion of the exam, but intraservice time still exists and mod sedation is properly documented. Code 99152 is not classified as an "add-on" code.

EKGs

Occasionally the EKGs will not have a reason why it was ordered on the interpretation or the orders. If the EKG isn't normal, I do not have a problem coding it. However, when the EKG is normal, that's when I need that information. Is it okay to look at a progress note, H&P, consult, or other documentation to find the reason the provider ordered the EKG? Does it have to be on the order or reading itself?

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