Knowledge Base

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Set Descending Direction

Attempted Access for Nephrsotomy Catheter Placement

"Fluoroscopy showed that a right double J ureteral stent was in place. Ultrasound showed that the collecting system was completely collapsed. The cephalad aspect of the stent could be seen. Following this, utilizing both ultrasound and fluoroscopic guidance with multiple oblique projections, attempts were made to enter the collecting system. However, this could not be accomplished, even when the pigtail of the double J stent was directly targeted. Intravenous countrast was administered; however, this resulted in no opacification of the right renal collecting system, whereas there was opacification of the left renal collecting system." Would we use unlisted code 53899 to report this?

Aspiration of Embolic Protection Filter

"An EmboShield filter is placed during a patient's lower extremity atherectomy/angioplasty. Completion angiogram reveals thrombus within the filter. The thrombus is aspirated, and the filter is removed." Is aspiration of an embolic protection filter considered part of the filter insertion and retrieval and therefore not codeable in CPT? Or can the aspiration be coded with 37186?

Pacemaker Quick Look

I have a report for pacemaker interrogation from Medtronic for a quick look. The report says "quick look up" in the left hand upper corner. How do I code this?

Calcaneal Nerve Injection Coding

Can you please advise on how to code the following (Marcaine/Celestone Soluspan) injection? "Ultrasound-guided perineural injection medial calcaneal nerve at the right medial hindfoot."

C-arm

Our group office recently installed a C-arm machine to help aid in spinal surgeries as well as musculoskeletal surgeries. In addition to the procedure code, what other code may use to indicate that a C-arm machine was utilized during the procedure? Should I add code 61783 for spinal surgeries and 20985 for musculoskeletal procedures?? I don't know if there is a better code than the above listed codes to describe the additional use of the x-ray image guidance. If so please advise on the procedure codes and the correct usage, and if any modifiers will need to be addended. I'm billing for the office. 

Q0 modifier on 33249

Is the -Q0 modifier still effective on 33249? Is there any situation when we should not append the -Q0 modifier to 33249? It is a clinical trial modifier. Do we need any other document such as registration to the trial, etc.?

Fluid Challenge

Patient has CHF. Right heart cath with fluid challenge done. Should 93463 be coded for the fluid challenge? What information needs to be documented to code 93463 for a fluid challenge? (Info that follows was copied from documentation.) "Fluid challenge of 250 mL bolus was performed. No improvement in cardiac output with fluid challenge. Notes: Post fluid challenge. PA: 28/12/16. PCW: 21/26/19. Thermo CO: 4.37 l/min. Thermo CI: 1.65 l/min/m2."

36221, 36252

The physician did selective left and right angiogram of renals, then did an aortic arch with findings that showed no significant stenosis, but tortuous corse. Can a selective (36252) and non-selective (36221) be billed together?

76882, Vascular vs. Non-Vascular

What is the appropriate coding when a complete bilateral duplex scan of extremity veins is being performed with spectral Doppler without color flow Doppler (93970-52)? 

93656 and 93655

Would ablation codes 93656 and 93655 be appropriate for the following procedures? Procedures: 1. Comprehensive EP evaluation w/ attempted induction and ablation for atrial fibrillation. 2. Cavo-tricuspid valve isthmus ablation for atrial flutter. 3. Left atrial mapping. 4. Intracardiac 3-D mapping. 5. Programmed stimulation with and without IV drug infusion. 6. Intracardiac echocardiography. 7. Transseptal catheterization x 2.

Using a TAA graft limb to fix a slipped AAA endograft

My provider repaired a breach of an AAA endovascular repair that had migrated by using a thoracic endograft limb to cover the breach. He was not repairing a TAA, but he wants to use code 33881. I don't think that's appropriate, and I think we should use 34825 instead. Which is correct?

ICD 10 CM Code: Common iliac artery 100% occlusion

What ICD-CM code should be used to code occlusion of common iliac artery 100% prior to intervention. 

Thrombolysis Subsequent Day

We are on day 4 of thrombolysis. My understanding is that we can only have one subsequent day of infusion. Is this correct?

Peripheral in-stent stenosis, ICD-10

Could you please clarify use for peripheral stent stenosis ICD-10 T82.858A before 10/01/2016 and T82.856A after 10/01/2016? Report states chronic total in stent re-occlusion right popliteal artery (DOS 08/01/2016). We are thinking this is T82.858A. I read that IF progression of atherosclerosis is documented, we should use I70.201, etc. Otherwise, it should be coded as complication with the T codes. 

37242

Patient had coil embolization of a branch of the femoral circumflex and coil embolization of the posterior branch of the internal iliac artery. I would like to bill code 37242 x 2. Code 37242 states that it is done per surgical field. How do you know when it is the same surgical field?

62311 vs. 64483

When the physician does a lumbar/sacral transforaminal epidural injection, would we always use code 64483 based on the needle approach, or if he does a transforaminal approach and the needle is inserted into the epidural space rather than into the nerve root would it be coded 62311? The example below was ordered as an epidural injection in the S1 region not a nerve root block; however, the doctor can’t go in that way, so they use the transforaminal approach. "TECHNIQUE: Using fluoroscopic guidance, a 3.5" 22 gauge B-D needle was inserted percutaneously into the epidural space employing a left posterior S1 neuroforaminal approach. Needle position in the epidural space was confirmed by injecting approximately 1 cc of Isovue-M-300. Epidurogram shows craniocaudal, left-sided flow of contrast material. Betamethasone 6 mg/cc 1.5 cc was injected with preservative-free lidocaine 1% 1 cc and normal saline 1.5 cc. Injectate flowed cranially above the level of the L5-S1 disc. Partially concordant symptoms were produced during injection. images showed washout of..."

"Other Qualified Health Care Professional"

Starting in 2017 the moderate sedation symbol has been removed from the cath lab/EP procedures (including vascular), so I am wondering if we (the hospital) can now use codes 99156 and 99157 for those procedures if hospital cath lab/EP nurses are giving the sedation as ordered by the physician performing the procedure and monitoring the patient throughout that procedure. I am confused on the verbiage "other qualified health care professional" vs. "independent trained observer" in reference to a hospital cath lab/EP nurse.

CO2 Angiography and Contrast

If C02 is used for fistulogram instead of contrast, could I bill the C02 with either A9698 (non-radioactive contrast imaging material) or Q9968 (non-radioactive, non-contrast)? Are either of these codes appropriate for theC02?

MRCP

Is 3D a required element for an MRCP?

Cerebral Artery Thrombectomy

Cerebral artery thrombectomy bundles ipsilateral stent placement and angioplasty. What if the stent was placed in the C1 segment of the internal carotid artery in addition to cerebral artery thrombectomy?

Femoral Stent to Stop Bleeding

A patient had a TAVR procedure and had continued bleeding of the femoral artery, so a femoral artery stent was deployed. What code do I use for this service? I see that the CPT book states, "Codes 37220-37235 are to be used to describe lower extremity endovascular revascularization services performed for occlusive disease," so I know that these codes do not apply since the stent was deployed for hemostasis. Is this a billable service?

10180 or 35860?

Patient had femoral embolectomy and returned for postop infection. Can you also give any guidance as to what is required for 35860 instead of 10180? "A 10 blade was used to incise the previous incision in the left groin. This was carried through the subcutaneous tissue with electrocautery. A large cavity of old hematoma was encountered. In order to completely evacuate the hematoma of the incision was extended distally. The majority of the cavity was unroofed. Once all gross hematoma was evacuated, the wound was copiously irrigated with normal saline. The area of necrotic skin was sharply debrided. Sharp debridement then continued to necrotic subcutaneous fat, muscle, and fascia. This was an excisional debridement of necrotic skin, subcutaneous tissue, muscle, and fascia measuring 100 cm2. Hemostasis of the subcutaneous tissue was then achieved with electrocautery. There was necrosis of some of the muscle fibers of the sartorius muscle. These were manually debrided. The wound was then packed..."

Transarterial Embolization

"Skull Base Glomus Tumor Embolization: The microcatheter was then advanced over a microguidewire into the vessels listed above that supplied the skull base glomus tumor.  Particles or coils were delivered as detailed above in materials or below in findings. Followup angiography was performed.Parotid Tumor EmbolizationThe microcatheter was then advanced over a microguidewire into the vessels listed above that supplied the parotid tumor.  Particles or coils were delivered as detailed above in materials or below in findings.VESSELS CATHETERIZED: Right common carotid artery, right internal carotid artery, right external carotid artery, right ascending pharyngeal artery, right occipital artery, stylomastoid branch, transmastoid branch, right posterior auricular artery, right middle meningeal artery, right transverse facial artery (masseteric branch), right posterior deep temporal artery, right femoral artery." Would this be reported as 61626 x 2?

Congenital LHC

The doctor performed a LHC only with coronary angiogram for ASD on a 4-year-old girl. However, I am not seeing a congenital code heart cath code for just a LHC only. I only see the RHC and the combination code for RHC and LHC. What code(s) should we use in this case where no RHC performed?

Shunt Series non vascular (for VP shunt malfunction)

Per imaging title "shunt series imaging done for possible ventriculoperitoneal shunt malfunction", imaging performed was frontal view of lower skull, neck, chest, abdomen, and pelvis, which was resulted all in one report. No contrast was given. Should this be coded as all separate x-rays (i.e., chest, abdomen, etc.), or should we use 75809? Again, no contrast was given.

-50 modifier on code 37221

When my physician performs a bilateral iliac stent placement, is it correct coding to append a -50 modifier to the procedure code (37221)? Or should it be -LT/-RT with a -59 modifier?

ICD-10-PCS, Open vs. Percutaneous

For ICD-10-PCS, we have differing opinions at our facility on the correct approach for procedures that are performed via a cutdown (i.e., AAA, TAVR, hybrid peripheral with endarterectomy followed by patch graft and then placement of a sheath through graft to perform a PTA of the popliteal artery, popliteal aneurysm repair with covered stent through common femoral cutdown). One opinion is that the cutdown is just the exposure of the vessel, but since it was not exposing the actual procedure site these are percutaneous procedures. The other opinion is since they opened the patient to the vessel these should be coded to the open approach. What are your thoughts?

Removing Tack Buttons

I'm having difficulty finding a code to match the procedure of removal of gastropexy T-tacks and three buttons, with fluoroscopic imaging of the G-tube. I think I can only report code 49465 (tube check, including imaging and contrast) because the buttons and T-tack (49460) are not obstructive, just causing the patient pain. Please advise.

Excision of AVF. Dx aneurysm of right arm dialysis AVF

How would you report this case (37607 or 35190)? "The patient was brought to the operating room and was placed in a comfortable supine position on the operating room table. The right upper extremity was sterilely prepped and draped. A longitudinal incision was made over the proximal portion of the arteriovenous fistula. This included an ellipse of skin that would also be excised with the fistula, removing redundant skin where the large aneurysmal segment was. Using a combination of electrocautery and scissor dissection, the cephalic vein was identified and dissected free. The vein was clamped and divided proximally, just beyond the arterial anastomosis. The proximal end was oversewn with a 2-layer running 5-0 Prolene closure. Distally, after excising approximately 10 cm of the fistula, the vein was clamped beyond the area of aneurysmal dilation and was divided. The distal end was suture ligated with a 2-0 silk suture. Wound was irrigated, and meticulous hemostasis was gained with electrocautery. The incision was then closed."

Left Arteriovenous Fistulogram with Central Venous Angioplasty

Please help; I'm very confused. I would like to know what codes to use for a left AV fistulogram with central venous angioplasty and left brachiocephalic arteriovenous fistula, surgical revision with flow reducing tapered plication of the AV anastomosis. "Patient with left upper arm brachiocephalic arteriovenous fistula with excessive pressure due to presumed venous stenosis and additional excessive arterial inflow. 54-year-old gentleman with longstanding history of end-stage renal disease on hemodialysis. He dialyzes via a left upper arm brachiocephalic arteriovenous fistula. He has undergone previous repair of an apparent bleeding pseudoaneurysm at an outside facility, but continues to have problems with dramatically swollen left upper extremity and wound breakdown at the previous surgical site. He comes to the operating room at this time for further evaluation and treatment as able."

Extracardiac Conduit Fenestration

How is closure of extracardiac conduit fenestration coded?

Catheter Selectivity with LE Intervention

The AAPC had the following example: "Rt femoral arterial access, catheter advanced into the aorta, aortagram performed, catheter advanced in the Lt common femoral, imaging obtained. Stent placed in Rt common iliac." They indicate that you could bill catheter placement code 36246-59 for catheter placement in the lt common femoral. I thought catheter placement was bundled into the interventional codes... is the AAPC example incorrect? Or is catheter placement that is bundled into the LE interventional codes only for ipsilateral placement?

76937 Documentation (again)

I have numerous clients that document a permanent recording of the US image. Is it really necessary to document "evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry"? It seems redundant. May we report code 76937 with only image recoding documented? 99% of the physicians from various practices in the US only use this documentation.

VA ECMO

We elected to place the patient on VA ECMO via the RFV and LFA using a 15 French cannula in the RFA and a 25 French cannula in the RFV. A 6 French sheath antegrade distal perfusion catheter was placed in the LFA. What CPT codes should I use?

Distal Aorta Angiogram

"The doctor places a cath in the distal aorta and takes an angiogram of the distal aorta and only images the iliac arteries bilaterally. Decision was made to intervene based on the findings, and bilateral kissing common iliac stents placed." Would I only bill codes 37221-50 and 75716-2659?

CT Myelogram

Exam ordered: CT myelogram lumbar spine. Documentation: Under fluoro guidance, a 22 gauge needle was inserted into the central canal without difficulty. I then injected 15 cc of Isovue 200 with good opacification of the central canal. The need is removed. Findings: Transpedicular interspinous fusion hardware noted at L5 - S1. Intrathecal contrast in satisfactory position. Impression: Lumbar myelogram without complication. The patient will be sent to the CT scan for additional imaging and will be dismissed from the hospital after the appropriate post procedural monitoring. Post lumbar myelogram CT performed and documented." In this scenario, should I report the following codes: 62284, 77003, and 72132?

Transcatheter perm occlusion or embolization

When coding for an embolization (61626 or 61624), and there was embolization in more the one vessel in the same territory, can you report code 75894 more than once?

JW Modifier

In your newsletter dated October 19, 2016, in Question/Answer #6 it states that the -JW modifier is not required for "drugs that are not separately payable, such as packaged OPPS drugs...".I cannot find that documented in the CMS Transmittal 3538 where it only states that the -JW modifier is not used on claims for CAP drugs and biologicals. Is there another document from CMS that states JW is not required for packaged OPPS drugs?

Intrahepatic Tract Emobolization

Should we code a balloon dilation in this case? And how should the intrahepatic tract embolization be coded? "A percutaneous transhepatic cholangiogram was performed. Due to the rapid passage of contrast through the duodenum, a 4 French Fogarty balloon was advanced through the sheath and inflated in the common hepatic duct to allow intrahepatic distention. A percutaneous transhepatic cholangiogram after this showed no evidence of dilated duct or filling defect. At this point, no further cholangiograms were attempted. The intrahepatic tract was embolized with two different 3 x 5.2 mm pushable coils. This was successful. Sterile was placed after hemostasis was achieved."

CPT for Direct Puncture for Embolization of Tonsilar Hemangioma

Would you use code 37241 or an unlisted code for the following procedure? "Sheath was inserted through mucosa of tonsil into central portion of hemangioma. Contrast was injected, showing amorphous vascular lakes. Physician then injected absolute alcohol slowly under digital roadmap imaging until radiopaque alcohol displaced collection with the hemangioma. Total of 3.5 mL of alcohol was injected."

Left Atrial Appendage Ablation for Atrial Fibrillation

What code(s) would you use for the ablations? "Physician performed TEE. Using ICE, transseptal puncture was done. Ablation catheter was placed in the left atrium, and 3D mapping of the left atrium was performed. It was identified that the pulmonary veins were silent. Assessment of the conduction via pacing of the pulmonary veins was done. It was identified that there was signal in the left atrial appendage. RF ablation and isolation of the left atrial appendage were done. Then it was identified that there was signal at the base of the right superior pulmonary vein, which was ablated as well. Conclusion: Treated atrial fibrillation with ablation without immediate complications. Isolation of the left atrial appendage." 

Lymphatic Malformation

Is it appropriate to code 49185 or 37241? "PROCEDURE: Lymphatic malformation sclerotherapy. Ultrasound mapping confirmed the presence of lymphatic malformation within area of concern, comprised of 3 dominant large macrocysts and multiple smaller macrocysts. The largest macrocyst was accessed using ultrasound guidance and a 20 gauge Angiocath needle. The cyst was aspirated to completion and injected with a dilute solution of Sotradecol 3%. The Sotradecol was left to dwell for approximately 5 minutes and then aspirated. The cyst was then injected with a smaller volume of the contrast-opacified doxycycline solution than was initially aspirated. The two remaining dominant macrocysts were each treated in a similar fashion. The remaining smaller macrocysts were accessed under ultrasound guidance, aspirated, and then injected with a slightly smaller volume of doxycycline solution. Post procedure ultrasound and radiograph confirmed the presence of contrast opacified doxycycline solution within the region of concern."

CT-guided embolization of the thoracic duct

What code should I use for CT-guided embolization of the thoracic duct? "Technique: Informed consent was obtained. The patient was placed on the CT scanner table. Right lateral chest wall was prepped and draped. Skin was anesthetized with lidocaine. Under CT guidance, two 20 gauge needles were advanced into the cisterna chyli/thoracic duct. The appropriate location of the needles was confirmed with repeat CT. 10 mL mixture of NBCA with Lipiodol was administered through the needles. The needles were removed. Post procedure imaging did not demonstrate any complication. Sterile dressing was applied."

Correct use of 93655

The patient has PAF and atrial flutter confirmed on an event monitor. He is referred for PVI and atrial flutter ablation. The PVI is completed successfully. Afterwards, the following is documented: "Burst atrial pacing and single/double atrial extrastimuli failed to induce atrial flutter, A-fib, and SVT. RF ablation was performed linearly across the CTI. Differential pacing confirmed bidirectional CTI block." Since the atrial flutter does not appear to have been "spontaneous or induced", as stated in the description of code 93655, would code 93655 still be appropriate here? Does a distinct arrhythmia need to be seen DURING the procedure in order to warrant the use of code 93655?

CTO vs. CAD

Provider did a coronary cath. For diagnosis I used CAD I25.10. However my auditor stated I needed to also use I25.82 (CTO) based on the fact of 100% stenosis with collaterals. Is she correct? CORONARY CIRCULATION: --  Distal left main: There was a 50 % stenosis. --  Mid LAD: There was a 100 % stenosis. --  1st obtuse marginal: There was a 100 % stenosis. --  2nd obtuse marginal: There was a 100 % stenosis. --  Proximal RCA: There was a 100 % stenosis. CORONARY CIRCULATION: The coronary circulation is right dominant. Distal left main: There was a 50 % stenosis. Mid LAD: There was a 100% stenosis. Circumflex: Normal. 1st obtuse marginal: There was a 100% stenosis. 2nd obtuse marginal: There was a 100 % stenosis. Proximal RCA: The distal vessel was supplied by extensive collaterals from the LAD. There was a 100 % stenosis.

G0288 for Pre-TAVR Pre-VSD planning

Can you bill code G0288 (recon CTA of aorta surgical planning) after a CTA was done at an earlier date of service for TAVR or VDS planning? Is the intent of G0288 only for the aorta? The physician is doing measurements several weeks/months later, and I want to use code G0288 for global office billing for this work (owns the independent workstation). 

Bilateral Iliac Stents

Abdominal angiography, bilateral lower extremity angiography, self-expanding stent placement to the right external iliac artery, and also self-expanding stent placement to the left external iliac artery. Would I submit code 37221-50, or are these considered separate families? What would the correct coding be for this procedure?

Co-Surgery EVAR - Two Vascular Surgeons

I am auditing claims for two vascular surgeons in the same group practice who are documenting co-surgery for EVARs. Surgeon A works on the left groin performing a cutdown and inserting a catheter into the aorta, and Surgeon B does the same on the right. They continue to work together simultaneously throughout the procedure to deploy the main body graft and any extenders. Since they are in the same specialty, can we bill a co-surgery on the main body and extenders where modifier -62 is permitted? CMS defines co-surgery as two surgeons (each in a different specialty) working together to perform part of a procedure reported with the same CPT code(s), but they also state that "co-surgery is also defined as two surgeons working simultaneously to complete a portion of the same procedure, e.g., bilateral knee replacements". Some MACs appear to indicate that co-surgeons can be of the same specialty in that latter definition of working simultaneously: http://www.wpsmedicare.com/j5macpartb/resources/modifiers/modifier62.shtml. 

Conduit Angiography

The patient had a Norwood/Sano/modified right BT shunt. What codes should we use for angiography of a Blalock-Taussig shunt from the RIMA to the pulmonary artery, angiography in the Sano conduit, and separate pulmonary angiography during a congenital heart cath? We submit code 93568 for the pulmonary arteries, but how do we code the angiography in the shunts?

Pubic Rami Fracture with Kyphoplasty Method

What code can be used for pubic rami fractures treated percutaneously with kyphoplasty balloons and filled with cement? Will 2017 CPT codes have anything to use for this procedure? It seems the only code now is an unlisted code. 

Echo

In order to bill a complete echo, the following structures have to be examined unless technically impossible: left/right atria; left/right ventricles; aortic, mitral, and tricuspid valves; the pericardium; and adjacent portions of the aorta. What exactly does "adjacent portions of the aorta" entail? Is it parts of the aorta itself or structures surrounding the aorta?

61640-61642

Do codes 61640-61642 include diagnostic angiography? Can they be used with codes 36221-36226?

Coding for discontinued CT-guided adrenal biopsy

Please advise on the proper coding of the below procedure (hospital and professional charges). "PROCEDURE: The patient was placed in the prone position. A time-out was performed, and the patient's skin was marked using imaging guidance. The patient's skin was then sterilely prepped and draped in the usual fashion. Local anesthesia was provided with injection of 10 cc of buffered 1% lidocaine. Using CT guidance, a 17 gauge outer needle was advanced towards the left adrenal gland. At this time, it was determined that there would be no safe window to approach from this location. The patient was then repositioned in the right lateral decubitus position, and again no safe window was visualized. After discussion with the patient it was decided to abort the procedure. The patient tolerated the procedure well, and there were no immediate complications. FINDINGS: CT images demonstrate initial placement of a 17 gauge needle without a safe window for left adrenal biopsy."

Septal Myomectomy

Can you code the septal myomectomy with a mitral valve repair? Diagnosis of septal hypertrophy. Documentation states that the clefts were being repaired. Is 33660 the correct CPT code to use for the septal myomectomy?

Specimen imaging post surgical biopsy

We performed a breast needle localization for the surgeon. We received the specimen and filmed it using mammography. Would this require us to bill an unlisted code as we would if done with ultrasound? Or can we use code 76098?

Patch Angioplasty Common Fem/ Profunda - only

We had a patient who underwent patch angioplasty with bovine pericardium for "stenosis" of the common femoral and profunda. Part of the op note reads: "We placed a Derra clamp on the common femoral artery and occluded the profunda branches with either a profunda clamp or Silastic vessel loops. The SFA was clamped. An 11 blade was used to create a longitudinal arteriotomy in the common femoral artery, and the Potts scissors were used to extend this both cephalad and down past the profunda stenosis and into the main trunk of profunda. I did have to go all the way to where it branched to find an endpoint to the disease. At this point, I decided not to do the endarterectomy due to the diffuse nature and just performed the patch angioplasty. A bovine pericardial patch was brought up on the field." What is the code for patch angioplasty only?

Brachial approach/celiac artery stent placed

I would like to verify the cath placement for a stent placed in the celiac artery. The approach is left brachial to the aorta. An aortography was done as well as an arteriogram. I know these are both included, since both were previously done. From there the cath was placed in the celiac artery and a stent was placed. 

AVF arterial graft segment angioplasty

I have an op note that states there were stenoses at the "arterial graft segment" as well as the venous anastomosis and venous graft segment. These were all angioplastied, and I was instructed to submit only code 35476 because the "arterial graft segment" is considered venous and not arterial. The explanation was that the angioplasty has to be at the arterial anastomosis or peri- or juxta-anastomosis area to be coded as 35475. Can you please clarify this for me? I have never heard this rule before. ASDIN states, "The arterial anastomosis with the adjacent approximately 2 cm of artery (peri-arterial anastomotic region) is defined as the arterial portion of the access, and the entire remainder of the access is defined as the venous portion for coding purposes."

PD cath revisions

For the following example, should we report code 49325 only? "The abdomen was insufflated with CO2. A 5 mm port was placed in the LUQ. The previous cath was removed with dissection of the subcutaneous cuff and peritoneal cuff through the entry site in the abdominal wall. The catheter was removed after which a new catheter was placed through the infraumbilical incision There was also a large piece of fibrin which was in the previous peritoneal dialysis catheter which was lying over the bowel, and this was removed as well. The catheter was then placed through a puncture wound in the infraumbilical region, placed into the pelvis, and then tunneled and brought out next to the 5 mm port in the left upper quadrant. The abdomen was desufflated, and 1 liter of saline was advanced through the catheter with ease which returned easily on egress."

Q0 modifier on the device charge

Do you need to add the modifier -Q0 on the ICD device code also? Or just for the CPT procedure code?

Urology Procedures

The urology procedures are confusing me on the required documentation for 74420, 74430, 74450, and 74455. What is the difference in documentation we should look for to code these codes correctly? They all appear to be retrograde filling, but I never know what else to look for in the dictation. Here are a few examples: 1) Spot films from OR procedure cysto-stent. The injection shows double-J left ureter stent. Would you code 74430-26-52 here? 2) Technique: Patient was cathed (51600) and contrast injected retrograde. Small reflux in the right ureter. Right stent is seen; no ureter injury. Post void films show normal emptying (74430). Any help you can give would be greatly appreciated. I never know when to use code 74450.

Neuroembolization

Should code 75898 be used for follow-up angiography after coil is deployed prior to detachment, or should it only be coded for follow-up after coil detachment?

C2623 with 37225

I have a patient that had atherectomy performed on a diseased segment in the SFA, followed by angioplasty with a drug coated balloon. This portion of the case was coded with CPT 37225 (atherectomy with or without angioplasty). Ucare has denied the claim citing MM9100 which indicates drug coated balloons C2623 should always be paired with either 37224 or 37226. They don't include 37225 as an allowable procedure code with C2623. Does this omission of 37225 from the transmittal make sense, or do you think this is a misapplication of logic? I have very clear sequence of events in the op note being atherectomy first, followed by angioplasty.

Baker Cyst Aspiration

Would you code an ultrasound-guided Baker's cyst aspiration as 20611 or 10160/76942? "Diagnosis: Right Baker's cyst. Ultrasound was used to examine the area within the right popliteal fossa area. Following infiltration with local anesthetic, a 21 gauge needle was advanced into the right Baker's cyst. Approximately 4 cc's of synovial fluid were removed with ultrasound guidance. There was no evidence of remaining fluid collection after aspiration. Images were stored for documentation."

Kissing Stents in Iliac

How are kissing stents in the iliac coded?

Toe Amputation

Is CPT 28820 correct for the procedure? Can we also bill for debridement? "Patient had a LT 1st & 2nd toe amputation on 8/15,complicated by delayed wound healing. The patient had several debridements on 8/21, 8/29, and 9/2 and 10/13/16.He was admitted on 10/13 with fever, chills, and necrotic, foul-smelling drainage from his left foot wound. He presents for planned 3rd toe amputation and further debridement of his wound. Using a 15 blade a circumferential incision was made to include left 3rd toe. Necrotic tissue was debrided from the wound edges as well as the wound bed. The incision was then carried down to the 3rd metatarsal bone using sharp dissection. The metatarsopharyngeal joint was then identified and the toe was disarticulated. Using a bone rongeur the head of the 3rd metatarsal was removed. The bone was soft and fell apart with debridement. Bone tissue samples were sent for culture. Further debridement was performed until healthy bone tissue was reached. The wound was then irrigated using normal saline. Wound measured approximately 12.0 cm x 7.5 cm by the end of the debridement."

Cutting Angioplasty with Perforation

"Under fluoroscopic guidance, the upper arm dialysis access fistula was catheterized and fistulogram was obtained. There was a greater than 50% stenosis within the mid cephalic vein that was dilated with an 8 mm angioplasty balloon and high pressure angioplasty balloon with no effect. The lesion was then dilated with a cutting balloon. Following angioplasty with a cutting balloon there was a leak identified from the cephalic vein. Multiple attempts at balloon tamponade were performed, and these were unsuccessful at controlling the leak. An 8 mm x 6 cm fluency stent graft was then placed across the leak and dilated to 8 mm. Follow-up fistulogram was obtained and showed free flow of contrast through the stent. Cephalic arch and central veins are patent. The arterial anastomosis is widely patent. There is a small pseudoaneurysm in the cephalic vein near the arterial anastomosis." I am assigning codes 36147 and 37238. Should something be stated about the perforation? If so, how should this be coded?

Exploration and Attempted Thrombectomy of AVF

Can we bill code 36831 for the attempted thrombectomy? We did pull thrombus out, it just wasn't all of it. I would love to know how you would code this. "Patient has a history of pseudoaneurysms, multiple interventions, and stents in the cephalic arch and the proximal AVF. Presents with it completely thrombosed. Incision was made, and embolectomy catheter was used to perform thrombectomy of the AVF. Fair amount of thrombus was retrieved from the mid portion as well as the pseudoaneurysms. However, unable to enclose the embolectomy catheter down towards the arterial anastomosis with the presence of a stent in the proximal segment of the AVF. Was able to direct the catheter in a retrograde fashion through the stent and was quite close to the arterial anastomosis. Stent was compressed, which made thrombectomy difficult. Thrombectomy was performed in the distal aspect of the AVF, and a small amount of backbleeding obtained. Due to difficulties advancing any further, the incision was closed. Will plan for AV graft insertion in a few weeks."

Iliopsoas Muscle Drainage

I'm having difficulty coding the following: "1% lidocaine was infiltrated into the subcutaneous tissues at the site marked for local anesthetic. Utilizing direct sonographic guidance, an 18 gauge needle was advanced into several small hypoechoic collections within the right iliopsoas muscle with approximately 1 to 2 cc of serosanguineous return."

AV Loop Graft

Patient with lower extremity traumatic wound with need for free flap underwent popliteal artery to popliteal vein AV loop graft using the greater saphenous vein for the later creation of the free flap at a later date. Would this be reported with code 36821?

Aortic innominate/carotid bypass through sternotomy hemashield graft

I need help with this case. I'm looking at codes 33881, 33884, 75957-26, 75958-26, and 37799 for the sternotomy: aortic dissection distal to left subclavian. "Procedure: Standard sternotomy was performed, and pericardial cradle was created. Ascending aorta and arch were dissected from surrounding tissue, and the innominate and carotid were encircled with vessel loops. Proximal and distal control was established. 14 x 7 mm hemashield bifurcated graft was brought to the field. Partial occlusion clamp was placed on the aorta, and the proximal was complete in a side fashion using 5-0 prolene. We then brought the limbs under the innominate vein, and sequentially the right common carotid and innominate anastomoses were created in a end-to-end manner using 6-0 prolene."

Mediastinal bleeding, status post orthotopic heart transplantation

Which CPT code is more appropriate for the following example: 32120 or 39010? "The previous sternotomy incision was reopened. Sternal retractor was placed. There was a moderate amount of clot that was removed. Irrigation with warm saline was then performed. I identified multiple spots on both right and left pericardium that were oozing, which were controlled with cautery. There was also significant periosteal bleeding that was controlled on either side. Patient was previously packed with lap pads, which were all removed. I then directed my attention to the LVAD pocket area, which also had an area of bleeding that was controlled with cautery. I then packed the mediastinum for a period of 15 minutes to assure hemostasis, removed the packing, and was satisfied with the amount of hemostasis. I made a decision to leave one lap pad in the LVAD pocket area, which was hard to control. The sternum was then closed temporarily with three sternal wires. Skin was closed."

Right leg wound debridement with excision of skin and wound VAC placement.

I would like to know how to code this procedure and the wound VAC placement please. "Right leg wound debridement with excision of skin, subcutaneous tissue, muscle, and tendon. Wound measures 24 cm long, 7 mm wide, and 4 cm deep upon completion. Wound VAC placement. Bland devitalized anterior compartment muscle underlying the entire volume of the open wound and extending proximally about 2.5 cm under intact skin. This is debrided down to moderately viable tissue at the base of the anterior compartment. The neurovascular bundle was preserved. There was moderate bleeding at the base of the wound with subsequent hemostasis acquired and a VAC dressing is applied with excellent seal. Evaluation of flexion contraction under anesthesia reveals a distinct contracture with a 'rock' of posterior compartment scar likely resulting in the contracture. Once hemostasis was acquired, the wound was irrigated with antibiotic saline and then a VAC negative pressure dressing was brought into the field. This was applied in a 2-layer technique. This was connected to a vacuum pump."

Epicardial Ablation

Is pericardial access billable when performed by a physician from a separate specialty during an ablation procedure? The physician has documented his own report for this procedure. If it is billable, what code would be used?

MRI Scapula

What is the correct CPT code for MRI scapula?

KX vs. SC Modifier

In instances where a biventricular pacemaker is being implanted, and the CPT codes are 33208, 33225, would a -KX or -SC modifier be appended or omitted considering the CMS article specifically states that that the information in the NCD only applies to single or dual chamber pacemakers? Or is this an instance where the we would look to the “Other” category/group list that is mentioned to not be all-inclusive? I would think that this may give us license to use the -SC modifier.

Angioplasy of Existing Stent

Patient has previous femoral artery stents that are now occluded. The physician does an angioplasty of the stent. Is that coded as a new angioplasty (37224)?

ECMO

If a surgeon inserts one ECMO cannula percutaneously in the RFV and a second ECMO cannula through open cutdown in the LFA, would it be appropriate to report codes 33954 and 33952-59 during the same encounter? I see that the edit between the two codes allows for a -59 modifier, but I'm looking for clarity on whether the separate anatomic sites for insertion is sufficient to unbundle or if the cannulae would actually have to be performed by a different provider or during a different encounter to unbundle.

Staple Removal

I enter charges for a cath lab in a hospital. A lot of the cases are done on an outpatient basis. I can't come up with an appropriate charge for this, so I would appreciate your input. "The patient is an 85-year-old male who had a dual chamber pacemaker done at an outside institution who presented to my office for staple removal. However, the staple at the medial superior edge of the incision did not affix correctly, and it seemed to fold in on itself. I was unable to remove it given the tools I had in the office, so I brought him to the lab for removal. LOCAL ANESTHESIA:  Lidocaine 2% 5 ml without epinephrine. The staple was removed using two Kelly clamps to straighten out the staple to allow for removal. Octyl liquid bandage was applied over the incision afterwards. No complications." Even though the patient was brought here to do this, it still seems like something we cannot separately charge for. What are your thoughts?

Endarterectomy with fem-pop bypass

If a patient is undergoing a femoral-popliteal bypass, and the surgeon documents performing an endarterectomy of the profunda femoral artery on the ipsilateral leg, can we unbundle the endarterectomy if the intent of that endarterectomy is not to facilitate graft placement? For example, an arteriotomy is created in the common femoral artery, and endarterectomy is performed in the CFA, which is the inflow vessel (bundled), carried into the origin of the SFA, and then carried into the profunda, but in the profunda, the endarterectomy is not just at the origin into the vessel; it extends 15 cm into the profunda due to extensive underlying disease. The surgeon has dictated that the intent of the profunda endarterectomy is not to establish inflow to the graft but to remove significant disease from the profunda itself and improve the patient's long-term outcome. Would we be able to report code 35372 for the PFA endarterectomy along with the bypass graft in this scenario? Would the scenario change if a second arteriotomy was made on the PFA itself?

Denver shunt inserted by a radiologist

What documentation supports the assignment of code 49425 vs. 49418?

Code with 33881 ,33883 3884 X4?

1. endovascular repair Type II thoracoabdominal aortic aneurysm using the multi-branched stent-graft technique, with placement of branches into the left renal artery, right renal artery, celiac axis and superior mesenteric artery

Open IVC Filter Removal

I have a patient who had a failed attempt at endovascular removal of the IVC filter. One month later the patient has developed abdominal and back pain and is deemed an appropriate candidate for exploratory laparotomy and open removal of the IVC filter. Would you code the open removal as 34502 or 35221? The filter penetrated through the IVC and duodenum, which another physician stepped in to repair (44602). Does 34502 or 35221 include removal of the filter with vessel repair, or should I look to using an unlisted code?

Denver Shunt Placement and Paracentesis

A patient presented for a Denver shunt placement and had ascites removed from the peritoneal space. Is paracentesis included with the shunt placement, or can this be billed additionally? We are reporting codes 49425 and 76000 for this procedure.

CRT-P at ERI and LV macrodislodgement

Patient presents with CRT-P gen at ERI and macrodislodgement of LV lead. LV lead is removed and replaced with new LV lead. Generator is exchanged. Can you confirm the correct coding of this case?

Ventricular program stimulation was performed

Can I still charge for 93641 when the MD states: "Induction of arrhythmias for testing of defibrillator and lead system. Ventricular program stimulation was performed. There was non-sustained ventricular ectopy induced, which was sensed normally by the device." Even though he did not do DFT shock testing.If I cannot charge for this, is there another charge I can use?

Removal Central Line with Percutaneous Stitch Repair of Carotid Artery

How would you code percutaneous stitch closure repair of the left common carotid artery? "Clinical: Iatrogenic left carotid artery injury with central line insertion. Procedure: Fluoroscopy reviews the tip of the central line in the descending thoracic aorta. A wire was placed through the line, and the line was removed. Percutaneous closure of the left common carotid artery injury was carried out. Hemostasis was achieved. The suture was cute and sterile dressing was applied."

Left atrial appendage resection during MVR or Maze

I’ve advised my providers that left atrial appendage resection is not separately billable with open mitral valve procedures, per STS guidance. They feel resection of the LAA is different than ligation/plication/clipping, and should therefore be billable with mitral valve procedures. 1) Is LAA resection/amputation also inclusive in mitral valve procedures? 2) Why is LAA included in both mitral valve and Maze procedures?

Open exposure fem artery

Can you report code 34812 with lower extremity bypass? Or only when AAA is performed?

Redo thoracotomy recurrent pleural effusion

"A 4 cm skin incision was the performed. The fascia and subcutaneous tissue were entered with electrocautery obtaining hemostasis simultaneously. The pleural cavity was entered, and immediately we recognized the large pleural effusion approximately 2 L of fluid were removed from the pleural cavity. The previously created pericardial window had remained patent, and it is possible that some of the fluid was coming from that area. The lung was stuck to the chest wall. Pneumolysis wasperformed with some degree of oozing around it from the pleural cavity. Once all the fluid was evacuated, the pericardium was drained with a pigtail catheter inside the pericardial cavity, anchored to the skin with a statlock. Intercostal nerve cryolysis was performed at the level of incision manner. 2 chest tubes were then placed through the incision anchored to the skin with heavy silk and connected to a pleural evac." Pt had a pericardial window 3 days prior to this service not sure what to code. 32551? what about the pneumolysis 32124?

Cpt code 93458 and 75756 be billed together

Physician performs a left heart cath and left internal mammary angiogram. Documentation states patient has severe 3 vessel disease including the LAD,LC, and RC. The patient needs to undergo bypass surgery with LIMA to LAD,SVG to OM1,SVG to OM2 and also PDA and posterolateral. He performed a left subclavian internal mammary angiogram. Could you bill cpt code 75756 for the angiography of the internal mammary along with the heart cath 93458?

Iliac Extension 34825

When placing a AAA graft, and the doctor documents iliac extension placed to the internal iliac take off, is this considered an extension? Or does it have to cross into the external iliac? I know with the FEVAR it has to extend to the external, but I didn't know about regular AAA single docking limb placements with extension if it was billable if it stopped in the common iliac.

CRT-P upgrade to CRT-D

Patient with ischemic cardiomyopathy, EF less than 35%, wide QRS (chronic right ventricular pacing), and NY Heart Assoc. class 2 to 3 symptoms who currently has CRT-P (RA and RV dual chamber). During the procedure, the physician upgraded to CRT-D and implanted LV lead. During the procedure it was also determined that the existing RV lead would be capped and a new RV lead implanted. The existing RA lead would be used with new defibrillator. We coded this as 33264 and 33225, but how would we code the insertion of the new RV lead?

Where does it end?

I am trying to figure out if the CPT definition of the anatomical extent of a dialysis shunt matches any ICD-10 definition of where the shunt begins and ends. In an earlier question (#8222) I asked if conditions relative to a dialysis shunt occurring between the arterial anastomosis and the right atrium should be coded with complication codes from the T82 series of ICD-10-CM. Sara’s answer was in the affirmative. Now I see that in the November Case of the Month, a stenosis of the Brachial vein (between the arterial anastomosis and the right atrium) in not coded with a complication code from T82, but rather with a disorder of vein code, I87.1. I would have thought that T82.858A was appropriate. I was further confused by your use of T82.898A for the venous collateral, which I have always coded with I87.8. Why is it that the second stenosis, on a direct path to the right atrium and in the same zone, is NOT considered related to the presence of the fistula? Yet, the venous collateral IS considered related to the presence of the fistula?

Transcatether Mitral Valve Replacement via Transapical Approach

What would be the proper coding for the following procedure? "The patient was then prepped and draped for transapical transcatheter mitral valve replacement. The physician will dictate all surgical aspects of the left ventricular transapical approach and closure. With the sheaths in place, we moved forward with the transcatheter mitral valve replacement via a transapical approach. The physician gained access to the left ventricular cavity with a Cook needle. A Rosen wire was then extended into the left atrium across the bioprosthetic mitral valve. We then advanced a long 7 French sheath into the left atrium. We exchanged an extra stiff Amplatz J-wire to the left atrium. An Edwards Sapien 29 mm XT bioprosthesis was malleted onto its transapical delivery system and advanced over the stiff wire. Under coaxial fluoroscopic guidance, we placed the XT transcatheter valve within the previously placed mitral valve prosthesis. Under rapid right ventricular pacing, we deployed the XT valve inside of the previously placed mitral valve prosthesis."

Abdominal Aortogram

I need some clarification on medical necessity for abdominal aortograms. Is peripheral vascular disease enough to justify an aortogram? I have been looking for aneurysm, pseudoaneurysm, abdominal bruit, aortic stenosis, and such. Please clarify what is sufficient.

Lower Extremity tPA with Thrombectomy

"Venogram was performed, demonstrating segmental thrombus throughout the right SFV, as well as popliteal vein. This was followed by placement of 4 mg of tPA infused with a mechanical device within the right lower extremity venous structures from the proximal SFV to the popliteal vein. Angiogram was performed, confirming some segmental thrombus in the right SFV and popliteal vein. This was followed by placement of a thrombectomy extraction 6 French catheter. Thrombectomy was performed within the right lower extremity from the SFV to the popliteal vein." Based on this documentation, can code 37212-59 be reported with thrombectomy code 37187? Via phone discussion, the physician states that after tPA the patient is sent to post-op for an hour and then brought back for the thrombectomy. Does the "mechanical device" used for the tPA support reporting the infusion service?

L subclavian angiogram during cardiac cath

Patient presents for cardiac cath and subclavian angiogram. Indications are positive stress test, angina, vertigo, memory issues, carotid US with suspicion of subclavian stenosis. Procedure performed via right radial artery access. Catheter placed in right subclavian artery and contrast injected, revealing diffuse atherosclerotic stenosis in proximal left subclavian artery. (Cardiac cath and intervention performed without issue.) How would the left subclavian angiogram be coded? Would this be reported with code 75710-LT?

Stent placed in Lower Exteremity Vein Graft to tibal artery

A patient with a LE vein graft to tibial artery was seen in office by surgeon. US revealed an impending stenosis. Patient brought to cath lab for angiogram and possible intervention. OP report states a 99% stenosis was seen proximal to a stent in the distal vein graft. More proximal vein graft lesions and the proximal posterior tibial artery were treated with a 5 x 40 and a 5 x 20 mm balloon respectively. Pre-occlusive stenosis in the distal tibial vein graft which was successfully stented. The proximal posterior tibial artery was also angioplastied1. Procedure was coded as 75710 37230. However, WPS Indiana has denied this due to non-covered diagnosis code T82.858A stenosis of prosthetic graft entered by coding. If believe dx code is incorrect since this is not a prosthetic graft. Is it appropriate to use 37230 for stent placed within vein graft? Or should a different CPT code be used. Recommendation of dx code. HP does not mentioned claudication.

Fractional Flow Reserve Without Catheterization

The physician performs a left heart catheterization at NCP cath lab and then transfers the patient to cath lab at hospital to do 93571. Since this is an add-on code and can't be billed alone, would you bill this with unlisted code 93799? The physician thinks that 93571-26-XE will get us paid for Medicare, and for commerical insurance to bill CORS only with 93571 to get paid. What are your thoughts?

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