Knowledge Base

Items 1301 to 1400 of 2009 total

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Set Descending Direction

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."

36870 vs. 37187

Can you provide the correct procedure code(s) for the venous thrombectomies in this patient with a right upper arm AV fistula? Some like 36870 only, while others like 36870 and 37187 since they feel the subclavian is substantially away from the fistula. "We then percutaneously accessed the proximal venous outflow just past the anastomosis of the cephalic vein…noted a moderate stenosis just past the anastomosis. We then noted that the cephalic vein was patent for approximately 10 cm and then became completely occluded. There was no reconstitution of this until the superior vena cava, and the fistula was draining through small collaterals into the basilic system. AngioJet catheter was used to perform a mechanical thrombectomy over the cephalic, axillary, and subclavian veins on the right side for a total volume of 323 mL. Completion fistulography showed a patent lumen throughout the fistula with heavily diseased venous outflow for the majority of the cephalic, axillary, and subclavian veins. PTA of SVC was performed…”

36000

Could you please clarify the use of code 36000? We have been reporting it when an IV catheter is placed by the nurse, usually antecubital, for an urgent care patient, but patient is taken to the ED without having had any infusion therapy in the clinic. NS may have been hung, running TKO. All other scenarios discussed seem much more complex; however, I cannot find any documentation that says this use is not appropriate. Thoughts?

Tomosynthesis Dictation

Does the dictation need to be in the body of the report as well as the exam title? Because our doctors use a predictated template, and it isn't dictating it in the body of the report. If so, where is the documentation stating that it needs to be in the body of the report?

Conversion to HeRO

If the vascular surgeon accessed and rewired an existing tunneled catheter, including removing the port with blunt dissection and packing the tract, and then tunneled the HeRO graft and anastomosed it to an existing AV graft, would 36558 still be the appropriate interventional code? Would a modifier be needed?

Ligation of AV Communication

When my vascular physician constructs an AV fistula for dialysis (36820, for example) he will also sometimes do "exploration of right arm arteriovenous fistula at the level of the mid arm with ligation of arteriovenous communications x 2 and exploration of right arm arteriovenous fistula in the upper arm with ligation of arteriovenous communication". Is this something that is coded separately from the 36820, or is it just part of the procedure?

Peritoneal Catheter Repair

What code would be appropriate for the repair of a peritoneal catheter? I liked 36575 until I saw that the description seems to be specific to central venous access devices. This describes what was done: "The catheter was divided above the damaged segment. The piece was removed. A new connector was inserted along with the betacap adapter and betadine cap. The valve was opened, and there was brisk flow of dialysate out of the catheter. The valve was closed."

AAA Trivascular Ovation Stent Graft

Physician places Trivalent Ovation stent graft in the aorta. He occludes the left limb of the graft with an Amplatzer plug. He places the right limb of the stent graft. Would you code this with 34803-52 or 34802? What about 37242 for the Amplatzer plug?

AFX Stent Graft for Aortic Stenosis

Please code the following procedure done for aortic stenosis: "Stent graft repair of the patient's abdominal aorta and common iliac arteries and then address residual disease in the external iliac arteries. We utilized the AFX stent graft system. We then used two 8 x 40 mm Armada balloons to perform kissing balloon angioplasty of the aorto-iliac bifurcation, as well as the right and left common iliac arteries. There was still some concern about a possible stenosis or dissection in the distal right common iliac artery and proximal right external iliac artery. IVUS revealed an area of dissection or residual thrombus in the distal right common iliac artery beyond the right limb of the endograft. There was also an area of dissection seen in the proximal to midportion of the right external iliac artery. We placed a covered stent across the distal right common iliac artery immediately above the takeoff of the right hypogastric artery. To cover the area of dissection in the right external iliac artery, we used an Absolute stent."

KX Modifier

Does anyone know if the hospital is to append the -KX modifier to the CPT code or the HCPCS device code?

Impella Insertion and RVAD via Sternotomy

Patient comes in through the ER with cardiogenic shock, s/p acute MI, taken emergently to OR; after emergent cath, LAD stenting, and IABP. Patient taken for emergent sternotomy for Impella left ventricular assist device, and after Impella placed, emergent insertion of Abiomed right ventricular assist device. Would code 33976 be used in this case? 

Arterial Graft Segment on Dialysis Graft

What would the "arterial graft segment" be considered for a dialysis graft? Is this like the "arterial limb" and considered venous for interventional purposes since it does not state it incorporates the arterial anastomosis? 

93662 with 0281T

We have recently started doing percutaneous left atrial appendage closures (0281T). Last week we had a case where the physician utilized an Acunav ultrasound catheter via groin approach to perform an ICE (93662) vs. a TEE. So the procedures that were charged were 0281T and 93662. Our department received a request for review of the charges in this case. I have researched the P-T-P edits for both, as well as checked in another qualified system to see if there was any issues in charging these together, and I have come up with no issues. What do you recommend to charge for the use of ICE during the 0281T procedure?

MUEs

Our facilities perform very technically challenging cases involving CPTs 37224-37230. We have run into an issue of going over the allotted MUEs for various C-codes such as C1769, C1887, and C1753. Our MAC states that there is no acceptable modifier to attach to these codes and has suggested a redetermination request for each procedure. Have you seen this issue in other facilities? Do you have any recommendations?

FFR at Time of Heart Cath

Are the correct codes for left heart cath with FFR of all three coronary vessels (specifically LAD, LC, RC) 93458, 93571, and 93572 x 2?

Abscess Drainage

Right subphrenic drainage catheter is removed (non-tunneled), and left posterior flank cavity drainage catheter is repositioned. What are the appropriate codes for both procedures?

92928 vs. C9600

Patient had an outpatient elective left cardiac cath procedure (93458) due to abnormal stress test, which led to PCI with a drug-eluting stent in LAD (92928-LD). Can the hospital modify the cardiac cath, as it was considered diagnostic (93458-XU, 92928-LD)? This is a Blue Cross account; if this was a Medicare account (93458-XU,C9600-LD).

Aortic Coarctation

"Catheter from left femoral artery access was advanced to the thoracic aorta where aortogram was obtained. Based on this finding it was decided to proceed with a 14 x40 balloon angioplasty. Repeat aortogram showed no change, so a 39 x10 mm Palmaz stent was placed at the level of the coarctation." How would you code this?

Generator Change with Lead Replacement

If a provider does a generator change and inserts or replaces a lead, do we code that as a new system placement? If so, do I base it off of how many leads total there will be or how many leads I inserted? For example, if a patient has a dual lead pacemaker, and we change the generator and one of the leads, would we bill as a single or dual lead placement?

Testicular Vein Embolization

"Entry from right internal jugular to IVC to left renal vein, then left testicular vein, then advanced into the lower portion of the left testicular vein. Venography was performed. Embolization of left testicular vein using coils and sclerosant mixture. Final venogram performed." I am unsure of adding any coding to the 37241. Your guidance is appreciated.

Limited vs. Diagnostic Studies

Can I charge for a limited venogram? I have found some online chatter about putting a -52 modifier on the venogram code when it is labeled as “limited”. I am a bit confused because one of our primary resources says, “Do not code separately for venography unless a full and complete diagnostic imaging procedure is performed. Guiding shots, positional, confirmatory, etc. injections should not be charged separately as diagnostic angiography when performing transcatheter therapy services.” The aforementioned limited venogram was diagnostic since there were stated findings of stenosis; however, it was not full and complete. Thoughts?

36251 bundled with EVAR 75952

After placement of the main body of an endovascular AAA graft, the physician performs selective renal angiography to verify the positioning of the graft and patency of the renals. Should the catheter placement into the renals (36245) be billable only and not 36251 or 36252, since the renal angiography was not truly diagnostic? 

CR 9078 documentation

Physician documents symptomatic bradycardia due to sick sinus syndrome on no rate slowing meds. The term "non-reversible" is not located in the documentation. Physician has stated that "on no rate slowing meds" is equivalent to "non-reversible". I would feel more comfortable having documentation that is specifically written in the CR. Am I being unreasonable and his documentation is appropriate and compliant enough for the application of KX modifier? Thank you very much!

ECMO

Is modifier -52 supported with code 33956 in the following case? "The previous sterile IV bag temporary chest closure was removed. Fibrillar and packing were removed. There was no compression of the superior vena cava. Right ventricular systolic function by inspection was depressed. Multiple felted 3-0 Prolene sutures were placed in the aorta and the right atrium for cannulation purposes. A 20 French arterial cannula and a 32 French venous cannula were then inserted into the ascending aorta and the right atrium. These were then connected to the ECMO tubing. ECMO flows were initiated at 2 L/kg/min without difficulty. The chest tubes were cleared of clot and placed back in the mediastinum. Hemostasis was achieved. A new IV bag was cut to appropriate shape and then sutured to the skin edges in a running fashion."

FFR/IVUS Hospital

I have read all the Q&As posted for FFR/IVUS that you have listed; however, I have another scenario for you. Patient is transferred from another hospital after having LHC, CORs, and LV. The cardiologist is unsure of the % of stenosis found in the mid LAD. He has the patient transferred for FFR and possible intervention. The cardiologist is not an interventional cardiologist, which is why the patient was transferred. The FFR shows 0.86%, which is stated as physiologically insignificant. Your instruction for stand-alone FFR or IVUS is to report code 93799. Does this also apply to the hospital setting? If yes, would you please explain why this is appropriate for the hospital setting so that I can educate staff and physicians? 

3D Rotational Imaging

Although you have stated that 76377 may only be charged once per encounter I cannot find it clearly stated in the CPT Codebook or any other source. I need to provide something to the facility that supports this statement. MUE is listed as 2 per day. Also when charging, as with all radiology, the images must be stored, but shouldn't there also be a separate report before charging 76377 (not just documented in the body of the physician operative report)?

Redo Exposure of Femoral Arteries

Our vascular surgeon believes that there is a different code for a redo exposure of the femoral arteries for EVAR. He states that the cutdown is much more difficult and requires more work. Is there a different CPT code that should be used, and/or would you recommend using a -22 modifier on code 34812?

37236 vs. 37242

If an AVM or perforation of a vessel is caused during a lower extremity intervention (in this case an SFA), can we code for fixing the AVM with 37242 (a covered stent was used)? Would we be allowed to code 37236 for placing a covered stent to fix a vessel that was perforated? 

Documenting Medical Necessity

Does medical necessity need to be documented in the operative report? For example, AHA states guidelines for screening of peripheral vascular disease include: 65 and older, claudication, lower extremity wound/ulcers, 50 and older who smokes, or with diabetes. So if any of these things are documented in the H&P/Consult/Admission note prior to an angiogram of head and neck, is that sufficient to support a diagnostic iliac angiogram? Or does the medical necessity need to be documented in the operative report?

Lead Testing for Epicardial Leads

Every time a cardiothoracic surgeon performs epicardial pacemaker generator change our EP attending will be in the OR during the entire procedure. He also interrogates/reprograms epicardial leads during procedure. Can we bill for his service as the co-surgeon?

Replacement of Pacemakers End-of-Life

I understand the new requirements for the -KX modifier on new pacemakers. We have recently been denied on replacement pacemakers (33228) for not having the -KX modifier. Are the requirements the same for the replacements?

Helix-FX EndoAnchor System Coding

Our vascular surgeon informed us on this new endovascular treatment (Helix-FX EndoAnchor System), and we were wondering if it is able to be billed, along with the other codes he has always used. He gave us some information on it and it is saying to use unlisted procedure code 37799 and use it comparable to 34825. What is your opinion on this?? In one case, he billed 34825 already for an extension cuff. Is this new system something that is separately billed? 

Fistulogram, Angioplasty, Embolization

I want to make sure this documentation is sufficient for billing the four 36011 codes. "Sedation was done. Access obtained in AVF in proximal aspect of the fistula close to the arterial anastomosis. Contrast was injected, and cephalic arch was angioplastied due to stenosis. Decision was made to approach branches from the other end of fistula. Sheath was removed, and fistula was accessed in proximal arm with the sheath towards arterial anastomosis. The side branches were selected. The selected side branches, 4 in total, were coil embolized using Cook Tornado coils. Result was acceptable and coils were in good position, and coil branches were totally occluded. Fistula was widely patent with no residual stenosis in cephalic arch. Procedure well tolerated." I would code 36147, 35476, 75978-26, 36011 (36148, deleted), 36011-XS x 3, and 37241. As always, I appreciate your input!

SVG Stent and RCA Stent

We have a case where the patient comes in having an MI. The doctor had to stent the totally occluded bypass saphenous vein graft, and from there he went to the native right coronary artery distally (as the proximal portion of the RCA was previously occluded, hence the bypass) and stented a distal lesion. A culprit lesion is not noted in the report, and we are trying to determine if we should code for C9606 and C9600, or if stenting the lesion in the SVG was integral to stenting the RCA and instead only code C9606-RC. Your thoughts?

Bilateral Lower Extremity Venogram

"The left popliteal vein was accessed. An advantage Glidewire was advanced through the catheter and directed into the femoral vein. A venogram demonstrated patency of the left popliteal and superficial femoral veins and left common, external, and common iliac veins. A 5 French straight flush catheter was advanced over the Glidewire into the left common iliac vein. A venogram demonstrated occlusion of the inferior vena cava in the mid abdomen. Prominent intrahepatic collaterals were noted providing drainage into the right atrium via a left hepatic vein. A C1 catheter was then used to select the right common iliac vein. A venogram demonstrating somewhat diminutive, but patent left common iliac, external iliac, and common femoral veins. A 2.8 French program microcatheter was advanced through the C1 catheter into the left superficial femoral vein. A venogram demonstrated tiny venous collaterals throughout the left thigh." Codes used were 88.66 and 88.51 with 36012 (left SFA) and 36011-XSRT (right common iliac vein), and 75822 (bilateral extremity), and 75825 (inferior vena cava).

Follow-Up Angiography After Embolizations

I need some guidance on how many times can I use 75898 for embolization of intracranial (CNS). Is it still as often as necesary to complete procedure? Six coils were placed with multiple angiographic views to ensure occlusion basilar tip aneurysm. Then two coils were placed posterior inferior cerebellar aneurysm with multiple angiographic views to ensure occlusion. Would this be 75898 x 8? For non-CNS/head and neck, SIR recommends coding only one follow-up angiography per embolization surgical site. Clarification on how to bill for CNS and Non-CNS would be helpful.

Aborted ASD closure

I had another attempted VSD closure that was aborted for technical reasons. Much effort went into closing it, but it was unsuccessful. In this situation, are we billing it as VSD closure with a modifier, or as 93531 and add the angios?

Nephrostomy Tube Conversion to Internal Drainage

Would code 50688 be correct for this procedure? "Placement of retrograde right ureterostomy catheter. Distal right ureteral dilatation. Following preparation using maximum sterile barrier technique and infiltration of the soft tissues with local anesthetic, the indwelling right nephrostomy tube was exchanged over a guidewire for an 8 French sheath. The sheath was negotiated into the ureter. A 5 French catheter was negotiated into the distal right ureter. A high-grade right ureteral stenosis was again identified. A guidewire was eventually negotiated through the stenosis into the ileal loop. The stenosis was dilated using a 6 mm balloon. This allowed passage of a guidewire out the ostomy. The guidewire was engaged in both entry sites. A 14 French x 45 cm catheter was advanced in retrograde fashion with the retention loop in the renal pelvis at completion of the procedure. The catheter protruded well enough to the ureterostomy bag. Successful placement of right retrograde ureterostomy catheter to allow "internal drainage" of the right kidney."

Extremity Venography for Venovenous Collateral Evaluation

If my surgeon documents that an initial angiography was performed and catheter positioned in the innominate vein with contrast injection demonstrating a large venovenous collateral arising from the base of the innominate vein, does this support the venography since the angiography was of the innominate vein?

93503, 93458, and 36556 on same day

Physician performed left heart cath via right common femoral (93458). He then placed a Quinton catheter per nephrologists’ request (36556) via the left common femoral and sutured in place. He then placed a Swan-Ganz catheter via the internal jugular and sutured in place (93503). Can I bill these codes together? Of course, we know there is some direction per the CPT Codebook stating we shouldn't bill 93503 with other diagnostic caths. However, when checking NCCI edits it is allowed. Your thoughts?

Vascular Surgery Bundled Component

My physician used bovine pericardial patch for a profundaplasty all the way up to the iliac. He calls this a patch angioplasty. I typically think of a balloon being used for an angioplasty. Would I use the repair codes for "other than vein" for this procedure (i.e., 35286, bovine pericardial patch)? Also, since the entire region from the profunda up to the iliac was repaired, do I report only one CPT code? At the same session he also performed endarterectomy of the same region and then went on to place stents in the iliac. Can I code all three procedures? Patch angioplasty, endarterectomy, and stent? This procedure was performed for severe atherosclerosis and stenosis in one extremity.

Breast Bracketed Seed Localization

"Using mammographic guidance, a bracketed approach using two I-125 seeds was chosen to localize the microcalcifications. Using aseptic technique, a small amount of 1% lidocaine was instilled for local anesthesia. The first18 gauge pre-loaded needle occluded with bone wax was then advanced into the posterior, superolateral aspect of the microcalcifications, and an I -125 seed was deployed. Same aseptic technique. A second site was chosen at the anterior, inferomedial aspect of the microcalcifications. A second pre-loaded needled occluded with bone wax was advanced into an anterior, inferomedial aspect of the microcalcifications, and an I-125 seed was deployed." Do I report this with a single code (19281-RT) because it's a bracketed approach, or do I treat this like I am coding a second lesion and add 19282-RT? Please advise because I feel like I should code this with a single code because it's bracketed. 

Ablation of coumadin ridge/ligament of marshall

Following a PVI ablation for atrial fibrillation, I will occasionally see documentation of a coumadin ridge/ligament of marshall ablation. The report reads, "Post ablation of the pulmonary veins, left atrial appendage as well as the coumadin ridge/Ligament of Marshall region were ablated with slowing and organization of the atrial fibrillation to atrial tachycardia at 180ms cycle length." I know that a roofline ablation is considered inherent to a PVI procedure, but I'm not familiar with the coumadin ridge/ligament of Marshall. Would this be coded as a second atrial fibrillation ablation, 93657?

36147

Because there were no diagnostic findings for this procedure, I am questioning whether or not I should add 36147 to the account. "Informed consent was obtained. Patient was placed in the supine position, and the left arm was prepped and draped. 1% lidocaine was used for local anesthesia. The graft was accessed. A 6 French vascular sheath was inserted over guidewire directed towards the venous anastomosis. A 5 French catheter was advanced over guidewire into left subclavian vein. Heparin was infused into thrombosed graft. Thrombectomy was performed. Injection showed a 2 cm intragraft stenosis along the venous limb cannulation zone near the apex. The stenosis was dilated with an 8 x 4 balloon at 6 ATM for 2 min. The balloon was used to iron the stents in the outflow vein and macerate residual thrombus. Sheath was removed from access site and redirected towards atrial anastomosis. Thrombus was removed from remainder of graft. A completion fistulogram was performed, which showed excellent flow. Central venogram was performed and found no stenosis." How would you code entire procedure?

49451 vs. 49452

This seems like a simple question, but we get these all the time and I have not seen it addressed anywhere. When replacing only the jejunostomy portion of a GJ tube, should that be billed as 49451 or 49452 since what is left at the end of the procedure is a GJ tube? 

Right Heart Cath with Pulmonary Artery Angio and CardioMems Implant

I searched the archives and found that you suggest to use (for the physician) unlisted code 93799 for CardioMems implant. Our doctor documented a right heart cath (93451-26) also and left pulmonary artery angiogram, as well as left pulmonary descending inferior posterior artery angiogram selectively. Is all of this included in the CardioMems implant, or should the pulmonary artery angiograms also be coded? 

Using QO Modifier with TAVR

I have been told that I need to use the -QO modifier with all TAVR procedures. However, the claims manual says it is required if patient is part of a clinical study. So which is true? Or is it similar to using primary prevention ICDs that are part of an ongoing registry?

Brachiobasilic Fistula Creation and Basilic Vein Transposition, Same Session

I have a provider that does the brachiobasilic fistula creation and the basilic vein transposition all in the same operation. How would this be coded? "The brachial artery was identified and encircled with a vessel loop, and control over the brachial artery was prepared for with vessel loops proximally and distally, and any branches were also controlled. The basilic vein was then tunneled along the anterior-lateral aspect of the arm. An arteriotomy was created. The basilic vein was then allowed to lie over the arteriotomy without a significant amount of slack. The end of the vein was spatulated to match the size of the arteriotomy. The anastomosis was then performed using a 6-0 Prolene running suture. At the completion of the suture line, the brachial artery and basilic vein were forward flushed and then allowed to back bleed. The sutures were tied, flow restored, and the fistula noted to have palpable thrill." This was done in one operation. I am not sure if I need one code or two codes for this.

Device Interrogations

Can you tell me for device checks does it have to be an EP provider that signs off and approves these, or can a cardiologist approve these also? We have general cardiology, interventional, and EP in our practice, and I just need to see if any of them can sign off on device checks.

Graft Intervention 92937 and 92938

A lesion was found in the venous graft of the RCA with a clot and another lesion in the distal RCA into the PDA. Both were treated with a bare metal stent. Can you bill codes 92937 and 92938 if a stent extended into the branch? Or in this case just 92937? How about if the stent didn't extend and there was a lesion in both the RCA and PDA stented; can you bill for two interventions or only one?

IVUS for Vessel Sizing

A physician uses IVUS for vessel sizing only before and after placement of a coronary stent. The only documentation in terms of IVUS findings read, "IVUS pre and post stent deployment shows adequate apposition of the stent struts with adequate lumen areas." Is this enough to bill an IVUS procedure? If the physician provides more detailed information regarding the vessel measurements, would IVUS be billable when used strictly for stent sizing?

Coil Embolization with Varicose Veins

We have a question about coil embolization for varicose veins. We have found the information that we cannot use code 37241, but we can’t find what we can use. The doctor images the greater saphenous vein, chooses the area to be coiled, and then drops a Medusa embolization coil. The doctor has previously tried ablation therapy (36478) and sclerotherapy (36471), and now the patient has recurring varicosities. What code should we use?

Transcatheter Thrombolytic Infusion and Relook

Can we bill anything for the relook in this case? "Sheath was placed in the left femoral artery. Catheter was inserted and advanced into the right EIA and angiography performed with unilateral run-off. Infusion catheter was inserted into the right EIA and infusion initiated (37211, 37246, 75710-26-59). Later the same day, patient is brought back to the cath lab for a relook. Infusion catheter was removed. Catheter was inserted into the existing sheath (in left femoral artery) and advanced into the right SFA and angiography performed with unilateral run-off. Catheter and sheath were removed." 

Microcystic Lymphangioma Embolization

Please provide the CPT codes with an explanation. "12 month old with large dominant macrocyst. Sclerotherapy of the left neck lymphatic malformation. In supine position, using ultrasound guidance, a 20 gauge angiocath needle was initially directed into the lobular posterolateral collection. Only a small amount of fluid could be aspirated, likely due to collapse of this smaller cavity. The catheter was removed. Using direct ultrasound guidance, a 20 gauge Angiocath needle was then used to access the large anechoic cyst more anteriorly. The needle was removed and a total of 10 ml of amber colored fluid was aspirated. The pocket of fluid again collapsed around the Angiocath, and access to the cyst was lost. After aspiration, on ultrasound, the large cyst was noted to be significantly smaller in size. No additional fluid was aspirated. The needle was removed from the sheath. Through the Angiocath, 100 mg of doxycycline (10 mg/mL) was injected under fluoroscopic guidance. Even filling of numerous adjacent microcysts. Sheath was removed."

Retrograde Approach for a Selective Common Femoral Angio

Can you please explain a retrograde approach for a selective common femoral angio? The physician directly accessed the popliteal artery. I feel like I am missing something. Here is the dictation: "Access was obtained in the right popliteal artery with micropuncture kit. Next NaviCross was placed over a wire into the right common femoral artery, and angiogram of the right iliac arteries as well as the right common femoral artery was performed." I coded for second order, but have a gut feeling I'm wrong.

Ax-Fem Bypass Graft

Physician states graft was accessed (does not state where) and contrast injection performed through micropuncture sheath, showing complete thrombosis of the graft proximally and distally. Due to volume of clot the patient was taken to the OR. How would you code this?

Selective Catheter Placement

I have been reviewing documentation for a new neurointerventionalist. The documenation states, "Through the sheath, a 5 French Davis was introduced and was navigated over a Glidewire for catheterization of the vessels as listed above. The arteriotomy was closed with Star close." In the heading of the report it lists: "VESSELS INJECTED: Left common carotid artery, left internal carotid artery, right common femoral artery. VESSELS STUDIED: Left CCA, cervical views; left ICA, intracranial views; right common femoral." The findings are listed clearly at the end of the report. With the impression, I am just wondering if this is enough documentation regarding the catheterization for each vessel.

75630 vs. 75716

My physician documents using "table step imaging" to perform abdominal aortography with bilateral runoff (results include iliacs, femoral, and sometimes popliteals). Would this documentation be considered appropriate for code 75630 since there is only one cath position vs. 75716?? "RCFA access with catheter advanced to abdominal aorta and bilateral lower extremity runoff was performed using table step imaging. On the right, severe common iliac, mild external iliac, and mild common femoral stenosis. Patent popliteal artery with three vessel runoff to the right foot. On the left, mild common iliac artery, mild external iliac artery, and mild common femoral artery stenosis. Patent popliteal artery with three vessel runoff to the left foot."

50688 vs 50387

For the following case, I am being advised that this is not 50688 but should be 50387. Can you clarify? "Clinical indication: Hematuria. Tube pulled back. Informed consent was obtained. The patient was prepped and draped in the usual sterile fashion. The existing nephroureteral catheter was injected with iodinated contrast. It shows opacification of the pyelocalyceal system and proximal to mid ureter. The intrarenal pigtail has pulled back into a lower pole calyx. The distal pigtail has uncoiled partially. Contrast is not seen extending into the ileal loop. A 0.035 guidewire was advanced through the existing catheter, and exchange was made for a new 8.5 French x 26 cm nephroureteral catheter. The proximal pigtail was coiled in the renal pelvis, and the distal pigtail was coiled in the ileal loop. Contrast was injected showing flow of contrast through the catheter into the ileal loop. There is minimal left-sided pyelocaliectasis."

FFR with Acetylcholine Challenge Test

Is FFR included in the Acetylcholine challenge or coded separately? "After diagnostic LHC/COR was completed, attention was turned to coronary reactivity testing. A Volcano FloWire was then placed into the proximal portion of the LAD. The following interventions were then performed in sequence according to protocol. 18 mcg of adenosine was given, 0.36 mcg of Acetylcholine was given, 36 mcg of Acetylcholine was given, 108 mcg of Acetylcholine was given, and 200 mg of nitroglycerin was given. The catheter was then removed, and the patient was taken to the holding area in stable condition. Baseline QCA was 2.2. Following high-dose Acetylcholine, was 2.1. Following nitroglycerin, was 2.6. The intracoronary response to Acetylcholine was negative 4.5, percentage saturation was positive 18%. Coronary blood flow was increased to 67%. Of note, following the 108 mcg dose of Acetylcholine, there was greater than 90% diffuse spasm of the LAD associated with 5/10 chest pain but no electrocardiographic changes."

Embolization Nephrostomy Tract

I am trying to find a CPT code for the embolization of a percutaneous nephrostomy tract. "The patient presented for a nephrostomy tube change. After replacing the tube, the contrast injection revealed abundant filling of the venous system and frank blood coming from the catheter. They tried to reposition, but this was not successful. Decision was made to embolize the nephrostomy tract. A coil was deployed within the collecting system followed by gelfoam along the tract." My understanding of the embolization codes is that they are for an endovascular procedure. Is this correct? If so, then I think I need to use an unlisted urinary system CPT code; do you agree with this?

Pulmonary Thrombolysis

Patient at first facility had echo and CT (they called it CTA, but it wasn't), which showed bilateral main branch pulmonary embolism. Two days later patient gets transferred out and goes to cath lab at major facility and has RHC with pressure measurements documented by Swan, pulmonary angio by pig, and bilateral thrombolysis is started. My coding is 93451, 93568, 37211-50. Patient assessed on unit next day and is clinically improving, so catheter is pulled out on unit. No trip to cath lab or any imaging done, based on symptoms and vitals. I do not believe 37213 and 37214 can be used for the visits to the unit when the MD goes up to assess patient and depending on day of cath removal, use these codes because it "includes ongoing E&M". Patient does not go back to cath lab at all. Would that not be part of the subsequent hospital care E&Ms and for procedures, only the 37211 code day 1?

Thyroid Biopsies

The patient has two thyroid nodules on the right side. The patient underwent ultrasound-guided FNA of the right upper pole thyroid nodule and the right mid/lower pole thyroid nodule. Are codes 10022, 10022-59, and 76942 correct?

Bone Biopsy, Bone Marrow Biopsy, and Bone Marrow Aspiration

Bone biopsy, bone marrow biopsy, and bone marrow aspiration are done. How do we code this? Can they all be reported together? "The patient was referred from ortho oncology for biopsy of known lesion of the right tibia with history of positive bone scan and bone marrow abnormality of magnetic resonance imaging at the mid-distal right tibia. Single pass of the 11 gauge Cook Osteo Site bone biopsy needle was made through the cortex of the tibia; additional three sites of core needle biopsy of the marrow with this needle were attempted; the specimen of needle biopsy of the right tibia was sent to surgical pathology. An aspirate of 3 ml of bone marrow was also obtained from the site and was placed in a CytoLyt and sent to cytology. Additional aspirate of 5 ml of bone marrow was obtained from the site, and this aspirate was sent to microbiology."

CT Abscess Drainage Tube Check

How do you code contrast injection of abscess drainage tube under CT? Tube injected followed by CT limited scan. Can it still be coded 49424/76080? Or 49424/76380?

35761 vs. 37799

"Pre-op diagnosis: 1) ESRD on HD. 2) Stenosis of left cephalic-axillary venous junction. Procedure: Left cephalic-axillary stenosis repair via venolysis. LT supraclavicular, aberrant cephalic vein at its axillary vein confluence was dissected circumferentially via an oblique incision.Venolysis of the entire 4 cm length cephalic-axillary vein segment was performed with tenotomy scissors. Markedly improved AVF flow was immediately noted. Vicryl 3-0 suture coapted the subcutaneous tissue, while the dermis with 4-0 Monocryl." We would much appreciate guidance on appropriate coding for this procedure. Would this be in the direction of a repair code? 

May-Thurner Syndrome

We have been unable to find a great example of a case covering May-Thurner syndrome interventions in any of the various resources. Are there any pointers you could provide when approaching these cases? Our physicians usually perform IVUS from the IVC through the common femoral, and usually multiple stents are performed. Assuming there are IVUS findings for all the vessels, should we be using them all? Does anything change when bilateral interventions are performed? On the surface it seems like many of these cases are fairly straightforward, but when you end up with so many codes the doubt creeps in.

Common Iliac Artery Thrombectomy with Stent

I know we typically would not report a thrombectomy of the common iliac (34201) with a stent of the common iliac (37221) together during the same case, as both interventions are in the same vessel and a thrombectomy is an inflow/outflow procedure typically. I have a case though where the provider passes a Fogarty three times to remove clot in the common iliac artery in the area of a prior Nellix device. The thrombectomy is the intended intervention in this case. He then shoots a completion angio, which reveals a patent common iliac artery, but there is an area of dissection distal to the prior Nellix device but still in the common iliac artery, and he deploys a 10 x 5 mm Viabahn stent that extends from the prior Nellix stent into the external iliac artery. In this case since the stent is distal to the area of thrombectomy and extends into the external iliac and is used to treat a dissection. Would you report both 34201 and 37221? I should mention the point of access for the thrombectomy is a CFA arteriotomy. 

Arcuate Ligament Syndrome, CTA, Catheter-based Angiography

I know if a patient has prior CTA that angios are only billable if diagnostic in nature. I am asking for a little more detail on this concept. For example, patient in for abdominal pain has CTA with findings of potential arcuate ligament syndrome. Patient is taken to cath lab and found to have high grade stenosis of celiac, exacerbated by arcuate ligament syndrome. No treatment performed at angio. Would the angio be billable? And the other way around... if CTA shows stenosis and patient is taken to cath lab for intervention, but then no stenosis found and just angio/cath placement performed, is angio billable since it showed no stenosis?

Fistulagram with Retrograde Access via Left IJ

How would an AV fistula case be coded with initial fistulogram (36147) performed from fistula? But to treat the arterial stenosis access was obtained via the left IJ, catheter advanced to left subclavian, and then glidewire was used to access the fistula retrograde and catheter brought across the arterial anastomosis. The arterial anastomosis and juxta arterial outflow were treated with angioplasty along with the remainder of the venous outflow. The graft is only described as a left UE bovine graft. I am stumped on coding for the retrograde access from the IJ approach and would appreciate your guidance. 

Visceral Angiography Pre Treatment Chemo Embolization Liver

Could you please advise coding of the following visceral angiography? "OPERATIONS: 1. Ultrasound and ultrasound-guided micropuncture of the right common femoral artery. 2. Selective catheterization of the SMA followed by angiogram 3. Selective catheterization of the celiac artery followed by angiogram. 4. Selective catheterization of the common hepatic artery followed by angiogram. 5. Selective catheterization of the proper hepatic artery followed by angiogram. 6. Selective catheterization of the right hepatic artery followed by angiogram. 7. Selective catheterization of the left hepatic artery followed by angiogram. 8. Selective catheterization of the medial division of the left hepatic artery followed by angiogram. 9. Selective catheterization of the lateral division of the left hepatic artery followed by angiogram."

CardioMems HF System

For hospital coding, we use C9741 for insertion of CardioMems, which includes a right heart cath. If a right and left heart cath were done at the same time of the CardioMems insertion, can we use code C9741 as well as left heart cath 93458? Or does code C9741 include both a right and left heart cath? 

37250 and 36200

I need a little guidance with this procedure: "Thoracic aortic aneurysm, s/p endovascular aortic aneurysm repair with small endoleak. Procedure: Bilateral groins accessed, catheter into aorta (36200). Aortogram was performed with cath in the ascending aorta (75605-26). This showed patent innominate artery, left carotid artery to subclavian bypass. Endograft in good position. No type I or II endoleaks. However, there is delayed filling of the pseudoaneurysm. I performed IVUS (37250/75945-26) of the aorta and the aortic endograft. The endograft was well approximated to the aortic wall. Findings: Small endoleak." Can you have non-selective cath placement with IVUS? Is this coding correct?

Transposition and Plication of AV Fistula

Would you bill 34819 only for this procedure (as I would think the plication would bundled)? "PROCEDURES PERFORMED: 1) Transposition of the brachiobasilic arteriovenous fistula in the right arm. 2) Plication of an area of 1 cm in the basilic vein proximal to the anastomosis. The basilic vein was then ligated at the most distal end after applying a clamp to the vein at the distal arm. The vein was flushed with heparin saline and noted to expand nicely without any evidence of stenosis or obstruction to the flow. The vein was then passed through the tunnel and brought out to the inflow vein. The end of the vein was spatulated to allow creation of a spatulated end-to-end venous to venous anastomosis. The anastomosis was then performed using 7-0 Prolene running suture. At the completion of the suture line the inflow vein was forward flushed. Attention was then turned to the Doppler signals and plication of the inflow vein to a diameter of 6 mm using running 5.0 Prolene suture for a distance of 1 cm." 

Non-selective Venous Catheterization

What is the proper code to bill for a non-selective venous catheterization of the lower extremity when a thrombolysis or venous angioplasty is being performed with no diagnostic venography? Code 36000 hits NCCI edits with 37212 and 35476.

Medical Necessity vs. Screening

I know we have asked a question similar to this one before; however, my compliance department wants me to ask this specifically. When a physician is treating patients for a surgical intervention for a different primary reason (i.e., stroke, carotid stenosis, etc.), would it be appropriate to perform and bill a diagnostic iliac angiogram based on the AHA guidance below? We want to confirm this guidance meets medical necessity. 2011 American Heart Association Guidelines for the Management of Patients with Peripheral Vascular Disease: The guidelines detail that screening for peripheral vascular disease is recommended for the following patient populations: age 65 or older • claudication • lower extremity wound or ulcers • age 50 or older AND smoking (active or history) • age 50 or older AND diabetes

Common Femoral Endarterectomy

Provider performed left common femoral endarterectomy with patch angioplasty, then a right external iliac balloon angioplasty. Can I report the iliac angioplasty, or is it included?

Coding for Subclavian, Innominate, and Brachiocephalic Trunk

I see the charging staff reporting 36225 when there is a shot in the innominate artery as the catheter is on its way up to the common carotids for selectivity there. I would consider this a "drive by" and only report the 36222 or 36223 depending on the cerebral angiography documentation. If the physician selects the common carotids first, then stops at the innominate on the way out, I would not code the 36225 then either. The confusion is also fueled with the description of the code 36225. It states '"selective catheter placement, subclavian, or innominate" etc. To me, this description reads that the subclavian and innominate are the same when using 36225. Can you help us understand the proper reporting of code 36225 and if the innominate artery can be reported with 36225 when shot in conjunction with a common carotid, etc.?

CTA Prior to Neurointerventional Procedure

Coding guidelines state that if a prior diagnostic imaging service is performed before an interventional procedure, such as a CTA, we cannot code diagnostic imaging for the procedure (only catheter placements). Our CTA studies are read by radiologists, and then the neuro IR physician reviews these prior to intervention; however, he is not the provider who did the CTA or initially read and interpreted the report. Do we still consider this a prior diagnostic study for the purpose of the procedure and only code cath placements such as 36217 instead of 36224? Your clarification would be very much appreciated! 

Hip Aspiration with Injection of Contrast and Methylene Blue

"With the needle in place, aspiration was performed. No fluid or pus was aspirated; however, there is minimal aspirate was obtained, which was sent to the lab for culture and sensitivity. With the needle in place, 10 cc of Omnipaque 350, as well as 5 cc of methylene blue, were injected into the joint. CAT scan was performed after the injection as well as a delayed scan after two hours. Most of the contrast is seen within the hip joint. No definite contrast is seen outside the hip joint (77012, 20610)." Is there a code to use for the Methylene blue injection, or do I use unlisted?

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