Knowledge Base

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Set Descending Direction

Facility Charging CPT 93355

For facility billing, if the anesthesiologist for a heart procedure also places a TEE probe, monitors the TEE, and dictates a separate report for an intraoperative TEE procedure while a cardiologist performs the transcatheter heart procedure (i.e., TAVR, MitraClip, Lariat, etc.), is the facility justified in billing 93355 for the intraoperative echo?

ICD-10 Coding for Device Checks

In the past we have used V53.31 to indicate a patient with an implanted device having a routine device check (programming). It now maps to ICD-10 Z450.010 (battery) and Z450.018 (other parts). Which is the correct ICD-10 code to use when performing a routine device check? And when would you use the other V-code?

KX Modifier Appendage to Hospital Claims

Pertaining to facility claims regarding the recent pacemaker NCD/LCD... Is there specific documentation or guidelines which state that the -KX modifier needs to be appended to the CPT code, rather than HCPCS? Several of our facilities are wanting to attach to the HCPCS code, while others want to attach to the CPT code. 

LVAD 33990 and High Risk Indication

For 33990, used for Impella assist during high risk stent placement, is coronary artery disease sufficient for medical necessity? What about current or old MI? 

Neuroprotective Device to Prevent Stroke During TAVR

Would placement of the Claret Medical Sentinel neuroprotective device under clinical trial be considered inclusive in the TAVR procedure codes for ICD-9-CM and ICD-10-PCS? Or should we be assigning a separate code for it? If it is to be coded separately additional information as to location of the device will be requested. "Using, micropuncture technique the right and left femoral arteries and right femoral vein were accessed. Heparin was given. A sheath was placed, and a Claret neuroprotective device was placed. Then, a 26 mm SAPIEN 3 was passed through the sheath into the descending aorta. The balloon was docked on the valve, and the valve was then passed across the aortic annulus and positioned using aortic root angiogram, fluoroscopy, and transesophageal echo. We deployed the valve under rapid ventricular pacing. Post deployment there was excellent hemodynamics, trivial regurgitation, and minimal gradient. We then removed the Claret neuroprotective device and then protamine was given. The patient will be returned to CICU in stable condition." 

Multiple Interventions Performed on Femoral Popliteal Arteries

We understand that we are to code only one intervention per side for femoral popliteal arteries. And, we would code the "most extensive" procedure. What would you do in the case that, say, an atherectomy and angioplasty were performed on the SFA (37225) and a stent was placed in the popliteal (37226). Would you "add" the interventions up and use a 37227? Or just use 37225 for the atherectomy?

Tunneled Peritoneal Catheter Exchange

Would the following example be reported with unlisted code 49999? If not, how would this be coded? "Patient with malignant ascites is in for a fluoro-guided tunneled peritoneal catheter exchange due to cuff being exposed. Patient is prepped, draped, and anesthetized. Using fluoroscopy, existing cath was exchanged for a guidewire, and over the guidewire a new tunneled peritoneal drainage cath was placed with distal tip in the pelvis. Fluid was easily aspirated from the new cath." 

Removal of Infected Patch

My physician performed/coded a surgery and needed help with a code for the removal of the infected graft. The patch was placed 13 years prior by another physician. 1) Removal of infected Hemashield patch on carotid artery with a vein patch angioplasty (right proximal saphenous vein harvest). 2) Reoperative carotid artery operation greater than 1 month,  35390 (however, I'm not sure if 35390 is appropriate since he was not the surgeon who performed the original surgery). 3) Resection of carotid artery wall and partial endarterectomy for completion of procedure, 35301 (since this was partial should we add modifier reduced services?). Any help would be appreciated. 

37233 with 37230

I had a patient with atherectomy/PTA of right anterior tibial, PTA with DES stent of right tibial peroneal trunk, and PTA of right posterior tibial and right peroneal. I have 37230 for posterior tibial and tibial peroneal trunk (which is considered part of tibial territory) PTA and stenting done and 37232 for PTA peroneal... I want to assign 37233 for atherectomy/PTA of right anterior tibial, but the code only says can be used with 37229 and 37231. What am I missing?

MR Guided-HIFU ablation

How would you code MR guided-HIFU ablation of thigh desmoid tumor or sites other than fibroids?

Billing 33241 and 33216

A question has been raised whether or not it is appropriate to bill for the removal of the generator at the time of insertion of a new RV lead. The patient did not have a new generator replaced; they used the existing generator. The codes in question are 33241 and 33216. Although these codes pass NCCI edits, is it assumed that the physician needs to remove the generator in order to place the new lead and, therefore, the generator removal cannot be billed?

37193-74 vs. 36011, 75825

Would you bill this with 37193-74 or with 36012, 75827, 75820? "Under direct ultrasound guidance, the right internal jugular vein was accessed utilizing micropuncture technique. An Amplatz wire was advanced into the IVC, over which a 5 French Berenstein catheter was placed. Digital subtraction cavogram was performed in the PA projection. An 11 French coaxial sheath was then placed over the wire and catheter and was advanced to the top of the existing IVC filter. Several attempts were made to traverse the IVC filter utilizing a combination of wires. The Berenstein catheter was exchanged for a Crosser support catheter. The catheter was advanced coaxially with the wire below the level of the IVC, and digital subtraction venography was performed from multiple locations. Digital subtraction cavogram was also performed via the sheath side arm. The catheter was then manipulated into the right femoral vein, and digital subtraction venogram was performed. Based on these findings, the decision was made to abort filter retrieval at this time."

Multiple 76937s and Billing

This case had ultrasound access (76937) used for right CFA access, left CFA access, and left brachial artery access. Our billing system keeps kicking the last 76937-59 out as a duplicate code. Any suggestions on how to get around this?

BRTO with TIPS Placement

BRTO is currently being used by our doctors, but I don't see a CPT code on VASCULAR, sclerosing agents selective injection followed by balloon occlusion of the gastrorenal shunt; the technique being done by our doctors also includes metallic coil embolization of the feeders/shunt. How would we code a balloon-occluded retrograde transvenous obliteration (BRTO) if done with a TIPS placement?

TPA into Both Ports of Dialysis Catheter

If tPA is injected into both ports of a dialysis catheter, can code 36593 be reported twice? 

Ethanol Ablation Renal Cyst

I thought at one time I had seen where you stated to use 53899 for ethanol ablation renal cyst, but someone said to use 20500 and 76080. Which is correct?

3D Interpretation During Mitraclip

I understand that 93355 should not be billed by the interventional physician performing a Mitraclip placement (33418). What if the guidance TEE is performed by a physician not performing the intervention and the interventional physician is performing the 3D interpretation? Would the interventionalist then be able to bill for this 3D interpretation (76376)?

Pacemaker Complication

"Patient was admitted with infected pacemaker pocket, had explantation of old transvenous pacemaker in the left subclavian region and removal of pacemaker generator and atrial and ventricular lead with antibiotic irrigation and closure of the pocket, and placement of a new temporary transvenous lead. The next day he had fever with positive blood culture for staph aureus, assumed pacemaker pocket infection." My question is, can the MD bill for a critical care service (99291) for this next day in which the patient had fever due to a pacemaker complicationt? I believe that is part of the global service period, but not sure. Please clarify.

93970 and 93965

I am finding codes 93971 (93970) and 93965 filed together and having difficulty understanding the difference and if they can, in fact, be filed together at the same session (e.g., leg swelling). 

Foley Insertion in the Cath Lab

A patient comes from ED or the floor (observation) to the card cath lab, and a Foley catheter is inserted in CCL. Can this Foley insertion be coded and charged? If not, why not? The cath lab is insisting it should be charged.

10160 vs. 10030

I see that this question was answered in 2014, but I did not know if the rules have changed since then. "Catheter needle was used to aspirate thigh seroma with sclerosing injection. No catheter was left in place." What is the appropriate code? Should I report 10160? Or 10030 with 20500?


When a diagnostic tech is in the OR with the portable fluoroscopy unit, but does not use the fluoroscopy because it was not necessary, can we still charge for the time the equipment and tech were in the OR?

Multiple Stent Placements from Different Access Sites

A patient has a left common iliac stent placed via a right internal jugular access site and has a left external iliac stent placed via the left femoral access site. Since the work is being done from two separate access points would the codes be 37238/37238-59, or would you use 37238/37239? I chose 37238/37238-59 because my understanding is that with a different access site the coding starts over. Is that correct? 

External Carotid Angioplasty at Time of Carotid Stent

Patient has severe stenosis on both ICA and ECA. With EPD, stent was placed in cervical ICA (37215). Then, left external carotid artery was gently angioplastied. What code should I use for the ECA angioplasty?

Cyst Aspiration and Ethanol Ablation

HIM coding 10030 and 58999. Is that correct? I would like to avoid the unlisted, if possible. Prepped -draped anesthetized etc.... Under CT guidance a 5-french multi-side-hole drainage catheter was advanced into the colleciton. A 0.035 wire was passed through the 5-french catheter and the drainage catheter was moved and an 8-french pigtail catheter was placed. From this catheter a total of 150 ml of clear yellow fluid was removed. The cavity was completeley collapsed. Next, 20 ml of ethanol were injected into cavity. the drain was capped. The pt was placed supine for 15 minutes, left lateral decubitus for 15 min, prone for 15 min, and right lateral decubitus for 15 min. Alcohol was aspirated and the drain was removed. Thanks

Permacath exchange with venous angioplasty of fibrin sheath

I'm trying to determine whether I should use 36595 and 75901 or 37187 for the angioplasty of the fibrin sheath. I prefer 36595 and 75901 due to them indicating it is due to the device and not just the vein but but Coding Clinic for HCPCS - Second Quarter 2012 Page: 5-6 indicates to use 37187. Can I get your take on this? Thank you! "The skin surrounding the indwelling left jugular permacath as well as the external portions of the catheter were prepped and draped using maximal sterile barrier techniques. Lidocaine 1% was infiltrated for local anesthesia. The catheter was freed from the subcutaneous tissues using gentle traction. The catheter was removed over two stiff glidewires. A 10 mm x 4 cm balloon was advanced the brachiocephalic vein for SVC venogram. Balloon dilatation was performed throughout the left brachiocephalic vein and superior vena cava. A 28 cm BioFlow DuraMax permacath was placed to the right atrial/SVC junction. The catheter easily aspirated and flushed."

Rupture of Foley Balloon of a Broken Foley Catheter

Would we use unlisted code 27086 for rupture of Foley balloon of a broken Foley catheter? "Under ultrasound guidance, a 25 gauge needle was placed into the Foley balloon. The balloon broke and the Foley catheter was easily removed."

Impella Device

When coding the insertion of an Impella device in ICD-10, one of the choices to be made is continuous vs. intermittent. Can you tell me when an intermittent device would be used and how to identify which device was inserted? Does the physician need to include the word 'continuous' or 'intermittent' in his documentation?

E/M and Carotid Stent Placement

The physician did carotid angiography two weeks prior to stent, and no E/M was done by the doctor. Research was directed by doctor to see if the patient would qualify for a carotid stent trial, and patient was not able to participate. Two weeks later the doctor did E/M the same day as the stent and explained the goals, risks, potential complications, and limitations, and the patient wished to proceed. We are getting a denial on codes 99223-57 and 37215. Insurance does not want to pay admit/consult because they want to bundle to procedure. Can the physician bill the E/M, or is it bundled? I have tried to find guidelines on this, but I am unable to find any.

Congenital vs Non Congenital Post Heart Transplant

It's my understanding that when a patient with CHD receives a heart transplant, if all aspects of the disease are removed due to the transplant, the patient is no longer considered congenital and therefore cath codes 93451-93461 should be used. What if a patient with hypoplastic left heart syndrome receives a heart transplant and disease remains in the aorta? We should use the congenital cath codes 93530-93533, correct? I was a bit confused because the example on page 152 (#4) of the Diagnostic & Interventional Cardiovascular Coding Reference shows a patient with HLHS and the non-congenital codes are used. Wouldn't disease in the aorta still be present for a HLHS patient post heart transplant? Or is that not always the case? Should the physician always document when disease is still present post heart transplant? These congenital pediatric patients can be a challenge. 

62284 vs. 62305

Please confirm if 62305 is correct for facility billing. "Myeolgram inj and images in X-ray, patient then sent for CT. HIM is stating 62284 is correct. Spinal needle into the L4 level under fluoro guidance Contrast injected into thecal sac. AP and lateral views show good contrast opacification of the lumbar thecal sac. There is myelographic block at T12-L1 . After extended time head down in prone and supine positions contrast does pass into the thoracic levels. Limited contrast visualized in the cervical levels, however patient did have pain from headache suggesting contrast of passage into the cervical levels. Successful myelogram demonstrate myelographic block at T12-L1. Separate CT dictation for complete details. The patient is tilted, etc., in X-ray."

Cath placement during and angioplasty for stenosis while replacing a central venous device

Patient comes in to have the central venous catheter replaced. When they removed the catheter they noticed stenosis in the SVC, so they angioplastied it and replaced the catheter. My question is, does catheter placement need to be reported with 35476/75978, 36581/77001? 

Wire Removal as "Foreign Body"

"Patient had occluded fem-pop graft. Operator attempted to cross native SFA, but due to stent complication and occlusion he proceeded with a retrograde crossing via the distal posterior tibial artery. MD inserted a micropuncture pedal access sheath in the posterior tibial artery and advanced a guide wire in the posterior tibial artery through proximal posterior tibial and tibial peroneal trunk and in the occluded fem-pop graft. Wire was retrieved through sheath. A support catheter was 'back loaded' over wire through the right femoral sheath and down into distal posterior tibial artery. Wire removed as foreign body." The operator used code 37197 to describe this separate and distinct procedure. Although there was work expended, I am questioning if this is a separately billable procedure that can be coded. Thoughts?


Condensed version of AAA 2 providers involved - bilateral femoral cutdowns were made on common fem, Seldinger tech. wires and sheaths were introduced in to each groin. Initially an aortogram was performed to delineate anatomy. the main body graft was placed via Rt. fem artery was Medtronic 28x16x124 graft, contralateral limb was placed via Lt fem artery 16x24x156 and then Rt. limb extension was placed via Rt. groin 16x28x93 which was a flare type graft. balloon angioplasty was then carried out. A second arteriogram was then performed for an endoleak. No endoleak all catheters & sheaths withdrawn fem artery repaired with 5-0 prolene suture. I have coded 34802,62 / 34825,62 / 34812,50,62,XS,51 / 75952,26 / 75953,26 / 36200, XS,51/ 36200,XS,51 - Am I coded this right my surgeons never say placed the catheters in aorta for aortogram simply say aortogram x 2 and do I coded the cutdown part correct with modifiers since cvt surgeon and cardiologist both doing this. I really thank you for your expertise.

Biopsy-Vocal Cord Mass

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

Open thrombectomy dialysis AV fistula with PTA & fistulogram

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

Above Knee Amputation

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

Anticipated catheter repositioning or replacement

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

75630 vs. 75625

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

Revision of Peritoneal Catheter Site

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


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

Adequate Documentation for CPT 93566

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

UroNav MR/US Fusion for Prostate Biopsy

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

BIV-ICD Pocket Hematoma Evacuation/Cautery

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

36819 or 36821

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

36818 vs. 36821

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

Diagnostic at Time of Intervention

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

Endologix endograft for aortic occlusive disease and iliac aneurysms

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

ICD-10-CM Code for Post Op Vists

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

Endoscopic Approach for Gastric Varix Embolization.

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

Ethanol Ablation

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

Percutaneous AV Graft Ligation

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

IR Myelogram Followed by CT Myelogram

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

Stress Test

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

37202/75896 Deleted in 2016

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

Left Heart Catheterization

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

Breast Fine Needle Aspiration and Placement of a Clip

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

Redundant ICA

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

Embolectomy with Patch Angioplasty

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

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

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

Lumbar Myelogram 62284 vs. 62304

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

Adrenal Biopsy

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

Acute MI

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


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

Acute Thrombosis ICD-10

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

AVM, Dural Fistula

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

Medtronic Valiant Stent Graft for Aortic Coarctation

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

TAA Endoleak Embolization

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

Revision, Ligation, and Miller Procedure

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

Sclerotherapy of Glomuvenous Malformations

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

Brief Ultrasound of AVF in the Office

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

Modifier for 93355 needed when reported with 93580

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

Thrombectomy 37184 and angioplasty 61630

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

AP Collateral Embolization

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

Mesocaval Shunt

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

TAVR with GZ 33361

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

Sclerotherapy Stomal Varices

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

Balloon Test Occlusion of Septal Perforator for Septal Hypertrophy

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

Billing 61624 More Than Once

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

76937, US Guidance for Vascular Access

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

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

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

Snare Capture Lead Fragment

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

Multiple Atherectomy Procedures

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

Thrombolytic infustion 36593 vs Port -a-cath stripping 36595

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

CHD and Melody Valve

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

50390 and 50392

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

Coil Localization

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

Ultrasound for Vascular Access

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

33249 NCD Edit

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

Breast Fiducial Markers

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


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

20604 vs 20600 follow up for question ID #6415

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

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

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

36200, 75710-26, 36221, 36216

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

Coronary Embolization

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

Bilateral Ureteral Obstruction

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

Coronary CTA

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


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

Upgrade from Dual Pacemaker to Biventricular AICD

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

May-Thurner Syndrome in ICD-10

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

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