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DynaCT coding

Greetings, Dr. Z, I have couple of questions regarding coding for this imaging devices; Dyna CT study and 180 degree Rotational angiogram. We have more and more procedures performed with using Dyna CT imaging. Our physicians asking if we can use code 3-D imaging codes (76376/76377) for the time and effort it takes to perform this kind of study including interpretation documented in the report. The following procedures are case examples we need coding clarification please: 1) Fluoroscopically-guided sacral mass biopsy and Dyna CT study was performed to delineate the position of the marker needle in relationship with the sacral mass. Once the position was established, biopsy needle was introduced and advanced toward the lesion. Confirmation of biopsy needle placement in the mass was performed by obtaining a second Dyna CT. (20225, 77012, 76377 Dyna CT post process is always on a separate workstation). 2) Fluoroscopy guided Lumbar kyphoplasty L4 and confirmation of bilateral cannula positioning was performed by obtaining a Dyna CT study. (22524, 72292, 76377) 3) Bilateral renal vein sampling and Dyna CT study (36500-50, 75893, 75893-59, and 76377) 4) Intracranial vessel angiogram, status post clipping communicating artery aneurysm now here for follow-up imaging. Selective left common carotid artery catheterization and angiogram with findings documented, a 180 degree rotational angiogram was also performed during injection of the left common carotid artery with findings documented (36216, 75665, 76377). Greatly appreciate all your recommendations and guidance.

Dynamic CT Myelogram of the Cervical and Thoracic Spine

The study performed was a myelogram, but instead of using conventional fluoroscopy, they did it under CT (62284, 72270, 72126, 72129).  Please advise us on coding and documentation.  "Patient in CT room, L2-L3 level was localized using CT scouts.  Needle was placed into the thecal sac under intermittent CT/scout guidance. Then underwent multiple CT scans using dynamic CT myelographic method. (1-5) acquisitions were performed using a cranial to caudal technique.  After injection of the full amount of intrathecal contrast to include the cervical and thoracic spine. Cervical: Ventral epidural extravasation of CSF is observed at the C4-5 level where there is also anterior cervical fusion with ventral plate. No other area of CSF leak is identified.  Anterior fusion hardware is also seen at C6-7.  Hardware is intact and unremarkable.  One of the C5 screws extends to the posterior cortical margin of the C5 vertebral body.  Vertebral body heights and alignment are maintained.  No fracture is seen.  Th: Vertebral body heights and alignment are preserved. No CSF leak is evident."

E&M

Seeing patients with advanced vascular disease we run into patients with multiple diagnoses outside of the vascular specialty. Once we report the E&M code and determine the appropriate principal vascular code(s), is there a benefit to submitting additional non-specialty vascular codes such as ring worm or diverticulitis (etc.) when submitting a claim? Is there anything lost or anything gained by including diagnosis codes that are outside the vascular specialty when submitting claims?

E&M

We are wondering if it is proper to charge an E&M code when we are performing a cardiac test on the same day in an outpatient setting. We would be the attending.

E&M codes and diagnostic angiography

I have searched the Q&A database and cannot find an answer in either that or the CCI Edits. Recently our medicare carrier has been denying procedure code 75625 billed with 2659 modifiers as this was performed at the hospital along with some other codes. They are denying this code against a visit code of 99204 which makes absolutely no sense at all. I see no edits on your site or in my recent CCI edits that we receive quarterly. I called Medicare and the person I spoke with said that it could not be billed with a visit code. Just wondering if you know anything of this. I could understand if it was being denied against another radiology code but not a visit. I just don't know what to do about this, as they are paying the same code when done at our free standing cath lab with no problem. Two differences are, at our facility we do not add the professional component modifier and I am not billing the visit code. Thanks Jene Central Florida Heart Center

Echo and fluoroscopic guidance 77002 and 76930

If a pericardiocentesis was performed with both echo and fluoro guidance, can we report both 77002 and 76930 for guidance?

Echo Dictation 93306

For echo (93306), what are the minimum required statement/elements needed to be mentioned or described by the dictating physician in order to code a full study?

Echo requirements

In reveiwing the two Echo interps below, I don't see documentation to support that the pericardium was evaluated. Per CPT guidelines, that is the only thing I see that is lacking in order to bill each of them as a complete Echo. Am I missing it? Thanks so much for your help! 1st Patient Example Indications for Study:TETRALOGY OF FALLOT. 745.2, F/U Procedures:CONGENITAL COMPLETE W/ DOPPLER AND COLORFLOW, Congenital Echo, Doppler and Color, Ekg, Colorflow Mapping, Echo Congenital Limited, Intracardiac Doppler Race:Caucasian Session ID: ************************************ SUMMARY: ************************************ Poor acoustic window. s/p repair of Tetralogy of Fallot, pulmonary atresia. with unifocalization. S/p bilateral branch PAs stent. H/o para-aortic abscess. s/p RV to PA conduit replacement. Stable paraaortic abscess pouch, unchanged from the previous study. Mild aortic regurgitation, stable. No residual VSD. No RVOT Doppler interrogation. Trivial regurgitation. Unobstructed flow through the steneted branch PAs. Mild dilatation of right ventricle with qualitatively normal systolic function. Normal LV systolic function. Atria: Situs: Solitus. RA Size: Normal. LA Size: Normal.Septum: Normal Defect sz. None. Shunt: None. Ventricles: D-looped LV size: Normal. LV function:Normal. Rv size: Dilated. RV function: Normal. IVS: Motion: Normal. Defect Type/Size: None./None. Shunt: None. ___________________________________________________________________________________________________ Grt Vessls: Normal. Aortic Root: Normal. MPA: RV-PA conduitLPA: StentedRPA: Stented Coarctation: No. PDA: No. Shunt:None. Coronaries: NOT VIEWED Systm Veins: SVC: Normal. IVC: Normal. Pulm Veins: Visualized: 2/4. Connections: 2/4 visualized ___________________________________________________________________________________________________ Mitral Valve: Structure: Normal. Stenosis: No. Regurgitation: No Tricuspid Valve: Structure: Normal. Stenosis:No. Regurgitation: Mild , estimated RVSP 40 mmHg+RAp. Pulmonary Valve: Structure: S/P HOMOGRAFT Stenosis: Not interrogated Regurgitation: Trivial. Aortic Valve: Structure: Normal. Stenosis: No. Regurgitation: Mild ************************************ MEASUREMENTS: ************************************ MMODE Left Ventricle LVIDd 5.29 cm (3.81-4.63)* LV%fs 37.8 % (28-40) LVIDs 3.29 cm (zsc -0.08) 2nd Patient Example ************************************ SUMMARY: ************************************ Limited subcostal views LV normal size and systolic function Atria: Situs: Solitus. RA Size: Normal. LA Size: Normal.Septum: Limited views Defect sz. None. Shunt: None. Ventricles: D-looped LV size: Normal. LV function:Normal. Rv size: Normal. RV function: Normal. IVS: Motion: Normal. Defect Type/Size: None./None. Est. LV-RV Press. Gradient:____mmHg. Shunt: None. ___________________________________________________________________________________________________ Grt Vessls: Normal. Aortic Root: Normal. MPA: Normal. LPA: Normal.RPA: Normal. Coarctation: No. Type: _____. Est. Pressure Gradient: _____mmHg. PDA: No. Shunt:None. Coronaries: Normal LCA, RCA origin not seen Systm Veins: SVC: Not viewed IVC: Not viewed Pulm Veins: Visualized: 2/4. Connections: Normal. ___________________________________________________________________________________________________ Mitral Valve: Structure: Normal. Stenosis: No. Regurgitation: No. Mitral 1/2 time____. Tricuspid Valve: Structure: Normal. Stenosis:No. Regurgitation: Trivial Est. RV pressure_____.+ RAp. Pulmonary Valve: Structure: Normal. Stenosis: No. Mean ___mmHg, Peak___mmHg. Regurgitation: No. Aortic Valve: Structure: Normal. Stenosis: No. Mean ___mmHg, Peak___mmHg. Regurgitation: No.

Echocardiography

I am new to cardiology coding and need some help with two echocardiography codes. 93303 and 93304 are echocardiography for congenital cardia anomalies, complete and limited respectively. The guidelines in CPT do not identify what needs to be included to be considered complete and when you should use the limited code. Any information you can provide would be most appreciated. Thanks!

ECMO

This is the first time I’m seeing a case done like this…have you seen this before and/or do you know how it’s being coded?  The only ECMO code that I’m aware of is 36822…not sure how to code for the graft part. Thanks! PREOPERATIVE DIAGNOSES: 1.  Ischemia of right lower extremity secondary to ECMO catheter. 2.  Need for new ECMO access. POSTOPERATIVE DIAGNOSES: 1.  Ischemia of right lower extremity secondary to ECMO catheter. 2.  Need for new ECMO access. OPERATION PERFORMED: 1.  Left groin cutdown, left common femoral artery exposure. 2.  Creation of conduit for ECMO ( 8-mm PTFE graft pulled through a 10-mm Dacron graft to left common femoral artery). 3.  Insertion of ECMO cannula arterial to left PTFE conduit. 4.  Right groin cutdown with right common femoral artery repair with bovine pericardial patch, decannulation of ECMO. 5.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm2, left groin. 6.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm in the right groin. ANESTHESIA:  General endotracheal anesthesia. ESTIMATED BLOOD LOSS:  Less than 100 cc. DRAIN PLACED:  Bilateral groin VAC. IV FLUIDS:  400 mL of crystalloid, 2 units of packed red blood cells, 2 units of FFP, 1 unit of platelets. CONDITION:  Critical. COMPLICATIONS:  None immediate. INDICATIONS:  an 18 years old female, who has been an ICU patient.  Her initial diagnosis was infectious mononucleosis, it was complicated by respiratory failure as well as cardiac myopathy as well as liver failure and the necrotizing pancreatitis.  The patient had right ECMO catheter placed for about 2 weeks.  Patient initially had intermittent signals in her right lower extremity, but appears that in past over the span of past 24 hours, the ischemia of the right lower extremity has got worse with mottling of right lower extremity.  Patient did not have great volumes on the right lower extremity.  Therefore, decision was made to proceed with this procedure for decannulation of the ECMO from the right side to improve the perfusion of the right leg and therefore help possible viability of right leg and to get access to the left leg for ECMO.  Patient was a very high-risk procedure.  I explained clearly the multiple risk of the procedure including risk of death.  The patient's parents wished to proceed with the operation. OPERATION:  After the informed consent obtained, the patient was brought to the operating room, placed in supine position.  General anesthesia was induced by anesthesiologist.  Patient's bilateral lower extremity was prepped and draped in standard sterile surgical fashion.  Anatomical landmarks were marked in the left groin including anterior superior iliac spine and pubic tubercle.  Vertical cutdown was performed in the left groin.  Skin was incised with a scalpel, soft tissue with the Bovie cautery.  There was massive tissue edema with infiltration with vitreous fluid.  Femoral artery was identified, common femoral, superficial femoral, profunda femoral artery were identified.  Vessel loops were placed across these vessels. Next, a 6-mm arteriotomy was created into the common femoral artery.  An 8-mm PTFE graft was then sewed end-to-side to this arteriotomy with the help of a running 5-0 Prolene in a 4-quadrant fashion.  After the anastomosis was completed, proximal and distal clamps were released, forward flush, backward flush performed.  Anastomosis appeared intact.  This PTFE graft was tunneled inside a 10-mm Dacron graft.  Both of these grafts were then tunneled underneath the skin area and then brought through a separate stab wound distally.  The PTFE graft was then connected to the ECMO arterial cannula.  Arterial cannula was then connected and appeared to have good blood flow through the arterial catheter.  At this point in time, distal stab incision was closed with the help of interrupted nylon in a vertical mattress fashion.  Wound VAC therapy was placed in the left upper groin because of the bulging nature of the wound.  On the right side, a groin cutdown was performed.  Skin was incised with the scalpel and subcutaneous tissue with the Bovie cautery.  The muscles appeared dark in the right thigh area and they were not responsive to Bovie cautery at all.  The right groin arterial catheter was removed.  Fogarty was passed proximally and distally in the common femoral artery as well as in the superficial profunda femoral artery.  There appeared to be no clot.  There were no thrombus.  There was good inflow and there was good back bleeding through both SFA and profunda.  All these arteries were flushed with half saline in an olive-tip.  Next, a bovine pericardial patch was used for performing the femoral patch angioplasty of the common femoral artery with the help of 5-0 Prolene, just before completion of anastomosis, forward flush, backward flush were performed with anastomosis appeared intact.  Anastomosis was completed and the flow was released.  There were palpable pulses in the superficial femoral artery and profunda femoris artery; however, we were not able to obtain Doppler signal in the foot.  However, at this point in time, the patient has been hemodynamically unstable, and we were in the OR for more than an hour.  Since the muscles of the right lower extremity were not contractile, I made a decision not to perform further revascularization of right lower extremity because of the concern that the leg may not be viable at all and the fact that the patient may not tolerate any more surgery at this point in time.  We placed the VAC therapy in the right groin where plan is to follow the right leg for next 24 to 48 hours.  Even after restoration of the blood supply  if her legs remain mottled for next 24 to 48 hours, she may need a high amputation possible above knee amputation, possible  amputation hip disarticulation level.  Wound VACs were placed and the patient was transferred back to Intensive Care Unit in critical condition.

ECMO

This is the first time I’m seeing a case done like this…have you seen this before and/or do you know how it’s being coded?  The only ECMO code that I’m aware of is 36822…not sure how to code for the graft part. Thanks! PREOPERATIVE DIAGNOSES: 1.  Ischemia of right lower extremity secondary to ECMO catheter. 2.  Need for new ECMO access. POSTOPERATIVE DIAGNOSES: 1.  Ischemia of right lower extremity secondary to ECMO catheter. 2.  Need for new ECMO access. OPERATION PERFORMED: 1.  Left groin cutdown, left common femoral artery exposure. 2.  Creation of conduit for ECMO ( 8-mm PTFE graft pulled through a 10-mm Dacron graft to left common femoral artery). 3.  Insertion of ECMO cannula arterial to left PTFE conduit. 4.  Right groin cutdown with right common femoral artery repair with bovine pericardial patch, decannulation of ECMO. 5.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm2, left groin. 6.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm in the right groin. ANESTHESIA:  General endotracheal anesthesia. ESTIMATED BLOOD LOSS:  Less than 100 cc. DRAIN PLACED:  Bilateral groin VAC. IV FLUIDS:  400 mL of crystalloid, 2 units of packed red blood cells, 2 units of FFP, 1 unit of platelets. CONDITION:  Critical. COMPLICATIONS:  None immediate. INDICATIONS:  an 18 years old female, who has been an ICU patient.  Her initial diagnosis was infectious mononucleosis, it was complicated by respiratory failure as well as cardiac myopathy as well as liver failure and the necrotizing pancreatitis.  The patient had right ECMO catheter placed for about 2 weeks.  Patient initially had intermittent signals in her right lower extremity, but appears that in past over the span of past 24 hours, the ischemia of the right lower extremity has got worse with mottling of right lower extremity.  Patient did not have great volumes on the right lower extremity.  Therefore, decision was made to proceed with this procedure for decannulation of the ECMO from the right side to improve the perfusion of the right leg and therefore help possible viability of right leg and to get access to the left leg for ECMO.  Patient was a very high-risk procedure.  I explained clearly the multiple risk of the procedure including risk of death.  The patient's parents wished to proceed with the operation. OPERATION:  After the informed consent obtained, the patient was brought to the operating room, placed in supine position.  General anesthesia was induced by anesthesiologist.  Patient's bilateral lower extremity was prepped and draped in standard sterile surgical fashion.  Anatomical landmarks were marked in the left groin including anterior superior iliac spine and pubic tubercle.  Vertical cutdown was performed in the left groin.  Skin was incised with a scalpel, soft tissue with the Bovie cautery.  There was massive tissue edema with infiltration with vitreous fluid.  Femoral artery was identified, common femoral, superficial femoral, profunda femoral artery were identified.  Vessel loops were placed across these vessels. Next, a 6-mm arteriotomy was created into the common femoral artery.  An 8-mm PTFE graft was then sewed end-to-side to this arteriotomy with the help of a running 5-0 Prolene in a 4-quadrant fashion.  After the anastomosis was completed, proximal and distal clamps were released, forward flush, backward flush performed.  Anastomosis appeared intact.  This PTFE graft was tunneled inside a 10-mm Dacron graft.  Both of these grafts were then tunneled underneath the skin area and then brought through a separate stab wound distally.  The PTFE graft was then connected to the ECMO arterial cannula.  Arterial cannula was then connected and appeared to have good blood flow through the arterial catheter.  At this point in time, distal stab incision was closed with the help of interrupted nylon in a vertical mattress fashion.  Wound VAC therapy was placed in the left upper groin because of the bulging nature of the wound.  On the right side, a groin cutdown was performed.  Skin was incised with the scalpel and subcutaneous tissue with the Bovie cautery.  The muscles appeared dark in the right thigh area and they were not responsive to Bovie cautery at all.  The right groin arterial catheter was removed.  Fogarty was passed proximally and distally in the common femoral artery as well as in the superficial profunda femoral artery.  There appeared to be no clot.  There were no thrombus.  There was good inflow and there was good back bleeding through both SFA and profunda.  All these arteries were flushed with half saline in an olive-tip.  Next, a bovine pericardial patch was used for performing the femoral patch angioplasty of the common femoral artery with the help of 5-0 Prolene, just before completion of anastomosis, forward flush, backward flush were performed with anastomosis appeared intact.  Anastomosis was completed and the flow was released.  There were palpable pulses in the superficial femoral artery and profunda femoris artery; however, we were not able to obtain Doppler signal in the foot.  However, at this point in time, the patient has been hemodynamically unstable, and we were in the OR for more than an hour.  Since the muscles of the right lower extremity were not contractile, I made a decision not to perform further revascularization of right lower extremity because of the concern that the leg may not be viable at all and the fact that the patient may not tolerate any more surgery at this point in time.  We placed the VAC therapy in the right groin where plan is to follow the right leg for next 24 to 48 hours.  Even after restoration of the blood supply  if her legs remain mottled for next 24 to 48 hours, she may need a high amputation possible above knee amputation, possible  amputation hip disarticulation level.  Wound VACs were placed and the patient was transferred back to Intensive Care Unit in critical condition.

ECMO

We placed an ECMO via the right common femoral vein and right common femoral artery. The next day we added an additional arterial cannula in the right subclavian artery. A few days later, we converted from a VA to a VV ECMO, with the repair of the right common femoral artery. Then we removed the ECMO a day later. Please advise me on this scenario, and please give me the documentation requirements for the maintenance codes 33960 and 33961.

ECMO Device

Patient was placed on ECMO device by the cardiac doctor, and the next day one of our vascular surgeons (surgeon A) was called in to place bypass tubing into the patient for ischemia of the foot. This was then connected to the EMCO device. Next, another one of our surgeons (surgeon B) was called in at a later date to remove the device from the LCF while the cardiac doctor removed the venous cannula. Thrombus was found in the LCF, and an open thrombectomy was performed (34201) by surgeon B. How would you code this for surgeon A and B? Is the removal of EMCO coded, or is this bundled with the open thrombectomy?

Edits with new cardiac catheterization codes

Good morning: I need some clarification on using our 59 modifiers for Diagnostic procedures done at the same time of an Intervention.Since the Diagnostic Cardiac codes that required a 59 mod are bundled into the new CPT codes,should we add the 59 modifier to the New diagnostic CPT when done along with the Intervention? Thank you for your time, Sylvia Roberts

Ekg abnormal findings

When a physician does an interpretation of an EKG and has listed "right atrial enlargment" and "Right ventricular hypertrophy", would you code that as 794.31, abnormal findings? In many instances, an ECHO is done the same day and there is no right atrial enlargement or right ventricular hypertrophy noted on the ECHO. Thanks for your guidance!

EKG and cardiac catheterization

Is there a reference or resource available for when it is and is not appropriate to separately report an EKG with cardiac cath or EP procedures? Thank you!

EKG with cardiac catheterization

Hi Dr Z. I have a question on basic EKG's. As a general practice all doctors order the standard pre /post EKG along with one view chest x-ray for standard cardiac procedures (LHC/ cardiac intervention/ EP / device implants PPM ICD etc) The billing office has always just added 59-74 or 76 to all 93005. In the pt's record I can't find documentation that the interpretation of pre /post or sequel ekg is referred to in any dicision making plans for the patient (I always think of doctors document from CCL - ex. from the angio findings, further intervention needs to be done etc.) I have also found that many times the EKG tracing are not signed and have no written interpretation from the doctor only the printed interpretation from the EKG machine, never any formal written report. Please let me know if you think the practice of adding 59/74/76 to all ECK codes 93005 is appropriate. Thanks According to the LCD from Trail Blazer L26535 - for a service to be paid the follow information need to be present in chart. Documentations Requirements Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request. Documentation should demonstrate that services are provided according to all requirements of this LCD. In this respect, the record should demonstrate the following: Evidence of recent, past, ongoing or suspected cardiac disease or symptoms. For patients in whom the ECG is performed as part of the evaluation of chest pain or symptoms that are atypical for cardiac ischemia, the record must substantiate that the ordering clinician has a valid concern that the etiology of the chest pain or other symptoms is cardiac in origin. Conversely, the record may show that the ECG is being used to exclude cardiac origin for symptoms (including chest pain) for which cardiac origin cannot be excluded by history or physical examination. For serial ECGs, information supporting the medical necessity for repeating the studies at the given interval should be present. Sequential ECGs, either short-term for an acute condition or long-term for a chronic condition, are often appropriate. Documentation must demonstrate that the findings of the test affect management of the condition. The report of the professional component (the interpretation) for the ECG must be a complete written report that includes relevant findings and appropriate comparisons. The interpretation may appear on the actual tracing or with a progress note or other report of an E/M service when the ECG is performed in conjunction with performance of an E/M service. An interpretation reported in the latter fashion, when billed as a separate service from the E/M service, should contain the same information as a report made upon the tracing itself. A simple notation of “ECG/EKG normal,” without accompanying tracing, will not not, in this circumstance, suffice as documentation of a separately payable interpretation. Preoperative ECG studies must indicate the underlying cardiac condition or risks, as well as the proposed operation for which cardiac evaluation is being performed. The ECG must be performed reasonably proximate to the proposed surgery to be considered medically necessary. Appendices N/A Utilization Guidelines Serial ECGs performed over both the short term (as for an acute condition) or over the long term (as for chronic conditions) may be appropriate when performed at a reasonable frequency. However, such ECGs will not be covered by Medicare unless it is clear that the tests are necessary for monitoring an evolving pathologic process for which the therapy will be altered based on the findings of the ECG. The interval between ECGs should be determined by the physician responsible for the patient’s care upon consideration of factors such as natural history and severity of the underlying condition, recent changes in the condition or onset of new symptoms relating to the condition, and/or the specific patient’s historical responses to therapy for his condition.

EKGs and cardiac catheterization

I am auditing the CCL of one of our smaller system hospitals that hasn’t been audited since before I joined the audit department a few years ago.  I have discovered that they are CPT 93005 (with and without modifier 59) performed with CPT codes 93458, 93459 & 93460.  The EKGs are ordered as part of the standard pre-procedure routine.  From my understanding, charging for the EKG is not allowed because it’s an NCCI edit.  I discussed this issue with other auditors who agreed that the hospital should not be charging, as our other hospitals that I have regularly audited do not charge for them; but I pulled the “National Correct Coding Initiative Policy Manual for Medicare Services” from the CMS website and in Chapter 11, Section I, Point #14 it states: “A cardiac catheterization procedures or a percutaneous coronary artery interventional procedure may require ECG tracings to access chest pain during the procedure.  These ECG tracings are not separately reportable.  Diagnostic ECGs performed prior to or after the procedure may be separately reportable with modifier 59.” This makes me think that the diagnostic EKG that is performed prior to the cardiac catheterization IS billable/reportable as long as it has modifier 59.  What is not billable is any EKG taken during the procedure.  If this is the case, then I need to instruct all of my hospitals to start reporting/billing this charge.  Do you agree?  I looked in your Cardiology reference guide but it only referenced that EKGs should NOT be billed with EP studies and doesn’t address cardiac catheterizations. Thank you,

EKOS

What is an EKOS considered? We infuse TPA and use ultrasound to break up the clots. We bring patient back between 6 and 24 hours for a recheck. Is it a mechanical thrombectomy because of the ultasound or infusion for thrombolysis?

Embolectomy in AV graft

If a dr enters a arteriovenous graft for embolectomy with a scalpel then performes an embolectomy with a catheter into the preexisting HeRO catheter, and then the Fogarty catheter was then passed to the arterial end with similar retrieval of arterial flow with brisk arterial bleeding. Can we charge 36831 for the arterial and 36831-59 for the HeRO catheter embolectomy? Thank you for your help!!

Embolic protection device

Good Morning Dr. Z, Yet another question, Our physician did a Fox Hollow atherectomy of the distal superficial femoral artery. There was a significant amount of atheramatous debris in the spider EX filter device. The filter was retrieved. Does this constitute a thrombectomy also??? Thank you and Happy Friday!! Tina Pihlainen

Embolization and Angioplasty

I have a case were a chemoembolization was performed in the hepatic arteries and an angioplasty was performed on the left external iliac artery. The angioplasty was not planned; stenosis was found when trying to cannulize the artery for the embolization. The problem is that I have to use codes 37243 and 37220 for two different vascular families, and due to the fact a diagnostic angiography was performed on the external iliac I have catheter placements for both areas of treatment, so codes 36247 and 36248 x 3 for the hepatic embolization and 36249 for the diagnostic angio in the external iliac. Due to code 37220, codes 36247 and 36246 both require a -59 modifier, but code 36247 overrides 36246. How do we address that so that both catheter placements are paid?

Embolization and diagnostic angiography

Dear Dr. Z: More CCI edits- eff 4/1/2011 75726 and 75774 bundles into 37204, 75894 and 75898. Can the pre-procedure angio no longer be billed when hepatic embolization is performed? Do the guidelines for angio performed at the time of a therapeutic intervention apply to this procedure, as stated in the instructional CPT notes in the Radiology section for Vascular Procedures? Thank you. mlb

Embolization Arteriovenous Fistula Head

I have a simple question that probably you can address. I have a case that I am auditing that involves an embolization of an AV fistula brain. I am recommending code 61624, but my question is regarding the catheter access. The radiologist punctures the arterial side and the venous side for proper embolization. I know to only code the embolization code once, but can I code the catheter placement for both vascular systems (36215 series and 36011 series), as he accessed the femoral artery and femoral vein? This case would follow CPT coding guidelines of 2012.

Embolization Fields

Patient has colorectal liver metastases. Yttrium 90 mapping arteriogram performed. Documentation indicates that left gastric artery microcoil embolization performed with post coil embolization arteriogram, right gastric artery embolization with post embolization imaging, medial branch gastroduodenal artery embolization with post embolization imaging, and lateral branch gastoduodenal artery embolization with post imaging are all performed. I am thinking this is one surgical field and would be reported with codes 37204 x 1 and 75898 x 1 (2013 case). The facility wants to report the embolization x 3 for the three separate vessels. Would this be considered one surgical field or more? 

Embolization for Adrenal Artery/Renal Artery

I have a case that the physician accessed the right renal artery, and right renal arteriogram was performed, demonstrating filling of the adrenal artery with supply up in to the right lobe liver mass. The right adrenal artery was selective along with an adrenal arteriogram (the adrenal artery comes off the renal artery). Chemotherapy was then infused into the right adrenal artery slowly over 20 minutes. Embolization was then performed with a combination of 100-300 and 300-500 micron particles of biospheres. Because the renal code 36251 includes the renal arteriogram, how would I code for the adrenal artery that comes off the renal artery? Would you report codes 36246 and 75731-26, or just code 36251?

Embolization later in day

I have a patient who had an Embolization of GDA in the morning (9:00 am) but after subsequent flow study there was evidence of extrahepatic flow with MAA injection. On correlation with prior angiogram and CT, it was evident that a unusual branch arising from the cystic artery was supplying extrahepatic omentum;therefore, a decision was made to bring the patient back for embolization of this small branch. In the afternoon (15:00 same day) embolization of an extrahepatic branch arising from the cystic artery was performed. Are we able to bill this additional embolization/cath placements/angio's? I am trying to locate information about how to do this if it is allowed. If so, would we use modifier 59 on these or 76? It is a repeat embolization but of a different area and many hours later. Any suggestions would be most appreciated! Thank you, Additional information received subsequently: I should have inquired about cath placement/imaging as well.  As it turns out this patient did have the sheath still in, so there was not a new access. Would we be able to bill the cath’s and angio’s for the afternoon procedure? I really appreciate your assistance!  My co-worker and I are really looking forward to your conference, but it looks like we won’t be scheduled until early next year.  

Embolization of a Single Site

This patient had renal artery embolization for a large renal metastatic mass. There are two left renal arteries. The vascular surgeon does an angiogram and embolization of the left UPPER pole renal artery in a third order branch, as well as an angiogram and embolization of the left LOWER pole renal artery in a second order branch. Does this represent one surgical site? And therefore only one 36253, 37204, 75898 set of codes? In your Interventional Radiology Coding Reference, I see that the right and left kidneys represent two surgical sites. But I don't know about two arteries on the same side. And would code 75894 only be reported once for follow-up? Thank you very much.

Embolization of AV fistula collateral

Dr, Z, Patient has AV fistula with a complication for dialysis. With two AV graft punctures and intervetion was performed using both accesses. Additonally a large accessory vein was seen arising from the venous outflow from the arteriovenous anastomosis. Using a catheter the accessory vein was selectively cathterized and was subsequently embolized using multiple coils. My question is can we assign 36217 36148 and 36299 for the accssory vein access? I understand we can't use more than two punctures for the AV fistula however this was an accessory vein so not sure of this, please advice. Thanks

Embolization of Gastrocutaneous Fistula Plug

What is your code recommendation of this case? "Upper abdomen was prepped and draped in usual sterile fashion. Contrast was injected into patient's indwelling percutaneous pigtail type gastrostomy tube, confirming intragastric location. Catheter hub was cut, and the catheter was removed over Amplatz superstiff wire. A 12 French sheath was advanced into the stomach in order to facilitate fistula brushing, which was performed with 3 mm bristle Cellebrity Cytology Brush over Amplatz wire as sheath was retracted from fistula. Next, Cook enterocutaneous fistula plug was deployed through 24 French sheath within the fistula. Inner disc was in appropriate position along gastric staple line, as confirmed with fluoroscopy and radiography in multiple obliquities. External portion of the plug was secured to abdominal wall with Molnar disc and trimmed. There were no immediate complications."

Embolization of Gastroduodenal Artery, Left Gastric Artery, and Thoracic Arteries

Initial Question: We have a physician who does embolizations on the gastroduodenal artery, left gastric artery, and thoracic arteries (normal anatomy), and I was wondering if we could not charge two embolizations since one is above the diaphragm and one is below the diaphragm and in two different coding family sets? I know it is once per surgical field and have heard if you make one puncture it is considered one surgical site, but if you do two different abdominal areas (e.g., liver, pancreas, spleen) it is considered two different surgical sites even though you go through one puncture site. Could you please clarify when charging two would be acceptable billing? Additional Info Provided Following Inquiry from Dr. Z: Most of the dx are a primary cancer (rectal, colon, etc.) metastatic to the liver and he says intercostal on the thoracic arteries. It looks like most of them are evualating suitability for Sirtex radioembolization. Please let me know if there is additional information I need to supply; I know nothing is ever black and white in coding.

Embolization of GDA and Inferior Pancreaticoduodenal

I have a question on embolization. I have a report where we went through the celiac artery, advanced in the common hepatic, ended in the gastroduodenal artery, and did coil embolization. The radiologist then went into the superior mesenteric artery and found additional bleeding went into the pancreaticoduodenal artery and did an additional embolization. My question is, can I code for both embolizations?

Embolization of ICA

Greetings, Pt had a coil embolization of the rt internal carotid at the cavernous and the supraclinoid. Am I correct in letting the physician know he can only code one embolization as it is in the same vessel. LW

Embolization of inferior epigastric branch artery

Dr. Z, I am having a bit of a dilemma over a procedure that was done in our IR lab. The patient presented with bleeding to the abdominal wall post op hernia repair. The radiologist did a distal aorta and bilateral iliac angiogram. He then selected the lt internal iliac ( to"confirm its position"). He then selectively catheterizes a branch of the lt inferior epigastric and proceeds to embolization. No mention of an angiogram for the internal iliac. He does perform an angiogram of the inferior epigastric artery branch. He then catheterizes the inferior epigastric (lt), does an angiogram, embolizes it and finally, a LIMA catheterization with angiogram. I have 2 concerns--1. What, if any, diagnostic angiogram code should I use? From his report, it would seem like I could use 75756 and 75716 with possibly 75774 but i am hesitant about the 75716. 2. For the selective catheterizations, would it be 36456 (inferior epigastric branch, 36246-59 (lt internal iliac), and 36215? I know that I need 75894, 37204, and 75898 for the embolization and follow-up. Thanks for any help. Chris

Embolization of kidneys

Hi Everyone, Embolization of the kidneys to we bill 37204 once or twice? Also emboliztion of an ovarian artery for abnormal bleeding should we use 37204 or 37210?

Embolization of Lower Pole and Midportion of the Left Kidney

"CFA is accessed. SOS catheter is used to selectively catheterize the LRA. Following review, decision is made to embolize two of the three branches of the left renal artery using ProGreat microcatheter, and coil embolization is performed. Following embolization, the percutaneous neprostomy catheter is removed. During removal of this, the existing double-J was also inadvertently pulled through the tract. Removal of the double-J was not intentional and was accidental."  Would we charge codes 37204/75984 twice? Also, would we charge for the accidental removal of the double-J tube? Not sure what all codes would be valid with this report.

Embolization of scrotal varices

Good afternoon to you all, My patient has scrotal varices and presented for embolization. We were unable to locate the left renal vein after injection in the IVC, therefore we did a selective renal artery injection to locate the renal vein. The arterial injection was not done for diagnostics only localization, would you still code 36245 for the catheterization? Appreciate your comments, jb

Embolization of superior and inferior left throcervical, internal mammary

Dr. Z, Coil occlusion of superior and inferior left thyrocervical artery, right internal mammary artery and right innominate vein, would these be coded with 37204 or 61626? Thank you

Embolization of Uterine Artery Punctured During Uterine Fibroid Embolization

While performing uterine fibroid embolization, an accidental puncture of the uterine artery was made. This required an additional coil embolization. Is there any way to code this separately?

Embolization Surgical Site

I understand that embolization is based on surgical site, so all embolizations done in AVF would only be billed one time. However for pulmonary AVMs, what is considered the surgical field when multiple lobes are treated? Are the entire lungs considered one surgical field? Per embolization? Any guidance is greatly appreciated.

Embolization with Diagnostic Angiogram

I hope you can help with this case: "Female patient with excessive post-partum bleeding presents in IR for eventual embolization of the bleeding vascular source. No previous diagnostic study performed. Bilateral selective (internal iliac arteries) pelvic diagnostic angiograms, complete (75736 x 2) and bilateral supraselective (uterine arteries: 36247 x 2) diagnostic angiograms, complete (75774 x 2) from left groin access were performed. Diagnostic angiograms reviled sources of bleeding resulted in decision for embolization. Embolization was performed, bilateral, with follow-up angiograms post embolization (37244)." Can we code and bill diagnostic angiograms along with embolization in this coding scenario?

Endarterectomy and Stent Placement

Original Question: Where can I find documentation on billing or not billing codes 35301 and 37215 on the same day in the same vessel? Follow-Up Information Provided Upon Request: The doctor performed an endarterectomy of the carotid bifurcation into the internal carotid and also did one of the external carotid and did a patch angioplasty. Then he punctured the patch and placed a stent in the origin of the common carotid.

Endarterectomy Procedures

If a patient has endarterectomies performed in the common femoral, profunda femoral, and superficial femoral, can all three be coded? Do the territory rules apply for the PTA/stent/atherectomy rules to the endarterectomy procedures (35301-35372), which only allow one intervention in the fem/pop region?

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.

Endograft Abdominal Aorta Bifurcated Modular, with No Docking Llimbs

Our physicians placed an abdominal modular bifurcated endograft, but they did not place the contralateral iliac docking limb. Instead they went through the brachial artery (due to left iliofemoral disease) and placed three iCast stents sequentially in the left common iliac artery. Should we charge code 34802 for all the work, or should we charge code 34805 and an iliac stent placement (37221)?

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

Ethiodol

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 AV Fistula/Graft

Access left radial artery with micropuncture, left arm AV fistulogram with interpretation. This is a radiocephalic fistula. Can code 36120 be used for direct radial artery puncture for evaluation of the fistula, or is that code only for the brachial artery (36120, 75791)? When a doctor uses the word "micropuncture", does this always mean percutaneous? First example: "Dissected out the fistula and then accessed the aneurysm with a micropuncture 6 French sheath." Second example: "We then accessed the graft with a micropuncture sheath near the arterial limb towards the venous outflow."

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?

EVAR and Co-Surgeon

Our general surgeons perform the exposure of endovascular AAA surgical cases for the interventional radiology group. The general surgeon performs a bilateral exposure (34812) and inserts the sheath. He leaves the OR at this point, and the interventional radiologist then presents to the OR and performs her portion of the AAA. The general surgeon then returns to the OR, removes the sheath, and closes the surgical site. The general surgeon dictates for the exposure and closure of the wound. Both the interventional radiologist and the general surgeon dictate as “co-surgeon” their individual portion of the case. Can we, as the general surgeon's office, bill for both the exposure (34812) and the repair of the AAA? The general surgeon is not in the OR during the time the interventional radiologist is doing her portion of the case. According to the interventional radiologist they suggest the general surgeon bills code 34802-62, as they say the general surgeon is there for the “critical” portion of the case. What are your recommendations on coding this?

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 vessel...one 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?

Externalization of Generator

We have a patient with an infected pocket. The doctor removed the generator, taped it to the patient's body, and cleaned out the pocket. The patient returns to the EP lab five days later for new leads and a new generator. When the doctor removed and externalized the generator, can we bill code 33241?

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?

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