Knowledge Base

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Portal Vein Branch Embolization

Portal vein branch embolization to stimulate hypertrophy of the opposite lobe of the liver is reported with code 36481 once for venous access to all selected intrahepatic portal vein branches, and code 37243 is used for embolization of this side of the liver to shrink it and cause hypertrophy of the opposite lobe. Do we need to report code 36481 since the non-selective catheter placement is bundled during embolization procedures?

TPA

Would you report code 37211 for the tPA? There is no time given, only the amount of tPA. "Under ultrasound guidance we obtained antegrade access to the femoral-popliteal bypass graft. With angled guidewire and angled glide catheter we were able to cross the area of thrombus in the popliteal artery and place the wire into the peroneal artery. We used a 4 x 40 mm balloon to angioplasty the popliteal artery with a reasonable result and now brisk distal flow. However there appears to still be a moderate to high-grade stenosis. We infused a total of 4 mg grams of tPA across the lesion. Repeat angiogram showed no significant resolution. It was then decided to stent that area."

Corpak Mechanical Disruption

Even though a CORPAK is not included in the CPT 49460 code description, is it permissible to code it for the case that follows? "CLINICAL INDICATION: ACUTE PANCREATITIS BEING FED THROUGH A CORPAK WHICH HAS BECOME CLOGGED. TECHNIQUE: A CORPAK WAS MANIPULATED WITH AN ANGLED GLIDE WIRE AND REPEATED FLUSHES OF SALINE AND THEN AFTER CONTINUED MECHANICAL DISRUPTION CANOLA OIL WAS INJECTED INTO THE CORPAK WHICH COMPLETELY RELIEVE THE OBSTRUCTED LUMEN. CONTRAST IS INJECTED TO CONFIRM THE POSITION OF THE CORPAK FEEDING TUBE. 1 MINUTES AND 36 SECONDS OF FLUOROSCOPY TIME WAS UTILIZED DURING THE PROCEDURE. FINDINGS: THE CORPAK LUMEN TOTALLY FILLS WITH CONTRAST AND CONTRAST EMPTIES INTO THE PROXIMAL JEJUNUM THROUGH THE TIP OF THE CORPAK."

Billing E&M on Same Day as Kyphoplasty

If a patient was admitted from ER for a fall and was diagnosed with "lumber spine (L2) compression fracture, severe pain, probably due to osteoporosis", can IR bill a consult (or in this case inpatient visit)? The order in the hospital computer from the referring MD says, "Reason for Consult: L2 acute compression FX." The IR does a complete HPI, ROS, Exam, and makes an assessment and plan to undergo kyphoplasty on the same day. I don't know if I should bill the inpatient visit code with a -25 modifier. I was told you can't use a -25 modifier for "decision for surgery". Can you please advise?

Fecal Transplants

I have a question regarding fecal transplants. We sometimes place the NJ tube (44500/74340) and do the fecal injection (unlisted 44799). Would you bill for both the tube placement and the fecal injection? Iif so, do you know which CPT code you compare the 44799 to for reimbursement? We cannot seem to find a good CPT code to compare it to for billing.

93657 for FIRM (Focal/Rotor Ablation) after PVI

"Left atrial FIRM mapping. Mapping of the left atrium was done with the aid of Navix electroanatomic 3D mapping and ICE. The 50 mm basket was now placed in the left atrium. FIRM Mapping results. 1) LA Site #1 – Mid roof (EF 2,3). 2) LA site #2 – Anterior to appendage (CD 3,4). Of note the patient had two left pulmonary veins and two right pulmonary veins. The pulmonary veins were checked for isolation, and the LSPV and the RSPV were isolated at the beginning. Using a Medtronic Advance cryoablation balloon catheter, the left inferior and right inferior pulmonary veins were re-isolated via an antral approach. The pulmonary vein signals on the Achieve catheter became isolated in less than 30 seconds with the first ablation of each vein. We then turned our attention to the areas of rotor activity. Using 3.5 mm tip F/J curve Thermocool catheter, the rotor sites were targeted for ablation. Patient spontaneously converted to sinus rhythm following ablation of the rotor sites, and patient remained in sinus rhythm for the remainder of the case." Can we report code 93657?

Biventricular Implantable Cardioverter-Defibrillator Change with Insertion of a New Right Ventricular Lead

This patient had a previous biventricular ICD in 2009 and is now having noise noted on the right ventricular ICD lead. "Patient presents today for insertion of a new right ventricular ICD lead and generator change from a D1-D4 device. The old right ventricular lead was cut and capped, and the old coronary sinus lead was also capped and left in place. The leads were attached to the new ICD generator, and the two old capped leads were also placed in the pocket. The old right atrial lead P waves measured 3 mv, RA lead impedance 490 ohms, and the old coronary sinus lead impedance was 690 ohms. ICD was programmed to its final setting. The final impression: 1) Successful implantation of a new RV St. Jude Medical ICD lead. 2) Capping of the old right ventricular Medtronic ICD lead and also old left ventricular lead. 3) Pulse generator change of a St. Jude Medical device from a DF-1 to DF-4 pulse generator. 4) Defibrillation threshold testing of less than or equal to 17 joules for ventricular fibrillation." How would this be coded?

Nephrostomy Tube Exchange x 3

We have a patient who has three nephrostomy tubes (two on theleft/upper and lower pole, and one on the right) that were exchanged at the same time. What would be the best way to list the 50435? Modifier -50 with the -59? Modifier -50 with the -LT? Or should we report 50435 three times? The patient has Medicare.

Rt heart cath and intra-aortic ballon pump placement.

"Under US and fluroscopic guidance an 8 French sheath was placed in the right femoral vein using modified Seldinger technique. A 7 French C-tip Swan-Ganz catheter was advanced in the right femoral artery and right heart pressures were measured. Then an 8.5 French sheath was placed in the right femoral artery using a modified Seldinger technique. Care was taken to access the common femoral artery above the bifurcation and below the access site from earlier this morning. Balloon pump was set to 1.1 augmentation. Sheaths were sutured in place." I reported codes 33967 and 93451, but I'm not sure if bundled. Do we have to code 93503? What are the appropriate ICD-10 codes?

Injection of Methylene Blue for Thyroid Nodule

Patient comes in for the injection of methylene blue to mark the area of excision, which will happen on the next day. "Under ultrasound guidance, a 25 gauge needle was advanced into the subcutaneous nodule. 0.2 cc of methylene blue was injected into the nodules." Would I use 38900, which is an add-on code, or should we use 38792? (Is the methylene blue radioactive?) If 38900 is the appropriate code, what would I use for the primary procedure? Or would this be an unlisted code? 

Is it appropriate to code 74485

Is it appropriate to code 74485 for the following? "The patient was placed prone on the fluoroscopy table. The skin was prepped and draped under sterile conditions and 1% lidocaine was used for local anesthesia. A posterior calix in the right kidney was accessed with a micropuncture needle using fluoroscopic guidance. A microwire was advanced centrally within the renal pelvis using fluoroscopic guidance. The AccuStick sheath was placed. Position was confirmed after injection of contrast. Contrast injection demonstrates large amount of calculus within the right collecting system. The wire was upsized. Using a combination of an angled catheter and Guidewire the wire was manipulated into the urinary bladder.  A 7 French sheath was then placed and a second safety wire was placed into the bladder. The large sheath for the nephrolithotomy was then placed into the urinary collecting system after tract dilatation. Nephrolithotomy was done per urology report. A catheter was placed into the urinary collecting system after the procedure as a nephrostomy tube."

Pulmonary Vein Isolation for SVT

Can code 93656 ever be reported for a diagnosis besides atrial fibrillation? If the physician performed a PVI, but the patient is in for atrial flutter and atrial tachycardia, would you report code 93653? If so, can codes 93462 and 93621 be reported as well for the transseptal puncture and left atrial pacing performed?

Catheter Placement Bundling

I have a question regarding coding for catheter placement along with diagnostic imaging and lower extremity bypass. Briefly, the patient had a previous MRA, which was considered inadequate and did not show whether or not the patient had a target for revascularization. MD performed an arteriogram to decide if a target was feasible for a bypass. I'm getting an edit for the catheter placement. Is it appropriate to bill for the catheter placement here (36140, 75710, and 35566)?

Contrast Enhanced Liver Sonogram

I have a question regarding the use of ultrasound contrast, Lumason, for hepatic lesions. Patient has lesions identified with CT or ultrasound. Recommendation is to have a contrast enhanced liver sonogram. The coding guidance I have found for a liver sonogram with contrast is 76705 (imaging), Q9950 (contrast), and 96375 (diagnostic injection). Would this be correct? As there are no "with and without" contrast codes for sonograms, would code 76705 cover pre-contrast scanning and post-contrast scanning? If a contrast enhanced liver sonogram was done on the same date of service as a complete abdominal sonogram (76700), would a modifier need to be appended to one of the codes? My radiologist tells me that he will utilize a contrast enhanced liver sonogram post CT-guided hepatic ablation. Will codes 76705, Q9950, and 96374 work for that exam along with ablation guidance code 77013 and surgical code 47382? 

Ultrasound Follow-Up CPT 76970

Have you ever seen code 76970 used? Could you provide any guidance in how it should be utilized? The scenario that was presented to me is... could it be coded for a follow-up ultrasound on a LT leg recently treated with EVLT on the same day as treatment is given on the RT leg with EVLT procedure or some other varicose vein treatments? I don't see any NCCI edits to disallow or bundle the service. I guess my concern would be medical necessity for the follow-up ultrasound and what the Carriers would expect for medical necessity. I have not found any payer specific policies yet on this code.

10160 vs. 10022

Using a Yueh catheter, 20 cc of pus was aspirated from a known subsplenic abscess with a sample sent for microbial evaluation (catheter was not left in place). My understanding is this would be reported with code 10160. However, it was brought to my attention that code 10160 is only appropriate if the abscess is drained and the fluid discarded, and that code 10022 would instead be appropriate in this case because a sample of the fluid was sent for evaluation. Does the drained fluid have to be discarded to use code 10160?

Event Monitors and ILR medical Necessity for Cryptogenic Stroke patients

We have recently been receiving patients from a neurologist ordering event monitors for patients with diagnoses of cryptogenic stroke, occult Afib. These are not appropriate diagnoses that meet medical necessity per WPS LCD. Private Payers show medical necessity for these patients. Are you aware of appropriate diagnosis codes to meet medical necessity for these patients with Medicare?

76377

Patient with acute SAH has head and neck CTA performed, which reveals a PCOM aneurysm, and NIR performs and bills for the professional component of the CTA. Same NIR takes the patient to the angio suite on the same date of service and performs a diagnostic angiogram with 3D recons. The payer is denying 76377-26 with the angiogram stating, "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed." Is it appropriate to bill for the 3D reconstruction during the diagnostic angiogram when a CTA has been performed on the same date of service by the same provider?

Post Biopsy Embolization

Is it appropriate to charge/code separately for an embolization done post biopsy via the same needle placement if it is being done as a precaution against bleeding?

Diagnostic RHC with tPA Infusion via EKOS Catheters in Bilateral Pulmonary Arteries, WITHOUT Pulmonary Arteriogram

As a follow-up to question #5393 from 3/3/14, if the physician states he did not do a pulmonary arteriogram, but did do a diagnostic right heart catheterization followed by overnight tPA infusion in bilateral pulmonary arteries, is it appropriate to report codes 93451 and 37211-50, without 93568? Or, is code 93568 still needed to cover cath placement and pressures in the pulmonary arteries? From the previous Q&A, it seems you either have a diagnostic RHC and pulmonary arteriogram (93451 and 93568), or you have cath placement in the pulmonary arteries (36014-50) without RHC, with/without pulmonary arteriogram (75743). 

Sclerotherapy Injections

How many times should I submit code 37799 for the following case? "HISTORY: Left neck lymphatic malformation for doxycycline sclerotherapy.  PROCEDURE: The left neck was prepared and draped in the usual sterile fashion. Using ultrasound guidance a 21 gauge Angiocath was advanced... five non-communicating cysts of the malformation... and Doxycycline was injected directly under ultrasound and fluoroscopic guidance. FINDINGS: Ultrasound of the left neck with greyscale and Doppler demonstrated a smaller macrocystic lymphatic malformation amenable to direct injection. Site 1 = 2 mls Doxycycline (20 mg). Site 2 = 2.5 mls Doxycycline (25 mg). Site 3 = 1 mls Doxycycline (10 mg). Site 4 = 1 mls Doxycycline (10 mg). Site 5 = 1 mls Doxycycline (10 mg). Permanent ultrasound and fluoroscopic images were obtained and stored in the PACS system. IMPRESSION: Successful 5 site direct instillation of Doxycycline for sclerotherapy of a smaller macrocystic lymphatic malformation."

CTO - 99% or 100% Stenosis

Is it appropriate to code angioplasty of a CTO (C9607/92943) when the physician documents CTO and 99% stenosis of the coronary artery? Per information found on the CDC website, CTO is typically described as greater than or equal to 99% stenosis. http://www.cdc.gov/nchs/data/icd/att1_CTO_mar06.pdf

Repair of the Brachial Artery after AVF Ligation

"Patient had brachial vein transposition and endarterectomy three days ago. He presented to the ED complaining of pain in her right hand. The patient was returned to the operating room. A dissection was performed to expose both the proximal and distal brachial artery; clamps were applied. The doctor made venotomy into the vein near the anastomosis, passing a Fogarty catheter distally until the clot was removed. He elected to repair the brachial artery using the vein that was present via the anastomosis from prior AVF. Therefore, AV fistula was ligated and divided without issues. The distal extent of the vein was used as a hood for the patch angioplasty." The physician wants to submit codes 34101, 34111, and 37607. Since he documents only one venotomy, is it appropriate to report code 34111 for a radial artery thrombectomy? Would the brachial artery repair be considered included with the ligation? 

36147-52

Would code 36147 require a -52 modifier if the patient had a previous fistulogram and returned for the intervention? "The patient returns today for interventions following a fistulogram that demonstrated high grade stenosis in the fistula and venous outflow tracts."

Hepatic Artery Dissection

The doctor was investigating lack of pulse within the hepatic artery. A small amount of thrombus was found; however, they ended up resecting a length of the artery because of a dissection and then connected the proper hepatic to the common hepatic artery. Can code 35121 be used for this? The description doesn't mention dissection like the EVAR codes do. Or would code 35221 be better?

AV Fistula Aneurysm Repair

We are receiving conflicting information on how to code AV fistula aneurysm repairs. Some coders are using code 35190, while some are using unlisted code 37799. What is the correct code for the following procedure? "The patient was taken to the OR. Left arm was prepped and draped in usual sterile fashion. A tourniquet was placed in the high arm. The aneurysm was appropriately marked with an indelible marker. An Esmarch was used to drain the arm, and the tourniquet was then insufflated to 250 mm of pressure. The anterior wall of the aneurysm was resected inclusive of the skin, subcutaneous tissue, and anterior wall of the vein. The vein wall was then reapproximated with running suture taken of 5-0 Prolene started at each end of the venotomy and tied at the midpoint of the venotomy. Antegrade flow was then restored by releasing the tourniquet. There was an immediate palpable thrill in the fistula. Hemostats were assured. The wounds were closed in layers with suture taken of 3-0 Vicryl at the subcutaneous tissue level. The skin was reapproximated with 4-0 Monocryl at the skin level."

93971

We are having a discussion about whether to use the -52 modifier on code 93971, when the study does not include both compressions and/or color flow. The description of 93971 says for "unilateral or limited study", so then why would a -52 modifier be needed? There is confusion on what limited for this study actually means. For example, if the patient has a 93971 on both the right and left without color flow on both, but with compressions on both, how would that be coded? Layman's terms would be much appreciated.

93005 vs. 93000

Currently we (hospital) report our EKGs with code 93005. Can a hospital report the EKGs with code 93000 instead to capture global billing? (Since we have cardiologists read all the EKGs, and they do not currently capture those reads.)

Post-procedure mammo with stereotactic guided breast biopsy

I have documentation from a few years ago from ACR.org stating that unless the patient is moved to a separate table for the post-procedure mammogram, it cannot be coded with a stereotactic-guided breast biopsy. Can you tell me if that is still currently correct? This has been a question here at our office, since the new NCCI edits allow post-procedure mammo to be separately coded, but now there is this notion that it cannot be coded if the patient is left on the same table and the same physician does the mammo. Please clarify.

Revision or Ligation and Thrombectomy

"Patient presented with massively dilated brachiocephalic AVF with discomfort. The left upper extremity of the patient was prepped. A skin incision one centimeter above the cubital fossa was made and deepened into the subcutaneous fat using electrocautery. After careful isolation of the arterial inflow to the aneurysm, the vein was encircled with vessel loop for traction. The inflow was ligated with 1-0 ethibond transfixion suture. An elliptical incision was made over the aneurysm, the outflow was also ligated with 1-0 ethibond, and aneurysmal sac was opened and partially excised. Doppler signal of the brachial artery was verified after skin closure, and radial pulses were still palpable." Should I report codes 37607 and 36831? Or 36833?

Right Carotid to Left Axillary Bypass Procedure

The doctor performed the following procedure: left axillary artery to right common carotid bypass. How it was done (in a nutshell): 1) Tunnel created between left axillary and left common carotid. 2) Tunnel created between left common carotid and right common carotid (anterior to spine). 3) One single graft threaded through both tunnels. 4) End-to-side anastomosis made between the graft and right common carotid artery. 5) End-to-side anastomosis made between the graft and left axillary artery. 6) The left common carotid artery was clamped, transected, and the distal stump was ligated while the free end was anastomosed end-to-side to the graft. The report reads as two separate bypass procedures, but they only used one graft, even though they anastomed it to three different arteries, but the end result is the right carotid to left axillary graft. Would this be reported with codes 35606 and 35601? Or code 35606-22? Or maybe something else altogether? 

MRI Shoulder Arthrogram

If an ordering physician orders an MRI shoulder arthrogram, what codes would we use? I am confused about when to use codes 77002 and 73040, also 73218 or 73219. "Patient comes to x-ray, and radiologist places a needle in the shoulder joint and injects contrast. The patient then goes to MRI for imaging."

34812-50 and 35371

When we have an EVAR with open exposure, then plaque is noted and is significant (preventing an easy closure), can we charge code 34812 on the same side with 35371 (CFA endarterectomy)? As you know, it requires a -59 (or -XS) modifier for NCCI, but is the bypass available thinking that it could be the other side? Like 34812-50 and 35371-59. I can't seem to find a definitive answer anywhere. 

Category III OCT 0291T

Some of our cardiologists are starting to use OCT over the IVUS, and it has been suggested that since it is a category III we should not bill it and write it off to medical necessity. However, it appears to have the same N status indicator as the IVUS, and we were questioning if Noridian would consider it as packaged or a medical necessity? Either way some of us strongly feel it should a least be billed to justify the work involved. Please share your expert advice.

Pulmonary Artery Band Adjustment

How would you code this? "Emergent mediastinal exploration, clot extraction of central aortopulmonary shunt, pulmonary artery (PA) band loosening, intracardiac Broviac placement, 4.2 French. A midline redo sternotomy was performed carefully. Subsequently a gentle dissection was made around the PA band and the shunt. The PA band was loosened after removing 2 clips and secured back with Prolene sutures over the MPA. The central shunt was opened with a vertical incision after securing it on each end with vascular clamps. The lumen of the shunt was occluded with clot and fibrin material. The shunt lumen was cleaned thoroughly and it was repaired back using 8-0 Prolene."

93566

Can you let me know if this documentation supports reporting codes 93566 and 93568? "Biplane cineangiogram with a pigtail catheter positioned in the proximal right pulmonary artery demonstrates mild narrowing of the proximal right pulmonary artery with unusual branching pattern of the branch pulmonary arteries with both the right and left pulmonary arteries coming off very close to each other. The left pulmonary artery has a hairpin turn as it comes off and then makes an immediate 90 degree turn to the left. There is moderate to severe pulmonary insufficiency. The right ventricle does not appear significantly enlarged on this angiogram." I initially only reported code 93568; however, another coder believes we can also submit code 93566. The only documentation that I'm able to see of 93566 is showing on a final angiography. Can we code a final angiography even if the provider doesn't document one done prior to the stent placement? Please advise.

Percutaneous Tunneled Catheter 49418

I have your Interventional Radiology Coding Reference (2016), and I'm looking at pages 415-416. In coding instruction #5, you indicate codes that 49083 and 49406 should not be billed at the same encounter, and I do see there are NCCI edits in place for this. How should we code if the doctor does a paracentesis (49803) and tunneled catheter (49418) at the same session? There are no NCCI edits on this, but it looks like he's using the initial puncture as part of the tract for the tunneled drainage catheter. I'm thinking I should only bill the tunneled drainage catheter. Please advise.

PFO

"Physician deployed a Gore Helex closure device for a PFO. The device became mobile, and he had to retrieve it from the aorta. He then proceeded to place a new closure device with success." Would it be appropriate to bill code 93580 as well as 37197?

US Knee Aspiration

"Patient comes to hospital for knee aspiration. Under ultrasound guidance no fluid is identified; no aspiration can be done." Do you charge for knee aspiration, as insurance has approved, and add modifier for reduced service? Or, do you charge for limited lower extremity ultrasound? Or perhaps cancel exam all together?

CT/CTA with Calcium Scoring

Does CT/CTA (i.e., 75572-75574) include calcium scoring? I know there is a separate code for CT without dye with calcium test.

ICD-10-CM code for in-stent stenosis - coronary artery

What ICD-10-CM code would you recommend for an "in stent re-stenosis" in the coronary artery? Documentation indicates that the patient had a prior stent in the LAD and now has a 99% "in stent" re-stenosis. In most cases where I encounter this diagnosis of "in stent re-stenosis", the patient has had a prior PCI with stent placement and is undergoing CABG or a re-do PCI procedure of both the vessel with the in-stent stenosis and other coronary arteries during the same encounter. I have researched this diagnosis extensively, and it appears to be a subject of debate in the cardio community. The differential recommendations are to report either T82.857A for the in-stent stenosis as the primary diagnosis or CAD of the native arteries with the appropriate code from category I25.1 as primary (since the patient still has CAD and the CAD could be viewed as the reason for the stenosis in the stent, though that is not always the case clinically speaking). What is your opinion?

Multiple Nodules on Thyroid

In ICD-10, if a patient has multiple nodules on the thyroid, and the physician is not calling it a goiter, do you code to single nodule (E04.1) or multinodular goiter (E04.2)? We are thinking we should code it to E04.2, but we're not sure since the physician is not calling it a goiter.

Stenting Two Major Coronaries, Same Session

When two major coronary arteries are stented during the same procedure, is it necessary to add a -51 modifier to the second stent code? The coronary artery modifiers would, of course, also be present.

CT Lung Screening - Registry

I have conflicting information about who reports to the registry when billing CT lung screenings. We are a hospital-based group, billing for the physician only. I was originally told the hospital reports to the registry. Now I'm hearing that both the hospital and physician have to report. Can you please provided clarification or guide me to some resources?

Holter Monitor Recording

If the patient does not return to our office to have the monitor disconnected, can we still bill code 93225? We connect a Holter monitor in office for 24 hours on a patient, and at the end of the monitoring period the patient disconnects the monitor and sends it in to our monitoring service. We have been billing code 93225 for the initial connections on the day that it was connected, as well as code 93227 for the interpretation under the day the physician performed his/her interpretation. We are being told that we should not be coding 93225 because we are not performing disconnection. Is this correct?

Axillary Vein Repair

Can you please help with codes for this situation? Our physician performed a repair of the axillary vein after another physician removed a right axilla mass. We did not perform the mass resection, a different physician did. We were only called in to repair the axillary vein. What codes would be appropriate for this?

Antegrade Ureteral Stent Placement

At the risk of sounding stupid, I just have to ask because I'm still not grasping the difference between the twp separate sets of stent codes when they are not clearly spelled out in the report (that I can tell). How do you know which this is, 50695 or 50433? My guess is 50433? "A 5 French coaxial introducer was placed the dilated left renal pelvis using micropuncture technique. A nephrostogam was done. Antegrade ureteral stent placement: A 0.035 wire successfully advance into the bladder . A 5 French Angiocath then was advanced over the guide wire in the bladder. The glidewire was exchanged with super stiff guidewire. The needle tract was dilated to 9 French . A 6 French x 22 cm was inserted over stiff guidewire under fluoro into the bladder. The guide was pulled back out of the upper end of the stent but was kept in the renal pelvis. An 8.5 French nephrostomy catheter inserted into the renal pelvis and the stiff guide wire removed. The nephrostomy catheter was secured on the skin with adhesive tape. The final image showed a good position of the stent and nephrostomy catheter."

Status Change after Intervention

Patient comes into the cath lab and has a left heart cath with LV pressures, an FFR of the LAD, and also intervention with a stent placed to the LAD. The patient started to experience chest pain before leaving the cath lab. A left coronary angiogram was performed and showed thrombus of the proximal portion of the previously deployed stent, and aspiration thrombectomy was performed along with balloon angioplasty of the LAD. The procedures originally coded were 93458-26XU, 93571-26, and 92928-LD. Since the patient developed the symptoms before leaving the cath lab, it would not be appropriate to code another coronary angiogram with a PTCA of the LAD, correct?

Catheter placement in the abdominal for diagnostic and embolization

"RCF was accessed advanced catheter into abdominal aorta. Catheter was then placed in SMA, celiac, left hepatic, medial branch of the left hepatic, left gastric, and right gastic; arteriograms were performed at each artery selected. Embolization of the right gastric artery (tumor)." I was thinking of reporting codes 36247, 36248 x 3, 75726 x 2, 75774 x 5, and 37242. Can you verify my codes?

ICD Generator Replacement RV/LV Leads Only

I have a question regarding the removal and replacement of an ICD generator when the device has RV/LV leads only. My physician wants to bill code 33264 to signify this as a multi-lead device. However, I'm thinking this should be reported with code 33263 instead, since we technically have two leads only. What are your thoughts?

Attempted FEVAR; converted to open repair AAA

Our surgeon attempted to perform a FEVAR on the patient, but, due to graft rotation and multiple attempts to salvage the orientation, it was unsuccessful. Catheters were selectively placed into the renals, and bilateral renal angioplasty was done prior to FEVAR attempt. He then converted to open repair of AAA and assoc. iliac artery occlusive dz with aortobifemoral bypass (18 x 9 bifurcated Dacron graft). Cutdown on both groins over femoral arteries. Explant of proximal body of a Cook Zenith fenestrated graft. Open repair ensued of above stated procedure." Please tell me how you would code this.

CT cystogram with insertion of contrast via foley catheter

If a CT pelvis is performed following insertion of contrast via Foley catheter, should code 72192 or 72193 be coded? Does the contrast administered via Foley count as "with contrast"?

Fibrin Sheath Stripping with Repositioning of CVC and Vena Cavagram

Please advise whether repositioning of CVC (36597), CVC catheter stripping (36595), and vena cavagram (75827, 75825) can be reported on this case. "Indication: Porta-cath appears to be curled up in left jugular vein. A 5 French dilator was introducted through the right femoral vein into the iliac vein and also into the inferior vena cava. With injection of contrast, the superior and inferior vena cava were patent. Using multiple snares and graspers, it was not possible to bring the loop of the CVC down into the vena cava. With manipulation of the port and through the neck with external massage, the tip of the catheter was advanced into the superior vena cava. A snare was introduced, and the tip of the catheter was pulled down to the inferior vena cava, but it bounced back into the left subclavian. At this point the catheter was pulled down into the inferior vena cava, and, through manipulation the fibrin sheath, the loop was advanced into the base of the neck. The sheath was stripped and the cath pulled down in the vena cava."

Documentation Question

I have a question about the ICD-10-CM guidelines for the physicians. Is an operative note required to be a stand-alone document for diagnosis documentation? Or can we obtain more details for the diagnosis from the hospital record? Could you point me to some written guidelines to help with our diagnosis documentation?

Stereotactic core breast biopsy using tomosynthesis

When the physician is performing a core breast biopsy using stereotactic guidance with the Affirm system tomosynthesis guidance, would we report unlisted code 19499? Or should we report codes 19081 and 77061?

Ultrasound-Guided Muscle Injection

I am wondering how we report the physician portion of an ultrasound-guided hip muscle injection. There is no mention of trigger point injection or tendon injection; it's specific to "left lateral hip muscle injection" for pain management. We were wondering about code 96372. However, that's a part A service only and not billable by the physician. Can you please direct me to the correct CPT code to use for this procedure?

Bilateral Renal Stents

If the physician places a stent in both the right and left renal arteries (he also did the angiography prior to stent placement), would I report codes 36252 and 37236-50? Or codes 36252, 37236, and 37237?

GI Bleed

If a patient is brought to the IR department for an active bleed due to trauma or a GI bleed, occasionally the physician won't see active bleeding or extravasation, but will embolize the artery that was seen on the CTA bleeding. Can we still use code 37244? I know a lot of times, especially with GI bleeds, the bleeding will wax and wane.

Myelogram 62304 vs Injection 62284 with bending views 72114 and Spinal CT 72132

Provider indicates, "Contrast is introduced into thecal sac and oblique views are obtained. Please see post myelogram CT for further details." I would report code 62284 based on the above documentation along with 72132 for the CT with contrast. However, bending views were performed. Do I bill code 72114 in this case with the above codes since we cannot bill for the full myelogram? Or if bending views are performed, does this mean we should bill for the lumbar myelogram 62304 with CT 72132? I don't think this matters either way, but my inquiry is for facility coding.

ABSORB Scaffold

We are getting ready to implant ABSORB product. Per the rep, "Absorb is not a stent, so you need to differentiate what is different between drug-eluding stents and the Bioresorbable Vascular Scaffold." If this is not a stent, how should we code it (CPT and ICD-10)? Any suggestions would be appreciated.

Cooling Catheter

I saw in your forum that code 36556 should not be used for a cooling catheter, but my physician states that he was told when hypothermia is being induced via catheter he should bill 36556 for catheter insertion, even though this is an insertion of non-tunneled centrally inserted CVC for patients age 5 years and older, and also bill 77001 for fluro. Please help.

Ultrasound Guidance during RHC

I have a physician who is wanting to charge for ultrasound guidance for sheath placement during a RHC. The code is 76937, but it is an add-on code, and 93451 is not an appropriate add-on code. Can you help me with if he can charge for this and how you would bill it? I have an example of what he is doing: “PROCEDURE: 1) Ultrasound-guided percutaneous right internal jugular venous insertion of a 7 French sheath after routine prep and drape and Lidocaine anesthesia. Insertion of the sheath was performed using a micropuncture needle and modified Seldinger technique under direct visualization of the needle entering the right internal jugular using ultrasound guidance. A representative ultrasound image is being stored in the electronic medical record. 2) Right heart catheterization, mixed venous oxygen sampling, cardiac output by Fick and thermodilution, wedge pressure determination using a 7 French balloon tipped Edwards Lifesciences TD catheter.” Any help on how or if he can bill for this would be great. 

New Approach at VT Ablation

We have a new physician starting at our facility who has a different approach for some VT ablations. If he finds that the VT is originating in the ventricle and from the epicardial space, he will ablate both areas. The epicardial space will be access from a pericardiocentesis type of approach, but without the fluid build-up in the pericardial sac, making the access that much more difficult. I am wondering if the charge for this type of approach would be included in code 93654. Is there an additional charge for this more specialized and more specific type of approach for VT ablation?

ICD Upgrade to Biventricular

I need clarification of charging codes. Patient has dual chamber ICD and now needs upgrade to biventricular ICD and requires placement of LV lead. I believe the codes should be 33264-Q0 and 33225. Is this correct? Does code 33225 need a -59 modifier?

Revision Catheter

What code(s) would be appropriate for revision of peritoneal dialysis catheter, open?

Revision of Fistula with Ligation of Tributary

Operative note states: "Fistulogram with angioplasty and revision of fistula with ligation of tributary. The patient has poorly functioning right radiocephalic fistula. Fistulogram was found to have stenosis just distal to the anastomosis up beyond a large tributary. This was angioplasited with 4 x 80 and 6 x 80 balloon, and large tribrutary was then ligated through separate incision. Wire was manipulated using a Bern catheter down into the radial artery. Angioplasty was performed of the stenotic area with good results. A large tributary was located and marked and the vein dissected free from surrounding tissue up to level of the fistula and ligated with 2-0 silk and divided." I am not sure if the ligation of tributary would be reported with code 37607, as it is not the fistula itself. Also, I do not believe this is a revision of the fistula. I am reading this as fistulogram (36147), angioplasty (35476, 75978), and the ligation. There really was no revision of the fistula. Your help is appreciated.

Addition of Slack to RA Lead

Patient with a biventricular ICD had a RV lead dislodged into RA. Patient had RV lead extracted and a new RV lead implanted. A stylette was placed down the RA lead after suture sleeve was freed up, given that slack on RA lead was significantly reduced after manipulation of the device and removal from the pocket. After addtional slack had been placed into the RA lead, suture sleeve was sutured to the underlying fascia, then reconnected to the existing ICD generator as was new RV lead. LV lead was never disconnected." How should this be coded? Will the RA lead be coded as a revision, repositioning, or something else?

-22 Modifier

One of our physicians has been told that using modifer -22 requires two seperate documentations. Can you tell me if a seperate statement on the operative report will suffice, or does there have to be a separate stand-alone document as well in order to use modifer -22? Where can I find some written guidelines on this?

Congenital Heart Defect

If a patient has an ASD closure and is seen once a year, every year, for a routine follow-up visit (standard office visit, EKG, echo), would we still always code them as Q21.1? Or should we be billing the follow-up code Z09 and the personal history code for a corrected cong malformation Z87.74?

AV Dialysis Shunt, ICD-10-CM

I realize that, for purposes of coding CPT procedures, an AV dialysis shunt (fistula or graft) is defined as beginning at the arterial anastomosis and extending to the right atrium. Procedures performed in any of those veins are considered shunt procedures. Based upon that definition I have assumed that problems with those same veins, all the way to the right atrium, would be reported with shunt diagnosis codes in ICD-10-CM. For example: I would use the shunt diagnosis code T82.868A for thrombus of the brachiocephalic vein in one of these patients. However, my auditor would use the regular venous thrombus code I82.290. Who is right, and where does the fistula or graft end and the vein begin for ICD-10 diagnosis coding?

Fluoroscopy

I have a question about the use of code 77001. In your 2016 Interventional Radiology Coding Reference, page 185, example #2, upon the injection of contrast (no mention of fluoroscopy) code 77001 is added. In one of the Q&As from your website (question ID #5789), with use of C-arm you suggest the imaging modality should be mentioned. Bottom line: is contrast injection through the access site/catheter enough to use code 77001?

Repair Right Iliac Artery Aneurysm and Type 1B Endoleak

Am I going down the right path to coding this case with CPT codes 34831 and 34825? I was also considering codes 36246 and 37242. "Aorto-bi-iliac angiogram, open exposure of right common femoral artery, and repair of right iliac artery aneurysm and type 1B endoleak. In 2012, endovascular AAA repair and right iliac artery aneurysm were done. Aneurysm extends down to the bifurcation of the external and internal iliacs with a short neck and graft had pulled up, making a large type 1B endoleak (distal)." I have very little experience with interventional radiology cases, and I am overwhelmed at this point. The case was performed in an Ambulatory Surgery setting.

AV Fistulogram with PTA

"PROCEDURE: Using real-time ultrasound guidance, the left brachial artery was accessed proximal to the anastomosis and fistulography performed from the anastomosis to the right atrium. A catheter was then placed in the brachial artery, and left upper arm arteriography was performed distally to the right hand to evaluate the patient's steal symptoms and identify a possible arterial stenosis. The transposed basilic vein was then accessed towards the anastomosis, and additional fistulography was performed. Based on the imaging findings and presenting symptoms, angioplasty of the proximal AV anastomosis was performed to 6 mm. Post treatment images were obtained, and both sheaths were removed. Pressure was held for hemostasis. Ultrasound was used for vascular access. Hard copies were retained for the patient's file. Sterile ultrasound gel and probe cover were used." What would be the appropriate codes for this procedure? I was considering codes 36147, 36120, 75710, 35475, 75962, and 76937.

Bypass Graft Procedure

"Four-legged Dacron graft was sewn into a patulous opening made in the aorta. The celiac, SMA, and bilateral renal artery origins were each ligated and transected off the aorta, and each attached to one of the limbs of the four-legged Dacron graft." I don't know if it matters, but the next day they are scheduled for EVAR. Would this be reported with code 35631 x 4?

Kissing Balloon Stenting

Can you help with the CPT codes for this scenario? (This is professional billing.) Can I use 92928 two times here, one for the LAD and one for the LC? "1) Left main lesion: An 8Fr guide catheter was positioned at the ostium of the LM........A BMW wire was advanced across the LM lesion and positioned in the LAD. A 2.0x12mm balloon was used to pre-dilate the lesion. A 2.5x15mm Emerge balloon was then used to further predilate the lesion. Two 3.5x23 Alpine drug-eluting stents were then deployed as kissing stents from the left main into the LAD and LCx. Very sluggish flow was observed in the LCx after opening the LM. In the summary of the report, it says "Successful deployment of drug eluting stents to the LM and ostial LAD/LCx . . . ." 

Transhepatic Access

How would you code the transhepatic approach? The report includes: "Attention was first turned to gaining access into the hepatic venous system. Due to known complicated vascular anatomy, decision was made to perform direct stick hepatic vein venogram. Under ultrasound guidance, the middle hepatic vein was accessed using a Chiba 22 gauge,15 cm needle. Contrast was injected filling the right hepatic vein. A nitinol wire was inserted, and the Chiba needle was exchanged for the inner cannula of a 6 French AccuStick catheter. AccuStick catheter was advanced into the middle hepatic vein. Contrast was injected and a venogram was performed. This showed patent middle hepatic vein filling to the right atrium. Decision was made to perform rendezvous procedure through from right IJV access."

Revision and Stenting of Fistula/Same Zone

This patient had a brachiocephalic fistula. Excision of an aneurysm/aneurysmorrhaphy was performed on the "middle portion of the fistula". Stenting was performed for an 80% "outflow stenosis", specifically the axillary vein. The Dr. Z Vascular & Endovascular Surgery Coding Reference states that, if surgical revision is performed on a graft, we should not code angioplasty/stenting within the graft (anastomosis to anastomosis). How do we code when it's a fistula? In the case above, is it okay to code the stent as well as the revision, since the stenting was performed in the axillary vein and the revision was on the brachiocephalic fistula? Are we looking to see if different veins are worked on or for words like "outflow"? Or do you believe we should not code for both a revision and angioplasty/stenting for fistulae when done in the same zone?

Aortic Paravalvular Leak Closure

Can you please tell me if there is a code for aortic paravalvular leak closure with Amplatzer vascular plugs? It's a bioprosthetic valve. I see the code for transcatheter mitral valve repair, but nothing for aortic. I'm assuming I need an unlisted code here?

37242

"The left hepatic artery was catheterized, and diagnostic angiography was performed. One-third of the 5 mCi 99m-Tc-MAA dose was injected into the left hepatic artery. The SMA was then selected, and, using the Progreat microcatheter, the replaced right hepatic artery was selected and diagnostic angiography performed. The other two-thirds of the 5 mCi 99m-Tc-MAA dose was then injected." I reported codes 36247, 36248, and 36245-59, but the reviewer is insisting that code 37242 should also be reported. What do you think?

Axillary Conduit

What code should I use for axillary conduit during endovascular procedure? Unlisted 37799 or 35266?

EP Study - Mapping

I was told by my trainer that if the physician states that "tachycardia cycle lengths" were measured, we could code 93609 mapping, since mapping measures cycle lengths. Can you clarify if this is accurate? I cannot find any documentation of this in my references.

Left heart catheterization for fluid management

Patient was here a week ago and had a LHC/RHC with angiography, and was found to have disease in his circ and is now back for stenting (no new symptoms). Physician did a LHC "to manage fluid status" before he placed the Xience stent. Would this be coded only with C9600-LC? Or would you also submit code 93452? There is a disagreement among our team. Also, does LHC follow the same rules as angiography for repeat serivces? 

Bilateral Access with LE Interventions

Please review and provide coding recommendations. "LC femoral artery cannulated using landmark technique. Bentson wire inserted into the aorta. Aortogram performed showing patent distal aorta, patent common iliac arteries bilaterally, patent external iliac arteries bilaterally, patent common femoral arteries bilaterally, no evidence of stenosis profunda femoris arteries. Right common iliac artery orifice selected. Angiogram performed of right lower extremity selectively showing an area of stenosis in distal SFA, chronic total occl of the popliteal artery w/ calcified plaque at that location & chronic total occl of the tibial/peroneal trunk with 90% stenosis of peroneal arteries. Peroneal artery was the dominant artery runoff to the foot with reconstitution distally of the posterior tibial artery. 6 French sheath, 55 cm placed in right common femoral arteries. These areas were traversed with a 0.018 wire under fluoroscopic guidance. These areas were balloon angioplastied from proximal to distal using drug-eluting balloon and Sterling non-drug-eluting balloons."

Excision of Venous Aneurysm

"Right arm prepped and draped in the usual sterile fashion. An elliptical incision was made at the base of this large venous aneurysm. Using electrocautery, the soft tissue around it was dissected free, and several small arterials were Bovied for closure. The base of the stalk was mostly fatty tissue with lymph and venous filling. These were controlled with electrocautery and Bovie as well. The aneurysm was excised and then sent to pathology. The wound deficit was extremely superficial and was closed with 2-0 Vicryl pops and 4-0 Moncryl for the skin and Dermabond." I am starting to get excisions of venous aneurysms from two of my doctors pretty often. When it's describe as being in an AVF/AVG, I usually lean toward the revision codes. But, what about this note where there is no mention of an AVF/AVG?

36228

The surgeon did an embolization for a menigioma. He selectively catheterized the right CC, right ICA, right ECA, left CC, left ICA, left ECA, left MMA, left IMAX, and left  accessory meningeal artery. He embolized the left  MMA. Would you code the left MMA, left IMAX, and left  accessory meningeal artery with 36228? Or are the IMAX and accessory meningeal artery bundled?

Charging 93623 with Other Heart Stimulants

According to your cardiology reference book, you can report code 93623 for inducing or suppressing an arrhythmia using drugs isoproterenol, epinephrine, procainamide, dobutamine, and adenosine. A report that I reviewed this morning used aminophylline to induce the arrhythmia. Is that or other stimulants like caffeine acceptable when coding 93623?

93621

If you pace the left side from the coronary sinus (CS) and not directly from the left atrium, can you still report code 93621? "A 7 French sheath and a 6 French sheath were placed the left femoral vein using the modified Seldinger technique. An 8 French sheath and two 6 French sheaths were placed in the right femoral vein using the modified Seldinger technique. Multipolar catheters were advanced to the high right atrium, His bundle recording position, the RV apex. A live-wire deflectable catheter was advanced into the CS. CS electrograms were recorded, and the catheter was subsequently used for left atrial recordings and evaluation. Programmed and incremental stimulation was performed in the atrium and ventricle at two times the diastolic threshold in the baseline state. Various diagnostic maneuvers were performed. AVNRT was diagnosed. An 8 French large curve 5 mm tip ablation catheter was advanced via the right femoral vein and positioned in the triangle of Koch posterior to the His at the level of the CS os."

Attempted Lower Leg Intervention

We treat in patients with severe PDA. Lately a few cases the physician has had failed attempts for access. These patients have had a previous angiogram and were scheduled to come back to have an intervention performed on the lower leg. Unfortunately the physician was unable to gain access. The patients were given sedation. The only purpose for being in the procedure room was to have the intervention performed. The question is, do you code (charge) this as an attempted intervention (37224-74)? The current practice at this facility is to charge only for the supplies. I believe I have read that if the patient was brought into the lab for the intent to do the angioplasty and was given sedation the -74 modifier could be used. Can you clarify when to use modifier -74 (especially for this particular scenario)? Is there specific documentation to explain when it is appropriate to use in cath and IR procedures?

EMBO

"PROCEDURE: The left axillary lymphatic malformation was examined with ultrasound and a suitable access site for needle placement was identified and the skin marked. The left axilla was prepared and draped in the usual sterile fashion. Using ultrasound guidance the first site (site #1) in the deep aspect of the axillary region was accessed with a trocar 6.3 French Dawson-Mueller pigtail drain. Next, using ultrasound guidance, the second, more superficial site (segment #2) was accessed with a trocar 6.3 French Dawson-Mueller pigtail drain. Finally, a superficial collection (site #3) was accessed with a 21-gauge micropuncture needle through which direct injection of 2 mL of doxycycline was performed. The predominant injection solution composed of a 4:1 dilution of doxycycline (10 mg/mL):Omnipaque 300 was injected under ultrasound and fluoroscopic guidance, according to the following outline: A total of 160 mg doxycycline in 16 mL saline was injected."

Q0 modifier with certain payers

Recently our hospital has been having denials from commercial payers, Medicaid, and Medicare HMOs on ICD implants placed for cardiomyopathy where a -Q0 modifier was added. Our billing department has requested that we only add -Q0, when indicated, to straight up Medicare payments only. Could you please tell me if -Q0 modifiers should be added to commercial payers, Medicaid, and Medicare HMO payers as well when placed for cardiomyopathy? And, would a -Q0 modifier be necessary when Medicare is secondary insurance?

Injection of Sinus Tract with CT Abdomen

Radiologist injected sinus tract with contrast and then scanned the patient's abdomen in CT (74150). Would it be correct to charge the injection code (20501) along with the CT scan? Or would both codes 76080 and 20501 be appropriate? "Non-contrast abdominal CT scan performed prior to and following the injection of the patient's fistulous tract with contrast." The draining wound was cannulated with small Foley catheter to define the tract of the coloncutaneous fistula. Documentation includes location, size, length with detail.

Brachiobasilic Fistula

"Incision was made between the basilic vein and the brachial artery. Dissection was carried down. Basilic vein was identified and mobilized proximally and distally. I then mobilized the brachial artery and anastomosed the basilic vein to the brachial artery in an end-to-side fashion." It says end-to-side, which is similar to 36819, but there are not two incisions, so it points me to code 36821, which is side-to-side. Which is correct? Does the side-to-side or end-to-side have to do with the code choice? What code would you use, and can you explain why you chose the code? 

34812 and billing for it with closure devices

Are these billable using code 34812, or should I be using G0269? "1) An oblique femoral cutdown incision was made. A 6 French sheath was then placed and flushed, and this was replaced with a 10 French Prostar device, which was deployed and the sutures laid out in a radial orientation for later direct femoral arterial repair at the conclusion of the case. Attention was then turned to the right groin. Using ultrasound guidance, the right CFA was accessed, and a wire was advanced up into the aorta under fluoroscopic guidance. An oblique femoral cutdown incision was made, and a 6 French sheath was then placed and flushed. This was replaced with a 10 French Prostar device, which was deployed and the sutures laid out in a radial orientation for later direct femoral arterial repair at the conclusion of the case. 2) The right common femoral artery was cannulated using a 18 gauge needle. An oblique incision was made in the right groin and dissected bluntly down to the anterior wall of the CFA with a hemostat. Two Proglide sutures were then placed in the right CFA for direct repair."

Snaring a Catheter

What code should we use for trying to snare a catheter? "This is a 48 year old male with history of metastatic pancreatic cancer. A Portacath was placed in the right chest approximately three months ago. His Portacath is not working very well during chemotherapy infusions. Portacath study today showed retraction of catheter tip from SVC into right brachiocephalic vein and a full circle turn in the catheter. Contrast sudy of Portacath showed a fibrin sheath around the distal part of catheter, but otherwise no leakage or break in catheter was seen. Using right femoral approach the femoral vein was accessed and a snare was advanced into right brachiocephalic vein. However despite multiple attempts the tip of catheter could not be engaged with the snare. Portacath was left accessed for use the next day."

ERFA with Sclerotherapy

The MD is performing ERFA of the left lesser/greater saphenous vein. There were secondary varicosities involving the left calf and thigh that were treated with ultrasound-guided scleral therapy. Can we report these separately with codes 36475 and 36471?

37184 vs. 37186, Primary vs Secondary Arterial Mechanical Thrombectomy

"A patient has PVD with no pulse in the left leg and goes for a diagnostic angiogram with IVUS of the SFA, popliteal, and proximal tibial vessels. Physician finds extensive thrombus and performs a thrombectomy in the SFA and popliteal arteries, followed by placement of a stent in the popliteal artery, atherectomy and stent in the anterior tibial artery, and atherectomy and angioplasty in the posterior tibial artery." Can you clarify whether we'd use code 37184 or 37185? The reason for the visit was not of a known thrombus; however, once the angiogram/IVUS was performed the treatment was for the thrombectomy, with the other treatments for the additional stenosis in the anterior and posterior tibial arteries. Do you recommend reporting codes 37184, 37185, 37252, 37226, 37231, and 37233? Or do you recommend coding thrombectomy with 37186, 37252, 37226, 37231, and 37233?

92928 and 92937 for the Same Vessel

A patient has stenosis of the proximal LD and is stented via the native LD, and a distal LD stenosis is stented via a saphenous vein bypass graft. Should you report both codes 92928-LD and 92937-LD?

32668 and 32507 for Medicare

For add-on codes 32668/32507, AMA's intent for these codes appears to be that they are reported when the intended procedure was therapeutic resection of the lung nodule/mass, but based on intra-op pathology a more extensive resection is needed and then performed, which causes the wedge resection to be "reclassified" as a diagnostic wedge resection (as per CPT Assistant, September 2012). That said, when I read the NCCI Policy Manual, Chapter 5, Section C.19, Medicare appears to be precluding payment for any diagnostic biopsy of the lung from a location that is removed in a more extensive procedure such as a lobectomy during the same encounter. However, CMS has assigned a fee to codes 32668 and 32507 on the MPFS, which seems odd if Medicare policy precludes payment for diagnostic wedge in the same area per NCCI and the only time you can report 32668/32507 is when they precede an anatomic resection in the same lobe/area. Do you know if the guideline in the NCCI Policy Manual is referencing codes 32668 and 32507, or are those exceptions to the rule based on the AMA definition?

21825

Would it be appropriate to bill code 21825 when performing an open heart procedure? Due to bilateral sternal fractures and a significant amount of osteoporosis, each sternal table was repaired with vertical Robicsek weaves using # 7 wires. If reported, what do you look for to determine the reporting of this? If no, please explain why. All the information I have found points to not being able to report the 21825 with the open procedures due to if you created it you must fix it. Any guidance would be appreciated. We have a physician who routinely wants to report this code with bypass procedures.

62284 and CT with Contrast

For the following procedure, should I report codes 62305, 62284, and 72270? Or should I only submit code 62305? "Using fluoroscopic guidance, a 20 gauge needle was directed with a single puncture into the thecal sac until CSF was yielded. Subsequently, 10 cc of Omnipaque 300 contrast agent was instilled intrathecally. Afterwards, the tubing was removed and the stylet replaced. The needle was removed and pressure applied. No complications were evident. Maneuvers to facilitate distribution of intrathecal contrast were performed. The patient did not complain of any lower extremity symptoms. The patient was sent to CT for further scanning. Single fluoroscopic image demonstrated a needle directed towards the thecal sac from an interlaminar paraspinal approach at L4/L5 on the left."

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