Knowledge Base

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Percutaneous Ampulla Sphincterplasty

Would you report codes 47511, 47500, 47555, 47999 (balloon sweep), 75982, 74363, and 74320 for the following case? "An 8 French sheath was placed into the common bile duct and a cholangiogram performed. A 5 French KMP catheter was then advanced over the wire and negotiated into the small bowel. The Glidewire was exchanged for a 0.035" Lunderquist wire. The catheter was removed over the wire, and a 10 mm x 4 cm Conquest balloon was advanced to the ampulla and sphincteroplasty performed to 8 ATM. Next, the Conquest balloon was exchanged for a 7 French Fogarty. The common bile stone was then swept into the bowel. A post cholangiogram was performed. The sheath was then exchanged for an 8 French internal external biliary drainage stent, which was secured to the skin and attached to external gravity drainage bag."

Carotid Bypass Excision and Revision

I am trying to determine coding for excision of previously placed carotid bypass and placement of another carotid-ipsilateral carotid bypass. Does this qualify for code 35501 or repair blood vessel code 35231, or is this unlisted procedure? "Procedure Description: We carefully dissected the common carotid artery bypass graft and then extended the dissection more distally and identified internal and external carotid arteries. These were encircled with vessel loops and clamped in order, internal, external, and common carotid. The graft was completely excised, and the proximal end of the greater saphenous vein was spatulated, and an end-to-end anastomosis between the vein and the very distal common carotid artery at the bifurcation was carried out using 6-0 prolene suture. Following completion of the anastomosis, the proximal common carotid artery was spatulated, the vein was cut to appropriate length and spatulated, and an end-to-end anastomosis was then created using 6-0 prolene suture."

Attempted Upgrade Dual Chamber ICD to Biventricular ICD

"MD Summary Conclusion: Unsuccessful attempt to 'upgrade' a dual chamber defibrillator to a biventricular defibrillator due to unsuitable venous anatomy. The left ventricular lead could not be passed beyond two of four electrodes in any given vein branch. Three separate vein branches were cannulated during these attempts. Three hours and thirty-six minutes were spent attempting to place left ventricular lead before upgrade procedure was aborted." If I code for successful procedure, it would only be a venogram (36005), which we don't typically bill. If I code for attempted left ventricular lead insertion (33225-74), it will edit due to add-on code without primary. I was considering using code 33224-74 because it most captures this situation. What would you recommend?

Multiple AVF Procedures, Different Zones

Could you please help with this coding scenario? The physician placed a stent in the innominate vein (37238) after accessing AVF (36147) and then placed a stent into the venous outflow, but also performed an angioplasty of the brachial artery. If the second stent is reported with 37239, can I report codes 35475, 75962 instead? Before, the rule was to code the arterial if they did both venous and arterial angioplasty.

IVUS or FFR Without Heart Catheterization

I am writing about a scenario that we sometimes see in the cath lab. The first physician performs a diagnostic heart catheterization, and then physician #2 comes in and performs the IVUS/FFR (one or the other). Most of the time, the patient leaves the lab and is held in the holding area and is then brought back to the lab for physician #2 to perform the additional procedure. Occasionally, there is no further intervention. So, how does physician #2 bill for his services since he only performed the IVUS/FFR, which are both add-on codes (either 92978 or 93571)? We were specifically wondering if it was appropriate for an unlisted code (93799)?

3D Reconstruction Multiple Sites

I have a question regarding codes 76377/76376 multiple sites. Has charging only once per session (unless two separate aneurysms) changed since your last response in 2011? There is some opinion that 3D can be charged per vessel. Is this correct?

Pediatric Congenital Cardiac embolization

I understand embolizations are reported per surgical site; however, I am confused as to how to apply that to pediatric congenital heart cases. If an embolization is performed both arterial and venous, is that only one embolization? Another example is embolization of the internal mammary and then embolization of the subclavian. I appreciate any explanation you can give me.

Angiography During Head and Neck Angio

Our physician recently has inquired about billing for angiography of the iliac system. In part he is doing this to ensure adequate sheath placement and for closure. He is also noting any underlying pathology, but is not treating any stenosis found, etc. In the past this was treated as road-mapping. As long as his documentation supports that he is performing a diagnostic angiogram of the iliac, is it billable? He is documenting the following: "...performed dedicated diagnostic angiogram of the left iliac system to evaluate for underlying pathology as well as to ensure adequate sheath placement." The findings are then detailed in the S&I section of the note.

Code 37186 Twice

How would I code for secondary thrombectomy in both fem-pop and tib-peroneal zones (in addition to primary atherectomies)?

MRI of the Abdomen With/Without Contrast, MRI Same Visit

We had a patient who needed an MRI abdomen with and without contrast for a pancreatic cyst for which the physician also wanted MRCP. We billed code 74181 for the MRCP and 74183 for the MRI abdomen, and our billers are requesting that we delete code 74181. This is a hospital setting. The patient was non-Medicare. What are your thoughts?

KX Modifier

Since the NCD for single and dual chamber pacemakers has been put on indefinite hold per MLN Matters CR8525, does this mean that we should not be appending the -KX modifier to pacemaker implants to indicate the patient has documented symptomatic bradycardia?

SAFARI Procedure

How is a SAFARI procedure coded ("subintimal and arterial flossing with antegrade-retrograde intervention")?

Biopsy of Mediastinal Mass After Pneumonectomy

I would appreciate uour input on this report. I was thinking this should be reported with codes 32405 and 77012. "History: Patient is status post left pneumonectomy due to lung cancer. Procedure: CT-guided biopsy performed of soft tissue mass in left hemothorax along the left heart border. Patient was supine with the left side elevated. Local ansthesia administered and skin nick made. A Cook 18-150-20 coaxial biopsy system used and trocar advanced to the lesion. CT images confirm proper localization. Several samples were obtained. Needle was removed, and hemostasis was obtained. Impression: CT-guided biopsy of mass long the left heart border in the pneumonectomy site."

Roadmapping a Vertebral

Could you please let me know if I need to report code 36226 if the physician states, "Right vertebral artery, roadmap images. Roadmap images of the right vertebral artery were obtained, showing normal caliber and contour of the right vertebral artery." The right vertebral was listed as one of the vessels selected during cerebral angiogram. Please let me know if you need additional information.

Code 93662

In reference to question IDs 5422 and 5442... You mentioned coding a right heart catheterization if done with ICE (93451 and 93662). We get an edit indicating that code 93451 isn't a valid base code for 93662. Is this correct?

Aptus Endoanchors

Is code 34845 the only code needed for extensions done? Do we bill unlisted for the anchors or include? From the report: "I placed an 8 x 5 Viabahn covered stent. This was placed into the SMA, making sure not to cover the bypass or any proximal main branches, and from the left side over the Lunderquist wire we placed a 31 x 14 x 13 Gore excluder C3. We continued deployment of the main body. Over the Lunderquist wire we placed a 23 x 14 limb on the right and placed a 20 x12 extension piece and the left iliac. We post-dilated using a q. 50 balloon. We performed a lateral angiogram, which unfortunately revealed a small type I endoleak seen along the posterior margin, which was not evident on the AP view. Given this finding and the large proximal neck with quick reversed tapering, we decided to place, and this tapers for better fixation particularly in the setting of the patient has had previous slippage of the graft. Two Aptus Endoanchors were placed posterolaterally, each 45 degrees off midline, but in the opposite direction of the snorkel."

Cisternogram Injection Code

What CPT code do you suggest for the injection portion of the cisternogram, 62311? "DESCRIPTION OF PROCEDURE: Lower back was localized with intermittent fluoroscopy at the L3-4 level. The L3-4 level was marked, prepped, and draped in the usual sterile fashion. 5 mL of 1% Xylocaine was infiltrated into the skin and subcutaneous soft tissues of the lower back at the L3-4 level. Under fluoroscopic guidance, a 3.5 inch, 20 gauge spinal needle was slowly guided into the dural sac at the L3-4 level, yielding spontaneous return of clear cerebrospinal fluid. A shielded syringe continuing 1.5 mCi indium 111 DTPA was attached to the hub of the needle and injected intrathecally. The stylet was replaced, and the needle was removed."

Catheter Placement for Venous Thrombolysis

We are new to coding thrombolysis cases, and we are questioning what catheter placement codes we can bill. Our report states, "Venous access was obtained via the left popliteal vein. Next, the catheter was placed into the left common iliac vein. Contrast injection was then performed in the iliac vein and IVC to perform venogram at this location to make sure there is no thrombus there. We then performed popliteal and femoral vein angiography to the side port of the 6 French sheath placed in the popliteal vein." We have come up with codes 37212, 76937-26, 75825-26, and 75820-26 for the ultrasound guidance for the thrombolysis and for the venograms. We are questioning what catheter codes we can use. We currently have 36005, 36010, and 36011.

50395 and 74485

The radiologist and urologist are working together on nephrolithotomy cases. Is it appropriate to report code 74485 for the radiologist when they work together in the OR? For example: 1) The radiologist creates the tract (50395). The radiologist joins the urologist in the OR and dilates the tract for the stone removal and dictates a procedure report. Can the radiologist bill code 74485 for dilating the tract, or is it included with stone removal? 2) The urologist creates the tract, the radiologist and urologist work together in the OR, and the radiologist dilates the tract for the nephrolithotomy and dictates a procedure report. Can the radiologist bill code 74485 for dilating the tract in this situation?

TAVR

I have a question regarding an open (33362) vs. percutaneous (33361) TAVR procedure. If the valve is delivered via percutaneous approach (i.e., modified Seldinger technique), but then the closure device fails at the end of the procedure, requiring an open femoral artery cutdown and repair, would you code the open procedure or percutaneous TAVR procedure? If you would still code as percutaneous TAVR, would you code separately for the cutdown (34812) and repair (35226)?

Surefire Filter to Prevent Non-Target Vessel Embolization during Y-90

I have a patient whom we are mapping for a Y-90 embolization. The physician comes back on the same date of service and places a Surefire Filter for infusion of Technetium 99m MAA. Is there a separate code for this? I was just going to code for the catheter placements on this particular exam and not the S&I since we had already done a diagnostic exam earlier in the day.

Transtelephonic Monitoring

Per the CMS NCD, frequency guidelines for TTM are divided into two categories: Guideline I and Guideline II. Can you clarify these two categories? Are they divided by specific devices?

Pacemaker Upgrade with LVL Placed

Patient has single chamber pacemaker with right ventricular lead who came in and was upgraded to a biventricular pacemaker with only left ventricular lead added. So no right atrium lead was added. How would you code this? I would code as a multi-lead change-out (33229) and left ventricular lead add-on (33225). Would this be correct?

Aortic Valve and Aorta Procedure

I need help with coding this case. The patient underwent a three-vessel bypass a couple of years ago. Now, he/she has returned because of ascending and arch aneurysm and needs aortic valve replacement. The physician performed the following procedures: 1. Redo sternotomy (33530), 2. Ascending and total-arch replacement with a 32 mm Gelweave graft under circulatory arrest and with proximal anastomosis at the sinotubular junction (33860, 33870), 3. Aortic valve replacement with a 27 mm Magna pericardial tissue valve (33405), 4. Saphenous vein interposition graft placed from the neoaorta to the right coronary graft (I don't have a clue), 5. Reimplantation of the right internal mammary artery free graft with aortic patch into the neoaorta (I don't have a clue), 6. Placement of atrial and ventricular temporary pacing wires (bundled no code), 7. Endoscopic vein harvest (33508). These are the only codes I could figure out: 33860, 33870, 33405, 33508, and 33530. I'm having trouble with procedures 4 and 5.

Brachial Vein Transposition

What code should we use for upper arm brachial vein transposition AV fistula? Code 36819 is for basilic, and code 36818 is for cephalic. Would you consider code 37799 or 36825?

Bypass Using Cryopreserved Artery

Procedures: 1) Redo left axillo-bi-femoral bypass graft using three pieces of cryopreserved superficial femoral artery. 2) Right common femoral to upper superficial femoral artery bypass using cryopreserved femoral artery. Physician used an unlisted code, and Medicare has continually denied for description issues. What would the proper codes be for these?

36247-50 for UFE Procedure

I'm hoping you might clarify something for me. With the new UFE procedure code, code 36247-50 is being recommended when performed bilaterally. I can understand the contralateral uterine artery being a third order, but the ipsilateral uterine artery appears to be second order (common femoral puncture - 36140, internal iliac - 36245, uterine artery - 36246). Am I thinking completely wrong?

Renal Hilar Mass 50200 vs. 10022

Can you tell me what code you would use for an FNA of a mass in the hilum of the right kidney? When I look at code 50390, it states it is used for cysts or urine in renal pelvis. Here is a portion of the report to help clarify. "Indications: An 81 year old female with history of infiltrating mass in the right kidney suspicious for malignancy probably transitional cell carcinoma, however, could also represent lymphoma. Under CT guidance, a 19 gauge guiding needle was advanced into the periphery of the right kidney. Through this access, a 22 gauge Chiba needle was utilized to fine needle aspirate the hilar mass. Three separate fine needle aspirations were performed, and the samples were sent to pathology. The needle was removed, and a sterile dressing was applied. Path report: Bloody material containing discohesive atypical cells and a few cytologically bland glandular appearing cells."

Exchange of Tunnelled Pleurx Chest Catheter

There is no CPT code for the exchange of a Tunnelled Pleurx Chest Catheter. What is your coding recommendation for the case example below: a) unlisted CPT code or b) 49424/76080?? "Chest and abdomen were prepped and draped in usual sterile fashion. The right-sided chest tube was removed over a stiff Glidewire, which allowed for placement of an 11 French peel-away sheath. After successful creation of a subcutaneous tunnel, the 11 French Pleurx catheter was advanced through the tunnel and through the peel-away sheath into the right-sided thoracic cavity. The incision was closed with 4-0 Prolene. Catheter was secured to the skin at the exit site from the tunnel with 2-0 Monosoft suture."

Venous Malformation Occlusion

If a patient is having a sclerosis as seen below, would I be able to use code 37241, or would I have to have an unspecified code 37799? "Multiple vascular malformation of left leg and left arm. Percutaneous track puncture sclerosis of vascular malformation. History: Multifocal venous vascular malformation. The patient presents for staged embolus embolization therapy of multiple focal low subcutaneous and superficial venous vascular malformations. Sedation: The patient received intravenous sedation with Versed and Fentanyl. Utilizing a combination of fluoroscopic and ultrasound guidance, access is gained to the multifocal malformation of the left leg and separately to the multifocal malformation of the left arm. With each puncture, embolization is performed utilizing Sotradecol mixed with contrast. Total procedure fluoroscopy time: 0.5 minutes."

Arterial Thrombectomy

I have a physician who wants to charge for three arterial thrombectomies. Here is his documentation: "We then attempted AngioJet with a thrombectomy catheter, which did resolve about 30% of the clot. We then pulse sprayed 50 of the 100 ml, so approximately 10 mg of tPA, and let this dwell for approximately 15 minutes. Angiography demonstrated resolution of clot within the left popliteal. There was flow into the left anterior tibial, but again, no flow into the left posterior tibial or peroneal. CONCLUSION: 1. Severe thrombotic occlusion of the left popliteal, which was 100% occluded. There was no visualization of any of the three infrapopliteal vessels. 2. There is suboptimal mechanical thrombectomy of the left popliteal and tibioperoneal clot. An AngioJet thrombectomy with thrombolysis with pulse spray was performed of the left popliteal, left tibioperoneal trunk, and left anterior tibial arteries." So the question is, do we charge for codes 37184 and 37185 x 2? Or just report code 37184?

Epigastric Vein Embolization

How would I code the following case? "Inferior epigastric vein catheterization from a right femoral vein approach with injection and imaging. Subsequently, the anterior abdominal wall in the distribution of the right lower quadrant parastomal region was interrogated. Just along the caudal margin of the stoma there was a small vein that appeared to emanate to the surface. This was slightly ectatic. With ultrasound and dressing maneuvering, brisk bleeding was initiated. This was immediately treated with compression. Subsequently the bleeding site was intubated with a 4 French dilator. 3 mL of 3 percent sodium tetradecyl sulphate was instilled. 5000 units thrombin were placed at the superficial surface of the bleeding site. Compression was performed. Subsequently the site was further treated with three 2-0 Vicryl sutures. Sterile dressing was applied. Osteoma stoma reapplied. Bleeding cessation was encountered."

Venogram

We have a physician who has us take a venogram via the existing sheath (36005). What I'm wondering is if we should also be charging code 75820 for the S&I of the venogram. Do we charge the same thing if he gains access to the vein with a micro needle and sheath?

Diagnostic Venography at Time of Venoplasty

My question is regarding the S&I codes for venography (75820) with venoplasty when both venography (75820, 76011) and venoplasty (35476, 75978) are performed in an outpatient acute care facility. We are coding for the facility. I have an edit for venography code 75820 being included in 35476. Is it appropriate to report code 75820 with a -59 modifier if no prior venography has been done?

Transseptal Codes

When performing atrial fibrillation ablation, can I code two transseptal punctures if one is for ablation catheter and one is for mapping catheter? I know code 93656 includes transseptal, but I'm not sure if I can code an additional.

Endovascular Aneurysm Repair with Aortic Cuffs

"Patient has history of end-to-side aorto-bi-femoral bypass and has developed a large AAA anastomotic aneurysm at proximal aorto-bi-fem bypass anastomosis. Aorto-bi-fem limbs are patent. After right fem incision, sheath was advanced up right iliac system. Surgeon placed aortic cuffs starting distally from old aorto-bi-fem bypass and building proximally up to infrarenal aorta utilizing 5 aortic cuffs overlapping. Proximal, distal, and junctions were ballooned. Angiogram revealed junctional leak. Reballooned. Persistent junctional leak. Two more cuffs were placed overlapping in midportion of previously placed cuffs and then ballooned. Leak improved, but was still faintly present. Patient not candidate for open repair. Surgeon feels that with heparin reversal and time this faint leak will seal." Is aneurysm repair with tube prosthesis 34800 and one cuff 34825? Or is the initial code 34825 since he used cuffs and it is for aneursym repair? I see the cuff code descriptions are for inital vessel and each additional vessel. This was all done in the aorta, so only one vessel had intervention. Seven aortic cuffs in all.

ICD Replacement

I would appreciate some help with this AICD scenario. The patients come in for a replacement atrial or ventricular lead due to malfunction of the lead (not a recall). The physician replaces the lead and also the generator. It is not dictated that the generator is at end-of-life. I believe the replacement is so that the patient does not have to have another surgery anytime soon when the generator is actually at end-of-life. I used CPT code 33249. Can codes 996.04 and V53.32 be used for secondary prevention in this scenario, even though the generator may not be at end-of-life? Or, can the lead issue be ignored and the -Q0 modifier used? These patients were originally primary prevention.

Chest Tube

Could you clarify when it is correct to code for open chest tube placement (32551) vs. pleural drainage (32556)? Also, what do you code when a chest tube is placed by thorascopy? I have gotten two different answers.

FFR in Non-Coronary Vessels

Would there be anything separately reportable on FFR performed on a renal artery, or would that be part and parcel of "including pressure gradient measurements when performed" in the description of CPT procedure codes 36251-36254?

Intraoperative ICD Testing

Can code 93641 be billed for intraoperative ICD testing, or is this only for defibrillation threshold testing?

Venography with Intervention, 75820

How would you code the following? Is the venography included in the new stent codes?  1) Ultrasound-guided left femoral vein access. 2) Iliocaval venography. 3) Intravascular ultrasound: Left common femoral, external iliac, common iliac, and inferior vena cava. 4) Left 20 x 80, 20 x 40, and 20 x 80 Wall stent post-dilated to 20 mm in the common iliac vein and 18 mm in the external iliac vein.

Left Heart Catheterization, 93451-93461

I'm new to cardiology coding. If a physician performs a left heart catheterization and bilateral coronary angiography, is it acceptable to report codes 93458 and 93454? I know the left coronary angiography is inclusive with code 93458, but can we report code 93454 for the right coronary angiography?

Thyroid Aspiration Biopsy

"The patient was positioned in left posterior oblique position. Under real-time ultrasound visualization, a suitable site for lateral to medial access of right supraclavicular nodule/node was localized. Four fine needle aspiration passes were performed with 25 gauge needles under direct ultrasound guidance, without and with syringe, in paths chosen to avoid transgression of visible blood vessels. Specimens were sent to on site cytopathology tech. Ultrasound images demonstrated needle placement within the target lesion." If done with syringe, would that be an aspiration? And would without a syringe be a core biopsy? Also, for the ultrasound specimen image, would we submit unlisted code 76999?

Hybrid Revascularization

Can you help clarify this vascular case? "An open endarterectomy is performed of the iliac and then the superficial femoral. There is residual stenosis, and iliac and popliteal stents are placed. They were unable to clean out the SFA, so the decision is made to do a PTFE fem-pop." If inflow and outflow are included by whatever means necessary, the endarterectomies are dropped, but do I still report codes 37221 and 37226? I have been having more and more hybrid cases and have been charging the stents. But when you read the "all inflow and outflow by whatever procedures necessary", I am questioning the correct coding. I would really appreciate your expertise.

Endarterectomy with Open Bypass Surgery

The physician performed left common femoral endarterectomy (35371), left axillary artery to common femoral artery extra-anatomic bypass (35621), and left femoral to below-knee popliteal artery bypass (35656). I run the NCCI edits, and all codes can be billed together. However, my confusion comes with your coding tips that when a new bypass is performed the inflow/outflow includes thrombectomy and endarterectomy related to the bypass. So, can I bill these three codes together?

Intra-Aortic Balloon Pump via Axillary

My physician is a vascular physician who inserts an IABP by transaxillary vein cuff approach. Is this reported with code 33973, even though he is not directly approaching the aorta? Or would it be an unlisted procedure? Also, four days later the IABP has migrated retrograde into the aorta and out into the subclavian artery, so the physician takes the patient back into surgery and reopens the previous incision and repositions the IABP further into the aorta and resutures. Is there coding for this, as I don't see a repositioning code for IAB's, only VADs?

93655 Billed Twice

I understand that code 93655 can be billed more than once when both arrhythmias are "discrete mechanisms". My question is, what exactly does it mean by discrete mechanisms? I do know that if one is A-flutter and another is another sort of SVT that would make them each distinct. But how about when both arrhythmias are the same kind (A-flutter) oroginating from different locations, for example, one LEFT mitral annular flutter and one RIGHT atrial flutter? Would these be considered "separate mechanisms?"

C9604 vs. 92937

I am trying to verify the correct code for an angioplasty on a bypass graft for a Medicare patient. My coding system leads me to code C9604. Can I use this for a revascularization procedure without the placement of a drug-eluting stent?

Duration Requirements 37211

What is the correct duration of an infusion in order to bill code 37211? Must it be more than 15, 30, or 60 minutes?

37214

The patient came in having a thrombolysis catheter in place from the previous day. They did a contrast injection, documented findings, and decided to discontinue the thrombolysis at this time. Since they did not do any thrombolysis at this time, can we still bill code 37214 for the cessation of thrombolysis treatment?

Attempted TIPS Revision via Combined Transhepatic and Transjugular Routes

How would you code for this thrombosed TIPS stent? "The RUQ was prepped, and under fluoroscopic guidance an 18 gauge Hawkins needle was used to access the proximal aspect of the Viatorr stent. A guidewire was successfully advanced into the right atrium. Then a gooseneck snare was advanced, via a previously placed left neck sheath, and used to capture the end of the wire. The wire was pulled through the vascular sheath and into the TIPS over the wire. A second wire and a catheter were inserted through the sheath into the Viatorr stent. The sheath was successfully advanced after the transhepatic Glidewire was removed, and it was advanced into the peripheral aspect of the Viatorr stent; however, multiple attempts that were made to recannulate the bare metal stent were unsuccessful. Procedure was aborted."

PVI and Additional Lines

We are debating a case and need your expert advice. Our EP physicians are saying we should be able to bill code 93657 x 2 for both of the additional ablations, and they indicated the medical necessity in their dictation. Due to the allowed space, I have only sent you their conclusion. "Successful EP study with successful ablation of the mitral isthmus line, anterior line, and septal line. Successful ablation guided by 3D mapping. Left atrial recording successful. Uncomplicated transseptal puncture assisted by intracardiac echo. EP study after Isuprel infusion with induction of typical right atrial flutter. Successful ablation of cavotricuspid isthmus with bidirectional block demonstrated. Successful cardioversion out of atrial fibrillation at the start of the procedure to determine whether the previous lines were blocked." We billed codes 93656, 93613, 93622, 93623, 93655, and 93657 x 2. Is there any time that you can bill 93657 x 2? We don't see this very often and would appreciate your advice and direction.

Empyema Drain 2014

Initial Question: Can you please clarify whether an empyema drain would be reported with code 49405 or 32557 for 2014? Follow-Up Question: I have a question about your response I received. Code 49405 lists lung/mediastinum in parenthesis in the CPT Codebook, and I have heard this is the way to bill for an empyema drain. If not, when would it be appropriate to bill code 49405 for the lung/mediastinum?  Thoughts? 49405   Image guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous

Repositioning LV Lead on Same Day as Biventricular Generator and Lead Placement

"Patient in for an implantable biventricular ICD and left ventricular lead placement, which was successfully carried out (33249, 33225). Left ventricular lead was steadily withdrawn with patient experiencing phrenic nerve stimulation and only intermittent left ventricular capture. Returned to cath lab, removed retention sutures, recannulated the coronary sinus and advanced the left ventricular lead into proximal portion, and withdrew left ventricular lead from its initial position and repositioned it into the posterolateral branch with good lead stability. Suture sleeve of left ventricular lead was attached to chest wall in two locations, pocket was flushed with antibiotic solution, and left ventricular lead was reattached to the biventricular generator." Can repositioning code 33226 be reported on the same date of service as the generator and left ventricular lead placement codes 33249 and 33225? When code 33226 is reported, we get an NCCI edit with 33249 saying that 33249 is code two of a code pair with 33226 that is not allowed even with an appropriate NCCI modifier. How should this be reported?

Stent and Catheter Placements

In your 2014 Interventional Radiology Coding Reference, page 196, example #2, there is a thrombolytic therapy procedure that ends with a venous stent placement. The venous stenting codes do not include the catheter placement, and according to the CPT manual you should report those in addition to the stents (37238-37229). The example only has code 37238 and does not list a catheter placement CPT code. The thrombolytic catheter is removed, and a new catheter for the stent placement is inserted. Other coding references have stated that if a new catheter is placed even from the same access, you would report the catheter placement for the intervention. Wouldn’t you report the venous catheter placement in this example? And if so, what code would you use?

Balloon Angioplasty of Right Internal Jugular Vein

I'm trying to code for a balloon angioplasty of the right jugular vein, and I'm not sure of the correct code. Also with contrast veno of inferior vena cava, superior vena cava, and right internal jugular vein.

Procedure Documentation

I recently started working for a new practice and have found that the physicians are not documenting the technique/description of the procedure performed. They are only documenting the findings of the procedure. Is the documentation of techniques and equipment used required for the procedure report?

33210 with 33233 Zero Edit

I understand not using code 33210 when doing permanent pacemaker or ICD change and patient is pacemaker-dependent... but can you charge 33210-59 in the same setting as removal of generator (33233) and leads (33235) if not replacing leads and generator at that time due to infection?

Epicardial Ablation

I have a couple of ablation cases that are confusing to me and wonder if these should be considered unlisted codes or if they are like the other ablations and are diagnosis-driven. I have one case that is left atrial and right atrial ablation for numerous atrial macroreentrant atrial flutters, vein of Marshall alcohol ablation for mitral isthmus-dependent flutter, antral pulmonary vein isolation, and CAFE ablation for atrial fibrillation. The other case is an epicardial ablation with a subxyphoid access for VT. My question is, do we use unlisted codes for the alcohol ablation and the epicardial ablation to capture the extra work ? Or should I consider using a -22 modifier?

Repeat Diagnostic Imaging

Am I correct in assuming that if a patient has a liver chemoembolization, let's say 75726, 75774, 36247, 37243 was initially billed. Now the patient returns for a repeat chemoembolization a month or so later, maybe a few months...for that return visit, would it be correct to bill just 37243/36247 unless the diagnostic imaging was done for a different purpose? You wouldn't re-bill the diagnostic imaging, correct?

Cardiac Device Checks

We are receiving denials for CPT codes 93293, 93294, 93295, and 93296 when they are performed more than once per 90-day period. However, these are being performed because the patient has received an alert or the programing information being reviewed by the provider indicates a potential problem. We are coding these with the ICD-9 code(s) 996.01/996.04 and V45.01 or V45.02 at the recommendation of the cardiac device rep. We have appealed these feeling they are medically necessary, but have been unsuccessful in getting the denials overturned. Do you have any advice or recommendations on proper coding for these instances?

Revision of Two Transvenous Leads

Should code 33215 be billed twice when the physician repositions both the right atrial and right ventricular lead at the same setting? The code description reads Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) electrode. However, the instructional notations for Pacemaker or Pacing Cardioverter-Defibrillator reads Repositioning of a pacemaker electrode, pacing cardioverter-defibrillator electrode(s), or a left ventricular pacing electrode is reported using 33215 or 33226, as appropriate. In the code description it has a singular electrode. In the instructional notes it states electrode(s).

Aortobifemoral Bypass and Jump Graft

My surgeon performed an aorto-bi-femoral bypass and jump graft from the aortic graft to interal iliac artery. All grafts were non-vein. We want to get your opinion to see if there is anything else we could bill for this scenario other than code 35646.

Ureteral Stent Exchange Confusion

Kindly provide your thoughts on coding the following report. I'm thinking code 50387. "A 79-year-old female with history bladder cancer and right ureteral stenosis relating to the anastomosis in the pouch. The patient presents for routine ureteral stent to change. A 45 cm 7 French ureteral stent has been utilized. The patient was placed supine on the angiographic table, and the area of the ostomy in the right lower quadrant was prepped and draped in a normal sterile fashion. Initial contrast injection showed a very mild hydronephrosis that has improved since the previous study 05/28/14. Following this, fluoroscopic guidance was utilized to place a wire through the catheter. The catheter was removed, and a new 45 cm 7 French ureteral stent was placed without difficulty. The patient tolerated the procedure well. 1) Initial nephrostogram shows mild hydronephrosis in the right kidney that is improved from previous study. 2) Fluoroscopic guidance utilized for ureteral stent exchange. 3) New 45 cm 7 French ureteral stent placed without difficulty."

Temporary Pacemaker on Separate DOS

If a temporary pacemaker is placed, and then within 72 hours a permanent pacemaker is placed, are we able to bill for both?

Acute GI Bleed

When a patient has an embolization due to a GI bleed (because of tumor), and bleed is not located but embolization is done, would the embolization code for hemorrhage be used (even though they did not locate the bleed)? I see this frequently, as we are a cancer hospital and tumors frequently cause hemorrhage. Here is an example: "Multiple attempts to access right gastric artery were attempted without success. Splenic artery was accessed with microwire and renegade catheter, which was placed distal to area of irregularity. 3 mm coils were placed. Findings: Tumor encasing splenic artery without active bleeding identified. Right gastric artery originates from tortuous left hepatic artery, and multiple attempts were made to access right gastric without success. No active bleeding identified from right gastric." Would cases like this be coded as hemorrhage (since reason was GI bleed), tumor (since the tumor is the cause of bleed and it states "tumor encasing splenic", which was embolized), or non-tumor? Please advise.

Vein Patch Angioplasty with Open Thrombectomy

What code(s) are appropriate to use when my physician performs an open thrombectomy in below-knee popliteal artery and proximal tibial/peroneal trunk using a saphenous vein harvested? I'm coming up with code 35304. I'm also looking at codes 37228, 35571, 35700, and 35572. Just need some direction.

75630 vs. 75716 and 75625

Would codes 36200, 75716-26, and 75625-26 be correct for the following case? Or would codes 36200 and 75630-26 be correct? "Patient placed in supine position. Bilateral groins prepped and draped in usually sterile fashion. Patient had easily palpable femoral pulses. The left common femoral artery was carefully anesthetized with 1% xylocone. The common femoral artery was punctured. A glide wire was placed under fluoroscopic guidance, and a 5 French sheath was placed over the glide wire. We then did an abdominal aortogram using 10 milliters a second of half strength contrast. The catheter was pulled down the aortic bifurcation, and we did a non-selective run-off of the bilateral lower extremities. We were concerned about the integrity of the right common femoral artery, so we did an RAO and LAO projection to look specifically at the common femoral artery. At completion all catheter wires and sheaths were removed."

EP Ablation Procedures

Is it appropriate to assign EP codes 93620, 93653, and 93656 when it is not necessary to induce an arrhythmia? In some cases, the patient presents for the procedure with an arrhythmia, such as atrial flutter, already present.

TAVR and Cutdown

We need clarification on the catheter access that is performed for a TAVR procedure. Our vascular surgeons are providing the access for the cardiovascular physicians for their TAVR procedures. We have been billing the access through our vascular physicians. We listened to a webinar that states we should not be billing the access separately even though the physicians involved are of different specialties. What is your opinion on this?

Portal Vein

What is included in code 36481? Is it the main portal, right and left portal, and any of the portal branches? I know if we select the veins off the portal (i.e., SMV, IMV) we can use codes 36011/36012, but does that apply to the portal branches if they are selected?

37215 vs. 35475

The following procedure was performed status outpatient. Code 35475 may not apply here, but what about 36222? "Patient in supine position...pigtail cath passed to level of ascending aorta and an arch arteriogram performed... Vertebral catheter used to select out left CCA. Cath advanced to the bifurcation level... to the left CCA level. Vertebral cath removed, and a 6.5 mm Accunet was passed up across the ICA high-grade stenosis into the mid-portion of the extracranial internal carotid artery. Attemped to pass a 7 to 10 Acculink stent across the area of disease involving the proximal left ICA but unable was to pass the stent into position due to critical stenosis present. Removed stent and passed 4 x 20 mm balloon up into position. It was inflated to 14 atmosphere pressure, and I did not see any improvement in the degree of stenosis of the proximal ICA. With no ability to pass the stent and my concern over the calcification of the ICA, I felt it best not to pursue further work at this point and to stop. Subsequent arteriogrm demonstrated no real change in the degree of stenosis."

LD Stent Via Right and Left Femoral Accesses

Would you report codes 92928-LD and 92928-59LD for the following case? "Right femoral access: Stent to the LD with subsequent angio showing excellent results. Removed wires and started to close groin when patient went into cardiac arrest. Angio showed thrombosis of LD. Could not access left femoral for IABP. Had to pull wires from right to insert IABP. With chest compression and IABP support we were finally able to access left common femoral and place a stent across LD thrombosis."

Contralateral Leg Intervention and Catheter Placement

I was reading an article published in an endovascular magazine. They had several examples, one of which was a peripheral intervention. We understand that if a true diagnostic study was done prior to an intervention in the leg, we can code it, however, not to show the catheter placements. In the example we are questioning is the following quote: "Code 36246 is reported in addition to the stent placement because the higher degree of selective catheter placement was performed for the diagnostic study, not the intervention." Is this true? If so, then would then the reverse be true on greater selectivity for interventions that don't include catheter placements (say diagnostic cerebral imaging and then greater selectivity to do the intervention)?

Retrieval of Migrated Stent

Can we bill this stent placement even if they had to remove it? Physician angioplasties two areas in the venous portion of an AV graft. In one of these areas there still remained a lot of dz, so it was decided at that point to place a stent. In deploying the stent, because of the narrowing, it created a "pumpkin seed" and migrated into the subclavian vein. They had to remove it by accessing the common femoral vein and used a snare device to remove it. They did not place another one after this. Would I code for the stent placement and/or code for the retrieval?

Bilateral Ovarian Vein Embolization

We have a scenario that is frequently encountered in IR, and we need clarifications for coding the number of surgical fields and if diagnostic imaging is warranted. It is my understanding that billing for bilateral ovarian vein embolization is a grey zone, and we see difference in the recommendations regarding coding one time embolization (37241) or two separate surgical fields (37241, 37241-59). "Catheter was advanced into left renal and left and right ovarian veins with imaging (36012, 36011-59, 75833). Selective catheterization of ovarian veins and coil embolization with post imaging. Left ovarian venography showed reflux of contrast into the deep pelvic venous plexus with multiple para-uterine varicosities. Varicosity also extends into the vulvar region. Initial hand injection into the right gonadal vein demonstrated no reflux of contrast towards the pelvis. The patient was therefore placed in 15 deg of reverse. Injection revealed reflux of contrast into the deep ovarian vein with opacification of small para-uterine varicosities."

Non-Contrast Intraoperative CT Lumbar Spine

Can I use regular CPT codes (CT without contrast) 72125, 72128, and 72131 to report intraoperative CT guidance with spinal procedure? Or would you recommend use of an unlisted code? "68-year-old woman undergoing L2-S1 revision of posterior spinal fusion. Non-contrast axial images of the lumbar spine were obtained intraoperatively for surgical guidance. Coronal and sagittal reformatted images were reviewed. There has been interval placement of a clamp on the T12 spinous process. Post-surgical changes are again demonstrated with posterior fusion hardware in the lower lumbar spine, extending from the L4 level to at least the L5 level. Note that the inferior extent of the hardware is incompletely included in the field-of-view on this exam. A soft tissue defect in the posterior midline soft tissues is compatible with the intraoperative state. Curvilinear, metallic structures within the posterior soft tissue defect may represent packing material/gauze. Multi-level degenerative changes are again identified with anterior and posterior osteophyte formation, disc space narrowing, and vacuum disc phenomenon at multiple levels. Additionally, there are facet joint degenerative changes in the lower lumbar spine."

Vasospasm Treatment, Iatrogenic

The provider performed a diagnostic angiography of the right lower extremity accessed through the ipsilateral CFA and stopping in the SFA (billing 36245-59, 75710-26-59). Then tried to cross the SFA to treat occlusion and was unable to. Closed this access up. Accessed the posterior tibial artery and advanced catheter to the SFA occlusion and did an atherectomy through this access (billing 37225). There was spasm in the posterior tibial artery, and the provider proceeded to balloon angioplasty the posterior tibial artery spasm (provider would like to bill code 37228). Can we bill code 37228 for treating the vasospasm?

Balloon Tamponade of Perforated Inferior Epigastric Artery

"Complications: After completion of left heart catheterization, a right iliac angiogram was done for closure device deployment. A small perforation was noted from needle stick in the inferior epigastric artery, which was successfully sealed off/tamponade by 7.0 x 20 Mustang over the wire balloon, with two inflations of 10 min at nominal pressures. Angiogram was repeated, which showed normal inferior epigastric artery with extravasation of contrast." This was recently performed in the heart cath lab. My question is how would you code this to reflect the procedure performed? The first iliac angio was done for closure device evaluation. The second was done to evaluate the perforation. A balloon was used to seal the perforation until hemostasis was achieved. I spoke with the cardiologist, and the balloon was inflated in the femoral/iliac artery area, and at no time did he enter the epigastric artery. Are codes 36245, 75710, and 37244 appropriate?

Left Heart Catheterization with Acute MI

When a patient has a left heart catheterization, followed by percutaneous intervention, both are considered necessary and can be billed. I'm not sure how to bill services provided when the patient emergently arrives to the hospital and requires this sequence: coronary angiography, percutaneous intervention, and left heart catheterization last. Is the catheterization still billable even though it was done second since there wasn't time to do it prior to the intervention? Or is it not supposed to be billed since it was not done to determine if the intervention should be put in? If not, can I bill for the coronary angiography since that was done prior to the intervention?

Iliac Aneurysm Treatment with EVAR and Two Extensions

Our surgeon treated an iliac aneurysm using a unibody bifurcated endograft that was deployed on the aortic bifurcation and two Iliac extension grafts (same side). Can code 34804 be used in this type of situation, even though the patient does not have an aortic aneurysm? Code 34900 is only for tube endografts. But can we use it anyway, because of the extensions? Or should we use an unlisted code? If yes, what code should we use for the extensions?

AVM Treated Via Venous Approach

Should we report code 37242 or 37241 if the anomalous venous drainage of an arteriovenous malformation is sclerosed without treatment of the arterial portion of the malformation?

Drainage Pseudoanerysm During AV Graft Stenting

Would you code separately for drainage of the pseudoaneurysm during the following AV graft stenting case? Would you use code 10030? "Through the existing sheath an 8 mm x 10 cm Viabahn covered stent was subsequently deployed with post-deployment venogram revealing excellent exclusion of aforementioned pseudoaneurysm. Under fluoroscopic guidance a percutaneous angiocatheter was introduced into the pseudoaneurysm sac at a separate site in the pseudoaneurysm and was drained after exclusion. Antegrade access was then acquired, being careful to avoid the recently placed stent. A 9 French sheath was introduced over wire and a 9 mm x 5 cm via bond stent was deployed at the cephalic origin into the innominate. Post deployment venography reveals exclusion of the primary collaterals and no significant intrusion centrally. Balloon angioplasty was subsequently performed with an 8 mm balloon within and adjacent to the more central stent."

36226, 36218, 75774 in 2015

I have a neuro angiogram where the bilateral vertebral arteries were selected (36226 -50), the bilateral ascending cervical arteries were also selected, and angio was performed. They were selected via the subclavians and thyrocervical trunk. My question is should this be reported with code 36228-50 or something else? I'm confused because this is not a common case for me. They are performing the angio for a tumor at the C2 spinal vertabre.

61626 with 75898

"Our physician did a complete diagnostic study of left and right internal carotid and external carotid arteries, right vertebral artery, and left superficial temporal artery. Embolization was done on the superficial temporal artery all from bilateral inguinal access. Following embolization he did the same studies left and right internal carotid and external carotid arteries, right vertebral artery, and left superficial temporal artery. The patient was then taken to surgery where the physician did a resection of the left superficial temporal artery pseudoaneurysm." Would codes 36224 x 2, 36226, 36227, and 61626 be correct? I'm not sure any of the post angiograms can be charged. The resection was billed with OR time. Our CEO is concerned we are not charging correctly for all the biplane procedures.

Thrombectomy Through Two Incisions

The physician opens common femoral artery at the groin and performs a thrombectomy, then opens medial calf at the tibials and performs additional thrombectomy. Can I report codes 34201 and 34203?

Saline Flush of Abscess

Can code 20500 be utilized when, at time of abscess catheter placement or exchange, the cavity is debrided of necrotic material using normal saline (500 ml, in this case)? This is time-consuming and goes above and beyond just placing or exchanging the catheter.

75716, 75625, 75630

I need your perspective on this one. At conclusion of study the provider mentions that the patient will need an aorto-bi-femoral bypass. "Operative Synopsis: Pigtail catheter placed first at renal artery and then pushed down to distal abdominal aorta. Then after completing peripheral angiogram, cardiac catheterization was decided." The provider mentions findings for abdominal aorta, common/internal/external iliacs, and bilateral SFAs. Report states that they were "unable to visualize clearly the below-knee vessels due to slow flow". I'm thinking this needs to be reported code 75625 only. My rationale is that the statement of slow flow to see below-knee vessels is not acceptable to also capture code 75716. I did not go with code 75630, as the catheter is not in one spot. With conclusion of statement that patient needs bypass, is this study then considered screening (G0278)?

Redudant Lead Sutured to ICD Pocket Floor

"Patient was brought into the electrophysiology laboratory in the fasting, non-sedated state. The patient was prepped and draped in the usual sterile fashion. 1 percent lidocaine was used for local anesthetic. An incision was made in the left infraclavicular region. The tissues were dissected down to the level of the ICD pocket. A redundant lead was extending just beyond the device with stretched skin and impending erosion. That lead was dissected free and turned into the pocket. The lead was sewn to the pocket floor with 0 silk. The pocket was irrigated with a combination antibiotic solution." We know this was not a pocket revision or move. How would this be coded?

Diagnosis

Can you please help with the correct diagnosis code for the following scenario? The patient has CRF and is coming in for creation of an AV fistula (36821). In my opinion the primary diagnosis would be for the CRF. Per our in-house auditor, the primary diagnosis should be V56.1. What are your thoughts?

Stereotactic EP Ablation

Our doctors have started using stereotactic technology to perform certain EP ablation procedures. Is there a CPT code for this?

Fistula Revision

Will code 36833 cover the following procedure? Or are codes 36147 and 36148 also needed? Please advise. "Patient with aneurysmal left brachiocephalic AV fistula with aneurysmal stick site, skin ulceration over upper stick zone. Micropuncture needle was inserted into proximal portion of fistula with wire advanced under fluoroscopy into upper fistula beyond aneurysmal stick zones. Sheath inserted up into subclavian vein and parked there with fistulogram done. Long segment of high grade stenosis (80%) began just beyond aneurysmal upper stick zone. Stenoses were balloon-dilated with good result and puncture site sutured. Attention turned to aneurysmal site in upper stick zone. Ulcer was excised with elliptical incision back to healthy skin on both sides, down to fistula. Inflow portion of fistula into stick zone was dissected and clamped. Patient was heparinized. Part of aneuyrsmal fistula was excised, revealing ulcer had penetrated into fistula with layer of thrombus between scabbed area and fistula. This was excised including excessive thrombus. Opening was oversewn in two layers, clamps were released, and suture line was hemostatic. Subcu and skin sutured."

33222 and 33228, Zero Edits

"11 year old male status post pacemaker for sinus node dysfunction, with a recent change to ERI mode. He presents for elective replacement of the generator. In pre-procedure discussion with the surgery team, it seems that the post-rectus device had possibly migrated upwards and centrally. We thus elected to have surgeon scrub in to the procedure to assist in removal of current generator. After removal, leads were tested and found to be stable in function. We thus proceeded to create a new pocket (33222) in the left-sided abdomen under the anterior rectus sheath above the rectus muscle. The existing leads were attached to a new device. Testing confirmed stable thresholds and impedences. The new device was placed in the new pre-rectus pocket (33228) on the left and closed in three layers. The old pocket was also closed in three layers. Patient tolerated procedure well." NCCI edits do not allow codes 33228 and 33222 to be reported together, no modifier allowed. Do you have any suggestions on an appropriate code combination that would allow reporting of pocket relocation?

Sinogram with Alcohol Sclerotherapy

Would codes 49424, 20500, and 76080 be supported for this procedure? "Contrast was instilled into the patient's indwelling right groin catheter/fluid collection under direct fluoroscopic guidance. Overall, the fluid pocket appeared similar in size compared to previous exam with no external communication. Contrast was aspirated and replaced with ethanol solution. Patient was repositioned into right and left decub positions. Alcohol was left in place for 30 minutes and then removed. Impression: Stable appearing fluid collection in the right groin with successful alcohol sclerotherapy of patient's lymphocele."

Balloon Maceration of Thrombus

Day One - Patient has a percutaneous thrombectomy, common and external iliac stents, and starts thrombolysis. Patient has a left iliofemoral thrombosis (37187, 37212-59, 37238, 37239). Day Two - Follow-up venogram shows residual thrombus in the left external iliac vein. The residual thrombus in the iliac vein was macerated using a pigtail catheter and 10 x 4mm balloon. Thrombolysis was completed (37214). Would you code the venoplasty (35476, 75978) for maceration of the residual clot?

Selective Nerve Block

Would I report codes 64483 and 64484 or codes 64493 and 64492 for the following case? These can be confusing at times. Please let me know how these can be easier. "History: Right L3 and L5 radiculopathy Summary: Uncomplicated right L3 and L5 fluoroscopic guided transforaminal epidural selective nerve root block. A combination of 2 mL 0.25% bupivacaine, 1 mL 1% lidocaine, and 40 mg Kenalog were injected at each level. Procedure: Using fluoroscopic guidance, a 22 gauge spinal needle was inserted into the right L3 and L5 neural foramina. Position within the nerve root was confirmed with small injection of contrast and digital fluoroscopic image. Medication was injected as above. Needles were removed. Total fluoroscopy time 2.3 minutes. 15 minutes intravenous conscious sedation with Versed and fentanyl were administered by sedation nurse under my supervision with continuous monitoring."

Superselective Imaging for Spinal

I'm only adding the procedures and not the actual description. I know the codes for the thoracic and lumbar etc., but I'm not sure what to use for the superselective injections. "Questionable spinal vascular pathology. POSTPROCEDURE: No vascular pathology identified. OPERATION/PROCEDURE: 1) Diagnostic cerebral angiogram 2) Right common femoral artery selective 3) Complete aortic survey 4) Left intercostal selective injection 5) Right bronchial superselective injection 6) Left bronchial superselective injection 7) Left T8 selective injection 8) Left T9, left T10, left T11, left T12, left L1, left L2, left L3, right T8, right T9, right T10, right T11, right L1, right L2, right L3, right vertebral artery, right subclavian, left vertebral artery, left thyrocervical, superselective injections 9) Personal review and interpretation of angiogram."

Internal Biliary Stent and Internal/External Biliary Drainage Catheter

Patient with jaundice presents for biliary evaluation. Physician performed: percutaneous transhepatic cholangiography (47500-59, 74320-59), cholangioplasty with stent placement (47556, 74363), and internal/external drainage catheter placement at the initial presentation. Would you please give us your insight on why the drainage catheter (47511, 75982) is not coded in addition to ductal dilation with or without stenting when the procedure was not staged?

Stent for Endoleak

Should I report the following with codes 36200, 34825, and 75953? Please advise. "The flush catheter was positioned in the proximal visceral segment of aorta. Aortography was performed. This identified some suggestion of a type 1 endoleak. Pre-close technique was used to fire two perclose devices in the right femoral artery and facilitate introduction of a 14 French sheath, which was done over a stiff Lunderquist wire after administration of systemic heparin to the therapeutic level. With the 14 French sheath in position, a 40 x 10 Palmaz stent was mounted onto a Coda balloon. This was advanced up to the level of the perirenal aorta, and the balloon mounted stent was then inflated and appropriately positioned."

Paravalvular Leak Treatment

In your "Ask Dr. Z" knowledge base forum, you previously recommended the use of unlisted code 93799 for percutaneous treatment of a paravalvular leak instead of code 37242. Would you please elaborate on why this is the case? I am assuming that since code 37241 is for venous embolization and 37242 is for arterial embolization you would not be able to use these codes, as a paravalvular leak treatment is used to treat a valve. The reps have also pointed us to the embolization codes (37241-37244), but I am reluctant to bill these out for treatment of a paravalvular leak. I am hoping you can shed some light on this relatively new procedure.

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