Knowledge Base

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Set Descending Direction

Biopsy-Vocal Cord Mass

Could you please help with the code for the procedure below? Code 38510 is what we assigned. Is this correct? "The patient was placed supine in the CT scanner. The patient's anterior midline neck was prepped and draped in a sterile manner. A hard stop time-out was then performed to verify the patient's identity, the planned procedure, and procedure location. After proper patient identification and verification of the planned procedure, the procedure continued. Local anesthetic was applied. Under CT guidance without the use of contrast, a 20 gauge, 15 cm Chiba needle was placed into the right vocal cord mass. The mass was difficult to access through the cartilage. The needle was continuously agitated in the lesion to obtain fine needle aspiration samples. Several biopsy specimens were obtained, which were immediately handed to cytology for evaluation. Samples were then sent to the laboratory as per the requesting physician's orders."

Open thrombectomy dialysis AV fistula with PTA & fistulogram

"The patient has outflow stenosis around the elbow with flow through the perforator vein into the brachial vein with stenosis there. The fistula was opened, and a large amount of thrombus was evacuated. A Fogarty was passed proximally and retrieved clots from there as well. After this the fistulotomy was repaired, and the fistula was then punctured with a needle wire and sheath, and fistulogram was performed. This demonstrated high-grade stenosis of the brachial vein down the perforator, which is the sole outflow of this fistula. We crossed the lesion with a wire and noted that we were in two different perforator systems and ultimately engaged each. These were treated with 6 mm balloon angioplasty. We then also treated the proximal fistula lesion with 8 mm balloon angioplasty. Repeat injection demonstrated improvement. The sheath was removed and the puncture site repaired." Can we report codes 36831, 35476, and 36147 for the same encounter/same physician? There is an NCCI edit on codes 36831 and 36147. Would it be appropriate to assign modifier -59 or-XU to 36147 in this scenario?

Above Knee Amputation

What code would you use for the following procedure and why? "Patient had a right below knee amputation (27880) two months ago and now has nonviable tissue of the BKA stump. Doctor is going to do above knee amputation. The nonviable tissues were debrided from the stump and got good back bleeding. The entire incision was opened; muscle was gray and nonviable. Gastrocnemius, soleus, and tibialis anterior muscles were all completely necrotic. BKA was nonsalvageable. For the AKA, dissection was carried down to the femur. The femur was divided. Popliteal artery and vein were clamped, and a rasp was used to file down the bone. Two 2-0 vicryl stitches were placed, pulling the fascia or the deep tissue over the femur, and then closed. Flaps came together nicely without tension." 

Anticipated catheter repositioning or replacement

Would you please tell us how you would code the following scenario? "Anticipated Catheter Repositioning or Replacement Impression: Good position of the PICC line and no kink identified. Indication: Nonfunctioning previously placed double lumen PICC line Comparison: Chest X-ray Findings: Preliminary spot filming shows the previously placed PICC line in good position and without kink. Both lumens flushed and aspirated easily. Preliminary spot film was performed by fluoro."

75630 vs. 75625

I am completely confused on abdominal aortic imaging. Does code 75625 require two catheter placements or not? For example: "Physician places catheter in abdominal aorta near renals and performs abdominal aortography; he also documents bilateral pelvic imaging along with common femorals. He then moves the catheter to the SFA and completes angiography with chase bolus runoff to the foot on the left." Is this coded as 36247, 75625, 75716? Or is it 36247, 75630?

Revision of Peritoneal Catheter Site

Pt on peritoneal dialysis, cath functions well but exit site borken down & infected. An elipse of infected skin down through subcu, including exit site & subcu cut out w/ scalpel & bovie cautery, sent for culture. Cuff then stripped, treated w/betadine, buried subcutaneously w/sutures, getting good amt of tissue around cath, closing skin with sutures. We have found nothing similar to this, how will this be coded?


Physician documents post ablation a-fib: "Adenosine is to induce arrhythmias. 6 mg given on each vein to check for pulmonary vein reconnection. Adenosine 6 mg confirmed persistent pulmonary vein isolation for each of the veins. BCL:890, PR:160... Parahisian pacing confirms no accessory pathway. Rapid pacing failed to induce any SVT." It appears he is doing both efficacy of ablation AND testing for new arrhythmias. Do you agree that code 93623 is supported due to documentation of "to induce arrhythmias"?

Adequate Documentation for CPT 93566

Can you please explain what documentation is required to report code 93566? Our physician would like to report it for the following procedure (in addition to CPT 93460): "We performed selective left coronary angiography. We obtained arterial sample for saturations. We then accessed the right femoral vein for the right heart study. The catheter immediately went across the large atrial septal defect into the left atrium. It was easy to get it into the pulmonary veins. We advanced it through the right heart and into the wedge position. We obtained saturations en route. We then pulled the catheter back and placed it in the superior vena cava. We obtained saturations in the low and mid right atrium and, of course, in the left atrium and in the pulmonary veins. A pigtail catheter would not readily go across the defect, although all of the wires did just because of angulation. We injected just above the right atrium with 20 mL of contrast. A large atrial septal defect was visualized with right to left shunting." 

UroNav MR/US Fusion for Prostate Biopsy

The urology group at our facility is looking to start utilizing the UroNav system for prostate biopsies. I am finding very little coding guidance on reporting this MR/US fusion technology. The AUA published a policy and advocacy brief back in February 2015, which directs to possibly using 76498. Other guidance points to 76999. Would you have any insight into how to address this new technology? 

BIV-ICD Pocket Hematoma Evacuation/Cautery

How do you suggest this be reported? "Patient underwent implantation of biventricular ICD system. On the day following procedure, there was evidence of a large hematoma with worsening pain despite the use of analgesics. Lidocaine 1% was infiltrated in the left subclavian region along the incision, and the incision was opened, removing sutures. A moderate amount of blood and clot was removed from the pocket. The pulse generator was removed from the pocket and irrigated with copious saline solution. Inspection of the pocket showed no clear source of active bleeding, but moderate diffuse bleeding. Very careful hemostasis was performed by quadrants in the pocket with extensive use of cautery. Persistent diffuse bleeding was observed in several areas, and more continued use of the cautery and suture with 2-0 silk was performed until adequate hemostasis was obtained. Surgicel was inserted in areas of diffuse bleeding in the pocket, and the generator was inserted in the pocket." 

36819 or 36821

"Basilic vein was explored and axilla noted to be about 5 mm. Cephalad mobilation revealed adequate venous size 4.5-5 mm and 3.5-4 mm distally. The vein graft was mobilized out of this by using multiple oblique and longitudinal incisions. The distal end below the elbow was controlled ligated, and the vein graft was lifted out of its bed maintaining proximal continuity. The brachial artery segment distal and proximal to the antecubital was skeletonized and encircled, after which the basilic vein graft was delivered through a subcutaneous tract to the artery. The basilic vein was anastomosed to the artery in an end-to-end fashion." This appears to be multiple incisions, tunneling. Would this be reported with 36819 or 36821?

36818 vs. 36821

"A transverse incision was made just distal to the left antecubital crease for a length of 2.5 cm. The cephalic vein was identified crossing obliquely. It was dissected proximally and distally, and vessel loops were placed around it. The radial artery was then dissected, and proximal and distal control was obtained by placing vessel loops around it. The vessel loops were clamped, and an end-to-side anastomosis between the cephalic vein and the brachial artery was created in a continuous manner." Should we report 36818 or 36821? There were two incisions, vein and artery dissected, no tunneling.

Diagnostic at Time of Intervention

Patient had an aortogram (cath in one position) and, based on the findings, bilateral iliac stents were placed. I know I cannot charge for catheter placement, but I am confused about whether I can charge for the aortogram (75630) or if it is bundled. 

Endologix endograft for aortic occlusive disease and iliac aneurysms

Need recommendation on coding since 34804 is for aortic aneurysm: "Patient does have extensive atherosclerotic and thrombus throughout his infrarenal abdominal aorta. This does all appear to be flow-limiting. The patient does have a large, approximately 2.5 to 3cm iliac artery aneurysms. Given the findings of severe occlusive disease, his infrarenal abdominal aorta as well as bilateral common iliac artery aneurysms, plan was to proceed with a stent graft placement using an Endologix device for occlusive disease of the abdominal aorta as well as to repair the bilateral iliac artery aneurysms and then placed the Endologix 17-French sheath over the stiff Meier wire up into the abdominal aorta. Through this, we placed our main body, which was the 25 x 120 x 20 main body... and the graft was secured over the aortic bifurcation. Graft was then deployed. We then placed a proximal extension 25mm in diameter. ____ proximal extension just at the level of the renal arteries."

ICD-10-CM Code for Post Op Vists

Would you explain what diagnosis code to use for a patient who is in a 90-day global period from a procedure and is being seen in the office for post-op visits (example: fem/pop bypass for atherosclerosis of right leg with ulcer of heel and midfoot, I70.234). Would you code Z09 and Z86.7 (follow-up examination after completed treatment for condition)? Or would you continue to use I70.234 due to the patient still having atherosclerosis with ulcer but the procedure has been completed to hopefully correct the problem? From what I have read, the Z09 implies that the condition has been fully treated and no longer exists. But in vascular patients the patient will always have atherosclerosis even after the comleted procedure. I'm confused! Could you please explain the correct use of these codes? 

Endoscopic Approach for Gastric Varix Embolization.

Interventional radiologist injected glue into a gastric varix. After endoscopy physician placed the endoscope down to the varix and punctured the varix. Code 43243 applies for the endoscopy MD, but would there be anything billable for the interventional radiologist since code 43243 does not qualify for co-surgery or assist-at-surgery? 

Ethanol Ablation

What codes would you use for CT-guided ethanol ablation of T-6 hemangioma?

Percutaneous AV Graft Ligation

How would you code a percutaneous AV graft ligation or collateral veins? I have three examples: Example #1) Two stab incisions were made at the site of the collateral once local anesthesia was infiltrated. Under direct ultrasound guidance, a Hawkins needle was passed deep to the collateral vessel from one incision out the next. Example #2) The collateral vein was identified with ultrasound, which demonstrated an early bifurcation. Under ultrasound guidance, a curved needle was used to guide 4-0 silk sutures around the larger branch, which was subsequently tied off. Example #3) Under ultrasound guidance, a Hawkins needle was advanced deep to the juxta-anastomic venous outflow segment, and a 0-0 silk suture was pulled through the soft tissues and out the skin. The Hawkins needle was then advanced superficial to the vein remaining deep to the skin, and the 3-0 silk suture was pulled in reverse through the soft tissues and out the skin. A surgical knot was tied down, reducing the diameter of the juxta-anastomotic venous segment to 5 mm.

IR Myelogram Followed by CT Myelogram

Confusion over how to code. IR dept does IR myelogram followed by CT myelogram. Order "lumbar puncture for cervical myelogram". IR physician report: "L5-S1 inerspinous region localized using fluoro. Spinal needle introduced. 10cc of 300 strength contrast injected with free flow within thecal sac. Contrast seen to upper thoracic level. Further imaging CT cervical region. CT Report: Axial images were obtained from the posterior fossa through the cervicothoracic junction with sagittal and coronal reconstructions in bone and soft tissue. There is good filling of the thecal sac with contrast with visualization of the posterior fossa cisterns and fourth ventricle. There is retrolisthesis of C5 on C6 of 2 mm with otherwise normal alignment. Vertebral body height is preserved. There are multiple anterior osteophytes from C3 through C7. At C2-3, there is a small right marginal osteophyte encroaching on the neural foramen with mild nerve root displacement. Facet arthropathy is present on the left. At C3-4, there are no significant abnormalities..."

Stress Test

To bill the stress test supervision only (93016), does the cardiologist need to have face-to-face with the patient to supervise, or can they be in the area and called over if something happens? The cardiologist MD I code for had a report of interpretation for a stress test, and he said he supervised the patient as well. Two weeks later, the patient was seen in his clinic because the test was abnormal. Would this be considered a new patient to this specialty if this was the only service they had?

37202/75896 Deleted in 2016

In reviewing the 2016 CPT Codebook that just came in, I noticed that they are deleting 37202 and 75896 for 2016; however, they only reference replacement codes related to intracranial non-thrombolysis infusions. It would appear that there will not be a code in 2016 for general non-thrombolysis arterial infusions (vasopressin for GI bleeds, etc.). Do you know anything about this? Is this an oversight by the AMA CPT panel? Will we be stuck with trying to bill unlisted code 96379?

Left Heart Catheterization

Is documentation of left ventricular pressure alone sufficient for coding a left heart catheterization, or do you need to also have documentation of catheter placement into the left heart chamber(s)? I have seen reports with documentation of pressure, without notation of catheter placement into a chamber.

Breast Fine Needle Aspiration and Placement of a Clip

I have a case where the physician performs a fine needle aspiration of an unspecified mass in the patient's breast under ultrasound guidance. After the physician performs the fine needle aspiration, he places a clip within the mass. I know we can bill 10022 for the fine needle aspiration and 76942 for the ultrasound guidance. Question is, can we bill anything for the placement of the clip using ultrasound guidance in addition to the fine needle aspiration?

Redundant ICA

Patient had CEA 3 days prior. Still inpatient, had kink of distal ICA with thrombus and stroke (co-surgery approach in OR for removal of redundant ICA and redo patch). Would this be exploration with repair (35800-62)? What global modifier would this be considered?

Embolectomy with Patch Angioplasty

My physician performed an embolectomy via cutdown on the leg. This was performed at the distal popliteal artery, all the way to the tibial trifurcation. When he only noticed backbleeding from the peroneal, he determined that there must have been a prior dissection or chronic occlusion in the anterior tibial and posterior tibial, because he was not able to advance the catheter into these two vessels. He then proceeded to perform a patch angioplasty on the origin of this area. Can I code for the patch angioplasty? If so, what code set would you suggest. (Bovine pericardial patch was used.)

Amputation (Guillotine) Below the Knee, Then Amputation Above the Knee 7 Days Later

Amputation (Guillotine) was performed below the knee, then Amputation above the knee was performed seven days later. How should I bill the second amputation? Is this considered a repeat amputation (27596)?

Lumbar Myelogram 62284 vs. 62304

Would this be billed as 62284 or 62304/72132? We seem to have a difference of opinion on this and would like clarification. CT indicates this patient has multilevel DDD and facet hypertrophy. "INDICATION: Neurogenic claudication. FINDINGS: Risks were explained, and informed consent was obtained. The back was prepped and draped in the standard fashion. A 22 gauge needle was introduced in the thecal sac using a right paramedian approach at L3. 8 mL of Isovue-M 300 contrast was instilled into the thecal sac. Needle was removed. Projections of the spine show the thecal sac to be widely patent. No definitive spinal stenosis is identified. The bulk of the information will be obtained during the CT examination. Fluoroscopy time: 0.9 minutes."

Adrenal Biopsy

Our hospitals are now having this debate. One group says that you code for the abdominal mass (49180), and the other side says the adrenal gland is a organ and therefore code 60699 is used instead. Has there been any kind of consensus or guidance from Medicare on this debate?

Acute MI

Patient came in with acute myocardial infarction, and the physician performed aspiration thrombectomy to the LC and RC, and then the patient coded and expired. Would you report code 92941 for this where aspiration thrombectomy was the only procedure performed?


Per the Journal of Vascular Surgery, May 2004, "Partial obstruction of post-thrombotic veins caused by endovenous scar tissue, which creates synechiae and septae that narrow and sometimes block the lumen of a vein." We did a venous disobliteration and PTA of the iliofemoral segment of vein, with a CorMatrix patch angioplasty of the left common femoral vein, followed by construction of a left femoral vein to left common femoral artery arteriovenous fistula. This fistula was to preserve blood flow, not a dialysis fistula. How would you code this?

Acute Thrombosis ICD-10

When assigning the ICD-10 codes for occlusion of the bilateral brachiocephalic veins, right internal jugular vein, right external vein, and right subclavian vein, would they be considered acute or chronic? I'm thinking acute, as it doesn't state chronic. Please clarify.

AVM, Dural Fistula

How many times can an extrancranial embolization be captured for dural AV fistula and AVM for both left and right?

Medtronic Valiant Stent Graft for Aortic Coarctation

A Medtronic Valiant Stent Graft was placed in the thoracic aorta for coarctation. The physician coded 33881, 36200, and 75957. I think it should be 37236, 36200, 75605. How would you recommend coding? "A 10 French sheath was placed in the right common femoral. A 5 French sheath was placed in the left common femoral. Lunderquist wire was passed into the ascending aorta through the right sheath, and through the left sheath, a 4 French pigtail marker catheter was placed in the aortic arch. Digital subtraction angiography demonstrated the coarctation as seen on the preoperative CT angiogram about 4.5 cm distal to left subclavian artery. A Medtronic Valiant 28 x 117 mm stent graft was delivered and then placed just distal to the left subclavian, encompassing the coartation, and placed in a suitable position so that about 4 cm of covered stent graft was just proximal to the coarctation about 6 cm distal to it. This was then angioplastied with a 16 x 40 Z-Med balloon followed by an 18 x 40 Z-Med balloon. Resolution of the waist after an 18 x 40 balloon was noted."

TAA Endoleak Embolization

Patient with a TAA endoleak with no mention of hemorrhage. What embolization code would be used? 37242?

Revision, Ligation, and Miller Procedure

I am trying to code a case, and my provider and I are in disagreement over my coding. He performed the following: 1. Repair of pseudoaneurysms x 2 AV fistulae, 2. Ligations saprophytic retrograde forearm cephalic vein AV fistula, 3. Miller procedure [minimally invasive limited ligation endovascular revision (4 mm angioplasty balloon), and 4. Fistulogram including central venogram. I coded this case with 36832, thinking that the ligations (37607) and the use of the balloon are included in the revision. I also did not code for the fistulogram (36147), thinking that this was a planned procedure and not the decision to treat. My provider thinks that he should get to code for all procedures. Am I correct in my thinking, or is he?

Sclerotherapy of Glomuvenous Malformations

A total of 5.5 cc of STS 3% was injected into the the glomuvenous malformation involving the right foot, left arm, upper back, and left shoulder using ultrasound guidance. Each are separate lesions. In this case, would I bill 37241 multiple times? If so, how many? 

Brief Ultrasound of AVF in the Office

Physician performed a brief ultrasound of the right AVF. There is fistula flow throughout the fistula. There is an area of focal mural thrombus in the lower third of the fistula, which is not causing a functional stenosis. The proximal is extremely tortuous. The AVF anastomosis is visualized and does not appear obviously stenotic. What CPT code would we report if performed in the office and the doctor says "brief" ultrasound?

Modifier for 93355 needed when reported with 93580

With regards to Q&As #7011 and #6409, we have a case of one physician closing the PFO percutaneously and another physician doing limited TEE monitoring during the case. NCCI edits are advising 93355 is code 2 of a code pair with 93580 that would be allowed if an appropriate NCCI modifier were present. Both physicians were cardiologists. Would modifier -59 be used in this case to get both codes paid?

Thrombectomy 37184 and angioplasty 61630

Patient with right MCA occlusion with stroke. CT with contrast demonstrates evidence of RT MCA occlusion with a large area penumbra on the perfusion imaging. Now for attempted thrombectomy and revascularization of the right middle cerebral artery. Selective right ICA and cerebral angiogram, catheter advanced up to the edge of the clot and aspirated for 60 seconds, after removing catheter there was no evidence of clot within the tube. Following mechanical thrombectomy with direct aspiration technique and stent retriever x2,we were unable to obtain revascularization(37184), most likely due to the high-grade stenosis from an atherosclerotic plaque of the distal M1 segment. There appeared to be a very firm lesion at the distal MCA consistent with possible atheroma, and at this point we advanced a balloon across the stenosis and performed transluminal balloon angioplasty (61630). This resulted in partial revascularization. Can we report both codes since thrombectomy attempted but results were not to his satisfaction then he proceeded to angioplasty of stenosis?

AP Collateral Embolization

Would I use code 37242 only once for the embolization of the RIMA and the three aortopulomonary collateral arteries that were embolized, or do I use code 37242 once for the RIMA and then again for the aortopulmonary collaterals that were embolized since it was two different sites? Do I also code for the angio that was performed during the embolization (i.e., RIMA, right subclavian artery, and right vertebral artery), or just the right vertebral artery since this is the highest branch order? Also, do I use code 93564 for the aortopulomonary angio that the physician did during the procedure? Can I code the LIMA that was performed during this procedure?

Mesocaval Shunt

Do you code a percutaneous mesocaval shunt like a TIPS? Code 37160 looks like it is for an open procedure. Is code 37182 for any percutaneous method used for a portal decompression regardless of the vessels used to do so? 

TAVR with GZ 33361

I had a provider that did a TAVR on a patient for non-FDA approved indications. I was wondering how we bill this to show the carrier that we did this procedure? Would I just bill the TAVR code with modifier -GZ?

Sclerotherapy Stomal Varices

I'm completely lost on this one. How would you code the following procedure? "The left abdomen colostomy stoma site was cleaned with Chloraprep and draped in sterile fashion. Ultrasound showed prominent varices adjacent and deep to the stoma. Local lidocaine was given and a micropuncture needle was used to access the varices. The 3 French sheath was placed and venogram was done, showing the stoma varices that subsequently drain through the inferior epigastric veins into the external iliac vein. The volume to fill the varices was about 4 cc. 2 cc of 3% sodium Sotradecol was mixed with 1 cc of contrast and 2 cc of air to make a foam mixture. While direct compression was held in bilateral groin near the epigastric veins, 4cc of the foam sclerosant was injected. Pressure was held for 5 minutes. Ultrasound showed echogenic sclerosant througout the stoma. The sheath was removed and hemostasis was achieved with direct pressure."

Balloon Test Occlusion of Septal Perforator for Septal Hypertrophy

What code/s would be appropriate for the balloon occlusion of the septal perforator in the followng case? "LHC with Dobutamine infusion for assessment of gradient performed & results documented. All vessels were patent. Next we advanced a JL4 guiding catheter and manipulated it into the left coronary artery. It was injected for an angiographic guiding projection. The angioplasty apparatus was loaded into the guiding catheter and successfully negotiated into the septal perforator. The septal perforator was occluded with a 2.25 x 12 mm balloon. Of note, heparin was given as 9000 unit bolus prior to the balloon occlusion. Performed bedside echocardiography, which revealed a larger LV outflow tract, proximal septum hypokinesis and marked lessening of the intracavitary gradient. The balloon was up for approximately 3 minutes. The procedure was then discontinued."

Billing 61624 More Than Once

Can we bill for more than one unit of 61624 when embolizing with the Pipeline device?

76937, US Guidance for Vascular Access

Can we use code 76937 if the needles we use for vascular access don't show up on the ultrasound? We are able to locate the vessel by watching its movement. 

Appropriate use of 7th character A, D and S when coding thrombosis of AV access

Does the initial encounter character "A" mean physician/patient encounter or first time patient's access has thrombosed? Does "D" mean subsequent thrombosis or subsequent physician/patient interaction? Please give example of when to use 7th character "S".

Snare Capture Lead Fragment

Patient presents for biventricular ICD system extraction. During extraction of leads, a piece of one of the leads fractures and lodges in the innominate vein. After leads are fully extracted, physician performed snare capture of fractured lead segment. Would you consider the snare capture a separately reportable procedure with CPT 37197, or would you consider it a part of the lead extraction code 33244?

Multiple Atherectomy Procedures

How should this scenario be coded? "TAMI solution was infused intra-arterial through the sheath. Right peroneal artery was successfully catheterized, 5000 units heparin administered IV, and laser atherectomy performed within the proximal right SFA, mid popliteal artery, tibial/peroneal trunk, and peroneal artery using a 1.4 mm spectranetics laser catheter. The right anterior tibial artery was selectively catheterized, and laser atherectomy was also performed across origin and into proximal aspect of the vessel. Angioplasty was performed in the proximal right superficial femoral artery and proximal and mid right popliteal artery using a 5 mm Ultraverse balloon catheter. Follow-up arteriography was performed. Angioplasty was performed across proximal right anterior tibial artery and tibial/peroneal trunk and proximal peroneal artery using a 3 mm Ultraverse balloon catheter. Follow-up arteriography was performed." 

Thrombolytic infustion 36593 vs Port -a-cath stripping 36595

I just started coding for our IR lab, and I'm trying to understand why you can't report codes 36593 and 36595 toegther. The patient was brought to the rRadiology depart and 5mg tPA was infused over an hour. Patient was then taken to vascular lab for stripping of the tip of the port cath. Is code 36593 included in 36595 when done on the same date? I understand the CPT Codebook says they cannot be report together; I'm just trying understand why.

CHD and Melody Valve

How would we code the following? "OPERATION: 1. Right and retrograde left heart cardiac catheterization. 2. Angiography: Left internal mammary artery/left coronary artery, main pulmonary artery, aorta. 3. Balloon angioplasty of right ventricle to pulmonary artery conduit with 20 mm BIB balloon and 22 mm Vida balloon. 4. Endovascular stent placement, right ventricle - to - pulmonary artery conduit (4010 Palmaz stent on 22 mm BIB balloon). 5. Percutaneous pulmonary valve placement (Melody transcatheter valve, 24 mm Ensemble delivery system)."

50390 and 50392

What is considered a confirmatory antegrade pyleogram vs. diagnostic? "The patient is pregnant with pylelonephritis and hydronephrosis by ultrasound. Using real-time ultrasound guidance, right mid pole calyx was punctured with a 21 gauge needle. Antegrade pyelogram was performed. Access was obtained into the kidney using an AccuStick system. Guidewire advanced into the ureter. 8 French nephrostomy tube was positioned with in the renal pelvis. The nephrostomy tube was sutured in place using 2-0 Ethilon. FINDINGS: ANTEGRADE PYELOGRAM: Moderate right hydronephrosis with drainage of contrast into the ureter. The distal ureter could not be visualized due to abdominal shielding. Nephrostomy Tube Placement: 8 French pigtail catheter positioned within the renal pelvis. Impression: 1. Moderate right hydronephrosis. 2. Placement of 8 French nephrostomy tube." I was thinking of reporting codes 76942, 50390, 74425, 50392, and 74475. Do you agree with coding both 50390 and 50392?

Coil Localization

How would you code coil localization? "Indication: 1.1 cm nodule rt lung (near the fissure rt middle lobe) preop coil localization requested. A pleural catheter is placed and secured (this was coded with CPT 32557). From a separate antral lateral approach site for coil localization was sterilely prepped all the way down to the pleura at the intercostal space. Unfortunately the lesion is deep to the patient's breast tissue requiring an approach through the breast . A 20 gauge Chiba needle was inserted and advanced to the periphery of the lesion. The localization coil was then partially deployed with the central aspect immediately adjacent to the lesion at the ant/sup/medial margin of the sm nodule. Needle Cobb off including the remainder of the long coil, was then withdrawn, pneumothorax enlarged with pleural air injection, and the remainder of the coil was deposited within the pleural space. Ndl removed. Pneumothorax aspirated and final CT images performed. Pleural cath left in place in case pt develops visceral pleural leak before entering OR."

Ultrasound for Vascular Access

When is it appropriate to code for ultrasound guidance (76937) when getting access to the artery or vein for either an angiography procedure or a cardiac catheterization?

33249 NCD Edit

With ICD-10 becoming effective Oct 1st, we began receiving edits that procedure code 33249 was not meeting medical necessity regardless of the fact that the -Q0 modifier was attached to the code. "938 NCD Edit: Medical necessity has not been met, as there is not a covered diagnosis present on the claim." I'm wondering if this is happening at any other facilities or if there is an error with the edit. We use the NCT# 0199140 for the ICD Registry 470.7 as a secondary diagnosis, condition code 30, and DX code Z0.06. Hope you can help us!! 

Breast Fiducial Markers

The outpatient centers want to start doing breast fiducial markers under mammography and want to use HCPCS code C9728. Would this procedure fall under the breast code 19281? 


Is code G0364 used in conjunction with 38221 billable to all insurances?

20604 vs 20600 follow up for question ID #6415

JOINT PROCEDURES (Arthrocentesis) 20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting Question: JOINT PROCEDURES (Arthrocentesis): 20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting; but what code would you use if the documentation only states under US guidance but does not mention permanent recording and reporting, do you still use the same code or can i use the code 20604-52 for reduced services or 20600 as if US was not used for this particular example. pls advise.

ICD-10-PCS Code for Temporary Balloon Occlusion of Right Interal Carotid Artery

What ICD-10-PCS code would you use for temporary balloon occlusion (TBO) of the right ICA? "Diagnostic cerebral angiogram showed right ICA aneurysm. During 40 minutes of ICA balloon test occlusion, no neurological deficits were observed."

36200, 75710-26, 36221, 36216

"Patient has known subclavian stenosis and was brought to the cath lab for an angiogram. Procedures performed: Left radial access, right common femoral artery access, thoracic aortogram, left subclavian angiogram. Multipurpose catheter imaged the left subclavian artery. Vertebral artery was also imaged. Sheath inserted into right common femoral artery. A pigtail was used to perform a thoracic aortogram concurrent with an injection on the left subclavian artery to map the entire subclavian stenosis." The report then goes into details of the findings of the left subclavian artery (which is occluded) and also the left vertebral artery (found to be enlarged). There is diffuse atheromatous disease of the aortic arch. The right common femoral artery has no significant stenosis. There was no more information on catheter placement, and the physician wants to bill codes 36200, 75710-26, 36221, and 36216 for this. I do not agree. What do you think?

Coronary Embolization

Physician performed coiling and placement of 18 mm cribiform occlude device in the large bilobed aneurysmal SVG to diagonal artery. LIMA graft and root angiography performed in conjunction. Would you use codes 37242 and 93455? For the root angiography there's nothing specifically documented other than catheter was placed and root injected. Would you add 93567?

Bilateral Ureteral Obstruction

After prepped, draped, skin anesthetized w/ 1% lido w/o epi, placed in prone position under gen’l anesthesia. Using fluoro guidance a 21-g needle was advanced into RT kidney collecting system in single pass. Contrast inj 74425-RT showed hydronephrosis & hydroureter to level of bladder. 4 Fr cath was placed, 8 Fr sheath placed, 4 Fr angled cath used to gain access into bladder. 8 Fr x 24 cm ureteral stent was deployed w/ distal pigtail in bladder, proximal pigtail in RT renal pelvis, noted to function. Using fluoro guidance a 21-g needle was placed into LT kidney collecting system in single pass. Contrast inj 50390-50-XU, 74425-LT showed hydronephrosis & hydroureter to level of bladder. 4 Fr cath was placed, 8 Fr sheath placed, 4 Fr angled cath used to gain access into bladder. A long 10 Fr peel-away sheath was placed, 8 Fr x 24 cm ureteral stent placed through sheath, sheath removed w/distal pigtail in bladder, proximal in LT renal pelvis, noted to function. 50393-50, Bilateral percutaneous accesses were removed. Any other codes or modifiers needed?

Coronary CTA

I have had two cases now where one physician has performed a complete cardiac CT angio showing non-cardiac and cardiac findings including coronaries and LVEF. The next day, a complete LHC with LV angio is performed by another physician. There are similar findings on both reports, but of course the LHC has the pressures and % of blockage in each vessel. I raised the question to the department, and they said it was because they needed views that can only be obtained with the cath. Will you please advise on the indications required to perform both procedures in the same visit and confirm that we are not "double billing"? What am I missing? Why do the CT first? I have never seen this done until just recently. As always, I appreciate your guidance and expertise.


When 73530 is done at time of hip surgery with films and interpretation by radiologist, would code 73530 be billed as views or as diagnostic?

Upgrade from Dual Pacemaker to Biventricular AICD

The upgrade to a biventricular AICD from a dual pacemaker leads me to codes 33230, 33233, and 33225. But this scenario is very confusing because the descriptor for 33230 says "with existing dual leads", so should I use code 33231 instead because now with the addition of the LV lead that was implanted along with the biventricular generator I have 3 total leads?

May-Thurner Syndrome in ICD-10

Would you agree that May-Thurner syndrome would be coded as I87.1 in ICD-10? Also, would other acute conditions that result from the compression be considered integral to MTS?

Coding for CAD

My physician saw a patient with atherosclerotic heart disease of native coronary artery without angina pectoris, as well as atherosclerosis of coronary artery bypass graft(s) without angina pectoris. In the ICD-9 world we were instructed to code 414.00 for this scenario. With the increased specificity in ICD-10 would it be appropriate to code both conditions, I25.10 and I25.810, when known? Another scenario: Patient has known atherosclerotic heart disease of native coronary artery without angina pectoris with a history of CABG. Patient has not undergone a heart cath since the CABG procedure, so the cardiologist does not know if the atherosclerosis has advanced into the bypass grafts or not. Would the correct codes for this scenario be I25.10 and Z95.5?

AARO with Lower Extremity Revascularization

3M Nosology is stating S&I is inclusive to lower extremity revascularization per 2015 AMA CPT Codebook, page 238, so even if a true diagnostic procedure is performed prior to intervention it is not separately coded. What would the codes be for this AARO with intervention? "The right femoral artery was entered with US guidance and permanent recording was made. An Omni flush catheter was placed in the abdominal aorta and aortography performed with runoff. The catheter was placed into the left external iliac artery and additional angiography performed, showing occlusion of the left common femoral artery. The catheter was placed into the distal SFA, and atherectomy device was utilized. Multiple runs were made of the vessel. Next, the sheath was retracted, and runoff of the RLE was performed." Would the correct code assignment be 76937, 75625, 75716, 75774, and 37225?

Subclavian Stent with Thoracic Aortogram

Does the documentation that follows support the following codes: 75600, 36140, 75710, and 37236? "Sheath left radial artery, retrograde catheter left brachial, left axillary, left subclavian point of high-grade stenosis. Hand injection was performed, demonstrating the 99% left subclavian stenosis. Combination angled glidewire/glide catheter traversed the stenosis and was able to get into the descending thoracic aorta. Injection performed thoracic aortogram. Passed magic torque wire through angled glide catheter then removed angled glide catheter, passing ansel sheath across the obstruction. Then advanced a balloon expandable stent into position extending out into the thoracic aorta."

77012 vs. 77013

Based on the below operative note, could 77012 and 77013 be coded together using an unbundling modifier? "The patient was placed on the CT table in the prone position. After obtaining general anesthesia, local anesthesia was obtained with 1% lidocaine. CT guidance was utilized for placement of an 18 gauge needle guide into the 2.5 cm heterogeneous mass within the upper pole of the left kidney. Once confirming satisfactory placement, multiple 18 gauge core biopsies were obtained and placed in the proper container for disposition. The needle guide was removed. Utilizing CT guidance, a radiofrequency ablation probe was advanced into the left renal mass. After confirming satisfactory placement, ablation was initiated. Radiofrequency ablation was performed, 2 separate burns for 8 minutes each. The probe was removed, and hemostasis was obtained with direct manual pressure. Post ablation CT was performed to document hemostasis."

Spinal Angiogram

How do you code for a patient who has received spinal angiograms on 10 levels (T8-L4) for a total of 20 units?

Pacemaker Lead Replacement and New Generator

Patient had a dual chamber pacemaker placed in 2009. He has had noise in his RV lead, as well as ERI of his generator. His generator was removed and a new generator inserted, and his current RV lead was capped and a new RV lead inserted. His existing RA lead was reused and attached to his new generator, as was his new RV lead. There is confusion as to whether 33207 should be coded vs. 33208, 33233. It is my understanding that 33207 should be coded based on the lead that was replaced, not on the generator (single vs. dual) system. Others feel 33208 should be coded because the patient has both an RA and an RV lead system implanted. In addition, can you please clarify if the -KX modifier should be appended to both the CPT code and the HCPCS supply code?

Upgrading a Pacemaker to a Biventricular Pacemaker

When upgrading to a biventricular pacemaker, do I charge for a new pacemaker with LV lead insertion and put a -59 modifier on the code for removal of the old pacemaker? Or do I charge for removal and replacement with biventricular pacemaker with a -59 modifier on the code for LV lead insertion? And with the second option, can I charge for the removal of the device?

Coils Looped Around Pacemaker

The doctor states he did a pocket revision, but technically he had to go in and un-wrap coils around the pacemaker. Would you consider this a lead reposition? As code 33222 has changed in definition to pocket relocation. 

Cooling Catheter

Should a cooling catheter be billed with code 36556 or an unlisted code?

Carotid endarterectomy with diagnostic carotid angiogram

"Patient came in for a right carotid endarterectomy with patch angioplasty. After completion, closure, and arousal from anesthesia, the patient was noted not to be able to move her upper extremities and had significant weakness in the left leg. Decision was made to re-explore the carotid artery. Wound was reopened and vessel examined. There was a pulse in the common, internal, and external carotid arteries, and decision was made to perform an angiogram. Contrast was injected through a butterfly needle placed in the CCA just below the patch to obtain a carotid angiogram. The CCA and ICA, as well as anterior and middle cerebral arteries, were patent. Decision was made not to reopen the patch. Incision was closed." I know to report the endarterectomy with code 35301. I am uncertain about the diagnostic carotid angiogram since it is open and there was no catheter selectively placed – just a needle directly placed in the CCA. What are your thoughts?

Peri-splenic and peri-renal abscess drainage

The patient has a peri-splenic abscess located around the spleen beneath the left hemidiaphragm. Would code 49406 be correct, as the abscess is not located within the splenic organ itself? Also, some consultants are recommending that a peri-renal abscess drainage be reported with code 49405. Since the abscess is not within the organ, wouldn't 49406 be correct? Are there any AMA references that address "peri" conditions for drainages?

WPS and Popliteal Aneurysm

With the new LCD for ICD-10, popliteal aneurysm I72.4 is not covered for 37236. It also is not covered for 37226. What do you recommend if a patient has a popliteal aneurysm and is MCR or MCR replacement in our area? The particular patient I have now is having thrombosis due to the aneurysm, but by coding guidelines it would be covered for intent, which is the aneurysm. The thrombosis is covered under 37226 if it is ok to code for thrombosis and not aneurysm. We do these all the time, this is just the first one that came up since ICD-10 and I need to be able to educate my physicians on coverage. 

Dual chamber pacemaker extraction and implantation

How would you code a dual chamber pacemaker extraction, including the leads from the left subclavian site, and reimplantation of new dual chamber pacemaker to the right subclavian site?

Stress Echo and Full Routine Echo Same Day

Can you bill a full echo (93306) and a stress echo (93351) done on the same day? We are doing a full echo, then we are stressing the patient and doing a stress echo. NCCI states a modifier is allowed. Do you have any documentation requirements for doing both on the same day? Also, would you have to have separate unique diagnosis codes for each? 

Coding for Penile Angioplasty

One of our new physicians has scheduled a case in the cath lab for penile angioplasty for erectile dysfunction. How would we code that procedure? He plans to do angiography first, then the plasty.

Two Stent Placements, Iliac Territory

I'm trying to sort out when I can charge for two stent placements in the iliac territory. Scenario 1: Patient has bridging lesions in the common and external iliac arteries. Two overlapping stents are placed. Scenario 2: patient has two non-bridging lesions in the same vessels. Two non-overlapping stents are placed. Can I report codes 37221 and 37223 for both of these scenarios?

93456 vs. 93460

This patient has CM and facility wants to bill RHC & LHC. I do not see they did an LV or crossed the Aortic Valve. Do you see something that indicates this was done? "Under ultrasound guidance a #5 French sheath was placed in the right radial artery, a #6 French sheath in the right brachial vein. Right heart catheterization was undertaken utilizing a 5 French Berman catheter. Oximetry performed. Coronary arteriography was then undertaken with multiple angulated views utilizing #5 French L 3.5 and R 4 Judkins catheters. After reviewing the films to ensure an adequate study, the catheter and sheath were removed. RESULTS: HEMODYNAMICS: Normal sinus rhythm, rate of 82. RA mean of 11. RV 41/14. Pulmonary complete wedge pressure 22. PA 41/19, mean of 30. Aorta 132/68, mean of 90. SvO2 75.1%. SaO2 92.8%. Cardiac output 6.85 L/minute. Cardiac index 3.75 L/minute/m sq. CORONARIES: He states - no atherosclerosis. Patient has Mild biventricular elevation of filling pressures with mild pulmonary HTN & preserved cardiac output."

IVUS with Two Access Points

Could you please clarify the use of 37250/75945 and 37251/75946 when two accesses are used? In the case where right and left femorals were punctured and IVUS performed of both left and right femoral veins, would both accesses allow the use of 37250/75945? Or should we use 37250/75945 for the first puncture and 37251/75946 for the additional? We do understand that in 2016 these codes are deleted and combined to a bundled code. 

CPT Codes for Insertion of Cardiohelp VAD

What would be the correct CPT code for this procedure? "Decision was made to place Cardiohelp device. Patient was undergoing CPR intermittently during this part of the procedure. Left subclavicular incision was made, and left subclavian and axillary artery was identified. This was dissected free from soft tissue attachments. Needle was inserted into the artery, and a wire was placed under fluoroscopic guidance. Wire was placed in descending aorta. Axillary artery was then dilated, and arterial cannula was placed over wire. This was positioned in the thoracic aorta. Tip was positioned in thoracic aorta under fluoro. Separately, a venous cannula was placed in the right femoral vein. This was placed percutaneously over the guidewire and placed in the right atrium under fluoro. The cannulas were then hooked up to the Cardiohelp device, and the device was turned on. Cannulas were then secured to the skin." From my research this seems more like an ECMO than a VAD. What are your thoughts?

Right Subclavian Atherosclerosis ICD-10

I am unable to locate a good ICD-10 code for right subclavian atherosclerosis. I have looked under atherosclerosis, but I'm unable to find a code that truly fits.

93458 vs. 93454

Is documentation of "no gradient across the aortic valve on pullback" sufficient to support coding a left heart catheterization? The only other documentation is "catheter placement in LV" and "LVgram deferred". No systolic, ventricular, atrial, or end-diastolic pressures are documented. Are we to assume that pressures were performed since he was able to evaluate there is no gradient? The physician documented coronary angiography as well, so the question relates to whether this should be coded as 93454 for coronaries only or 93458 coronaries with left heart cath. 


Can you report code 70544 twice if you perform an MRA and MRV of the head on the same date of service, if they are performed at two different times?

Bilateral Outflow Venograms

This one is confusing me. How should I code the following? "PROCEDURE: Outflow venograms of the upper extremities. TECHNIQUE: Using ultrasound guidance, superficial veins in the wrists bilaterally were accessed with 22 gauge Angiocath cannulas bilaterally. Segmental venograms were performed of each arm bilaterally, including forearm venograms with and without tourniquet placement cephalad to the elbow joints bilaterally. Additionally venograms were performed of the thoracic inlet during bilateral contrast injections for evaluation of the subclavian and brachiocephalic veins. On the left there is a mild to moderate small segmental narrowing underlying the left clavicle, most likely related to extrinsic compression by the overlying bone. No collateral vein formation is seen; however, minimal reflux into the left axillary veins is identified."

TIPS Insertion with Thrombectomy

Our physician did a TIPS insertion followed by venous thrombectomies in the inferior, superior, and splenic veins. Can these thrombectomy procedures be reported in addition to the TIPS procedure? I'm looking at codes 37187, 36011, and 36012 in addition to 37182. 

Single ICD Upgrade to Biventricular System

Indications CSHF, NYHA Class III, EF 10%, Chronic RV Pacing, Sustained VT. Existing single chamber ICD, placed in 2013, is replaced/upgraded with CRT-D. From your Q&A and book I understand that I should code this with 33262 and 33225, but how do we code for the added right artrial lead? 

Angiography Left Ophthalmic Artery

What is correct code for this angiography? "After informed consent the patient was brought into the angiography suite and placed supine on the angiographic table. The right groin was prepped and draped using sterile technique. Ultrasound guidance was used to evaluate the right groin site, and patency of the right femoral artery was noted. Using a 5 French micropuncture kit with ultrasound guidance under real-time visualization, the micro-puncture needle was advanced into the right femoral artery, and intravascular location of the needle tip was confirmed on ultrasound and documented in PACS. Then the provided micropuncture dilator was placed, the inner stylet removed, and the outer dilator was connected to an RHV. Multiple attempts using a 0.008" Mirage microwire and Standard Magic Microcatheter to catheterize the left ophthalmic artery were unsuccessful. The left ophthalmic artery was successfully catheterized utilizing a Synchro 10 microwire and Marathon microcatheter."

Sheath Insertion into Atrium

Is there a code for insertion of a sheath into the atrium? The surgeon performed this in preparation for the interventional folks to place a stent in the pulmonary venous confluence. "...We introduced a vascular sheath into the right atrium (open chest). The vascular sheath was secured, and the patient was transferred to the cath lab for placement of the stent in the pulmonary venous confluence. Following the placement of the stent, the chest was closed..." The reasoning was due to lack of alternative access to this area after Fontan procedure. 

Removal of FFBPG at Same Time as ABF

A patient has a fem-fem bypass graft that keeps clotting. Doctor wants to “take down” the fem-fem graft and put in an aorto-bi-femoral graft. I cannot find a code for the take-down of the graft other than removal of infected graft. This fem-fem graft is not infected. Is the take-down included in the aorto-bi-femoral graft, or would a -22 modifier be appropriate? Any suggestions?

Repair of Ventricular Perforation, S/P TAVR

How would you code the following? "A small subxiphoid incision was made and carried down in the chest. The pericardium was opened and the tamponade released with several hundred mL of red blood in the pericardium. I tried to see where this bleeding was from, but I could not see it. Therefore I opened and did a median sternotomy and explored the chest. The main perforation appeared to be on the posterior wall of the left ventricle near the second obtuse marginal artery. It was repaired with 5-0 pledgeted prolene suture. Two mediastinal chest tubes were placed. I then closed the chest with interrupted sternal wires. She was stable and taken back to ICU."

ICD-10 Status Diagnosis Z-code Z76.82

When doing a cardiac cath for pre-evaluation for organ transplant, would it be appropriate to report code Z76.82 (awaiting organ transplant) as the primary diagnosis? There is conflicting information that shows it should not be used as a PDX, but on the professional side there is nothing concrete to back that up. Understanding that patients over 40 with history of heart disease or significant smoking history are required to have this done. For example, a patient awaiting lung transplant for J60 (Coalworker's pneumoconiosis) and pulmonary fibrosis. Would you report code Z76.82 primary, or use the reason for lung transplant?

ICD-10-CM, Gunshot Wound

Our coders are trying to decide which ICD-10-CM code(s) would be best to describe a gunshot wound, and the x-ray shows the bullet or bullet fragments. If we use "open wound" there is no option for "with foreign body". Some coders are thinking "puncture" or "laceration" because they both give the option of "with foreign body". I can't find any written guidance (other than external causes). Can you please advise?


Physician stents the bilateral common and external iliac and removes IVC filter using US guidance. I'm reporting codes 37238-50, 37239 x 2, 37193, and 76937. Codes 37238 and 37239 have MUEs attached. Code 37239 can only be reported twice and code 37238 can only be reported once, so I'm appending modifier -50 to code 37238. Am I doing this correctly?

Billing Chemotherapy with Fluoroscopy 96450/77003

Since we have the chemotherapy nurse administer the chemotherapy, I have not billed the chemotherapy charge on physician billing side. Is this incorrect, and I should bill the chemotherapy administration?

Tumor Imaging

We have patients who come in for tumor imaging spanning 3-4 days. Day 1 is the injection, day 2 is the first image, day 3 is the second image, and day 4 is possible third image. We are currently reporting code 78802 per image and 78803 for the SPECT. Should this be billed with code 78804?

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