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Diagnostic Angiography

From a claims review perspective for interventional radiology procedures that include angiography in the CPT description, would the procedure note include documentation to support billing a diagnostic angiography procedure? It's not always clear, especially if there is no prior angiography, change in the patient's condition, etc. referred to in the note and could result in non-reimbursement of a code (which is unfortunate considering the work that was done).

Diagnostic angiography and lower extremity revascularization

Greetings, I have a angio intervention on the illiac vessel with a stent. I know this is coded as 37221. The diagnostic angio performed at the same time is what I am having trouble with. The cath is placed in the aorta and a runoff is performed with no cath movement. Then,a diagnostic inturp through the tibials bilaterally is documented. How would you code this with the new code 37221? Can you also coded a 36200 as it is through the same femoral access? Thanks,

Diagnostic Angiography and Y90 Embolization

I have a physician who insists that the angiograms performed before and after embolization are diagnostic. I have provided the following indications as to when a diagnostic angiogram would be justified based on coding guidelines: 1) decison to perform intervention based on study, 2) change in patient condition, 3) inadequate visulaization of anatomy/pathology, 4) clinical change during procedure requiring new evaluation outside of target area of intervention. The rationale I received from the physician is as follows: "THE DIAGNOSTIC ANGIOGRAMS WERE NECESSARY, AS THERE IS A NEED TO EVALUATE FOR NEW COLLATERAL VESSEL FORMATION PRIOR TO THE ADMINISTRATION OF Y-90 SIRSPHERES TO PREVENT NON-TARGET EMBOLIZATION. WE ALSO NEED TO DOCUMENT ADEQUATE FORWARD FLOW BOTH BEFORE AND AFTER ADMINISTRATION OF Y-90 SIRSPHERES. FURTHERMORE, THIS PATIENT'S DISEASE HAS STEADILY PROGRESSED DESPITE NUMEROUS INTERVENTIONS." I do not see the requirements for diagnostic angiography being met, but I would like your opinion and rationale. Can you help me?

Diagnostic angiography at the time of an intervention

My docs have asked me two specific questions after I forwarded the latest Dr Z newsletter to them: “Diagnostic Angiography at the Time of an Intervention -- your ZHealth Online Newsletter for August 15, 2011”. 1) Does this apply to all interventions equally – Lower extremity, visceral, head & neck, etc.? 2) Does this apply to Part A and/or Part B or both  

Diagnostic angiography at time of intervention

Hey Dr. Z! In 2011, a DIAGNOSTIC lower extremity angio is codeable (with a modifier) prior to an intervention correct?

Diagnostic at time of intervention with prior color flow doppler study

Please do NOT include any actual patient medical records with your question. Your guide states that diagnostic imaging (when medically necessary) is separately billable when done at the same time as LE revascularization if not recently performed but not for confirmation of a known lesion seen on prior cath-based angiograpy,diagnostic CTA or MRA. My question is, since I am not familiar with alot of these tests, if the patient had a vascular study done about a month prior and imaging was obtained using gray-scale, pulse wave and color doppler, would the diagnostic imaging at time of revascularization still be seperately billable since they had the vascular study? Would it make a difference if patients symptoms had changed or condition worsened? I'm just unclear in these kinds of circumstances and would appreciate any assistance you may be able to offer.

Diagnostic cardiac catheterization with cardiac intervention NCCI edits

Hi, It seems I am asking a question every other week now. I thought I had a good grasp on the the new Cath codes for 2011, and for the most part I still do. However I have had some Medicare denials when billing a coronary stent placement (92980-RC) in the same setting as the left heart cath (93458-26) I know as of last year when we billed a STENT or PTCA, at the same time as the cath codes, we would have to put a 59 modifier on the 93555-26, and 93556-26, otherwise Medicare would deny those two codes as included with the intervention. Would billing 93458-26 with a 59 modifier be the way I should be billing? or would this be improper. The only other code that was billed the same day was a critical care E&M code 99291. What am I doing wrong, can you please help. Thanks Jene Anderson Central Fla Heart Center.

Diagnostic catheter placement followed by intervention that includes it

Dr Z and/ or Dr Dunn: I think I am confusing myself but want a little clarification. Cath placements for diagnostic purposes and then cath placements for the purpose of the intervention in the cerebral artey(s) can be billed/coded seperately correct? This would be in the same setting/time. I am getting conflicting information and want to check myself. Thanks

Diagnostic Cerebral Angiogram

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!

Diagnostic Cervical Angio

This is my first time coding for a diagnostic cervical angio. I've done thoracic and lumbar. Are there specific codes for the cervical?

Diagnostic imaging at time of an intervention

Dr.Z, Before a Kissing Balloon and Stent placements were performed Bilaterally on the Common Iliac Arteries, an Abdominal Aortogram with the catheter positioned above the bifurcation for a Bilateral Lower Extremity Run-off Angiogram. In a case like this with intervention in the Common Iliacs, would 75625 and 75716 still be reportable? There were findings and interpretation provided for the abdominal aortogram and extremity angiograms.

Diagnostic Imaging for Splenorenal Shunt Outflow Venography

Would you please guide us through coding this case?  What would be the correct diagnostic code for splenorenal shunt outflow venography? The report is included below: SPLENORENAL SHUNTOGRAM AND GASTRIC VARIX EMBOLIZATION (BRTO) CLINICAL INDICATION: Portal hypertension with spontaneous splenorenal shunt and large gastric varix. The patient has developed refractory encephalopathy. Right common femoral vein accessed. Selective catheterizations of the left renal vein were performed with a 5 French multipurpose catheter, which was ultimately manipulated into the splenorenal shunt outflow vein (36012), and venography was performed (75887) OR (75810). A 16 mm x 4 cm Atlas balloon catheter was then positioned across the splenorenal outflow into the left renal vein. The balloon was inflated, and contrast was injected. Venography revealed opacification of a gastric varix with a couple of small veins extending toward the gastroesophageal junction. The splenorenal shunt was occluded with the inflated balloon.with the balloon inflated, embolization was performed with foam (37204, 75894). A total of approximately 25 mL of foam was delivered until complete opacification and stasis in the gastric varix was noted at fluoroscopy.The inflated balloon and introducer sheaths were then fixed in the right groin, and a sterile dressing was applied. The patient was transferred to the PACU in satisfactory condition with no complication. FINDINGS: Balloon occluded shuntogram reveals opacification of the large gastric varix projecting over the medial aspect of the gastric body. No collateral flow into the IVC nor portal vein is appreciated. IMPRESSION: 1. Large gastric varix emptying into a spontaneous splenorenal shunt to the left renal vein. 2. Successful gastric varix embolization 3. Followup venogram will be performed in 4-6 hours. Following routine sterile preparation and local infiltration with 1% lidocaine around the indwelling 9 French right transfemoral venous sheath, injection of the occluded balloon in the splenorenal shunt demonstrate stasis alongside the gastric varix cast (75898).The balloon catheter was then slowly deflated and withdrawn, with no evidence of washout from the gastric varix. The left renal vein remains patent with brisk antegrade emptying into the inferior vena cava. IMPRESSION: Successful occlusion of gastric varix and spontaneous splenorenal shunt following BRTO.

Diagnostic nephrostogram

I have a guestion as to when a study is diagnostic in nature. We currently have a disagreement as to when to code for 47500 and/or 50390.The patient is referred to the radiologist for either a neprostomy catheter placement or a internal/external transhepatic stent placement . The report states that the patient has a stricture and needs a tube placement. The radiologist performs a 47500 or 50390 prior to placing the catheter with I want to code. In the sample below I am coding to 50390 as I see this diagnostic (Findings) and not just for localization. Any feedback would be appreciated.Would this be a diagnostic in nature? I guess my question is if the patient is scheduled for such procedure is any finding not codable? Will give an example: My CPT codes would be: 50390-59, 74425-59, 50392, and 74425 CLINICAL HISTORY: Reason: recurrent cervical cancer s/p posterior exenteration on 7/12/11 at LAMC, progressive right hydro with acute renal insufficiency, please place right percutanous nephrostomy tube, thank you OTHER MEDICATIONS: 1% lidocaine,1mg of Versed and 2mg of Morphine. CONTRAST: 20 ml of Visipaque 320. FLUORO TIME: 78 Seconds PROCEDURE TIME: 30 minutes of conscious sedation monitored by the radiology nurse J. Rigo, RN. FINDINGS: Following careful explanation of the potential risks and benefits of the procedure with the patient and/or family member , oral and written informed consent was obtained. The patient was placed prone on the angiographic table and RIGHT flanks were prepped and draped in the usual sterile fashion. Local anesthesia was achieved with 1% lidocaine. Under ultrasound guidance, a permanent image was recorded, a 22-gauge AccuStick needle was advanced into the lower pole calix of the RIGHT kidney. The stylet of the needle was removed and clear urine returned. Contrast was injected which demonstrated mild hydronephrosis. An 018 wire was inserted and the needle was exchanged with a 5-French dilator. The 018 wire was exchanged with a 035 wire. An 8-French nephrostomy catheter was inserted. The catheter was secured to the patient and connected to a drainage bag. Patient tolerated the procedure well and was discharged from the department in stable condition. IMPRESSION: Successful insertion of RIGHT nephrostomy catheter without apparent complications.

Diagnostic Nephrostogram When Doing Stent Placement and Tube Change

I have a chart where the doctor is stating procedure reason is "to place internal stent". The history says, "Patient returns for diagnostic antegrade pyeloureterogram and stent placement." The dictation says, "The contrast through existing tube. Cath was cut and removed. Fluoroscopy confirms uretral stone. Double J stent placed, new percutaneous catheter was placed, contrast confirmed position, and tube placed to gravity drainage." (I am shortening this a lot.) In the findings, doctor says pyelogram shows decompression and dilation of ureter, 1 cm stone that has migrated, ureter is obstructed at the level of the stone, and calcified uterine fibroid noted in pelvis. I know I can report codes 50393/74480 and 50398-59/75984, but is this enough info to also report codes 50394/74425?  Your book says it has to be diagnostic to be coded, and I feel this is diagnostic, but I'm not sure. Can you explain what I need to look for to be able to code diagnostic grams?

Diagnostic or screening mammogram when only one breast is symptomatic

Please do NOT include any actual patient medical records with your question. We have some confusion on how to charge for mammograms on patients where one breast is asymptomatic and the other breast is symptomatic. If physician orders a unilateral diagnostic mammogram and unilateral screening mammogram because a patient has symptoms in one breast and it is also time for the other breast to be screened should change the order to a bilateral diagnostic exam? I have always been under the impression if one breast is asymptomatic that the exam automatically becomes a diagnostic bilateral exam to compare breast tissue. Also, if a patient has had prior unilateral diagnostic exams for an area that is being watched or a past biopsy and that breast is due for a six month followup unilateral diagostic exam but, it is also time for a screening exam on the other breast can we then charge for unilateral screening mammogram and a unilateral diagnostic mammogram or should that also be a bilateral diagnostic exam? Thank you for your advice! Sorry if the

Diagnostic Test 75710, Medicare Guidelines

I thought that in your book you referenced Medicare guidelines regarding diagnostic test (75710) done the same day as an intervention. But I can't seem to find it. I need to show one of my doctors that it does indeed come from Medicare and not something I made up.

Diagnostic Venography at Time of Venoplasty

My question is regarding the S&I codes for venography (75820) with venoplasty when both venography (75820, 76011) and venoplasty (35476, 75978) are performed in an outpatient acute care facility. We are coding for the facility. I have an edit for venography code 75820 being included in 35476. Is it appropriate to report code 75820 with a -59 modifier if no prior venography has been done?

Diagnostics at time of intervention

Hello! We listened to your 2011 IVR Updates webinar last week and heard that we cannot code diagnostic angios if the patient has had a prior catheter based angiogram. Our question is since CTA, MRA and vascular ultrasound are not catheter based, we're assuming that we can code for diagnostic angios even after these procedures. Would this be correct?

Diagnostics at Time of Intervention

I was taught that if an intervention was done after venography and access I should code only the intervention. I seem to have come across some confusion with this. I think I understand that if intervention was done on one leg, and just venography done on the other leg, I can bill the venography for the other leg separately, and just the intervention on the other extremity. Can you please give me some guidance as to how these are to be billed?

Dialysis Fistula

I am new to IR coding. I have an operative note for a fistula to the radiocephalic for dialysis. It looks like they did an anastomosis. Please help with the correct CPT and ICD-9 procedure codes.

Dialysis graft aneurysm repair

greetings, A Pt has a old dialysis graft not functional for over a year as it was ligated. It develops a aneurysm. The physician excises the aneurysm and ligates a posterior branch running alongside of the graft. Would this be 35011? Thanks, LW

Difference between a device interrogation and a device programming

Please do NOT include any actual patient medical records with your question. Could you please clarify the difference between a device interrogation and a device programming? When our Docs do a device check,93279-93281 and 93282-93284, I am being told that when the doc does the check he will make changes to the device, i.e. check the impedance level and parameters, to check it and then set the program back to the original setting, and this should be considered a reprogramming, CPT codes 93279-93281,93282-93284. I have also been told that these codes depend on whether or not the doc made changes to the final programming of the device, if he changed it from the original setting prior to the device check. I also was under the impression that If the doc did a check and made no changes to the device, "the final program" that this would be considered an interrogation of the device and to use 93288 or 93289.Your input on this would be appreciated. Thank you! Rick

Difference between codes 34201 and 35371 or 35372

I am wondering how this should be coded....we have had many a discussion on the difference between the two codes of 34201 and 35371 or 35372. We were hoping you would be able to clarify the difference. The procedure is as follows: 7 cm incision was made just below the inguinal ligament...dissection was carried distally to the deep and superficial branches of the common femoral artery. A puncture site was noted with clot coming out of it...arteriotomy made through arterial puncture site..clot was removed. Fogarty catheters were placed....no more clot was retrieved. The arteriotomy was closed with a Hemashield patch in both directions with 6-0 Prolene suture allowing backbleeding and forward bleeding before tying the last stitch.

Differences between 76937 and 76942

Can you elaborate please on when it is appropriate to report codes 76937 and 76942? Can these codes be reported by both the hospital and the physician when ultrasound is used to to locate vascular access? From the facility side, we report 76937 when placing central venous access devices, such as dialysis catheters. The Interventional Radiologists also frequently use the Sonosite ultrasound device to locate vascular access during lower extremity diagnostic and interventional cases and fistulagrams. Is it appropriate to report 76937 for the routine use of the Sonosite during cases other than central venous access cases? (Provided that images are saved and ultrasound use is documented in the dictation). The physician coders and the facility coders are trying to be sure that we have the correct practices in places in regards to these codes. Thank you so much!

Dilation of Tract for Nephrolithotomy

We need your help, as we are seeing conflicting guidance on the use of code 74485 on the day a lithotomy is performed. If the patient has existing access and the tract is dilated by the IR doc, but the nephrolithotomy is performed by a different physician, can code 74485 be reported? Or is that still bundled with the nephrolithotomy? Or is it more appropriate to report code 50398, 75984, or 50387 for the IR doc (depending on the position of the sheath) or if the tract isn't dilated?

Dilation of vein with sheath for PICC add -22 modifier

I researched the Q&A list. I would like to know if a venoplasty is appropriate under these circumstances? I know that in several non-vascular dilations, it is acceptable to use a balloon or a dilator. But is that true for vascular angio/venoplasty? He says, "A 7F dilator sheathe was then placed and the venogram performed via the sheath. Narrowing of the proximal subclavian vein was noted. A 7F dilator was then advanced over the .018 wire, through the level of narrowing. A 6F dual lumen PICC line, measuring 40cm in lentgh, was then advanced over the guide wire through the area of previously noted narrowing, with the tip positioned at the junction of the SVC and right atrium. Impression: Successful venoplasty, proximal right subclavian vein as discussed above. Coded as 35476,36569,75978, & 77001 Thank you for your consideration.

Dilation with fogarty balloon for fistula creation

The patient came for possible creation of AV graft. No prior mapping was done prior to arrival in OR. A venogram was performed via direct puncture. Venogram showed several areas of stenosis within the cephalic vein; however, decision was made to proceed with PTA of cephalic vein prior to creation of brachiocephalic fistula. Dissection was carried down to the cephalic vein and vessel exposed. A Fogarty balloon catheter was used to dilate the vein. Following successul angioplasty, the fistula creation was completed. Would it be appropriate to code the open PTA (35460) and the venogram (36005/75820) separately or are these considered part of the AV creation? Thanks in advance for your assistance.

Direct Access Sclerotherapy AV Malformations

Your February 2014 Q&A answer to the question on sclerotherapy for lymphatic malformation was not to use an unlisted code for this type of embolization in 2014. Would this also apply, for example, to direct access for sclerotherapy (i.e., facial AV malformation - 37799/37242)? Would I also report unlisted code 36299 for direct access if 37242 is to be used?

Direct Access Sclerotherapy AV Malformations, Face/Head

This is a follow-up question from Question ID# 5436. You mentioned in your answer that "we may still need to utilize an unlisted code 37799 for facial direct access venous and lymphangiomatous malformation therapy" for direct access sclerotherapy of facial AV malformation. You didn't like codes 37241 or 61626, but recommended code 37799. Have you heard different? Is your recommendation still to use code 37799? Also in the same coding scenario, would you use code 36005 or 36000 for venous access for AV malformation treatment of the face?

Direct needle stick into a non-vascular lymphatic system for treatment

Hi Dr Z, I need help with coding this case. The diagnoses are Lymphatic leak/cholothorax. Bilateral cutdowns were done on the dorsum of each foot, lymphatic channels were cannulated and Ethiodol was slowing injected for 1 hour with fluoroscopy used to observe lymphatic flow. Diagnostic lymphangiogram under fluoroscopy of the pelvic, abdominal, thoracic and neck areas was done. Extravasation was noted at the L1/L2 level. The abdomen was prepared. Using direct stick technique under fluoro guidance the area of extravasation was directly studied. Embolization was then performed using nBCA. Is 37204 appropriate here or should an unlisted lymphatic code be used?

Direct Puncture Embolization of AVM in 2014

Reading through your 2014 Interventional Radiology Coding Reference, you state to use code 37241 for treatment of a true venous malformation (via direct puncture or leg vein access). We are wondering if we can use code 37242 for direct puncture embolization of an AVM or aneurysm, or is it still an unlisted code in 2014?

Direct Puncture Embolizations

One of our doctors does a number of direct puncture embolization procedures under fluoroscopic and ultrasound guidance. I'm using code 37799, unlisted vascular surgery procedure, with codes 77002 and 76942 for the guidance. Is it appropriate to code both ultrasound and fluoroscopy with the unlisted procedure code?

Direct Puncture Therapy

Here is a procedure that was performed that I need some assistance in correctly coding. These unusual procedures can get very confusing.  DEVICES UTILIZED: Two separate 21 gauge micropuncture needles were utilized. PROCEDURES: 1. Ultrasound and fluoroscopically guided percutaneous access into the venous malformation in two separate areas. 2. Percutaneous venography of the venous malformation, times two. 3. Injection of Sotradecol into the lesion, three separate times, ten minutes apart. Using sterile technique, local anesthesia, general anesthesia, ultrasound and fluoroscopic guidance, two separate 21 gauge needles were placed within the lesion. Injection of contrast material was performed, demonstrating the extent of the filling of the lesion. The contrast material was then allowed to drain and the volume was replaced with Sotradecol. The Sotradecol was allowed to stand for ten minutes before attempting to remove it and reinjecting the same space with Sotradecol. This was performed twice from the first needle position and once from the second needle position. At the termination of the procedure the needles were removed, and band-aids were placed over the skin puncture site(s). The patient tolerated the procedure well, and no complications were encountered during or immediately following the procedure. FINDINGS: The first injection from the first needle placement demonstrated excellent filling of the lesion, representing the majority of the lesion, with a multi-lobulated appearance. The venous drainage was into an external jugular branch draining inferiorly. The second injection was in the most superior part of the lesion, filling the superior third. Venous drainage was as outlined above. IMPRESSION: Good filling of the lesion was achieved with Sotradecol, for purposes of sclerotherapy of the venous malformation within the substance of the left masseter, as described above.

Direct thrombin via needle into hepatic aneurysm

Dr Z. and all, wondering if you could recommend how I would code a CT guided percutaneous thrombin injection of a right hepatic artery pseudoaneurysm? Which was un-reachable via the common femoral artery. Thanks

Discontinued galactogram

If a patient comes in for a Galactogram (77053, 19030) and the radiologist cannot to get into the duct, can we charge due to the amount of room time, tech time and radiologist time and supplies. The biggest difference between these to me is that this patient has had invasive procedure done before they have to stop the exam. How would you code this?

Discontinued Procedure, PCI of CTO

When a patient is in for a planned staged intervention on a chronic total occlusion, and the physician is unable to cross with a wire after a prolonged attempt, do you recommend coding 92943-74 or 92920-74? The reason I’m asking is in the past you’ve recommended using the lowest level intervention when it’s aborted for this reason. The code for a chronic total occlusion is weighted much higher for the facility, the same as a stent or atherectomy. Should we use the lower weighted intervention code for an angioplasty instead?

Discontinued Stereotactic Breast Biopsy Procedure

Good afternoon. How would you code the following scenario? Would modifier -73 or -74 be appropriate to report in this instance since this is a radiology procedure? Would the modifier be applied to the RS&I or surgical component or both? "An attempt was made to perform a stereotactic biopsy. The calcifications could not be localized with stereotactic technique. The biopsy could not be performed. The patient understood the explanation. The microcalcifications may have to be biopsied with needle localization technique."

Discontinued TIPS procedure

I am not sure how to code this discontinued TIPS procedure. When I look at valid modifiers for 37182, I do not see -73, -74, or -52 modifiers as being okay to use. Should I code this as a diagnostic study and use codes 36011, 75889, 36481, and 75887? Condensed version of procedure: "Approach from right internal jugular. A 5 French multipurpose catheter was placed used to obtain pressures in the right atrium, after which it was manipulated into the hepatic IVC where another pressure was obtained, and then into the right hepatic vein for free and wedged pressures. Several passes into the liver were made with a needle wire and 5 French catheter. The right portal vein branch was entered, but the wire could not be manipulated peripherally into the left lobe. After exchanging multiple caths a stiff glidewire was placed into the more central right portal vein but was not able to cross into the main portal vein. Contrast injection showed filling defect within the main portal vein. Wire, catheter, and sheath were removed, and hemostasis was obtained."

Discontinued vertebroplasty

The patient was positioned for the procedure on the scanner, and scout images obtained for CT-guided vertebroplasty.After establishing pulse oximetry, BP and EKG monitoring by the radiology nurse, moderate sedation with Tordal and Fentanyl was administered. My intra-service time was less than 30 minutes. Despite the administration of IV pain medication as above the patient could not tolerate the positioning for the procedure. He demanded that we stop the procedure. It was therefore terminated, before any steps of the vertebroplasty were initiated. This is an outpatient. Could we use a modifier 74 for this?

Discrepancy between Order and Radiology Exam--hospital billing

I have run across a couple of situations (post-discharge) where the order and the radiological exam do not match exactly. For instance, a patient came in through the ED with pain that radiated from her abdomen down to left leg with history of pelvic fx last year. Pelvic x-ray was negative and lumbar x-ray w L3 fx indeterm age. So, the physician ordered MRI. The computerized order was for “MRI Lower Extremity Joint Left WO Contrast” (CPT 73721). It doesn’t look like the physician was actually looking for joint pathology. So, based on medical necessity, and the MRI report makes no mention of joints (mentions no fem neck fx or pelvic fx, etc.), it looks like the order should have been for non-joint (as in 73718 or 72195). Ideally, this order should have been corrected at the time of service. As this issue has been found after the procedure was provided and the patient was discharged, what is the best way to compliantly handle this situation? Code 73721 has been denied for medical necessity, and I would like to re-bill this with code3 73718, as this appears to be what the order should have been.

Disruption of left femoral-popliteal bypass graft and left femoral artery pseudoaneurysm

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? ?????

Dissection and 37221

Does the dissection below justify 37221 ? I have 34802,34812-50, 75952-26, 36200-50 with no true extension? Could you please advise? Bilateral groin incisions were created and we dissected down to the common femoral artery. We gained proximal and distal control and heparinized the patient with the appropriate amount of heparin. We cannulated each artery with large bore needles and inserted wires into the suprarenal aorta. Wires were switched out appropriately with a guide caths and placement of a stiff wire. We planned for deployment of the Medtronic Endurant stent graft, main body through the right limb and contralateral limb being managed by Dr. Kunstmann. We performed angiography and identified renal artery orifices. We planned for deployment of the stent graft in an infrarenal artery location and using spot fluoroscopy, we deployed the stent graft in an AP cross limb fashion. The contralateral gate was cannulated from the left lower extremity. Left lower extremity was measured to length with pigtail and fluoroscopy and when we had appropriate length, the left lower extremity or contralateral limb extension was placed by Dr. Kunstmann and brought down to the internal, external iliac junction. We deployed the remainder of the main body and limb into the right common iliac artery. ** There was a small area of dissection with aneurysmal dilatation that we felt needed to be covered and, therefore, we brought an atrium stent into the case and placed it into the sheath and further into the common iliac artery and deployed the atrium stent which was 8 x 38 stent, but ballooned up to a 12 balloon proximally.** Once this was complete, we used a Reliant balloon and ballooned as usual the proximal and distal extensions and gait junctions. Then we performed completion angiography. Completion angiography was satisfactory and; therefore, we removed the wires, catheters and sheaths, repaired the common femoral arteries with 6-0 Prolene suture in a running fashion.

Distal Aortogram

"Procedures Performed: 1) Left groin access under ultrasound guidance. 2) Bilateral lower extremity angiography with distal aortogram. 3) PTA and atherectomy of right CFA and proximal SFA. 5) Intra-arterial nitroglycerin and Mynx device closure for left groin. 6) Selective catheter placement in the right CFA and angiography." I reported this with codes 76937, 75716-59, 37225, 36247-59, 37202, and 75896. I am not sure about distal aortogram. What code should I use for it?

Documentaion for left atrial pacing and recording

When billing for left atrial pacing and recording (93621) what documentation should be present? Is the mere mentioning that the wire is placed in the coronary sinus enough to bill this code, or should there be mention of the findings of the left atrium stimulation be present in the documentation? Thank you, Ana

Documentation

Got a question for you¦ I have a case here where the patient is coming in for angioplasty/stenting of the right common iliac artery (DOS 1-14-2010). The patient had a prior CT angiogram 11-13-2009 which was mentioned in the H&P and I did review the actual report. Essentially the same findings are seen in the prior study as what is seen in the current study; and there is nothing said by the MD that really gives medical necessity for a repeat study. I do believe that this is pretty cut and dry that the repeat study cannot be reported. However, my question is can the selective catheter placement still be reported even though the angiography is not going to be reported? In this case the right femoral was the puncture site. He takes the cath to the abdominal aorta for aortogram, then up and over to the left common femoral artery for left lower extremity angiography. At this point the cath placement is at 36246-LT. Then, he comes back to the right side, does injection for run-off, and performs angioplasty and stenting of the right common iliac artery. (If there had not been any angiography performed (or angiography of the right leg only), there would be no selective catheter placement; as the right side was the puncture site, and the right common iliac was the vessel intervened upon. The catheter placement code would be 36140-RT just for the puncture.) I am confused about whether to report the 36246-LT. Should this still be reported (even though the diagnostic study is not being reported)? I canâ?Tt find a specific resource to back that up. I looked in the Dr Z book and on the Q&A site. What do you think? Any guidance would be greatly appreciated! Pat  

Documentation

Do you have any material published or available that explains how the procedures need to be documented? Is there specific verbage necessary? Are there any CMS guidelines stating specifically what they are looking for in a cath lab procedure report? Thank You

Documentation

Dr. Z, In the description of Procedure portion of a Left Heart Cath an Abdominal Aortogram with runoff is described. But that's it. There is no description of the renals or legs. I've requested an addendum asking for the findings for the Abdominal Aortogram and runoff as well as the reason for it (medical necessity). In his addendum it only included the "uncontrolled hypertension" as the reason. For the purpose of any potential future audits, shouldn't there be 'findings' of the abdominal aortogram and runoff describing the condition of the renals, abdominal aorta, and legs?

Documentation concerning selective

DR Z, This may seem like a simple question but I have a physician that wants to charge a Selective Bilateral Renal Angiogram (36245-50) based on the following Documentation. What do you think? PROCEDURE PERFORMED: Aortic angiogram and bilateral selective renal angiography. INDICATIONS: History of PTA of the renal arteries bilaterally in the past along with resistant hypertension. PROCEDURE: After the patient was prepped and draped in a sterile fashion the left groin was infiltrated with 10 cc of 2% lidocaine. Access into the LSFA was done using 6-French arterial sheath. After images were obtained and hemodynamics were measured, an attempt was made to place a 6-French Angio-Seal. The artery was felt to be too hard and we had a little bit of trouble pushing the Angio-Seal so this was stopped. Manual pressure was applied. The patient tolerated the procedure well and left the cardiac catheterization laboratory without complications. FINDINGS HEMODYNAMICS: AO is 180/80. AORTOGRAM: An aortogram was done in an AP position. Diffuse atherosclerosis was noted. Both renal arteries were seen. LEFT RENAL ARTERY: The left renal artery shows moderate 30-40% proximal stenosis. RIGHT RENAL ARTERY: Right renal artery shows a 20% mild renal artery stenosis. SUMMARY: 1. Mild right renal artery stenosis. 2. Mild to moderate left renal artery stenosis. RECOMMENDATIONS: Medical treatment I only coded this as a non-selective aortogram (36200) and he says there is documentation based on the "Procedure Performed" listing. Please Advise.

Documentation for a LHC

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?

Documentation for Catheterizations

For a left or right heart catheterization, my physician is currently documenting the following: "Access was obtained from the right femoral artery, and a left heart catheterization was done using standard guide wire approach using standard Judkins catheters." For correct coding guidelines, should the physician be more specific in stating where the catheter goes? Such as stating the complete path of the catheter through the femoral, iliac, aorta, and over the arch into the left marginal artery? Would this have anything to do with ICD-10 -PCS coming?

Documentation for Double Contrast UGI

A report for a UGI stated: "A normal swallowing mechanism was noted with free passage of barium through the esophagus and into stomach. There is a small hiatal hernia with trace gastroesophageal reflux. The stomach is distensible throughout. Visualized gas mucosal was unremarkable." Is this enough documentation to support code 74246 for a double contrast UGI? I was told the "visualized gas mucosal" indicates the air contrast.

Documentation for Endarterectomy

My doctor reported thrombectomy from beginning and throughout the report, but I think a couple of words at the very end of the report may have changed the coding from a thrombectomy to an endarterectomy. Does this limited documentation support reporting code 35371? "Incision overlying the femoral vessels... dissected out the common, superficial, and profunda vessels. Controlled vessels... arteriotomy extensively on the CFA and extended to the SFA. Fogarty catheter was placed, retrieving thrombus from the distal SFA out of the arteriotomy… thrombectomized the profunda vessel - flushed all the thrombus and clot out of the proximal CFA and actually endarterectomy of the CFA was also done with some degree of endovascular plaque disease, typical of atherosclerosis as well."

Documentation for Right Heart Catheterization

The cardiologist has reported a right heart catheterization (93451) for this procedure, and I'm not sure if his documentation is adequate. The report reads: "The right femoral vein was accessed using the modifier Seldinger technique. I then attempted to use the Edwards pulmonary catheter, but it would not cross into the pulmonary vein. I then switched to the 7 French Arrow catheter. After manipulating for about 5 minutes, I was able to cross into the pulmonary artery. At this point, this was placed in the pulmonary artery, but it would not wedge. I was able to get pulmonary artery pressures with this and then subsequently able to get PA and RV as well as SVC, IVC, and right atrial pressures." Can I assume he went through the tricuspid valve since he went from the pulmonary vein into the pulmonary artery?

Documentation guidelines on performing biopsies

Where can I find documentation guidelines on performing biopsies? For example, does the body and/or impression need to state whether a core biopsy or and FNA was performed? Can the decision to code either a core or FNA be determined from the size of needle used? If you can reply asap, I would very much appreciate it!! Thank you for the assistance!!  

Documentation IVUS

Good Morning Dr Z! My question has to do with documentation of IVUS. If the physician states that he passed the IVUS catheter thru the right common femoral vein, external iliac vein, and inferior vena cava and took images,but only reports what was found in the common femoral and external iliac, should I report 37250, 37251, 75945,75946 or 37250,37251 x2, 75945, 75946 x2?

Documentation of aorta for use of 75630

Please do NOT include any actual patient medical records with your question. Hello Dr. Z, I have a physician who dictates abdominal aortogram performed, along with unilateral or bilateral peripheral angiogram. However, findings start with the iliac arteries and proceed down the leg. Does a description of iliacs support 75625, or do I need to have a description of the abdominal aorta or renal arteries to support 75625? I have been coding 75710 or 75716 unless there are findings describing the abdominal aorta or renals, at which time I code 75625 along with 75710 or 75716. Thanks!

Documentation of Cerebral Angiography

We have a question concerning documentation. Is it enough to charge for fluoroscopy during a VAD insertion when the fluoroscopy is only documented in the list of procedures and not mentioned in the body of the operative report? Also, is the following sufficient to charge? Again, the actual selective vessels are listed at the top of the report, with the “select the above mentioned vessels” in the body of the report. The findings are documented. We do believe this documentation is sufficient, but I want to ensure it would hold up on an audit. "Vessels catheterized: 1) Right common carotid artery. 2) Right vertebral artery. Technique: Cerebral angiogram performed. Next, using a micro-stick singlewall puncture, the right common femoral artery was accessed and a 5 French sheath placed with a modified Seldinger technique. A 5 French DAV catheter and 035 Glidewire were navigated under fluoroscopic guidance to select the above-mentioned vessels. Multiple angiographic images were obtained. At the end of the procedure, all catheters and wires were removed."

Documentation of induction of arrhythmia and mapping

Hello Dr. Z- We're having difficulty coding EPS Studies and Ablations. Specifically we're having trouble determining if an induction of arrhythmia was performed and if the mapping that was done was 3D or not. We're being told that these things are being done but we don't see them in the documentation. If you would look at the following procedure note & tell us how it should be coded we would be very grateful! Procedure: The patient was brought to the lab in the fasting state, catheters advanced to the high right atrium and into the HIS bundle region and the RV apex. A catheter was left in the HIS region. There was a CS catheter advanced to the coronary sinus, his revealed proximal to distal atrial flutter. A mapping catheter was placed into the right atrium. He had a patent foramen ovale and the left atrium was mapped as well briefly. Catheter was pulled back quickly to the right atrium. The right atrium was mapped as well. He had a head meets tall counter-clockwise flutter which was typical flutter, energy applications along the cavotricuspid isthmus terminated flutter back to sinus rhythm. He had unidirectional block post procedure. He was in sinus bradycardia at the end of the case. He tolerated it well. There were no adverse complications.

Documentation of mapping

Is it always necessary to do mapping prior to the SVT ablation? I was told that even if the mapping isn't stated in the dictation, it is always required so I should code it. I disagree with this. Below is a dictation that I don't see "mapping" but was asked to add the 93609. The codes I used are 93620, 93621, 93462, 93651. PROCEDURE: This patient with a history of recurrent, symptomatic PSVT was brought in for an electrophysiologic study and/or ablation. The patient presented to the EP laboratory in sinus rhythm. Catheters were placed in the right atrium, His-position, coronary sinus, and right ventricle for pacing and recording. Baseline measurements were recorded. During PSVT, the fastest tachycardia cycle length was 380ms with eccentric atrial activation (CS 3-4 was earliest when CS catheter was in the coronary sinus). Transeptal puncture utilizing fluoroscopy was used to access the left atrium. The catheter was then placed at the position of CS 3-4, where there was noted to be a fusion of the ventricular and atrial potentials. Upon ablation, within 4 seconds, the patient's tachycardia broke, and the patient returned to sinus rhythm. Many ablation points were done at and around this area. Afterwards, when ventricular pacing was performed, whereas previously there was eccentric atrial activation, after ablation, there was concentric atrial activation. Also, after ablation, when performing AV Nodal ERP, there were no evidence of accessory pathway echos, whereas prior to the ablation, we saw many accessory pathway echos. We were not able to induce tachycardia after the ablation was complete. Ablation was performed in the left atrium, at the 5 o'clock, 5:30 o'clock position on the mitral annulus (in LAO view). After ablation was complete, post-procedure measurements were obtained. Attempts to induce the arrhythmia were performed with programmed stimulation or rapid pacing. Procedure went well without any complications. Thanks. Your assistance would be greatly appreciated.

Documentation Required for CVC Cath Placement to code CPT 36556

When a CVC is placed, is it necessary for the physician to document where the catheter tip terminates (i.e., sublcavian, brachiocephalic, etc.)? Our physicians document location: right femoral, ultrasound guidance used, successful placement, but not where the tip is. Our coding staff state that if the site the cath tip is terminated is not documented they must code to CPT 36000. Any guidance would be appreciated.

Doppler of Aorta

What comprises a complete aorta-only Doppler (93978), and what comprises a limited aorta-only Doppler study (93979)? My understanding is that code 93978 is for complete study of the aorta, IVC, iliac vasculature, or bypass grafts, while code 93979 is unilateral OR limited study of the aorta, IVC, iliac vasculature, or bypass grafts. 

Doppler prior to tunneled central venous catheter placement

Dr Z WHAT CODE CAN I USE WHEN MY DOCTOR DOES A NECK/JUGALUR VEIN DOPPLER EVALUATION. BEFORE PLACEMENT OF TUNNNELED 5 FRENCH DUAL LUMEN CENTRAL VENOUS CATH.

Dottering of iliac artery angioplasty stent placement aorta

On the following procedure we are questioning if we can code the stent and the angioplasty and also would you code abdominal aortogram and iliac? In your opinion did he do an angioplasty of the iliac? Another question?? Is this an Inpatient only procedure since he did cut down? DESCRIPTION OF PROCEDURE: With patient lying in a supine position on the operating table, a #16 Coude catheter was used to place in the urinary ostomy. Prior to the procedure by myself, I modified this catheter to cut the tip of it off very short since palpating the urinary bladder, it was only about 3 cm in depth. I placed a 5 mm balloon catheter in the stoma, by holding pressure on it and then cutting the end of this in 3 different places,I was able to get urine and irrigant with saline through this area from the stoma. This was then excluded from the field with an loban drape, and then the abdomen was sterilely prepped and draped. Another loban was placed over the entirety of the abdominal prepped area, after towels were placed and then a full draping. The operation was begun with a transverse incision right over the inguinal ligament. This basically was the same incision as previously, it is approximately 8 cm in length, and since this was exactly in the groin crease, I dissected upwards after dividing through the subcutaneous tissue and actually divided about 1 inch of the inguinal ligament in order to get control of the distal external iliac artery, which had not been dissected out preVioUsly. This was a small artery about 5 mm in size and so went ahead and dissected it out, and then dissected back on the extensive scar tissue over the common femoral, and in so doing, I was able to get control of about 2.5 cm of the distal external iliac and proximal commoril'emoral. There was 1trip branch that I had to tie off that was about a 2 mm collateral that took off laterally from the external iliac vessel and this was closed over with a figure-of-eight•.5-0 Prolene suture. Then, the patient was heparinized with a total of 7000 units of heparin. Seldinger needle was used to access the vessel and a .f-wire was placed through this and then a short 6-French sheath was placed over that into the vessel. Arteriogram revealed that the wire hung up at the distal stent graft'and th;tihe iliac was of narrow caliber. It appeared to be about a 5-6 mm vessel all way up to the common iliac. At any rate, Iwent ahead then and because the f-wire would not pass up through the stent, I went ahead and got a angled glide catheter (a Berenstein catheter) and then using this was able to advance the j-wire through the midportion of the stent. It went smoothly up into the distal thoracic aorta, and then the Berenstein catheter was rernoved'Ieavinq the J-wlre in place and then a 4-French angioplasty ealloon catheter was inflated and passed through this and then passed up with it being already inflated up the wire and it went smoothly through the stenotic lesion of the aorta and therefore I felt that the wire was through the midportion of the graft and had not gone underneath 1 of the stents. Then, the balloon catheter was advanced to the distal thoracic aorta and through this, I passed a Lunderquist wire to obtain stiff wire access through the lesion and then once that was accomplished, the Berenstein catheter was removed and then a 16-French long sheath was exchanged for the 6-French sheath, which was in the groin. This was passed up with some difficulty and went very slowly and with push-pull maneuver, was able to advance it through some areas, which felt like a stenosis but ifl fact this performed probably a Dotter dilatation of the iliac and once it was in place, it was advanced up to the distal to the level above the renal arteries. Then, a 40 diameter Palmaz stent approximately 3 cm in-lenqth was placed on a Coda balloon and then advanced through the long sheath and I neglected to say that an aortogram ha'd been accomplished through the sheath. A glow tape had been placed on the abdomen and I precisely identified the stenosis, which was right in the mid portion of the previously placed stent graft. I then pulled back on the long sheath, exposing the Palmaz stent, which was loaded on the Coda balloon and then deployed it by inflating the Coda balloon. Unfortunately, the Coda balloon was.not strong enough which with a low pressure balloon to dilate the lesion. The Coda balloon was removed leaving the stent in good position, and then a 14 mm diameter and 4 cm in length angioplasty balloon was exchanged for the Coda and placed in so that it extended on either side of the Palmaz stent and insufflated. There was an obvious waist on this where the in-stent stenosis had been, but it dilated nicely and dilated the Palmaz stent very successfully. This is a nice 14 mm lumen and a confirmatory arteriogram by hand injection through the long sheath, confirmed that the lesion was nicely dilated. Then, I removed the long sheath, slowly and pulled it back into the iliac and performed 3 hand injections as I pulled this back to confirm that there was no leak from the iliac artery, since I had felt that this had dilated the iliac considerably when it went in. Once it was back to the external iliac, and no leak from the iliac vessel was seen on the 3 arteriograms that I did and there was good flow all the way down and up across the bifurcation. The stent was then removed. Tapes were pulled up on the distal external iliac and common femoral vessel and then I closed the common femoral vessel with interrupted stitches of 5-0 Prolene and 6-0 Prolene suture. I used an interrupted closure so as to not create any stenosis of the femoral at that level. Once that was accomplished, a Doppler signal and palpable pulse was much stronger since the initial pulse was barely palpable in the groin and it was not palpable through the skin, but was barely palpable when the artery was exposed. It was much stronger and when hemostasis was felt to be secure, I closed the groin incision with 2 layers of running 2-0 Vicryl suture and skin clips were applied to the skin. An occlusive dressing with Betadine ointment and 4x4s were placed over the incision and then lastly the Foley catheters removed from the urinary stoma and an occlusive urinary stoma dressing was applied with Stomahesive and a small flange was placed over this and then attached to urinary drainage bag. The patient had a triphasic dopplerable signals in the foot at termination of procedure, and both right and left foot indicating much a very good result. The patient tolerated the procedure well and was extubated in the operating room, transferred to the recovery room in good condition.

Downgrade of ICD Generator to Pacemaker Generator

What would be the correct coding when changing out ICD generator, capping atrial lead, capping the charging part of RV lead thus leaving the pacing part of RV lead and inserting single pacer generator?

Doxorubicin Beads

I have a question about how to report the Doxorubicin beads 100-300 micron in size used for chemoembolization of a liver tumor? In the ZHealth online Q&A 2215 a similiar scenario is listed. You state the hospital should also report the J code for the drug. I have researched this and am only coming up with codes J9000 and J9001. My understanding is that these codes are to be used when the drug is administered via IV. What J code do you recommend to use for chemoembolization with Doxorubicin beads? Thank you.

Drainage Catheter Advancement

In a facility setting, how would the following procedure be coded? "The patient presents with a 10 French Malecot type catheter in a pelvic collection previously shown to be associated with a colocutaneous fistula. Catheter has been connected to a bag with minimal drainage. Aspiration of the catheter yields only 1 cc of serous fluid. The catheter was NOT injected with contrast material or saline. The suture material retaining the catheter is removed. The catheter is advanced out about 2 cm and resutured to the skin under local anesthesia. Total fluoroscopy time 0.6 minutes."

Drainage Catheter and Sclerotherapy

My IR physician are performing a new sclerotherapy procedure. A drainage catheter is placed into the lymphatic cavity (ie, axillary or thigh lymphocele) under ultrasound guidance, sclerosant agent is infused, and drainage is secured. Patient returns in a few days or week later. Next visit the contrast is injected in the drainage catheter for evaluation. Lymphocele has become infected in setting of obstructed catheter. Drainage catheter exchanged for new. Sclerosant therapy was infused into the collection and drained. How would this case scenario be coded?

Drainage Catheters

Our doctors were delighted to clear up the catheter drainage issue based on your respected publication regarding leave in or take out after drainage. The AMA/CPC and research I have done all agree with your original definition. The doctors said the extra work of catheter for drainage is the same whether it is left in or removed. And with the only publication I found that stated the catheter had to be left in when researched, upon further communication, the author stated it was her interpretation since 2005 that it should be left in and that it was not a direct quote from the AMA/CPC. So my question is, I am curious why the errata regarding catheter must stay in after procedure?

Drainage of Bakers Cysts

Under ultrasound guidance, a 18-gauge needle was advanced into the cystic collection (Baker's Cyst). 6 mL of highly viscous straw-colored fluid was aspirated. There was marked collapse of the cavity. We then proceeded to inject 3 mL of a 1:1:1 solution of 1% Lidocaine, Depo-Medrol, and Kenalog. Please help. I thought 20612, 76942. Thanks

Drainage of chest wall collection

History: Patient with left chest wall collection here for drainage Procedure: Left chest wall fluid collection drainage with 10-French tube Informed consent was obtained. Risks and possible complications were described in detail. The patient's left chest wall fluid collection was identified and drained with a 5-French needle. We then advanced over wire and placed a 10-French tube. 30 cc of purulent material were removed and sent for testing. Repeat ultrasound confirmed residual fluid and septations. The drain was secured to the skin and we placed some TPA with one hour dwell time in the holding room. The patient will receive one week of antibiotics and will follow with Dr. Gates in pulmonary clinic. Please note the patient was sedated for 30 minutes using 4 mg of Versed and 200 mcg of fentanyl. Impression: Successful left chest wall abscess drainage.

Drainage of previously placed pleural catheter

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!

Drainage Pseudoanerysm During AV Graft Stenting

Would you code separately for drainage of the pseudoaneurysm during the following AV graft stenting case? Would you use code 10030? "Through the existing sheath an 8 mm x 10 cm Viabahn covered stent was subsequently deployed with post-deployment venogram revealing excellent exclusion of aforementioned pseudoaneurysm. Under fluoroscopic guidance a percutaneous angiocatheter was introduced into the pseudoaneurysm sac at a separate site in the pseudoaneurysm and was drained after exclusion. Antegrade access was then acquired, being careful to avoid the recently placed stent. A 9 French sheath was introduced over wire and a 9 mm x 5 cm via bond stent was deployed at the cephalic origin into the innominate. Post deployment venography reveals exclusion of the primary collaterals and no significant intrusion centrally. Balloon angioplasty was subsequently performed with an 8 mm balloon within and adjacent to the more central stent."

Drains

Can you tell me which drain code should be used for an inguinal fluid collection? Would this be code 10160, 49021, or 49061?

Dual Chamber AICD Replacement with Insertion of a Subcutaneous Coil

I have a case where the patient had a dual chamber AICD generator replaced for end-of-life. They then inserted a subcutaneous coil. I coded this with 33263, C1721, C1896, and 0320T. We are getting an edit saying C1896 needs one of the following codes: 33216, 33217, 33249, or 0319T. We are not sure what to do with this. Do you have any advice on how to code this? Thank you for your help.

Dual Chamber ICD Generator Replacement with Lead Insertion

We are debating over two sets of codes for this situation. The patient presented for a generator replacement of a dual chamber ICD. They discovered the old RV lead was defective, so they capped the old RV lead, inserted a new RV lead and a new dual chamber ICD, and lead and device testing were performed. The department reported code 33241 for removal of pacing ICD generator only, 33249 for insertion/replacement of ICD system with single or dual leads, and 93641 for DFT testing at time of implant. The coding department chose code 33263 for removal and replacement of ICD generator and dual lead system, 33216 for insertion of a single transvenous electrode, and 93641 for DFT testing at time of implant. Which set is correct and why?

Dual Isotope Nuclear Stress Test - 78452 Problem

My doctor is doing dual isotope adenosine nuclear stress test. Isotopes are Myoview (A9502) and Thalium (A9505). For patients who are not able to walk on a treadmill we are using adenosine injecting along with normal saline (J7050) for creating the stress. Here I have two questions: 1) We are using code A9502 (Myoview) 30 mci, for which we are coding two units, and we are using code A9505 (Thalium) 3.6 mci, for which we are coding four units. Are we correct in billing these two and four units for these isotopes as per dosage? 2) We are giving adenosine IV in mixture with normal saline. Does the dosage of this normal saline have to be 250 cc? Because the HCPCS code for normal saline (J7050) is showing for 250 cc... so could someone help me with this? Is it mandatory to use 250 cc normal saline solution in order to inject adenosine?

Dual to Biventricular, Unsuccessful Placement of the LV Lead

The patient presented with a dual chamber defibrillator and a planned upgrade to a biventricular ICD. The right ventricular lead was replaced, with the existing right ventricular lead removed. The atrial lead was existing and attached to the new generator. The left ventricular lead was inserted, but was unable to be advanced through the CS OS and was eventually removed and the LV port capped. Would this be reported with code 33249?  Or with codes 33263, 33216, and 33244?

Dual to Single Pacemaker Generator Change

What is the correct way to report a pacemaker generator change when the physician removes a dual chamber generator, caps off and abandons the right atrial lead, and then places a single chamber generator. If we code a dual generator change, we get an edit with the single generator supply. If we try to code a generator removal and placement (33233 and 33212) this pairing is not allowed. What is the most appropriate way to report this procedure?

Duplex Scan of arterial Inflow and Venous Outflow Breast Lesion

We are using Doppler in suspicious breast lesions to assess the presence or absence of blood flow suggesting cancer versus a cyst. Are we able to charge for this separately, or would this be considered part of the breast ultrasound? If so, which code would be appropriate? Same situation regarding liver scan looking for tumor where direction of portal venous flow is documented?

Duplex scan of upper and lower extremities

Dr Z, When we provide a duplex scan of extremity veins(CPT 93970), how should we be charging for the following exams? Case #1 Bilateral upper and lower extremity Case #2 Unilateral upper and lower extremity Thanks for any help you can give me.

Duplicated IVC with filters

hello, I have a case where a patient has a duplicate vena vaca arising from the renal vein. I am thinking of coding everything twice my only concern is if i should code the duplicated vena-cava as 36010 or 36011 since it came from a selective renal vein. codes 36010,37620x2 75940 x2 75827 (as he found the duplicate vena cava via this study)for the additional vena cava i am not to sure. Here is the example: please advise as i am at a lost..thank you for your help The patient's right neck was prepped and draped using sterile technique. 1% lidocaine solution was used for local anesthesia. Under real-time ultrasound guidance, the right internal jugular vein was punctured using a 21-gauge needle and a 0.018 wire was passed into the inferior vena cava. The needle was then exchanged for a 5 French micropuncture catheter. Through the micropuncture catheter, a 0.035 stiff shaft Glidewire was advanced into the inferior vena cava and eventually into the left common iliac vein. The micropuncture catheter was exchanged for a 5 French pigtail catheter which was placed into the left common iliac vein. Then, inferior vena cavogram was performed. The inferior vena cavogram demonstrates a patent inferior vena cava. There is, however, a duplicated inferior vena cava present extending from the left common iliac vein to the left renal vein. There is intraluminal thrombus seen within the left common iliac vein extending slightly into the inferior vena cava as well as extensive amount of thrombus within the duplicated inferior vena cava. Then, over a stiff shaft Glidewire the pigtail catheter was exchanged for a 9 French vascular introducer. The vascular introducer was placed within the intrarenal inferior vena cava and a Gunther-Tulip filter was advanced and deployed within the infrarenal inferior vena cava above the thrombus within the inferior vena cava. Then selective catheterization of the left renal vein was performed using a Cobra 2 catheter and the vascular introducer was advanced over the Cobra 2 catheter into the left renal vein and eventually into the duplicated inferior vena cava. A venogram was then performed which again demonstrates thrombus within the duplicated inferior vena cava and a patent left renal vein with no evidence of intraluminal thrombus. There appeared to be a small amount of space within the superior aspect of the duplicated inferior vena cava where a filter could be placed without protruding into the left renal vein. Through the vascular introducer, a second Gunther-Tulip filter was advanced and deployed within the duplicated inferior vena cava above the thrombus within the duplicated inferior vena cava. The filter did not protrude into the left renal vein. The vascular introducer was then removed. Complete and immediate hemostasis was achieved

Duplicated Nephrostomies

One of our physicians performed the following procedures: 1) IV conscious sedation, 2) Left lower percutaneous antegrade pyelogram, 3) Left lower percutaneous nephrostomy catheter placement, 4) Left upper percutaneous antegrade pyelogram, and 5) Left upper percutaneous nephrostomy catheter placement. I've never seen two nephrostomy tubes on the same side. How would you recommend coding this? Can they both be coded?

Duration Requirements 37211

What is the correct duration of an infusion in order to bill code 37211? Must it be more than 15, 30, or 60 minutes?

DynaCT coding

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

Dynamic CT Myelogram of the Cervical and Thoracic Spine

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

E&M

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

E&M

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

E&M codes and diagnostic angiography

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

Echo and fluoroscopic guidance 77002 and 76930

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

Echo Dictation 93306

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

Echo requirements

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

Echocardiography

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

ECMO

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

ECMO

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

ECMO

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

ECMO Device

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

Edits with new cardiac catheterization codes

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

Ekg abnormal findings

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

EKG and cardiac catheterization

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

EKG with cardiac catheterization

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

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