Knowledge Base

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Set Descending Direction

Pacemaker Set Screw Tightened

Our EP physician brought the patient in for what he thought was a dislodged or malfunctioning pacemaker lead. Once the pocket was opened and the leads were detached from the pacemaker and examined, it was determined that they were fine. There was a set screw that was loose, and this was tightened down. Leads were attached to the same pacemaker and pocket closed. Our EP lab manager has only seen this a few times. What can I code for this, if anything? If fluoroscopy was used, can this be charged? Any suggestions would be most beneficial.

Ablation and EP Study

I have a question about the EP study with the ablation. Your cardiology coding book said the physicians don’t have to do a complete study when it is not necessary. Do you have to document a reason the complete study wasn’t done in the report? If not, do you bill with the reduce service modifier? The reason for my question is I was told by an EP consultant that I must have the reason the complete study was not done in the report to bill the ablation without a reduce service modifier for the incomplete EP study. I would like to know your opinion on this as to what a good documentation policy should be regarding this.

Intra-Arterial Aortic Sac Pressure

Patient has a history of ELG with a type 2 endoleak (not global). During an open embolization of the aortic sac and ligation of IMA, the physician inserted a sheath into the aortic sac and obtained intra-arterial pressures. Is that a separate billable service? If yes, what code(s) would I be able to use? We currently have code 37244 for the embolization and code 35221 for the ligation of the IMA.

NCD for Biventricular Pacemakers

When we are coding for biventricular pacemakers, we are having a conflict with the NCD for Single and Dual Chamber Pacemakers. The claims are being held if they do not have diagnosis acceptable for this NCD. Is there a separate NCD for biventricular pacemakers? We can only find NCD for biventricular defibrillators. This seems to be a recent development.

Coding for Two Day Procedures, Pre and Post Laser Lithotripsy

I need help on coding the attached two-day procedure. "PROCEDURE DETAIL: Nephroureteral stent was injected outlining the renal pelvis. Scout films demonstrated calcification in the proximal ureter. An exchange length Amplatz wire was passed down along the tube and into the bladder. The nephroureteral stent was removed over the wire. The wire was then secured to the skin. FINDINGS: Renal stone in the left ureter. Removal of the ureteral stent with wire placed into the bladder. IMPRESSION: Successful removal of left nephroureteral stent over a wire, with the wire left down into the bladder for laser lithotripsy. The following day after patient had laser lithotripsy and insertion of double-J ureteral stent by surgeon. PROCEDURE DETAIL: Using fluoroscopic guidance the Amplatz wire was removed using continuous visualization of the double-J tube to ensure no movement. FINDINGS: No significant movement of the double-J stent upon removal of the Amplatz wire. IMPRESSION: Successful removal of Amplatz wire without disruption of the double-J stent."

Pre Nephrolithotmy Catheter Placment

Day 1: Patient comes to IR for the radiologist to percutaneously place a nephrostomy tube with ultrasound, fluoroscopy, and contrast guidance. Day 2: Radiologist assists urologist by removing the previous placed nephrostomy catheter. Serial dilations to a 28 French sheath. The urologist removes the stone through the sheath, and a nephrostomy catheter is placed by the radiologist. Day 3: The radiologist injects contrast (does a full nephrostogram dictation) and then removes the nephrostomy catheter. Can I only bill codes 50395 and 74485?

Sternoclavicular Joint Biopsy with Fine Needle Aspiration

 Could you please help with correct coding of following case? "Patient has sternoclavicular lesion. Under ultrasound guidance, a needle was advanced to the right sternoclavicular joint, and a core biopsy was obtained. In addition, fine needle aspirates were obtained."

Abscess Catheter TPA Infusion

I have an abscess catheter check. A decision was made to place TPA through the catheter. A total of 2 mg of TPA mixed in 15 cc of saline and infused to the catheter with the catheter capped for one hour. What code, if any, can be used for the TPA infusion? The doctor is asking for code 37212, which I believe is incorrect. Some places it states not billable. Could you please clarify if this is billable and what code would be used?

Left Heart Catheterization at Time of VT Ablation

One of our providers is wanting to bill for left heart catheterization (93452) with VT ablation (93654). It's my understanding that VT ablation includes a comprehensive diagnostic study of the right heart and left ventricle. I've noticed we can bypass the NCCI edit by adding modifier -59, but I am wondering when it would be appropriate to bill separately when performed with the VT ablation.

Distal Aortogram

"Procedures Performed: 1) Left groin access under ultrasound guidance. 2) Bilateral lower extremity angiography with distal aortogram. 3) PTA and atherectomy of right CFA and proximal SFA. 5) Intra-arterial nitroglycerin and Mynx device closure for left groin. 6) Selective catheter placement in the right CFA and angiography." I reported this with codes 76937, 75716-59, 37225, 36247-59, 37202, and 75896. I am not sure about distal aortogram. What code should I use for it?

E&M

Seeing patients with advanced vascular disease we run into patients with multiple diagnoses outside of the vascular specialty. Once we report the E&M code and determine the appropriate principal vascular code(s), is there a benefit to submitting additional non-specialty vascular codes such as ring worm or diverticulitis (etc.) when submitting a claim? Is there anything lost or anything gained by including diagnosis codes that are outside the vascular specialty when submitting claims?

Catheter Placements

Hi Dr. Z, I'm a PB Coder for several Cardiologist MDs who have started seeing patients now to do peripheral interventional type of cases. They need help in their documention to explain their catheter placements, repositioning, etc. for proper assignment of codes. The start out explaining their access site but then go into the findings of the cases. Do you have any recommendations that provide detailed information that they can use as a teaching tool for both MDs and Coders to use? I know they are doing a lot of work but they are not seeing the proper reimbursement for it. Thanks!

Transvaginal Fetal Echo

One of our providers performed a transvaginal fetal echo. What codes do we use? We are thinking about codes 76817, 76827, and 93325. Is this correct? Or do we need to use an unlisted code?

Potential Disruption of Fibrin Sheath

Do you think it is appropriate to use codes 36595 and 75901 for the disruption of any "potential" fibrin sheath during the exchange of a tunneled CVC?

Neck Ultrasound Procedure

"Transverse, longitudinal, and oblique ultrasonic sections of both neck were performed. Color Doppler evaluation also was performed. Entire study was real-time with no images. Right lower neck and left lower neck level VI lymph nodes are localized on the overlying skin. Right neck level III and level II jugular chain of lymph nodes are identified and localized on the skin. Findings were demonstrated and discussed with physician on real-time images. FINDINGS: Bilateral lower neck level VI and right level II and level III nodes were identified and localized on the skin for surgical planning." I'm not sure what the appropriate CPT code to use would be. I'm thinking of maybe unlisted code 38999 for lymphatic system. Any suggestions?

Technetium MAA Infusion

Could code 37243 be billed with the note below? Our doctor wants to bill code 37243, and I do not see where an embolization is documented, and I don't believe code 37243 should be billed. Could you advise? "Simmons 1 glide catheter was formed over the aortic bifurcation and advanced into the proximal superior mesenteric artery. Arteriography was performed to confirm position. A microcatheter was then advanced into the right hepatic artery. From that position, a subselective right hepatic arteriogram was performed. With the microcatheter in the appropriate right hepatic position, 5.5 mCi technetium MAA was slowly infused from this point. When the infusion was complete, the catheter was removed, hemostasis obtained, and the patient transferred to the nuclear medicine department for liver lung shunt imaging."

Spin Arteriogram

Can code 76377 or 76376 be used for a "3D spin arteriogram" of the carotid artery?

IFR Assessment

I was wondering if you had come across anyone who has had a physician using the Volcano IFR. Code 93571 cannot be used since adenosine is not injected, but I was wondering if you had any ideas if this can be charge captured or not?

Physician's Assistant

The physician's assistant performs the entire procedure. The vascular surgeon, who provided general supervision via the phone, dictates the report. What wording should be used by the vascular surgeon in the body of the operative report to indicate that he provided general supervision and that the physician's assistant performed the entire procedure? Also can you provide guidance to how the vascular surgeon should bill for the physician component in these types of cases?

Pacemaker Prior to AV Node Ablation, ICD-9

With the new pacemaker requirements from CMS taking effect July 7, 2014, I need to know how we should bill for pacemaker implant inserted for atrial fibrillation with future plans of AV node ablation. There are a few physicians who implant pacemakers for a-fib and then ablate the node (in a future procedure), inducing complete heart block, which then makes the patient dependent on the pacemaker. The Medicare instructions specifically state that any pacemaker code (33206, 33207, 33208) billed with 427.31 will be denied. How would you recommend billing this? I don't see how we could use 426.0 (CHB), as the patient isn't in CHB until the AV node is ablated in a future procedure.

Vasospasm Treatment

A question has come up about vasospasm treatment. Is vasospasm treatment always billable? For example, if the physician documents that there was a mechanically induced vasospasm (meaning that it was as result of the intervention or catheterization), can we bill for the treatment done during that same intervention or cath operative session? I seem to recall seeing somewhere that if we cause the vasospasm we can't bill for the immediate treatment done in the same operative session. However, now I can't find that documentation to support this.

TEE cancelled after probe placed followed by TTE

Patient arrived to the hospital's CCL for outpatient procedure. "Procedure: Transesophageal echocardiogram (TEE). Reason for test: Abnormal echocardiogram (performed in cardiologist's office). Conscious sedation: IV Fentanyl and Versed. After conscious sedation, TEE probe was placed. Unfortunately, the patient could not tolerate the probe. So, the probe was removed, and the TEE was aborted (no images acquired). Physician then performed a limited (per cardiologist) transthoracic echo (TTE) with contrast study using agitated saline (bubble study) to confirm presence of PFO." Charges submitted were code 93308 for the limited TTE, code J3010 for the Fentanyl, and J2250 for the Versed. Should we add a charge for the cancelled TEE (93312-74)?

92941 and NSTEMI

I have been told that you shouldn't use code 92941 for non-ST MIs. Is this correct?

Subclavian Brachial Artery Bypass Graft

My doctor was treating a patient in a motorcycle accident. He had a traumatic injury to the right subclavian artery with loss of blood flow to the right arm. Due to the extent of injury to the subclavian artery, he decided to do a subclavian-brachial bypass with graft. I’m not coming up with any CPT code to describe this based on the distal portion of the bypass being the brachial artery and the use of the graft instead of a vein. Should I use the unlisted code?

Exchange of Biliary Draing

I have a patient that we are exchanging an external biliary tube with an internal external biliary tube. Would I just code for the placement of the new internal external tube?

ICM Remote Interrogation

If remote ICD and ICM interrogation is performed, can the next remote ICM interrogation be performed on day 31? Are the service periods separate for ICD and ICM?

Mediastinal Node Biopsy

How would you code for a core needle biopsy of a mediastinal lymph node? The report stated the biopsy was challenging because the lymph node was close to the heart and pulmonary artery, so it definitely was not superficial. We didn't think code 38505 really applied here, but it is not abdominal or retroperitoneal, so we didn't know if we could use code 49180 here. Would it be appropriate to report code 32405 for a mediastinal lymph node or not?

Independent Interpretation of a Cardiac Cath

We've got a physician who just started with us who states that he has been able to bill for independent interpretations of cardiac caths that were previously done on a patient. Is that possible? What code would we use?

Attempt at Acute MI

Patient with AMI taken to lab. Diagnostic cardiac cath (93455) was performed, and upon trying to intervene on the culprit lesion the physician was unsuccessful in crossing the lesion and the procedure was discontinued. The physician does not document the intended procedure (i.e., angioplasty alone, angioplasty with stent, angioplasty with atherectomy, or all three). In the absence of clear documentation of the intended PCI procedure, considering code 92941 requires combination of angioplasty with either stent and/or atherectomy, should we report code 92920-74? Being conservative rather than assuming without documentation that a stent and/or atherectomy was planned?

Percutaneous Conversion to Open Saphenous Vein Therapy

If attempting venous laser ablation of incompetent vein (36478) and encounter stenosis/blockage that you cannot get wire/cath through, and you abort procedure and do open ligation, would you only code the open ligation and omit code 36478-74 modifier entirely? I cannot find this particular example documented.

Arc of Riolan Catheter Selection

I need your guidance please. Patient has a type 2 endoleak and is coming in for angiography and possible glue embolization. This is the condensed portion of the report: "The right CFA was accessed with a micropuncture system. This was exchanged for a stiff Glidewire, short 5 French sheath, and pigtail catheter. Aortogram with mesenteric run-off was done. The IMA entering the sac was identified. A 0.18 Glidewire and Renegade catheter were used to traverse the tortuous arc of Riolan and access the IMA and the sac. Glue was diluted 1:3 with oil, and 3 cc of this was used to embolize the sac and distal IMA." I am reporting code 37242 for the embolization, but I'm unsure about the catheter placement. The physician indicated that this was a third order. Since the SMA and IMA are two separate families, should I be reporting codes 36247 and 36245-59?

Thyroid Artery Embolization

Can you please help clarify catheterization of just the external carotid? "Patient presents for arteriogram and embolization. Femoral is accessed and catheter is placed in the thoracic aorta with angiogram revealing common carotid, subclavian, and innominate patency. Wire is changed followed by selective cath of the external carotid into the thyroidal vessel with angiogram, revealing AV malformation, which was coiled." What do we do with procedures when a carotid wasn't performed, only external carotid? Codes 36227 and 36228 do not work with 36221 per coding guidelines. The verbiage suggests that the physician was going to perform embolization but was verifying condition. I have seen two of these cases where they only select the external carotid (36227) and, in this case, went beyond into the thyroid artery. Code 37242 is for coil, but can we proceed to 36217 for thyroid cath? And in the other case where they went directly to the external for angio, how do we code?

Coding fLateral Branch Block

I have a case where the physician injected bilateral S1, S2, and S3 LATERAL branch block for bilateral sacroilitis. He states he used a 25g spinal needle directed to os lateral to the S1 foramen at the 3:00 position. He then injected bupivacaine. Procedure was repeated at the 11 & 5 o'clock positions. He then repeated this at S2 and S3 bilaterally. I am not quite sure what this is. Any help would be appreciated.

MitraClip Billing for Two Clips

I appreciate your feedback on the following question regarding billing of two MitraClips. "PROCEDURAL DETAILS: 1) 7 French sheath was placed in the right femoral vein. 2) A Baim-Turi catheter was used to perform right heart catheterization. 3) Using TEE guidance, transseptal access was performed using lamp 45 catheter and BRK1 needle. 4) The lamp catheter was used to position an Amplatz Super Stiff wire in left upper pulmonary vein. The dermotomy was enlarged with a 16 French sheath. A 24 French clip delivery sheath was inserted into left atrium. 5) MitraClip was advanced into left ventricle. After several attempted grasps, A2 and P2 were successfully approximated slightly medial to midline of the line of coaptation. This resulted in reduction of MR from 4+ to 3+ with no change in transmitral gradient. The clip was deployed. A second clip was positioned just lateral to the first clip and grasped A2-P2 relatively easily. MR reduced to 1+ with no change in transmitral gradient. The second clip was deployed."

Ultrasound Guidance, Code 76942

If a patient has two breast lesions (one lesion is a core biopsy 19083 and second lesion is a final needle aspiration 10022) that are performed with ultrasound guidance, may we report code 76492 for the fine needle aspiration? Should we report a -59 modifier with code 10022?

Venous Duplex

We get different information from different sources regarding downcoding venous duplex studies. Here is an example report. How would you code it? "Lower Extremity Duplex Venous Ultrasound: Technique: Doppler examination of the right lower extremity was performed for evaluation for deep venous thrombosis. Findings: The common femoral vein, superficial femoral vein, popliteal vein, and posterior tibial veins are all well visualized. There are no intraluminal echoes. The veins are all compressed with minimal transducer pressure. Doppler interrogation yields good venous signals in the above veins. In addition, there was significant augmentation with manual compression of the lower extremity inferior to the transducer. Impression: No evidence of deep venous thrombosis of the right lower extremity."

Non-Maturing AV Fistula

I was hoping you would help to clarify some global surgery modifier usage for me on the following: "Patient is brought in for AV fistula creation for dialysis access. Weeks later it is found that the AV fistula is not maturing, so the provider decides to bring the patient back electively for balloon-assisted AV fistula maturation." In a few cases I've seen, the patient is brought back for this same procedure multiple times during the post-operative period. I feel like the first balloon-assisted AV fistula maturation procedure should be coded with a -78 modifier due to a non-maturing AV fistula. In his operative report for the first procedure he indicates that the patient will be brought back again in 2-3 weeks for another balloon-assisted maturation procedure. Do you think the first procedure should be billed with a -78 modifier and then all subsequent procedures with a -58 modifier since the provider is indicating in his previous operative report that the patient will be brought back again?

Fistulogram of Abdominal Wall

"Operative report: The catheter was placed in the fistula located in the left abdomen near the lap band adjustment port. Next, contrast was administered during fluoroscopy observation. Contrast is administered, which demonstrates a fistulous track between the skin and the implantable port. There was a contrast leakage along the catheter to the skin surface. No intraperitoneal extravasation or fistulous connection is seen." Code 76080 has been billed for this procedure, but shouldn't a surgical code such as 10030 or 20501 also be reported in this case?

CPT 96420 for Chemoembolizations

I was reviewing chemoembolization guidelines, and it says that code 96420 can be reported per the 2014 CPT Codebook, but I always understood that code 96420 should not be reported in a facility setting for physicians (only in an office setting). I work for a cath lab in a hospital where they perform these procedures. It is considered an outpatient department for billing purposes even though inpatients and outpatients are treated there. I do charge capturing for the facility side and coding for the physician side. The physicians note in their reports that "chemotherapeutic agents were prescribed and administered by (physician name)". I have not reported code 96420 in the past or currently based on guidelines. I do use code 79445 for the Y-90 cases we do. But I've had some of the business staff and physicians asking if I'm coding this because they are doing the work, so they think it should be coded. Am I correct not to report code 96420, or should it be reported? I need some clarification on the guidelines.

Breast Localization Brachytherapy Sources

Would you please guide us with the following question? We’re going to start a new service where we inject radioactive seeds under mammographic guidance or ultrasound guidance for women who will have subsequent breast tumor removal. The seeds will be removed with the tumor during the operative exam. We need the localization and supply codes for the seeds.

Procedures on the Vessels of the Foot

What code(s) should be used when angioplasty, atherectomy, or stenting is done to the arteries or veins of the feet?

Venous Duplex with Vein Mapping

Patient presents for bilateral evaluation of lower extremity varicose veins and venous insufficiency. We perform a venous duplex Doppler examination that includes vein mapping. Are we able to charge anything in addition to code 93970 for the vein mapping?

Unsucceesful Stent vs. Successful PTCA

The physician made several attempts to cross the lesion in order to place a stent. It was unsuccessful. He ended up doing a plain old balloon angioplasty. The stent will be replaced by rep. What should we bill for hospital, code 92928-74FD or 92920? And what codes for physician billing, code 92928-53 or 92920 (with location modifier added also)?

Drainage Catheters

Our doctors were delighted to clear up the catheter drainage issue based on your respected publication regarding leave in or take out after drainage. The AMA/CPC and research I have done all agree with your original definition. The doctors said the extra work of catheter for drainage is the same whether it is left in or removed. And with the only publication I found that stated the catheter had to be left in when researched, upon further communication, the author stated it was her interpretation since 2005 that it should be left in and that it was not a direct quote from the AMA/CPC. So my question is, I am curious why the errata regarding catheter must stay in after procedure?

Repair Catheter, 36575

Can this code be used for re-stitching the catheter place? Or is it only for replacing the hubs? Are there other uses for this code?

Hydrocele Aspiration

Would aspiration of hydrocele be reported with code 55000? I noticed this is not listed in the ZHealth IR book and just want to be sure this is the code you would recommend. "Title of Procedure: Ultrasound-guided aspiration of hydrocele. Under sonographic guidance one step needle advanced into the left scrotum and a total of 470 mL of straw/amber fluid was removed. Catheter was removed at the termination of the procedure. A 22 gauge needle was advanced into the right scrotum where a total of 80 mL of straw-amber fluid was removed."

Right and Left Heart Catheterization and 36822

The cardiologist coded this as atrial septostomy (92992), which can't be right. Except for transseptal puncture nothing else is the same. The report reads more like percutaneous LVAD, but not quite. The patient was on ECMO from the day before. According to this report, transseptal puncture was to place a venous cannula and connect it to the ECMO circuit. So would this be reported with codes 36822, 93453, and 93462 if the report says only right heart catheterization was done? Dx 425.4  "The RFV was accessed percutaneously. A 10 French sheath was placed in the vein. Right heart catheterization was performed without incident. Cardiac output was determined using FICK method. A 7 French adult transseptal sheath was advanced to the SVC. A transseptal needle was introduced, and the sheath was brought down along the atrial septum. The needle was used to puncture the septum, and the sheath was advanced across the septum. An Amplatz superstiff wire was positioned in the left atrium. The long sheath was exchanged for a 17 French ECMO cannula with the tip and drainage holes in the left atrium. The ECMO cannula was sutured into place."

Single Chamber Pacemaker Upgrade to Dual Chamber

"Patient came in for elective subcutaneous pacemaker generator change. This was performed and seemed successful. But, prior to extubation, pacemaker lost capture. It was decided to replace the whole system. Patient was re-prepped and draped. A sternotomy was performed. Bipolar epicardial lead placement, with suboptimal parameters; a unipolar screw-in lead was then placed in the right ventricle at base of heart. Process was repeated, with same leads then placed in the right atrium free wall. Unipolar leads showed good threshold. The pacemaker pocket had been opened and subcutaneous pacemaker removed. All four new leads were tunneled to the pocket. Pocket was revised to hold new hardware. Bipolar leads were capped; original V-lead was also capped. New unipolar leads were connected to new dual chamber pacemaker." I know I need to report code 33202 for the epicardial lead placement. My dilemma is that the CPT Codebook says to use code 33202 with 33213 for pacemaker insertion with existing dual leads, but isn't code 33213 for when a previous generator is not being removed during same session? Would it be appropriate to bill either codes 33202/33228 or 33202/33214 for this scenario?

Code 76536

We receive orders for patients with a history of thyroid cancer and enlarged lymph nodes. We are asked to perform an ultrasound evaluation of the thyroid postsurgical bed and to map the neck lymph nodes levels I - VI, bilaterally. Are we able to charge more than once for CPT code 76536 because of the amount of work involved and the different anatomical body parts?

Stress Echos for Physicians

I recently started billing graphics again after many years. Since I last coded them I see they have added the option of a -26 modifier on code 93351. I would like to know if code 93351-26 includes the tracing (93017). My physicians do not do the tracing, so I thought I should be using codes 93350-26, 93016, and 93018. However, in a past question here, the answer stated that code 93351-26 includes codes 93350, 93016, and 93018 with no mention of 93017. In the CPT Codebook it says when all professional services of a stress test are not performed by the same physician to use code 93350 with the appropriate codes (93016-93018) for the components that are provided. Since my physicians do not perform the tracing, this sounds to me like I should be using codes 93350, 93016, and 93018 instead of 93351-26. Thoughts?

37217 vs. 37799

Should we use code 37217 or 37799 if the doctor directly exposes the carotid and inserts a stent that extends from the ICA into the carotid bifurcation? The stenosis is in the ICA. Code 37217 is intrathoracic, and ICA is not intrathoracic.

Carotid Angioplasty 35475

For PTA of an in-stent re-stenosis of the right common carotid near its origin, would I use codes 35475, 75962, and 36223 (findings were given on common, anterior, and middle cerebral arteries)? Or, would I use the unlisted px code 37799 with a -GZ modifier and 36223 for my catheter placement?

Mechanical Removal Explanation

What specifically would be considered mechanical removal for coding? For example, what types of procedures would need to be performed for reporting code 49460?

E&M

We are wondering if it is proper to charge an E&M code when we are performing a cardiac test on the same day in an outpatient setting. We would be the attending.

Rhythym Strip Before, During, and After Adenosine

The physician wants to perform this in the office during patient office visit. I do not think there is a code for this if done in the physician's office, but of course I can't find anything on it so maybe I'm wrong. Is there a CPT code for a rhythm strip before, during, and after adenosine is given? And is it supported when done in the office?

Color Flow Documentation on Echo

I am being told that if the doctor dictates findings such as "left to right atrial shunt" or a "valve insufficiency" that this supports reporting code 93325 and that they do not need to dictate the technique used. My understanding is that color flow is a visual assessment, so you would need to note those findings were by color flow.

Aorta Graft Procedures

I'm trying to determine how to code this case correctly. "A midline sternotomy was performed. The physician replaced the ascending aorta graft (33860), total arch replacement with hybrid debranching graft to 10 mm branch to innominate artery, 8 mm branch to left common carotid, and 8 mm branch to left subclavian (33870, 35626 x 3). Then he performed a stent graft repair of descending thoracic aortic aneurysm with coverage of the subclavian with TAG graft (33880). A Dacon graft was sewn end-to-side to the innominate artery for the purposes of cerebral perfusion. Epiaortic ultrasound of ascending aorta (76998-26)."

FEVAR

When choosing the code for repair of an AAA with a fenestrated device, is the code determined by the number of fenestrations or the number of stents placed in visceral arteries? The CPT code description says "including 1, 2, 3, or 4 visceral artery endoprostheses", which leads me to think the code is determined by the stents... but then how would I code a graft with four fenestrations and zero stents? My physician has done several cases where there are four fenestrations, and he only places stents in one, two, or three arteries.

New to Interventional Coding

I am also new to vascular coding. Which of your products (webinar, reference book, anatomical illustrations)would help to clarify catheter placement by order? Interventional cardiology is what I will be coding.

35907

In my research for excising an aorto-bifemoral graft, the only case I came across was one that was done on separate days of service. My question is, do I use code 35907 for the abdominal graft (they do incise the abdomen) and 35903-50 for the femoral grafts? Or do either of the codes include all of the graft? I am new to these vascular procedures.

Percutaneous Angioplasty Lumbar Artery

Our physician is doing a right hypogastric artery percutaneous transluminal angioplasy (37220), but he is also doing a right lumbar artery percutaneous angioplasty. Should this be reported with unlisted code 37799 with the selective catheter placement and 75962-26? I didn't think the lumbar was a visceral artery, which is why I only see an unlisted code here (the S&I states other peripheral artery).

Externalization of Generator

We have a patient with an infected pocket. The doctor removed the generator, taped it to the patient's body, and cleaned out the pocket. The patient returns to the EP lab five days later for new leads and a new generator. When the doctor removed and externalized the generator, can we bill code 33241?

Maceration of Clot during Thrombolysis

For codes 37211-37214 (infusion therapy), if they are using a Mustang balloon to macerate the clot during infusion therapy, is this included in the codes above? Is there anything we can bill for the maceration procedure?

Cystic Lymphocele Ablation with Alcohol

I seem to have a hard time grasping these sclerotherapies. I get the 37241, but I dont know what else I can code with this case. "Using ultrasound, a Chiba needle was introduced through the skin and in between the pancreas and the kidney. Small amount of hydrodissection was employed to make a space between the kidney and the pancreas. After getting past the kidney and the pancreas, the lymphatic malformation was entered. Wire was then placed since the needle into the cyst, and a 3 French portion of the 3-4 dilator was placed into the lymphatic malformation over the wire. Contrast was injected through Touey, which showed filling of the lymphatic malformation. A Rosen wire was then placed into the lymphatic malformation, and a 5 French Yueh centesis pigtail was placed over the wire into the lymphatic malformation. 24 cc of 70% ethanol was injected through the catheter, filling the cyst. Unfortunately at the very end of the injection, the back end of the malformation ruptured. We waited five minutes for the alcohol to react with the lymphatic malformation wall."

Evaluation of AV Fistula/Graft

Access left radial artery with micropuncture, left arm AV fistulogram with interpretation. This is a radiocephalic fistula. Can code 36120 be used for direct radial artery puncture for evaluation of the fistula, or is that code only for the brachial artery (36120, 75791)? When a doctor uses the word "micropuncture", does this always mean percutaneous? First example: "Dissected out the fistula and then accessed the aneurysm with a micropuncture 6 French sheath." Second example: "We then accessed the graft with a micropuncture sheath near the arterial limb towards the venous outflow."

G-J Tube via Nasal Approach

Initial percutaneous placement of G-tube into the jejunum or duodenum is reported with codes 49440 and 49446. Using that same logic, would it be incorrect to report codes 43752 and 43761 for G-tube placement into the duodenum via nasal approach for enteral nutrition? The description of code 44500 in the Coder’s Desk Reference does not seem to describe what was actually done. Example: "Under fluoroscopic guidance, a 10 French nasoduodenal/jejunal feeding tube was advanced using real-time fluoroscopic guidance as well as a 0.035 stiff Terumo Glidewire and positioned in the proximal jejunum."

Biliary Case

How would you code the following scenario? "Known CBD stricture, intrahapetic access obtained unable to cross the stricture. Alligator forceps biopsy performed. External drain placed but bleeding noted. Sheath choliangiogram performed, showing opacification of the portal vein. Portal veinogram done, two portal vein communications found. Larger external drain inserted, bleeding still noted, external drain left in place. Celia and SMA angiograms done with angio-seal to close the femeral artery access."

Multiple Pelvic Hemorrhages

Please advise on the following. "History: Pelvic trauma and bleeding. Multiple pseudoaneurysms and one actively bleeding. The physician goes into the right internal and into anterior division and embolizes pseudoaneurysms. Then goes into the right internal iliac and into the anterior division and embolizes pseudoanerysms. Next, goes into the IMA and shoots angios of the superior hemorrhoidal artery - not bleeding. Goes into the middle sacral artery, which does show the vessel supplying the aneurysm, which was bleeding. It's embolized." Would this be considered all one surgical site and only code one embolization (37242 or 37244)?? Or do we code two different embolizations since one was for hemorrhaging and the other was to exclude non-bleeding aneurysms?

Alcohol Ablation Splenic Cyst

How would you code a CT-guided alcohol ablation on a splenic cyst?

Abdominal Aortogram and selective extremity arteriogram

I have documentation of catheter placement at the infrarenals and the only impression is that of aneurysm and then movement of the catheter contralateral into extremtiy and ateriogram and impression of that entire extremity. Should the coding be 75630 and 75710 (with 59) or 75630 and 75774? I have no indication as to why they went selectively after the abdominal aortogram.

Removal of Temporary Pacemaker

I was reviewing another coder's case, and they coded the removal of the temporary pacemaker. The situation is the patient comes in the ER during the night with symptomatic bradycardia and the on-call cardiologist puts in a temporary pacemaker (33210). The next day the implant physician places a dual chamber pacemaker and removes the temporary pacemaker. She is reporting codes 33208 and 33234. Is this correct?

AAA Endoleak

"Patient has AAA and prior endoprosthesis now with endoleak. Access via right CFA, micropuncture catheter was removed, and a series of dilators were passed until a sheath was positioned, extending into aortic stent graft via right iliac system. Selective catheter was advanced and positioned above the stent graft. Contrast was injected; multiple attempts to advance catheter into SMA were unsuccessful due to dilated AO. This was abandoned in favor of direct injection of endoleak under CT guidance. Site was selected, marked, and prepped on skin of lumbar region. Using coaxial Chiba needle, a 22 gauge Chiba needle was advanced into site of enhancement with subsequent return of blood flow. Needle was flushed, then n-butyl cyanoacrylate glue was injected. Needle was withdrawn." Is there a code similar to 36002 for percutaneous injection of an aortic aneurysm? Please advise how this is coded.

Ascending and Descending AA Repairs

How would you code for the ascending aorta stent grafts in the following scenario? "The physician joined me during this portion of the case. He selectively cannulated the left ventricle using a combination of angled Glidewire and angled glide catheter, and a wire exchange for the Lunderquist wire was performed into the left ventricle. This was left in to mark the ostium of the left coronary artery. Injection of contrast allowed us to perform left coronary angiogram. Wire was left in the anterior descending coronary artery, and catheter was left in the ostium. I proceeded with stent graft repair of ascending thoracic aorta. Cook 38 x 77 stent was introduced and advanced and deployed 5 mm distal to the left coronary artery, then ballooned and pulled distally so the distal portion of the graft abutting the ostium of the innominate artery. Next a Cook 42 x 81 stent graft was then placed and deployed 5 mm distal to the left coronary artery. Two stent grafts were then placed T11 to T4. Additional stent graft was placed just distal to the subclavian artery down to the previously placed stent."

Dilation of Tract for Nephrolithotomy

We need your help, as we are seeing conflicting guidance on the use of code 74485 on the day a lithotomy is performed. If the patient has existing access and the tract is dilated by the IR doc, but the nephrolithotomy is performed by a different physician, can code 74485 be reported? Or is that still bundled with the nephrolithotomy? Or is it more appropriate to report code 50398, 75984, or 50387 for the IR doc (depending on the position of the sheath) or if the tract isn't dilated?

EVAR and Co-Surgeon

Our general surgeons perform the exposure of endovascular AAA surgical cases for the interventional radiology group. The general surgeon performs a bilateral exposure (34812) and inserts the sheath. He leaves the OR at this point, and the interventional radiologist then presents to the OR and performs her portion of the AAA. The general surgeon then returns to the OR, removes the sheath, and closes the surgical site. The general surgeon dictates for the exposure and closure of the wound. Both the interventional radiologist and the general surgeon dictate as “co-surgeon” their individual portion of the case. Can we, as the general surgeon's office, bill for both the exposure (34812) and the repair of the AAA? The general surgeon is not in the OR during the time the interventional radiologist is doing her portion of the case. According to the interventional radiologist they suggest the general surgeon bills code 34802-62, as they say the general surgeon is there for the “critical” portion of the case. What are your recommendations on coding this?

CHD

Our cardiologist stated he did a "right heart catheterization and retrograde left heart catheterization" in a patient who has a history of AV canal defect with hypoplasia of the left ventricle, single atrium, single right ventricle, D-transposition of the great arteries, and subaortic stenosis with an interrupted inferior vena cava with azygos continuation into the SVC, status-post bulboventricular foramen enlargement, Damus-Kaye-Stansel procedure with placement of graft between the proximal pulmonary artery and the ascending aorta, as well as bilateral bidirectional Glenn shunt. At some point the patient also underwent an extracardiac Fontan completion. In the description of the procedure, access is gained in JV/FV/FA - does go into the Fontan, the Glenn anastomosis, into the right ventricle and into the (right?) atrium. We aren't sure if he truly has a single atrium or if it's just that the septum has been removed for the extracardiac Fontan (is that that done?). No left heart cath pressures are recorded. Is it because there isn't a left heart cath per se and one chamber is acting as systemic chamber? Is this really a left heart catheterization?

Endograft Abdominal Aorta Bifurcated Modular, with No Docking Llimbs

Our physicians placed an abdominal modular bifurcated endograft, but they did not place the contralateral iliac docking limb. Instead they went through the brachial artery (due to left iliofemoral disease) and placed three iCast stents sequentially in the left common iliac artery. Should we charge code 34802 for all the work, or should we charge code 34805 and an iliac stent placement (37221)?

Venous Stenting

Right and left venous access, two kissing stents placed in the vena cava, two stents placed in right and left common iliac, two stents placed in superficial femoral vein. All lesions were separate and distinct. Bilateral diagnostic venogram also performed.

Stand Alone FFR or IVUS

Patient has a coronary/LV angio (93458) and attempted FFR via radial access. FFR is unsuccessful due to spasm, so it wasn't charged. The angio findings are documented with a note that the patient will return at a later date for FFR and possible intervention by another physician. This occurs nine days later. The second dictation gives the findings of the FFR x two vessels and states that no intervention is needed. After querying the physician, he states that a repeat angio was performed, but not dictated, because the findings were documented in the initial report. He added the angiogram in an addendum. Initially I felt that that we would not be able to charge for the second procedure at all because the repeat angio was not indicated and 93571/93572 are add-on codes. With the addendum, would it be appropriate to charge codes 93454-77, 93571, and 93572? Also, what if there was no addendum?

Subcutaneous Implanted ICD

We are currently discussing the new way of implanting an ICD via subcutaneous device insertion and lead placement via tunneling the lead to beside the sternum. It has been stated by one of our physicians that we should charge code 3918T. So, what I am wondering is, do we report code 33249 and then a tunneled catheter charge (36558)? Or the 3918T?

ICD to Pacemaker

"Patient has multi-lead ICD. Generator was explanted and replaced with pacemaker generator. Atrial lead was capped, then existing right ventricular and left ventricular leads were attached to new pacemaker generator." How would this be coded? Would it be reported with codes 33213 and 33241?

Attempted Subclavian Angioplasty

Highlights of procedure: "Left femoral artery cannulated. Catheter from left femoral into aortic arch. Aortic arch angiogram. Catheter to left subclavian artery, selective left subclavian angiogram. Total occlusion of left subclavian artery. Angioplasty attempted with several wires and catheters. No access. Total occlusion appeared to be extremely chronic. Under ultrasound guidance, visualized the left brachial artery. Using micropuncture needle, artery was cannulated. Catheter was advanced from the left brachial artery up to the subclavian artery and selective subclavian angiogram. Again used mutiple wires and catheters and were unable to cross the lesion. Procedure was terminated." The codes I came up with are 35475-53 (x2?), 75978(x2?), 75710, and 36216. What else am I missing? Can they be billed x 2 since he tried from the femoral approach and then from the brachial approach?

Collateral Vein Embolization

Can you clarify why embolization of collateral vein(s) would be reported with codes 36011, 37241, and 75791 and not 37241 and 36147 if an angioplasty is done first? The outflow was access next to the anastomosis, catheter was placed into the superior vena cava, and the angioplasty was done of the cephalic vein. Then the embolization of the collateral vein of the fistula was performed with only one access. I am trying to explain this to our analyst.

Nose Embolization

We often bill for multiple embolizations in a single AVM procedure (embolizing multiple arteries). For external carotid embolization, such as particle embolization for epistaxis, does the same apply? Routinely we inject particles into the IMAX artery on each side. Can we bill multiple (two) extracranial embolization codes for those cases?

Selective Catheterization of Subclavian Artery

When coding the following scenario, we thought this to represent 36216, but we also question 36225. There was selective catheterization of the right subclavian and innominate with dye. Could you please clarify the difference? Operative note excerpt: "We then used a Shuttle sheath and a Vtech introducing cannula and catheterized the innominate artery. A 6 French Shuttle sheath was placed. We obtained a selective innominate angiogram with 10 cc of dye. We cannulated the right subclavian artery and performed a selective catheterization of the subclavian artery. This study revealed a chronic occlusion of the axillary artery. We did attempt to pass a wire through this area, which appeared to be chronically occluded. The catheter and sheath were removed, and a Mynx device was used to close the groin."

Suture around a CVC

"INDICATIONS/COMMENTS: Poorly functioning access. RESULT: The patient was scheduled for left groin tunneled catheter exchange. The patient stated that the catheter is working well and requested that not be changed. As the initially placed sutures had come out, the catheter was sutured to the skin using sterile technique. The patient tolerated the procedure well without evidence of immediate complication." Is there anything that can be coded here?

Sclerosing of Inguinal Seroma

Would you assign codes 20500, 76080, and 77002 for a sclerosing of an inguinal seroma? Here is the procedure: "The inguinal seroma catheter was carefully identified under fluoroscopy and the inguinal site sterilely prepared. Through the catheter, contrast injection identified the size and distribution of the catheter. There was no evidence of extravasation or communication with adjacent vascular structures. The catheter was then aspirated and filled with a small dilution of doxycycline for an interval of time. This was subsequently aspirated and put the bulb suction. Impression: Successful inguinal seroma cavity fluoro injection identifying no communication with adjacent structures. This was subsequently infused with doxycycline to help promote sterilization and sclerotherapy of the cavity. The catheter was removed."

Chest Tube for Pneumothorax

What is the correct coding for placement of a chest tube for a pneumothorax when done in an IR lab? There is always disagreement when this procedure occurs.

When To Use Code 75774

My colleague and I would like some coding advice on the following example: "A 5 French Contra catheter was advanced into the abdominal aorta, and an AP abdominal aortogram was performed. The Contra catheter was pulled down to level of the aortic bifurcation, and bilateral pelvic oblique arteriograms were performed. Findings include renal arteries, aorta, bilateral common, internal and external iliacs, and common femorals. The Contra catheter was used to select the left iliac system, and the Contra catheter was advanced into the left external iliac artery (36246), and a left lower extremity run-off arteriogram was performed. The Contra catheter was removed, and a right lower extremity runoff arteriogram was performed via the right groin with 5 French vascular sheath." Would this be reported with codes 75625 and 75716 or with codes 75625, 75716, and 75774?

Wire Removal

I still need help coding the following two-day procedure. "PROCEDURE DETAIL: Nephroureteral stent was injected, outlining the renal pelvis. Scout films demonstrated calcification in the proximal ureter. An exchange length Amplatz wire was passed down along the tube and into the bladder. The nephroureteral stent was removed over the wire. The wire was then secured to the skin. FINDINGS: Renal stone in the left ureter. Removal of the ureteral stent with wire placed into the bladder. IMPRESSION: Successful removal of left nephroureteral stent over a wire, with the wire left down into the bladder for laser lithotripsy. The following day after patient had laser lithotripsy and insertion of double-J ureteral stent by surgeon. PROCEDURE DETAIL: Using fluoroscopic guidance the Amplatz wire was removed using continuous visualization of the double-J tube to ensure no movement. FINDINGS: No significant movement of the double-J stent upon removal of the Amplatz wire. IMPRESSION: Successful removal of Amplatz wire without disruption of the double-J stent."

Lombard AorFix Device

Physician used a Lombard AorFix device to repair a common iliac aneurysm that extended into the internal iliac artery. Internal iliac was embolized, and the device was placed just below the renal arteries, seated at the aortoiliac bifurcation, with one docking limb extending down the common/external iliac and covering the internal iliac. Reason for device was due to torturous aorta in a patient with multiple surgeries for colitis with a colostomy and a chronic abdominal fistula.

Liver Biopsy with Tornado Coil Placement

Physician performed a percutaneous needle core biopsy of the liver using ultrasound guidance (47000 and 76942). At the end of his dictation for the biopsy he said, "An introducing needle was then placed into the lesion. An 8 x 4 tornado coil was placed through the introducing needle." Can I code for this coil placement? If so, what code(s) would I use?

CT Lumbar Spine with CT Abdomen/Pelvis

Is it appropriate to charge for both when doing a reconstruction-reprocessing of CT abdomen/pelvis to create a CT lumbar? Some of the hospitals are charging for CT abdomen/pelvis only, others for the CT lumbar spine only, and others for both.

93653 with 93655

Is it appropriate to use codes 93653 and 93655 for the following? Or does it have to be a different type of SVT, not just a different site? "RF ablation catheter was advanced to the right atrial TA-ER isthmus for CTI ablation purposes. Radiofrequency electrical energy then was delivered to this region using dispersive electrodes placed on the patient’s back. Multiple radiofrequency ablation applications were delivered and typical CTI-dependent atrial flutter terminated with ablation. Immediately after atrial flutter termination, a second atrial flutter developed, mapped via PPI assessments to the mid CS. Ablative energy was delivered to this region, with resultant development of atrial flutter parred via PPI assessments to the His bundle region. No ablation energy was delivered here out of concern for rendering complete heart block."

Leads and 93640

Should code 93640 be used for the testing of "leads only" at time of initial ICD implant or ICD generator change? For example the report reads, "Ventricular pacing and sensing thresholds were checked and were good. Final sensing and pacing thresholds were checked and were good." I have been instructed to use code 93640 with modifier -52 (reduced services) because sensing and pacing were checked, but no arrhythmia was induced for termination. Is this an appropriate use of code 93640? Or is the checking of leads for pacing and sensing thresholds considered part of the ICD implant procedure and not billed separately?

Coronary Angioplasty

When angioplasty is documented in the proximal right coronary artery and right coronary artery posterolateral extension, are codes 92920 and 92921 appropriate?

96564

In what context can code 93564 be used in a congenital heart setting where there are not any true bypass grafts but patients do have conduits?

Sclerotherapy of Varicose Veins

Can code 76942 be billed with -RT and -LT or with a -50 modifier when done for sclerotherapy?

Hepatic Artery Catheter Placement Coding

Could you please clarify the proper coding of catheter placements in the hepatic arteries off the celiac artery? What we most commonly see is that the doctor will place the catheter in the common hepatic (36246), but after that, we have conflicting coding information. If the catheter is placed in the proper hepatic, left hepatic, and right hepatic, is it correct to report with codes 36247 and 36248 x 2 since these are all third order vessels? Or are the proper and right hepatics considered one coded vessel for some reason, and if the catheter is placed in both of these, it is only reported with code 36247? Also, where does the middle hepatic come into play? I often see this artery mentioned, but it's not listed in any reference book that I have.

Modifier 74 with Ablation Codes

We are trying to come up with a guideline for this. What is your opinion? If the physician doesn't give a reason for doing less than a comprehensive diagnostic study before an ablation, I believe that modifier -74 should be appended by the hospital rather than the -52 modifier, since the time, staff, and equipment remains pretty much the same. If I remember correctly, modifier -74 is also appropriate to indicate that a planned surgical or diagnostic procedure was partially reduced at the physician's discretion.

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