Knowledge Base

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Complex Carotid and Selections

I need help with the coding of the catheterizations and angiograms for the following procedure: "The patient has an AVM in the apex of the right lung. There was not a previous diagnostic angiogram. He punctured the right brachial artery, then he advanced to the right subclavian where he catheterized and did diagnostic angiograms of the following: 1) AVM feeding vessel that arises from the right subclavian. 2) Right thyrocervical trunk with selective catheterization of the dorsal scapular, the inferior thyroidal, and the suprascapular arteries respectively. The dorsal scapular came off the transverse cervical. 3) Right vertebral artery to verify that it was not feeding the AVM. He then embolized the AVM feeding vessel." With these new bundled codes in the head/neck, I am not sure how to code this procedure. Can I only report vertebral catheterization code 36226 and add 75774 for all of the other angios? Or can I code for the selective caths using the old 36215-36218?

Complex lesion breast 19103

I do not feel this documentation supports additional coding above the currently reported (19103LT, 76942, 19295LT, 77055) Understanding 76942 can only be reported once per encounter (NCCI Manual: Chapter 9, page 10); Do the biopsies obtained at the two "linear extensions" sites and current documentation support additional coding of 19103LT-59, 19103LT-59 and 19295LT-59, 19295LT-59? HISTORY: Lump in the left lower medial breast. Mammography and ultrasound show a highly suspicious mass, and biopsy was recommended. TECHNIQUE: The procedure of ultrasound-guided vacuum-assisted core needle biopsy was explained in detail including potential risks and complications such as bleeding and infection. Informed consent was obtained in writing. On the pre-biopsy scanning, I noted the bulk of the mass is accompanied by two somewhat linear extensions away from the larger body of the mass. I decided to biopsy all three areas and place clips in the two linear extensions for purpose of helping to guide the excision later. The skin and area around the mass were anesthetized with percutaneous injection of 9 cc of 1% buffered lidocaine. We then injected another 2 cc of lidocaine 1% with epinephrine into the deeper tissues for hemostasis. Once local anesthesia was achieved, a nick was made in the skin, and the Celera 12-gauge vacuum-assisted needle was advanced to the target labeled site 1, which is the bulk of the mass. We obtained three core samples in the usual way. Because this area is easily palpable, no clip was placed. We then reoriented the needle to the proximal slightly inferior projection, which was labeled site 2. Again, a 12-gauge sample was obtained under ultrasound visualization. We labeled this site with a CeleroMark clip. We then reoriented the needle towards a slightly more cephalad site labeled site 3, again using the 12-gauge vacuum assisted device, obtained one sample, and placed an Inrad clip in this area. Manual pressure was applied for hemostasis for about 10 minutes. We then obtained two-view mammography for assessment of the clip position. It shows both clips were deployed in the areas described adjacent to the bulk of the mass. Further manual pressure was applied for better hemostasis. A pressure bandage was applied, and post-biopsy instructions were given both verbally and in writing. The patient tolerated the procedure very well and left our office in excellent condition. CONCLUSION: Technically satisfactory ultrasound-guided vacuum-assisted core biopsy left 9 o'clock position, three sites were sampled. A total of five core specimens were obtained. Pathology is pending. Two small contiguous but slightly separate-appearing portions of the mass were sampled in addition to the larger aspect of the mass.

Complex pneumothorax treatment 32551

Physician inserted 3 indwelling chest tubes on the left with radiological guidance for treatment of hydropneumothorax. Can we code 32551, 32551-59, 32551-59, 75989?

Complex tumor obstruction of veins treated with angioplasty/stent

The physician wants to code a venoplasty and a stent placement in this case. I am leaning more towards a thrombectomy since the physician is describing clot not stenosis and I'm aware that mashing a clot with a balloon catheter is not an angioplasty. It seems that the underlying issue here is compression from a tumor with resulting narrowing of the vessel. Please tell me if my codes are correct: 36299, 75827, 36010, 37187, 37205, 75960. I chose the 36299 as I can't tell from his dictation where he was when he initially injected contrast but since he accessed the IJ it seems he was nonselective. Thank you very much! Patient with lung cancer and significant face and head swelling secondary to SVC syndrome. Patient is here for further evaluation and possible treatment. PROCEDURE: Using a micropuncture kit and under direct ultrasound visualization, the right internal jugular vein was accessed and an 0.018 wire advanced. The needle was removed and a 4 FR conversion sheath inserted over the wire. Wire and introducer were removed and runs were done demonstrating extensive clot and tumor burden seen within the right internal jugular vein. The right braciocephalic vein and the proximal SVC. Using glidewire, access into the right atrium was achieved. Sheath was up-sized to a 7-French vascular sheath. Angioplasty was performed using a 10X6 balloon. Using a 12X40 Smart stent, this area was then secondarily stented as there was no significant interval improvement. Follow-up runs demonstrated mild improvement with residual high-grade stenosis and using a 12X40 Atlas stent, this area was then re-angioplastied. Follow-up runs demonstrated marked improvement but with significant residual stenosis which was refractory to further angioplasty. There is, however, no relux seen up towards the head. Tumor involvement is seen within the proximal right atrium.

Complication Question

I am hoping you can lend your expertise on whether or not you consider this to be an adverse event/surgical complication/misadventure. The account is being audited, and third party believes it should have been coded with complication code 996.1 and manufacturer notified of defective coil. "While the coil was being introduced into the aneurysm, a snap was felt. At this point the coil was attempted to be removed, but it was clear it was broken and detached. At this point a 2 mm snare was brought up over the microcatheter after the microcatheter was cut, and the distal hub was removed. The coil was then ensnared and removed along with the microcatheter. There was a total of 4 coils placed into the aneurysm, and post coil emobolization after final coil demonstrated good position of the coiling with no herniation into the parent vessel and no associated thrombus or embolus. There's a small neck remnant remaining in close proximity to the PCOM measuring 1.1x1.1 mm, but the PCOM filled appropriately and control angio showed no filling of aneurysm neck."

Conduit on Axillary Artery for Impella Placement

Are you aware of a CPT code we can bill for putting in a conduit on the axillary artery for Impella placement? Or should we bill an unlisted code?

Cone Beam Technology

We have a new piece of equipment that is being used to assist in guidance. The doctors each dictate the use of it a little differently, but in essence it looks to me like it might be most accurately coded with 76377. Here is a sample of the technique description: This case was performed using the I-guide feature of the Siemens artist Q. fluoroscopy suite. Guidance was performed using rotational cone beam, the 3D reconstruction, with extensive use of a workstation 2 project and then confirm the needle trajectory." Is this description adequate to capture CPT code 76376 or 76377? Can we even code for the use of this type of guidance?

Cone CT

Can code 76380 be added to the interventional coding for the following? "IVCgram with complex retrieval of IVC filter requiring dissection. Post retrieval cavagram and cone CT without contrast demonstrate a single fractured filter leg as seen on cone CT and with fluoroscopy."

Congenital Cardiac Catheterizaion

Good Morning Dr Z, once again I need your help in determining the correct way to code/bill this procedure. We coded 93799, 93544, 75774, 36215,75898 and 37204. Can we code 36215 for the selective catheterization for the AP collateral off of the aorta? I attended one of your Webinar's (which was wonderful) and you addressed the issue of collateral catheterization, but I cannot remember just what you said about these when a HC is done. ~thanks Catheterization for PDA occlusion. Procedure Note: A complete right and left heart cardiac catheterization was performed. All the appropriate chambers and vessels were entered, including SVC, RA, RV, MPA, LPA, LV, AAO and DAo. Oxygen saturations and pressure measurements were obtained by standard catheterization technique. After the hemodynamic data was obtained, a pigtail catheter was advanced to the base of the distal aortic arch and a descending aorta gram was performed. The PDA was identified. There was a moderate-sized PDA that tapered to approximately 2mm at the pulmonary artery insertion site. The geometry was suitable for a ductal occluder. We also noticed a very prominant bronchial collateral supplying the right lung which was felt to be hemodynamically significant and also likely require intervention. We then proceeded with the occulsion of the PDA usinga 6-French delivery sheath. By way of the right femoral vein, over a wire, we positioned the delivery sheath in the descending aorta. We loaded a 6/4 ductal occluder in the usual fashion and deployed the device. We then performed an angiogram with the device still attached to the delivery cable. It was in excellent position fo released in the usual fashion. We then turned our attention to the AP collateral. Using a 4-French angled Glidecatheter, we engaged the collateral which was just to the right of the PDA. We then performed select hand injection in the collateral. There was a very prominent collateral that supplied both the right middle and right lower lobes of the right lower lind. Measured 2 mm in diameter. We selected a 2x3 diamond shaped Vortex coild with the microcatheter positiioned deep in the AP collateral we depolyed in the usual fashion, followed by a 3mmX6cm.

Congenital Echo

Do the same rules apply for a congenital echo that apply for congenital heart caths for patients with a diagnosis of coronary anomalies, PFO, etc.? In other words, for patients with PFO/coronary anomalies, would I code the echo as congenital or non-congenital?

Congenital heart cath without ASD closure

Dr.Z, Question for ASD closure. During a routine echocardiogram, found to have a small left to right shunt across the atrial septum for which she was offered to have closure of ASD. After obtaineing pressures, ICE was performed and showed a small ASD near the foramen ovale. Then with transcranial Doppler in place, injectged several times the agitated saline of bubble contrast and there was no right-to-left shunting. After confirming that there is no right-to-left shunting and study was negativ e, concluded the cardiac catheterization and patient did not receiv e any closure for her defect. Our cath charges these with 93530 93662 and the order is for Right and left heart cath ASD closure with Helex TCD/ICE. Please advice. Thansk

Congenital heart catheterization

Dr. Zielski, We only treat adults in our Cardiac Cath lab. What kind of congenital defects will merit the use of the Congenital Catheterization codes in an ADULT? I went the Las Vegas meeting in November, and there is slide where some congenital defects are listed. Can I go by that list? I thought of using it, but I remembered that you mentioned that PFO is not an indication to use the congenital codes. Should we exclude any others?

Congenital left heart catheterization only

Dr. Z, Question#3 Is there a code that can be used other than 93452 if a physician perform a Left Heart Cath(+/-left ventriculogram) on a congenital patient? I cannot found one so I’m thinking that this is the only code.

Congenital Saturation Study

My physician performed a right and left heart catheterization on a patient. The physician states in the findings/impression of his dictation that a congenital saturation study was done with no evidence of significant intracardiac shunt. Is there a code that I could bill for that, or would that be inclusive with the right and left heart catheterization?

Congenital vs. Non-Congenital Heart Cath Codes

There has been lots of back and forth over the years on whether or not congenital heart transplant patients should continue to be reported as congenital for heart cath coding purposes. Physicians state that once congenital always congenital, but I've understood from consultant recommendations that unless the new heart has a congenital defect or complex re-routing of vessels due to congenital cardiac anatomy, then all heart caths for transplant patients are coded as non-congenital. Can you please clarify?

Congential Heart Catheterization

I am having trouble coding one of our physician's dictation. He is trying to bill a left and right heart catheterization as well as left and right congenital heart catheterization. Is that possible?  He wants to bill the following: 93460-26, 93531-26, 93463, 93464-26, 93567, 93568.  Would this be appropriate? CARDIAC CATHETERIZATION INDICATION FOR STUDY: Evaluation of hemodynamic significance of patent ductus arteriosus. FINAL IMPRESSION: 1. Angiographic confirmation of a 3.8 mm diameter patent ductus arteriosus with an associated QP:QS shunt fraction of 1.25. 2. Mild pulmonary hypertension. 3. Elevated left ventricular end-diastolic pressure. 4. Widened pulse pressures secondary to patent ductus arteriosus. 5. Normal pulmonary vascular resistance and pulmonary vascular resistance index and transpulmonary gradient. 6. Normal coronary anatomy. DISCUSSION: The hemodynamic significance of the patient's patent ductus arteriosus is likely a modest contributor to the patient's exercise intolerance and recent heart failure admission. Her QP:QS is likely underestimated as a definitive sample distal to pulmonary flow was difficult to ascertain, but was confirmed as best as possible via angiographic method using a JR4 catheter. Her other contributors to exercise intolerance include obstructive lung disease, the etiology of which is yet to be elucidated, particularly given her abcense of smoking history. Alpha 1-Anti trypsin serology is pending. Formal pulmonology consultation has been undertaken and her high resolution CT scan today evidences air trapping of unclear etiology. Consideration may be given to coiling of her patent ductus arteriosus or the usage of an Amplatz occluder. Formal consultation with pediatric cardiology at XX Hospital may be considered. PROCEDURE: Risks and benefits were explained to the patient. The patient was brought to the catheterization lab in a resting fasting state. The right femoral artery and vein were chosen for vascular access. JL4 JR4 catheters were used for selective angiography. Pigtail catheter was used for aortic angiography. A JR4 catheter was used for pulmonary arterial angiography. At the conclusion of the procedure, a StarClose device was deployed for hemostasis. No immediate complications were noted. CARDIAC CATHETERIZATION DATA: 1. Weight 56.7 kg. 2. Body surface area 1.56. 3. Blood pressure 109/41 with a mean of 60. 4. Oxygen consumption directly measured outside the catheterization lab was 208 mL per minute. 5. Respiratory quotient 0.78. 6. RA pressure, 8/60 (4). 7. RV 36/1, 7. 8. PA 26/ 3 (15). 9. With exercise, mean PA pressure was 20/8 with mean of 13. 10. Wedge pressure was 10/9 (7). 11. Aortic pressure 118/50, mean of 76. 12. LV pressure process 125/4, 19. 13. Saturations in the aorta were 96%. 14. PA saturation was 76%. 15. Pulmonary capillary wedge saturation was 92%. 16. Right ventricular saturation was 73%. 17. Right atrial saturation 64%. 18. Superior vena cava saturation 69%. 19. Inferior vena cava saturation 74%. 20. Attempts to cannulate patent ductus arteriosus, either from the pulmonary or arterial circuit were unsuccessful using a JR4 and IMA catheter. Wires including a BMW wire and Versa Core wire. Selective angiography of the pulmonary arterial tree did not evidence a communication with the aorta likely secondary to increased aortic pressures relative to pulmonary artery pressure; however, communication was identified from the arterial circuit to the main pulmonary artery in the LAO 60 degree position. 21. Hemoglobin 10.5. 22. Heart rate 65. 23 QP:QS 1.25. 24. Cardiac output and index by the Fick method were 6.12 and 3.92 respectively. 25. AVO2 difference 3.4. 26. Transpulmonary gradient 8. 27. Pulmonary vascular resistance 1.3. 28. Pulmonary vascular resistance index 2.04. 29. Right ventricular stroke work index 663. 30. Aortic root angiography demonstrated a 3.8 mm ostial diameter of a patent ductus arteriosus. The maximal luminal diameter of the ascending aorta was 34.9 mm. 31. Pulmonary artery angiography did not evidence a communication to the aortic circuit. CORONARY ANATOMY: Left main arose from the left coronary cusp, bifurcated into the left anterior descending and left circumflex coronary arteries, and left circumflex was dominant. The right coronary was nondominant and arose from the right coronary cusp. COMPLICATIONS: None. FLUOROSCOPY TIME: 30.9 minutes. TOTAL CONTRAST ADMINISTERED: 180 mL.

Conscious sedation

Hi Dr. Z, For a long time we have not billed for any conscious sedation with our Interventional radiology/cardiology procedures. We were told that it was included in the procedure. Is that right? We bill for the medication but not the administration. Thanks,

Conscious sedation

Dr. Z, In the hospital outpatient setting, many patients are given moderate sedation for MRI, CT etc.. procedures. Can the hospital charge for moderate sedation if the radiologist is not in the procedure room? Often times, the radiologist is in close proximity i.e reading room, control room etc. but not physically in the MRI or CT room. Thanks, Judy A.

Conscious sedation billing for hospital and physician

Hello, I have a question when it comes to conscious sedation facility vs. professional billing. If the physician performs conscious sedation on a procedure that does not have a bullet, can cpt code 99144 be added to both the hospital claim and the cm 1500 form. New to hospital billing and not sure if I can add the code to both claims. I do know that modifier 26 or TC do not apply. Thank you for your help.

Consult and Procedure

Our interventionist cardiologist has requested to clarify if he consults a patient in the hospital and does a procedure (i.e., cath/stent/PCI) in the same day can he bill for both?

Contralateral Leg Intervention and Catheter Placement

I was reading an article published in an endovascular magazine. They had several examples, one of which was a peripheral intervention. We understand that if a true diagnostic study was done prior to an intervention in the leg, we can code it, however, not to show the catheter placements. In the example we are questioning is the following quote: "Code 36246 is reported in addition to the stent placement because the higher degree of selective catheter placement was performed for the diagnostic study, not the intervention." Is this true? If so, then would then the reverse be true on greater selectivity for interventions that don't include catheter placements (say diagnostic cerebral imaging and then greater selectivity to do the intervention)?

Contralateral SFA with Ipsilateral Iliac Stent

For the following example, is code 36247 billable for the selection of the right SFA because it was more distal than where the intervention was performed? Also, is it acceptable to bill for the retraction of the catheter into the left CFA with subsequent run-off (36140)?  "Access via left groin, catheter placed into aorta for dx aortogram (75625). Catheter advanced to the right SFA for selective RLE run-off and catheter retracted to ipsilateral left common femoral artery for LLE run-off (75716). Access then warranted on the right side for kissing angioplasty and stenting of the common iliacs (37221-RT & -LT)."

Contrast Echo

How would we bill for Definity administered as contrast during a non-stress echo? Code 93352 is defined as used during a stress echo, but they did not perform the stress portion and they used Definity instead of doing a bubble study. Would 93352 still be the correct code in addition to 93306?

Contrast in Interventional Radiology

How should we charge for contrast in interventional radiology? Do we charge the amount ordered or the amount us (if we order a vial 100 ml and used/injected only 50 ml) since the amount needed determined at the end of the procedure? My question is regarding if the contrast comes in a premeasured single use vial, and they don’t use all of it they can still bill the amount in the vial because it can’t be reused and what is not used is wasted. Can we charge the entire amount as long as there is documentation of the waste? How do we charge the contrast if it is not a single use vial? Then they can only charge for the amount given? I could not find any guidelines in the CPT Assistant since it is not a CPT code. Would you please inform us with your answer and any reference and guidelines from CMS, HCPCS, or Federal Register to support this. Here is a case scenario to support the question: Patient is having abdominal aortagram 1.6 Creat. 50 ml Iohexol 300 on the table for test dose. 10 ml 50% diluted contrast used for test 50 ml Iohexol Injector 40 ml Injected 50% diluted contrast for Aortagram 100 ml Iohexol 300 Opened / 25 ml Iohexol 300 actually used How should we bill?

Contrast Material with a Cardiac Cath

Does the hospital charge for the contrast material itself with a cardiac cath procedure, or is it considered included?

Conversion of Inferior Vena Cava Filter to Stent

I was wondering if you have ever seen this before? And what you would code to? An IVC filter, stent? "Utilizing the gooseneck snare and sheath, the hook of the filter was engaged with the snare. Gentle traction was then placed on the gooseneck snare and sheath to allow the hook to be disengaged from the filter and removed in its entirety under fluoroscopy onto the table. A fluoroscopic image was taken, demonstrating that the struts of the inner portion of the filter did not fully deploy. A 5 French Sos catheter was advanced over the wire into the inferior vena cava under fluoroscopy. Several passes were made with the catheter in order to remove any fibrous bands. Repeat images demonstrated that several of the struts were not fully deployed. Further maneuvers were performed with a Rim and Cobra catheter. Despite these additional maneuvers with these catheters, there were two struts that were not fully deployed. At this time, a balloon was used to assist deployment of the struts fully. Following the use of a balloon, the structures were fully deployed."

Conversion of PCN to PNU

I'm not quite sure what codes should be used for this. The radiologist is stating that this is a conversion of an existing nephrostomy tube to a nephroureteral stent. "A scout image demonstrated the existing catheter in place. Contrast was injected into the tube, which demonstrated filling of the renal collecting system. Contrast flowed into an irregularly opacified bladder. A suprapubic catheter was in place. A wire was passed through the catheter, and the catheter was removed. A new 10 French nephroureteral stent was advanced over the wire, and its distal loop formed in the bladder, with the proximal loop in the renal pelvis. The catheter was sutured to the skin, and a sterile dressing was applied. The tube was capped. A drainage bag was provided to the patient in case the tube becomes obstructed."

Conversion of ureteral stent out of stoma to nephrostomy tube

Hi Dr. Z, Hope you can help. Patient new to our system with Nephroureterostomy tube. We converted patient to a Ureteral Stent exiting out of stoma into bag with Nephrostomy Tube placed at end of case to be removed at later date if Ureteral Stent is draining into bag ok. Nephrostogram demostrated well positioned nephroureterostomy tube with distal portion in neobladder. Wire placed through Nephroureterostomy tube with wire tip into bag and tube removed. 26cm Uretereal Stent placed from posterior approach over wire and deployed in kidney and stoma, Nephrostomy tube placed and capped. I am thinking: 50394/74425 for nephrostogram, 50393/74480 for stent insert and 50398-59/75984 for nephrostomy tube change. Do you think this is OK for a Nephroureterostomy tube changed to a Ureterostomy stent and nephrostomy tube? thanks, Paige Harris

CoolGuard Cooling Catheter

I'm not sure how to code this procedure. "The patient who suffered an out of hospital cardiac arrest came into the ER. Patient previously had a PFO closure and a history of LBBB. A left heart catheterization and coronary angiogram were performed and were completely normal. At the intensivist request, a Cool Guard Cooling catheter was placed via the right femoral vein." I am not really sure how I would bill for the cooling catheter. 37799 maybe? I was wondering if you could give me some input on which code should be used.

Core Biopsies

Patient had core biopsy (did seven cores in one breast, one lesion). How do you code it (mammographic biopsy)?

Core biopsy changed to FNA by radiologist

On an outpatient, if a biopsy is requested and the radiologist performs an FNA as he believes it is less invasive and decreases the chance for the patient to return due to an inadequate sample, is a new order needed? Should the radiologist include documentation in the report why FNA was performed instead of a core biopsy?

Coronary Angio Considering Bypass

I have a question on my physician’s dictation. He places a temporary pacemaker because the patient had a heart monitor (week prior) that revealed significant AV block along with episodes of asystole lasting 13 sec. The patient was admitted urgently and referred for placement of a temporary pacemaker to protect him from recurrent bradyarrhythmias. Because the patient has severe aortic stenosis, he also needs to be considered for aortic valve replacement, as well as coronary bypass. So he undergoes a coronary angio with left heart catheterization and proximal aortography at the same time as the temporary pacemaker placement. The physician also performs a left subclavian angio to ensure that the left internal mammary was an adequate conduit for bypass. The physician wants to bill the procedure with the following: 93458-26, 93567, 36215, 75710-26, and 33210-59. I think it should be billed differently: 93459-26, 93567, and 75710-26. I wasn’t sure about the reporting the temporary pacemaker due to being unable to code for temporary pacemaker placement when placed to prevent or treat bradyarrhythmias induces by the coronary angio or intervention.  What are your thoughts?

Coronary angiography 93454 with left ventricular electrophysiology ablation

HI Dr. Z, I have a case in which the patient had an EP study with 3D mapping and ablation of V-tach. However, prior to beginning the ablation a LCA angiography was done "to outline the course of the coronaries on the epicardial surface to ensure the ablation spots were safe distance away from these vessels." Can I bill 93454 or is the angio included in the EP study and ablation? Thanks so much for your help!!!

Coronary Angiography during Ablation

When a patient is in the EP lab for an ablation, and a coronary angiogram is done (to determine ablation locations so as not to disrupt coronary), the coronary angiogram is performed by a cardiologist during the EP ablation, not by the electrophysiologist who is performing ablation.  Can we charge code 93454?

Coronary AngioJet Thrombectomy without Primary Coronary Intervention

A left heart catheterization was performed with an LV-gram. There was a 99% thrombus burden found in the right coronary. A temporary pacemaker was placed, and AngioJet thrombectomy was performed in the right coronary with multiple runs. Bolus injections of Integrillin were given. One more AngioJet run was done, and the patient had a VT arrest and needed to be shocked. Post procedure films showed the 99% thrombus burden was reduced to about 85%, but there was TIMI 2.5 flow and a satisfactory result considering the thrombus burden. Via a 1.5 x 20 Clearway, 2.5 verapamil and 200 mcg of Nipride were given. Since code 92973 is an add-on code to a primary coronary intervention procedure, what can be billed?

Coronary Angioplasty

When angioplasty is documented in the proximal right coronary artery and right coronary artery posterolateral extension, are codes 92920 and 92921 appropriate?

Coronary Artery Fistula Closure

I'm still pretty new in coding cath and want to make sure I'm on the right path. One of my providers performed a coronary artery fistula closure with a congenital cath plus coronary angiogram and supravavular aortography. This is what I'm coming up with so far: 37242, 93531, 93567, and 93563.

Coronary artery MRI

At our facility, we are coding C8909, C8910, or C8911 for imaging of the coronary arteries only; the radiologists are NOT evaluating diseases of the cardiac muscle. The patients' orders document the diagnosis of ARVD (Arrhythmogenic Right Ventricular Dysplasia). Are we correct with our coding or should we use CPT 76498? If we are not correct, can you explain why we are not?

Coronary Grafts via Root and Subclavian

I have a coronary CABG case where the cardiologist engaged the RC and LM then did root shot for venous graft info and subclavian shot for LIMA info (B.P. cuff blown up). Would you report a graft code because he selected the subclavian?

Coronary intervention

We have a difference of opinion among our coders regarding the correct coding of certain interventional procedures. The following is an example: "Percutaneous coronary intervention was carried out on a totally occluded saphenous vein graft. Initially a balloon was used but failed to open the vein graft. Next an Export extraction atherectomy catheter was used. Provider was able to suction out some of the clot. A balloon was used to pre-dilate a lesion in the distal vein graft allowing placement of a bare metal stent." Some coders coded an atherectomy while others coded an angioplasty. Apparently the physician's use of the term "atherectomy catheter" is prompting some of the coders to code an atherectomy. Can you provide our coders with some guidance regarding the appropriate codes for the procedure described?

Coronary Intervention, Codes C9600 and 92921

How would you code for a drug eluting stent to the obtuse marginal and an angioplasy to the left circumflex? Would you report codes 92920 and C9601 since the angioplasty was in the major coronary artery and the stent is in a branch? Or, would you report codes C9600 and 92921 based on the higher intervention per coronary vessel distribution regardless of whether it is a major vessel or branch?

Coronary IVUS

This question was brought up, and I would like to have your opinion. Prior to 2013 there were only three coronary arteries recognized by CMS. Therefore, prior to 2013, you could bill 92978 x 1 and 92979 x 2 for IVUS during PCI, if performed. Now that 2013 AMA and CMA both recognize five coronary arteries (LM, LD, LC, RI (if applicable), and RC) could it be possible to bill IVUS more than a total of three times?

Coronary Sinus Venogram

How would you code this? "The pacemaker was explanted. Using a modified Seldinger technique with extrathoracic approach, subclavian vein was accessed x 1. Guidewire was cannulated. Over the guidewire, a Medtronic long sheath to access the coronary sinus was placed. The standard sheath was unable to cannulate the coronary sinus; therefore, it was changed to a wider coronary sinus sheath. The coronary sinus did appear to be cannulated. Guidewire was advanced. The position of the guidewire appeared to be far more lateral on the lateral wall of the ventricle. Therefore, a venogram was performed. The venogram showed that the guidewire and the sheath were actually into the pericardium and it perforated the right ventricle. Therefore, the sheath was withdrawn. A STAT echocardiogram was ordered and showed the presence of approx a 2.5 cm pericardial effusion. An emergent pericardiocentesis was performed. This drained 250 cc of pericardial effusion. The pocket was extended and irragated, and the previous pacemaker was placed back inside."

Coronary Sinus Venogram with Embolization of Fistula from LAD to Left Ventricle

A coronary sinus catheter is placed via left subclavian vein for a CS venogram to locate site of a fistula from distal LAD artery to what appeared to be CS, found to actually be the left ventricle. Catheter was placed into the distal LAD, traversing the fistula to deploy coils and close off the fistula. Verified results with final angiography. We reported codes 37204, 93454, 75894, and 75898. How would the coronary sinus venogram be coded?

Coronary sinus venography

If a coronary sinus venogram during an EP study reveals that the patient has an abnormal takeoff or other anatomical abnormlaity of the coronary sinus, is there a set of codes that should additionally be billed to describe these services in conjuntion to the EP study codes (ie. 93620/93621)?

Coronary Sinus Venography After EP and Ablation

The patient had supraventricular tachycardia. Electrophysiology was done, as well as ablations. At the end of the procedure, additional final venogram was done, which showed the coronary anatomy to be the same as when the procedure was started. Do you code separately for a venogram of the coronary sinus anatomy after EP and ablation?

Coronary sinus venoplasty

Are there any additional charges that could be billed in a BIV ICD replacement case to describe a pta of a coronary sinus that was stenosed due to scar tissue buildup from multiple LV lead revisions/replacements?

Coronary Stent Placement Left Ventricular Branch

Could you please assist me with this scenario? Physician has placed drug-eluting stents in the posterior descending artery as well as the left ventricular branch. For coding purposes, is the left ventricular branch considered an additional branch off the right coronary artery? If so, are we allowed to code for stent placement in this vessel?

Coronary thrombectomy must be performed with mechanical device

Is the most recent news letter that was sent this month "AMA Supports ACC Position on Use of Coronary Thrombectomy Code 92973" effective as of right now? we have a vender that is disagreeing with this and stating that it will not be effective until 2012. thanks so much!

Costocervical/Thryocervical Artery Imaging

When a cerebral angiogram is performed, and they catheterize and image the bilateral internal carotids, vertebrals, and external carotids, as well as the bilateral costocervical and thyrocervical arteries, do we code for the catheterization of the costocervical and thryocervical arteries? Right now I'm looking at reporting codes 36226-50, 36224-50, 36227-50, 36217 (right costocervical), 36218 (right thyrocervical), 36216 (left costocervical), 36218 (left thyrocervical), and 75774 x 4 (arterial imaging).

Covered stent in ruptured coronary artery after DES

We had a case in our cath lab the other day that I had not seen before and I would like your opinion on the codes we used. The patient came in and had a left heart cath with left ventriculogram. Then the physician placed drug eluting stents in the RC and LC. During placement of the RC stent, the vessel was perforated. They placed a JoMed Graftmaster covered stent to tamponade the perforation. We coded the diagnostic cath and G0290-RC and G0291-LC for the stents. We couldn't find any code to use for the covered stent since we had already used G0290 for the RC. Are we correct on this or is there some code we are missing for the use for the covered stent? Thanks for your help.

CPR with Heart Cath

If while performing a diagnostic or interventional heart cath the patient requires emergent CPR, do we code for the CPR separately in addition to the heart cath procedure? Or is it considered part of the procedure?

CPT 36832 for Collateral Vein Ligations

We are report code 36832 for ligation of collateral veins off the AVF. If we have multiple cut-down incisions with more than one vein ligated, can we bill code 36832 more than once per encounter?

CPT 93463

"Left heart catheterization with intraprocedural Nitroglycerin administration with hemodynamic monitoring. A 6 French JL4 catheter was advanced into the ascending aorta. Aortic blood pressure was measured. It was markedly elevated at 220/110. The patient was administered 0.4 mg sublingual Nitro. Hemodynamic monitoring was performed. Repeat blood pressure was obtained a few minutes after Nitro administration, and blood pressure had dropped to 160/100." Can code 93463 be billed for this part of the heart cath procedure? My physician needs clarification regarding the criteria for use of this CPT code.

CPT 93623 performed after the ablation

Typically, when our physicians perform CPT 93623, it is done during the EP study but before the ablation. We're seeing a case where it's documented as "post ablation testing" and IV isoproterenol was admininistered following the ablation. Is code 93623 billable in this circumstance?

CPT 96420 for Chemoembolizations

I was reviewing chemoembolization guidelines, and it says that code 96420 can be reported per the 2014 CPT Codebook, but I always understood that code 96420 should not be reported in a facility setting for physicians (only in an office setting). I work for a cath lab in a hospital where they perform these procedures. It is considered an outpatient department for billing purposes even though inpatients and outpatients are treated there. I do charge capturing for the facility side and coding for the physician side. The physicians note in their reports that "chemotherapeutic agents were prescribed and administered by (physician name)". I have not reported code 96420 in the past or currently based on guidelines. I do use code 79445 for the Y-90 cases we do. But I've had some of the business staff and physicians asking if I'm coding this because they are doing the work, so they think it should be coded. Am I correct not to report code 96420, or should it be reported? I need some clarification on the guidelines.

CPT 96450

How would you code the lumbar puncture if the puncture is by the interventionalist and the chemotherapy injection is by the oncologist through the same access?

CPT Changes for 2014 for Imaged-Guided Breast Procedures

I have a question regarding the 2014 NCCI narrative instruction Chapter 9, subsection D, #11, and I would like to get your opinion on what this means for outpatient radiology facilities. It is regarding post procedural mammograms and that there should not be a separate charge reported when the breast procedure is done with mammographic guidance. Does this mean that if the breast procedure (biopsy or needle loc) is done by ultrasound or MRI guidance that a post-procedure mammogram can be reported?

CPT code 35875, 35876

Greetings, Would a open thrombectomy of a fem pop bypass graft be coded as 34201 or 35875? LW

CPT code 36246 75716

Can you code 36246 and 75716 when an interventional procedure is not involved?

CPT Code 37607 vs. 36832

Is code 37607 used only when the AVF is completely ligated? Example: On page 363 of your Vascular & Endovascular Surgery Coding Reference, we are directed to use code 36832 for ligation of collateral veins that are preventing maturation. If the vein in the AVF is ligated due to steal of the flow, is 36832 still the correct code?

CPT code 93432 and 93581

Can 93463 be reported with 93581? Catheterization codes (93531, 93565) are included in 93581 but our cardiologist is repairing the VSD and then doing a nitric trial with documentation of R/L heart hemodynamics. Thanks

CPT code for injection into the symphysis pubis

Good evening Dr Z, Would the following be considered an unlisted injection? Following consent, following sterile prepping and draping and under fluoroscopic guidance 20 gauge needle is advanced into the symphysis pubis and steriod with local anesthetic injected. 20999 vs 27299 I'm leaning 20999, 77002 Appreciate your thoughts, Judy

CPT code for marking chest for subsequent thoracentesis

DR. Z, I am a coder having a disagreement with another department on coding a tunneled PleurX catheter for malignant pleural effusion. The doctor writes in the progress notes " 12 pleural cath ..place via ultrasound guidence 1600m of fluid removed. He types up a report that states "ultsonography guided right pleurX catheter placement...Ultrasonography was performed at the bedside and revealed a large right pleural effusion which was echoic in nature, suggesting blood or thick fluid. A mark was placed in the patient's chest for proper needle placement. The patient was then cleaned with ... and a drape was placed. The right pleurX cahterter was placed in the right midaxillary line. It was tunneded under the skin to about 7 mm into the chest. There was good drainage of serosanguineous fluid which was removed without difficulity. I think the codes should be 32250 and 75989 but the department insist that 78989 should not be added because the ultrasound guidence is FOR LOCALIZATION: THis is the response representing the department: I have to ask whether the procedure was actually guidance vs. localization. To report ultrasound guidance I would expect documentation to support continuous ultrasound guidance as the following Thoracic Intervention Seminar demonstrates. This particular patients procedure note only describes using ultrasound to locate a large pleural effusion.The operative report does state Ultrasonography Guided Right PleurX Catheter Placement. It may be poor physician documentation but I would imagine that it was used only to localize. Thoracentesis under ultrasound guidance is usually performed with the patient in a sitting position on the edge of the bed, leaning forward with the patient's arms resting on a bedside table. When the patient is not able to be placed in a sitting position, the lateral decubitus or supine position can be used. Preprocedural ultrasound evaluation can localize the pleural fluid pocket and skin entry site at the posterior intercostal space, which is prepared and draped in a sterile manner. A skin entry site is then anesthetized using 1% lidocaine with epinephrine. The access site should be along the superior margin of the rib to avoid the injury to the intercostal artery, which runs along the inferior border of the rib. After making a small skin incision, an 18-gauge over-the-needle sheath is then advanced into the pleural fluid under continuous ultrasound guidance." What do you think should be coded for this procedure 33251 and 75989 or just 33251? I think they are getting 75989 mixed up with 76937. Thanks so much for your website and books. I could not do my job without them!! Kelly Hill Coder

CPT Code for Radiofrequency Ablation of the Sphenopalatine Ganglion

What is the correct CPT code for radiofrequency ablation of the sphenopalatine gaglion?  I am looking at unlisted code 64999, as there is not a specific code that names this group of nerves under the Destruction section 64600-64681.

CPT Code Question How To

How would you code the following?  Stent graft angioplasty of old cadaeric vein bypass, balloon angioplasty of right anterior tibial vessel, selective angiography of right lower extremity with third order catheter placement, and replacement of infusion cath for another 24 hours.

CPT Codes 93621, 93622, and 93623

AMA has clarified information on EP coding, but CMS Transmittal 2636 conflicts with the AMA's revision, so I'm questioning if we will continue to see issues with these codes until CMS updates their information. NCCI also lists a bundling issue with codes 93623 and 93653, and I'm not sure that it would be appropriate to append a modifier to unbundle. Thoughts?

CPT codes for embolectomy and iliac angioplasty

Hello Again, I am having a hard time with this case. I am debating between cpt codes 32401 with 75710-59,37220 or 35371,37184, 37220 and 75710-59. I am helding more on 32401 codes as i see the incision and repair and a catheter is also used. for the second pair of codes i really dont see the andarterectomy 35371 done as the surgeon states. Please help as the more i read it the more confused i get. Thanks for your help.... PROCEDURE: 1. Right common femoral artery exploration with endarterectomy. 2. Right SFA embolectomy. 3. Right common femoral embolectomy. 4. Right external iliac embolectomy. 5. Right iliac angiogram. 6. Right common iliac embolectomy with over the wire Fogarty, 4 French. 7. Right common femoral angioplasty with 8 millimeter x 60 millimeter balloon. 8. Right common femoral artery repair with patch angioplasty. - SURGEON: Kin-Man Lai, M.D. - ASSISTANT: John Beemer, Physician's Assistant. - ANESTHESIA: General endotracheal anesthesia. - ESTIMATED BLOOD LOSS: 50 cc. - ESTIMATED FLUID: A liter of normal saline. - COMPLICATIONS: None. - DISPOSITION: To the recovery room in stable condition. - BRIEF DESCRIPTION OF PROCEDURE: This is a 52-year-old gentleman with known peripheral vascular disease status post right common iliac angioplasty and stenting with double stent in the past and status post left common femoral artery endarterectomy and patch angioplasty repair 2 years ago who presented to the emergency room today with a four day history of right lower extremity numbness. The patient's symptoms progressively worsened with inability to walk and pain. - The patient was immediately evaluated with bedside ultrasound which noted there was little to no flow in the common femoral artery. The patient has flow in the SFA and profunda femoral artery via collateral. The patient also has no flow in the external iliac artery. Due to these findings and history of peripheral vascular disease and stenting, the patient was deemed to have evidence of acute on chronic ischemia. The patient was then given the option to go to the operating room to have this repair emergently. The risks and benefits of this procedure were carefully explained to patient and wife in full detail who wished to proceed. - The patient was then brought to the operating room, placed on the operating room table. After adequate anesthesia was achieved, the patient was appropriately prepped and draped. We made an incision approximately 3 inches above the groin crease. The subcutaneous tissue was then dissected with cautery device. With Weitlaner in place we dissected all the way down to the common femoral vein following the epigastric branch. We also ligated the epigastric branch and saved it for patch angioplasty repair at the end of the procedure. - We isolated the common femoral artery which has no pulse. A vessel loop was then placed around each one, the distal aspect of the common femoral artery. The patient was given 5000 units of heparin. When the heparin had been in for five minutes we opened up the arteriotomy with an 11 blade, extended it with Potts scissors. We then performed a Fogarty angioplasty with #3 Fogarty down the SFA and then #4 Fogarty at the common femoral and external iliac. We were not able to pass the Fogarty retrograde past 15 millimeters. Due to these reasons, I suspected a possible occlusion or stenosis of the previous atrium stent. We therefore placed a 6 French sheath in place and used 4 French over the wire Fogarty to open up a small passage. Under fluoroscopic guidance we were able to gain access to above common iliac artery on the right side. - Angiogram with Kumpfe catheter revealed no flow into the right limb of the iliac artery. We therefore proceeded to perform over the wire Fogarty with a 4 French system. We removed a small amount of clot. At this point we did not have good flow under completion angiogram. We therefore used an 8 millimeter x 60 millimeter Admiral balloon and performed angioplasty of this stent. This was performed successfully. Post procedure we had an open channel in the common iliac. We had good flow into the right iliac and retrograde flow into the aorta and the left iliac system. - At this point, after multiple angioplasty was performed, we elected to remove the sheath and proceeded to irrigate the arteriotomy and then we paired this arteriotomy with the epigastric branch saphenous vein. This was repaired with a 6-0 Prolene. This was repaired without any difficulty. We backflushed and foreflushed the conduit and irrigated the repair area with heparinized saline. The patient has good pulse at the end of the procedure. - We then proceeded to apply thrombin soaked Gelfoam for hemostasis. We then proceeded to close the wound with 2-0, 3-0, and 4-0 Vicryl and then Biosyn. The patient's wound was then carefully cleaned off and local anesthesia was infused. DermaFlex was then used as a sterile dressing. The patient tolerated the procedure well. No complications. The patient was then taken to recovery in stable condition. - -

Creation/Closure of New Generator Pocket

"Patient had a previous ICD that was infected and removed. Several days later we created a new pocket on opposite side. We attempted to access veins, and venogram with contrast was done, which showed everything to be occluded. Procedure was aborted and the new pocket was closed." Is there a code for just the creation/closure of the new pocket?

Crosser

Hi Dr Z: I was informed that one of the hospitals across town is billing for an atherectomy procedure when using a Crosser device is used to make a path in a vessel. Should we bill for an atherectomy when the Crosser is used? Thanks

Crosser CTO Recanalization Catheter

Do you know if the Crosser Catheter system has been approved for use other than atherectomy? An issue has come up with the product being used for "recanalization of an occluded vessel" prior to proceeding with angioplasty. Product has a C-code of C1714, which is going to edit since documentation only supports the angioplasty procedure. Is "recanalization of occluded vessel" enough to justify changing this procedure to an atherectomy? I don't feel that it is.

Crossing a CTO

Can you please clarify what constitutes an atherectomy for crossing a CTO? Would I bill code 37224 or 37225 for the following? "A 12 gram Cook Advance CTO guidewire was then used to try to recanalize the occlusion of the right popliteal and tibioperoneal trunk vessels. It would not pass. A miracle Brothers 3 gram guidewire was substituted and met similar difficulties. A 6 French Cook ansel contralateral guiding sheath was then advanced over a Supracore wire into the right superficial femoral artery Viabahn. Angiography was then performed, and the Miracle Brothers 3 gram guidewire was then reintroduced with use of a Trailblazer catheter for support. The right popliteal artery occlusion was then treated with percutaneous transluminal angioplasty using a 4 mm x 40 mm balloon. This was followed by exchange for the Supracore wire, using a 4 French straight diagnostic catheter. At this point, the Supracore wire was successfully advanced into the peroneal artery."

Crossing occlusions

Dr. Z, we are seeing an increase in the use of "crosser" catheters for CTO use in peripheral vessels. We now have a plethora of such catheters being brought in by various vendors (Flowcardia Crosser, CTO Frontrunner, Quick-Cross Spectranetics, etc, etc). The physicians and the techs want to code the use of these catheters as angioplasties. Last year we had discussed with ZHealth and we had been advised that these are "glorified" catheters and not to code anything additional for their use. Today I happened to be in the IR Suite and one of the reps was telling the physicians that they recommended the use of unlisted cpt 37799. Have you any updated information on these catheters and their use? What would your recommendation be? Thanks for your insight, we breathe easier knowing we have ZHealth resources to help us!

Crossing occlusions

Dr. Z, we are seeing an increase in the use of "crosser" catheters for CTO use in peripheral vessels. We now have a plethora of such catheters being brought in by various vendors (Flowcardia Crosser, CTO Frontrunner, Quick-Cross Spectranetics, etc, etc). The physicians and the techs want to code the use of these catheters as angioplasties. Last year we had discussed with ZHealth and we had been advised that these are "glorified" catheters and not to code anything additional for their use. Today I happened to be in the IR Suite and one of the reps was telling the physicians that they recommended the use of unlisted cpt 37799. Have you any updated information on these catheters and their use? What would your recommendation be? Thanks for your insight, we breathe easier knowing we have ZHealth resources to help us!

Crossing Septum for Congenital Heart Catheterization

When we do a congenital right and left retro catheterization (93531) and take sats in the LV, then later in the case they go across the ASD to the LA (and don't take sats), but go on into the pulmonary veins for pressures or angio, how do you code the catheterization???  With code 93531 or 93533? Is going across the septum for any reason cause to change to code 93533?

Crossover is now atherectomy

Bard, Inc. has apparently received approval from the FDA in August to market the CROSSER Recanalization System as an atherectomy device, equivalent to the Diamondback and Turbohawk devices. Does this change your opinion that use of the crossover catheter should not be billed as atherectomy (at least for the Bard device)? Can we now bill for atherectomy when we use the Bard crossover catheter to cross a lesion? Thank you in advance.

Cryoablation of bone tumor 20999

Please do NOT include any actual patient medical records with your question. Our physician performed a CT guided core bone biopsy of a right tibia mass. Following the biopsy a 17 gauge cryoablation probe was inserted into the mass. Limited CT images were obtained at 2 minute and 6 minute intervals to evaluate the progression of the ice ball. These demonstrated circumferential coverage of the mass. Following removal of the cryoablation probe, limited CT was performed revealing hypodensity within the region of the mass consistent with the ice ball. Sterile dressing was applied. How would you code the cryoablation portion of this procedure? Would you use 20999 or 20982? Thank you.

Cryoablation of lung 32999

Dr. Z, In the area of cryoablation of the lung, I have suggested 32999 as the appropriate code, others are stating that microwave, radiofrequency and cryoablation would use the same code: 32998. Could you please clarify this as our hospital uses your guidelines but we do not have anything in writing on this issue. Another issue that has led to some confusion is that the physician used the RFA equipment but changed the needles on the equipment to perform the cryo? Documentation reads: Two 24L cryoablation needles were subsequently inserted into the lesion. Multiple adjustments in the position of the needles were made followed by limited CT scans in full expiration were performed until correct positioning was obtained. During this process, the patient developed a moderate volume pneumothorax for which an 8 French APDL pleural catheter was placed. Intermittent hand aspiration was performed to maintain lesion targeting. One run of 30 minutes was performed to ablate the lesion. The ablation needles were then removed and the tract was ablated. A sterile dressing was applied and the pleural catheter was left in placed to 20 mm Hg of wall suction. Thanks in advance for your help with this problem, Rhonda, Ancillary Manager

Cryoablation of Neck Mass

I need your help coding this procedure. "Serial CT images of the left upper neck and chest demonstrate a large soft tissue mass corresponding to area of suspected metastasis noted on outside MRI imaging. This area was targeted for ablation. The overlying skin was prepped and draped in normal sterile fashion. After local anesthetic was given intended needle tract, 4 x Ice Rod Plus probes were advanced with serial CT guidance. Confirmation was performed utilizing CT scan in multiple planes. After confirmation of appropriate positioning, ablation was commenced. Ablation commenced with two cycles of 10-minute freeze and 6-minute active thaw. At the conclusion of this, the Ice Rod Plus probes were removed. At the conclusion of the procedure, post-procedure CT of this region was obtained, which failed to demonstrate evidence of hematoma and appropriate coverage of the lesion with the ice-ball formation. Sterile dressings were applied."

CS Catheter

Dr. Z,  93621 is the bane of my existence! Below I have two separate excerpts which I would appreciate if you could tell me equal 93621. I can't recall any situation when I have specifically seen "LEFT atrial pacing/recording". (Well, maybe one.) Additionally, is there a specific phrase or wording I could suggest to the physician that would make it easier for everyone? Or, wording that I can specifically look for? Is coronary sinus cannulation sufficient? Because he almost always says that. He is very good about documenting comprehensive EP study. 1) Quadripolar catheter placed in high right atrium. Pacing septal and lateral to the isthmus. Rapid pacing in the atrium showed Wenckebach cycle.  Coronary sinus was also cannulated and mapped. 2) Quadripolar mapping and cryoablation catheter was placed in the right atrium and the right ventricle, and the coronary sinus.  Comprehensive EP study performed.  Patient had pacing, both septal and lateral.  Rapid atrial pacing.  Pacing in the RV. I have referred to your Q&A's from 7/30/10 and 12/28/09 as well as scrutinizing the CPT description for 93621, but I still wrestle with this. YOUR HELP IS GREATLY APPRECIATED.

CT Abdomen Multiphase

Dr. Z, A question has come up about charging for a CT Abdomen Multiphase. We are charging a 74170 CT Abdomen w+w/o contrast,but should we be charging a 74178 CT Abdomen+Pelvis w+w/o because the pelvis is included in the study? For renal multiphase, we scan the 1)abdomen+pelvis w/o 2)abdomen with contrast(arterial phase)3)abdomen with contrast(venous phase) 4)delay abdomen+pelvis(delay phase). We scan the pelvis with all multiphase-liver,pancreas,renal,except for adrenals. My physician thinks we are under charging because no pelvis charge in 74170. I think we should have a CT Abdomen+Pelvis Multiphase charge-74178 for liver, renal,pancreas and a CT Abdomen Multiphase charge-74170 for adrenals. The radiologists dictate the pelvis on these cases as well as the abdomen. I just got the Diagnostic Radiology E-book, it is really helpful!! Thank you, R Mercer

CT and CTA of the chest

Dr. Z Can I code a CT of the Chest w/contrast 71260 with a CTA 71275 if the reports evaluates the lungs as well as the non-coronary vascular structures of the chest?

CT brain w/o contrast with cerebral perfusion exam

Is a CT brain w/o contrast included in a cerebral perfusion analysis exam?

CT Cystogram

My question today is how to code for a CT cystogram. We have been charging CT pelvis with and without contrast, CPT 72194. In the 2013 Diagnostic Radiology Coding Reference, it says to charge the anatomy that is imaged, but does not mention using code 51600 for the delivery of contrast into the bladder. On the Z website there is a Q&A regarding this that says to add the injection code 51600 (but it is from 2008). We are getting more and more outpatients for this procedure, so I want to make sure we are charging correctly.

CT due to Trauma

Scenario: ER physician orders a CT abdomen/pelvis, CT lumbar, and CT thoracic due to trauma. The patient is taken to the CT Department for scans. A “whole body” CT scan is obtained. The technologist manipulates the films, and the radiologist separately reports on each orderable. Please validate if it is appropriate to charge separately for a CT abdomen/pelvis, CT lumbar, and/or CT thoracic... or if the CT lumbar and CT thoracic would be considered “2D rendering”.

CT Guided Breast Clip Placement.

We are reporting CT-guided breast clip placement with an unlisted code. Do you agree, and what is the reasoning behind not setting up a CT-guided code in the 19281-19288 code range? Was it lack of use? No one covers this in their references.

CT guided nephrostomy placement

Dr. Z This is a CT-Guided Nephrostomy Placement question. CT is used to direct entry into the left collecting system. Left back is sterily prepped and draped. There is placement of a 17-French introducer guide and the needle is removed. Bloody urine is obtained. 0.038 Benson wire is placed through the introducer guide and the needle is removed. Over the wire a 6-French dilator is placed. That is removed. Finally there is placement of an 8-French pigtail type catheter which is coiled in the left renal pelvis and its pigtail locked. Codes 50392 and 74475 were used but the question is can we also code the 77012 for the CT-guidance? Your interventional book mentions that fluoro and ultrasound are both included but is the CT?

CT Guided Nonvascular Alcohol Ablation Lymph Node

Would code 20500 be appropriate for this non-vascular alcohol ablation? What about code 77013? Thanks for your feedback. "Percutaneous ethanol injection into the portal enlarged metastatic lymph node PET positive lymph node. Under CT guidance, Chiba needle advanced into the target lymph node. Anhydrous ethanol was injected in small aliquots with intermittent scanning to observe the distribution and position of the needle. We injected approximately 17 mL of absolute ethanol intralesionally. Particular care was used to avoid needle entry and injection into the biliary and vascular structures."

CT Lumbar Spine with CT Abdomen/Pelvis

Is it appropriate to charge for both when doing a reconstruction-reprocessing of CT abdomen/pelvis to create a CT lumbar? Some of the hospitals are charging for CT abdomen/pelvis only, others for the CT lumbar spine only, and others for both.

CT Perfusion

At our institution, CTA brain and separate perfusion analysis with Diamox challenge is performed. We've referenced your 2014 Diagnostic Radiology Coding Reference, which states to code only non-contrast CT. We're performing CTA; how should we code the study? Can you explain to us why it is or is not appropriate to code 70496 and 0042T?

CT-Guided Needle Placement for Intraoperative Biopsy

CT-guided needle placement within an expansile mass in the lateral right rib for intraoperative biopsy (Note: Patient was brought to OR. The right eighth rib mass identified and biopsies were taken. However, more tissue was needed, so partial resection was done to provide more tissues.)

CTA of the chest, abdomen, and pelvis

Hello: I am coding for CTA of the Chest-71275-26, ABD-74175-26 & Pelvic 72191-26. For 2012 new code 74174 is for bundling of the Abdomen and Pelvis. The discription in CPT does not state anything about Chest. Have you heard of any problems in regrds of billing for the chest 71275-26 with the 74174-26? This is my 1st time using code.. Thank you

CTA or MRA with catheter based angiography

Is a CT angiogram now considered an equivalent study to a catheter based angiogram? Why am I asking this question?  Well, each year I print out the NCCI written instructions, place it in a binder in the MD reading room.  I highlight and flag the different practice areas for my physicians here. This is the version that releases in Oct."XX.3."  I was looking last week for this year's release, it is not being released until December this year.  I happened to glance through it and it stated that diagnostic angiography cannot be billed if the patient has had a CT angiogram or prior diagnostic catheter based angiogram.  (Unless of course those were suboptimal images or change in patient status/symptoms).  Has this changed then in the past year or so?  I attempted to find a clarification in your 2011 Diagnostic & Interventional Cardiology Coding book, but was unsuccessful. (I trust your guidance over others!)  Recently, I am seeing more patients coming in having had a CT angio now that suggested stenosis or aneurysm. NCCI Version 16.3 Chapter 9 CPT 70000-79999- D. 4.-- 4. Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59. If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier 52 to the angiogram CPT code. If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure. It appears that I am not able to charge for a diagnostic catheter based angiogram when  a  patient comes in for a diagnostic study and possible intervention if they have already had a CT angiogram that was a complete study and they have not had any changes in their symptoms.  Do you concur? Thank you so much for your time,guidance and patience.  Every day is a new day of learning!!!

CTA prior to catheter based intervention

Am I correct in thinking that if the patient had an outside CTA of extremities and then presents to our lab for intervention, we shouldn't report 75716 in addition to 33221? Thanks~

CTA/catheter based angiogram

I know that we cannot code angiograms if the patient has had a prior catheter based study to determine the need for intervention. We are doing more CTAs and MRAs in our institution. These images are obtained with a power injection into a IV. We have not been considering this catheter based, so if the patient is in the IR suite and angiograms are done to determine the need for intervention, we have been coding them. Is that correct?

CTA/PE 71275

It is my understanding the axial data set from which 3D images are created is insufficient for reporting of a CTA study. When reformatted images are acquired and interpreted in addition to the CT axial images, the reformatted images are part of the study. We have a customer indicating they perform CTA on all PE studies - they have a Philips scanner that has a MIP button to indicate - an axial MIP with 2D MPR in the coronal and sagittal plane - or - an axial MIP (but not 3D). The directive is to code these studies with 71275. The consultant for the customer is stating, "MIPS qualifies as 3D; so long as the physician includes that in their documentation you meet the requirements for CTA." The physicians are not documenting "MIPS" in their dictations. Should these representations (2D MPR) by the customer be coded as standard CT with contrast?

CTO

Does the physician have to specifically state "CHRONIC total occlusion" to use CPT code 92943? What if they only state 100% occlusion?

CTO with Dual Injections

At our facility we have started a new CTO program. These cases are, as expected, more complex. The technique that has been adapted here is bilateral access with dual injections of both the LMCA and RCA to assess the collateral flow for a potential retrograde approach. The physician who has been doing these procedures feels that we should be able to charge something in addition to code 92943 or C9607. I have been expressing my disagreement with him. I feel that the CTO charge already encompasses the additional access and greater procedure involvement. Please advise.

Cutting balloon

Greetings! Maybe you could clear things up with a quick question. If a cutting balloon is coded in the coronary arteries as Percutaneous Transluminal Coronary Atherectomy(92995) Can't you code a cutting balloon used within a dialysis graft as Atherectomy Brachiocephalic(0237T)? Thanks, Melissa

Cutting Balloon Angioplasty

If a cutting balloon is used to do an angioplasty, do we report an atherectomy?

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