Knowledge Base

Items 1301 to 1400 of 1928 total

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Set Descending Direction

Chemoembolization Mass within Liver

"The right hepatic artery was selected. A single branch of the right hepatic artery was feeding the mass. The branch was totally embolized. The catheter was pulled back with the other branches of the right hepatic artery evaluated and none appeared to feed the mass. The catheter and sheath were removed from the celiac axis. A Simmons catheter over a glidewire; the SMA was selected. Contrast was injected with no evidence for feeding artery from the SMA to the hepatic mass. The catheter and sheath were removed." I was using 37243, 37247, and 75726. Should code 75726 be removed from this case? I was using it since the SMA was selected and imaged after the chemoembolization.

Modifier 22 for Complex Coronary Intervention

Please help me code the following: 1) Coronary angiogram. 2) Angioplasty of distal RCA in-stent restenosis. 3) Angioplasty and stenting of mid RCA. 4) Angioplasty of proximal RCA. Report states this was a complex intervention due to multiple stents in place and a moderate tortuosity of the mid RCA, where the stent had been previously placed. Can modifier -22 be used when the MD has documented the difficulty of the case, such as complex intervention, challenging case with multiple attempts?

Pulmonary Vein Angiography without Heart Cath

How would you code diagnostic pulmonary vein angiography and catheter placement for following pulmonary vein procedures if no heart cath was performed? 1. Left lingula pulmonary vein dilation (35476/75978). 2. Left upper pulmonary vein dilation and stent placement (37238). 3. Right upper pulmonary vein dilation (35476/75978).

LHC, Repeat Coronary Angiogram, Stent, Repeat PTCA

The cardiologist performed a LHC, and an interventional cardiologist performed stent in the LD and RD. In the recovery the patient developed chest pain, which brought him to the cath lab. The interventional cardiologist performed a coronary angiogram and found the RC stent to be patent, but found thrombus on the newly placed LAD stent, which was successfully treated with PTCA. Can we charge for the repeat coronary angiogram for the different physician for change in medical necessity as new chest pain?

Angioplasty of Iliofemoral Venous Bypass

"Aortogram performed (75625) and LLE angiography performed (75710). Patient has iliofemoral venous bypass graft. Stenosis found at distal margin of venous bypass at junction of superficial femoral artery. This was angioplastied. Thrombus was found at blind ending portion at the anastomosis between the iliac limb and bypass vein graft and was treated with AngioJet." How would you code the angioplasty and thrombectomy? Would this be considered arterial or venous?

Coil Embolization and Stenting of Fistula Between Carotid Artery and Internal Jugular

"A patient has a left internal jugular vein to left common carotid artery fistula. A stent was placed in the left jugular vein, spanning the insertion of the fistula into the vein (via a left common femoral vein access). Coil embolization was placed in the distal aspect of the fistula at the jugular communication via the left common carotid artery (by right common femoral access)." Will I be able to report codes 61624 (36223, 75894, and 75898) and 37238 (36011) for the above procedure?

CTO Staging

We have recently started a CTO program. Here's the scenario: Heart cath performed by Physician 1. Physician 1 comes to the conclusion that the lesion present is a CTO. Physician 1 consults Physican 2 about the CTO case. Viability study done. Heart muscle viable. Physician 2 looks at films from recent (within the allowed period of time) heart cath. (Patient has not had a change in status.) Finds that the images don't show the collateral circulation well enough. Physician 2 decides to bring the patient back to re-study the coronary anatomy to fully assess the collateral circulation as staging for future CTO case. What can/do I charge for this encounter?

93567 vs. 36221

Physician states he performed left heart catheterization with coronary angio with grafts, FFR, and aortogram to see left subclavian stent stenosis. Do I use code 93567 since catheter is placed in aortic root, or do I use code 36221 since he is looking at the subclavian stent restenosis? His findings were well documented.

Ganglion Impar Block

You advised to use 64999 to describe ganglion impar sympathetic block. I've been looking at using 64520 for this procedure. If the needle is passed through the sacrococcygeal ligament and placed along the anterior coccyx, or just inside the coccyx with injection outlining the inner aspect of the coccyx, wouldn't 64520 be more appropriate?

Intravascular Foreign Body Retrieval

I've coded the removal of the catheter with 36590, but the MD also reported they punctured the common femoral vein and advanced a 7 French sheath into the IVC and used a snare to remove the broken fragments. Can this be separately coded? If so, what code?

Removal of GI Feeding Tubes

I'm a radiology coder at a large hospital. Can we bill a low level E&M code for the removal of a GI feeding tube that has no CPT code? We will receive orders to remove a feeding tube that was placed by my facility or an outside facility. This is the only procedure that the patient is having done.

Fractional Flow Reserve Study at Time of Heart Catheter

Can I add code 93571 for the following example? "While the patient has left heart catheter, FFR on mid circumflex was done. Adenosine (90 mg/90 ml NS) 140 mcg/kg/min IV was started. Then FFR 185 cm Pressure Wire Prestige Straight was assessed at mid circumflex. Adenosine was discontinued. FFR: 0.92 was documented."

Graft Angioplasty

I have a patient with an aorto-bi-femoral graft with bilateral stenosis at the distal anastomoses. Angioplasty of the right and left limb was done. Would you code for one (37224) or two (37224-50) angioplasties of this graft?

AAA with Aortic Endarterectomy

My physician performed AAA. Can he also code an aortic endarterectomy at the same time? If so, do you use an unlisted code?

2 Intracranial Aneurysm Embolizations

I am confused about coding for intracranial embolization. If the patient has an aneurysm of the anterior communicating artery AND aneurysm of the right internal carotid artery (both treated with coil embolization), do I code 61624, 75894-26 twice? I have instructions that say, "Assign one procedure code regardless of the number of studies per operative field or site. However, multiple pathologies qualify as multiple sites." I know the "head" is one operative field, but I guess my confusion is since it is two separate aneurysms; does this qualify as "multiple pathologies-multiple sites?"

Removal of AV Graft

"Patient had a removal of an AV graft that was painful by taking the graft off the brachial artery just above elbow and suturing it. Incision was then made over the graft in loop-like fashion up the axillary vein, with graft removed from subcutaneous tissue. A large stent was removed as well, which was across the venous anastomosis, then the vein was sutured. Arm was then sutured." I thought 36815 included a revision or a closure, but it has a device-dependent edit. With removal there was no device placed. Is this code correct? If it is correct, how do we get this paid with the device-dependent edit? If not, what would be correct?

Poor Maturing Fistula

I need a little guidance. Patient underwent fistulogram a week ago, and the MD recanalized and angioplastied the cephalic vein. Vein was not matured, and patient returns for repeat fistulogram and balloon maturation of fistula. "Procedure: Left renal cephalic fistula accessed, and micropuncture needle placed into fistula. Fistulogram was performed (36147). Cephalic vein measured 5 mm. It was patent and much improved from previous procedure. The physician angioplastied antecubital fossa to wrist to 7 mm (35476, 75978-26)." Is this correct, and does catheter placement always get coded with the venoplasty?

Esophageal Atresia with Magnet Treatment

We recently performed a pediatric magnet procedure (for children who have esophageal atresia). There is no CPT code yet for this procedure. We charged fluoro room time. Do you have any suggestion as to what CPT code to use for this? Or are you aware that a CPT code exists?

TAVR Evaluation

Could you please help code the following non-coronary IVUS and coronary IVUS performed 2 days prior to TAVR? "Procedures performed: 1) IVUS assessment of ostial RCA lesion. 2) Peripheral angiography. 3) Peripheral IVUS. Prior coronary angiography was completed and revealed a 70% ostial RCA lesion. Access RFA. After angio, a steelcore wire was placed in the descending aorta, and IVUS measurements of the right-sided iliac and femoral vasculature were obtained. A 5 French RIM catheter was used to redirect the steelcore wire into the left iliac artery, and the wire was advanced into the left common femoral artery. IVUS of the left femoral and iliac. Angiographic diameters and IVUS diameters were recorded for the CIA, EIA, and CFA bilaterally." Non-coronary codes: 37250/75945, 37251/75946, 36245, 75630. Coronary IVUS: 93799. Should the peripheral IVUS codes be reported for each vessel on each side (total of 6), or just once on each side? Do you feel first order catheter selection is supported?

CT-Guided Aspiration of Deep Rectovesical Fluid Collection

Pt was scanned in LT decubitus position & a LT parasacral skin entry site was sterilely prepped, draped,local anesthesia infiltrated. Using intermittent CT fluoro guidance, an 18-gauge needle was advanced into rectovesical fluid collection. Was only able to aspirate a small, 2 mL amount of cloudy, old sanguinous material which was submitted for culture purposes. No further material could be aspirated,needle was removed. This catheter is not of sufficient size for drainage catheter placement. A skin entry site medial to RT iliac crest was then sterilely prepped, draped local anesthesia by infiltration additional 7 mL 1% lidocaine. Using intermittent CT fluoro guidance, a 22-gauge needle was advanced into the RT pelvic sidewall cystic area, FNA was performed yielding scant material. Using CT fluoro guidance a 20-gauge needle was advanced into this area & was then able to aspirate 2 mL of clear, amber fluid. All material aspirated from RT pelvic sidewall was submitted for cytology. Please advise as to correct reporting of these services & rationale for same.

Sclerotherapy

What code is used for injection of varithena into the greater saphenous vein for venous insufficiency? Would code 36470 or 37799 be used?

AFX to Treat Aortoiliac Arterial Stenoses

We placed an AFX Endovascular AAA System in a patient with distal abdominal AO stenosis and separate (non-bridging) lesions in the right and left common iliacs. Our question is, would we just code the AO stent placement with 37236, or would we also code 37221-50? The nature of this stenting system is that the main body, as well as the ipsilateral limb and the contralateral limb, are housed together in the same delivery system, but each limb is pulled down and deployed separately. The contralateral limb is on its own wire and crimped to the side of the mainbody delivery system. The wire from the contralateral limb is snared and pulled through and out the other groin access sheath and is pulled down and placed using that wire. We are not sure if this would be considered one stent covering multiple lesions or separate stents covering separate and distinct lesions. The device was placed into the abdominal aorta via the left groin and an Omniplush catheter from the right for catheter placements of 36200, 36200-59 only if we code it just as a 37236 correct?

Cath placement w/ 33210 and 33967

From the right approach a temporary pacemaker wire and intraaortic balloon are placed. From a left approach a limited coronary angiography is performed. Can catheter placement on the right side be billed for this event?

Billing for a Cone CT Scan

When a cerebral angiogram (36224) is done, and a 3D reconstruction is done on an independent workstation (76377), as well as a cone CT to check for a bleed, can the CT scan be billed? if yes, would billing it as a limited (76380) or (70450) be correct ? If a limited CT is done for a non-invasive spinal procedure, would the CT be bundled into the S&I code?

BT Shunt Evaluation Prior to PA Evaluation

A 6-week-old girl with HLHS, interrupted aortic arch type B, and moderate VSD who is status post Norwood, modified BT shunt and DKS presents with concerns for RV dysfunction with moderate tricuspid regurgitation and LPA stenosis on last echo. She presents for diagnostic cath to rull out causes of RV dysfunction and/or possible intervention. A right and left heart cath via existing atrial septal opening (93533-26) was done. Contrast injection of the innominate artery shows a right-sided BT, which is widely patent. The RPA appears to be of good caliber. There is severe long segment stenosis of the LPA with severe hypoplasia distally with normal pulmonary venous return of the left atrium." Is the statement 'rule out causes of RV dysfunction' sufficient documentation to support medical necessity for billing the S&I for the BT shunt (75710-26)? Also, can we bill for the catheter placement in the innominate artery (36215), or would that be bundled in the pulmonary angiography code 93568?

Venogram - Abdominal

"We have a patient who presented to IR for an attempted transvenous esophageal varices sclerotherapy. The portal vein, splenic vein, and superior mesenteric veins are known to be occluded. The access site was the right femoral vein. A draining vein for a splenorenal shunt was selected without success in accessing the varices. Catheter was moved superiorly into the inferior phrenic vein (36012) and venogram performed with no access. Catheter withdrawn to find second vein from the femoral vein without success. Venocavogram was then performed at the level of the kidneys and catheters removed." We have findings for the selective vessels, vena cava, and kidneys. What would we use for our imaging codes? I don't think medical necessity was met for the vena cava imaging, but I also cannot find a code for the visceral venous imaging.

36147

Does code 36147 include selective venography of a collateral vein to assess for surgical turndown option? Or should I use codes 75791, 36011? "Patient has left upper brachial artery to cephalic vein fistula. Lower fistula is punctured and contrast injected, demonstrating decent flow through the fistula which is well-dilated peripherally. There is one focal area of mild narrowing in the mid fistula which is not felt to be flow limiting. There is diffuse stenosis of the cephalic arch with collateral vessels draining to the axillosubclavian veins. Left-sided central veins are widely patent, as is SVC. Next a glidewire is advanced centrally and a sheath placed. A glide catheter was used to selectively catheterize the left arm basilic vein. Diagnostic venogram was performed at the same time that the fistula imaging was performed to assess the feasibility of surgical turndown option. This showed the basilic vein to be a large caliber vessel comparable in diameter to the fistula. It was widely patent through its transition to the axillosubclavian vein."

37220 vs. Nothing for Angioplasty of Iliac to Place Carotid Stent

For the following case, are the angioplasties performed in the iliofemoral billable, or would they be considered bundled into the carotid stent with filter procedure (37215)? "The patient has extensive lower extremity vascular disease. The right femoral artery cannot be accessed percutaneously, and left side is therefore accessed. Severe occlusive disease is present in the iliofemoral segment. Angioplasty was required with a 6 mm balloon of the external iliac and common femoral on the left, allowing placement of 6 French sheath. A 6 mm balloon was dilated to 12 atmosphere pressure of the left external iliac and proximal-mid common femoral. Stenting was not performed. The physician went on to selectively catheterize bilateral common carotids, and left subclavian retrograde for grams, and eventually placed a right carotid artery stent with filter."

CVL with Redo Same Session

If a central line is placed (including a central venogram because of concerns that the left brachiocephalic might be occluded) and able to be placed "with its tip located in the mid superior vena cava even when the catheter was fully inserted. This high location and visualization of a kink in the neck suggested that this access would be problematic. It was felt that another puncture into the left internal jugular vein could be performed from a slightly lower location and using a different angle that would likely be less prone to create a kink in a catheter." So another access in the left jugular was used to replace the central line. Can the first access and venogram be placed in this situation in this situation in addition to the CVL placement or not?

Removal of Non-Infected AVG

I could use your input on the following scenario: The patient has a non-functional AV bovine graft in the left forearm, which our physician ligated and removed to prevent steal phenomenon in a new upper arm fistula, which he created in this same operative session. Normally, I would code for the ligation of the AV graft (37607) and the creation of the new upper arm direct type fistula (36821). Is there another code that could be used for the ligation and removal of the old forearm graft, which was not infected? The ligation was successful, but our physician was concerned that once he created the new AV upper arm fistula the patient would develop a steal phenomenon without removing the old forearm graft.

3D Reconstruction

A 4-vessel cerebral arteriogram was performed on a patient with two aneurysms on two different vessels. 3D spin with reconstruction was performed on each vessel with the aneurysms. Can we bill 76377 for each spin that was done?

Thoracoabdominal Aortic Aneurysm Treatment with Combined Open and Percutaneous Treatments

POSTOPERATIVE DX: Enlarging symptomatic thoracoabdominal aneurysm. PROCEDURE: 1. Left iliac artery to superior mesenteric artery bypass. 2. Left iliac artery to hepatic artery bypass. 3. Endovascular repair of thoracoabdominal aneurysm using Medtronic Valiant thoracic stents x2. IMPLANTS: 1. 12 x 6 bifurcated knitted Dacron graft. 2. Thoracic stent Valiant Medtronic 44 x 44 x 150, proximal main. 3. Valiant thoracic stent 46 x 46 x 100, distal main.

Graft and Native Interventions

We are having difficulty determining whether we should code both C9604-LD for the drug-eluting stent and 92928-LD for the bare metal stent. Can you help? Report follows: "Saphenous vein graft to diagonal was selectively engaged with the left coronary artery bypass graft catheter. A 0.014 filter wire was advanced through mid body lesion of the graft. There is a 90% lesion with what almost looks like a dual tract. After crossing the lesion, a 3 x 12 mm stent was advanced and deployed at high pressure. There is an 80% to 90% lesion in the diagonal below the graft as well. At this point, filter wire was retrieved, and a 0.014 All Star wire was used to cross the diagonal lesions. A 2 x 23 mm Vision mini stent was deployed with no residual stenosis. The patient tolerated the procedure well, and there were no immediate complications. IMPRESSION: Successful drug-eluting stent deployment to mid body of saphenous vein graft and also a bare-metal stent deployment to diagonal downstream."

NCCI Edit for Bilateral tPA

We are receiving denials for bilateral tPA codes 37213 and 37214. We spoke to a customer service rep at Medicare (First Coast Service Options) and were informed that a -50 modifier is appropriate for the initiation of (venous in this particular case) tPA (37212). However, codes 37213 and 37214 may NOT be filed with a -50 modifier, as the second will be denied for MUEs. My question is, if Medicare allows bilateral initiation of tPA, why are the subsequent and final day tPA codes not allowed with a -50 modifier? FCSO also does not allow anatomical modifiers (-RT/-LT). This appears to be a contradiction. To your knowledge, is someone working on this MUE/NCCI edit? We appreciate any insight you have with this issue.

Evaluation for SIRTEX Radioembolization

It's our understanding that if/when a CT angiogram is performed prior to a Y-90 pre-treatment selective catheter study, then the diagnostic angiogram is not separately billable. (That is, unless there is a qualifying reason why another diagnostic study was necessary.) Having said that, when there is no documented reason for another "diagnostic" study and no need for protective embolization during the pre-treatment study, what codes should be reported? The selective catheter placements and MAA injection only?

Placement of Left Ventricular Epicardial Pacemaker Lead and VVI Permanent Pacemaker Generator

I am new to thoracic coding and could use some help. "A small left anterior thoracotomy incision was made, and the chest was entered through the 3rd intercostal space. Pericardium was tented and opened. An area on the lateral side of the left ventricle was identified, and an epicardial pacemaker lead was affixed to the left lateral ventricular surface. Parameters were excellent. The lead was then connected to a VVI permanent pacemaker, and it was placed in a left upper quadrant pacemaker pocket."

32551 vs. 32557

Could you please help with the case below? We have a disagreement regarding which code is appropriate to report (32551 or 32557) and why. I want to assign 32557 since 32551 states it is an open procedure. "After local anesthesia was administered with lidocaine 1%, a 18 gauge coaxial needle was advanced into the air pocket in the left posterior chest wall using CT guidance. A stiff 035 Amplatz wire was advanced into the air collection through the coaxial needle. After the tract was dilated, a 12 French locking pigtail catheter was advanced into the collection. A completion non-contrast CT was performed to evaluate catheter positioning. The catheter was secured to the skin using 2-0 Prolene suture and attached to a Pleur-evac at 20 cm suction. A sterile dressing was applied."

Percutaneous Paravalvular Leak Repair

Is that description automatically a TMVR? Can't this procedure be done on other valves as well?

Device Checks After Device Implantation

Patient has a device (e.g., dual chamber pacemaker) placed on day 1. The next day (before hospital discharge) a device check or reprogramming occurs. Is this device check/reprogramming billable? We have differing opinions on this. Opinion 1: No, it is part of the device implantation and is not separately billable. Opinion 2: Yes, because the CPT Codebook states that you cannot bill device evaluations, etc. “in conjunction with” the device or “at the time of implant”. Because it is the next day, it is neither “in conjunction with” or “at the time of implant” and therefore is billable. Please advise with definitive documentation (if possible) to support, as this both sides feel confident in their positions. I have done searches at HRS and coding websites with no definitive answers.

Stent Graft to Seal an Aneurysm in a Fem-Pop Vein Bypass

This case has really gotten me stumped. My provider used a covered Viabahn stent graft to exclude an aneurysm in a saphenous vein bypass graft from the femoral to the popliteal artery. "A micropuncture wire was advanced into the bypass graft and sheath advanced over the wire. Dilator was removed and an Amplatz superstiff wire placed distally. A 6 French Pinnacle sheath was placed over the wire. Angiographic images confirmed aneurysmal dilation. A 5 x 8 cm balloon was placed and low-inflation dilation performed. We then placed a 5 x 15 cm self-expanding Viabahn covered stent graft. A 5 x 12 cm balloon was then used for light post stent angioplasty. Angiography revealed no further residual aneurysm." I don't think this code would be from the 37221-37235 group because it is not to treat occlusive disease. It was not an open procedure, so I don't think codes 35141-35152 apply either. Should I use an unlisted code?

Type A Dissection with Aortic Root Repair Using BioGlue

After a cath, it was determined that the patient needed a CABG and repair of aortic root dissection. The surgeon used BioGlue to glue the root back together, then fully transected the aorta and performed an end-to-end anastomosis to prevent it from propagating any further. I'm considering using modifier -22 on the CABG CPT code, but I'm not sure. The only other code for aortic repair is 33320, but I'm not sure about that either. Please share your thoughts.

Unsuccessful Thrombectomy

Can you use code 92973 if a mechanical thrombectomy is attempted but clot could not be removed? Would a modifier suffice?

Saphenous Vein Graft Bypass to PTFE Graft

How would I code a bypass from the saphenous vein bypass graft (fem-pop bypass) to the bovine carotid artery graft (iliofemoral bypass)?

76937

Can you use code 76937 with arterial access? This is why I am asking... CPT Assistant, December 2004, page 13, states: "This imaging includes preaccess assessment of venous patency and actual real-time visualization of needle passage to the venous lumen. The descriptor for code 76937 includes all phases of actual guidance, documentation, and reporting required to perform this procedure. Use of code 76937 requires a permanent recorded image(s) of the vascular access site to be included in the patient record, as well as a documented description of the process either separately or within the procedure report. Therefore, for those instances when ultrasound is utilized only to identify a vein, mark a skin entry point, and proceed with nonguided puncture, it would not be appropriate to report code 76937 for ultrasound guidance."

Aspiration of Ascitic Fluid through Peritoneal Port

Can code 49083 be reported for aspiration of ascitic fluid when performed with fluoroscopy and the peritoneal port is what was accessed for the aspiration?

Cutdown to Remove Balloon

One of our physicians had a complication during a venous intervention, and I'm just wondering if it can be billed and, if so, what the correct codes would be. "The patient had stents placed in the bilateral common femoral veins, external iliac, common iliac vein, and a double-barrel stenting of the IVC. The complication occurred during the ballooning of the last stent in the left common femoral vein. The balloon ruptured and would not deflate fully; it appeared to get stuck on the stent and pull it in a more caudal position. After multiple attempts to remove the balloon it was decided he would have to do a cutdown. The physician opened the femoral vein, removed the balloon and stent, explored the vessel, and closed." He is billing 35860 and 37197, and I'm pretty sure they are not correct. Can this complication be additionally coded, or is this included in the primary codes? If it can be coded, what would the correct codes be?

Intraoperative Angiogram

Cerebral carotid angiogram was done and determined that aneurysm clipping would be done by craniectomy (not done same day). An intraop angiogram was done (36224) after surgery and within the report it states, "See separate dictated operative notes for details." Would this be billable? I am thinking not (done more for a check of the aneurysm), but I was thinking if angiogram is not billable would I be able to bill for the catheterization (36217)?

G0278 Denials

I have always billed G0278 to Medicare patients for non-selective injection of the iliofemoral system. Recently, I have seen a lot of denials for medical necessity, insufficient documentation, CAD, SOB, etc.... none of these are deemed medically necessary. Should I not bill code G0278, or should I appeal with notes? I have not had a problem with denials before, but now that there are more my billing system has created an edit to stop these from being billed and I'm not sure what is the proper way to proceed.

Kyphoplasy vs. Vertebroplasy

Does this report support a kyphoplasty? Does the statement that the curved needle was rotated 360 degrees support a cavity being created? "The needle insertion site and periosteum of the left L5 pedicle were anesthetized by lidocaine injection. The left side of the L5 vertebral body was accessed with an 11 gauge needle via a transpedicular approach. A curved needle was introduced and directed under fluoroscopic guidance to the midline of the L5 vertebral body. The curved needle tip was clearly within the large cystic cleft seen on recent lumbar spine MRI. The needle tip was rotated 360 degrees under continuous fluoroscopic guidance in order to confirm placement within the cleft. Under continuous fluoroscopic guidance, cement was instilled through the curved needle. There was excellent filling within the anterior and middle aspects of the vertebral body as well as the superior and inferior halves of the vertebral body. There was also good filling into both the right and left sides of the vertebral body. There was no posterior cement leakage evident."

Double J Stent Removals

Patient has bilateral nephrostomy catheters with separate double J stents. We were asked to remove the stents and replace the existing nephrostomy catheters. Code 50387 is for an exchange of nephroureteral stent, which we do not have. Your guidance is appreciated.

Mulltiple Endarterectomies

"Arteriotomy was made coursing from the takeoff of the SFA up onto the CFA and was continued as a branch onto the PFA. Large plug of plaque was removed, and endarterectomy was carried out of the PFA as well as the CFA. There was a large amount of plaque at the external iliac artery, and remote atherectomy was carried out proximally. The SFA and PFA takeoffs were then anastomosed separately thereby creating a joint posterior wall. We attempted access of the SFA for arteriogram, but it was totally occluded. A remote atherectomy was then carried out with an 8 ring stripper to the popliteal. Arteriogram shows residual plaque, and cutter was reintroduced and additional plaque removed. Another arteriogram reveals residual stenosis in the popliteal and stent was placed." I am getting different opinions on what codes to use. Should we use 35351, 35302, 35372, and 37226? Or just 35302, 35355, and 37226? Would you please give us your expert opinion?

CardioMems

We are wondering what documentation is sufficient enough to bill for outpatient interrogations for CardioMems. Can the nurse make a note that the MD reviewed the downloads and bill for that? Also, what CPT codes are used? Can they program the device?

Spectranetics Laser for PPM/ICD Lead Removal

I have a physician who wants to start using the Spectranetics laser for removal of PPM/ICD leads. I have checked the CPT Codebook along with your web site and have not found any information about how you would go about coding for this procedure. Would the only codes you could use be 33234, 33235, or 33244?

Ultrasound Chest and Thoracentesis

If a patient has an order for a thoracentesis, in the hospital setting, can the radiologist request that ultrasound be used to assess for pleural fluid, dictate a diagnostic chest (76604), and then proceed to perform an ultrasound-guided thoracentesis (32555) and dictate this separately? Does it matter if there has been any previous imaging that the ordering physician is using as a basis for ordering the thoracentesis?

PICC Line with Dual Chamber Pacemaker

Patient was getting a dual chamber pacemaker inserted, but a vein was collapsed, so a PICC line had to be inserted as well. Can I bill for the PICC line with the pacemaker (33208, 36569)?

Thrombin Injection for Ruptured Vein

"Balloon angioplasty of an AV fistula resulted in the rupture of the vein at the second of the two strictures. Attempts at sealing the rupture were unsuccessful. Therefore, thrombin was injected directly into the hematoma under direct ultrasound guidance, resulting in closure of the rupture." How would this be coded? Or is this included in the procedure?

Endoleak Repair with a Stent after AAA Repair

Not sure what 30000 series and S&I codes to code here. "The right common femoral artery was accessed percutaneously. A catheter was advanced into the aorta, and abdominal aortogram confirmed a type 2 endoleak. The hypogastric was selectively engaged, and selective angiogram of the hypogastric artery was performed. An attempt was made to engage the descending branch from the hypogastric, but because of the sharp takeoff just a few millimeters from the origin of the hypogastric artery, this was not successful. Therefore, prior to proceeding any further, using the Omni Flush catheter, the superior mesenteric artery was engaged, and a contrast injection into the SMA was performed with delayed views to see if there was a communication between actually the mesenteric vessels and the lumbar artery, and obviously not appeared to be the case. After the hypogastric artery again was engaged, the area of the takeoff of the feeding branch for the lumbar was treated by placing a 6 mm Viabahn x 2.5 mm covered stent with complete obliteration of the origin of the feeding vessel."

Venous Embolizations

What do you code when an arteriovenous fistula is treated on the venous side only? My IR surgeon believes that code 37242 is appropriate, as the condition treated (AV fistula) is critical in code selection, not the portion of the cardiovascular system treated (venous vs. arterial). I have an additional question as a result. A number of sources (CPT, CMS, etc.) state that non-selective catheterization and non-diagnostic angiography are inclusive to code 37242, yet there are no NCCI edits for diagnostic extremity venography (36005, 75820) for code 37242 (arterial malformation). Would codes 37242, 36005, and 75820 be correct in this scenario?

Use of 52 vs. 74 Modifier, Graft Angiography

Coding advice from another vendor is to append modifier -52 to 93455 when only selecting and injecting coronary bypass grafts instead of modifier -74. See their rationale below: "The appropriate modifier for hospital use would depend on the circumstances. If the planned procedure was to do bypass grafts only, modifier -52 is appropriate even for the hospital. If the planned procedure was a coronary angiogram to include both native arteries and grafts, but for some reason only the grafts were imaged, then modifier -74 would be the appropriate modifier for the hospital. The rationale for the above is that -74 is a “discontinued” service, and the description says 'due to extenuating circumstances or those that threaten the well being of the patient', while modifier -52 is for services that are 'partially reduced or eliminated at the discretion of the physician or other qualified health care professional'.” We are now uncertain of the correct modifier to use in this coding scenario, as we have been advised by your company to use -74 if anesthesia was used. Please advise.

CT Change of Drain Catheter

Would it be appropriate to use code 75984 when using CT guidance? I was under the impression it is understood to be via fluoroscopy guidance. I'm seeking your validation for the appropriate use of this code, fluoroscopy or CT. Thank you.

Eversion Endarterectomy

The physician performed endarterectomy of common femoral artery (35371), and an eversion endarterectomy of external iliac was also performed proximally. What code should I use for eversion endarterectomy of the external iliac?

Tunneled Peritoneal Catheter

What is the correct code for insertion of Pleurex catheter for drainage of ascites under ultrasound when the catheter is left in place and secured? Can code 49083 be used if the catheter is left in place?

Thoracic Outlet

Patient underwent rib resection with scalenectomy (21705) as well as excision of the pectoralis minor. Is there a code for the additional work involved in excising the pectoralis minor, or should this be billed with a -22 modifier?

Incompleted Staged Stent Procedure

Patient came in and had left heart catheterization and drug-eluting stent to RCA. Noted severe lesions in LAD, but due to stress test results felt RCA should be stented first, as it was a more critical blockage. Two weeks later for elective stent LAD, and after angiogram and FFR the physician noted lesions to be less than originally noted and chose medical therapy. Should we code 93455 with FFR? Or abort drug-eluting stent?

Coronary Stent with Angioplasty through Stent Struts

If a provider deploys a stent in the left main, which extends into the left circumflex (92928-LC), and then "inserts a balloon through the stent and performs an angioplasty of the LAD through the stent", would the angioplasty be separately reportable? My concern is the documentation mentions in the conclusion that he is "dilating the struts of the stent" into the ostia of the LAD with no residual stenosis in the left circumflex or the LAD. There is "no significant stenosis" in the LAD per the diagnostic cath and "minimal plaquing", so I'm not sure this is a medically necessary angioplasty or just facilitating the final stent placement and more of a "bridging lesion" scenario. Any help you can provide is appreciated!

Closure Device Angiography vs. True Diagnostic Leg Angiography for Medical Necessity

"Retrograde access was achieved in the left common femoral artery with a micropuncture set, and a 6 French sheath was placed. Arteriography of the left femoral bifurcation was performed using carbon dioxide and contrast. A 5 French Omniflush catheter was positioned in the distal abdominal aorta and bilateral iliac arteriography performed using carbon dioxide. Catheter was positioned across the aortic bifurcation into the distal right external iliac artery and right lower extremity arteriography performed using carbon dioxide and contrast." While arteriography of left femoral bifurcation only is being performed, and a complete run-off on the right side, should it be considered unilateral or bilateral angiography of lower extremity?

Repair of Ruptured Retrovisceral Aorta

I am confused about how to code for the 4-vessel debranching of the visceral aorta through a midline laparotomy. "The patient was opened, and four of the visceral vessels were debranched, and a Coselli graft was sewn in to revascularize the renal, mesenteric, splenic, and superior mesenteric. A wire was placed through the Coselli graft, and a Gore tube graft was deployed to cover the descending thoracic aorta and visceral abdominal aorta. This is the end of the procedure." Would I go with unlisted?

Arterial Line and Monitoring 36620

Can we report code 36620 for placement of an arterial line during a diagnostic/interventional cath procedure if placed in a different access than what was used to perform the primary procedure? "A 7 French sheath was placed in the right femoral vein, and a 4 French sheath was placed in the right femoral artery for pressure monitoring purposes. A complete right heart catheterization was performed using a 7 French balloon wedge catheter, and RV and pulmonary artery angiograms were performed using the 7 French cardio marker catheter."

37184 vs. 37186

We have started doing complex lower extremity interventions in our lab. A question has been raised about the proper use of codes 37184, 37185, and 37186. Would you still use code 37186 (secondary thormbectomy) if, after stent deployment in the SFA, there's a need to perform thrombectomy in the AT, PT, and peroneal vessels using a mechanical thrombectomy device? This doesn't seem to fit the limited or short segments of thrombus, which is used to describe secondary thrombectomy (37186).

Two Catheters in One Lower Extremity

"The patient has a left femoral to below knee popliteal artery bypass graft and a left abandoned bypass graft. A micropuncture needle was advanced in a midline retrograde fashion and a sheath placed. A pelvic angiogram showed occlusion of the bypass graft, and a 10 cm infusion Cragg-McNamara infusion catheter was placed and positioned across the proximal arterial anastomosis. Then under direct ultrasound guidance a micropuncture needle was advanced into the proximal graft and in antegrade fashion, then sheath was placed followed by lower extremity angiogram. Next a 10 cm infusion length Cragg-McNamara catheter was advanced across the distal anastomosis. 1 mg tPA per hour split between the two infusion catheters with 300 units per hour." Since there are two separate access sites, can I report codes 36140 x 2, 37211 x 2, and 75716? Please advise because I am not sure if I can code both since it's the same leg (although there are two separate access sites and two infusions catheters placed).

Catheterization of MCA M1 and M2 (Embolization or Mechical Thrombectomy)

I see middle cerebral branch M1 and M2 or unnamed feeding branches selected without imaging for an intervention. May we now report code 36228-52? And are M1 and M2 reported with 36228 x 2, or do you consider the entire MCA one vessel?

FFR Done Alone

One of our physicians would like to charge FFR (93571-26) and states “that not all FFR needs PCI and in fact most don't”. The doctor did not do anything else with the patient. "Procedure: Approach into right radial artery, lesion site dCIRC, pre-stenosis 60%, post stenosis 60%. FFR Finding: FFR resting result: 1.08, FFR result:1.09, FFR result: 1.07. PCI Equipment: Verrata pressure wire 180 cm (non-consigment)." Would you report this with an unlisted code? Any information is greatly appreciated!

75898

The physician did a transjugular liver biopsy. After the biopsy was taken he dictated: "Hand-injection digital subtraction venography was performed through the sheath demonstrating no extravasation of contrast material following the biopsy.” Another coder wants to add code 75898 for this injection. Is this an appropriate use of 75898 in this situation?

Bending Views with Myelograms

There seems to be a discrepancy as to whether we can bill for bending views (72114) during the same session as a myelogram. The facility I work for does bending views with all their myelograms. I do not hit any NCCI edits, but one person is telling me it is inclusive.

Thoracoabdominal Aneurysm Repair with Endarterectomies

Without going into too much detail, the vascular surgeon I code for performed a type 4 thoracoabdominal aneurysm repair along with endarterectomy of the renal arteries bilaterally and endarterectomy of the celiac and superior mesenteric arteries. I was wondering if I should report code 33877 with 35341-51, 35341-59, and 35341-59. It's the endarterectomies that have me confused.

Multi Level Kyphoplasty and Ablation

I hope you can clarify something. One of our radiologists performed kyphoplasties on L1, L2, and L3 with RF ablations done at each level for bone mets. Our radiologist feels that the ablation should be charged per level. I feel the CPT code describes the full ablation theray. So if one or more tumors are ablated in a session, regardless of how many spinal levels this involves, you only charge the ablation code 20982 once. Can you please provide some clarity for the correct charging of this?

Bubble Study

Which CPT code or HCPCS code should we use for a bubble study? Is the infusion or injection of saline charged separately?

Occluded Percutaneous Peritoneal Dialysis Catheter

How would you code removal of intraluminal obstruction of peritoneal dialysis catheter (up to and including use of tPA)?

Q0 on ICD Removal

We have a denial from Medicare (WPS), and they are stating that we need to include the -Q0 modifier and clinical trial number on our ICD removal codes (33244 and 33241). I can't find documentation anywhere that this is needed on removals. I was under the impression that it was just applied to initial implants meeting the criteria for primary prevention.

Triple Rule Out Study

Could you please clarify which CPT code(s) would be reported when a triple rule out study is ordered and performed to evaluate for pulmonary embolism, coronary artery disease, and aortic dissection in one scan?

Poor MD Documentation

In reviewing charges for a procedure, I came across a case coded 75625, 75716, 37228. The operative report states selective right leg angio and PTA to anterior tibial. Procedure portion states, "LCFA accessed and wire into aorta with use of Omniflush catheter to access left iliac. Omiflush catheter exchanged for 65 cm sheath. Selective angiogram with multiple views performed. PTA to anterior tibial performed." The physician's report is finalized with an impression, which dictates findings of an abdominal aortagram and findings of only the right side extremity and angioplasty. Due to the difference in charges and report I viewed the x-ray films. These show Omniflush catheter just below renals and abdominal aortagram imaging; next I see bilateral lower extremity imaging from bifurcation to toes. The selective right angio and PTA imaging. I queried physician to verify clarify op report and filming. I suggested including catheter position in their report to assist in proper coding. Physician says will not dictate maneuvers not performed. How can this be coded 75710, 37228?

Disc Aspiration Biopsy

Are disc aspiration biopsies coded with 64999 and 77003? This is what I have seen the last few years. Is this still the current way to code these type of cases? "Examination: IR disc aspiration percutaneous x 2. History: Imaging findings concerning for discitis. Summary: Uncomplicated L1-L2 and L2-L3 disc space biopsies. Multiple 18 gauge core needle specimens were sent from each disc space for cultures. Procedure: The left flank was prepped and draped using maximal sterile barrier technique. Using fluoroscopic guidance, a 17 gauge coaxial introducer needle was inserted into the L2-L3 disc space after appropriate local anesthesia with 1% lidocaine. Multiple 18 gauge core needle specimens were obtained as above. Using fluoroscopic guidance, a 17 gauge coaxial introducer needle was inserted into the L1 to disc space after appropriate local anesthesia with lidocaine. Multiple 18 gauge core needle specimens were obtained as above. The needles were removed. Total fluoroscopy time 4.7 minutes."

CT or US Guided Talimogene Laherparepvec Administration into Liver

We will be doing a new procedure where we will use either cat scan or ultrasound guidance for needle placement. Then we will be injecting Talimogene laherparepvec into the liver tumor. Would code 47399 and either 77012 or 76942 for guidance be correct? I was also thinking about code 20500. This would be for hospital outpatient. Please advise.

MCA Aneurysm Embolization

Patient comes in and physician places one coil in the MCA to treat an aneurysm. After which he documents that the coil is unstable. He removes it and ends the procedure. Can 61624 be reported with a -74 modifier in this case?

Bridging Aortoiliac Disease Treated with Stent

PROCEDURE: R/L CATH, COROS, NO LV; AORTOGRAM. PTA WITH STENT OF THE DISTAL AORTA AND RIGHT ILIAC ARTERY. INDICATION: SOB, RIGHT LEG PAIN, AND PAD. Taken from op report: "Decision to intervene on the total right ostial iliac occlusion and the distal aorta with balloon angioplasty first, after deployed stent. Balloons were used to predilate and inflated/deployed stent at the level of the bifurcation not to preclude or occlude the access to the left illiac ostium. The distal aorta was also predilated with the above balloons, and there were excellent angiographic results." I am enclined to code for PTA/stent to right iliac, 37221 (stent placement, w/wo angioplasty illiac artery, and PTA to aorta). I did not read anywhere on report that he stented the aorta. I'm not sure what to code. I came up with 35472 (percutaneous angioplasty, aortic). Please help.

AMI with Thrombectomy Only

Patient presents with AMI. Culprit lesion treated with aspiration thrombectomy followed by AngioJet thrombectomy (92973). The physician tried to wire lesion past occlusion but could not make it across. Can I charge 92941 for the aspiration thrombectomy if it's the only intervention performed in the list of included components for 92941?

Thromboendarterectomy Documentation and Coding

I have coding questions regarding thomboendarterectomies. Basically my question is, if our physicians do a thromboendarterectomy of the iliofemoral vessel and the incision is in the groin only, no abdominal incision, can you bill 35355? One of my physicians documented the following: "The right groin was opened in an oblique fashion, and the common femoral artery, profunda femoral, and SFA were dissected out. I made a vertical incision and did an extensive endarterectomy from the iliofemoral down to the common femoral. I had to get to the origin of the profunda femoral and down into the SFA removing a very extensive amount of calcific hemodynamically significant plaque... I patched it with a Gore-tex graft and closed." He is billing 35355. What are your thoughts on the correct code for this procedure? My concern is the description of 35355, which states an abdominal incision is made to access the iliacs and a groin incision for the femoral (there is no abdominal incision).

77011

If a technologist provides stereotactic CT guidance in the OR, but no radiologist is present, and then a formal report of the body system follows the surgery with a dictated report signed by a radiologist, do we report CPT code 77011? Or the CT for the body part that was operated on (i.e., 77011 or 70486, if sinuses were surgically repaired)?

IV placed in IR for CT scan with contrast

If a patient comes in for a CT scan and requires an IV access to be placed by IR due to "poor venous access", is the 36000 and 76937 seperately reportable? Typically the 36000 is bundled, but due to the poor access and the fact that they are taken to IR for the procedure, does that warrant the charges? The fact that is performed for the sole purpose of administering the contrast, regardless of the reason they have poor access, does that void charging the 36000/76937 seperately?

Percutaneous Ovary Biopsy

Can a biopsy of an ovary be performed percutaneously? If so, what would be the proper CPT code to use?

Reconstruct CT Images

The physician has ordered an abdomen and pelvis CT and a lumbar CT. Instead of direct scanning the patient twice, the technologist manipulates/reconstructs the abdomen/pelvis images and creates the lumbar imaging, axial, coronal, and sagittal images. What do we charge for the physician reading the lumbar CT images? Currently we are charging 74177 for abdomen/pelvis CT and 72131 for lumbar CT, so the physician has the separate dictation for the CT lumbar. How do we move forward?

MIdline/PICC for IR/OR procedures

Refering back to Question ID 3402, sheath placement for CTs, you state if it were a CVC we could code that, but if midlines and PICCs placed for purposes of administering anesthesia and meds during an IR or OR procedure would they be bundled into the main procedure? Would it matter whether it was done at bedside in the OR or seperately in the IR department prior to going to the OR for the procedure? Documentation lacks in regards to whether the midline/PICC is immediately removed following the procedure. Thank you.

AngioVac for Valvular Vegetation Removal

Can code 36800 be billed with 33460/36010/93314-26? "Ultrasound-guided access with utilized to access both the right internal jugular vein and left CFV. 7 French sheaths were placed. A 26 French DrySeal sheath was placed in the right IJ. A return catheter was placed in the left CFV. The sheath was advanced across the tricuspid valve. The angio catheter was advanced into the ventricle, and the balloon was inflated. The patient was placed on cardiopulmonary bypass. The sheath and catheter were withdrawn into the atrium, and multiple passes across the tricuspid valve with the AngioVac catheter were done. Debridement of the mobile vegetation was done. Cultures sent to pathology. Patient was weaned from cardiopulmonary bypass. Completion TEE was performed."

Bypass Graft and Native Artery Intervention

I know for coding purposes the bypass graft is counted as one vessel; however, what if an intervention was done in the native vessel and the bypass graft? It was a common femoral to peroneal bypass with PTA done in the native peroneal, and also PTA done all the way up through the anastomosis to the common femoral. Would this be coded as 37228 for the native peroneal and 37224 for the bypass graft in the fem-pop zone? 

Revision of Fem-Pop Bypass

The patient underwent fem-pop bypass with a reversed SVG, which thrombosed after 2 days. He was returned to the OR where the surgeon determined that the SVG was too small to salvage, and the cephalic vein was harvested and used as conduit. Operative note: "Attention was turned to the vein graft. It was divided proximally and withdrawn from its anatomic tunnel. The vein was opened near the distal anastomosis. In order to get all the clot out, it was opened down to within a cm of the artery, affording excellent visualization of the interior of the anastomosis and confirming removal of all thrombus distally. A tunneler was used to tunnel the cephalic vein in a subQ position from the groin to the popliteal incision. An end-to-end oblique anastomosis was created to the hood of the previous vein graft distally. Proximally, the old vein graft was opened and an incision made in the hood of that vein graft. An oblique end-to-side anastomosis was created. Flow was established." Code 35500 cannot be used in conjunction with 35876, so how should this procedure be reported?

93355 During ASD Closure

For the following case, is code 93355 appropriate? "Initially, the physician performed TEE. This demonstrated a 9-10 mm secundum ASD with evidence of right heart volume overload. Antero-superior rim 4 mm. IVC rim 15 mm. The right femoral vein and artery were entered. 6 French and 3 French sheaths were placed. Heparin was given. ACT was monitored during the case. Prograde right heart cath was done. Catheter course was consistent with a normal left innominate vein. The atrial septum was crossed, and the left atrium was entered. The left upper pulmonary vein was entered, and a 0.035 Amplatz guidewire was placed. A 25-3 NuMed sizing balloon was advanced over the guidewire, and ASD sizing was done using the stop flow technique. Balloon sizing measurements were 9-10 mm. The balloon catheter was removed, and a 10 French short sheath was placed. A 20 mm Cardioform Gore Septal Occluder was implanted across the ASD. Further TEE showed the device in good position. Push pull maneuver confirmed stable device position. The device was then released. Final TEE images showed good device position with no residual shunt." 

CPT for a CVC into the Jugular Bulb

What would be the appropriate CPT code for a CVC into the jugular bulb? Would it be 36011?

Transhepatic Cholangiogram with Biliary Drainage Tube Insertion

Can you clarify your answer to question 4251? If a diagnostic transhepatic cholangiogram (47500) is performed prior to insertion of either an external biliary drainage tube (47510) or internal/external biliary drainage tube (47511), can 47500 be billed with a modifier in both cases? Or is code 47500 only billable with 47511, not 47510?

Subclavian Angiogram and Stent Placement

A patient was referred for subclavian stenosis. The physician performed a selective angiogram on the subclavian artery, and then the decision was made to angioplasty and stent it. Which CPT code(s) would be used? Would the angiogram be bundled with the stent?

Fibrin Sheath

Can you please help me decide how to code this account? I am not sure if it should be coded with 36595, 75901, and 36581 or with 35476, 75978, 36011, and 36581. "The existing right hemodialysis catheter was prepped and draped in the usual sterile fashion. 1% lidocaine was administered for local anesthesia. Blood could not be aspirated; however, saline was flushed without difficulty. The existing hemodialysis catheter was removed over two 0.035 Glidewires, and a 10 French sheath was placed through the tract. A small venogram was performed, suggesting a fibrin plug. An 8 mm balloon was placed through the sheath over the Glidewire and used to plasty the SVC tract. This was repeated using a 10 mm balloon. The sheath and balloons were moved over the wire, and a new 23 cm right internal jugular tunneled hemodialysis catheter was placed with tip in the right atrium. The catheters were aspirated and flushed unremarkably without complication. The catheter was sutured to the skin using 2-0 silk, and a sterile dressing was applied."

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