Knowledge Base

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Midline Catheter Insertion

Is it appropriate to bill code 36568 or 36569 for a midline insertion with a modifier -52?

75825

What information should be documented in an IVC venography report when performed alone or in conjunction with lower extremity venograms? Many times catheter placement is in the iliac vessels, and the reports state, "IVC patent." Is this sufficient to bill 75825? Is it necessary for the IVC venograms to be documented as a full and complete study?

PCI for under-deployed stent

Patient presents with chest pain, status-post stent in the LAD several months ago. Coronary angiogram was done, and IVUS shows under-deployed stent in LD; angioplasty was done to expand the stent. Can we show an angioplasty here? There was no documented stenosis in the report, only the under-deployed stent. 

EKOS Procedure and Pulmonary Angiography

Can I use code 75743 when the physician dictates EKOS done under fluoroscopy (no injection)? "INDICATION: Dyspnea, saddle pulmonary embolism with right heart strain. RECENT HISTORY: ECHO and CT scan show significant PE burden and right heart strain. PROCEDURE: Placement of ultrasound-accelerated catheter-directed thrombolysis to bilateral pulmonary arteries via right femoral approach. TECHNIQUE: Right femoral vein was cannulated using micropuncture, followed by insertion of 6 French sheath. With similar technique, another 6 French sheath was introduced just distal to first sheath, then pigtail cath was advanced into the pulmonary artery with pressures recorded (32/11 with mean 20 mmHg). Following this, two EKOS catheters were placed in each pulmonary artery bilaterally under fluoroscopy and secured in position. The patient was then given 1 mg of tPA through each EKOS catheter for a total of 2 mg. At the end of the procedure, the sheath was then sutured in place, and the patient was transferred to the ICU for 12-hour tPA continuous infusion via sheath." I plan to report codes 37211-50, 36014-50, and possibly 75743. Is that correct?

Diagnostic arteriography during angioplasty or stent.

"The patient is a 74-year-old woman. Approximately 6 months earlier patient underwent treatment of left lower extremity femoral popliteal artery occlusive disease and disabling claudication with placement of covered stents in her left superficial femoral artery. She has developed recurrent disabling claudication symptoms. A recent ultrasound study revealed a new stenosis near the distal end of the stent in the popliteal artery. The decision was made to proceed with further evaluation with diagnostic arteriography and possible percutaneous reintervention. There was no CT scan done." Can I bill 75710-2659 as diagnostic study during the intervention, or would that be considered run-off angiography and bundled with stent placement? We are performing selective left lower extremity arteriography and left lower fem-pop balloon angioplasty.

93976/93975

The CPT descriptions for both codes 93975 and 93976 contain the wording: "Duplex scan of arterial inflow and venous outflow of abdominal....organs" limited or complete. Do both codes require documentation of arterial inflow and venous outflow? If either one of those components is missing, do we code the limited exam, or do we not code the duplex exam at all for lack of documentation?

Vascular Study Question/Technician vs. Reading Physician

For vascular study readings, our workflow is as follows: A vascular test is done. The technician enters the information into the report. The report has his/her name and time listed directly below the impression on the report. Then the reading physician signs each report electronically after he/she reviews the report and the attached images. The physician may or may not make changes to the documentation. If changes are made, the original person (technician) who added the documentation will be removed at that time; however, if no changes are made, the technician’s name will remain on the report. My question is, since the impression was already originally entered by the technician, can we bill for the reading physician since he/she is reviewing the findings? Example: "Conclusion: Negative study for deep vein thrombosis within the left lower extremity [10/6/2017 7:17:25 AM - Doe, John]."

Lower Extremity Duplex

The EHR system used will only allow the physician signature once they have reviewed the images for the duplex study. Once they have reviewed, they can then sign the computer generated interpretation and report. For CPT code 93925-26, would a computer generated report for which the physician makes any necessary changes and signs the report be sufficient to bill for the professtional component?

Failed Watchman

Patient arrived for Watchman. Transseptal puncture was done along with left atrial angio and left atrial appendage angio. After reviewing the angios and intra-op TEE, it was determined there was not enough depth to place the Watchman. The hospital updated the patient's status to outpatient and billed 93452. I'm not sure the coding is correct for this failed Watchman. I was thinking of 33340-Q053; however, this must be billed as inpatient. Please advise.

Procainamide Study

What is the appropriate coding for procainamide challenge to rule out Brugada syndrome?

Treatment for in-stent restenosis

Situation: 64-yr-old female with left lower extremity claudication (lifestyle limiting), status post SFA recanalization and stenting. On follow-up, U/S velocities were 600 cm/sec, suggesting high grade stenosis. Patient was asymptomatic at the moment. We performed an angiogram showing 80% stent restenosis, treated with angioplasty/re-stenting. How would you code this?

Stent in RC and then angioplasty in 2 branches of the RC

Physician placed a stent in the RC (92928-RC), followed by angioplasty in the RPDA (92921-RC). Then, he did kissing balloon angioplasty in the RPDA and RPLV (92921-59RC). Can I bill for the third procedure in the right coronary?

64646

A patient is scheduled for a ventral hernia repair. Patient comes in on a separate visit than the surgery for a Botox injection into six different abdominal muscles to relax them prior to the scheduled surgery. Should this be coded with 64647? Or would it be coded with 96401?

Portal Vein Thrombectomy

What code would be used for an open portal vein thrombectomy? The portal vein thrombosis was found at the time of another abdominal surgery. Provider is trying to bill code 34401.

AV Fistula Creation and Ligation

We have a case where the patient had a synthetic AV graft. "Dr. X removed the graft and performed thrombectomy and angioplasty of stenosis to re-establish flow, but due to poor pulsation they harvested the basilic vein and performed an interposition graft. They then created a new direct AV graft, but due to the fact that they found it had poor flow, they tied off the fistula in order to divert all blood flow to the upper extremity." All this was performed during the same operative session. We're looking at code 35236 for the repair and code 37607 for tying off of the newly created AV fistula, but it seems like we're missing something. Since the AV fistula was created and left in (albeit ligated) at the end of the procedure, can we report those codes? And the thrombectomy and angioplasty performed prior to the interposition graft, do we lose those codes because it wasn't successful and therefore the doctor decided to perform the interposition graft and created a new AV graft at a different location instead of replacing the AV graft that was there?

Coil Embolization

Can code 37241 be reported for coil of the right and left perforator veins if the diagnosis is venous stasis ulcers and vein reflux?

37218 or 37236?

For the documentation that follows, how would you code the subclavian stent via femoral access: 37218 or 37236? "We exchanged the 5 French sheath for a 9 French sheath. We then accessed the left subclavian artery with a 6 French Neuronmax access catheter and performed multiple angiograms to better characterize the area of stenosis. We coaxially advanced a 6 x 30 balloon with a Transend wire into the left subclavian artery and performed an angioplasty. Using the rapid exchange system we then advanced and deployed a 6 x 8 x 30 XACT stent at the origin of the left subclavian artery. A follow-up angiogram for surveillance and interpretation demonstrated excellent flow through the left subclavian artery and visualization of the left ascending cervical arteries."

Transcarotid TAVR Approach

Is unlisted code 37799 still the recommendation for TAVR delivered through transcarotid approach? Would code 33366 apply?

Sacral Bone Biopsy

Would a sacral bone biopsy be considered deep or superficial (20220 vs. 20225)?

Ultrasound Guidance

Would you bill the ultrasound guidance in the following scenario? "The patient's groins were prepped and draped in the usual sterile fashion. Given the patient's prior history of a difficult aortic arch and tortuous anatomy, it was decided to obtain access via the right radial artery. The right wrist was prepped in the usual sterile fashion using Chloroprep, and the arm was positioned on an arm board. Under ultrasound guidance the right radial artery was punctured, and a 6 French radial sheath was inserted. This was followed by administration of 500 microgram of verapamil and 3000 units of heparin."

Ultrasound-guided direct puncture of native AAA

History: Patient with AAA with EVAR with type II endoleak. Procedure: Right common femoral arterial access. Distal aortogram. Ultrasound-guided direct puncture of native AAA. A distal aortogram was performed, which demonstrated no feeding vessels supplying the aneurysmal sac. Other attempts were made to undermine the graft but were unsuccessful. Catheters and wire were removed. Anterior abdomen was prepped and draped in sterile fashion. The native aneurysmal sac was accessed with acupuncture needle utilizing ultrasound guidance. Sonographic image was retained. A 0.018 Mandrel wire was advanced and curled in the native sac. A Neff set was advanced over the wire and utilized as access sheath. Contrast was injected, demonstrating thrombus throughout the sac. A Bentson guidewire and glide catheter were used to select various portions of sac, and contrast was injected, demonstrating thrombus within each area; however, no definitive feeding vessels were identified. Wires and catheters were removed." How would the direct puncture of the AAA sac be reported? With unlisted code 36299?

Charging 3D mapping with Biventricular Pacemaker Insertion

Is there a specific CPT to report when 3D mapping is done with biventricular pacemaker insertion, or is this considered inherent to the work of the pacemaker insertion? Example report: "Using mod Seldinger technique, axillary vein accessed x3. We first advanced a St. Jude 2088TC to the RV, but did not actively fixate it. We made sure we had capture and used this as temporary pacer wire in case of heart block. Coronary sinus was cannulated without difficulty. Selective venography showed anterolateral and mid lateral branch and middle cardiac veins. No posterolateral branch seen. Anterolateral branch was mapped with a quadripolar catheter on the 3D electroanatomic mapping system. QLV was 60 milliseconds. Midlateral branches anticipated with much later. Apical portion of this mid lateral branch was much later and yielded QLVF of 140 milliseconds than more proximal and basal aspects. St. Jude1458QL was advanced. We were able to bracket latest activity region on the 3D map with distal 1&2 poles. Bipolar with threshold 2 voltage @ 0.5 milliseconds, impedance of 510 ohms."

Sacrococcygeal Injection for Coccydynia

Which CPT code should be assigned for sacrococcygeal injection? We are considering 20600, 20605, or 64999. "Fluoroscopy was used to identify the bony landmarks of the vertebrae and the planned needle approach. The skin, subcutaneous tissue, and muscle over the area were anesthetized with 1% lidocaine. With fluoroscopy, a 25 gauge 2.5 inch spinal needle was gently guided to the sacro-coccyx joint. Approximately 0.5 ml of non-ionic contrast agent was injected under direct real-time fluoroscopic observation. Correct needle placement was confirmed by production of an appropriate arthrogram, and then the medication (including 40 mg of depomedrol and 0.25cc of 0.5% ropivicaine) was injected. All injected medications were preservative free. Sterile technique was used throughout the procedure."

Bilateral Internal Mammary Artery Duplex

I am having trouble finding the correct codes for the following procedure. I am not finding an IMA duplex study code. "VASCULAR DUPLEX REPORT INDICATIONS: Pre-op CABG. EXAM DESCRIPTION: Bilateral internal mammary artery duplex. FINDINGS: Right IMA Prox 78cm/sec 3.2 mm in diameter Mid 64cm.sec 2.8mm in diameter Dist 56 cm/sec 3.4mm in diameter Left IMA Prox 73cm/sec 2.9mm in diameter Mid 61 cm/sec 3.1mm in diameter Dist 63cm/sec 2.5mm in diameter. CONCLUSIONS Patient s right IMA appears to be WNL per arterial color duplex and doppler flow imaging. Patient's left IMA appears to be WNL per arterial color duplex and doppler flow imaging."

Therapeutic Knee Arthrogram

A patient is seen for knee pain and gets a diagnostic knee arthrogram on the first visit, which is charged with codes 27370 and 73580. The patient is scheduled to come in for the 2nd-5th visits for the pain knee injection. The physician is injecting contrast prior to the drug injection on each of the subsequent visits. The physician is calling this a "therapeutic arthrogram" and would like to charge codes 27370 and 77002 for each of the 2nd-5th visits. I would recommend charging codes 20610 and 77002 instead, since the patient is coming in for the pain injection. What are your thoughts?

Duplex Documentation Requirements

What are the documentation requirements for duplex studies? Can a duplex (93970) be billed if documentation only states, "Bilateral lower limb venous duplex with no evidence of acute DVT"? Or does the provider need to document, “Gray scale imaging, spectral analysis, and color Doppler flow”? Also, do you recommend downcoding from 93970 to 76882 if the needed documentation is not supplied? 

Pacemaker firmware update for cyber security

Our hospital may be having patients come in for pacemaker firmware update for cyber security. When this happens, would we use unlisted code 93799 for this, or is there a specific code that we can use for these updates?

Resection of Infected Saphenous Vein, lower left leg

I've not been able to find a suitable code. Please help. "Patient has phlebitis. Incision to the left leg below the knee. Resection of the infected part of the saphenous vein. The wound was cleaned completely and irrigated using pulsavac. Dressing applied."

Limited femoral angiogram w/cardiac cath

Should code G0278 be reported for the limited femoral angiogram with cardiac cath? We submitted codes 93458 and G0278. "Planned for right femoral arterial approach. The right groin was prepped and draped in the usual sterile fashion. Under Lidocaine 2% local anesthesia a mini-stick needle was then used to access the right femoral artery. The mini-stick sheath was inserted. Limited femoral angiography was performed with hand injection. The mini-stick sheath was then exchanged over a J wire for 5 French pinnacle sheath. A 5 French JL 4.0 diagnostic catheter was used to engage the left coronary artery. Left coronary angiography was performed in multiple views by hand injections of Omnipaque. A JR 4 diagnostic catheter was then used to engage the right coronary artery. Right coronary angiography was performed in multiple views by hand injections of Omnipaque. The JR4 catheter was used to cross the aortic valve and LV pressure measurements were obtained. The catheter was then removed over the J wire." 

PERCUTANEOUS PNEUMATOCELE DRAINAGE

Would the code for the aspiration be 10160? "Small dermatotomy was made. A 19 gauge needle was passed into the fluid collection under CT guidance. Approximally 70 ml of clear yellow fluid was apirated from the left apical pneumatocele and was sent for analysis. The needle was removed, and hemostasis was acheived with manual pressure." 

Fistulogram with Two Access Sites

"Once this was completed, we then accessed a second site more proximal in the arm, this time directed toward the arterial anastomosis and passed a wire through the anastomosis into the pulmonary arch hand injection arteriography through a catheter. We then performed over the embolectomy and Angioscore sculpting balloon angioplasty of the anastomosis using a 5 mm angioplasty balloon. As we performed over the wire embolectomy, we brought the clot within the system toward the tip of the opposite sheath where Penumbra When that was completed, hand injection fistulography showed excellent result proximally with a widely patent arterial anastomosis. More centrally, however, there had been re-occlusion with what appeared to be fresh clot, and we retrieved more clot in this location. We also identified a small venous anastomotic stenosis and angioplastied this with a 6 mm angioplasty balloon. At the completion of this, fistulography showed an excellent result." Should this be reported with codes 36905 and 36909? Or 36905 with 36215 and 75710?

Mitral Valve Replacement Code

Successful transcatheter mitral valve replacement using a transfemoral route and a #26 mm SAPIEN 3 device. What's the correct code for this procedure? 

Reoperation before leaving room

This is in follow-up to question #7320 (post-operative complication). "Patient has a carotid endarterectomy. After arterial and skin closure while still in surgery, patient is awakened and cannot move left arm. Patient's neck is opened back up. Patch was removed, and some platelet debris was removed. A cerebral and carotid angiogram was performed, which showed some haziness along the bifurcation but no clear abnormalities." This was a 36223 due to perioperative stroke while still in surgery. Can we charge this? The doctor wants to bill 35800, but as the patient was still in surgery, we are assuming we cannot charge this. These were both performed after patient was completely closed. What are your thoughts?

Descending Thoracic Aneurysm Repair

The report is way too long to type, but this is the basics of this exam: "Ultrasound-guided bilateral common femoral artery access. Endovascular thoracic aneurysm repair with Gore 40 x 10 graft (x 2), left iliac artery repair with 10 mm x 10 cm Viabahn (x 2), completion left iliofemoral bypass." This doesn't cover the vertebral.

Edit - Do Not Report 37215 with 36223?

We reported codes 36223-RT and 37215-LT, but we're hit an edit stating, "Do not report 37215/37216 with 36222-36224." The book states, "If not previously studied, the carotid vessel not being stented may be imaged and reported separately as a unilateral study." Are we wrong? Report: "Access to the right common femoral artery. A Sim 2 catheter was placed at the RCC and into the LCC. Bilateral carotid and cerebral angiography was performed. RCC is free of significant disease. RIC is 100% occluded. LCC has mild luminal irregularities. LIC has a 70% to 80% stenosis. Decision was made to intervene on the LIC artery. Over an Amplatz wire, I placed a 90 cm Penumbra sheath using a Sim 2 catheter. The tip of the sheath was in the distal LCC artery. I put a filter in the petrous portion after starting Angiomax. I pre-dilated with a 3.0 x 30 mm balloon up to nominal pressures that are better luminal expansion and positioned an 8 x 30 mm Precise Cordis carotid stent. The stent was post-dilated with a 4.5 mm balloon. The 80% stenosis reduced to less than 10% stenosis, excellent flow before and after."

Stent-Assisted Coiling

Can you bill codes 61635 and 61624 for the stent-assisted coiling? "Diagnostic cerebral angiogram and stent-assisted coiling. Subsequently the stent was placed and unsheathed through the supraclinoid and ophthalmic segment of the ICA. DSA AP and lateral demonstrated optimal wall apposition. At that time the coil was introduced completely into the aneurysmal dome. Under new roadmapping a 5 x 15 hydroframe coil was introduced into the dome."

Can you bill the femoral angiogram when performing a cerebral angiogram ?

Can you bill the femoral angiogram when performing a cerebral angiogram? "Vessels selected and injected: right vertebral artery, right common carotid artery, right internal carotid artery, left common carotid artery, left internal carotid artery. Findings: Femoral injection: The external iliac artery, common femoral artery, proximal profunda and proximal superficial femoral arteries were normal in caliber and branching. There was no significant atherosclerotic obstruction."

OPEN EXCISION OF THROMBOSED VARICOSITIES

"Patient presented with hematoma rt thigh after foam sclerotherapy; with ulcer. The physician decided to do debridement of the draining hematomas and ulcers. After general anesthesia was administered, the open ulcer was probed; it was draining old blood as was the second ulcer. The bleeding and ulcer tracked along the thrombosed varicosities; it was decided to excise the varicosities en bloc. The physician deepened the elliptical incision and excised them, closed the subcutaneous tissue with sutures." Not sure what the correct code is for this procedure. Nothing really seems to fit. Any suggestions?

Anticipated complete AV block due to catheter ablation of the AV junction

I know you addressed this question in 2016. Since then, our Medicare MAC created a coverage article for single and dual chamber PPM. The article says that the -KX modifier is appropriate for catheter ablation of the AV junction and post-operative AB block that is not expected to resolve after cardiac surgery. Do you think this covers being able to use the AV node block diagnosis code on a PPM even if the PPM is implanted the day before the ablation?

3 Branches in same Major Coronary tree Circumflex

A response to a question posed in 2016 was similar to my question only in regards to interventions of the D2, LAD, S1, where you advised to code all 3 branches using a base code and two add-on codes. When reading the CPT Codebook, "PCI is reported for up to two branches of a major coronary artery. Additional PCI in a third branch of the same major artery is not separately re portable." This seems to say that only two PCIs in the coronaries would be reported per area. Is your advice still valid? I have one I continue to get back and have been asked to clarify this by finance. Does this mean one major (i.e., LC and two branches of it) for a total of three? I have a case where the patient presents with total occlusions his mid-CIRC noted as a CTO, total occlusion of his third obtuse marginal (not noted to be chronic), and stenosis in his second obtuse marginal (this was treated with stent). The circ was treated with stent, and the third obtuse was PTA. I used 92943-LC, 92944-LC, 92929-59LC. Thanks for any advice you have or other sources you may have found. 

His Bundle Lead Placement

Looking for some guidance on a His bundle lead placement for biventricular device. Other leads placed were in the atrial and ventricular. Is unlisted recommended?

Clarification on 76937 "permanent recording"

Does the permanent recording have to be a picture in the medical record, or can it be an uploaded image saved under patient's encounter identifier for date of service that can be accessed if necessary?

Attempted Left Ventricular Lead Placement but Procedure Discontinued

67-year-old male with ischemic heart failure and paroxysmal atrial fibrillation as well dual chamber defibrillator since 2013. Admitted now for defibrillator upgrade to biventricular defibrillator due to left bundle branch block/predominant ventricular pacing. Device was explanted from the pocket and disconnected from the leads. At this point attention was moved to middle cardiac vein, which provided retrograde flow to posterolateral branch; however, the vein itself would not accommodate 4 French LV lead. Then the old defibrillator generator was attached to the leads. In conclusion, attempted left ventricular lead placement; procedure was discontinued due to coronary vein occlusion and lack of other suitable targets." Should I bill codes 33226 and 33215? Or should I report code 33273?

IVUS of Graft

What is your coding recommendation for the following: IVUS and stent of mid left circumflex, IVUS and stent of SVG to OM1, IVUS and balloon only of LAD? Our biggest question is if we can code IVUS of left circumflex and IVUS of SVG to OM1.

Limited Duplex Study

Please assist with coding the below procedure. Should this be coded 93971-52RT for hospital billing and 93971-2653RT for the professional component? "TECHNIQUE: Multiple gray scale color and spectral Doppler images of the right upper chest in the region of the subclavian vein were obtained in both the transverse and sagittal planes. FINDINGS: There is marked tortuosity of multiple vessels within the right subclavian region. The right subclavian vein and superior vena cava could not be confidently identified. The tortuous vessels identified may reflect the respective veins or collateral vessels. No focal thrombus or occlusion. IMPRESSION: Limited exam without focal thrombus or occlusion. Tortuous vessels of the right subclavian region may represent collateral vessels versus right subclavian vein and superior vena cava."

Replacement of Impella left ventricular assist device

Patient has post cardiotomy shock, and Impella device was previously placed. The device has become nonfunctional; however, patient still requires hemodynamic support, therefore a new device is being placed. How do I code for a removal and new VAD placement? Do I report code 33990 or use unlisted? Everything I am reading notes that I cannot code the removal and new VAD codes during the same session.

Total Body MRI

How would you code for a whole body MRI with a diagnosis of Li-Fraumeni syndrome? The provider wants to bill unlisted. Our coders want to bill each body area. What are your thoughts? "FINDINGS: Neck: Non-enlarged cervical lymph nodes bilaterally. No suspicious mass lesion identified. Thorax: Minimal left basilar atelectasis, likely related to sedation. No pulmonary nodule is identified. This a small area of T2 hyperintensity in the right paraspinal region in the chest (series 401, image 20), which was partially imaged on the prior study, unchanged. This is of uncertain clinical significance and could represent a lymph node.   Abdomen and pelvis: Postsurgical changes of right adrenalectomy. No suspicious mass in the right suprarenal fossa to suggest recurrent tumor. Liver, spleen, pancreas, and kidneys are normal in contour and signal intensity. No mass lesion identified. Trace amount of free fluid in the pelvis, physiologic. Lower extremities: Bone marrow is normal in signal. Muscles are normal in bulk and signal intensity. No abnormal fluid collection." 

Kyphoplasty vs. Vertebroplasty

"Through the existing 11 gauge needle, a curved needle is used to create a void within the vertebral body with a mechanical to and fro motion. Then, under fluoroscopic imaging, internal fixation was achieved through a low pressure injection of the bone cement." Is this a kyphoplasty or a vertebroplasty?

TAVR with 2 temp PM

I have a question regarding temporary pacemaker being placed at the same setting as a TAVR. My physician usually places a pacemaker prophylactically at the start of the case (I know this would be inclusive with the procedure). However, in this case the circumstances were a little different. Two different temporary pacemakers were placed, one at the start of the case as usual. Then, after the valve was placed, another temporary pacemaker was placed due to the underlying significant conduction abnormalities, as well as a large 10-second positive post pacing run and an increase in the PR interval from 220 ms to proximally 270 ms. The DR exchanged the venous central line in the patient's IJ that was placed by anesthesia with a locking sheath and floated alone tipped temporary pacemaker from the neck. Electrophysiology was also consulted and recommended this approach without the placement of a permanent pacemaker at this point in time. Due to the different access site as well as the patient’s condition changing, would it be appropriate to report the temporary pacemaker placed at the end of the procedure?

CT exam with PO and/or PR contrast and IV contrast

We are performing CT exams with both PO or PR contrast and IV contrast. The guidelines say to code it as a CT with/without contrast because the PO and/or PR contrast does not count, only the IV. But what CPT should we use if they take a PO or PR contrast and IV contrast in the same setting and do a single CT scan?

Attempted Repair of Ruptured AAA

"Patient with ruptured AAA comes to OR via ER, unstable with BP 50 systolic. Laparotomy incision made, free rupture confirmed, loss of BP, chest compressions started, supraceliac clamp placed. Exploration continued, iliacs claimped, ACLS protocol followed, v-fib with eventual sinus bradycardia. Aneurysm exposed, large hole in aneurysm confirming free rupture. Patient unstable, loss of BP, ACLS protocol performed, asystolic, time of death called." Should this be coded as 35082-52 or 35082-53? Or is it just an exploratory laparotomy (49000) since the "repair" or "grafting" portion of the AAA had not yet begun?

Embolization Guidance with code 75898

You state on page 241 of the Interventional Radiology Coding Reference that code 75898 may be used once per surgical field for head and neck embolization follow-up imaging (or as often as medically necessary for CNS embolization procedures per SIR). Does this apply to codes 37241-37244 and/or 61624, 62626, 61710, and 75894?

Intracranial Thrombectomy with Carotid Stent Placement

We performed intracranial thrombectomy with removal of clot at the ICA terminus. Following that a stent was also placed across the proximal ICA/distal common carotid for stenosis. Initial common carotid arteriogram showed "complete occlusion of the cervical internal carotid artery". Following the thrombectomy of the ica terminus the common carotid arteriogram results were "residual severe stenosis of the proximal cervical left internal carotid artery, flow-limiting". Do these results support 37215 for the stent placement? Also, we code 61645 for the thrombectomy. If we use an Ace reperfusion catheter with a 60cc syringe for suction, can we use 61645?

Revascularization using distal inflow(RUDI)in LT upper arm w/GSV conduit

"The proximal left radial artery was used for inflow. It was heavily and circumferentially calcified, but was patent and did serve as effective inflow. The outflow was the first 2 cm of the left cephalic vein just upstream from the AV anastomosis. The cephalic vein fistula was dilated to greater than 1 cm and had excellent flow. The great saphenous vein was of good quality for a conduit and was harvested from the distal thigh and proximal calf and dilated to beyond 3 mm in diameter. Following the bypass, there was a good flow within the fistula and there was a weakly palpable thrill, and the bypass graft itself had an easily palpable thrill. The perianastomotic brachiocephalic arteriovenous fistula was ligated, and this was done between the arteriovenous anastomosis and the bypass graft anastomosis." The GSV was used as bypass from the radial artery to cephalic vein somewhat similar to a DRIL, but how would I code this?

Tarsal Tunnel Injection

How would you code an injection of anesthetics and steroids into the tarsal tunnel? 64450, 20550, or 28899?

Consultation for G-Tube Placement

If the attending physician has ordered placement of a G-tube for a patient, would it be appropriate for the interventional radiologist to bill for a consultation prior to the procedure?

Coding of Ascending Aorta with Dacron Graft

"Patient had an enlarged ascending aorta. Surgeon chose to wrap the ascending aorta in a Dacron graft. He cut the graft longitudinally to make a sheet and wrapped it around the ascending aorta from the ST-junction to the distal ascending aorta. Graft was approximated to constrict the aorta using 3-0 Prolene running suture." What is the most appropriate code for this procedure? I thought about 33860 with a -52 modifier... or would this be an unlisted vascular procedure (37799)? There were no procedures done on the aortic valve.

ICD Upgrade to Biventricular

Would you use CPT codes 33216 and 33264 for this procedure? "Conscious sedation, biventricular AICD generator upgrade. Procedure: The patient was prepped and draped in sterile technique. Approximately 5 mL of 2% lidocaine was used for local anesthesia. The pocket was opened with sharp dissection followed by blunt dissection. The generator was removed from the pocket, and the leads were detached from the old generator. An 18 gauge needle was then used to canulate the left subclavian vein without difficulty, and a coronary sinus guide was advanced over the wire using Seldinger technique. The coronary sinus lead was advanced into an inferior branch of the coronary sinus, as there were no suitable posterolateral branches. The lead was sutured into the pocket, and the pocket was then irrigated with an antibiotic solution. All leads were attached to the new AICD, and the AICD was then implanted in the pocket. A CorMatrix envelope was used to cover the AICD. The pocket was closed within interrupted subcutaneous stitch followed by a running subreticular stitch and Dermabond glue for final skin closure."

Liver Chemoembolization

Should we be reporting 77300, 77790, and 79445 with 37243? I get an edit on 77790 stating not allowed with 79445. Codes 99152 and 99153 were also reported, and are getting an edit to add a -59 modifier when used with 77300, 77790. How should I handle?

DynaCT post kyphoplasty

On occasion a DynaCT is performed post kyphoplasty to verify cement location. Can we use code 76377 along with normal kyphoplasty charges? Are there specific dictations requirements?

Excision of Intravascular Stent CPT Coding

My physician performed a thromboendarterectomy of the left common femoral, superficial femoral, and profunda arteries and an excision of common femoral stent. Is there a CPT code I can use for the extra work removing the stent?

Cath with an Iliac Angiogram

So we have a case where our regular cardiologist did a coronary angiogram and aortography because of cath placement issues, and then the interventional cardiologist came and did a failed PCI of the left main and a bilateral iliac angiogram. The question is, can we bill the bilateral iliac angiogram separately from the coronary angiogram that the regular cardiologist did?

Lead Removal

I have seen a few cases where a pacemaker or ICD lead is removed and replaced due to the patient having "twiddled" the generator, causing a lead to coil up within the generator pocket. Sometimes the lead is completely coiled, and all of it comes out when the generator is removed from the pocket. I know that removal of the generator from the pocket is bundled into the code for the new lead install, but should I code for lead removal (33234 or 33244) when the lead is completely coiled within the pocket? What about removal of a partially coiled lead?

93355 without probe placement

The anesthesiologist actually places the TEE probe. A separate cardiologist is preforming the guidance. Is that cardiologist (who is NOT performing TAVR only the TEE guidance) allowed to bill 93355, even though he/she didn't drop the probe?

CIA Aneurysm Repair with Iliac Branch Device

Patient with history of AAA repaired 12 years ago now with CIA aneurysm. Repair of same with iliac branch endoprosthesis (IBE) and placement of aortic endovascular bifurcated stent graft Gore Excluder to anchor IBE. Patient does not have current AAA or failure of previous endograft, but patient anatomy requires the anchor bridge of the aortic endograft for the IBE. Can we capture the aortic endograft (34802/75952-26) along with 0254T for the IBE? How do we support medical necessity for the aortic endograft without a current diagnosis of AAA? 

Ascending Aorta and Hemi Arch Repair

Would it be appropriate to bill an ascending arch (33860) and the transverse arch (33870) when only the hemi arch was repaired? These are the details: "Two layers of felt sandwich were placed around the proximal aorta and sewn in place. We trimmed the aortic wall up to the level of the innominate artery and then sewed in two-layered felt sandwich to the distal end of the aorta. The remainder of the aortic arch appeared normal, and we doubled the aortic transection on to the underside of the arch. We then used a 28 hemashield graft and beveled and inserted it into the distal anastomosis using a 3.0 prolene suture."

Kyphoplasty vs. Vertebroplasty

Kyphoplasty was planned at T-11. Vertebral body was too small for balloon, so cement was injected and procedure was completed. I think this should be coded as a vertebroplasty instead of a kyphoplasty with a reduced modifier. Is this correct?

AV fistula declot & stenting failure;TPA and repeat stent for extravasation

Should we code the following with 36906? Or 36906 and 36903-59? Or 36906 and 36906-58? "AV left forearm graft fistulagram showed extensive thrombus in main draining vein up to level of distal third of humerus. Crossing sheaths placed. Angiojet cath used to treat arterial and venous anastamosis. It worked for arterial but not venous. Angioplasty of arterial anastamosis, and arterial flow re-established. Stent was placed across venous anastamosis to improve outflow. Patient continued to clot despite administration of 10,000 units of heparin during the procedure. Multiple passes again made with angiojet. Flow was not re-established. Decision made to initiate TPA therapy for 2 hours with an endhole ciatheter tip at the arterial anastamosis. After 2 hours, imaging demonstrated extravasation from two thirds of the graft, this was treated with an 8 cm fluency stent overlapping the previously placed Viabahns stent, the stent was balloon dilated to 6 mm. Extravasation ceased, arterial flow could not be established despite multiple maneuvers. Decision made to terminate procedure."

Aortic root angiography only

The heart cath was not done with the aortic root angio. How would this be coded? "The area of the right femoral artery was prepped and draped in the usual sterile manner. A timeout was performed. Approximately 10 cc of lidocaine was intermixed in the area of the right femoral artery. Using ultrasound guidance, a Cook needle was used to cannulate the femoral artery. There was resistance in advancing the guidewire; an arteriogram was performed through the needle, which demonstrated a tortuous femoral artery. A guidewire was inserted through the needle, nick incision was made in the skin over the needle, and a 6 French vascular access sheath was advanced into the femoral artery. Dr. X was then asked to assist with vascular access. A 6 French 55 cm Ansel highflex sheath was placed. A J L4 catheter was advanced over the guidewire, but was unable to reach the left main due to residual tortuosity in the femoral artery. A 125 cm JR4 catheter was then advanced over with dilated aortic root; the JR4 catheter was unable to reach left main."

Cyropreserved human aortoiliac prosthesis

My surgeon had an infected AAA status post endograft. Complete resection of AA with removal of infected graft; he also repaired the aortoduddenal fistula with an omental patch flap and inserted the cryopreserved human aortoiliac prosthesis. We reported codes 35907 and 35870. Can we also get a graft placement and omental flap codes with this? If so, what would you use for the placement of the cyropreserved prosthesis?

64530 when bilateral

Physician dictates "Fluoroscopic-guided bilateral celiac plexus block". Should I submit with modifier -50, or only bill 64530 alone?

AAA Repair with Chimney Type Procedure

"Patient with a fem-fem bypass for occluded left common iliac and AAA that is juxtarenal with a short and angled neck and angled suprarenal aorta. Procedure: 1) Left axillary cutdown. 2) Right femoral cutdown. 3) Endovascular repair using Medtronic Endurant-2 aorto-uni-iliac stent 36 x 14 x 102 mm, a right iliac docking limb 16 x 20 x 156 mm and chimney renal stents, 6 x 5 mm right renal artery Viabahn stent, and 5 x 5 left renal artery Viabahn stent. AUI stent advanced and positioned at the perirenal aorta. Viabahn stents advanced well into the renal arteries and the stent graft was deployed with the fabric being a few millimeters above the origin of the renal arteries and then the suprarenal fixation stent was deployed. Flush angiogram of right iliac system, marked level of the hypogastric artery and advanced the right iliac docking limb and deployed that successfully." Would this be coded 34812 for femoral cutdown; 37799 for axillary cutdown; 34805 and 75952 for the AUI; 36245-50, 37236, and 37237 for the renal stents; and 34825 and 75953 for the limb?

76998

Per NCCI edits, code 76998 (with modifier -59) can be reported with a CABG. Can code 76998 also be reported with an aortic valve repair or replacement, a mitral valve repair or replacement, or a tricuspid valve repair or replacement?

Facet Joint Injection with Synovial Cyst Rupture

What is the appropriate code to report the injection(s) for below? I think it is 64999 for synovial cyst involving facet joint, but some coders think that it’s both 64493 for facet joint injection and 64499 for rupture of the synovial cyst. What are your thoughts? “The patient was placed prone on the CAT scan table. The patient's back was prepped and draped in usual sterile fashion. Multiple sections were obtained through the patient's back at the appropriate level. A 20 gauge spinal needle was introduced into the facet joint. The location was confirmed with a second physician confirming the location. 1 cc of Omnipaque contrast was introduced. This was followed by injection of 3 cc of fluid containing 80 mg of triamcinolone mixed with 1 cc of 0.5% bupivacaine. Contrast was noted extending outside the borders of the synovial cyst into the epidural space indicating rupture of the cyst.”

DRIL of lower extremity

We have a patient who has a lower extremity arteriovenous graft (popliteal artery to common femoral vein) that is used for dialysis, as patient has no viable options left on upper extremity. The patient developed severe extremity pain suggesting of steal syndrome, therefore a DRIL procedure was done on the lower extremity. As code 36838 specifies upper extremity, would the coding be 36832 (a revision to AV fistula), or would this be reported with an unlisted code?

Screening or Diagnostic Mammogram

If a patient schedules an annual screening mammogram, and then before the screening exam starts, the patient reports new signs or symptoms that are concerning to her (like lump, pain, etc. on a questionnaire before exam, discussion with tech, etc.), would this still be considered a screening mammogram, or do these patient-reported signs/symptoms cause the patient to be no longer considered asymptomatic from a coding perspective and thus cause the exam to be coded as a diagnostic exam instead of a screening exam? Coders are wondering when to code a mammogram as screening vs. diagnostic when the patient reports signs symptoms at the same encounter as the planned and scheduled annual screening. They have symptoms, which points to diagnostic, but they are also due for an annual exam anyhow, which points to screening. Please advise with the rationale.

TAVR and E&M

Our provider frequently performs TAVR (33362) and wants to also bill for either a consultation or inpatient E&M code on the same day. He feels a modifier to override the edit is warranted, as the decision for the procedure is made during the evaluation. Our coders are disputing this, as code 33362 has a zero-day global period and therefore modifier -57 is not applicable. Would modifier -25 be appropriate as long as the documentation clearly supports the decision for the procedure on the same day?

Documentation for Mod. Conscious Sedation 2017

Is this enough documentation to report codes 99151-99152-99153 with the new codes for 2017? "Moderate conscious sedation was used with an intraservice time of 40 minutes. All monitoring was done by the radiology nurse under my direction." Would the provider have enough documentation to report codes 99152 and 99153 x 2 in this instance? Or does there need to be more specific documentation like what vitals were monitored, the preservice review of the chart, and the preservice exam along with the post service work like what was communicated to the family? After reading the CPT guidelines for new moderate conscious sedation codes, it seems like there is a lot expected for reporting moderate conscious sedation codes, but it's not clear on how much details need to be documented by the provider. 

Excimer Laser Atherectomy - Physician Billing

What CPT code would you recommend for excimer laser coronary atherectomy for physician billing? My first thought was an unlisted code (93799); however, the more I researched and thought about it, would is still be appropriate to use 92924 if the laser atherectomy was performed percutaneously?

One surgical site or two for embolization of AP and rt int mammary?

One surgical site or two for embolization of AP and rt int mammary? The procedure included diagnostic catheterization with oximetry, hemodynamics, angiography, 3D reconstruction on an independent workstation, and agitated saline study. The intervention included stent placement in left pulmonary artery, embolization of two aortopulmonary collateral arteries, and embolization of the right internal mammary artery.

ESI transforaminal

I'm not sure if this is considered two levels 64483/64484 or one level 64483? "The left L5-S1 and left S1 foramina were localized with fluoroscopy, and the skin over these areas was infiltrated with 2% buffered lidocaine. Under direct fluoroscopic guidance, a 25 -gauge spinal needles were advanced percutaneously into the left L5-S1  and left S1 foramina. Contrast injection demonstrates proper positioning of the needles and contrast flow in the lateral epidural space at L5-S1 level as well as along the left S1 foramen superiorly into the left lateral recess at L5-S1 level. Subsequently, 9  mg of Celestone and 1 cc of Marcaine 0.75% were injected at each level. The needle was then removed, and hemostasis was achieved with adequate pressure." 

Subclavian vein stenosis ICD 10

What would be the appropriate ICD-10 for the following findings? "The left subclavian vein is nearly 100% occluded where the pacemaker leads into the subclavian vein. Well-developed collaterals are seen around the stenosis."

Intraaneurysmal Intracranial Angiogram

We have looked for a code for this "intraaneurysmal intracranial angiogram" and cannot find. Can you please lead us in the right direction?

Transthoracic Echocardiography TAVR Coding (TTE TAVR)

How do you code for a TTE (transthoracic) TAVR please? Cardiologist MD performed a complete echo with 3D imaging during a TAVR. (He did not perform the TAVR.)

Exploration for Postop Hemorrhage

"Once we open the below-the-knee incision there was a large hematoma and active pulsatile bleeding. The bleeding was coming from a tear on the vein graft. This was located on the below-knee incision. The area where the bleeding was coming from was very friable; it was where a 6-0 Prolene suture was placed for a vein branch during the initial operation. This was repaired with interrupted 6-0 Prolene sutures." Should we report code 35226 or 35879 or use an unlisted code?

Stress echo in office setting different physicians 93351?

If the "supervising" physician and the "interpreting" physician are different (same group practice/same specialty), is it still appropriate to report the in OFFICE stress echo using code 93351? Our report lists Dr. A cardiologist as the "supervising physician", and Dr. B cardiologist signs the report (interp/report provider). Since Dr. A is overseeing (supervising physician) the tech should he be reporting 93350 and Dr. B be reporting the interp/report stress code 93018?

Percentage stenosis considered medically necessary for peripherals

I see in question ID 9237 dated April 12, 2017 your response on percentage of stenosis for coronary, carotids, av fistula interventions. Is there any guideline that speaks to percentage of stenosis deemed medically necessary for intervention in the extremities, subclavians, and renals?

Hero Device

When coding for placement of Hero device would you use codes 36830 and 36558 together?

Documenting Review of Systems for New Patients

I code for physicians, and I have a question on how they document their review of systems in their notes. Do any of these examples count as complete to code 99204, 99205, 99222, 99223 if other components qualify too? Examples of documentation: "comprehensive review of systems are negative" and/or "as in hpi, otherwise negative" (but they will list only a few not 10 systems or more in the hpi). And what reference could I use to support/back-up what I tell them?

37243 & 37242 Embolization

I've read previous threads and have a question about the surgical field. Coding from a hospital, the procedure was an embolization of the right hepatic artery with Y90 microspheres. (37243) The dx is metastatic liver cancer. During the procedure and prior to the embolization of the right hepatic artery it was determined that the proximal GDA needed to be embolized. Therefore the GDA was embolized with a MVP plug and coils. Once this was done the Right Hepatic Artery was embolized, normal anatomy, with Y90 microspheres. The right gastric artery was previously embolized. The GDA & right hepatic artery embolizations were done on the same dos and same surgical session. Is this considered the same surgical field and only 37243 is coded per the NCCI edits or can we code 37243 & 37242-59 (XE) because the GDA embolization was not done to treat the cancer area. We also coded the selective catheter placements of 36247 & 36248. 

EKG Machine(s) with Interpretation

Our EKG machines have Interpretation software. The EKG is printed off the EKG machine with the interpretation. The MD will confirm the interpretation and sign below it. Is it necessary to include other notation(s) such as "agree" or "okay"? If the MD disagrees with the interpretation he will add his own interpretation and sign below.

Lymphatic System as a Route of Contrast

I wish to refer to an earlier question regarding MR lymphangiography and the use of contrast. (See Question ID: 7416 Answered on 12/29/15.) The answer at that time included information that the lymphatic system is not a route of contrast administration that would allow billing a contrast study. CPT guidelines state that “with contrast” represents contrast administered intravascularly. There are resources that indicate the lymphatic system is a component of the vascular system as a whole. If so the lymphatic system should be an acceptable route of contrast administration. It would be greatly appreciated if you could please review the response to the initial question and provide additional feedback. We are beginning to see more and more MR lymphangiograms and we definitely want to get it right. 

Documentation for 93613

I was trained that it was unacceptable for the provider to only document the brand name of the mapping machine used during an EP study/ablation and not differentiate whether the medium was single plane/2D or 3D. They hate this requirement, and I have always been a stickler for explicit documentation of the type of medium. Now I am unable to identify source for this requirement. Is this an old wives' tale, or is there a credible source you are aware of that mandates this?

LHC and Attempted PTCA

One physician performed a LHC, and another physician attempted to intervene on a CTO of RCA on the same patient at the same setting, but the wire would not cross the lesion. For the first physician I reported code 93458. Can I report code 92920-74 for the second physician? The PTCA will be attempted at a later date.

Coding both 36558 and 36581?

Is it appropriate to code both 36558 and 36581? "A micron shunt was used to access right internal jugular vein. A coaxial catheter was placed. There was difficulty in place a coaxial catheter. Attempts made to place a Bentson wire were unsuccessful. A venogram was performed showing an angle jugular vein and brachycephalic vein. The access site looked low and a slightly higher access point was chosen. A micropuncture used to access the jugular vein. An angled catheter was used to place a wire in the IVC. A tunneling device used to place a tunneled ounces catheter in the subcutaneous tunnel. The right jugular access was dilated. The catheter was then placed via the peel-away sheath. There was an acute angle at the apex of the catheter. Multiple attempts were made to reposition the catheter was unsuccessful. The catheter was removed. A new more lateral subcutaneous tunnel was chosen and a new dialysis catheter was placed in the subcutaneous tunnel. A peel-away sheath was placed in the right neck the new catheter was in placed via the peel-away sheath. The catheter tip positioned in the RA/SVC junction."

Unsuccessful PM upgrade with LV lead not placed or generator replaced

We have a patient where the intended procedure was to upgrade a dual pacemaker to a biventricular pacemaker; however, after a venogram was performed and a wire passed multiple times unsuccessfully into the distal subclavian vein, it was decided to put the original dual pacemaker generator back in, reattach to the current RA and RV leads, and close the pocket. Can you please advise us on the correct coding for this scenario when the original dual pacemaker generator was put back in to the existing pocket, and the LV lead was never inserted/attempted since the venogram and wires were unable to gain adequate access? Is code 33224-74 appropriate for facility coding for this scenario, even though the existing dual pacemaker generator would not be able to accommodate an LV lead? In order to use the 33224 code, does the generator already in place have to be a biventricular generator? Would we only code for a venogram in this scenario if we should not code with 33224-74?

Endomyocardial Biopsy with a RHC and angiography

Would it be appropriate to use codes 93505 and 93454 for an endomyocardial biopsy with a right heart catheterization and coronary angiography when there is no medical necessity for the RHC only that it is a routine follow-up after a heart transplant?

Moderate Sedation Administration

In our hospital facility, the moderate sedation is ordered by the physician performing the procedure, but the medication is administered/pushed and monitored by the RN. Can we report code 99151, or does the MD have to push the medication?

Iliac stenosis with lower leg claudication diagnosis

I recently had a patient that had leg claudication and had angiography selecting the iliac and locating stenosis at the iliac. I used I70.8 for my diagnosis and was told by an auditor: "Common iliac arteries are native arteries in the legs, and when there is PVD with claudication this codes to I70.213 (atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs). You would not code atherosclerosis to the iliac artery; you would code to the extremity." Can you please give me some insight on this?

Repair In-Situ Bypass Lower Extremity

Would you use blood vessel repair code 35226 for suture ligation of branches off an in-situ vein graft fem-pop bypass performed several months after initial bypass surgery?

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