Knowledge Base

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Set Descending Direction

Repeat Stent Separate Session

I would appreciate you help with this scenario. We did a drug-eluting stent procedure on the LAD (C9600-LD). Later in the day, this patient developed pain and returned to the cath lab. The diagonal was closing down, and the same physician put a drug-eluting stent in the diagonal. For the second encounter, would I report code C9600-76-LD, or would I report code C9601-LD?

Stent with Melody Valve

"Patient with history of congenital aortic stenosis who had valvuloplasty done at 3 days old followed by Ross procedure with bioprosthetic valve in 2009. Now comes in with severe stenosis of the bioprosthetic valve. Doctor performed a balloon angioplasty with bare metal stent placement in the bioprosthetic valve (Palmaz 3110 XL stent inflated to 20mm) and a transcatheter placement of a Melody valve on a 20 mm Bib balloon within the stent complex." I am thinking of using code 37236 for the stent placement, but I'm not sure about the placement of the Melody valve within the stent.

Transhepatic Portography and Portal Vein Embolization

"Patient with metastatic gallbladder cancer to the right lobe of the liver and segment 4. This procedure is being performed to increase the size of the future liver remnant in preparation for extended right hepatectomy. Patient presents today for right portal venous embolization for future extensive hepatic resection. Puncture of a branch of the right portal vein via intercostal approach. Catheter was then reformed and positioned in the main portal vein (36481) with portography and evaluating suitable portal veins for embolization (75887-59). Catheter was manipulated into the left portal vein, subsegment 4A and 4B branches of the left portal vein, and selective portogram was performed followed by embolization with plug and coils." We are hoping to get your thoughts on selected codes please. Should we report code code 37241 or 37243 for embolization in this case?

Arterial Anastomosis and Venous Outflow Intervention

"Left arm fistula was accessed and diagnostic fistulogram performed. Venous outflow stenosis was identified and angioplasty performed. The result was a focal rupture of the fistula requiring placement of a bare metal stent. Attention was then turned to the arterial anastomosis where a web-like stenosis was identified. Arterial anastomosis angioplasty was performed." I believe codes 37238 and 36147 would be correct, but I wondered about the PTA of the arterial anastomosis (35475, 75962). Is that considered inclusive to venous stent code 37238, or is it separately reported?

Tunneled Peritoneal Catheter Repositioning

Would you mind telling us how you would code the following? "Initial scout imaging demonstrated a peroneal dialysis catheter coiled within the right lower quadrant. Gentle contrast administration demonstrates patency of the catheter and positioning in the peritoneum. Under fluoroscopic guidance, a 0.035-inch stiff glide wire was advanced to manipulate the catheter. A tip deflecting wire was also used. These were unsuccessful. Then, a 5.5 French Fogarty balloon catheter was advanced into the distal end of the peroneal dialysis catheter, and attempts to reposition the catheter were unsuccessful. The stiff guidewire was used to push the tip of the PD catheter into the right upper quadrant. A 5 mm x 2 cm Mustang balloon was advanced over the wire into the distal end of the PD catheter, and manipulation was attempted. This was followed by the Fogarty balloon. All of the attempts to reposition the PD catheter into the pelvis were unsuccessful."

Cone Beam Technology

We have a new piece of equipment that is being used to assist in guidance. The doctors each dictate the use of it a little differently, but in essence it looks to me like it might be most accurately coded with 76377. Here is a sample of the technique description: This case was performed using the I-guide feature of the Siemens artist Q. fluoroscopy suite. Guidance was performed using rotational cone beam, the 3D reconstruction, with extensive use of a workstation 2 project and then confirm the needle trajectory." Is this description adequate to capture CPT code 76376 or 76377? Can we even code for the use of this type of guidance?


Please help with coding this report. Would codes 33320, 36010, and 75827-26 be appropriate? I was also thinking about codes 36597and 76000 since they had to reposition it back in place. Do I separately code for thoracotomy? I am really lost on the coding for this one! "Fluoroscopy was used, demonstrating that the proximal port was in the SVC and the distal port was within the pleural space. Completion venogram showed distal port was now in the right atrium. Once the cath was originally determined to be in the pleural space, the patient was placed in the left lateral decubitus position, sterilely prepped, and sterilely draped. A thoracotomy incision was made. Entry was through the fifth intercostal space. Lung was retracted and cath identified. Purse-string suture in position, and cath was then pushed back into the SVC and placed into the right atrium. Suture was tied. There was no hemorrhage from suture, and the chest was closed. Chest tube in place. Fluoroscopy was brought back into position and distal tip in the RA."

Tube Repositioning with Paracentesis

For the following, would you use codes 49424 and 76080-26 for the evaluation, code 49999 for repositioning the catheter, and code 49082 for the paracentesis? "Right abdomen and pleurx site were prepped and draped. A short multiside hole seroma catheter was used to access the pleurx, followed by contrast administration to evaluate the pleurx drain. Using a combo of glide catheter and Amplatz guidewire, the pleurx catheter was slowly repositioned from the pelvis to the contralateral left lower quadrant and superiorly along the left abdomen. A repeat contrast evaluation was performed. At this point, the pleurx was accessed for a therapeutic paracentesis. The entire site was then sterilely dressed."

Facet Injections, Determining Number of Facets Injected

Can you clarify something for me? This relates to question 5222 where you said if injections were done of the L2, L3, and L3 facets that you would only code two injections (L2-3 and L3-4). If my physician dictates that he did facet injections of the L2-3, L3-4, and L4-5, would you then code three injections because he is giving the levels?

Dog Bone Stent in Atrial Septum

I can't find a code(s) for percutaneous transcatheter stenting of the atrial septum in a three-month old born with discrete coarctation of aorta, small left-sided structures, and pulmonary hypertension.  Here's an example dictation: "TEE probe was placed. ABG was performed and was reassuring. Swan catheter removed from pre-existing 5 French sheath. 5 French sheath in left femoral vein was exchanged for new, sterile 5 French sheath. JR 2.5 catheter was inserted in femoral venous sheath and advanced to the right atrium, and pressures were recorded. Baylis system was set up. Microcatheter followed by RF wire were advanced through JR catheter to tip of catheter. Guidance confirmed catheter in central location on the atrial septum, away from aorta and LA free wall. Wire was advanced and contact with atrial septum. Single application of energy was performed (10W for 2 sec), and bubbles were seen in the left atrium. Wire was advanced into left atrium, followed byt microcatheter and then JR catheter. Wire and microcatheter were removed and left atrium pressure recorded. Terumo Glide wire was placed through JR catheter 7 and advanced into LLPV. Catheter was advanced into PV, and wire was removed. 0.014" AllStar wire was advanced through catheter and catheter removed. Pre-mounted 3.5 mm x 12 mm stent was advanced over wire, and TEE was used to center stent in atrial septum. Stent was expanded under 5 ATM of pressure. Balloon was deflated and removed with wire."

Port Removal, 36590

Are codes 36011, 36590, and 77001 correct for the following case? If not, what do you advise? "Known thrombus associated with the central line of port. RUE prepped amd draped. With ultrasound guidance, a small caliber needle was directed into the right basilic vein. Guidewire was directed centrally, needle was removed, and dilators were passed until a 5 French cath could be directed into right subclavian vein. Contrast was injected under fluoroscopy with digital images recorded. Cath was then directed into upper aspect of SVC and advanced into the left innominate vein. Repeat injections of contrast agent performed. Cath was removed and hemostasis achieved. The right anterior chest wall was prepped and draped and anesthetized with local anesthesia. A transverse incision was made over the port and was then removed in its entirety with the attached central line. Pocket was closed, as was skin. Findings: Superior vena cava is chronically occluded with reversal of flow into the azygous system, which is now capacious. A port, which is no longer functional, was removed."

Slightly Pulling Back a G-Tube When Done with Tube Check

I have a case in which they had a GJ, and they repositioned it and now it is a G-tube. I have code 49465 for the injection, but I am not sure about the repositioning. "Dysphagia displacement - gastrojejunostomy tube injection, gastrostomy tube repositioning. Person with need for long-term enteral nutrition. Tube was pulled back and then readvanced. Please evaluate positioning. Impression: 1) Contrast material was injected into the indwelling 14 French Shetty gastrojejunostomy feeding tube, confirming appropriate positioning of the distal tip in the proximal jejunum. The catheter is patent and amenable to immediate use. 2) Contrast material was injected into the indwelling pigtail gastrostomy. The gastrostomy tube had migrated into the proximal small bowel. For this reason, the catheter was slightly retracted and repositioned into the gastric lumen."

Fluoroscopy/CT Myelography and NCCI Edits

In light of the July 2014 NCCI edit update, we (hospital staff) have been debating whether or not it is appropriate to append a -59 modifier to existing myelography codes when a CT scan of the same area is performed on the same date of service. We routinely perform a full and complete conventional myelogram with a separate report amd then send the patient to CT. Bottom line - can we bill separately for the conventional myelogram, or is it now considered bundled with the CT study performed in the same patient encounter?

Needle Localization of Left Flank Glomangioma

We billed unlisted code 17999 for this. Can you suggest a valid CPT code that would most closely describe the following procedure? "A Kopan needle was advanced with intermittent CT guidance into the left flank tumor. Position was confirmed, and Kopan wire was positioned and needle partially withdrawn. CT confirmed needle and Kopan wire position. The needle was then completely removed over the Kopan wire. Kopan wire was secured to the skin."

Blood Patch at Time of Lumbar Puncture

If a lumbar puncture (62270), myelogram injection (62284), and blood patch treatment (62273) are all done at the same level (i.e., L3-L4), is the blood patch billable? Current NCCI edits allow the -59 modifier if appropriate. Does that mean only if done on a different level?

Diagnostic Venogram with IVUS and Stent across multiple Veins

Documentation shows both a diagnostic extremity venogram and venacavagram, as well as IVUS of the external iliac, common iliac, and vena cava. Can both be coded together? Also, he states a stent is placed across the external iliac, common iliac, and vena cava. The vena cava is normal, so I am thinking it's a bridging stent and to code only the stent for one common iliac vessel; although, he says he starts to see narrowing in the external iliac. "Duplex US to puncture the greater saphenous vein at the knee antegrade to place 10 French sheath. Catheter into the femoral vein, venogram with digitlal subtract tech fluoro contrast showed normal anatomy. Vena cava looked patent. IVUS up the femoral vein into the external iliac vein and started to notice some narrowing then in common iliac vein narrowing going down to 4 mm. Vena cava normal at 18 mm. Wall stent placed 12 x 90 into vena cava across common iliac vein into external iliac vein. IVUS shows resolution of narrowing."


If you were to approach this physician on his documentation of the below generator changeout, what would be your exact verbiage? There is no documentation of work done, nor info on implanted device (only intraprocedural measurements). "PROCEDURE PERFORMED: Generator replacement of a dual chamber biventricular cardiac defibrillators, fluoroscopy of device and lead, and capsulectomy pocket revision. Explanted device is a Guidant CRT-D model D224TRK. Existing leads: Atrial lead is Medtronic model 5076, length 45 cm in the right atrial appendage. The ICD lead is a Medtronic model 6947, length 58 cm in the right ventricular apex, and the CS lead is Medtronic 4196, 78 cm long in the lateral branch. Tachy detection at 300 millisecond. Tachy interval for ventricular fibrillation, first therapy 35 joules then 35 joules x 5. Bed rest for 4 hours. Antibiotics used."

37236, 35371

My surgeon approaches this like an endovascular AAA repair; however, it is for severe atherosclerotic disease (not aneurysm), so I know we need to use lower extremity stent codes. My problem is deciding what is bundled due to inflow/outflow. HELP! "Bilateral fem exposures were made, and embolectomy was performed on one side just to get to aorta to take grams, which revealed patency of renal arteries and abdominal aorta to just inferior IMA, then occluded. Right external iliac is occluded. Large amount of thrombus both chronic and subacute from aorta and right iliac arteries retrieved. Flow was established and majority of clot burden removed. Good flow down the right iliac with multiple areas of stenosis and dissection. Neither internal iliacs filled, nor did the left common or left external iliacs. Angioplastied aorta, bilateral common iliacs, and bilateral external iliacs. Bilateral femoral embolectomy performed with severe residual stenosis. Bilateral stents from IMA into origin each common iliac. Two more bilateral common iliac stents. Two bilateral external iliac stents. On the right, common iliac residual disease beyond the stent at site of initial femoral incision required full endarterectomy with large core removed."

Antimicrobial Envelope with AICD Replacement

The cath lab would like to charge codes 11983, C1781, and 33263 when a dual chamber AICD is replaced and an antimicrobial envelope is used. Is code 11983 appropriate in this case?

Facet and Nerve Root Injection at Same Time

Our physicians state they are performing a facet joint injection and a nerve root block. If both of these procedures were performed at the same session, are we allowed to report both codes 64483 and 64493-50? "Utilizing sterile technique, fluoroscopic guidance, and local anesthetic, 22 gauge spinal needles were advanced into the bilateralL4-L5 facet joints. After injection of dilute contrast into the joints, confirming the needle position, 1 ml mixture of 0.25% bupivacaine and 20 mg of Kenalog were injected into each joint space. Utilizing sterile technique, fluoroscopic guidance, and local anesthesia, a 22 gauge spinal needle was advanced into the perineural space of the left L4 nerve root. After injection of dilute contrast into the perineural space, confirming needle position, 1 ml mixture of 0.25 bupivacaine and 20 mg of Kenalog was injected."

Diagnostic Angiogram with Thrombectomy and Stent

Is it appropriate to charge the cerebral diagnostic angio (no prior study) when a planned thrombectomy is done that resulted in the need for a stent by applying modifier -59, as the ipsilateral study is bundled with the stent? But in the case where the stent is not a planned event, can modifier -59 be used?

Venous Thrombectomy and Anastomosis

Our surgeon performed a cephalic vein thrombectomy and later performed an internal jugular vein end-to-end venous anastomosis ot the cephalic vein. How would I code the venous throbectomy and anastomosis? See operative: "The microscope was brought into the field, and after the placing vascular loops to stop the blood flow through the internal jugular vein, a venotomy was created. Then, utilizing of Synovis 2.5 mm venous coupler ring, an end-to-side venous anastomosis was created from the cephalic vein into the internal jugular vein. There was excellent blood flow, and we placed a little bit of Gelfoam to bolster the vein to prevent kinking."

Renal Embolization of Transplant Kidney

Can you help me code this (selective renal transplant arteriogram with embolization). Report excerpt: "Micropuncture was performed of the right common femoral. A 0.018 wire was inserted, followed by placement of 5 French micropuncture set and subsequently a 5 French sheath. A 5 French Kumpe catheter was then advanced into the iliac artery, and injection was performed in the right external iliac artery, opacifying the feeding vessel to the transplant kidney. This was then superselected with a Kumpe catheter and formal arteriogram performed, showing evidence of renal cortical thinning. There is normal arterial blood flow. A 3 French microcatheter was then advanced selectively into the distal vascular bed of the transplant kidney. n-Butyl Cyanoacrylate (1 mL mixed with 4 mL of ethiodol) was then subsequently injected under fluoroscopic control, withdrawing the catheter and filling the entire vascular bed of the transplant kidney. The microcatheter was then subsequently removed. A follow-up injection was then performed with a Kumpe catheter in the right external iliac artery, showing complete occlusion of the transplant renal artery and no evidence of residual arterial flow."

Lymphatic Malformation Embolization

How would you code aspiration and embolization of facial macrocystic lymphatic malformation? "US 20 gauge needle into neck/facial lymph malformation. Aspiration of fluid sent to pathology. Injection of contrast for lymphangiogram under fluoroscopic guidance was performed, confirming isolated cystic structure. Contrast was aspirated, and we performed infusion of doxyclcline with sterile water and contrast under fluoroscopy. No evidence of non-target embolization. Catheter tract was plugged with collogen matrix."


"A 5 French micropuncture sheath was advanced into the cephalic vein, followed by an exchange to a 7 French Pinnacle sheath. Next a 5 French puncture sheath was placed into the reverse saphenous vein graft and the patient’s DRIL bypass. Initially the arterial anatomy was scrutinized: widely patent anastomoses of DRIL graft. Axillary and brachial arteries were moderately calcific but patent. Then a venogram of the cephalic vein was performed: critical stenosis of the LT subclavian vein just distal to its subclavian and innominate confluence. This finding is consistent with venous TOS. Through the sheath, a glidewire with a 5 French Kumpe catheter traversed the tandem venous stenoses. A superior venacavagram was performed. Next, serial venoplasty with Armada 8 x 40 cm balloon, followed by ConQuest 10 x 40 cm balloon, was performed. Post venogram revealed widely patent venous segments." Here are our coding thoughts: DRIL access (36120, 75710-26), venacavagram with venous access (36005, 75820-26), venoplasty (35476, 75978-26). Provider is asking for fistulogram. Is the DRIL part of AV fistula?

Interventional Cardiology Physician Specialty Code C3

I have a doctor who is an interventional cardiologist, and he has recently asked me about his specialty being considered a separate specialty/sub-specialty of cardiology, which has been the case for EP. He states that he heard CMS has now officially recognized "Interventional Cardiology" as a separate specialty. He wants to know if this is true, and if so did it start in January 2014 or is it to begin in January 2015?

IVUS Without a Base Code

I thought I read something about a change. The patient has known CAD, and the only procedure done is an IVUS of the left main and LAD. "Patient's groin was prepped, and a 5 French sheath was placed and guide advanced. Wire was placed down to the LAD, and IVUS of the left main and LAD was done." I have documentation of the IVUS findings. Catheter as well as sheath were removed. IVUS would be reported with codes 92978 and 92979, but current edits indicate a base code is needed. We don't have a base code. Was there a change so this can be coded, or is there another code that we are to add? Or is the claim going to be denied?

35556 vs. 35151

"Patient has aneurysmal development of the distal SFA in above- and below-knee popliteal arteries. Doctor performed left distal superficial femoral artery to below-knee popliteal artery bypass using non-reversed transposed greater saphenous vein, ligation of below-knee popliteal artery, and ligation of above-knee popliteal artery with plication of popliteal aneurysm." Would code 35556 be more appropriate than 35151 due to involvement of SFA and popliteal? The physician also advised ligation would not normally be included. Do we need to report code 37618 x 2?


We are reviewing documentation for echocardiograms and are debating what needs to be dictated to prove spectral Doppler and what is needed to prove color flow Doppler. We are confused on how to prove/differentiate the two forms of Doppler spectral and color flow.

Exceeding MUEs, Change of Nephrostomy Tubes

Patient with duplicated right kidney has a bilateral nephrostogram and nephrostomy tube change in addition to a nephrostogram and nephrostomy tube change on the right duplicated kidney (two on right, one on left) because of poor drainage from the catheters. Initially we reported codes 50394-50, 50394-59RT, 50398-50, 50398-59RT, 75984-50, and 74425, but we got an MUE of 1 on 50394-59RT, 50398-59RT. What's the correct way to code this?

PICC Line Insertion

I have a situation where there is a question about what CPT codes can be billed together with a PICC line insertion. I have a charge for the insertion of the PICC (no pump > 5) and ultrasound charges for US-guided vascular access (76937) and duplex UE/LE unilateral (93971). Can codes 76937 and 93971 be billed together for PICC line insertion? There is documentation by the radiologist that "US evaluation was performed of the left UE to evaluate vessel patentcy and the basilic vessel was deemed patent. During real time sonographic imaging, access was gained into the basilic vein utilizing micropuncture technique. Sonographic imaging obtained for confirmation." The documentation for the duplex states to "please correlate with the PICC line placement." If both ultrasound codes cannot be billed, which is the appropriate one to use?


Do we use code 34802 or 34203 for an Endurant 2 stent graft for AAA?

Thoracic Aortic Angiogram

Is there a CPT code specifically for thoracic aortic angiogram?

Two Lobe Liver Embolization, Surgical Sites

The CPT Assistant article from November 2013 states embolization of liver tumor in two separate lobes may be reported with codes 37243 and 37243-59. Does this update your response to question ID #5157 from 10/22/13 that stated the liver is one surgical site? Our patient had radioembolization of right and left hepatic arteries for bilobar hepatic metastases, so we are using codes 37243 and 37243-59.

Contrast Material with a Cardiac Cath

Does the hospital charge for the contrast material itself with a cardiac cath procedure, or is it considered included?

Iliac-Popliteal Bypass with Graft

Our physician did an external iliac-popliteal bypass with graft. I am not seeing a CPT code for this procedure. Since the popliteal is included in the femoral family for percutaneous intervention, would it be correct to report code 35665, or should we use an unlisted code for this procedure?


Patient has a left to right femoral-femoral bypass with a PTFE graft. Using the same graft, the physician does a left femoral-popliteal bypass graft. Can I use both codes 35656 and 35661, as two bypasses were done but only one PTFE graft used?

Reporting 33215 and 33226 Together

I researched prior questions along with your cardiovascular coding book and could not locate an answer to my question. Patient has a biventricular ICD in which the left ventricular lead is repositioned in the anterior cardiac vein, the dislodged right atrial lead is repositioned, and adequate slack was added to the right ventricular coil. I want to report this with code 33215 along with 33226, but I am encountering an NCCI edit. Please advise.


Could you please indicate how to code this case? A stent was placed in an AV graft venous outflow while an angioplasty was performed on arterial anastomosis.

Renal Vein Transposition

I'm looking at using an unlisted code for this procedure (37799): renal vein reimplant to the IVC/renal vein transposition (being done for nutcracker syndrome on one case, and renal vein entrapment with pelvic congestion syndrome on another). I wasn't sure if you were aware of something better to use.


Can I bill surgical cutdown codes 34812 and 34834 along with fenestrated aortic stent graft with three visceral artery endoprostheses?

Vein Patch After Removal of AV Graft

Total excision of an infected left upper extremity AV graft was performed. Afterwards they harvested the distal brachial vein for a vein patch. The vein patch was sewn onto the brachial artery to repair the artery after the graft had been removed. I reported code 35903 for removal of the infected graft. Should a code also be assigned for the vein patch repair of the brachial artery?

Removal of Temporary Pacemaker

Patient had temporary pacemaker placed a week ago. He came in today and had it removed, and a permanent pacemaker was placed. Would you just charge a pacemaker lead removal and the insertion of the new device?

Sizing Balloon for ASD, PFO Closure

What CPT code can we use (if any) to bill for sizing of an ASD?

Ventricular Lead in the CS

We have had a few patients with tricuspid valve issues that require our MDs to put the ventricular lead in the CS (using a CS lead), rather than the RV, for a dual chamber pacemaker. How do we code this?

Catheter Placements with EVARS

I am having issues with insurance companies (multiple) denying 34812-50-62-59-51, 36200-50-59-51 with code 36245 on the AAA procedures. The CPT codes that I am charging are: 34802-62, 34825-62, 34812-50-62-59-51, 36200-50-59-51, 36245, 37250, 37251, 37251-76, 75952-26, 75953-26, 75945-26, 75946-26, and 75946-26-76. I am at a loss because I have always charged this and have had no problem before.

Evaluate/Drain Tunneled Pleural Catheter

We have a patient who was brought to the IR department and had an ultrasound scan performed of the left chest to evaluate pleural effusion. The patient was then positioned in right decubitus and had the drain attached to suction to remove fluid. Would you recommend billing for a limited ultrasound, unlisted procedure, or a clinic visit for this service? The order was for a pleural drain evaluation, possible removal versus tPA of loculated collection.

Replacement of LV Lead to Existing Biventricular ICD System

We explanted a left ventricular lead and replaced it while attaching it to an existing biventricular generator. The best code I can find is 33224, yet the code definition doesn't seem to capture the explant of the lead, only the implant.

Hepatic Shunt Study

How would I code the NM study performed in conjunction with a pre-Yttrium MAA injection? We coded the following report as 78201. "NM liver imaging static hepatic shunt study. 3mCi of 99mTc MAA was administered into the hepatic artery by the staff. Subsequent images of the liver and lungs were performed with calculation of a lung to liver shunt fraction. It was calculated that 2.25% of the administered activity into the hepatic artery appeared in the lungs. The remainder of the activity visualized appears to reflect elution of pertechnetate judging from its biodistribution. Impression: Negative intrahepatic shunt study, shunt fraction calculated at 2.25%."

Fluoroscopially-guided Balloon Dilation of Esophagus

Could you please tell me if unlisted code 43499 should be used in this scenario, or can code 43453 be used? I am thinking of the unlisted but need help. "A 5 French Berenstein catheter, in combination with a 0.035 inch Amplatz guidewire, was advanced through the oropharynx and cervical esophagus across the anastomosis and into the thoracic stomach. A 14 mm Atlas balloon was advanced over the guidewire and into appropriate position. The balloon was inflated. The waist resolved with inflation to 20 atmospheres. The balloon was left inflated for 1.5 minutes. The balloon was then deflated and removed. Repeat dilation was performed using a 16 mm balloon and inflated to 20 atm for 1.5 minutes. A repeat esophagram was performed. This demonstrated improvement in luminal caliber. There was no extravasation demonstrated."

Fetal Echos

Pediatric cardiologists bill codes 76825, 76827, and 93325 for fetal echos. They also look at the umbilical artery. They want to bill code 76820 in addition to the three above codes. Looks like there is a bundling issue with codes 76820 and 93325, but 76820 pays more. I can't seem to find anything about billing these codes together. I'm assuming code 76820 cannot be billed in addition to these codes, but I would like to confirm.

X-ray of skull and X-ray of orbit in the same day

We had a patient come for X-rays. The patient had an X-ray of the skull 70250 and an X-ray of the orbit. Per coding guidelines it states to use cot code 70250 when less than four views are taken of the orbit. This patient's orbit X-ray was less than four views. Please advise me of how to code this since both an X-ray of skull and orbit were done on the same day. Please advise me of the appropriate CPT code usage along with the correct modifier. If a modifier is necessary please provide me to which procedure code the modifier should be attached to.

Q0 Modifier with Box Change

Could you help to clarify the use of modifier -Q0 in certain circumstances? Let’s assume the patient had the original acid placed for primary prevention and is coming in because the acid is at the end of life and the dx v53.32 is coded on chart. If patient comes in to have only the generator replaced, do you add modifier -Q0 to codes 33262-33264? If patient comes in to have a lead replaced to the existing generator, is modifier -Q0 added to code 33224? If the total system is replaced or upgraded, do you add modifier -Q0 to the CPT codes? Or are the above examples considered secondary intervention and modifier -Q0 not assigned because you have a qualifying dx on the claim (V53.32)?

New Modifiers XE, XS, XP, XU vs. 59

I'm confused as to what modifier would be appropriate for a diagnostic coronary angiogram that leads to the decision to do an intervention. It doesn't seem like any of the new modifiers fit the bill. Would you suggest still using a -59 modifier or using -XU (as that seems closest)?

37236 and 37237 for Aortic and Celiac Stents

Our physicians have placed stents in the celiac artery and lower abdominal aorta due to high grade stenosis. Is 37236 the correct code for the stent placement? The LCD for our area does not include coverage information for the celiac artery or abdominal aorta like it does, for example, the renal and mesenteric arteries. Since it is not included in the policy, does that mean it would be considered investigational for the celiac and aorta or just not covered? Is there any way to be reimbursed for these procedures?

Biliary Tube Removal

Which unlisted code would you use for this case: 47999 for biliary or 44799 for intestine because they went into the duodenum? Also would I skip coding the conscious sedation because the ERCP immediately  follows? "Procedure summary: 1. Informed consent. 2. Conscious sedation with continuous vital sign monitoring provided by the nursing staff with physician supervision. 3. Injection of existing PTC catheter with small volume of contrast. 4. Removal of the existing PTC catheter over a 0.035 C-wire. 5. 4 French Kumpe catheter advanced over the wire to the level of the mid common bile duct. 6. Mid/distal common bile duct stenosis crossed with the Kumpe catheter and 0.035 Glidewire. 7. Kumpe catheter advanced to the level of the third portion the duodenum. 8. Placement of a 0.035 Jag wire to the level of the ligament of Treitz. 9. Jag wire secured to the skin and patient transferred to the endoscopy unit for further intervention."

Cerebral Venous Catheter Placements and Imaging

Below is an operative report from one of my providers. The provider is indicating we bill as indicated below; however, I think there may be more catheter placements or angiographies. What are your thoughts? • Digital subtraction cerebral venography. • Introduction of needle catheter into the right femoral vein under continuous ultrasound guidance (76937). • Selective catheterization/venography right jugular bulb. • Selective catheterization/venography anterior third of the superior sagittal sinus (36012/75870). • Selective venography torcula second order vessel venous system, AP and lateral views centered over the skull. • Selective catheterization/venography left jugular bulb across the bilateral transverse sinuses (36012/75860 only billing once, not bilateral). • Selective venography left transverse sinus second order vessel venous system, AP and lateral views centered over the skull (36012/75860). • Venous sinus pressure measurements through catheter of the anterior middle and posterior superior sagittal sinus torcula, left jugular bulb, + 9 other vessels (75898 x 1).

Ileal Conduit Stent Placement

We are hoping for guidance on a CPT code for when a stent is placed through the ileal conduit. I have a case where the patient presents with a stricture in his ileal conduit at the ureteral anastomosis causing hydronephrosis. "Through the Berenstein catheter, a Super Stiff Amplatz wire was advanced until it passed through the urostomy orifice. The wire was partially pulled through, and the catheter was removed. A pigtail catheter was then advanced in a retrograde fashion such that the pigtail loop was located in the renal pelvis. The wire was removed, and the catheter was locked into position. Final imaging shows the pigtail loop appropriately positioned within the renal pelvis."

Ileal Conduit Dilation

I'm not sure how to code this. Would it be unlisted, urinary, or intestinal section? "PE: Abdomen/Flank: Soft, non-tender, non-distended. Positive for bowel sounds. No palpable masses or flank tenderness. Well-healing incisional wound. Ileal conduit with clear urine. Stoma somewhat retracted but reddish mucosa visible. The skin may have pulled away from the bowel mucosa. She was experiencing continuous urinary leakage due to a large vesicovaginal fistula at the trigone of her bladder. Patient is now s/p an ileal conduit urinary diversion and closure of VVF defect with democusalized detrussor flaps and concomitant ventral hernia repair. She had revision of her stoma for stenosis, and the stoma unfortunately re-stenosed. Has been staying relatively open - dilated to 28 French today without issues. Patient instructed on how to use self-dilator and will continue to do this several times per week."

Micropuncture Via Open Access Site

Does using a "micropuncture" needle/sheath mean that a procedure was done percutaneously, or can it sometimes mean open? Examples: 1) Dissected out the fistula and then accessed the aneurysm with a micropuncture 6 French sheath. 2) A right upper arm incision was made distal to the axilla. The brachial artery and vein were identified. The brachial artery was circumferentially dissected and encircled with Vesseloops. Needle access to the brachial vein was obtained with a micropuncture needle, allowing placement of a micropuncture sheath. Right upper extremity and central venograms performed, showing occlusion of a previously placed right innominate vein stent. A 6 French sheath was inserted. A guidewire was advanced across the right subclavian and innominate vein occlusion. Balloon angioplasty of the stent performed. The 6 French sheath was exchanged for 12 French peel-away sheath. Gore hybrid stent graft was inserted using the introducer sheath. It was placed into the right brachial vein and deployed after removing the peel-away sheath. The graft was tunneled in a loop fashion.

Lumbar Medial Branch Blocks

For the case below, the coder reported codes 64493-50 and 64494-50. However, the provider wants codes 64493-50, 64494-50, and 64494-59 to be reported. Which, if either, is correct? "Procedure: Lumbar medial branch blocks, BILATERAL L3, L4, L5. The lumbosacral area was prepped with Chlorhexidine and draped in sterile fashion. The skin over the target medial branch nerves was anesthetized with 0.5% lidocaine. A 22 gauge 3.5-inch needle was inserted into the target medial branch nerve under fluoroscopic guidance at each level and location. No paresthesia was elicited with needle placement, and aspiration was negative for blood and CSF. Next a mixture of 40 mg of Triamcinolone mixed with 5 cc of Bupivicaine, 0.25% was evenly divided and injected at each level. An additional 0.5 ml of lidocaine was injected in the needle tract as the needle was withdrawn. The identical procedure was performed at the remaining levels. The skin was cleansed and a sterile bandage applied. Following the procedure the patient's vital signs were stable. Patient tolerated procedure well, and no complications were encountered."

FRED Device

Would placement of the FRED (Flow Re-Direction Endoluminal Device) be coded as an embolization or a stent? It looks like a stent, but it is used to occlude an aneurysm.

Aortic Cuff Placement with IVUS for Endoleak

How would you code repair on Type I endoleak with aortic cuff and IVUS of one vessel?  "Procedure(s): Repair of Type I endoleak with 32 x 39 mm Cook Aortic cuff. Right femoral artery cutdown. Left femoral artery percutaneous access with ultrasound guidance. Intravascular ultrasound of aorta."

Thrombectomy and Atherectomy at the Same Place with Same Device

What is your opinion of reporting code 37186 as add-on to 37225 when thrombus is identified and documented in the primary atherectomy site (NOT in distal anatomy)? Single rotational/aspiration device is used.

Neuro Codes 36215, 36222

My physicians perform femoral cerebral angiograms with endovascular embolizations for maxillofacial AVM. I am not clear on the difference in these codes and which would be a better selection. Please explain because this is unclear to me.

Limited Aortography

I am not sure what I should be coding for this procedure. My physician did a limited aortography. "The sheath was placed in the right femoral artery using the Seldinger percutaneous technique. The catheter was used to perform an ascending aortography, and limited views were obtained. Once he ascertained that there was an aneurysmal dilation of the aortic arch, the procedure was terminated. Conclusion: Aortic arch and descending aneurysm." Since he only did the aortography, I wouldn't be able to report code 93567 due to being an add-on. I was maybe thinking codes 36200 and 75605-26, but I'm not sure. What are your thoughts?

IVUS of IVC and Catheter Placement

Does the IVUS catheter placed at the IVC get reported with code 36010 along with 37250? Here is the verbiage from the operative report: "A venography was performed via the sheath placed in the left common femoral vein with manual injection. I then advanced a Storq wire, after 3000 units of heparin were given, into the inferior vena cava. A peripheral intravascular catheter was then advanced and placed in the mid IVC. Manual peripheral IVUS was then performed from the IVC down to the level of the sheath." Am I correct to report the following: 36010, 37250/75945 (IVC), 37251/75946 (iliac), 37251/75946 (femoral, level of sheath)? The physician did report on the findings of the IVUS at the IVC, iliac and common femoral veins.

Dual Box Change Attached to a Single Existing RA Lead

Per Ask Dr. Z question ID #6250, Dr. Dunn advised coding based on the type of generator replaced. For the case below, will we use code 33228 (dual chamber pacemaker generator) for what was placed, or should we use code 33227 (single chamber) for what it is pacing? "Patient came in for replacement of dual chamber pacemaker battery, which was carried out. Right ventricular lead was left in place and capped. Right atrial lead was left in the right atrial appendage. Guidant Model 1298 generator was removed from the chronic leads. Leads were inserted into the header of the new generator, Boston Scientific Ingenio Mode 390813 (C1785), tightened in place with immediate pacing,  sensing noted, and pocket closed." Later the same day, an addendum was added to supplement the operative note: "Severe scar tissue over leads and generator. When checked, ventricular lead was not capturing, but atrial was working. We were unable to advance wire into proximal subclavian. When given contrast, vein appeared occluded. Instead of going to right side, we assessed the AV, and it was conducting 1:1 even at rate of 140. We implanted generator on this side and put patient on AAI mode." 

Aortic Atherosclerosis Diagnosis

When ordering an aortic study and an ABI study, is it acceptable to use dx code 440.0 for both studies?

Status Indicator N Specifically on 95940

We report code 95940 for IOM monitoring in the operating room. In our system the techs are reporting the total number of minutes of monitoring. I think this should be converted to 15 minutes = 1 unit for reporting on the UB04. Since it is status indicator N, Medicare is not going to pay. Is the correct way to report this in units or minutes? I see in your book that it is important to be reported accurately. Can you explain so that I can explain it to them?

Lead Interrogations

There are several different CPT codes for pacemaker and defibrillator interrogations, and they are separated by the description of single, dual, and multiple leads. Sometimes we have a patient who has a biventricular device with three leads, but one of the leads is turned off, so during the visit you only do threshold testing on two of the leads. Should this be coded as a dual lead check instead of a multiple lead check?

VP Shuntogram

I have a patient with a diagnosis of hydrocephalus. We are performing an injection of the indwelling ventriculopleural shunt. The only code I see is for the peritoneal (78291 and 49427). What are your thoughts?

Thrombectomy, Fasciotomy, and Arteriogram

I need assistance please. Is the arteriogram considered a separate procedure and billable? I'm thinking of codes 34201, 27602, 75710-2659. The thrombectomy was descrbed in detail. "After completing thrombectomy and we had good inflow, we closed the common femoral with running 5-0 prolene sutures and restored flow to the right lower extremity. The patient, however, had no improvement in perfusion and no signals in the right foot. Having found this disappointing outcome after thrombectomy, we removed the prolene sutures and placed a sheath into the right common femoral artery and then did an arteriogram. C-arm came in for this procedure, and we did a number of studies of the right lower extremity using visipaque. Superficial femoral and popliteal arteries were essentially clot free, then we had a "string sign" of the remaining vasculature with what appeared to be vasospasm. After giving verapamil into the sheath and repeat arteriogram, there still showed vasospasm. We decided to perform four compartment fasciotomy." (This procedure is explained in detail.)

Angioplasty of Superior Gluteal Artery

For the following case, would you code additionally for the superior gluteal artery angioplasty? If so, what code would you use? "Thrombectomy (37184) is perfomed of the superior gluteal artery and the main trunk of the internal iliac artery. Following thrombectomy, there is residual thrombus at the origins of both anterior and posterior division branches, in addition to superior gluteal stenosis and weblike origin stenosis of the internal iliac artery. 4 mm angioplasty was performed of the entire thrombectomized segment, including the two stenoses. The internal iliac artery is stented (37221). Additional thrombectomy was performed of the superior gluteal artery followed by additional angioplasty. tPA is infused along with additional angioplasty. No significant change. Follow-up angio is performed again, and an acceptable result was obtained with good flow."

Occlusion of Left Iliac Limb of the Endovascular Aneurysm Stent Graft

Please advise on the following case example: "Cutdown left common femoral artery. AngioJet device was positioned in the iliac limb. 10 mg of tPA was infused with the pulse generator of the AngioJet into the thrombus of the left iliac limb. We then ballooned that area with a Reliant balloon. We still had thrombus at the top of the main body of the graft overhanging the origin of the left iliac limb. We decided to extend. We got percutaneous access using ultrasound guidance on the right side. We then deployed an aortic extension cuff just below the renal arteries. We then deployed a right and left iliac extension. We pulse dilated with kissing Reliant balloon."

Unsuccessful Placement of ASD Occluder Device

Is the following considered a reduced or discontinued service, as the closure was not completed? "Device was deployed across the AS defect; however, after the sheath was sutured in place, a quick fluoroscopy revealed the device was freely moving in the left atrium. Multiple attempts were made to snare the ASD device, but we were unable to pull the device into the sheath. Emergent CT surgery consult and sent to OR for retrieval."

FFR Repeat Coronary Angiography

The patient first had a left heart catheterization with angiography at his doctor's office owned by our hospital (93458). The patient then was sent over to the hospital for FFR of the LAD and RCA. Our hospital cath lab charged code 93454 for the coronary angiography and codes 93571, 93572 for the FFR. When computing, we are getting an edit stating that code 93454 is a component of 93458 (because the charges for the two facilities are being combined). Is it acceptable for the hospital cath lab to charge for the coronary angiography once again (with the -59 modifier) since it was already performed by the physician office during the heart cath the same day? Or should the hospital cath lab only charge for the FFR? Current charges are: 93458, 93454, 93571, 93572.

CPR with Heart Cath

If while performing a diagnostic or interventional heart cath the patient requires emergent CPR, do we code for the CPR separately in addition to the heart cath procedure? Or is it considered part of the procedure?

XU Modifier

With the new modifiers that go into effect starting on January 1, 2015, could you clarify which modifier we would use in a case where the physician performs a bilateral lower extremity angiogram (75716-26) and then crosses over the bifurcation and performs a POP angioplasty (37224)? Would we still use the -59 modifier on code 75716-26, or would we need to use one of the new modifiers? If so, which one would be appropriate?


Are codes 33946 and 33947 for physician use only? Should codes 33951-33954 be used for facility billing of placement of cannula in the cath lab setting even on first day, or are they only for subsequent cannulas (after day 1)?


Patient with common femoral thromboendarterectomy with patch graft performed above the fem-pop bypass. The artery was severely degraded and fell apart during patch angioplasty necessitating the need to go higher in the iliac requiring conversion to ilio-fem bypass. An 8 mm Gore-Tex graft was brought to the table. It was beveled and attached to the iliac with the distal end extending into the bypass graft and sliding nicely together. Would I code for both the endarterectomy and, say, a revision of the graft? Codes 35371 and 35883? Or 35876 alone?

Intended Procedure Cancelled After Anesthesia

I know I can report the intended procedure code using modifier -74, but can I also report the S&I if there is one?

Replacement of One Lead of a Dual Lead Pacemaker

Patient had dual lead pacemaker with RA lead dislodged. Generator was removed, and RA lead repositioning was attempted but was not effective. The RA lead was removed and replaced with an active fixation lead. Both leads were positioned carefully and the device returned and attached to leads. Only one lead was removed, but because this is a dual lead system, should I use code 33235? It was suggested to me that code 33234 should be used since only one was removed. Could you clarify please?

Electroporation with Nanoknife

I've done my share of research, but I can't find much information on the use of NanoKnife for tissue ablation. My initial thought is to use an unlisted code, but I just wanted to run it by you.

Repeated Stress Test

We have an EP physician who wants to do multiple treadmill stress testing (weekly, for approximately 3 to 4 weeks on same patient) for patients starting Flecainide. He is watching for QRS widening under stress. Is it appropriate for our physician to bill codes 93016 and 93018 (93017 for hospital) each time we do this test?

Stroke Protocol

With patients who have possible symptoms of stroke, we perform an MRI and MRA to rule out a stroke. If the MRI comes back negative, we then do an MRA. Can we charge for both or only one? If yes, what modifier would we use?

Nuclear Stress Test, Hospital Coding

The cardiologists in our practice have recently become employed by the hospital, and we need to start billing the nuclear stress test as a global procedure. The hospital was billing codes 93017 and 78452, as well as the radiopharmaceuticals and other drugs used. What codes should we be billing now to cover both the physician charges and the hospital charges? Also, are the injection and infusion codes billable from the hospital side? The place of service is hospital outpatient.

New Modifier Usage, XU Modifier

With the implementation of the new modifiers -XE, -XS, -XP, and -XU, which would be used to report when no previous diagnostic imaging was recently performed? Would modifier -59 still be used in this instance?

Breast Mammograms with Tomosynthesis, Coding CAD Additionally

If a hospital department is performing breast mammograms with tomosynthesis, would you say across the board that the CAD codes should not be coded additionally? The mammogram coded with the tomography code would become the base code for the CAD add-on code. We have checked, and some of the coding pairs (77062 & 77052 and 77063 & 77052) are on the NCCI edit list preventing their use together, but others (for e.g., 77061 paired with 77051) appear to be allowable. I have not been able to find any further guidance to help clarify. I would appreciate your help and expertise.

Femoroperoneal Bypass Graft with Graft Revision

I am hoping you can help with the following case. I don't believe that code 35879 should be billed at the same time as code 35566, but I am considering the use of a -22 modifier. "Once femoroperoneal bypass was completed, ultrasound Doppler was used to evaluate graft, and the graft was found to have relatively low velocities of 15cm/sec in the thigh. There was a significant flow difference noted with velocities of 80 cm/sec in comparison to adjacent velocities of 15cm/sec. Incision was made over the graft, graft was mobilized, and it was decided to proceed with patch angioplasty since abnormality was likely a frozen valve. A segment of residual GSV was harvested and opened longitudinally for patch purposes. Arteriotomy was made through the valve and fibrotic tissue debrided away from the wall. Standard onlay vein patch angioplasty was then performed. Repair was complete, flow restored, and duplex showed no abnormalities with significantly improved velocities. Total procedure time was 7 hours."

Documentation Issue, Paracentesis with Catheter Not Removed

We would sure appreciate your advice. We have a physician who performs paracentesis with an angiocatheter. She does not feel that is necessary to document that the catheter was removed at the end of the procedure because she states that "it is common sense that an angiocatheter cannot be left in the belly". Can we report this to as a paracentesis with code 49083, or do we need to use code 49406 because the documentation doesn't reflect that the catheter was removed? We also have a similar situation with a thoracentesis. She doesn't document removing the catheter (angiocatheter), and she is tellling us that "if she doesn't state it was sutured to the skin then she removed it". Please advise.

Stent of the Common Carotid Origin

One of our surgeons placed a stent at the origin of the left common carotid artery by open cutdown along with aortic arch angiogram. Pre and post angioplasties were performed of the common carotid origin as well. A filter was not used for this case, and the patient has Medicare. The question is, do we consider the procedure of the left common carotid artery origin to be a carotid stent code or unlisted code? Not sure how to properly code this one.

Midline Peripheral Catheter Placement

What is the correct for midline (peripheral) catheter placement? I keep hearing either that codes don't exist or they haven't been clarified. I'm having trouble getting clarification from anyone.

59 Modifier in 2015

I have cases in which two separate procedures were done on the same day by the same physician. For example, a GI tube was placed, and a port-a-cath was done. I have codes 49440, 36561, 77001, and 76937. The documentation is appropriate to what was done. Now I have an edit of code 77001 needing a modifier due to code 49440. With the new 2015 modifiers (-XE, -XS, -XP, and -XU), which one would I use instead of modifier -59?

Vertebral Fistula

In question ID 5037 from the Ask Dr. Z Database, you suggested code 61624. Does the same hold true for this report? "The right vertebral artery was catheterized with a balloon microcatheter. Balloon was positioned in the high cervical vertebral artery segment. A microcatheter was introduced and navigated into the right vertebral artery and into the origin of the vessel dissection and into the fistulous pouch. Several attempts were made to deploy 3 x 6 mm helical and three-dimensional coil under continuous balloon inflation. Once the balloon was deflated it was noted that the coil was very unstable. The coil was removed. Several attempts were made to reposition the catheter more optimally within the fistulous pouch. When catheter was positioned within the origin of the fistulous pouch, injection was performed to confirm position of the catheter and to evaluate flow through the fistula. During the process of multiple attempts to the further coils within the fistula's pouch, it was noted that after last attempt the fistula was longer present and likely spontaneously thrombosed."

Upgrade to ICD from a Biventricular Pacemaker

Generator and lead isolated. Add leads and connect to new generator. Please suggest CPT codes.

Amplatzer Plug for Biliary Tract

If an Amplatzer plug is placed after the removal on an internal/external biliary drain, would this be an embolization of the hepatic parenchyma? What code would we use for the embolization of parenchyma? "Removal of internal/external biliary drain and placement of metallic biliary stents in a patient with malignant distal common bile duct obstruction. Because the tube tract was not mature, and because the patient has ascites, the hepatic parenchymal tube tract was occluded with an Amplatzer plug."

Balloon Angioplasty Sciatic Artery for Pseudoaneurysm/AV Fistula

Could you please assist with the correct procedure code? I am unsure of which code is most appropriate (37799 or 37220). "5 French Cobra Glidecath was advanced through the sheath into the distal aorta and advanced over a Glidewire to the contralateral left internal iliac artery. Digital subtraction arteriography was performed over the pelvis and upper thigh. Cobra catheter was exchanged over a guidewire for a 12 mm diameter by 4 cm long angioplasty balloon, which required exchange of a 5 French angiographic sheath, a 4 a 7 French Balkan cross-over sheath, into the contralateral persistent sciatic artery. The antiplastic balloon was inflated across the arteriovenous fistula in the distal persistent sciatic artery, and digital subtraction arteriography of the popliteal and lower leg region was performed to the level of the hindfoot. The balloon was deflated and exchanged over a guidewire for a 5 French Davis catheter, which was advanced into the pseudoaneurysm arising from a persistent sciatic artery, and digital subtraction arteriography was performed."

Drainage of Gluteal Seroma with Ablation

Which code (49406 or 10030) should be used for drainage of a gluteal seroma followed by alcohol ablation? And would code 20500 be correct for the ablation? Procedure details (partial): "Following preparation of the right gluteal region and administration of 8 mL, 2% lidocaine local anesthesia, a 12 French pigtail catheter was introduced into the collection using serial CT guidance and Seldinger technique. A total of 480 mL of turbid dark brown fluid was aspirated, and CT scan was performed to confirm coaptation of seroma capsular membrane. Next, 50 mL of absolute alcohol was introduced into the collection. The alcohol was allowed to dwell within the cavity for 5 minutes, during which time the patient was repositioned, and the cavity was compressed externally to distribute the sclerosant CT-directed, catheter drainage, alcohol ablation of pelvic, seroma..."

Indwelling Stent Exchange through Urostomy

What is the correct coding for this case? "The urostomy site was prepped and draped in the usual sterile manner. A scout image demonstrated ureteral stents in place. A 0.035 Coons wire was advanced through the indwelling ureteral stents, which was subsequently removed. Bilateral 7 French Bander catheters were placed over wire. Impression: Fluoroscopic-guided retrograde bilateral ureteral stent exchange for 7 French Bander catheters."

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