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Endarterectomy vs. Stent Placement

I cannot locate information for coding femoral endarterectomy and stent placement. "Operative Note: After completion of the endovascular stent graft, the external iliac, profunda femoris, and SFA were clamped and the sheath removed. A longitudinal incision was created in the common femoral artery, and extensive plaquing was noted, necessitating endarterectomy of distal external iliac, common femoral, and profunda femoris origin. Additionally, a stent was placed in the proximal superficial femoral artery to tack down the plaque at this level. This was performed, and then a patch angioplasty was used to close the arteriotomy." Would it be appropriate to code for the endarterectomy (35371) or the stent (37226), as I don't feel you can code for both procedures since they are within the same vessel.

Endo Leak Status Post EVAR

Can you take a look at this case for me? I have seen a few of these, and I am not sure if I am coding these correctly. The codes that I am coming up with are 76937 (ultrasound), 36246 (left internal iliac), 75736 (left internal iliac), 37204, 75894, 75898 (embolization), G0269 (Mynx), 36245 (right L3 lumbar artery), 36245, and 36248 (left L3 artery including 2 feeding ascending lumbar pathways). Please let me know if I am close and thank you for your help.  Here is the procedure: Reason for Exam: Abdominal aneurysm.  Findings Exams: Abdominal aortogram with selective left internal iliac arteriogram disease (3rd order), embolization non-neuro, placement of vascular closure device. History: Abdominal aortic aneurysm, status post EVAR with type II endoleak and enlarging aneurysm sac Technique: Intravenous conscious sedation with Fentanyl and Versed was administered in my presence. The patient was continuously monitored by a special procedures nurse for a duration of one hour and 30 minutes. Fluoroscopy time: 28 minutes. The left groin was prepped and draped with the maximum sterile barrier technique. Ultrasound was used to identify a patent left common femoral artery and image recorded in PACS. Using ultrasound localization, sterile technique, and lidocaine anesthesia, a 21 gauge needle was placed into the upper left superficial femoral artery and exchange made for a 5 French sheath. Aortogram, selective arteriography, and intervention is as detailed below. Findings: Abdominal aorta: AP aortography shows no evident type I endoleak, however delayed imaging shows prominent flow through the left ascending lumbar artery with retrograde flow into the left L3 lumbar artery and perfusion to the endoleak cavity. The inferior mesenteric artery fills via the marginal artery, but does not course back to the aneurysm sac and is not felt to be a contributor to the endoleak. Both renal arteries show mild stenoses with some irregularity of the main renal arteries which may be due to fibromuscular disease. Left internal iliac artery: Selective injection shows prominent ascending lumbar artery which bifurcation shortly after its origin and filling of a large L3 lumbar artery which is patent to the endoleak cavity. This felt to be the etiology for the endoleak. Catheterization of the ascending lumbar artery with negotiation of the multiple turns required to catheterize the endoleak cavity was quite difficult, but eventually was achieved with a Progreat catheter. Injection within the endoleak cavity confirms appropriate placement with outflow via the right L3 lumbar artery. The endoleak cavity was then filled with multiple 8 and 10 mm Nester microcoils. Catheter was negotiated into the proximal right L3 lumbar artery and occlusion done with 6 mm microcoils. The left L3 lumbar artery as well as 2 feeding ascending lumbar pathways were occluded with multiple 2 mm to 4 mm Nester microcoils. Completion and spot films show no residual filling to the endoleak cavity. The left femoral access site was assessed and closed with the Mynx closure device. Good hemostasis was achieved. Impression: 1. Type II endoleak via the left ascending lumbar and retrograde flow in left L3 lumbar artery. Successful coil occlusion of the endoleak cavity and feeding arterial pathway was done as detailed above.

Endoleak Repair with Endostaples

"A patient had an AAA repair approximately 10 years ago. He developed a type 1 endoleak and presents to the endovascular suite for repair. There was a cutdown on the right side with placement of a catheter into the aorta. A percutaneous approach was done on the left side with a catheter into the aorta. The endoleak was located and repaired with the Aptus endostapler to seal the leak at the top of the stent graft." Since this is not a repair using an extension, we were not sure how to code this. Would it be an unlisted code? Any guidance would be appreciated.

Endoleak treatment with 37205

Please do NOT include any actual patient medical records with your question. Hello again, If a patient returns for endoleak a few days after AAA repair, and two Palmaz stent are deployed in the AAA neck and two more additioanal extensions in the common iliacs can I charge for the stents (37205 & 37206). I am heading more for a "NO" as this were done for anchoring purposes not for stenoses.. Please Advise...

Endologix AFX Device

The IRs are recently using the Endologix AFX device, but dictation is very poor, making it difficult to decide if I should be using codes 34804/34825 or 34845. I am leaning towards code 34845 because, in their reports, they state they are placing the main body device and then placing a proximal device in the infrarenal location without comprising the renal arteries.

Endoscopic Vein Harvesting

Physician harvested saphenous vein endoscopically (33508). Vein is no good, so same procedure is performed on the opposite leg. Can he bill code 33508 two times?

Endovascular Reconstruction for Occlusive Disease (not AAA)

What codes would you recommend for endovascular reconstruction of the aorto-bi-iliac vessels for occlusive disease? Exact same technique as an AAA repair, but not for aneurysm. Bilateral cutdowns. Bifurcated endoprosthesis deployed in aorta and bilateral iliacs, and iliac extender. Would you recommend unlisted? Or code it with the new stent codes (37236/37237)? According to the CPT Codebook, 348XX codes are exclusive to aneurysm repair.

Endovascular Repair of Popliteal Aneurysm

What code should I use for a Medicare patient with popliteal aneurysm when the physician plans to repair with percutaneous placement of a covered stent graft?

Endovascular Thoracic Aorta Stent Graft Procedure

I've got a couple of questions regarding the below patient. Is femoral cutdown (34812) always performed with these procedures? Our provider didn't document an open cutdown, only that 5 french sheath was placed into the common femoral arteries. "Following deployment of the endograft with intentional partial left subclavian coverage (33880-62) he attempted to close the left femoral arteriotomy using the Perclose Prostar sutures; however, they prematurely knotted in the subcutaneous tissue because of vessel depth in this obese patient. In order to control bleeding without vascular control of the artery established, he used a balloon in the iliac artery so he could surically repair the left common femoral artery with placement of a bovine pericardial patch." I'm thinking I should code this part of the procedure as 37204, 75894, and 35286, but I wanted your expert opinion. Here are the codes I came up with: 36200-50, 33880-62, 75956-26, 37204, 75894-26, 35226.

Endovascular Thoracoabdominal Aneurysm Repair

Patient with a stent graft in the proximal to mid descending thoracic aorta who is 8 months out s/p. Now with enlargement of not stented area (thoracoabdominal aneurysm repair). Physician performed the repair with stenting thoracic and abdominal aorta with total of four stents starting from abdominal aorta bifurcation and last one overlaps the previous stent in thoracic aorta. Is this correct to code aneurysm repair in the thoracic aorta (36200, 33881, 75957) with proximal extension (33883, 75958) and abdominal aorta aneurysm repair (34800, 75952) separately? Does the way the physician builds the grafts in thoracic aorta (proximally or telescopic way) affect coding (e.g. in this case the main body first in distal thoracic with one extension proximally to overlap with previous stent)?

Endovenectomy with Patch Angioplasty

"Procedures performed: Bilateral groin cutdown with common femoral vein exposure. Extensive left  common femoral vein endovenectomy followed by patch angioplasty. Focal right common femoral vein endovenectomy with primary closure. Kissing stents from IVC into the iliac system... Left groin venotomy was made and extended. An extensive amount of scarring was saline(?) as typical of chronic thromboses with recanalization and anatomy was seen. Extensive endarterectomy of the common femoral into the profunda and also the femoral vein and distal external iliac vein was performed. A bovine pericardial patch angioplasty with 6-0 prolene running suture was performed." We were unsure if open thrombectomy code 34421 would be appropriate in this case without findings or removal of thrombus. Is the reference to the scarring typical of chronic thromboses sufficient? We were unable to locate a venous equivalent to an endarterectomy. Your guidance is greatly appreciated.

EP Ablation Components

I know this has been addressed many times, but I'm still not totally clear on the requirements of the new ablation codes. The errata says to document the reason any components might not be performed in order to use code 93656, which doesn't seem logical to me since the new descriptor states "when possible". I would think the reason for not performing would be needed on 93653 and 93654 instead. Do you recommend including the reason for not performing on all three ablation codes? I realize that would seem to be the easiest fix; however. I'm still struggling to get my physicians on the bandwagon and don't want to ask for more than I need.

EP and echocardiogram

Dr Z I would really appreciate your assistance in the EP case below. The intended procedure was EP ABL w/ 3D mapping for A-fib. However all that was done was 93662 intracardiac echocardiogram which is an add on code with 93651 which did not take place. I have searched your database extensively and the only example I can come up with is for a PFO in which you suggested to use a 74 modifier for the intended procedure along with the add on code. Based on this would I charge 93651-74 and 93662. Or charge for possibly TEE 93318 as a completed procedure? Thank you for your expertise, Terri DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the electrophysiological laboratory in a fasting state. The patient's oropharynx was anesthetized using aerosolized lidocaine spray. Once sedation was achieved, I manually advanced the echo probe passed the oropharynx into the lower esophagus. Limited echocardiographic images were obtained in multiple views. FINDINGS: Left ventricle size is grossly normal. There appears to be left ventricular hypertrophy. Global left ventricular systolic function is normal. Ejection fraction is visually estimated to be 60-65%. There are no regional wall motion abnormalities. Right ventricular size and systolic function within normal limits. The mitral valve is morphologically normal. The tricuspid valve is grossly normal. The left and right atria both appeared mildly dilated, both measuring approximately 4.5 cm. The intraatrial septum is intact to 2-D imaging. There is a mass in the tip of the left atrial appendage thrombus highly suggestive of thrombus. Doppler velocities in the left atrial appendage are less than 0.4 meters per second. CONCLUSIONS: 1. Normal left ventricular size and systolic function. 2. Biatrial enlargement. 3. Left atrial appendage thrombus. PLAN: Based on this study, we will defer on left atrial ablation. His anticoagulation will be restarted and we can consider restoring sinus rhythm in approximately 1 month.

EP codes

Dr. Z, I have a couple of questions on 2013 codes. For 93656 I have heard that HRS is trying to get clarification or re-wording on the code so it does not read like all components must be done and if this is not accomplished a 52 modifier will be needed for professional billing. What are your views on this? And have you heard if there is to be any clarification of the code? Second question, there is no reimbursement on the SICD T codes is there? Thank you, Debbie Grant Follow-up Question: Dr. Z,   Thank you for your answers.  I know that you are recommending not charging for 93623 now and was wondering about 93621.  It is still an add on code to 93620 and causing an edit with 93653 and 93654 due to no primary procedure code.  What are your recommendations for this?   Thank you,   Debbie  

EP Possible Parent Coding 93653 and 93654

Below is a report from one of our physicians. Both coders disagree on the coding, and I would like your input, as it involves parent codes 93653 with 93654. Coder #1 reported codes 93654 and 93623. Coder #2 reported codes 93653 and 93621. PREPROCEDURE DIAGNOSIS Supraventricular tachycardia. POSTPROCEDURE DIAGNOSIS Typical atrioventricular nodal reentrant tachycardia. PROCEDURES PERFORMED 1. Comprehensive electrophysiology study with coronary sinus pacing and recording. 2. Arrhythmia indJction. 3. Drug infusion with isoprotereno~ 4. ~electroanatomic mapping. 5. Radiofrequency ablation of typical AV nodal reentrant ta~rdia with modification of the AV nodal slow pathway. HISTORY OF PRESENT ILLNESS This is a 61-year-old female ~.~tmedical history significant for recurrent frequent episodes o~dpalpitations. The patient had a recent visit to the hospital at Flagler where she was noted to have heart rate of approximately 200 beats per minute, which terminated with adenosine. The patient now presents to electrophysiology laboratory for further evaluation and management. DESCRIPTION OF PROCEDURE The patient was brought to electrophysiology laboratory and appropriately identified on the table. Twelve-lead ECG electrodes were placed in the patient and vital signs were recorded at baseline. A conscious sedation was administered by the nursing staff with intravenous fentanyl and Versed. The patient was prepped and draped in standard sterile fashion. Sheaths were inserted using modified Seldinger technique as indicated below. Catheters were then subsequently advanced to the sheath and placed in the heart under a cardiac fluoroscopy. Baseline intracardiac recordings were obtained followed by standard EP study. During the entire procedure, the patient's vital signs were continuously monitored, remained stable. Details of the EP study and subsequent ablation were outlined below. The patient remained hemodynamically stable and com£ortable throughout the en~ire procedure. At the conclusion of the procedure, all catheters were removed from the heart and woa~d sites were then dressed and the patient wls transferred to t~e Recovery Room '£~ea in stable condition. The postoperative orders were wfitten at that t~e. ; SUPPLIES < Diagnostic catheters were placed at the level of the high right atrium, His, right ventricular apex. A diagnostic catheter was also placed in the main body of the coronary sinus. A 4-mm radiofrequency ablation bidirectional catheter was used for right atrial mapping and ablation. BASIC EP STUDY FINDINGS 1. The AH interval was 101 msec, the HV interval was 39 msec. 2. The VA Wenckebach cycle length was 360 msec at baseline. The right ventricular effective refractory period while pacing from the right ventricular apical catheter was 220 msec at a pacing cycle length of 600 msec. 3. The AV Wenckebach cycle length was 400 msec while pacing from the high right atrial catheter. 4. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec. ARRHYTELl\,fIA AND ABLATION The patient presents to the electrophysiology laboratory in normal sinus rhythm. Following administration of conscious sedation, we proceeded with a basic EP study. The patient had normal EP study findings at baseline. Upon insertion of the catheter, she immediately went into a spontaneous supraventricular tachycardia. The tachycardia was typical AV nodal reentry for the following reasons. 1. The septal VA t~~e during SVT was approximately 0 msec, making typical AV nodal reentry the likely diagnosis. 2. The SVT tachycardia cycle length was 410-420 msec. 3. During a right ventricular apical pacing, the atrial activation sequence in the coronary sinus catheter was concentric, making left lateral pathway and AVRT unlikely. 4 .. During SVT, entrainment from the right ventricular catheter revealed a VAHV response to pacing, making atrial tachycardia unlikely. 5. During supraventricular tachycardia, right ventricular entrainment revealed a post-pacing interval minus tachycardia cycle length of 145 msec, making AV nodal reentrant tachycardia the likely diagnosis. 6. His-synchronized ventricular premature depolarizations during SVT did not reveal the presence of a septal bypass tract and was not able to the atrium. The patient had easilY sustained episodes of supraventricular tachycardia, which were spontaneous and also reproducible with both ventricular and atrial extrastimuli from the high right atrial, coronary sinus, and right ventricular catheters. We observed both echo beats and sustained tachycardia. At this t~~e, we proceeded with modification of the AV nodal slow pathway. The ablation catheter was positioned across the posterior septum just posterior t{ i the coronary sinus ostia. 3D electroanatomic mapping prior to this was used to identify the dehisced as well as the coronary sinus ostia. Ablation catheter was positioned across the tricuspid valve annulus with an A-V ratio of approximately 1-4. Using power controlled settings of 50 watts and 55 degrees under temperature, serial ablation was performed in this area. We monitored the AH and HV intervals during this time and a junctional ectopy was observed throughout the duration of these lesions. At final conclusion of my ablation, I rechecked the patient for dual AV nodal physiology. No sustained tachycardia was observed. Isoproterenol w~started up to 2 mcg per minute and no evidence of inducible SVT was no~ecr. With frequent atrial and ventricular extrastimulus pacing, the patient did have 1 echo beat with atrial extrastimuli; however, with continued decremental pacing on our extrastimulus beat, the patient would block on the subsequent beat. At this time, this was considered an acceptable endpOint as the patient previous to my ablation had easily inducible SVT. After waiting period, we attempted arrhythmia induction again and SVT was no longer observed. At this time, the procedure was terminated. AH and HV intervals remained stable and comparable to baseline. The postablation AH and HV intervals were 85 and 42 ITsec respectively. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec at this time. The catheters and the sheaths were then removed from the heart and body. Hemostasis was achieved. The patient made a complete neurologic and hemodynawic recovery. CONCLUSIONS 1. Normal EP study findings. 2. Typical AV nodal reentrant tachycardia. 3. Successful ablation of typical AV nodal reentrant tachycardia with modification of the AV nodal slow pathway.

EP repeat study

Hello Dr. Z, In your book you mention that a repeat EP study should not be coded â?oon a subsequent date unless there is documentation of a new arrhythmiaâ?. What types of circumstances would this include? VT vs. SVT? Same type of arrhythmia in a new location? Examples of when it would be appropriate to code an EP Study on a subsequent date due to a new arrhythmia would be especially helpful. I would appreciate any input you can provide. Thank you for your time. Jill Paul CPC-San Diego

Epicardial Ablation

I have never coded for the epicardial access for EP ablation and have not been able to find information. Would you give your insight on what the following procedure coding would look like? The patient was brought to the EP lab. The ICD was reprogrammed and interrogated. Both groins were prepped in the usual fashion. Local anesthetic was applied to the skin. Following a modified Seldinger technique, one 8 French sheath and one 11 French sheath were placed in the left femoral vein. A 4 French sheath was placed in the right femoral artery. Via the subxiphoid approach, epicardial access was obtained with an epidural needle and an 8 French flexible steel Arrow sheath. Mapping and ablation catheters were placed in the 9 French sheath and 9 French Arrow sheath. A 3D map of the epicardium was created. The 4 French arterial sheath was exchanged for an 8 French Arrow sheath due to the torturous nature of the aorta. During epicardial mapping an IBI HIS catheter was placed in the right and left ventricles for pacing. There was a patent foramen ovale present. The mapping and ablation catheter was advanced through the aorta to the left ventricle via the retrograde approach. Left ventricular pacing and recording were performed, a 3D map of the endocardium was created. Ventricular stimulation was performed and programmed ventricular stimulation was performed. Several different VT morphologies were induced by ventricular pacing. All of the VTs were mapped to an area posterior to the mitral valve. RF energy was delivered with termination of the VTs from within the left ventricle, epicardially, and from the anterior cardiac vein. Aspiration of the pericardial space was performed throughout the case. At the end of the procedure, protamine was given, Solumedrol 125mg was given via the epicardial sheath, the sheaths and catheters were removed, and good hemostasis was achieved with direct manual pressure.

Epidural and transfemoral injections in same encounter

What are the correct CPT codes if radiologist performs L5 epidural injection followed by L5 transforaminal injection, followed by S1 transforaminal injection, uncomplicated procedure. The only diagnosis is radiculopathy. CCI edits state that the transforaminal injection is a component of the epidural injection, but isn't the transforaminal a more selective injection? I see a prior answer that states only 1 injection procedure should be coded, but which injection? 62311/77003 or 64483? thank you.

Epidural Blood Patch

I'm coding a fluoroscopically-guided lumbar puncture and epidural blood patch. I understand the CPT codes for the epidural blood patch are 62273/77003, but I'm a bit confused as to whether I need to also report codes 62270/77003 for the lumbar puncture. "TECHNIQUE: Under fluoroscopy the L2-L3 interlaminar space was identified, and a 22 gauge spinal needle was advanced into the thecal sac. A total of 8 ml of clear fluid was obtained in four tubes and sent to the lab. At the L4-L5 level a 20 gauge spinal needle was advanced into the epidural space under fluoroscopy. Subsequently, 9 ml of autologous blood was injected into the epidural space w/o complication. The needle was then removed." Please advise regarding the correct codes to use for this procedure.

Epidural Fibrin Glue Injections

I need to confirm how to code for selective transforaminal approach epidural fibrin glue injections for treatment of CSF leak. Levels were bi-lat L1-2, L2-3, and T9-10 with contrast and fluoroscopic guided needle verification. Is it correct to code to blood patch injections because the fibrin glue is a blood products, and it used for CSF leak repair? 62273-50, 62273-50-59, 62273-50,59, and 77003? Or, 62310, 62311, and 77003? Or 64999, 77003?

Epidural steroid injection post discectomy

Dr. Z, Our radiologist did a discectomy 62287 and a week later the patient came back in because the pain was not gone. He did an ESI and transforaminal injections. My question is there is a 90 day global for the discectomy. Do I not bill for the ESI and transforaminal injections? Thanks

Epinephrine challenge

One of our EP doctors did a provocative testing drug study on a patient with recurrent syncope using Epinephrine and Procainamide. I have no idea what the code would be for this! When I checked my CPT book, it led me to 95078 which appears to have been deleted. Would I use the unlisted code 95199 instead?

EPS Study with Cardioversion

For the following report, can the cardioversion be coded along with the EPS study and injection of Isuprel? Patient was brought to the EP Lab in the fasting state, sedated by the Anesthesia Team. The right and left groins were prepped, and the right neck was prepped. A catheter was advanced. Patient had atrial fibrillation that was seen with catheter manipulation. This had to be cardioverted back to sinus rhythm. Patient had an EP study done and had no inducible SVT, no evidence for dual AV node physiology, and no evidence for an accessory pathway. VA conduction was not present. We started Isuprel, and the patient went into A-fib again, so we had to discontinue the Isuprel, and the patient received another cardioversion once the Isuprel was discontinued and went back to sinus, but then degenerated back into A-fib again. The patient also had an episode of atrial flutter that appeared to be typical flutter. Procainamide was ordered and was about to be hung, but the patient went back into sinus rhythm just as we were about to start the Procainamide. The patient was awake at this time with a baseline heart rate about 100. The EP study was repeated and again no VA conduction was seen during the awake state. The patient did have occasional episodes of a very short three to ten beat runs of nonsustained SVT that may have been an atrial tachycardia earliest in the high atrium, and it is possible that this may be the patient's clinical diagnosis. All catheters were removed. No ablation was performed. IMPRESSION: EP study significant for inducible atrial flutter, which was typical, atrial fibrillation and also a short atrial tachycardia that was nonsustained. Hard to know what is her clinical tachycardia. It may be the nonsustained atrial tach. The patient felt better on the Digoxin. We are going to resume Digoxin.

Ergonovie and acetylcholine challenge

Will you please clarify which of these instructions is the current one to go by in regard to this question posted 9/1/11: Is 93024 the appropriate code for a coronary artery spasm test using acetylcholine (acetylcholine challenge) during a heart catheterization procedure? Answer was no additional codes are reported for acetylcholine challenge tests. In AHA Coding Clinic for HCPCS Third Quarter 2009 the following coding instruction for hospital billing was given: • Do not report additional codes for performance of an acetylcholine (Ach) challenge test performed during cardiac catheterization. It is included in the cardiac catheterization procedure. Per page 505 in the Cardiac ebook: The ergonovine test - otherwise known as a "provocation test" - is not done often, but can be performed if angina is thought to be caused by coronary artery spasm. The procedure is conducted during coronary angiography.  "The artery-narrowing drug ergonovine (or, alternatively, acetylcholine) is injected to provoke coronary artery spasm.  The person's response to the ergonovine is then documented."  If the individual experiences severe arterial spasm in response to ergonovine, he or she probably has variant angina due to coronary arterial spasm. Coding Instructions: 1. Do code ergonovine provocation in addition to cardiac catheterization if documented. 2. Do not code separately for the injection of the pharmacologic agent, as it is considered part of the test and is not separately reimbursable. Thank you


If Ethiodol is injected during a visceral angiogram on a patient with a hepatic mass, is it correct to charge for an embolization?

Evaluation of Drains in 2014

It is my understanding that billing for contrast injection/evaluation of drains is discouraged in 2014. There are instances in which our doctors evaluate these because of rising bilirubin (biliary), obstruction (urinary, biliary), etc. We are a cancer center; therefore, there is quite often obstruction. In what instances are we allowed to bill for these? This is an example: "Bilateral biliary catheters were removed over a wire and bilateral cholangiograms performed from the skin surface, demonstrating poor opacification of biliary tree, worse on the right than left. Plans were discussed with patient for possible need for a third biliary catheter in future. New bilateral 10 French internal/external biliary catheters were placed over the wires and sutured to the skin." In this example would you bill for these bilateral evaluations? Am I correct in billing codes 47505/74305 twice for these (injection was performed "from the skin surface")? There are also times when a cholangiogram is done in order to determine whether internal/external drain can be internalized. Would this also justify?

EVAR and Billing

I am not able to get a straightforward answer on billing EVAR with modifier -62. Everything in print states that two surgeons are allowed to use this modifier. If an interventional radiologist and vascular surgeon are performing this procedure, but the radiologist does not make any incisions, then how can he or she be classified as a surgeon?

Exchange of Abdominal Catheter

Just curious what you come up with...thanks! PROCEDURE(S): Peritoneal Dialysis Catheter Repositioning HISTORY: End Stage Renal Disease INDICATION: Catheter Malfunction MEDICATIONS: Fentanyl 200mcg; Midazolam 4mg CONTRAST: Omnipaque 350, 3510 ml COMPLICATIONS: None. TECHNICAL: Following informed consent, and verification of the appropriate patient identification and procedure to be performed, the abdomen, including the indwelling peritoneal dialysis catheter were sterilely cleaned, prepped, and draped. Contrast was injected via the peritoneal dialysis catheter. A stiff Terumo wire was advanced through the catheter until the tip of the peritoneal dialysis catheter was redirected into a different portion of the peritoneal cavity. Post repositioning contrast injection confirmed free flow into the peritoneal cavity. The catheter was flushed with saline and sterilely dressed. FINDINGS: The existing peritoneal dialysis catheter was in a small contained space. Contrast flowed back along the distal 10 cm of the catheter until instilled into the open peritoneal space. The peritoneal dialysis catheter was repositioned from the contained space into the open peritoneal cavity. IMPRESSION: Peritoneal dialysis catheter repositioning as described.

Exchange of Biliary Draing

I have a patient that we are exchanging an external biliary tube with an internal external biliary tube. Would I just code for the placement of the new internal external tube?

Exchange of femoral CVC with bilat upper extremity selection via same acces

We did an exchange of existing right femoral CVC with the selectively of both the RT and LT upper extremity veins and  a bilateral venogram was done.  I’m thinking that we can not bill for the selection of the bilateral upper extremity nor the venogram because it is done via the CVC exchange access site and it is encompassed into the exchange code. The physician also accessed the lt ext jugular vein and angioplastied the Lt Brachiocephalic vein (occlusion) and placed tunneled CVC. Your thoughts,

Exchange of Rt femoral CVC with bilat upper extremity selection same access

We did an exchange of existing right femoral CVC with the selectively of both the RT and LT upper extremity veins and a bilateral venogram was done. I’m thinking that we can not bill for the selection of the bilateral upper extremity nor the venogram because it is done via the CVC exchange access site and it is encompassed into the exchange code. The physician also accessed the lt ext jugular vein and angioplastied the Lt Brachiocephalic vein (occlusion) and placed tunneled CVC. Your thoughts,

Excision of Infected Stent Graft Under the Clavicle

Could you please assist with coding the following? Indications and findings: ESRD patient noted swelling in the region of his LT chest/shoulder. MRI suggested a subcu mass superficial to the mid clavicle, suspicious for a complex loculated fluid collection, with angulation of the stent. The patient's stent graft in the axillary vein was known to be thrombosed.  I&D of abscess was performed; however, after one month, the wound has not completely closed. Today, the patient was found to have a chronic draining sinus, which extended down below the clavicle. There was an infected stent graft within the axillary vein identified at this level. The vein wall appears to have necrosed, and purulence was identified associated with the graft. After establishing proximal and distal control, the stent graft was removed. (From body of note:) ...I then made a curvilinear incision around the base of the previous LT shoulder wound....this was deepened and extended toward the clavicle....we also began exploring the base of the wound...the center of the wound...could be probed down and there appeared to be a sinus tract going below the level of the clavicle. We continued our excision of the surrounding tissue in an elliptical fashion along this sinus tract. At the base of the wound, we identified an FB...we identified a stent graft, going along with the history of previous LT axillary stent graft placement...we extended our incision medially and laterally along the course of the clavicle. This gave us better exposure along the segment of the axillary vein. This procedure does not fit codes 35903 nor 35905 [site is shoulder/chest, instead of extremity or thorax (within pleural space)]. Do we need to go with an unlisted procedure code?

Excision of Seroma Capsule

I have asked other coders and no one really can give me a clear answer on this... A patient develops a seroma, and an incision is made and it's drained, then the decision is made to excise the capsule. Since it is connected to the artery normally, it is more complex than just an incision and drainage. So what would you code the excision as?

Expiring Code HCPCS G0275

Any suggestions for a replacement code for G0275?

Explanation of Dual Chamber Pacemaker and Implant of Single Chamber Pacemaker with Issues

"An incision was made paralleling the old scar, and the pacemaker was isolated. The pacemaker was explanted, and multiple attempts with multiple screwdrivers were made to detach the atrial and ventricular leads. The screws were stripped, and the patient is pacemaker-dependent. Attempts were made to access the left subclavian vein, but the lead would not pass at the junction of the subclavian vein and superior vena cava due to an occluded vein. The pacemaker was placed back in the pocket temporarily. A new pacemaker pocket was created on the right side. The pacemaker was implanted, and the ventricular lead was advanced to the level of the right ventricular and sutured in place. The atrial port was plugged. Attention was turned back to the left side. The leads were removed by pulling the leads apart from the headers, and the leads were capped. The pacemaker was explanted, and the pocket was irrigated." Would I bill code 33228 or 33227 since the final result was a single lead system as well as code 33222 for a pocket revision?

Exploration of vessel

Hi Dr. Zielske and Dr. Dunn, I need some assistance with coding a femoral vein venotomy and foreign body removal. This is a condensed portion of the procedure: During an IVUS procedure of the IVC and lower extremity veins stenosis was found in the left common iliac vein. Angioplasty was done on this vein. Balloon ruptured and upon removal the balloon remained in the left common femoral vein and became detached from the catheter. An incision was made over the left groin and a left femoral vein exploration was carried out. The femoral vein was identified and a venotomy performed. The ruptured balloon was then extracted under direct vision from the left femoral vein and the venotomy was repaired with 4-0 Prolene until hemostasis was achieved. I have searched my CPT book and have come up with 35226 for repair of a blood vessel or 37799 for an unlisted vascular procedure. Is there a better way to code this? As always, thanks for your assistance. Pam Johnson

Exposed Opthalmic Catheterization

I need advice with the following case please. "Intra-op direct exposure of superior opthalmic vein with angiocath access was secured. Patient then brought to IR department for embolization of carotid-cavernous fistula. In IR, angiocath sticking out of opthalmic vein accessed with microcath and moved to cavernous sinus with coil placement. After embolization, patient went back to operating room for decannulation and ligation of opthalmic vein."  Would you do anything for the catheterization into cavernous sinus from superior opthalmic (36211)? Unlisted (36299)? Or just stick with embolization codes and follow-up angio from RCCA? There is no mention of imaging findings through opthalmic vein, just advancement of microcath and coil embolization into cavernous sinus.

Expression of blood post plebectomy

If a patient comes in to have a varicose vein procedure (phlebectomy 37766/endovenous ablation 36478) and they’re within the global period of having the same procedure done on the opposite leg, and during this visit the physician nicks and expresses old blood from the previous wounds, would 10140-79 be appropriate for that?  I put a -58 on the 37766/36478.  Or wouldn’t the 10140 be billable? Thanks!

Extension vs. Stent placement

If a physican places a stent at the time of an AAA graft, but he specifically states it is for stenosis, do you use code 37221 or 34825? It is placed inside the distal portion of the graft down to the external iliac stent that was placed at a previous session.

Extensions, 34825

I have another question for you this morning...if extension pieces are placed after an endograft and two pieces are placed in the same overlapping the other to make it longer, would you consider that one 34825? I didn't think 34826 would be appropriate since it was within the same vessel...It was mentioned that 34825 x2?? your thoughts? thanks!

External Biliary Drain Replacement

Patient presented to the ER after biliary drain fell out. Initially the tract was recanalized with a Kumpe catheter and a Benston wire. Following a diagnostic study, the tract was dilated, and a new 8.5 Dawson Mueller external biliary drain was replaced. Can we report this with codes 47500/74320 and 47510/75980?  Or report this as a replacement with code 47525? If we code this as a replacement, how do we capture the diagnostic study?

External Marking Scans Pre-Biopsy Procedure

In your Diagnostic Radiology Coding Reference book, page 212, item 10, it states it is appropriate to report code 76645 when ultrasound is used to externally mark the breast for subsequent biopsy or aspiration. Does this concept apply to all biopsy/aspiration procedures (e.g., thyroid biopsy)? If yes, do we need to append a -52 modifier to the limited scan CPT since it is not a complete scan?

Externalized Pacemaker Insertion

We had a patient who needed a pacemaker in place for anticipated surgery, but could not have a permanent pacemaker due to infection. So a permanent lead was placed in the right ventricle through the jugular vein and attached to a new single chamber permanent pacemaker externalized. What can I charge in this case?

Extremity angiograms

A patient comes in on day one and has an aortogram and right lower extremity angiogram. Doctor starts TPA infusion in SFA, then later in the day does a follow-up. Day two, he does a follow-up and left lower extremity angiogram. My codes are 37201, 75896-59, 36247-RT, 75625, 75710-RT and 75898 for day one. Day two 75898 and 75710-LT. Should I code for two separate lower extremity angiograms or combine them using 75716 since it was a continuing procedure. Thanks, Cynthia Boyer

Extremity angiography before transfemoral heart valve implant (TAVR)

This may be the second time I'm sending this, I can't tell if the first one went through.... Hello Dr. Z and Associates, Our physicians have started performing peripheral angios and IVUS to evaluate lower extremity peripheral arteries for possible transfemoral heart valve implant (0256T). This is normally done a few days before scheduled valve implant. Would this meet medical necessity requirements for 75716 and/or 75945/75946? Thank you!

Extremity Bypass Graft

I have never coded a procedure like this, so I would love your assistance. The surgeon did a right fem bypass graft to the left iliac artery. He then attached the iliac artery on the left to the previous fem/pop bypass graft on the left. Then from the pop bypass graft he did a graft to the tibial artery. Would you use code 35665 ileofemoral and then 35671 popliteal-tibial? The right femoral to left iliac has got me stumped.

Extremity Distal Bypass Graft

Is it okay to use code 35571 for distal bypass graft to dorsalis pedis artery using cryopreserved saphenous vein? Or should we use code 35671?

Facet Cyst

The radiologist injected bivicaine into the L4-5 & L5-S1 facet joints bilaterally. He also aspirated synovial fluid from the right L5-S1 facet joint. How would you code the aspiration?

Facial sclerotherapy

Hello Dr. Z A percutaneous neuro sclerotherapy was done on facial venolyphatic malformations. The ethanolamine was injected through a direct puncture 22 gauge butterfly needle of the mandible lesion with live fluoro Should the 37799 or 36470 code be uses along with the 77002 for needle placement guidence?

Failed Lumbar Puncture

If we went through the whole process of performing a lumbar puncture after anesthetizing the area and could not obtain any fluid, do I have to modify the procedure as attempted but failed?

Failed/Unsuccessful CTO Crossing Lower Leg

How does one properly code for a failed/unsuccessful procedure to recanalize (cross a CTO) an obstructed peripheral artery (e.g., lower leg)?

FB Modifier Pertains to 2013

If a warranty credit is received in 2014 for a procedure that took place prior to January 1, 2014, do we still use the -FB/-FC modifiers? Following is an extract from MLN Matters® Number: "MM8572 No Cost/Full Credit and Partial Credit Devices Effective January 1, 2014, CMS will no longer recognize in the OPPS the FB or FC modifiers to identify a device that is furnished without cost or with a full or partial credit. Also effective January 1, 2014, for claims with APCs that require implantable devices and have significant device offsets (greater than 40%), the amount of the device credit will be specified in the amount portion for value code “FD” (Credit Received from the Manufacturer for a Replaced Medical Device) and will be deducted from the APC payment for the applicable procedure."

Fem-Pop Bypass with Angioplaty of External Iliac Artery

My physician completed a right fem-pop bypass using saphenous vein. As the right external iliac was not clampable for an endarterectomy, he instead balloon angioplastied the stenotic segment and placed a stent through a micropuncture needle in the common femoral artery. I would only code for the bypass, as I would consider this part of localized inflow and outflow. My provider disagrees and thinks this should be billed in addition to the bypass. Can you please provide your thoughts?

Femoral arteriovenous fistula for a pedicle free flap to lumbosacral area

Greetings, I have a physician completing a femoral arteriovenous fistula for a pedicle free flap to the lumbosacral area. They tried a iliac artry exposure first but due to scar tissue they had to expose the femoral vessels. The physician harvested the entire greater saphenous vein,then anastomosted the vessel to the common femoral artery. This was then tunneled to the lumbosacral area. While tunneling the illiac vein was injured. How would I code this? A fistula tranposition code with a 36818- 22. The unlisted code 37799. Do you have any advice? Thanks, LW

Femoral to Femoral Bypass Same Leg

How do I code for a common femoral to profunda bypass using a Dacron graft same leg?

Fenestrated Codes for 2014

My question is regarding the new codes for fenestrated grafts for repair of the visceral aorta. Am I assuming these codes apply to grafts from the manufacturer and ones that are custom made by the surgeon in the OR suite?

Fenestrated EVAR

Our practice just performed their first fenestrated EVAR. They used a fenestrated aortic cuff with a bifurcated stent graft. They also stented both renal arteries with iCAST stents and used an extension on the right iliac and used an iCAST stent on the left iliac. From what I have researched, I believe the codes would be 0078T, 0079T, 0080T, 0081T for the fenestrated cuff with bifurcated EVAR graft, and codes and 34825, 75953-26 for the extension on the right iliac. Are the renal stents included in the fenestrated graft codes, or can they be coded additionally? And can the iCAST stent for the left iliac be coded with 37221? A stent was done because 'there was only 4-5 mm of available iliac artery to extend the graft and there was noted to be poor apposition of the stent wall due to tortuosity of the proximal iliac artery'.

Fenestrated Repair of Aortic Dissection

We've just done our first fenestrated repair of an aortic dissection, and we are needing help with coding it. Can you help us? Here is what was done: 1) Successful balloon-assisted juxtarenal and infrarenal aortic fenestration. 2) Unchanged SMA occlusion. Patent celiac axis, IMA, and bilateral renal arteries. 3) Occlusion of right common iliac artery successfully treated with bare metal stent.

Fetal Cardiac Interventions

One of our doctors will soon begin doing fetal cardiac interventions (aortic valvuloplasty, pulmonary valvuloplasty, ASD creation, pacing) in conjunction with doctor from Maternal Fetal Medicine for the access to the fetus. Any idea how both doctors would bill for these procedures? Please help.


The doctor did a FEVAR (with the graft covering the entire abdominal aorta) with placement of stents into bilateral renals and bilateral femoral exposure. One side was inserted through the "scallop" and the other through the fenestration. Is this reported with code 34846? Or with codes 34845 and 37236?

FFR 93571 and Drug-Euting Stent C9600

We are hitting an edit whenever we code an FFR 93571 with a drug-eluting stent procedure. We are told that we need a primary procedure code with 93571 and that C9600 is not acceptable. (Note, this is a hospital.) The acceptable codes for 93571 are the heart catheterization codes and the bare metal stent codes. I would appreciate you help.


Dr Z ~ Now that we can charge for individual vessels for PCI (LAD, diagonal) can we also charge separately for Radi wire diagnostic, per vessel (93571 and 93572)?

FFR in renals

Hi Dr Z, One of our physicians recently performed a bilateral renal angiography, and placed a FFR wire in the left renal artery. It is my understanding that the FFR is not separately billable with a non coronary angiography. Thank you

Fibrin sheath disruption with a balloon

Distruption of fibrin sheath with angioplasty balloon 2011 Z Health Vascular & Endovascular Coding Reference lists 36595-52 & 75901-52. Distruption of fibrin sheath with angioplasty balloon 2012 Z Health Cardiovascular Coding Reference lists 36595-52 & 75901 without the 52 modifier. Why the difference in 2011 & 2012?

Fibrin Sheath PTA for Hospital (Same Access)

Can you please explain why when fibrin sheath PTA is done via the same access in a hospital facility modifier -52 is not utilized only on the physician side? This modifier is used in other outpatient hospital coding and is approved per the CPT Manual (where modifiers are listed). I know this is in your literature but not the explanation behind it.

Fibrin Sheath vs. PTA

Is the following coded as a fibrin sheath (36595-52), a PTA (35476), or both?  "A pull-back SVC venogram was then performed, revealing a fibrin sheath and stenosis at the superior cava/right atrial junction. The existing catheter was exchanged for an 11 French vascular sheath. Balloon angioplasty was performed using a 12 mm balloon, followed by a 14 mm balloon for fibrin sheath disruption and stenosis dilation. Follow-up venogram demonstrated satisfactory results with disruption of the fibrin sheath and slight improvement in the SVC stenosis."

Fiducial Markers

Is a biopsy performed at the same time as a fiducial/vesicoil placement inclusive? So, if the physician performed a vesicoil placement in the chest under CT guidance and performed a biopsy at the same encounter, I would report codes 32553 and 77012 only, correct?

Fiducial Markers and Biopsies

I had previously submitted the question, if a biopsy and a fiducial placement were performed at the same encounter, could they both be billed. You answered that they COULD both be billed. My compliance department wants to make certain they can both be billed if the biopsy and fiducial marker placement are performed from the same access point with the same needle.

Filter Removal

We have multiple opinions flying around on this one, so I wanted to run it by you. Patient has/had DVT of the lower extremities and had a filter placed. She is seen now to have a lower extremity venous ultrasound done prior to removing the filter to check the status of the DVT. On the left it looks to have resolved, but on the right it's undeterminable if it has completely resolved. Would you use the DVT diagnosis (453.41/453.42), a follow-up (V58.81/V58.89), or a pre-op (V72.83) diagnosis code? I'm leaning towards the DVT, but a few do not agree, so I was hoping to get your opinion on it.

Filter retrieval from the pulmonary artery, 37193

Dear Dr. Z: IVC filter migrated into the right lower lobe pulmonary artery requiring removal. Would 37203, 75961, 36014 be reported or would we report the standard filter retrieval 37193? Thank you. mlb

Filter wire

I apologize for my last question: It should have read what is the coding difference between a flow wire/pressure wire (93571-26) and a filter wire. I do not have a code for the filter wire.

Fistula Anastomosis

Is the fistula anastomosis considered an arterial anastomosis or a vein anastomosis? I have been coding a stenosis in the fistula anastomosis (like a brachiocephalic fistula) with codes 35475/75962.

Fistulogram and intervention in two settings

Dr Z, we had an interesting case in which a patient with a brachio-cephalic AVF was complaining of severe arm swelling. Fistulogram was performed revealing the fistula to be widely patent, so an upper extremtiy arteriogram was performed revealing an occluded brachial (just distal to the anastomosis) and ulnar artery, as well as occlusion of a previouslly placed stent in the left subclavian. At this point the sheath is pulled and hemostatis is achieved. Vascular surgery consult is obtained. Later the same day, they re-access the AVF, but this time a diagnostic exam is not performed, just thrombectomy and restenting. How do you recommend we code the re-accessing of the AVF on the same day, should we use 36148 even though it is a separate session? Thank you

Fistulogram with Thrombolysis and PTA Coding Assistance

The following case was coded with 35476, 36870, 75978, 36147. We were asked to add codes 37212 and 75791 by our HIMS dept. Not sure if this would be appropriate. "The graft was accessed with a micropuncture needle in an antegrade fashion. A fistulogram was then performed from the right atrium to the level of the fistula. Two improve visualization of the central stenosis a Kumpe catheter was advanced to the subclavian vein and subsequent venography performed. Fistulogram demonstrated a large thrombus within the fistula distal to the venous anastomosis. Thrombolysis was performed and this thrombus was laced with 6 mg of TPA. After a short waiting period a catheter and wire were advanced beyond the thrombus. Another 6 mg of TPA were used to lace the venous outflow thrombus. Mechanical thrombectomy was performed through the outflow vein and the fistula thrombus. The above described conduit and venous outflow stenosis was negotiated with a glide wire. Subsequent balloon angioplasty was carried out without significant residual. Brisk flow was acheived."

Flair and Fluency stent grafts

Hello. My question is regarding C1874 stent coated/covered with delivery system. Is the flair stent inserted in this example a drug eluting stent? Does the HCPCS code C1874 necessarily equal a drug eluting stent? thanks for your help! Utilizing 2% lidocaine as local anesthesia a 21-gauge needle was corrected into the arterial limb of the AV dialysis graft directed towards the venous anastomosis. Subsequently, a AV shuntogram was performed demonstrating a high-grade focal stenosis involving the venous anastomosis. A 6 French sheath was placed and the anastomosis crossed. This was then dilated to 7 mm which appeared to improve flow, however, residual intimal regularity remains. As a result, a 7 mm x 5 cm fluency stent was deployed across the venous anastomosis. This was then dilated to 7 mm. The graft also demonstrates mild diffuse intergraft stenosis. This was also dilated to 7 mm. A post procedure shuntogram demonstrates no significant residual stenosis, however, the thrill was suboptimal following this procedure. As a result, the arterial anastomosis was evaluated. This demonstrates a high-grade arterial anastomotic stenosis. A 21-gauge needle was then directed into the venous limb of the graft directed towards the arterial anastomosis. A 5 mm x 2 cm balloon was then inflated across the anastomosis. A post procedure fistulogram was then performed demonstrating no significant residual stenosis. A nice palpable thrill was achieved within the graft. As a result, the access guidewires, vascular sheath, and balloon catheter were removed.

Flecainide challenge

Dear Dr. Z, Thank you for taking the time to consider my question. Our facility treated a patient who they suspected as having Brugaga Syndrome so a flecainide challenge was done. The patient had a base EKG done then was given 400mg of oral flecainide. EKG’s were then done after one half hour, one hour, two hours, three hours and four hours. My question is what CPT code (if any) would be appropriate for this procedure? I have reviewed the Noninvasive Physiologic Studies and Procedure section of the CPT book and 93799 – unlisted cardiovascular service or procedure is the only one I feel can be used. The other option I have considered is to only code the EKG’s and not apply a code for “flecainide challenge”. Thank you in advance for your input. Debra Patterson, RHIT

Flolan 93463

Can we use 93463 for the evaluation of pulmonary hyperetnsion reversibility using intravenous Flolan (epoprostenol)during a right and left heart cath?

Flow Diversion into A1 and M1

I am coding a case of a dissecting aneurysm of the supraclinoid left internal carotid. The physician used a Y-stenting technique without the use of coils to divert flow and "occlude" the aneurysm. One stent was placed in the supraclinoid ICA and A1 segment. The M1 segment was selected through an open cell of the previously deployed stent, and a second stent was deployed in the supraclinoid ICA and M1 segment, bridging the aneurysm. This created aneurysm occlusion through flow diversion. Would this be coded as an intracranial embolization with code 61624, or should I use an unlisted code? I have read that this is a new technique used for wide-necked aneurysms, aneurysms where the emanating branches are incorporated in the sac, or it's a giant aneurysm causing mass effect.

Fluoro Guidance during Operating Room Procedure

Can we charge for fluoroscopy guidance (77003) when the fluoroscopy is provided by a radiology tech and the procedure is performed by a surgeon? The surgeon dictates fluoroscopy guidance was used in the operating room procedure. An example is code 62311, epidural injection (myelogram, epidurogram, and arthrogram are not performed in the OR procedure).

Fluoro guidance for epidural and facet injections

Dr. Z, If a patient recieved an epidural injection along with a facet injection, can I add a modifier 59 to 77003 (fluoro guidance for the epidural)? Patient has right lower back pain radiating to the right lateral thigh. Impingment of right L3 and L4 nerve roots seen on recent MRI. Patient also has moderate central canal stenosis and facet arthrosis per the CT done 9 days earlier. Thanks for any help you can give me. Michelle

Fluoro Guidance with Port Removal

One of our IR docs is taking a spot image after removal of a port and cath, and we are trying to determine if it is appropriate to bill code 77001-26 in this circumstance (pro fee side).  What are your thoughts?

Fluoro of the diaphragm with heart cath and biopsy

Here is a brief synopsis: the patient is having prolonged post-transplant hospital course with persistent pericardial effusion and persistent mild respiratory distress. The patient presents to cath lab for fluorscopic evaluation of the diaphragm as well as her routine post-transplant RHC and biopsy. The eval of the diaphragm is a fluoroscopically saved image which demonstrated that the left hemidiagphragm is paretic with evidence of paradoxial motion of the diaphragm. The existing pericardial drain and 350 ml of straw-colored fluid was removed. Oximetries & hemodynamics of the RH were done pre and post pericardial drainage. Endomyocardial biopies were done X5. I wanted to bill 93451-26-59, 93505-26, 33010, and 76000-26. However,76000-26 hits an edit with 93505 as bundled and no modifier is allowed. Is there another code I should be using or is the evuluation of the diaphragm non-billable? Thanks so much for your help with this scenario!!!

Fluoroscopic insertion of spinal fiducial marker

What are the appropriate facility codes for the fluoroscopic insertion of spinal fiducial markers for a spinal tumor? If the patient is a medicare outpatient, would HCPCS C9728 and 77002 be the correct codes for this type of case?

Fluoroscopy and G0260

Dr.Z, Since code 27096 now includes fluoro, does G0260 follow the same rules and include Fluoro? Thanks so much Henri

Fluoroscopy and room time

Dr. Z, a facility wants to charge 76001 for a tech and a fluoro machine being in the OR for more than an hour even though the documented time for use of the fluoro is less than an hour. There is a physician in the room for more than an hour but the fluoro machine is not being used for the whole time. What is the correct way for the facility to code for the fluoro when the OR procedure does not involve an S&I code and the documented time is less than time in the room. Thank you.

Fluoroscopy Documentation

Is it enough to dictate that 6 minutes of fluoroscopy was used to support the use of the code 77001 or 49440? If not, what would be the appropriate documentation? For example, if the dictation stated that the wire was advanced under fluoroscopic guidance, is that enough? Or should the use of the fluoroscopic guidance be matched up with the final placement of the catheter?

Fluoroscopy to check a valve or a lead

Hi Dr. Z We were discussing the fluorscopy code (76000) vs the cineradiography code (76120). If the doctor uses fluoroscopy to check on a valve or a lead, takes some images and that is all....which code is appropriate or can both be used? Thanks for your help!

Fluoroscopy with Tunneled Catheter Removal

Original Question: Will you please address the issue of tunneled catheter removal since it now has its own code (32552)? Is it appropriate to code a fluoro guidance code, 76000 or 77002? I don't get an edit, but the your IR book states S&I is N/A. In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter. The catheter could have been compromised because of infection. Why is this?  Thank you! Additional Information: In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter.  The catheter could have been compromised because of infection.  

FNA Thyroid

We have a question regarding FNA of thyroid nodules. We have a physician who mentions in his report that he is doing a capillary and suction technique, but never mentions FNA. When we say we need documentation for FNA versus core, his reply is "capillary and suction technique" is FNA. Can we assume and code these as FNA? Please advise.

FNA vs. Core Biopsies

I have a radiologist who has told me whenever he does a biopsy of the thyroid it is always core; however, he never dictates "core" in his reports... he always just says "tissue". Pathology from the hospital always says FNA. So my question is, do I report code 60100 because that's how he instructed me to code, or do I go with the pathology and report code 10022?

Foley Balloon Placement in Pleural Space

We have a patient who had an IR px for insertion of a Foley balloon into the pleural space with injection of calcium channel blocker to stop a massive hemothorax.  Once bleeding was controlled, it was determined that the intercostal artery was punctured from a previous chest tube placement. Do you have a suggested CPT code and ICD9 px code?

Foley catheter placement in the cath lab or EP

Can we code/charge for foley catheter placement in Cath lab or EP lab? It's done prior to long procedures in EP. It's done in the Cath lab if the bladder is too full or patient will have difficulty using bed pan after procedure. As always, we appreciate your assistance! Thank you!

Follow up CT MRI during 90 day global

Dr. Z, Our radiologist does Discectomies, vertebroplasties, and kyphoplasites quite a bit. He always has a follow up CT/MRI in 2 weeks to 1 month. These procedures have a 90 day global, can I charge for the follow-up CT/MRI? Thanks

Follow-up angiography

For follow-ups post infusion/embo (75898), I know it's to be done once (other than for intracranial procedures), but my physician asked about doing multiple AVM's (right and left lung), if they embo there, is that still just one follow up? or would it be two, one for each lobe? Same for multiple hepatic tumors? one follow up even if they embo multiple tumors through different cath. placements? thanks!

Follow-up angiography following cerebral aneurysm embolization

Please do NOT include any actual patient medical records with your question. DR Z I have a general question about Follow-Up (75898 ) charges. We coiled a cerebral aneurysm. Nine coils were placed into the aneurysm but only the last 2 were deployed.The other seven were removed because the DR did not like their placement. After each placement a follow-up angio was performed. Do you charge 9 follow-up's or only 2 for the 2 coils that were leftin for the embolization? I say you only charge Follow-up for the coils that actually embolized not the ones that were removed. TY

Follow-Up Diagnostic Mammography with CAD

A question came up as to whether or not it is appropriate to charge for CAD when performing "spot compressions" on a follow-up diagnostic mammogram. Is there a requirement for the type/number of images on a diagnostic mammogram in order to charge CAD?

Follow-up on Carotid Cavernous Embolization

"Patient had right-sided carotid cavernous fistula and upon imaging before embolizing the right they discovered that a left carotid cavernous fistula was present, so they came back two days later to embolize the left. They performed a bilateral cerebral angiography from the common carotids prior to the embolization, which was performed from the left cavernous sinus via femoral vein access. After embolizing, the physician came back and performed cerebral angiography as a follow-up from the bilateral internal carotids, the bilateral external carotids, and the left vertebral." So my question is, can I code the extrernal carotids as angiography?  Or do I have to consider those a follow-up? Also since the catheter went further and since we code to the highest catheter placement, I am unsure if I should code the highest order and use the internal carotid code 36224 instead of the common carotid code 36223... or should it be 75898?

Follow-up to Cone Beam CT coding (Question 2143)

Does a separate report need to be created to support the filing of both codes 76380 and 76377 when a cone beam CT hepatic artery injection and 3D reconstruction are performed in conjunction with diagnostic hepatic arteriography in Y-90 planning? Alternatively, in reporting codes 76380 and 76377, is it sufficient to only note that the cone beam CT was completed during the angiographic procedure? Findings are reported as a single discussion without specifically noting what modality (angio or CT) was used, both having been completed. Reference is made to the angio and CT in the conclusion. How much documentation is required to support these codes?

Fontan Fenestration dilation

Dr Z, What is the appropriate code for balloon angioplasty of a Fontan fenstration? " we then turned out attention to the Fontan fenestration. We crossed the Fontan fenestration with a coronary wire and glide catheter. We then exchanged the Glide catheter for an Apex RX 4.5 mm x 20 mm balloon. We advanced the balloon over the wire, across the Fontan fenestration and made a total of 3 inflationsfor a total of 6 seconds each. We then repeated the IVC angiogram and this revealed much improved shunting throught the Fontan fenestration and a slight drop in arterial saturations." Cath lab is using 92992, however I don't think that's correct. Is this an unlisted 93799 or would it code to a valvuloplasty code? Thanks!

Foreign Body Removal of Occluder Device

After a PFO closure procedure (93580) the occluder device was seen to be floating in the left ventricle. During a second procedure, on the same day, the same doctor retrieved the device. To capture the device he actually pulled it back into the ascending aorta and there successfully pulled it into the sheath. Can I use code 37197 for this procedure or go to an unlisted procedure code?

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