Knowledge Base

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Set Descending Direction

Axillary to Axillary Bypass Graft

I just would like some clarification on code 35650. Is this code for when a bypass is done from the right side to the left side? I have a case where he states, "Bilateral axillary arteries were exposed, a tunnel was created in a somewhat curvilinear fashion over the Manubrium, and a 6 mm ringed GORE-TEX was tunneled." It also states that the right-sided anastomosis was completed first, followed by the left side anastomosis. My concern is that the description of code 35650 does not state if left to right, etc. It states, "He then passes the graft around the blockage and sutures it to the other side." It's clear as mud to me. I just want to verify that this is NOT just for unilateral procedure.

AV Fistulogram with Right Atrial Pressures

Is there an additional code (or codes) that should be assigned if an AV fistulogram is performed by the radiologist (36147) and he decides to investigate the patient's hypotension and advances the catheter into the right atrium and transduces right atrial pressures? It was 0 mmHg. He then pulls the catheter back, and his venous pressures were between 0-1 mmHg. 

Tunneled Peritoneal Catheter Exchange

Is there a CPT code for the exchange of a tunneled peritoneal catheter?

Bronchial artery & Pulmonary artery embolizations during the same encounter

The doctor performed a left bronchial artery embolization (arterial access) and left pulmonary artery embolization (venous access). Although these are separate vascular systems and we can code the catheter placements and imaging as such, the question that has come up is whether we can code both of the embolizations or if this is considered one operative site and we should code for only one embolization?

Temporary Ureteral Occlusion

Is it appropriate to use add-on code 50705 for non-permanent ureteral occlusion? "OP: Successful uncomplicated placement of a left modified 10.3 French nephroureteral stent with distal end, intentionally trimmed and occluded as described in detail above. The ureteral segment of this modified nephroureteral stent results in functional left ureteral occlusion by antegrade nephrostogram. The tube is in satisfactory position and placed to gravity drainage... Indication: Severe urethral erosion to the bladder neck with Resulting continuous urinary incontinence preventing the healing of chronic decubitus ulcers." I coded 50434 for conversion of a nephrostomy to a nephroureteral stent via the existing nephrostomy tube tract performed. Modification: utilizing methodology as published by Bush and Mayo in the Journal of Urology Volume 43, Number 5 (May 1994), a 10.3 French Boston Scientific nephroureteral stent was intentionally modified by..

Lower Extremity Imaging

"Right CFA was cannulated, and a 5 French sheath was advanced. Through this, a catheter was advanced to the distal abdominal aorta and angiography was performed, which showed a widely patent distal aorta and common external and internal iliac arteries, femoral arteries, and proximal SFA and profunda femoris arteries. Next an angled taper catheter was advanced to the left SFA after exchange over a wire, and left lower extremity runoff angiography was performed. This showed a relatively focal 95% stenosis of the distal SFA just above the adductor canal with patent popliteal artery and three-vessel runoff to the foot. After a series of catheter exchanges over a wire, a 6 French sheath was advanced to the left SFA and the patient was heparinized. The lesion was crossed with a wire, and the lesion was dilated with 5 and 6 mm balloons yielding dissection requiring stenting. Next a 7 x 80 mm self-expanding stent was deployed and post-dilated with a balloon with 0% residual stenosis and excellent result." Would you use codes 75630/75774 for imaging, or something else?

Radiofrequency Wire Recanalization

"LT brachiocephalic vein catheterization and venography via RT CFV access. Next, the LUE fistula was cannulated and a catheter was then advanced to the left axillary vein and venography performed from LUE access. Venograms demonstrated total occlusion of the left subclavian vein with large and tortuous draining collateral vein. A catheter and hydrophilic wire were then used thru the RT groin sheath in an attempt to negotiate thru the occluded left subclavian vein. A gooseneck snare was advanced thru the LUE catheter in attemtp to capture the wire from above, however this was unsuccessful despite multiple attempts. It was decided to perform radiofrequency wire recanalization. Appropriate grounding pads were placed on the patient's thighs and the radiofrequency wire was advanced thru a catheter from below and recanalization performed in the subclavian/axillary vein junction. The wire was snared with a gooseneck and removed thru the LUE. Balloon catheter was used to perform venoplasty of LT subclavian vein." Are codes 35476, 36147, 36012, 75820, and 75978 correct? Are there additional codes for radiofrequency wire recanalization?

Stent Repair of Hole in Bifemoral Graft

"Patient with history of PVD and aortobifemoral bypass 35 years ago. He presents with a right leg pseudoaneurysm. After brachial cutdown, right limb of graft was accessed and injected, revealing a leak in the graft about 1 1/4 inches from the anastomosis to the common femoral artery. A 38 mm stent was deployed extending slightly into the common femoral. A second 38 mm stent was deployed to overlap the first and to cover the leak into the pseudoaneurysm." I reported codes 37236, 36246, and 75710-XU because the current indication is a leaky graft. However, the auditor says codes 37226 and 75710-XU are correct. Is she correct in using the revascularization code since the original indication for the graft 35 years prior was PVD?

PVI for A-Flutter

If the physician did PVI for A-flutter, do we still charge PVI a-fib or SVT?

Peritoneal Dialysis Injection and Manipulation

"Patient came to IR to have peritoneal dialysis catheter evaluated and manipulated, if needed. The radiologist injected the catheter and found the catheter in a small loculated cavity with no free spill and some adhesions. He used a wire to attempt to break up the adhesions and change the position of the catheter." Would it be appropriate to code this as 49400 and 74190 for the injection and 49999 and 76496 for the manipulation? A fibrinolytic was not used, so I am questioning if codes 49999 and 76496 should be reported for this procedure.

Spinal Angiography

My physician has heard that, when doing spinal angiography, if he were to image the thyrocervical trunk and the costocervical trunk he could use code 75705 for the supervision and interpretation of these vessels. Would this be appropriate during spinal angiography?

Dobutamine Stress Test with cardiac cath procedure

Will you please advise on coding a Dobutamine stress test done during a cardiac cath procedure? MD states it was done to assess for transvalvular gradient and severity of aortic stenosis. Procedure is described as being done with a pigtail advanced across AV into the LV. Initially measured the baseling gradient and then up to 40 mcg of dobutamine was infused. The finding are as follows: "Good contractile reserve in response to dobutamine infusion with improvement in LVEF from 25% to 45% with increasing transaortic gradient from 25 to 49 mmHg at peak dobutamine infusion, suggestive of severe aortic valve stenosis."

33282 and 33284

Patient has SVT with an implanted loop recorder due to unsuccessful ablation and breakthrough SVT on medical treatment with atenolol. He presented for removal of loop recorder due to end of life of the battery with insertion of new loop recorder. Can we bill code 33282 with modifiers -52 and -59 appended, along with code 33284?

Separate Access for LE Endovascular Revascularization

"The patient is brought to the operating suite for recanalization of an occluded left fem-pop bypass graft. A Destination sheath was placed at the left brachial artery and advanced to the distal aorta. The sheath was then directed into the left common iliac artery. Attempts to cross a severe stenosis at the common femoral artery in antegrade fashion were unsuccessful. Under US guidance, access was obtained via the dorsalis pedis artery, and a V18 wire was advanced in retrograde fashion all the way into the common femoral artery crossing the occluded fem-pop graft. The wire was snared and externalized at the left brachial artery, allowing advancement of a NaviCross catheter into the popliteal artery in antegrade fashion. A Pilot 200 wire was advanced into the peroneal artery. Multiple severe lesions at the common iliac, the entire fem-pop graft, and the common femoral artery were treated with balloon inflations." Can the access obtained via the dorsalis pedis be reported separately with code 36140-59? Or does this access also bundle with the intervention?

93623

I am a little confused about when we can report code 93623. I know if they are just checking the efficacy of the ablation it cannot be coded, but I read somewhere that if they are looking for other arrhythmias then the code can be added. If the physician does an ablation and then administers isoprotenolol and notes that "no other inducible arrhythmias were found", would this be good enough documentation to support the separate reporting of code 93623 since they looked for additional arrhythmias?

CT-Guided Wire Localization, Lung Mass

Would you recommend using code 32553 for a 20 gauge hooked localization wire placed into a left lower lobe mass for planned surgical resection?

TAVR Assistant Surgeon

When billing for a TAVR case (i.e., CPT 33361 – TAVR with prosthetic valve; percu femoral artery approach), we have a cardiothoracic surgeon and two interventional cardiologists on the case. Would it be appropriate to report code 33361 with modifier -82 (assistant surgeon) appended if there is no qualified resident available, and there is a statement from the provider for medical necessity for the assistant surgeon for the second interventional cardiologist, in addition to 33361-62 for cardiothoracic surgeon and 33361-62 for the first interventional cardiologist?

Angioplasty for Acute Coronary Artery Thrombus

Please help with the following scenerio: Patient had a diagnostic cath performed, and a thrombus formed as a consequence/complication of the cath in the RCA. Patient then had angioplasty for the acute total occlusion. Since an AngioJet wasn't performed, code 92973 wouldn't be appropriate, would it? Would we just code this to a plasty ? Or would we code it at all?

Aborted Upgrade from RV Lead Pacemaker to CRT-ICD

"The device was freed from the surrounding tissue and brought to the surface. A pocket was modified inferomedially using blunt dissection and electrocautery to accommodate for bigger device. The axillary vein was accessed two (2) times via the modified Byrd technique with the guidewires placed into the right heart. A 9.5 French sheath was placed in the axillary vein. However, the vein was dilated with serial dilators prior to this due to stenosis at the subclavian and brachiocephalic vein junction. The RV lead was advanced into the RA through the 9.5 French sheath with difficulty, as the sheath was kinked. I was not able to advance the RV lead into the RV due to difficulty in torquing the lead, likely due to stenosis in the SVC. At this point we had used almost 55 minutes of fluoroscopy. Hence the procedure was aborted on the right side. The old device and lead were placed into the pocket, and the wound was closed in layers. CONCLUSION: 1) Unsuccessful right-sided CRT-ICD upgrade. Plan for left-sided biventricular ICD upgrade." Codes 33212 and 33233 do not work. Do you have any suggestions?

Septal Dilation After Transseptal Puncture

When performing a full combined congenital right heart catheterization and transseptal left heart catheterization through intact septum (93532), my doctors feel that if the septum is then balloon dilated to allow for the sheath to pass through to get to the left atrium, we should also be able to bill for an atrial septostomy (92992). For example: “Transseptal needle puncture: The atrial septum was punctured with an adult transseptal needle through a 7 French long sheath. Injection of contrast confirmed placement in the left atrium, after which a 5 x 2 Maverick was inflated across the atrial septum, allowing advancement of the long sheath.” The doctor is billing codes 93532 and 92292. I believe the septum balloon dilation would be included in the transseptal puncture in this case, and that we should bill code 93532 only. I would greatly appreciate your input on this.

Cath for Angiogram

I am unsure whether the cath for the right side for the angiogram would be billable. There was intervention on both the right and left sides, but it was through the left access. "The decision to intervene was based on today's study, and there were no prior cath based studies to compare. Percutaneous 5 French RIGHT common femoral artery access. Cannulation of abdominal aorta. Pelvic arteriogram. Percutaneous 6 French LEFT common femoral artery access. 6 mm balloon angioplasty of the LEFT external iliac artery. Cannulation of RIGHT common iliac artery. Recanalization of chronically occluded RIGHT internal iliac artery. Primary balloon angioplasty to 4 mm of the origin of the RIGHT internal iliac artery."

Breast Mass Biopsy

If a patient has a soft tissue mass at a previous mastectomy site, and this soft tissue mass is biopsied, should I report code 20206, 76942, or 19083 for ultrasound-guided biopsy?

Balloon Sweep of Biliary Duct

"A 10 mm x 2 cm Armada balloon was advanced into the biliary system for balloon sweep of both the segments 1 and 3 biliary ducts into the common bile duct." Can we use code 47542 for balloon sweep of biliary duct? Or not code it? This was done at the time of an internal/external biliary drain exchange (not really a dilation, but not 47544 either).

Coronary Angiogram with Lower Extremity IVUS

Selective coronary angiogram and IVUS of bilateral common iliac, external iliac, and common femoral arteries. One access in the right femoral artery. Physician performed coronary angiogram and then catheter from right common femoral artery into descending aorta. IVUS catheter from descending aorta into the common iliac, external iliac, and common femoral. Then crossed over into left common iliac, all the way to the SFA, and pullback from common femoral into the external and common iliacs. Physician gives IVUS interpretation of all vessels. Can we add codes 37252 and 37253 in addition to code 93454? Can we add cath placements as well?

Manual Compression Pseudoaneurysm

"Patient with femoral pseudoaneurysm status post cardiac cath almost 2 months prior. Patient was taken to the cath lab, and manual pressure was applied to right groin area for 20 min." How would this be billed? There is no mention of US guidance. Is this even billable?

Rapid Atrial Pacing During Pacemaker Implant

The patient underwent an implant of a dual chamber pacemaker (33208). The report next states that the patient was in atrial flutter at the time of the lead placement. The ventricular thresholds were measured and were adequate. The atrial sensing thresholds were tested, and the patient was rapidly atrial paced and was converted to sinus rhythm. Are we able to code anything for the rapid atrial pacing? If so, what is the appropriate code?

Sequential Vein Dilation

While placing a dual chamber pacemaker, the patient was found to have significant subclavian vein stenosis via venography. “There was a stenosis of the left subclavian with collateral veins. An incision was made in left deltopectoral groove. Left cephalic vein access with a cutdown technique. The micropuncture wire was unable to be advanced from the cephalic to the subclavian, and would enter different collateral channels. Contrast injection showed wire to be intraluminal. Terumo glidewire was maneuvered across the subclavian stenosis, and using serial dilation with 7, 8, 9, and 10 French dialators, the stenosis was traversed and dilated. Sequentially two 7 French safesheaths were advanced to allow delivery of the leads.” I realize that in this case the venography would likely be considered roadmapping and would not be separately billable. However, could we bill anything for the sequential dilation of the subclavian vein? The physician states that this is a preferable technique (vs. balloon venoplasty). Please advise on appropriate billing in this case.

Stent Placement and Intercoronary Suction Thrombectomy

My question is regarding removal of an intracoronary thrombectomy at time of a stent placement. Biller says it's bundled, I believe there has to be a separate code when it’s a STEMI acute MI. Study performed reads: "Left heart catheterization, left ventriculography, selective coronary angiography, complex percutaneous coronary intervention to right coronary artery involving balloon angioplasty, suction thrombectomy, and intracoronary stent placement." Keyed codes: 93458-XU and C9606-RC.

Three Interventions in LD Distribution

The attending physician performed the following three interventions: PCI of the m D2 using Synergy stent (C9601/92929) PCI of the p-m LAD using Synergy stent (C9600/92928)  PCI of the S1 (LAD septal perforator) with balloon dilation  Is the LAD septal perforator S1 considered a branch of the LAD? And, as such, can it be coded as an additional intervention?

Valve Disease on Echo

When an echo reveals only trace or trivial valve regurgitation, do you apply an ICD-10 code for the regurgitation? Or would this be considered a normal echo? My physician indicates the regurgitation in the body of the echo report, but his impression states unremarkable echo.

PTA Carotid Subclavian Bypass Anastomosis

I am unsure how to code this case of PTA of a bypass graft. What do you think of reporting codes 75710-XU, 36215-LT, 36222-LT, 75962, and 35475-LT? Or should I ignore the carotid since it was the bypass that was selected? "DESCRIPTION OF PROCEDURE: The patient was taken to the angiography suite. We accessed the left brachial artery. We did access the common carotid to the subclavian bypass. We did upper extremity arteriogram, a left carotid arteriogram, and then we did an angioplasty of the proximal anastomosis. FINDINGS: LEFT CAROTID ARTERIOGRAM: The previously placed left carotid stent at the origin is patent. The distal carotid stent is patent. There was a high-grade stenosis of the proximal anastomosis of the carotid subclavian bypass. LEFT UPPER EXTREMITY ARTERIOGRAM: The subclavian and brachial arteries were patent. ANGIOPLASTY OF PROXIMAL ANASTOMOSIS: An angioplasty was performed of the left carotid to subclavian bypass graft at the proximal anastomosis with a 6 x 4 balloon. Completion arteriogram revealed it was widely patent."

Clarification on Aortograms

I was under the impression that, in order to bill 75625, the physician must document the findings from the renal arteries or visceral arteries on down to the aorto-iliac bifurcation. Now I am not seeing where I got that information. Can you please clarify what all must be visualized and documented in order to bill code 75625? Do the bilateral common femoral arteries need to be mentioned in order to bill code 75630?

75630 vs. G0278 and 75625 with heart cath

Could you please clarify some confusing verbiage from your Diagnostic & Interventional Cardiovascular Coding Reference? Patient is having right and left heart cath (93460) and aortic root angiography for aortic stenosis (93567). Patient also has PVD with diffuse iliofemoral disease, renal artery stenosis, and disease of the distal aorta, so they did an abdominal aortogram and bilateral iliofemoral study from one catheter position in the aorta. Your guidelines state to use code 75630 if there is no catheter repositioning and if it is medical necessity for AAA. Your notes also state not to use 75630, but rather to use codes 75625 and G0278, if done during cath for "screening". Well this isn't a screening, and if it were just a screening with no medical necessity, we wouldn't code it anyway, correct?? So are we using code 75630 since there is medical necessity, even though it's not an AAA, or do we use codes 75625 and G0278?

Placement Bilateral Balloon Cath Prior to c-sect

How would I code for placement of bilateral internal iliac angioplasty non-inflated balloon catheters in preparation for C-section (possible focal placenta accreta), with possible inflation later by OB physician? Contrast and fluoroscopy were utilized.

CAV and CAD of Transplanted Heart

I read somewhere that when a patient has CAD in a heart transplant that it is coded as I25.811. Others have told me that the ICD-10 code should be T86.20, which is a complication code. Can you tell me the difference between the two and what ICD 10 codes are valid for each of these?

LE Revascularization

Is this coded correctly? Can code 36246-XU be reported in this scenario? 75710 59, 37252, 37253 x 3, 37226, 37221, 37222. "1 U/S guide cannulation RT C Femoral A 2 Aortoiliac angiogram 3 LT LE angiogram 4 IVUS pre/post LT C ext. Iliac, c femoral, sfa, popliteal, tpt trunk arteries 5 angioplasty lt sfa 6 stent lt sfa and popliteal 7 stent lt c iliac 8 angioplasty lt external iliac PROC: RT C Femoral A cannulated, sheath placed, cath positioned in infrarenal aorta and aortoiliac angiogram done...stenosis in C Iliac A and bifurcation. Up and over technique, cath positioned in LT C femoral A. LT LE angiogram done. Occluded SFA and Popliteal w. fx stent in P SFA. 1 vessel runoff. Heparinized. Quick cross and wire traversed occluded stents and reenter TPT trunk. angiography. Emboshield. Balloon angioplasty SFA and popliteal. both IVUS. stenosis along SFA. Both Stented and angioplasty. IVUS C. Femoral A, stenosis. Stent and angioplasty to C. Iliac A. Balloon angioplasty entire external Iliac A. IVUS E Iliac A."

93655

If during an ablation an arrhythmia is terminated, but later the same arrhythmia recurred in the same location and requires mapping and ablation, can code 93655 be billed? Or is this arrhythmia inclusive to the primary ablation?

Angiogram and Liver Embolization

Is this enough documentation to support coding 37243, 36247, 75726-26-XU, 75774-26-XU, and 96420 (facility only)? "Via left common femoral artery access, a selective celiac arteriogram to the portal venous phase demonstrated the hepatic artery origin from the celiac axis and absence of a replaced right hepatic artery and patent portal vein. Selective right hepatic arteriogram shows tumor blushes in the inferior right hepatic lobe and the hepatic dome, both originating from branches of the right hepatic artery. Chemoembolization utilizing mitomycin, pva, ethiodol, saline, and contrast was administered through the catheter into the right hepatic artery."

Redo fem exposure of prior bypass

How do you code redo fem exposure of prior bypass (35656, +35700, or 35883)? "Skin incision of left limb of a previous aortobifemoral bypass graft was isolated. An incision was then made in left medial calf, exposing the b/k popliteal artery. A subsartorial tunnel created between the incisions, through which a Propaten PTFE graft was passed. Vas clamps applied to the left limb of the aortofemoral graft. A portion of the graft was excised. The fem-pop bypass graft cut on a bevel, and an end-to-side anastomosis was created using 5-0 Prolene. Upon venting the artery, the vascular graft was occluded, and flow was restored into the patient's native circulation. Attention was directed distally. Vas clamps were applied. An arteriotomy was made. The popliteal artery was partially calcified, extensively atherosclerotic, and smallish in caliber. The graft was cut on a bevel. An end-to-side anastomosis created. Prior to completion of the anastomosis, the graft was flushed and the artery was back bled."

Vascular Femoral Artery Compression Screening

Recently we started getting reports from our hospital-based cardiology group for "Vascular Femoral Artery Compression Screening". The hospital is billing code 93971 for this procedure, but I'm not sure if that is the correct code. We are billing for the cardiology reading only. Here is an example of the report: "The femoral vein was three times larger than the femoral artery, and it did not expand with cough. The meaning of these findings showed that the patient had borderline fluid overload with possibility of pulmonary hypertension." Is 93971-26 the correct code for this?

Modifier 78 vs. 79

Which modifier is more appropriate (-78 or -79) during a 90-day global period for dialysis procedures? Example: During initial visit patient's graft is thrombosed, and there is also a venous stenosis (36870, 35476, 75978). Patient returns several weeks later, and there is a recurrent stenosis (35476, 75978). Would you use modifier -78 or -79 on code 35476?

75710, 37221

"Abdominal aortogram with left lower extremity runoff. Cannulation of left radial artery using # 6 French slender sheath. Placement of a pigtail catheter in the abdominal aorta and performance of the left lower extremity runoff. Percutaneous transluminal angioplasty and intravascular stent placement in the left common iliac and external iliac artery. Selective left lower extremity angiography. Placement of a terumo band for closure of the left radial artery." What do you suggest we code? 

Sano Shunt Takedown

I have a question in regards to the Sano shunt takedown. One of our providers, who is very much dedicated to coding and reimbursement, has instructed us to bill code 33924 for the Sano shunt takedown. I am confused because the description of CPT code 33924 is the takedown of a systemic-to-pulmonary artery shunt, and the Sano is a RV-to-PA shunt. Is this correct? If not, what code would you recommend for the Sano shunt takedown?

Angioplasty of Subclavian Vein and SVC CTO's During Pacemaker Upgrade

"Patient came in for a dual pacemaker to biventricular upgrade. After accessing the subclavian vein, a distal CTO was encountered and angioplasty was performed. The same thing happened in the superior vena cava. They were then able to successfully upgrade this patient's dual pacemaker to a biventricular pacemaker, using the patient's prior leads and inserting an LV lead and new generator." For the pacemaker portion we are charging codes 33229 and 33225. Can you charge anything for the angioplasty of the subclavian vein and superior vena cava CTO lesions?

Congenital heart cath with angiogram of the brachiocephalic

Should the following congenital heart cath be coded 93533 and 93567? Or 93531 and 36221? Would we need more documentation of the specific vessels visualized to submit code 36221? "Patient has a history of a large VSD, a PDA, LAD coronary artery to RV fistula. A catheter was advanced to the right heart, and a pressure and saturation sweep was performed. The Wedge catheter was also advanced across the atrial septum to the left lower pulmonary vein where pressures and saturations were recorded. A careful pullback from the LV to the descending aorta was performed using a Pigtail catheter. The catheter was placed in the aorta, and two angiograms were performed in the aortic root. Aortic Root: Two angiograms via the Pigtail catheter demonstrate the aortic root and left arch with normal brachiocephalic branching pattern. Both angiograms demonstrate the coronary artery branching patterns, without specific evidence of coronary artery fistula."

Bedside TQ Placement

An ICU patient needed a temporary Quinton placed for CVVHD and was too unstable to travel. The radiologist performed this procedure bedside, utilizing the cath lab staff, supplies, and ultrasound (properly documented). We feel that codes 36556 and 76937 are the appropriate charges for this procedure. However, our manager (who came from a different hospital system) is telling us that charging for this procedure is fraud because it is built into the ICU room charge. Can you help clarify what is appropriate to charge for these bedside procedures?

Removal of venous component of thrombosed upper extremity HeRO graft

"One of our patients had a thrombosed HeRO graft of the left internal jugular. The procedure started with removal of the venous component by our vascular surgeon. It was replaced with 16 French peel-away sheath. The interventional radiologist then tunneled a hemodialysis catheter from the left anterior chest wall to the left neck incison. The tip was positioned in the superior vena cava under fluoroscopic guidance. Catheter was then flushed and secured to the skin." Is this a co-surgery, and what code should we use? Or are there two separate codes, one for the vascular surgeon's removal and one for the interventional radiologist's placement of a tunneled left internal jugular hemodialysis catheter? And what would those codes be?

Transtelephonic Rhythm Strip Pacemaker Evaluation

We bill codes 93294 and 93296 for remote pacemaker interrogation along with codes 93295 and 93296 for remote ICD interrogation. Is there a tech charge that should be billed with 93293 for transtelephonic rhythm strip evaluation?

Stent Spanning the Lower Abdominal Aorta

I'm not sure the codes the physician is advising us to use are correct. He advises codes 37220-50 and 37236 for aortic stent. Code 37220 seems okay, but I'm unsure of the stenting code he has chosen. Your opinion would be greatly appreciated. Here is the dictation: "With great difficulty, angiographic catheter was maneuvered from each groin through the high-grade at lower abdominal aortic stenoses. Kissing balloon dilation was performed, dilating the lower aorta and proximal common iliac arteries bilaterally. A 40 x 12 mm stent was then deployed spanning the lower abdominal aorta. Completion angiography was then performed. Angio-Seal closure of each groin was performed after fluoroscopy revealed normal appearance of the distal common femoral arteries bilaterally."

Inquiry from the 2016 Updates Webinar re: IVUS, slides 64, 65 and 66

We need clarification for a MD, Slide 65 states, “Codes are per vessel imaged however only 1 code is reported for multiple contiguous vessel lesions (DVT eval from POP vein to IVC is reported as one IVUS)”. Slide 66, IVUS Case 71, states, “Venography shows DVT throughout the LE veins. Thrombectomy performed. IVUS of entire venous system on the LT from POP to IVC with findings described.” Coding indicated 37252 as the only IVUS code, no add-on code 37253. Our question: Is the IVUS only coded once IF a contiguous lesion is found crossing the vessels? Otherwise, if no lesion is identified, or separate lesions documented in the separate named vessels then each vessel is coded individually (initial vessel 37252 plus each additional vessel studied with 37253?) Ex: If the MD uses IVUS to view the TP tr, POP and SFA, documents findings in each vessel as separate lesions in each named vessel, would this be reported as 37252, 37253, 37253-59, although they are contiguous vessels? Since there is not a contiguous lesion documented can the IVUS be reported per vessel?

Retrograde Ureteral Stent Conduit

Do I report unlisted 53899 code for a ureteral stent placement via the ileal conduit?

Brachial Cutdown Not Involving AAA Repair

I have used code 34834 for a brachial artery cutdown for AAA repair. Can you please advise on what CPT code should be reported for cutdown of brachial artery for repair of SFA aneurysm with a VIABAHN stent?

Repositioning an Implantable LVAD

How would you code repositioning an implantable LVAD on a subsequent day? If unlisted, what do you feel is comparable (33393 for repositioning percutaneous VAD doesn't seem to reflect the complexity to me)? "I opened up her previous subxiphoid incision, exposed the actual outflow portion of the pump, and extended this to her inferior sternal and took out two sternal wires. I took out the previously placed external bolsters and repositioned the pump, and there was no change in her degree of pump malfunction. I did elect to cut the entirety of the bend relief around this pump site to relieve any potential kinking, and as soon as I did this and spread the xiphoid, her pump started functioning appropriately again. At this point, having repositioned this multiple times, I elected to make a small laparotomy to allow the pump to sit intraperitoneal, as well as the driveline, and at this point, I thought it best to also reapply the coupling device, which I did."

Periorbital Cystic Hygroma

I am wanting to code the below example with just code 37242. Is that correct? "Ultrasound evaluation of the right periorbital cystic hygroma was performed, and a permanent recording of the ultrasound image was saved to the patient`s medical record. Using sterile technique and under ultrasound guidance, a 19 gauge butterfly needle was inserted within the cystic hygroma. 3 cc of 3% Sotradecol solution were injected within the cystic hygroma. The Sotradecol was allowed to sit for approximately 10 minutes and was then aspirated from the hygroma. 3 cc of a mixture of doxycycline and contrast were then instilled within the cystic hygroma. This mixture contained 100 mg of doxycycline. Butterfly needle was removed and hemostasis obtained with manual compression."

Angio of the Deep Circumflex Artery

Recently I have come across two cases in which they accessed the deep circumflex iliac artery for an angiography: one case for a possible endo leak and the other was for a evaluation of the branch vessels directed towards the right paraspinous and retroperitoneal soft tissues. In both cases they were looking at the L4. For these types of cases what angio code would you recommend? 75705?

Occlusion of Enterocutaneous Fistula Track

"Under fluoroscopic guidance, access was obtained to the patient's fistula tract. The catheter was then placed within the bowel, and contrast injection confirmed position of the catheter within the bowel. Following this, flossing of the fistula tract was carried out. Following this, a bio design enterocutaneous fistula plug was introduced into the colon at the site of the fistula with the distal end of the device deployed within bowel in the plug traversing the fistula tract." Are codes 20500 and 76080 appropriate?

Epidural Injection with CT Guidance

I see CT-guided epidural injections all the time. In another question regarding fluoro-guided epidural injections, you quoted CMS in saying, “After considering comments received, we are finalizing CPT codes 62310, 62311, 62318, and 62319 as potentially misvalued, finalizing the proposed RVUs for these services, and prohibiting separate billing of image guidance in conjunction with these services.” I noticed it just says image guidance and does not specify what kind. Our pain management coder is telling me that only fluoro guidance is bundled, but that CT guidance is separately reportable. Is that true?

Peripheral Coding

Can you please clarify the appropriate CPT codes for these procedures? 1) Selective catheter placement in third order with selective placement in the left brachial, axillary, subclavian, and aorta with DSA imaging via left radial artery access. 2) Selective separate catheter placement in additional second order via right radial artery access in the right brachiocephalic and subclavian artery and DSA imaging. 3) Successful PTA and 8.0 x 37 and overlapping 8.0 x 57 stent to the left subclavian artery. 4) Successful PTA and 5.0 x 40 mm stent of the left brachial into the axillary artery in second arterial territory. 5) Thoracic aortogram.

Balloon Pericardiotomy

What code would you suggest for percutaneous balloon pericardiotomy?

Atherectomy in the Medial Plantar Artery

Can I code for atherectomy/PTA of the medial plantar artery? I know the medial plantar artery is a continuation of the posterior tibial artery. Is it appropriate to assign it code 37229?

Repositioning of Biliary Catheter

Would you just code the cholangiogram (47531) and/or repositioning of biliary drain (47999)? "Procedure: Initial cholangiogram demonstrates contrast opacification of the duodenum with no significant intrahepatic biliary tree opacification. It was therefore decided to reposition the biliary drain catheter proximally. The catheter was pulled back with the tip at the level just distal to the biliary stent. Contrast opacification of the nondilated intrahepatic biliary ducts noted. There is no evidence of contrast leak. Catheter was then sutured to skin. Impression: Cholangiogram performed via existing biliary drainage catheter with repositioning of the catheter as above."

Multiple Liver Biopsies

If a physician performs a percutaneous liver biopsy on the left and right lobe of the liver under ultrasound guidance, can we bill for both biopsies (47000 x 2)? Or is it still considered one surgical site and only one biopsy is allowed during the procedure? If the reason for each biopsy in the left and right lobe is done for different diagnosis, could both biopsies be billed then?

Aborted Endovenous Laser Vein Abalation

We treat patients with great saphenous vein reflux on ultrasound with endovenous laser vein abalation. Lately a few cases the physician has had failed attempts for the wire after access to the vein. "With ultrasound guidance, attempts were made to cannulate the great saphenous vein below the knee and at the level of the knee and slightly above. Ultrasound indicated that the needle was in the vein, and the wire would not pass. The size of the vessel indicated that there is reflux, but unable to pass wire. After adequate amount of time trying, I elected to terminate the procedure." Patient declined any lidocaine for needle access, but the venous laser sterile procedure pack had been opened. Can we charge code 36478-74? If not, can we charge for the ultrasound (76937) and supplies( A4649)? Not sure if the HCPCS code is correct.

Resection venous malformations left forefoot

I was unable to find a code for resection venous malformations left forefoot, so I was considering to use unlisted code 37799. Would that be appropriate? Please help. "Complex venous malformation overlying the 1st metatarsal head. This is resected with tributary ligation at all points possible. There is no arterial component to the venous malformation. After an appropriate timeout procedure, the left foot was evaluated. A 4 cm long longitudinal skin incision was created over the dorsomedial aspect of the 1st metatarsal head down through the center of the region of venous malformation. A tedious dissection was carried through the subcuticular and subdermal tissues and very irregular, friable venous anatomy was carefully teased out of the trabecular tissue. The veins were traced back to normalization proximally, bilaterally, and distally, and feeding/draining branches were ligated with 4-0 silk ties. Dissection of the venous malformation at the medial and plantar aspect was more difficult as the venous dilations were more intimately intertwined with the trabecular connective tissue of the fat pad."

Attempted Thrombectomy

Would you bill the attempted thrombectomy with a modifier -53 or not at all pn the below scenarios? "First patient -I passed the 0.014 wire beyond the area and I used a 4-French Fogarty thrombectomy over the wire to try to do a thrombectomy. We did not extract anything. FINDINGS: Distal SFA and proximal popliteal thrombosis and restenosis, Second Patient -. Next, we removed the Impella catheter Left femoral artery Impella catheter removal and allowed the arteries to back bleed. no thrombus came out, so I used a #4 Fogarty catheter just to path it and make sure there was no thrombus lodged, and nothing came out. FINDINGS: Adequate arterial flow to the foot, no thrombosis of the iliac or femoral arteries, left thigh and calf muscles not responding to electrocautery; however, not grossly necrotic at this point."

Left-Sided Lead, Documentation

My question hinges upon the use of the phrase “left-sided lead”. "Indications: Infected pacemaker with need for AV nodal pacing backup AV sequential pacemaker was inserted in the right subclavian area with leads to the RT atrium and RT ventricle, next.... The left subclavian area then was exposed. After local, the preexisting pacemaker was explanted. Cultures were obtained. The preexisting left-sided lead had traction applied, and it was explanted easily. The pocket was then irrigated. The necrotic tissue was excised.” I coded 33233, 33208, then the lead removal with 33235, believing that a “left-sided lead” referred to a lead to the left ventricle, and thus a dual or multi-chamber device. Some think that code 33234 should be used, which would indicate a single chamber device. No other leads are removed or capped. Does “left-sided lead” always refer to a lead to the left ventricle, or can it refer to any lead implanted in the left chest?

Dual PPM upgrade to BiV PPM with LV port capped

Can you please provide the correct CPT codes for this procedure? "Planned upgrade of her existing dual chamber pacemaker to a biventricular pacemaker to prevent pacemaker mediated cardiomyopathy. An incision was made over the existing pulse generator and carried down to the pocket itself. The device was carefully removed. We then began working on left ventricular lead placement. We then spent the next hour and a half trying to engage this vessel using Whisper wire. It appeared the vessel had an anterior and directly inferior takeoff after tortuosity in the coronary sinus. After unsuccessful cannulation of this vessel, we decided to upgrade her existing pulse generator can to a biventricular pacemaker can and refer to CT surgery for an epicardial lead placement. The RV lead was quickly swapped over to the new device. Following this, the atrial lead was switched over and left ventricular lead port was capped. This was an uncomplicated yet unsuccessful attempt at an upgrade of an existing dual chamber pacemaker to biventricular pacemaker."

Denver Shunt Stripping

We have physicians wanting to bill code 36595 for stripping of the venous limb of a Denver shunt. Do you agree with this?

Pulling peritoneal catheter out - no incision

When a peritoneal dialysis catheter is removed only by pulling it out (no incision made), do you recommend submitting any CPT codes for that? "We then also applied gentle traction on his peritoneal dialysis catheter, and it released the two cuffs. A dressing was placed over the site, and the patient tolerated the procedure well."

EKG's performed in office & hospital need 25 mod with an E/M code?

We are discussing this in our office. When an EKG is done the same day as an office visit or hospital E/M level, do we need to add the -25 modifier to the E/M code? 

37236 vs. 34900 for Iliac Aneurysm

The physician placed an I cast covered stent and a Fluency Plus covered stent in the iliac artery for an aneurysm. Would this be reported with code 34900? And is a covered stent considered an endovascular graft?

TOF with PA and a transannular patch repair is done

Patient has tetralogy of Fallot with pulmonary atresia and has a transannular patch repair done. CPT code 33694 is for a patient who has TOF without pulmonary atresia. Would you recommend reporting code 33694 for this case, or would you go the unlisted route?

0281T Co-Surgeons Modifier Not Allowed

For Watchman procedure 0281T, modifier -62 is not allowed per our coding software. If two providers state they are co-surgeons, can this code be billed as 0281T without any co-surgeon modifier?

Drainage seroma spinal fixation hardware and sclerosis

What do you recommend for the following? "Under ultrasound guidance a 5 French Yueh was utilized to access the collection. An Amplatz 0.035 wire was introduced via the yueh needle and after dilatation with a 6 French dilator, an 8 French 35 cm length skater drain was placed and then sutured into place with 2-0 silk suture. After the drain was placed approximately 270 cc of dark yellow serous fluid was aspirated from the collection. Betadine was then introduced into the collection and the patient was scanned with CT. The Betadine was then aspirated and the cavity irrigated with normal saline. Then 20 cc of 2% lidocaine were introduced into the cavity for local anesthetic, prior to the subsequent sclerosis of the cavity with 60 cc of ethanol. The three-way stopcock was turned off to the patient allowing the ethanol to remain in situ for 30 minutes with the patient changing orientation every 10 minutes to allow uniform distribution of the sclerosant. The ethanol was then aspirated."

Intravascular Ultrasound

I was wondering if you have to bill intravascular ultrasound with code 36005, 36200, and 36245. We have a provider that billed codes 93454, 36225, 37252, and 37253, and we received a denial on codes 37252 and 37253 because we didn't have a primary code.

92941 vs. 92943

I need help determining the different documentation needs of codes 92941 and 9294.. Providers are clearly documenting the total occlusion when doing the stents, but not that the occlusion is chronic or acute. Sometimes there is an MI within the previous 4 weeks, and sometimes no MI is involved. I want to give appropriate feedback to providers of documentation needs to appropriately code these procedures.

Separate Access 36000

Would it be appropriate to report code 36000 in addition to 36569 in this scenario? "Utilizing ultrasound guidance, a 21 gauge micropuncture needle was advanced into the right arm vein. Through the needle, a 0.018 wire was placed. Over the wire, a peel-away introducer sheath was placed. Some resistance was felt in passing the wire centrally, and small contrast injection was performed, which demonstrated extravasation. A second micropuncture access of a right arm vein was performed. A 018 wire was passed, and a peel-away sheath was placed. Through the sheath, a 4 French, 41 cm double-lumen PICC line was advanced to the SVC/RA junction."

93228 vs. 93272

Will the monitor type determine the correct CPT code to bill? For example, would monitor type (LifeWatch ACT-3-Lead MCT) be considered code 93228 for the interpretation? Or is it 93272? I have confusion as to when to code as an event vs. an ACT.

Open thrombectomy AVF with open angioplasty/stent venous anastomosis

Which code(s) would you recommend for an open thrombectomy of right upper arm AV graft with an open angioplasty and stent placement for a tight stenosis at the venous outflow? "Patient had near complete thrombosis of AVG. A graftotomy was performed, and a Fogarty was used for thrombectomy of the arterial and venous limbs. A fistulogram was then performed, which demonstrated tight stenosis at the venous anastomosis. The stenosis was treated with balloon angioplasty and subsequent stent placement. Graftotomy was then repaired and wound closed in layers." Can we assign both codes 37238 and 36831? There is an NCCI edit that says code 36831 is a component of code 37238. Is thrombectomy included in code 37238?

Thrombectomy

"After attempted percutaneous thrombectomy, patient was taken to the OR emergently for open thrombectomy. Incision in distal popliteal artery on medial aspect of leg. Fresh clot retrieved from popliteal, anterior tibial, posterior tibial, and peroneal arteries (34203). Good backbleeding obtained from the anterior tibial and popliteal but not in the peroneal. Arteriotomy closed. Doppler signals in the anterior and posterior tibial and peroneal, but none noted in the foot. Diagnostic angiogram (75710-59) showed just before midcalf level anterior tibial artery is occluded, and there is no flow to the foot. Posterior tibial and peroneal not visualized. At this point an incision was made between the 1st and 2nd metatarsal. Small incision was made in the dorsalis pedis artery, and embolectomy catheter was advanced to the popliteal artery. Fair amount of clot in the anterior tibial artery removed and flow obtained. Despite multiple passes no backbleeding was obtained in the dorsalis pedis. Arteriotomy closed and a palpable pulse felt in the dorsalis pedis." Can I bill code 34203-76 since a new incision was made for the dorsalis pedis artery?

Severed radial artery with end-to-end anastomosis

What CPT code for severed radial artery with end-to-end anastomosis? "This patient arrived to hospital following a bow accident. The patient was induced under general endotracheal anesthesia. He was then prepped and draped sterilely following a tourniquet being placed on his right upper arm. In addition, his left lower leg was shaved and prepped and draped as well. A 7 cm incision was made over the radial artery and the radial artery was explored. It was found to be transected and thrombosed proximally and distally along with the radial vein. No major neural structures were found and no foreign bodies were visualized. The radial artery was then freed approximately 3 cm proximally and 3 cm distally to allow approximation of the artery without undue tension. Approximately 1 mm debridement was performed of the radial artery in the proximal and distal section due to necrotic and torn edges. The vessel was then spatulated proximally and distally. Interrupted 7-0 Prolene sutures were then utilized, following embolectomy of the distal segment. Flushing is performed, and the end-to-end anastomosis was completed."

Aneurysmal Bone Cyst Embolization Sclerosis

Please review and advise: "Ultrasound evaluation demonstrated increased cortex overlying the lesion. With a central area of thin cortex. Images were saved to PACS. Under ultrasound and fluoroscopic guidance, two 4 cm, 18-gauge needles were advanced into the lesion, from medial to lateral, criss-crossing into areas of bony lucency. Contrast was injected and digital subtraction imaging was performed. INTEROSSEOUS VENOGRAM FINDINGS: Contrast opacifies a lesion within the right scapula with several internal septations were noted. No venous outflow was observed. There is much less vascularity compared with prior studies. INTRAOSSEOUS ANEURYSMAL BONE CYST TUMOR EMBOLIZATION: 1 mL ethanol was slowly injected to promote thrombosis within the cavity wall. A emulsion of 1 mL ethiodol, 4 mL sotradecol, and 2 mL air was injected under fluoroscopic guidance. After a dwell time of ten minutes, the sotradecol emulsion was aspirated." What are your coding recommendations?

Intraperitoneal Tract Infection

Patient had an intraperitoneal dialysis catheter that became infected and was removed. The subcutaneous tract was also infected and was therefore excised and sent to pathology. What would we code for the excision of the subcutaneous tract?

Knee Arthrogram

I code for a hospital. The patient had an ultrasound-guided injection of contrast pre-arthrogram, plus a limited knee ultrasound. Would the appropriate codes be 27370, 76942, and 76882?

75898 Denial

My provider performed a difficult thrombectomy on a patient during 2015, when 37214 was still being used to code cerebrovascular thrombectomy. "After numerous attempts the thrombus was finally cleared. Two follow-up angiograms were performed to check if the thrombus had been fully cleared." United Healthcare is saying that they are only covering one. Where might we find the documentation to support the billing of this procedure twice that I may use in my second appeal? You mentioned in your webinar that I studied that "follow-up angiography and intra-vascular catheter exchange during thrombolysis are bundled with codes 37211-37214 (do not use 75898 for follow up)“. Codes 37211-37214 were not reported for this procedure. Codes that were included were: 37184, 36224, 36226, 36223, 36228, 36120, 75898 x 2, and 76377.

AAA Repair Open After Failed Percutaneous 34831

I'm not sure if I can code for the attempted endovascular AA repair or if I should code just the open AAA repair 34831. All work was done for the AA repair, but patient had what appeared to be a type 1A endoleak or type III, given the persistent filling of sac. Provider elected to abort the endovascular repair and perform an open AAA repair. Would it be correct to just code for the open repair?

93656 vs. 93653

Doctor did a previous pulmonary vein isolation (93656), and now they are going in for repeat ablation (billing 93656 again). However I thought it should be 93653. The SVC was isolated this time around, but not a pulmonary vein. “No pulmonary vein electrograms were noted in the pulmonary veins or in the posterior wall consistent with prior ablation with a box isolation with the majority of the left atrium with no viable electrograms. Three-dimensional electro-anatomical mapping of the right atrium revealed intact SVC potentials anteriorly. As this is often a cause of non-PV mediated trigger of atrial fibrillation high output pacing did not reveal any phrenic nerve capture radiofrequency ablation was placed at 20 W anteriorly which resulted in disconnection of the SVC."

MRI Perfuson Study

MRI brain perfusion studies are being requested, and the CPT code I see recommended is 76498. The MRI brain with contrast will be imaged; however, the department doesn't feel a brain with contrast should be charged due to the limited amount of brain images taken. We would like to stay away from an unlisted code if possible. What would you recommend for CPT coding of this procedure?

Cath Placement During an Embolization

When performing a CNS coil embolization, is it appropriate to bill for a catheter placement when an injection is not done?

Cone Beam CT

1) Is 76377 billable when done with theresphere planning? 2) This code requires a base radiology code. Is 76380 appropriate? 3) Is the following sufficient documentation? "Cone beam CT with 3D reconstructions were then performed. Post-processing was performed on an independent workstation." Or must the doctor state "concurrent supervision"? 4) Are 76377 and 76380 only billable once per session? 

Assistant Surgery

Are there any neuro-endovascular procedures that allow an assistant surgery?

93975 vs. 93978

Our physicians are documenting the following for an abdominal aorta duplex: "CONCLUSIONS: 1) Mild atherosclerosis of aorta demonstrated, no evidence of stenosis or aneurysm formation. 2) Patent IVC with unremarkable flow. Study Data-Mid abdominal aorta duplex evaluation. Complete study, duplex scan, and Doppler flow study including spectral analysis, color and gray scale imaging. A vascular evaluation was performed. Image quality was good. ARTERY MAPPING: Measurements of the suprarenal aorta, juxtarenal aorta, infrarenal aorta, right common iliac, left common iliac. FINDINGS: There is a mild atherosclerosis." Is the comment on the patency and flow of the IVC along with the comments on the abdominal aorta enough documentation to report this as a 93978? Are we looking for iliac vasculature documentation in order to report 93978? Does the lack of documentation of the iliac vasculature indicate we should report as 93975?

Doppler Studies

During an EP ablation for A-fib, if a provider uses ICE and Doppler, are there any restrictions with regards to coding for 93656, 93662, 93321, and 93325? The provider confirms no full TEE. Per NCCI, there are no bundling issues, but if a full TEE is not performed, are codes 93321 and 93325 billable without the primary 933XX codes? “The ICE catheter was removed from the 9 French sheath, and then deployed through the Agilis sheath for left atrial access. ICE was employed for a careful assessment of the left atrial appendage (imaging at a frequency of 11.5 MHz), during which no thrombus was identified, though 'smoke' was evident. Color flow and pulsed Doppler revealed low flow at the neck of the enlarged left atrial appendage <0.2 meters/second. ICE also was used to generate spatial shells depicting the left atrium and esophageal volume, in addition to the left atrial appendageal volume. The ICE catheter then was removed from the Agilis sheath, and redeployed via the 9 French femoral sheath to the right atrium for subsequent use in monitoring the patient's status.”

ICD-10-CM Question: No Significant Stenosis

What is the appropriate ICD-10-CM code? The patient has stenosis, but he determines it is not significant. Documentation states: "The patient has no significant stenosis in either carotid bifurcation region, clearly less than 50% stenosis with normal peak systolic flow velocities bilaterally." Can the stenosis code be assigned? What would the code be?

Guidance Concerning Minimal Coronary Stenosis % Amenable to PTA or Stenting

Could you provide a link or point me in the right direction to locate CMS guidance on what percentage of a blockage in the coronary artery is considered too small in order for a PTA or stenting to be medically necessary?

S&I with lower angioplasty

"The left femoral artery was accessed under fluroscopic guidance with a micropuncture needle, wire, then sheath. A 4 French sheath was inserted over a wire. A wire, then catheter was inserted into the aorta. An aortoiliac arteriogram was performed. A bilateral lower extremity arteriogram was performed. The right iliac, then common femoral artery was selectively catheterized, and an arteriogram was performed. The right superficial femoral artery was selectively catheterized and angiography performed. Two severe stenoses were identified in the right popliteal artery, in the P1 and P2 segments. An up-and-over 5 French sheath was inserted over the wire into the right superficial femoral artery after 3000 units of intravenous heparin was administered and three minutes allowed to elapse. Balloon angioplasty of the right popliteal artery was performed using a 5 mm cutting balloon." How would you code the S&I: 75630 or 75625, 75716?

Attempted Access for Nephrsotomy Catheter Placement

"Fluoroscopy showed that a right double J ureteral stent was in place. Ultrasound showed that the collecting system was completely collapsed. The cephalad aspect of the stent could be seen. Following this, utilizing both ultrasound and fluoroscopic guidance with multiple oblique projections, attempts were made to enter the collecting system. However, this could not be accomplished, even when the pigtail of the double J stent was directly targeted. Intravenous countrast was administered; however, this resulted in no opacification of the right renal collecting system, whereas there was opacification of the left renal collecting system." Would we use unlisted code 53899 to report this?

Aspiration of Embolic Protection Filter

"An EmboShield filter is placed during a patient's lower extremity atherectomy/angioplasty. Completion angiogram reveals thrombus within the filter. The thrombus is aspirated, and the filter is removed." Is aspiration of an embolic protection filter considered part of the filter insertion and retrieval and therefore not codeable in CPT? Or can the aspiration be coded with 37186?

Pacemaker Quick Look

I have a report for pacemaker interrogation from Medtronic for a quick look. The report says "quick look up" in the left hand upper corner. How do I code this?

Calcaneal Nerve Injection Coding

Can you please advise on how to code the following (Marcaine/Celestone Soluspan) injection? "Ultrasound-guided perineural injection medial calcaneal nerve at the right medial hindfoot."

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