The procedures I am auditing are performed by an interventional cardiologist (who is also dictating the reports for the procedures). The co-surgeon is the cardiovascular surgeon. Cutdowns are being performed by the vascular surgeon. Is there any coding I can do for them? I want to be sure I am looking at these procedures correctly.
How would you code this scenario? PTCA in the diagonal for chronic total occlusion and PTCA with drug-eluting stent to the mid LAD (no total occlusion). I want to report code 92943 for the CTO and 92929 for the drug-eluting stent; however, code 92929 states in the descriptor that it is for a branch of the major coronary artery, not the major coronary artery itself. So then it is code 92928 for the major coronary artery and 92944 for the CTO... but that is also not coding by the guidelines since it states you code by the hierarchy of services based on the intensity of the service. Thoughts?
I need to know when I can code both a fine needle aspiration and a core biopsy. Sometimes our physicians do not say why they go on to obtain a core after an FNA has been done. If a reason is not documented, should I just code for the core biopsy? Following is an example: "Ultrasound of the neck revealed 2.5 cm of right cervical lymph node/mass. A 25 gauge needle was advanced into the mass with ultrasound guidance, and an FNA was obtained and given to pathology. The needle was removed, and a total of six core biopsies were also obtained. Post ultrasound demonstrated no hematoma or complication."
I am having an issue with denials when reporting code 93580 with codes 93568 and 93567. Do you have any suggestions on how we can get this paid when billed?
Follow Up to Question ID #5966, it states: ‘A caveat would be if two physicians are in same group and use same billing number then code as usual, as add-on code 93571 would be okay with the heart cath.’ Can you further clarify what is meant by ‘code as usual’? Do you mean first physician can code and bill add-on code since second physician is in the same group even though first physician didn’t perform add-on procedure? CPT manual, p. xiv outlines: “The add-on code concept in CPT 2014 applies only to add-on procedures or services performed by the same physician. Add-on codes describe additional intra-service work associated with the primary procedure…Add-on codes are always performed in addition to the primary procedure and must never be reported as stand-alone code.” CMS 1/1/14 policy outlines the same principal. Also, if FFR/IVUS is performed on same day as heart cath but by two physicians in different groups then do you recommend each physician code their part with second physician utilizing unlisted code 93799 to capture the stand alone px of FFR/IVUS.
For the following case, are codes 36012-50, 36005-59, 75822, and 75825 correct? Using US guidance, a micropuncture needle access attempted into small irregular LT CFV (36005-59). Several attempts were made to pass a wire up through left iliac stents but were unsuccessful. Then access was from the right IJV down into the left SFV and right CFV with catheter placement (36012-50). We traversed entire length of existing iliac venous stents. Contrast injection digital subtraction LLE and left pelvic venogram were performed. Could not traverse beyond region of proximal left thigh due to significant venous irregularity. Catheter was pulled back and positioned in distal aspect of left iliac vein stents, and contrast injection pelvic venograms were performed to evaluate stent patency. Next, access was gained into right iliac vein with glide catheter and with resistance in expected region of right CFV. Could not advance beyond level of right femoral head. Contrast injection digital subtraction right pelvic venogram performed with catheter in right CFV (75822). Catheter was pulled up into central right common iliac vein, and then IVC venogram was performed (75825).
I am not sure if this unsuccessful AV fistula placement should be reported with 36821-53 x 2 or some other code. What are your thoughts? A longitudinal incision was made to wrist between the cephalic vein and the radial artery. The cephalic vein was exposed proximally and distally along the incision, and after inspecting the vein, it appeared to be less than 2 mm and appeared inadequate for fistula placement. Because of that, this incision was closed with 2 layers of absorbable suture. A second incision was made in the upper arm, above the elbow crease, over the cephalic vein. Again, the vein was then inspected for adequacy and the vein was sclerotic and again not adequate for fistula placement. This incision was then closed in 2 layers. After discussion with the nephrologist, it was felt not to place an AV graft at this point.
We have a case where we placed a subcutaneous ICD lead and then placed the ICD generator in the retroperitoneum. What would you recommend coding for this? Code 0319T, even though the generator is in the retroperitoneum, or possibly code 33999?
Would I use code 75625 for this procedure? I understand if just the distal abdominal was performed I would not use code 75630. I am not sure when to use code 75625 vs. 75630. Can you tell me how to distinguish the difference? Right lower extremity angiography with run-off to the foot was then performed with hand injection of dye. A 5 French Omniflush catheter was advanced to the distal abdominal aorta, and abdominal aortography with iliofemoral run-off was then performed with hand injection of dye. The catheter was then advanced over a Glidewire to the left common femoral artery using standard crossover technique, and left lower extremity angiography was performed with run-off to the foot with hand injection of dye. The catheter was then advanced over a Glidewire to the left common femoral artery using standard crossover technique, and left lower extremity angiography was performed with run-off to the foot with hand injection of dye.
I need help coding this report. The procedures were left heart catheterization, selective cornonary, saphenous vein and IM angiography, ventriculography, RAO view, aortography, AP view, right iliac angiogram, and primary stenting of vein graft to RCA with use of spider. Closure of access site using Mynx grip. Here is the part of the note that I don't know how to code: "Aortography was performed in the AP view, as patient was complaining of discomfort in his right leg. This shows significant stenosis of 60-70% in the right common iliac, which with the placement of the catheter was obstructing flow. Following this, selective right iliac angiogram was performed, and this iliac appeared to be diffusely diseased with 60-70% narrowing, but I felt I could get the procedure done and bring him back for elective intervention of his iliac vessel." I am new to cardiac coding, so I'm feeling very lost. The patient has Medicare.
A patient had a biventricular AICD with a right atrial lead. They brought the patient to the EP lab and did an AV node ablation. Then they added a His bundle lead and capped the right atrial lead. They replaced the generator with a biventricular pacemaker generator. I am unsure of how to code this. I was thinking of reporting codes 93650, 33207, and 33241. What are your thoughts?
Can codes 36598 and 36597 be charged together? Here are the highlights of the report: "Spot image of tunneled CVC shows tip flipped superiorly into left brachial cephalic vein. Saline injections attempted to move catheter were unsuccessful. Access was gained into right common femoral, and catheter was advanced into SVC. Catheter used to hook the CVC catheter tubing and reposition the tip into the SVC. Contrast injection into the CVC catheter demonstrates rapid flow through CVC with tip in SVC." My thought was to report codes 36598 and 36010-59, but now I'm questioning if we should also add code 36597, as I don't see any edits for coding the repositioning and the evaluation together.
Is it CMS guidance that separate reporting of 93623 is never appropriate with EP ablation procedures? Or is it appropriate to report code 93623 if the service is performed during diagnostic programmed stimulation and pacing or after ablation is delivered?
"Patient has paracentesis. Then, right common femoral vein is accessed and catheter advanced to thoracic aorta. Pressure bad with continuous saline flush started. Then, right jugular is accessed and catheter is advanced to IVC where a pressure bag with continuous saline flush is also started." Are the selective catheter placements and the "flushes" considered part of the paracentesis?
Would there ever be a circumstance in which suction thrombectomy and atherectomy could be performed together? Physician insisting that suction thrombectomy of CFA, SFA, popliteal, and anterior tibial was performed after atherectomy "with removal of debris" after an SFA atherectomy. My understanding is if thrombectomy is performed (even with different device) it is part of the atherectomy itself unless there is a distal thrombus being treated in an entirely different vessel. Is there some source documentation I can supply to the physician to indicate we cannot bill a separate thrombectomy?
What is the recommended CPT code for placement of a leadless pacemaker? "A pigtail catheter was then advanced into the right ventricle and a hand injected RV gram showed normal RV function and the RV apex was nicely visualized. Subsequently with serial dilation over an amplatz super-stiff wire, the 8F sheath was upsized to an 18F delivery sheath.The Leadless pacemaker delivery apparatus was then assembled with appropriate flushes and was then advanced under flouroscopic guidance carefully into the RV. A suitable spot in the mid RV septum was chosen to deliberately avoid the apex, given a very small heart. A contrast injection showed good septal wall apposition on both LAO and RAO projections. The pacemaker helix was then torqued in 1.25 turns. The sheath was then released and a vigorous tug test showed no lead dislodgement."
Is it okay to report code 93580 (fenestration closure) and 93568 (pulmonary angiography) when the angiography is done after the fenestration closure when documentation states that "angiography revealed complete occlusion of fenestration in right atrium"? It is my understanding that codes 93580 and 93568 are bundled and should not be billed separately.
Pt had a positive finding for traumatic retro bleed found on CTA. Selective cath plmnts 2nd & 3rd lumbars, contralat. common, internal & ext iliacs w/embo of 3rd lumbar. dr also comments that in order to "locate" the lumbar artery's he also selected splenic, lt gatric, lt renal, and IMA. I feel those would be considered roadmapping or guiding shots so I did not code them. I've coded the following-37244,36245x2 for lumbars, 36246 for ext common iliac and 36248 for internal. No S&I's since CTA. Would this be correct or should I code what I think to be the guiding selective catheter plmnts also? Thanks in advance for your help!
Technique: After informed written consent was obtained, the patient was prepped and draped in the usual sterile manner. Access was obtained using CT fluoroscopic guidance. An 8 French catheter was advanced into the distended bladder. Subsequently, as the patient drain uterine the bladder contracted. The pigtail catheter utilized was unable 2 remain within the lumen of a contracting bladder. The referring urologist was notified. The patient left the department in the same condition. Once the bladder had retracted a window through the lower pelvis was not identified for replacement. The bladder capacity was an inadequate target for a replaced catheter. The patient tolerated the procedure well. The patient left the department in the same condition. Unsuccessful attempt at placing a super pubic catheter with an 8 French pigtail drain. The catheter was placed within the lumen and the bladder was drained. As the bladder retracted the pigtail catheter sideholes were eventually excluded from the smaller capacity bladder. The referring urologist was notified.
If order states ultrasound pelvis, and the radiologist does only TV, but does all the elements of the pelvic ultrasound (and documents), are there any concerns on passing that as a valid order? I have asked that they also document why they did the TV approach.
I received this new code in an October 2014 OPPS new service update from Med Assets. Will this new C-code (C9741) go with the existing right heart CPT codes (93530, 93460, etc.), or will it have one of its own (primary or add-on)? Or is this a stand-alone code? I thought that C-codes were only on supplies and sometimes needed in conjunction with a CPT code. I am personally very confused about this new code. Any clarification that you can offer in regards to this would be much appreciated.
We had a patient who was referred over to us for an MRI of the right clavicle. The right clavicle was imaged. Which modifier should I addend to code 71550? Should I use -RT, or should I use -52? What is the correct coding with modifier usage if modifier(s) are applicable?
Would you agree with the following joint injection assigments? Subtalar joint injection: Intermediate Talonavicular joint injection: Intermediate 1st or 2nd Tarsometatarsal joint injection: Small
How do we code for saphenous vein transposition as thigh AV fistula?
We have a case were the vascular surgeon placed a TAA and AAA graft with iliac coil embolization and also placed a renal stent. Are we allowed to bill an open femoral exposure (34812) and/or a brachial exposure (34834)? Or are they considered bundled due to the other procedures done during the case?
Do you have guidance when it comes to disruption of a fibrin sheath with a CVC diaylsis catheter exchange (not a Tessio catheter)? If a fibrin sheath was disrupted in the SVC and another fibrin sheath in the innominate vein, would codes 36595-52/75901 be assigned twice (once for each vessel) or just once (similar to guidelines of coding only one central PTA)?
We have an ESRD patient who ran out of dialysis access options. Two surgeons worked on her. Physician #1 (thoracic surgeon) did an incision of RT anterior chest wall, entered pleural space, excised pericardial fat pad, incised pericardium and dissected the RT atrial appendage free from aorta & SVC. Physician #2 (vascular surgeon) created a tunnel across anterior chest wall, brachial artery was fragile & injured requiring a bovine patch. He then made an arteriotomy on the patch & anastamosed a Goretex graft to the ptach and tunneled the graft across the anterior chest wall. Next the other end of the graft was anastamosed to atrial appendage by Physician #1. Chest tube was place in the RT pleural space and attached to Pleur-Evac suction. There are three billers involved in the coding. One biller states it can't be an AV dialysis graft, as no vein is involved. However, the RT atrium is acting as the venous anastomosis, according to the vascular surgeon. How would you code this case? We are considering codes 36830-22 and 32551, but we really are out of our comfort zones.
CT Physician created open drainage via a thoracic window. Starting posteriorly the 7-8th rib space was identified and using cautery the intercostal muscle was removed from the top of the rib. Dissection of pleural space, encountered extremly thick rind, frozen section of pleural was sent to check for malignancy. Resected through the 7th rib to gain more access to the chest cavity. A rongeur was used to removed 5cm segment of rib. Rind was entered and was almost 3 cm thick and was removed to the size of the incision. Debris was sent for cultures. Removed calcified purulent debris. Performed open drainage via a thoracic window. The 8th rib was resected in a similar fashion. Skin edges around the rib resection were marsupialized, muscle was closed and then deep dermis and skin stapled around the window. I think this would be a 32036 except for the fact that this is Thoracotomy. Would it be more descriptive to bill unlisted procedure?
Bilateral groin cutdowns (34812-50) were made. Rt CFA accessed and catheter advanced to the ascending aorta, Lt CFA accessed and positioned at L1 (36200-50) Main body deployed (34803, 75952-26). Angiogram done which showed 90% stenosis of rt renal artery. Using lt groin access angiogram obtained and contralateral limb deployed proximal to the bifurcation of CIA. Rt docking limb deployed above bifurcation and limbs were dilated. Post dilation angiogram revealed good flow in stent but proximal aspect was found to have migrated more distal than what was the initial placement. There was concern so Dr elects to proceed with placing a cuff to obtain a more proximal seal. Aortic cuff placed and post dilated (34825, 75953-26). Angiogram shows significant stenosis of Rt CIA. Stent placement done in rt CIA (37221) post dilation angiogram revealed excellent results, but there was impingement of the lt CIA, so Dr placed stent in the lt CIA (37221-59). Post stenting angiogram revealed good results. Does this look correct? The common iliac artery stents have me confused.
I have a question about coding using modifier -59. Scenario is patient receives SIJ injection with fluoroscopic guidance (27096) and at the same session has TP injections at a separate body area under fluoroscopic guidance (20552/77002). Would it be appropriate to add a -59 modifier to code 77002 since the guidance was provided at a separate body area from the SIJ?
"Patient had a CTA with run-off showing AV fistula at the fem-pop bypass graft and came to IR. Bilateral run-off was done, catheter was placed in the graft, and embolization occurred with many coils. PTA was done in the popliteal artery at the anastomosis." I believe I should report code 37242 for the embolization and code 37224 for the PTA of the popliteal. The vascular surgeon wants to code the bilateral run-off plus catheter placements. Would you verify for me please?
A question has come up from a Radiology bill. The radiologist coded 76870 and 93976, the hospital coded just 76870. My question is what documentation is needed to be able to code the 93976? An example of the documentation, "Color and duplex doppler interrogation of both testicles confirms normal testicular vascular flow bilaterally" or "Color Doppler and spectral waveform analysis demonstrates normal arterial waveforms within both testicles". My understanding was that "inflow and outflow" needs to be included or "Arterial/Venous flow" must be documented. I want to code correctly but not to over code.
"Patient presents for ablation of atrial flutter. They are post MAZE/MV replacement procedure for a-fib at another facility and has since had continued issues with a-flutter. EP and ablation today show patient to have reconnection of one pulmonary vein with LA, which is causing the a-flutter. Another a-flutter mechanism is also identified in the RA." Should this situation be reported using codes 93656/93655 or using codes 93653/93655?
How would you report a percutaneous ultrasound-guided fine needle aspiration biopsy right axilla with post-biopsy metal marker placement? "Six aspiration passes were made with a 21 gauge needle. A cytopathology technologist was present to confirm adequacy of the samples. A spring-shaped Hydromark MRI compatible stainless steel marker was deployed through an incision under direct ultrasound visualization into the biopsied area." We have billed codes 10022 and 76942. Do you agree? Would we code for post biopsy metal marker placement? If yes, what code we could use?
95% of the patients my practice sees have chronic total occlusions. This is shown through CTAs prior to the patient being presented for the operation. The doctors thus pre-plan thrombectomies for the occluded vessels. After performing an aortagram, sometimes transluminal angioplasty, stent placement, and atherectomy are required in the femoral artery. We use 37227 for this. My question is this: Can we perform 37184 and 37185 in addition to 37227 if the thrombectomies are pre-planned? The most common vessels they perform thrombectomies on are the CFA, SFA, Popliteal, and Peroneal.
Common femoral with advancement of diagnostic catheter. Selective catheter placements second order RT common carotid artery, third order RT internal carotid artery, third order RT external carotid artery, superselective greater than third order RT ascending pharyngeal artery. We use cpt code 36224. Please help!
I have an exam that the physician selects the left renal vein for a venography and then advances the cath to the left gonadal vein. I know the selection will be a 36012, but what code whould I use for the interpretation of the gonadal vein?
When access is made in LCFA to REIA 36246 with 75710 of the Rt lower extremity. A second access is made in RCFA and angioplasty is done of the RATA 37228 from the second access site. Do we bill for the catheter placement from the first access (LCFA)? Since the procedure was done on same extremtiy as catheter placement but (sep access) I wasn't sure if billing catheter would be correct.
The radiologist states in the dictation that contrast was infused after catherization by gravity (following placement of a tube)Does that satisfy the requirements to bill 51600 CPT? Does the infusion "by gravity" change anything in regards to the coding the injection CPT 51600?
We are a group of cardiologists, we have one interventionalist. we have situations were our cardiologists consult on a patient and then on occassion call in our intervention cardiologists and 2 consults are done the same day. Is there a way we can get paid for both the interventionalist and the managing cardiologists the same day when they are trying to determine need for surgery AND surgery is not needed.
Would a balloon occlusion of the distal thoracic aorta just above the diaphram for the purpose of temporizing be coded when a stent graft is placed in the SMA for a hemorraging pseudoaneurysm d/t pancreatic carcinoma. The balloon in the aorta was deflated just before the stent was placed in the SMA. I've coded 37236 for the stent but am not sure if the balloon is included in this case since.
I thought I had this figured out but I need to clarify. I always coded a fistula anastomosis plasty to an arterial. But then reading up in your book, you state that there are both venous anastomosis and arterial anastomsis in a graft. You also state we should code arterial anastomosis or perianastomotic region angioplasty to an arterial 35475/75962. If the physician states that the angioplasty is of the anastomosis,how do you know if it was arterial or venous anastomosis? Does it matter? Do all anastomotic strictures of the fistula automatically get an arterial angioplasty code assigment?
I just recieved a referral on code 20600 small joint/bursa. The Doctor injected the navicular cunieform joint space of the foot with Kenolog and they would like me to chance the coding to intermediate joint/bursa injection. I was always taught that only the ankle joint was concidered an intermediate joint so the only intermediate joint on the foot would be the Calcaneus bone I'm I correct in my thinking?
Hi! One outpatient department performs this procedure. The patient comes in with a previously placed pleural catheter. The catheter is attached to a drainage system to drain fluid. Since the catheter was already in place, it does not seem appropriate to report CPT code 32556. Should the hospital report a low level E/M code or 32556 with a 52 modifier? Thanks in advance!
Question: Is the cephalic arch considered separate central venous zone for coding 37238? If so would this case be coded 37238 and 37239? 1. Multifocal short segment cephalic arch stenoses treated with angioplasty and telescoping stents. 2. Intra-stent venous limb restenosis treated initially with angioplasty and restenting with markedly improved luminal flow and post intervention venogram.
I have a question regarding -51 modifiers. I am billing out a 37229, 37233, 37224 for charges. Is it neccesary to add a -51 modifier to the 37224? If so, why? We are having some debate in our office.
Would it be appropriate to code 35371, 35372, 35741 for this case? Incision left groin, exposing the distal external iliac artery, entire common femoral artery, several centimeters of superficial femoral artery and well down into the profunda femoral artery as well- extensive endarterectomy of the entire common femoral artery extending well down into the profunda femoral artery. The superficial femoral was totally occluded - We divided that beyond its origin, the SFA, about 6cm distally and divided it, over sewed the distal SFA. The proximal and then the 6 cm stump was opened on its inferior surface, endarterectomized and this was used as the patch for the profunda endarterectomy. We then opened up the profunda femoral artery for several centimeters, did extensive endarterectomy of the profunda. The vessel of course was opened here and we did an extensive endarterectomy of the common femoral artery through this same access. He also did an exploration of the popliteal artery for possible by-pass but found that it was a non-bypassable vessel
Patient has a draining sinus tract from a non healing abdominal wound. Patient taken to the operating room where the sinus tract was then probed with forceps. It went about 4-5 cm deep and was narrow. An incision was made with a scalpel through the old midline suture surgical scar spanning the mouth of the sinus tract. Essentially this sinus tract was split all the way down to it's base. Halfway down we encountered the first piece of ethibond suture which was barely incorporated and easily removed. Then using electrocautery, the scalpel and Kocher clamp the subcutaneous scar was cored out and circumferentially around the sinus tract saw more fibrous material at the base and pulled on this and removed another piece of unincorporated ethibon suture. Palpating the wound we could not feel anymore scar. It was healthy tissue thoughout the entire wound bed now. The wound was irrigated, no further bleeding identified and no foriegn bodies were seen. All the tissue was healthy. Sutured deep cavity and skin. Excision and repair?
We are uncertain of the appopriate code to use when the provider describes the use of a bifurcated graft placed at the aorta with one leg of the graft anastomosed to the right common iliac artery and the other leg anastomosed to the left common femoral artery. There are three anastomoses (Aorta, RT CIA, LT CFA) thus we are unsure if two separate bypass codes would be appropriate in this case or if this may necessitate an unlisted code (which comp code would be appropriate?) Your guidance would be greatly appreciated. Thank you .
Our surgeon performed a cephalic vein thrombectomy and later performed a internal jugular vein end-to-end venous anastomosis ot the cephalic vein. How would I code the venous throbectomy and anastomosis? see below op note The microscope was brought into the field, and after the placing vascular loops to stop the blood flow through the internal jugular vein, a venotomy was created. Then, utilizing of Synovis 2.5 mm venous coupler ring, an end-to-side venous anastomosis was created from the cephalic vein into the internal jugular vein. There was excellent blood flow, and we placed a little bit of Gelfoam to bolster the vein to prevent kinking.
After the hemodynamic data were obtained, an aortogram was performed using a 4F Pigtail catheter in the standard PA/LAT projections and the fractured coarctation stent was identified and appropriate measurements made. Using a 4F angle glide catheter a super stiff Amplatz wire was parked in the distal right subclavian artery. The catheter was removed and the sheath was exchanged over the wire for a 14F x 80-cm Check-Flo sheath. An 18 x 30-cm Gore graft was mounted onto a Palmaz 4010 stent and then the entire stent system was mounted on an 18-mm x 4-cm BiB balloon catheter. The balloon was inserted over the wire and centered within the previously placed, now fractured, coarctation stent. The BiB balloon was deployed in the usual fashion, first by inflating the inner balloon, checking position, the finally inflating the outer balloon for definitive stent deployment. The outer balloon, unfortunately, burst before reaching nominal pressure but the stent was expanded enough that it did not migrate or embolize on balloon deflation.
According to your reference and previously asked questions, codes 47805 and 74305 are reported for a cholecystostomy tube check. I'm coding for a "follow-up of post gallbladder drainage" in which "scans are obtained through upper abdomen without contrast and after injection of the drainage catheter. After injection there is filling of the gallbladder." The impression was "after injection of contrast through the drain there is a small amount of leakage into the pericholecystic region." So I am told by the IR coder that in this case code 74150 should be used. However, could code 47505 also be used for the injection into the catheter? Or is code 47505 only to be used for a specific check of the tube functioning?
A stereotactic breast biopsy was attempted but on the stereotactic localization images of the breast the lesion could not be found so the biopsy was not performed. What if anything can the physician bill for?
Our neurointerventionalist performed a coil embolization of the ophthalmic artery. After the coils were placed there was a protrusion of two loops that required emergent stenting which was accomplished with a neuroform EZ stent. The doctor is trying to bill for both the embolization (61624) and the stent placement (61635). It's always been my understanding that any complications that arise during the procedure that were caused by the physician are not billed when corrected. Can you point me to something to give back to the provider regarding this? Is he correct that, in this scenario, both the stenting and the embolization are billable? Any insight on this would be greatly appreciated.
What do you suggest for the cardiologist who is performing the ECHO guidance during a TAVR? I see a code for 2015, but what do you suggest for 2014 and what type of documentation is needed.
What CPT code or codes would you use if we are performing an IR prostate artery embolization?
Please provide the correct catheter selection code for this procedure: Left groin prepped & draped & a 4 French sheath placed. Flush catheter introduced in the proximal abdominal aorta. An aortogram revealed normal aortoiliac system. Bilateral patent renal arteries and the SMA well visualized with the catheter selected into the distal right external iliac artery. Right femoral angiography revealed patent common femoral, deep femoral, and superficial femoral artery with the superficial femoral artery selected. The distal superficial femoral artery was widely patent. All 3 tibial vessels were patent with direct runoff into the foot. The catheter was removed.
The pt had Bentall procedure 2mo ago with Magna valve and Valsalva graft.Now has returned due to pseudoaneurysm of the ascending aorta.CP bypass was initiated. His previous median sternotomy incision was opened.I crossclamped ascending aorta.We entered the rt coronary button and a thrombus around the graft.Thrombus was removed.There seemed to be bleeding coming up from underneath the right side coronary button,coronary sinus and rt/lt commissure area. We then performed a transverse incision thru the previously placed Dacron graft, above the sinus of Valsalva section of the graft. There was no evidence of injury of the valve.I then cut alongside the rt coronary button down thru the Valsalva segment of the graft.It was difficult to find hole where the bleeding was coming from. I then decided to reinforce the whole area with sutures. These were placed thru the prior sinus segment, LVOT, and back up thru the sewing ring of the valve and the rt coronary sinus segment. I then repaired the sinus of Valsalva graft segment with Prolene. Then graft incision was closed.
Our hospital/neurosurgeons use fluoro in all their spinal cases. What is the instruction for charging/billing for fluoro done in the OR for these cases? It seems that cpt codes for open procedures 63001 and on, do not include fluoro. The minimally invasive/percutaneous procedures 0274T and 0275T seem like they do include the fluoro charge. If we do charge for the fluoro, would we use 77003 or 76000. Thank you very much.
What is the correct coding for a femoral acetabular impingement (FAI) exam? In our protocol, we perform a CT through the bony pelvis and proximal femurs, 3D reconstructions are created of both hips. In addition we obtain axial CT imaging through the knees to evaluate for femoral anteversion. Since this exam is primarily focused on the hips it seems most appropriate to code this as a Bilateral CT Lower Extremities (which covers the hips and knees) and include a 3D post processing component (76377). We also considered billing it as a CT Pelvis with 3D post processing component however that seems to ignore the added imaging through the knees?
All of the following is through one SVG: Physician stents the body of the SVG to RCA and also a spot in the RCA - one charge 92937. In the same setting he also stents the PDA branch of that RCA, still through that same SVG. Can I use 92921 with the 92937?
One of our doctors marked his rounding with VT ablation (93654) and another arrhythmia (93655) for the second PVC that he treated. The doctor describes these as two entirely discrete PVCs but he was aware of them from a prior outpatient study. When code 93655 was introduced we were taught that the doctor could not be aware of the arrhythmia prior to the procedure..that the other arrhythmia had to emerge during the procedure in order to get credit for the 93655. Is that correct? Should we give him the 93654 only for treating both PVC's or should he get the 93654 and 93655? The doctor also states that the source of the PVCs would be the mid LV and that PVC1 was spontaneous and that PVC2 was triggered and that Isoproterenol was infused to facilitate increased frequency of PVCs.
How would you code additional venography if MUEs for 75820/75822 is one? Do we code additionals with 75820/75822 with 59 modifiers, or use 76496? Venography below performed with heart cath. RT/LT arm venograms: Injections via peripheral IVs revealed patent axillary veins, with complete occlusion of RT/LT subclavians. SVC: complete occlusion of SVC. RIJ peripheral: Injection reveals complete occlusion at clavicle, with a network of collaterals. LT cephalic: Selective injection via left brachial sheath. Left cephalic vein enters collateral network that drains to left paravertebral plexus. There is complete occlusion of communication into subclavian vein. LT subclavian vein: With catheter in LT subclavian vein shows complete occlusion of LT subclavian vein as it passes between first rib and clavicle. Lt innom vein: Catheter advanced to LT innom vein, it is diminutive and completely occluded at SVC connection. RT innom vein: With catheter in RT innom vein it is found to be diminutive from caudal aspect of the RIJ into SVC.
I have a scenario where one cardiologist did a lhc and then during the same operative setting, another cardiologist stepped in and did a rhc. Would I bill these out separately as they were performed? Or bill as 93460-26 for both? If 93460, what modifier would I use? They have both dictated their own portion but modifier 80 doesnt seem to fit and modifier 62 isn't allowed for this px.
I was hoping you could shed some light on a case for me. A patient is brought in for an ICD battery replacement due to end of life. Prior to ICD replacement, the physician performs DFT testing with the old device to check the lead integrity. The results are normal and the physician proceeds with ICD replacement. Once the new device has been placed, the physician performs DFT with the new device. I know that CPT 93641 would be used for DFT after the replacement, but what can we use for the testing prior to the replacement? Is it appropriate to use CPT 93642 or is it possible to use CPT 93641 and 93641-59 or 93641-76?
ESRD pt w/hx of coiling of a branch vein originating from immature AV fistula w/coil migration to the RT heart. RT CFV was punctured w/ placement of 7 French sheath, pigtail cath advanced over Bentson guidewire into descending branch of LT pulmonary artery (36014), contrast injected & imaged showing coil lodged at bifurcation of descending pulmonary artery branch. A 9-15 mm EN-snare was used to capture end of coil & retracted into RT iliac vein & as it was pulled into the sheath began to unravel. Sheath removed, unraveled wire clamped w/hemostat. Maln coil mass was still in iliac vein. CFV was punctured a 2nd time, slightly higher than initial puncture. 7 French sheath was placed & coil mass then easily captured with snare & removed. (36000-59) The other guidewire fragment was cut at the skin & removed through the 2nd venotomy. Imaging confirmed complete removal of the coil. (37197) Will codes 37197, 36014, and 36000-59 accurately represent this procedure? Clinic says 36005 should be charged, not 36000-59. Which do you advise?
Propaten bypass graft placed from external iliac artery to fem-pop bypass graft at midthigh. All incisions closed. New incision to expose common femoral artery pseudoaneurysm. Lumen opened 1 liter of blood lost. Ligation ofcommon femoral, profunda femoris, superficial femoral. Proximal end of fem-pop bypass graft separated from previous patch graft. Patch graft resesected and sent for culture and suture ligated. The proximal portion of the fem-pop bypass graft avulsed from leg and proximal portion removed intact and sent for culture. 35665? 37618? ?????
Our institution will start implanting the CardioMEMS HF System. What codes do we use for implanting the device and remote monitoring?
Need assistance with coding an excision of paranganglioma of the vagus nerve. I'm thinking 64771, but possibly needs to be an unlisted procedure. Procedure: A transverse incision was made from the midline laterally approximately 2 fingerbreadths above the clavicle. Dissection was deepened. The platysma was divided and platysmal flaps were raised. Dissection was deepened and jugular vein was dissected along it's medial edge and retracted laterally. The paranganglioma was identified and it was clearly not only adjacent to, but part of the vagus nerve. We carefully dissected this trying to ascertain whether or not the paranganglioma could be resected and the vagus nerve preserved, however, it was apparent that the lesion was actually part of the nerve itself. For this reason, we resected the paranganglioma with a section of vagus nerve proximally and distally. Pathology was obtained and sent for exam. Careful inspection for any other areas of neoplasm was carried out and none were seen. Closing began.
I'm looking for the appropriate cpt code(s) for repeated angioplasties in the left dorsalis pedis artery and distal anterior tibial along with repeated angioplasties proximal and origin of left anterior tibial artery for severe ischemia of the left lower extremities.
RT groin, under ultrasound guidance, RT common femoral vein accessed. a vascular sheath was advanced over a guidewire. then advanced in the rt external iliac vein with venogram. next, using a catheter the confluence of the bilateral iliac veins were catheterized w/subsequent inferior venacavogram. next cath was advnced beyond the area of narrowing along the infrarenal IVC and a ssuperior venacavogram was done. At this point all cathes and wires were removed. The codes I think should be 36011, 75825-26, 75827-26 and 75822-26
Since the co-surgery surgical indicator is "0" for the new FEVAR codes, how do you suggest coding a procedure when two vascular surgeons (partners) work together equally on a case?
Here is the procedure: 1. Right common iliac artery (end-to-side) to right renal artery (end-to-end) bypass with 7-mm PROPATEN graft. Right renal artery proximal ligation. 2. Left external iliac artery (end-to-side) to left renal artery (end-to-end) bypass with 7-mm PROPATEN graft. Left renal artery proximal ligation. Question: Are these ligations part of establishing flow and included in the bypasses?
For this case, is it possible to bill 33853 with 33854? The physician actually extended the graft to the distal arch because it was hypoplastic, so I wanted to know if I could bill both codes under these circumstances. Procedure performed open repair of coarctation PROCEDURE NOTE: A left-sided posterolateral thoracotomy was made. The distal aortic arch and proximal descending thoracic aorta were mobilized. The Control of the distal aortic arch and subclavian artery was obtained. CPB was utilized. The coarctation was then resected and sent to pathology. In order to sew a larger graft to the distal arch, the arch was opened up into the left Subclavian and a 22 mm graft was then sewn to the distal aortic arch and subclavian. The graft was then trimmed to size and sewn to the descending thoracic aorta distal to the aortic coarctation Interposition graft was approximately an 4 cm long. FINDINGS: His distal aortic arch was hypoplastic measuring approximately 18 mm between the carotid and the left subclavian. The aortic coarctation was distal to the left subclavian in the isthmus area. We resected the coarctation area and performed an end-to-end anastomosis with interposition graft and 22 mm Dacron graft.
What CPT code is appropriate for ligation and excision of venous aneurysm? The left upper extremity was prepped and draped in the usual sterile fashion. He received intravenous antibiotics preoperatively, and an appropriate time-out was performed. There was a dilated mass overlying the forearm distally in the mid forearm basilic vein. Local anesthetic was infiltrated in this area. A small longitudinal incision was made. The venous aneurysm was exposed, and it was quite dilated, but the more proximal and distal veins were completely normal. The forearm basilic vein was then ligated proximal and distal to the venous aneurysm which was then excised and handed off the field as a specimen. Hemostasis was ensured, and the wound was closed in layers.
We have 49180 for deep lymph node biopsy for all peritoneal/retroperitoneal lymph nodes. What about deep axillary or intramammary lymph nodes? If unlisted, would you use 38999 even if a clip was placed at the biopsy site?
The physician initially attempts a right radial approach and documents that he has difficulty and brings the catheter up to the aortic arch and into the ostia right subclavian and documents that the patient has an anomolous takeoff of the right subclavian off the aortic arch. The doctor then takes a femoral approach and performs a standard left heart cath. No vertebrals were mentioned. I'm thinking 36215-59 (separate takeoff of the right would make this a 1st order, correct?) and a 75710-RT-59 as well as the 93458 for the garden variety LHC and a 93567 as he does discuss the aortic arch but that was after with the LHC approach. I considered 36225 but no vertebrals were mentioned and it didn't seem like this was really the intent of the angiography. I'd really appreciate your thoughts on this. Thank you.
Closure of perivalvular regurgitation of bioprosthetic mitral valve using Amplatzer VSD occluder. Patient had severe perivalvular bioprosthetic mitral valve regurgitation in the lateral sie with congestive heart failure symptoms. TEE probe placed and 3D images were obtained. Identified area close to the left atrial appendage and the perivalvular mitral valve regurgitation occurred was severe. Access from right groin, RCFA & RCFV followed by transseptal puncture . Notes are not clear as to what happened next? It appears d/t an inability to cross the perivalvular space he used a balloon to open then he was able To pass a shuttle inside the left ventricle, but still unable to advance the sheath in the perivalvular space. At this point a wire was placed in the ascending aorta. Using a large EnSnare he was able to snare the wire from the ascending aorta and brought into the RCFA. He was able to deploy the Amplatzer closure device into perivalvular space. Repeated procedure 2 more times. Uncertain if 93799 or 0343T x 1 & 0344T x 2
When using bilateral procedure codes and separate S&I codes, ie. 50394/74425, 50398/75984 or 50390/74470 etc, how would you report the S&I? Would it be: 1)50394-50 and 74425 and 74425-59 2)50394-50 and 74425 x2 3)50394-50 and 74425 x1 ??? I seem to remember reading somewhere that you would code the 2nd one with a 59 but I can’t find it now...
50398 vs 50387? And why. Contrast material was then instilled through the bilateral nephroureteral tubes, and the images obtained show appropriate positioning and bilateral hydronephrosis/hydroureter. A Bentson wire was inserted through both of the existing 8 French nephrostomy tubes. While maintaining the guidewires in place, on each side the previously placed nephroureteral tubes were removed, and new nephroureteral tubes were advanced over the wire. New 8 French 26 cm tubes were introduced over the wire under fluoroscopic observation. The proximal loops were formed in the renal pelvis and the distal loops formed within the bladder. Contrast material instilled through these new tubes, and films obtained show adequate contrast opacification of the collecting systems. The nephroureteral tubes were then secured to the skin with revolution devices and sterile dressings were applied.
I coded 36247 Rt & 75716-26, is this right? What am I missing? REASON: Nonhealing rt leg wound. PROCEDURE: 1. Distal aortic angiography w/nonselective bilateral iliac angiography. 2. Rt femoral angiography w/runoff (via third order). 3. Lt femoral angiography w/runoff. 4. Successful atherectomy of mid right SFA using TurboHawk. 5. PTA of femoral popliteal artery.
Is it appropriate to add an extra cpt code of 36248 for the proper hepatic when a diagnostic arteriogram if performed? The celiac was selected,type 1 celiac anatomy, selected common hepatic, , The G.D. was selected. To prevent reflux and nontarget embolization in the GDA. The cath was positioned in the proper hepatic artery, an arteriogram was performed. The r. gastric artery was identified arising from the r. hepatic artery. This was selected microcath, arteriogram done. To prevent reflux & nontarget embolization into the RGA, the RGA was occluded with coils. The cath was directed deeper in the r. hepatic artery, arteriogram was performed. 1.5 mCi of tech 99 MAA was infused into the r. lobe. The cath was then directed into the l. hepatic artery. 2.5 mCi of tech 99 MAA was infused in the l. lobe. Codes used: 37242,36247(G.D.),36248X4(proper hepatic, r. gastric, r. hepatic, l. hepatic) & 79445. My understanding is we can add a 36248 for the proper hepatic, because they stopped at this level to do a diagnostic arteriogram. If the cath was going from the proper to the hepatic, not stopping to do an arteriogram of the proper hepatic, then we would pick the highest cath placement?
Can these two codes be billed with the diagnostic codes for 36221-36228? What kind of information should be documented? Are the words as described above enough or should there be more? I have searched everywhere for documentation guidelines and have been unable to find. I was under the impression these codes were only to be billed with just the other 70,000 code series(e.g CT or MRI).
Pt. came in as a stemi. Pt. had previous grafts and the physician stented the native circumflex,not going through svg.In the final impression he stated that the svg to the om was the culprit lesion. I'm assuming, due to years working in the cath lab, and not what the physician stated in his dictation that he opened the native circumflex to get flow to the om. If the pt. comes in infarcting but he doesn't do the culprit lesion, can we still charge AMI-92941?
To code a left heart catheterization there must be documentation that hemodynamic measurements were performed. If the doctor documents: HEMODYNAMIC DATA: The hemodynamic data obtained from the left heart was normal Is that sufficient to code the catheterization or does the doctor have to give the actual measurements?
Patient admitted with an acute myocardial infarction. Procedure note documents that a stent was placed in the diagonal vessel of the left main which was presumed to be the culprit vasculature. They then redirected the wire down the left anterior descending artery and in the proximal left anterior descending artery, stented an eccentric lesion that was 85% stenosed. The wire was redirected down the circumflex system and a stent was deployed across the circumflex marginal vessel. The physician is billing 92941, 92938 and 92944. I don't agree with this code selection.
Right arm fistula procedure. Normal access of the fistula and imaging (36147). There was a stenosis present in the innominate branch. Multiple attempts were made to cross this lesion from the inital access site. This was unsuccessful. The decision was made to obtain groin access and address the lesion from below. This attempt was successful. Now comes the question you've been waiting for... What on earth do I charge for the groin access and the venoplasty of the brachiocephalic? I did give a good ole college try...this is what I billed: 36147,36011, 35476 and 75978. i'm hoping that I wasn't too far off.
If a patient has a congential heart defect such as a PFO and they are coded as congenital 745.05 and we perform a congenital Echo 93303. Then the patient comes back a year later and the PFO has closed and the Echo is now showing normal would you still code them as congenital?
Coding Clinic states that a diagnostic left heart cath may be reported with the TAVR (ICD-9), but states that sampling or monitoring of heart pressures is included in the TAVR procedure. What would indicate that a left cardiac cath is done for a diagnostic purpose? Is the physician's statement that it is a "diagnostic left heart cath" enough? He gave indications (acute on chronic dias heart failure from aortic stenosis) and only provided the LEDVP. It seems to me that all patients who require a TAVR probably have some degree of acute or chronic heart failure. Would this scenario be sufficient to code the CPT for the diagnostic left heart cath in addition to the TAVR? I am hoping this will provide some insight into my ICD-9 coding.
My doctor is checking the activated clotting time and post stent placement, and sometimes does this two or three times. Is this something that would be included with the stent placement procedure, or is it something that we should be billing for? I am confused as to what code to use, if indeed we can bill.
What are the correct surgical CPT codes for lateral branch blocks in the sacrum? The orthropaedic physician says he is injecting bilaterally the lateral branches S1-S4. The radiology guidance reports seeing four needles into the SI joints; however, the physician says he is not injecting the joints, rather he is performing lateral branch blocks. The physician also confirms he used four needles for the injections, and he advises the codes for this are 64493-50, 64494-50, and 64495-50. My question is, if he is using four needles, would three levels be injected bilaterally? Also, I am seeing on some pain management websites recommendations to use code 64450 for lateral branch blocks, as they are considered peripheral nerves in the sacral area. Please advise.
If a CHD patient receives a heart transplant, are heart cath and echos coded as congenital or non-congenital? Physicians insist on congenital, but problem then is what congenital diagnosis can we use if it no longer exists? Also, see the following example of patient with post transplant complex anatomy. Should this patient be coded as congenital? Patient's native IVC and SVC were left-sided; complex re-routing of the systemic veins was performed at the time of his transplant. A flap of atrial tissue was used to redirect the IVC to the right atrium, while the donor innominate vein was anastomosed to the recipient left-sided SVC to the right atrium. Instead of using a congenital code, should we be adding a modifier -22 for this patient?
Thank you for the information on this drug test and the information included in my cardiology book. I have been working on getting this procedure code added to our system for our EP physicians to use in ordering and performing the tests. Code 93799 (unspecified code) would be used for this study. I need to provide the closest code to this unspecified code. I felt the ergonovine provocation test (93024) would be closest. I also see in the guidelines for the ergonovine test that it would include the drug used. Would this be the same case for the procainamide drug challenge? Any and all information regarding this is appreciated.
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."
Our physician replaced a pacemaker generator. He removed a single chamber device and replaced it with a dual chamber device; however, there is still only one lead in the ventricle. He pinned the atrial lead port. Would this be reported with code 33227 or 33228?
Our hospital started doing CardioMems HF system in 2014. We see that there is a new HCPCS code for OP coding as of October 1, 2014: C9741 (RHC with implantation of wireless pressure sensor in the PA including any type of measurement, angio, imaging supervision and interpretation report; includes provision of patient home electronics unit). Would it be appropriate to code a diagnostic right heart cath when pressures are taken in the RA and RV if it is done for diagnostic purposes since the CardioMems itself includes a RHC? Can you touch on IP vs. OP vs. physicoan coding (CPT and ICD-9 px)? We know what the vendor is suggesting as far as coding, but we are lacking official coding guidance. Also, do you know of any medical necessity ICD-9 diagnosis requirements?
I am unsure about how to code a TAVR procedure where subclavian artery access was used (cutdown). Do I need to use an unlisted code, or would I be able to use code 33363 (TAVR open axillary approach)?
The pre-operative embolizations are sometimes confusing because they are done for varying reasons. When embolization is arteries supplying tumor, would this be considered "tumor embolization"? Patient has metastatic renal cell carcinoma to femur. "Title of Procedure: Transarterial particle embolization of left femoral metastasis. Indication: Preoperative embolization. Impression: Large hypervascular lesion in distal left femur, receiving blood supply from multiple branches of superficial femoral artery. Successful embolization of 3 branches of left SFA with approximately 90% of tumor vascularity embolized using 500 um and 700 um particles." I would appreciate your input.
Could you please let me know if the we are coding correctly (50398, 50394, 74425)? "A preprocedure fluoroscopic image was obtained. Contrast was injected through the right percutaneous nephrostomy tube. The tube was cut and removed over a Bentson wire. A completion fluoroscopic image was obtained. A sterile dressing was applied to the site. Removal of the right percutaneous nephrostomy tube was completed."
Regarding Q&A #6213, in review of your diagram of the Pulmonary Arterial System, the left pulmonary artery is a first order vessel (36014, and the diagram is color coded as first order down to where there are branches off). Because documentation referred to the vessel as "descending branch of left pulmonary artery", without further specification of location of cath tip, could you please explain what indication makes this a second order vessel (36015)?