Knowledge Base

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Set Descending Direction

76937

Can you use code 76937 with arterial access? This is why I am asking... CPT Assistant, December 2004, page 13, states: "This imaging includes preaccess assessment of venous patency and actual real-time visualization of needle passage to the venous lumen. The descriptor for code 76937 includes all phases of actual guidance, documentation, and reporting required to perform this procedure. Use of code 76937 requires a permanent recorded image(s) of the vascular access site to be included in the patient record, as well as a documented description of the process either separately or within the procedure report. Therefore, for those instances when ultrasound is utilized only to identify a vein, mark a skin entry point, and proceed with nonguided puncture, it would not be appropriate to report code 76937 for ultrasound guidance."

Aspiration of Ascitic Fluid through Peritoneal Port

Can code 49083 be reported for aspiration of ascitic fluid when performed with fluoroscopy and the peritoneal port is what was accessed for the aspiration?

Cutdown to Remove Balloon

One of our physicians had a complication during a venous intervention, and I'm just wondering if it can be billed and, if so, what the correct codes would be. "The patient had stents placed in the bilateral common femoral veins, external iliac, common iliac vein, and a double-barrel stenting of the IVC. The complication occurred during the ballooning of the last stent in the left common femoral vein. The balloon ruptured and would not deflate fully; it appeared to get stuck on the stent and pull it in a more caudal position. After multiple attempts to remove the balloon it was decided he would have to do a cutdown. The physician opened the femoral vein, removed the balloon and stent, explored the vessel, and closed." He is billing 35860 and 37197, and I'm pretty sure they are not correct. Can this complication be additionally coded, or is this included in the primary codes? If it can be coded, what would the correct codes be?

Intraoperative Angiogram

Cerebral carotid angiogram was done and determined that aneurysm clipping would be done by craniectomy (not done same day). An intraop angiogram was done (36224) after surgery and within the report it states, "See separate dictated operative notes for details." Would this be billable? I am thinking not (done more for a check of the aneurysm), but I was thinking if angiogram is not billable would I be able to bill for the catheterization (36217)?

G0278 Denials

I have always billed G0278 to Medicare patients for non-selective injection of the iliofemoral system. Recently, I have seen a lot of denials for medical necessity, insufficient documentation, CAD, SOB, etc.... none of these are deemed medically necessary. Should I not bill code G0278, or should I appeal with notes? I have not had a problem with denials before, but now that there are more my billing system has created an edit to stop these from being billed and I'm not sure what is the proper way to proceed.

Kyphoplasy vs. Vertebroplasy

Does this report support a kyphoplasty? Does the statement that the curved needle was rotated 360 degrees support a cavity being created? "The needle insertion site and periosteum of the left L5 pedicle were anesthetized by lidocaine injection. The left side of the L5 vertebral body was accessed with an 11 gauge needle via a transpedicular approach. A curved needle was introduced and directed under fluoroscopic guidance to the midline of the L5 vertebral body. The curved needle tip was clearly within the large cystic cleft seen on recent lumbar spine MRI. The needle tip was rotated 360 degrees under continuous fluoroscopic guidance in order to confirm placement within the cleft. Under continuous fluoroscopic guidance, cement was instilled through the curved needle. There was excellent filling within the anterior and middle aspects of the vertebral body as well as the superior and inferior halves of the vertebral body. There was also good filling into both the right and left sides of the vertebral body. There was no posterior cement leakage evident."

Double J Stent Removals

Patient has bilateral nephrostomy catheters with separate double J stents. We were asked to remove the stents and replace the existing nephrostomy catheters. Code 50387 is for an exchange of nephroureteral stent, which we do not have. Your guidance is appreciated.

Mulltiple Endarterectomies

"Arteriotomy was made coursing from the takeoff of the SFA up onto the CFA and was continued as a branch onto the PFA. Large plug of plaque was removed, and endarterectomy was carried out of the PFA as well as the CFA. There was a large amount of plaque at the external iliac artery, and remote atherectomy was carried out proximally. The SFA and PFA takeoffs were then anastomosed separately thereby creating a joint posterior wall. We attempted access of the SFA for arteriogram, but it was totally occluded. A remote atherectomy was then carried out with an 8 ring stripper to the popliteal. Arteriogram shows residual plaque, and cutter was reintroduced and additional plaque removed. Another arteriogram reveals residual stenosis in the popliteal and stent was placed." I am getting different opinions on what codes to use. Should we use 35351, 35302, 35372, and 37226? Or just 35302, 35355, and 37226? Would you please give us your expert opinion?

CardioMems

We are wondering what documentation is sufficient enough to bill for outpatient interrogations for CardioMems. Can the nurse make a note that the MD reviewed the downloads and bill for that? Also, what CPT codes are used? Can they program the device?

Spectranetics Laser for PPM/ICD Lead Removal

I have a physician who wants to start using the Spectranetics laser for removal of PPM/ICD leads. I have checked the CPT Codebook along with your web site and have not found any information about how you would go about coding for this procedure. Would the only codes you could use be 33234, 33235, or 33244?

Ultrasound Chest and Thoracentesis

If a patient has an order for a thoracentesis, in the hospital setting, can the radiologist request that ultrasound be used to assess for pleural fluid, dictate a diagnostic chest (76604), and then proceed to perform an ultrasound-guided thoracentesis (32555) and dictate this separately? Does it matter if there has been any previous imaging that the ordering physician is using as a basis for ordering the thoracentesis?

PICC Line with Dual Chamber Pacemaker

Patient was getting a dual chamber pacemaker inserted, but a vein was collapsed, so a PICC line had to be inserted as well. Can I bill for the PICC line with the pacemaker (33208, 36569)?

Thrombin Injection for Ruptured Vein

"Balloon angioplasty of an AV fistula resulted in the rupture of the vein at the second of the two strictures. Attempts at sealing the rupture were unsuccessful. Therefore, thrombin was injected directly into the hematoma under direct ultrasound guidance, resulting in closure of the rupture." How would this be coded? Or is this included in the procedure?

Endoleak Repair with a Stent after AAA Repair

Not sure what 30000 series and S&I codes to code here. "The right common femoral artery was accessed percutaneously. A catheter was advanced into the aorta, and abdominal aortogram confirmed a type 2 endoleak. The hypogastric was selectively engaged, and selective angiogram of the hypogastric artery was performed. An attempt was made to engage the descending branch from the hypogastric, but because of the sharp takeoff just a few millimeters from the origin of the hypogastric artery, this was not successful. Therefore, prior to proceeding any further, using the Omni Flush catheter, the superior mesenteric artery was engaged, and a contrast injection into the SMA was performed with delayed views to see if there was a communication between actually the mesenteric vessels and the lumbar artery, and obviously not appeared to be the case. After the hypogastric artery again was engaged, the area of the takeoff of the feeding branch for the lumbar was treated by placing a 6 mm Viabahn x 2.5 mm covered stent with complete obliteration of the origin of the feeding vessel."

Venous Embolizations

What do you code when an arteriovenous fistula is treated on the venous side only? My IR surgeon believes that code 37242 is appropriate, as the condition treated (AV fistula) is critical in code selection, not the portion of the cardiovascular system treated (venous vs. arterial). I have an additional question as a result. A number of sources (CPT, CMS, etc.) state that non-selective catheterization and non-diagnostic angiography are inclusive to code 37242, yet there are no NCCI edits for diagnostic extremity venography (36005, 75820) for code 37242 (arterial malformation). Would codes 37242, 36005, and 75820 be correct in this scenario?

Use of 52 vs. 74 Modifier, Graft Angiography

Coding advice from another vendor is to append modifier -52 to 93455 when only selecting and injecting coronary bypass grafts instead of modifier -74. See their rationale below: "The appropriate modifier for hospital use would depend on the circumstances. If the planned procedure was to do bypass grafts only, modifier -52 is appropriate even for the hospital. If the planned procedure was a coronary angiogram to include both native arteries and grafts, but for some reason only the grafts were imaged, then modifier -74 would be the appropriate modifier for the hospital. The rationale for the above is that -74 is a “discontinued” service, and the description says 'due to extenuating circumstances or those that threaten the well being of the patient', while modifier -52 is for services that are 'partially reduced or eliminated at the discretion of the physician or other qualified health care professional'.” We are now uncertain of the correct modifier to use in this coding scenario, as we have been advised by your company to use -74 if anesthesia was used. Please advise.

CT Change of Drain Catheter

Would it be appropriate to use code 75984 when using CT guidance? I was under the impression it is understood to be via fluoroscopy guidance. I'm seeking your validation for the appropriate use of this code, fluoroscopy or CT. Thank you.

Eversion Endarterectomy

The physician performed endarterectomy of common femoral artery (35371), and an eversion endarterectomy of external iliac was also performed proximally. What code should I use for eversion endarterectomy of the external iliac?

Tunneled Peritoneal Catheter

What is the correct code for insertion of Pleurex catheter for drainage of ascites under ultrasound when the catheter is left in place and secured? Can code 49083 be used if the catheter is left in place?

Thoracic Outlet

Patient underwent rib resection with scalenectomy (21705) as well as excision of the pectoralis minor. Is there a code for the additional work involved in excising the pectoralis minor, or should this be billed with a -22 modifier?

Incompleted Staged Stent Procedure

Patient came in and had left heart catheterization and drug-eluting stent to RCA. Noted severe lesions in LAD, but due to stress test results felt RCA should be stented first, as it was a more critical blockage. Two weeks later for elective stent LAD, and after angiogram and FFR the physician noted lesions to be less than originally noted and chose medical therapy. Should we code 93455 with FFR? Or abort drug-eluting stent?

Coronary Stent with Angioplasty through Stent Struts

If a provider deploys a stent in the left main, which extends into the left circumflex (92928-LC), and then "inserts a balloon through the stent and performs an angioplasty of the LAD through the stent", would the angioplasty be separately reportable? My concern is the documentation mentions in the conclusion that he is "dilating the struts of the stent" into the ostia of the LAD with no residual stenosis in the left circumflex or the LAD. There is "no significant stenosis" in the LAD per the diagnostic cath and "minimal plaquing", so I'm not sure this is a medically necessary angioplasty or just facilitating the final stent placement and more of a "bridging lesion" scenario. Any help you can provide is appreciated!

Closure Device Angiography vs. True Diagnostic Leg Angiography for Medical Necessity

"Retrograde access was achieved in the left common femoral artery with a micropuncture set, and a 6 French sheath was placed. Arteriography of the left femoral bifurcation was performed using carbon dioxide and contrast. A 5 French Omniflush catheter was positioned in the distal abdominal aorta and bilateral iliac arteriography performed using carbon dioxide. Catheter was positioned across the aortic bifurcation into the distal right external iliac artery and right lower extremity arteriography performed using carbon dioxide and contrast." While arteriography of left femoral bifurcation only is being performed, and a complete run-off on the right side, should it be considered unilateral or bilateral angiography of lower extremity?

Repair of Ruptured Retrovisceral Aorta

I am confused about how to code for the 4-vessel debranching of the visceral aorta through a midline laparotomy. "The patient was opened, and four of the visceral vessels were debranched, and a Coselli graft was sewn in to revascularize the renal, mesenteric, splenic, and superior mesenteric. A wire was placed through the Coselli graft, and a Gore tube graft was deployed to cover the descending thoracic aorta and visceral abdominal aorta. This is the end of the procedure." Would I go with unlisted?

Arterial Line and Monitoring 36620

Can we report code 36620 for placement of an arterial line during a diagnostic/interventional cath procedure if placed in a different access than what was used to perform the primary procedure? "A 7 French sheath was placed in the right femoral vein, and a 4 French sheath was placed in the right femoral artery for pressure monitoring purposes. A complete right heart catheterization was performed using a 7 French balloon wedge catheter, and RV and pulmonary artery angiograms were performed using the 7 French cardio marker catheter."

37184 vs. 37186

We have started doing complex lower extremity interventions in our lab. A question has been raised about the proper use of codes 37184, 37185, and 37186. Would you still use code 37186 (secondary thormbectomy) if, after stent deployment in the SFA, there's a need to perform thrombectomy in the AT, PT, and peroneal vessels using a mechanical thrombectomy device? This doesn't seem to fit the limited or short segments of thrombus, which is used to describe secondary thrombectomy (37186).

Two Catheters in One Lower Extremity

"The patient has a left femoral to below knee popliteal artery bypass graft and a left abandoned bypass graft. A micropuncture needle was advanced in a midline retrograde fashion and a sheath placed. A pelvic angiogram showed occlusion of the bypass graft, and a 10 cm infusion Cragg-McNamara infusion catheter was placed and positioned across the proximal arterial anastomosis. Then under direct ultrasound guidance a micropuncture needle was advanced into the proximal graft and in antegrade fashion, then sheath was placed followed by lower extremity angiogram. Next a 10 cm infusion length Cragg-McNamara catheter was advanced across the distal anastomosis. 1 mg tPA per hour split between the two infusion catheters with 300 units per hour." Since there are two separate access sites, can I report codes 36140 x 2, 37211 x 2, and 75716? Please advise because I am not sure if I can code both since it's the same leg (although there are two separate access sites and two infusions catheters placed).

Catheterization of MCA M1 and M2 (Embolization or Mechical Thrombectomy)

I see middle cerebral branch M1 and M2 or unnamed feeding branches selected without imaging for an intervention. May we now report code 36228-52? And are M1 and M2 reported with 36228 x 2, or do you consider the entire MCA one vessel?

FFR Done Alone

One of our physicians would like to charge FFR (93571-26) and states “that not all FFR needs PCI and in fact most don't”. The doctor did not do anything else with the patient. "Procedure: Approach into right radial artery, lesion site dCIRC, pre-stenosis 60%, post stenosis 60%. FFR Finding: FFR resting result: 1.08, FFR result:1.09, FFR result: 1.07. PCI Equipment: Verrata pressure wire 180 cm (non-consigment)." Would you report this with an unlisted code? Any information is greatly appreciated!

75898

The physician did a transjugular liver biopsy. After the biopsy was taken he dictated: "Hand-injection digital subtraction venography was performed through the sheath demonstrating no extravasation of contrast material following the biopsy.” Another coder wants to add code 75898 for this injection. Is this an appropriate use of 75898 in this situation?

Bending Views with Myelograms

There seems to be a discrepancy as to whether we can bill for bending views (72114) during the same session as a myelogram. The facility I work for does bending views with all their myelograms. I do not hit any NCCI edits, but one person is telling me it is inclusive.

Thoracoabdominal Aneurysm Repair with Endarterectomies

Without going into too much detail, the vascular surgeon I code for performed a type 4 thoracoabdominal aneurysm repair along with endarterectomy of the renal arteries bilaterally and endarterectomy of the celiac and superior mesenteric arteries. I was wondering if I should report code 33877 with 35341-51, 35341-59, and 35341-59. It's the endarterectomies that have me confused.

Multi Level Kyphoplasty and Ablation

I hope you can clarify something. One of our radiologists performed kyphoplasties on L1, L2, and L3 with RF ablations done at each level for bone mets. Our radiologist feels that the ablation should be charged per level. I feel the CPT code describes the full ablation theray. So if one or more tumors are ablated in a session, regardless of how many spinal levels this involves, you only charge the ablation code 20982 once. Can you please provide some clarity for the correct charging of this?

Bubble Study

Which CPT code or HCPCS code should we use for a bubble study? Is the infusion or injection of saline charged separately?

Occluded Percutaneous Peritoneal Dialysis Catheter

How would you code removal of intraluminal obstruction of peritoneal dialysis catheter (up to and including use of tPA)?

Q0 on ICD Removal

We have a denial from Medicare (WPS), and they are stating that we need to include the -Q0 modifier and clinical trial number on our ICD removal codes (33244 and 33241). I can't find documentation anywhere that this is needed on removals. I was under the impression that it was just applied to initial implants meeting the criteria for primary prevention.

Triple Rule Out Study

Could you please clarify which CPT code(s) would be reported when a triple rule out study is ordered and performed to evaluate for pulmonary embolism, coronary artery disease, and aortic dissection in one scan?

Poor MD Documentation

In reviewing charges for a procedure, I came across a case coded 75625, 75716, 37228. The operative report states selective right leg angio and PTA to anterior tibial. Procedure portion states, "LCFA accessed and wire into aorta with use of Omniflush catheter to access left iliac. Omiflush catheter exchanged for 65 cm sheath. Selective angiogram with multiple views performed. PTA to anterior tibial performed." The physician's report is finalized with an impression, which dictates findings of an abdominal aortagram and findings of only the right side extremity and angioplasty. Due to the difference in charges and report I viewed the x-ray films. These show Omniflush catheter just below renals and abdominal aortagram imaging; next I see bilateral lower extremity imaging from bifurcation to toes. The selective right angio and PTA imaging. I queried physician to verify clarify op report and filming. I suggested including catheter position in their report to assist in proper coding. Physician says will not dictate maneuvers not performed. How can this be coded 75710, 37228?

Disc Aspiration Biopsy

Are disc aspiration biopsies coded with 64999 and 77003? This is what I have seen the last few years. Is this still the current way to code these type of cases? "Examination: IR disc aspiration percutaneous x 2. History: Imaging findings concerning for discitis. Summary: Uncomplicated L1-L2 and L2-L3 disc space biopsies. Multiple 18 gauge core needle specimens were sent from each disc space for cultures. Procedure: The left flank was prepped and draped using maximal sterile barrier technique. Using fluoroscopic guidance, a 17 gauge coaxial introducer needle was inserted into the L2-L3 disc space after appropriate local anesthesia with 1% lidocaine. Multiple 18 gauge core needle specimens were obtained as above. Using fluoroscopic guidance, a 17 gauge coaxial introducer needle was inserted into the L1 to disc space after appropriate local anesthesia with lidocaine. Multiple 18 gauge core needle specimens were obtained as above. The needles were removed. Total fluoroscopy time 4.7 minutes."

CT or US Guided Talimogene Laherparepvec Administration into Liver

We will be doing a new procedure where we will use either cat scan or ultrasound guidance for needle placement. Then we will be injecting Talimogene laherparepvec into the liver tumor. Would code 47399 and either 77012 or 76942 for guidance be correct? I was also thinking about code 20500. This would be for hospital outpatient. Please advise.

MCA Aneurysm Embolization

Patient comes in and physician places one coil in the MCA to treat an aneurysm. After which he documents that the coil is unstable. He removes it and ends the procedure. Can 61624 be reported with a -74 modifier in this case?

Bridging Aortoiliac Disease Treated with Stent

PROCEDURE: R/L CATH, COROS, NO LV; AORTOGRAM. PTA WITH STENT OF THE DISTAL AORTA AND RIGHT ILIAC ARTERY. INDICATION: SOB, RIGHT LEG PAIN, AND PAD. Taken from op report: "Decision to intervene on the total right ostial iliac occlusion and the distal aorta with balloon angioplasty first, after deployed stent. Balloons were used to predilate and inflated/deployed stent at the level of the bifurcation not to preclude or occlude the access to the left illiac ostium. The distal aorta was also predilated with the above balloons, and there were excellent angiographic results." I am enclined to code for PTA/stent to right iliac, 37221 (stent placement, w/wo angioplasty illiac artery, and PTA to aorta). I did not read anywhere on report that he stented the aorta. I'm not sure what to code. I came up with 35472 (percutaneous angioplasty, aortic). Please help.

AMI with Thrombectomy Only

Patient presents with AMI. Culprit lesion treated with aspiration thrombectomy followed by AngioJet thrombectomy (92973). The physician tried to wire lesion past occlusion but could not make it across. Can I charge 92941 for the aspiration thrombectomy if it's the only intervention performed in the list of included components for 92941?

Thromboendarterectomy Documentation and Coding

I have coding questions regarding thomboendarterectomies. Basically my question is, if our physicians do a thromboendarterectomy of the iliofemoral vessel and the incision is in the groin only, no abdominal incision, can you bill 35355? One of my physicians documented the following: "The right groin was opened in an oblique fashion, and the common femoral artery, profunda femoral, and SFA were dissected out. I made a vertical incision and did an extensive endarterectomy from the iliofemoral down to the common femoral. I had to get to the origin of the profunda femoral and down into the SFA removing a very extensive amount of calcific hemodynamically significant plaque... I patched it with a Gore-tex graft and closed." He is billing 35355. What are your thoughts on the correct code for this procedure? My concern is the description of 35355, which states an abdominal incision is made to access the iliacs and a groin incision for the femoral (there is no abdominal incision).

77011

If a technologist provides stereotactic CT guidance in the OR, but no radiologist is present, and then a formal report of the body system follows the surgery with a dictated report signed by a radiologist, do we report CPT code 77011? Or the CT for the body part that was operated on (i.e., 77011 or 70486, if sinuses were surgically repaired)?

IV placed in IR for CT scan with contrast

If a patient comes in for a CT scan and requires an IV access to be placed by IR due to "poor venous access", is the 36000 and 76937 seperately reportable? Typically the 36000 is bundled, but due to the poor access and the fact that they are taken to IR for the procedure, does that warrant the charges? The fact that is performed for the sole purpose of administering the contrast, regardless of the reason they have poor access, does that void charging the 36000/76937 seperately?

Percutaneous Ovary Biopsy

Can a biopsy of an ovary be performed percutaneously? If so, what would be the proper CPT code to use?

Reconstruct CT Images

The physician has ordered an abdomen and pelvis CT and a lumbar CT. Instead of direct scanning the patient twice, the technologist manipulates/reconstructs the abdomen/pelvis images and creates the lumbar imaging, axial, coronal, and sagittal images. What do we charge for the physician reading the lumbar CT images? Currently we are charging 74177 for abdomen/pelvis CT and 72131 for lumbar CT, so the physician has the separate dictation for the CT lumbar. How do we move forward?

MIdline/PICC for IR/OR procedures

Refering back to Question ID 3402, sheath placement for CTs, you state if it were a CVC we could code that, but if midlines and PICCs placed for purposes of administering anesthesia and meds during an IR or OR procedure would they be bundled into the main procedure? Would it matter whether it was done at bedside in the OR or seperately in the IR department prior to going to the OR for the procedure? Documentation lacks in regards to whether the midline/PICC is immediately removed following the procedure. Thank you.

AngioVac for Valvular Vegetation Removal

Can code 36800 be billed with 33460/36010/93314-26? "Ultrasound-guided access with utilized to access both the right internal jugular vein and left CFV. 7 French sheaths were placed. A 26 French DrySeal sheath was placed in the right IJ. A return catheter was placed in the left CFV. The sheath was advanced across the tricuspid valve. The angio catheter was advanced into the ventricle, and the balloon was inflated. The patient was placed on cardiopulmonary bypass. The sheath and catheter were withdrawn into the atrium, and multiple passes across the tricuspid valve with the AngioVac catheter were done. Debridement of the mobile vegetation was done. Cultures sent to pathology. Patient was weaned from cardiopulmonary bypass. Completion TEE was performed."

Bypass Graft and Native Artery Intervention

I know for coding purposes the bypass graft is counted as one vessel; however, what if an intervention was done in the native vessel and the bypass graft? It was a common femoral to peroneal bypass with PTA done in the native peroneal, and also PTA done all the way up through the anastomosis to the common femoral. Would this be coded as 37228 for the native peroneal and 37224 for the bypass graft in the fem-pop zone? 

Revision of Fem-Pop Bypass

The patient underwent fem-pop bypass with a reversed SVG, which thrombosed after 2 days. He was returned to the OR where the surgeon determined that the SVG was too small to salvage, and the cephalic vein was harvested and used as conduit. Operative note: "Attention was turned to the vein graft. It was divided proximally and withdrawn from its anatomic tunnel. The vein was opened near the distal anastomosis. In order to get all the clot out, it was opened down to within a cm of the artery, affording excellent visualization of the interior of the anastomosis and confirming removal of all thrombus distally. A tunneler was used to tunnel the cephalic vein in a subQ position from the groin to the popliteal incision. An end-to-end oblique anastomosis was created to the hood of the previous vein graft distally. Proximally, the old vein graft was opened and an incision made in the hood of that vein graft. An oblique end-to-side anastomosis was created. Flow was established." Code 35500 cannot be used in conjunction with 35876, so how should this procedure be reported?

93355 During ASD Closure

For the following case, is code 93355 appropriate? "Initially, the physician performed TEE. This demonstrated a 9-10 mm secundum ASD with evidence of right heart volume overload. Antero-superior rim 4 mm. IVC rim 15 mm. The right femoral vein and artery were entered. 6 French and 3 French sheaths were placed. Heparin was given. ACT was monitored during the case. Prograde right heart cath was done. Catheter course was consistent with a normal left innominate vein. The atrial septum was crossed, and the left atrium was entered. The left upper pulmonary vein was entered, and a 0.035 Amplatz guidewire was placed. A 25-3 NuMed sizing balloon was advanced over the guidewire, and ASD sizing was done using the stop flow technique. Balloon sizing measurements were 9-10 mm. The balloon catheter was removed, and a 10 French short sheath was placed. A 20 mm Cardioform Gore Septal Occluder was implanted across the ASD. Further TEE showed the device in good position. Push pull maneuver confirmed stable device position. The device was then released. Final TEE images showed good device position with no residual shunt." 

CPT for a CVC into the Jugular Bulb

What would be the appropriate CPT code for a CVC into the jugular bulb? Would it be 36011?

Transhepatic Cholangiogram with Biliary Drainage Tube Insertion

Can you clarify your answer to question 4251? If a diagnostic transhepatic cholangiogram (47500) is performed prior to insertion of either an external biliary drainage tube (47510) or internal/external biliary drainage tube (47511), can 47500 be billed with a modifier in both cases? Or is code 47500 only billable with 47511, not 47510?

Subclavian Angiogram and Stent Placement

A patient was referred for subclavian stenosis. The physician performed a selective angiogram on the subclavian artery, and then the decision was made to angioplasty and stent it. Which CPT code(s) would be used? Would the angiogram be bundled with the stent?

Fibrin Sheath

Can you please help me decide how to code this account? I am not sure if it should be coded with 36595, 75901, and 36581 or with 35476, 75978, 36011, and 36581. "The existing right hemodialysis catheter was prepped and draped in the usual sterile fashion. 1% lidocaine was administered for local anesthesia. Blood could not be aspirated; however, saline was flushed without difficulty. The existing hemodialysis catheter was removed over two 0.035 Glidewires, and a 10 French sheath was placed through the tract. A small venogram was performed, suggesting a fibrin plug. An 8 mm balloon was placed through the sheath over the Glidewire and used to plasty the SVC tract. This was repeated using a 10 mm balloon. The sheath and balloons were moved over the wire, and a new 23 cm right internal jugular tunneled hemodialysis catheter was placed with tip in the right atrium. The catheters were aspirated and flushed unremarkably without complication. The catheter was sutured to the skin using 2-0 silk, and a sterile dressing was applied."

36870 vs. 37187

Can you provide the correct procedure code(s) for the venous thrombectomies in this patient with a right upper arm AV fistula? Some like 36870 only, while others like 36870 and 37187 since they feel the subclavian is substantially away from the fistula. "We then percutaneously accessed the proximal venous outflow just past the anastomosis of the cephalic vein…noted a moderate stenosis just past the anastomosis. We then noted that the cephalic vein was patent for approximately 10 cm and then became completely occluded. There was no reconstitution of this until the superior vena cava, and the fistula was draining through small collaterals into the basilic system. AngioJet catheter was used to perform a mechanical thrombectomy over the cephalic, axillary, and subclavian veins on the right side for a total volume of 323 mL. Completion fistulography showed a patent lumen throughout the fistula with heavily diseased venous outflow for the majority of the cephalic, axillary, and subclavian veins. PTA of SVC was performed…”

36000

Could you please clarify the use of code 36000? We have been reporting it when an IV catheter is placed by the nurse, usually antecubital, for an urgent care patient, but patient is taken to the ED without having had any infusion therapy in the clinic. NS may have been hung, running TKO. All other scenarios discussed seem much more complex; however, I cannot find any documentation that says this use is not appropriate. Thoughts?

Tomosynthesis Dictation

Does the dictation need to be in the body of the report as well as the exam title? Because our doctors use a predictated template, and it isn't dictating it in the body of the report. If so, where is the documentation stating that it needs to be in the body of the report?

Conversion to HeRO

If the vascular surgeon accessed and rewired an existing tunneled catheter, including removing the port with blunt dissection and packing the tract, and then tunneled the HeRO graft and anastomosed it to an existing AV graft, would 36558 still be the appropriate interventional code? Would a modifier be needed?

Ligation of AV Communication

When my vascular physician constructs an AV fistula for dialysis (36820, for example) he will also sometimes do "exploration of right arm arteriovenous fistula at the level of the mid arm with ligation of arteriovenous communications x 2 and exploration of right arm arteriovenous fistula in the upper arm with ligation of arteriovenous communication". Is this something that is coded separately from the 36820, or is it just part of the procedure?

Peritoneal Catheter Repair

What code would be appropriate for the repair of a peritoneal catheter? I liked 36575 until I saw that the description seems to be specific to central venous access devices. This describes what was done: "The catheter was divided above the damaged segment. The piece was removed. A new connector was inserted along with the betacap adapter and betadine cap. The valve was opened, and there was brisk flow of dialysate out of the catheter. The valve was closed."

AAA Trivascular Ovation Stent Graft

Physician places Trivalent Ovation stent graft in the aorta. He occludes the left limb of the graft with an Amplatzer plug. He places the right limb of the stent graft. Would you code this with 34803-52 or 34802? What about 37242 for the Amplatzer plug?

AFX Stent Graft for Aortic Stenosis

Please code the following procedure done for aortic stenosis: "Stent graft repair of the patient's abdominal aorta and common iliac arteries and then address residual disease in the external iliac arteries. We utilized the AFX stent graft system. We then used two 8 x 40 mm Armada balloons to perform kissing balloon angioplasty of the aorto-iliac bifurcation, as well as the right and left common iliac arteries. There was still some concern about a possible stenosis or dissection in the distal right common iliac artery and proximal right external iliac artery. IVUS revealed an area of dissection or residual thrombus in the distal right common iliac artery beyond the right limb of the endograft. There was also an area of dissection seen in the proximal to midportion of the right external iliac artery. We placed a covered stent across the distal right common iliac artery immediately above the takeoff of the right hypogastric artery. To cover the area of dissection in the right external iliac artery, we used an Absolute stent."

KX Modifier

Does anyone know if the hospital is to append the -KX modifier to the CPT code or the HCPCS device code?

Impella Insertion and RVAD via Sternotomy

Patient comes in through the ER with cardiogenic shock, s/p acute MI, taken emergently to OR; after emergent cath, LAD stenting, and IABP. Patient taken for emergent sternotomy for Impella left ventricular assist device, and after Impella placed, emergent insertion of Abiomed right ventricular assist device. Would code 33976 be used in this case? 

Arterial Graft Segment on Dialysis Graft

What would the "arterial graft segment" be considered for a dialysis graft? Is this like the "arterial limb" and considered venous for interventional purposes since it does not state it incorporates the arterial anastomosis? 

93662 with 0281T

We have recently started doing percutaneous left atrial appendage closures (0281T). Last week we had a case where the physician utilized an Acunav ultrasound catheter via groin approach to perform an ICE (93662) vs. a TEE. So the procedures that were charged were 0281T and 93662. Our department received a request for review of the charges in this case. I have researched the P-T-P edits for both, as well as checked in another qualified system to see if there was any issues in charging these together, and I have come up with no issues. What do you recommend to charge for the use of ICE during the 0281T procedure?

MUEs

Our facilities perform very technically challenging cases involving CPTs 37224-37230. We have run into an issue of going over the allotted MUEs for various C-codes such as C1769, C1887, and C1753. Our MAC states that there is no acceptable modifier to attach to these codes and has suggested a redetermination request for each procedure. Have you seen this issue in other facilities? Do you have any recommendations?

FFR at Time of Heart Cath

Are the correct codes for left heart cath with FFR of all three coronary vessels (specifically LAD, LC, RC) 93458, 93571, and 93572 x 2?

Abscess Drainage

Right subphrenic drainage catheter is removed (non-tunneled), and left posterior flank cavity drainage catheter is repositioned. What are the appropriate codes for both procedures?

92928 vs. C9600

Patient had an outpatient elective left cardiac cath procedure (93458) due to abnormal stress test, which led to PCI with a drug-eluting stent in LAD (92928-LD). Can the hospital modify the cardiac cath, as it was considered diagnostic (93458-XU, 92928-LD)? This is a Blue Cross account; if this was a Medicare account (93458-XU,C9600-LD).

Aortic Coarctation

"Catheter from left femoral artery access was advanced to the thoracic aorta where aortogram was obtained. Based on this finding it was decided to proceed with a 14 x40 balloon angioplasty. Repeat aortogram showed no change, so a 39 x10 mm Palmaz stent was placed at the level of the coarctation." How would you code this?

Generator Change with Lead Replacement

If a provider does a generator change and inserts or replaces a lead, do we code that as a new system placement? If so, do I base it off of how many leads total there will be or how many leads I inserted? For example, if a patient has a dual lead pacemaker, and we change the generator and one of the leads, would we bill as a single or dual lead placement?

Testicular Vein Embolization

"Entry from right internal jugular to IVC to left renal vein, then left testicular vein, then advanced into the lower portion of the left testicular vein. Venography was performed. Embolization of left testicular vein using coils and sclerosant mixture. Final venogram performed." I am unsure of adding any coding to the 37241. Your guidance is appreciated.

Limited vs. Diagnostic Studies

Can I charge for a limited venogram? I have found some online chatter about putting a -52 modifier on the venogram code when it is labeled as “limited”. I am a bit confused because one of our primary resources says, “Do not code separately for venography unless a full and complete diagnostic imaging procedure is performed. Guiding shots, positional, confirmatory, etc. injections should not be charged separately as diagnostic angiography when performing transcatheter therapy services.” The aforementioned limited venogram was diagnostic since there were stated findings of stenosis; however, it was not full and complete. Thoughts?

36251 bundled with EVAR 75952

After placement of the main body of an endovascular AAA graft, the physician performs selective renal angiography to verify the positioning of the graft and patency of the renals. Should the catheter placement into the renals (36245) be billable only and not 36251 or 36252, since the renal angiography was not truly diagnostic? 

CR 9078 documentation

Physician documents symptomatic bradycardia due to sick sinus syndrome on no rate slowing meds. The term "non-reversible" is not located in the documentation. Physician has stated that "on no rate slowing meds" is equivalent to "non-reversible". I would feel more comfortable having documentation that is specifically written in the CR. Am I being unreasonable and his documentation is appropriate and compliant enough for the application of KX modifier? Thank you very much!

ECMO

Is modifier -52 supported with code 33956 in the following case? "The previous sterile IV bag temporary chest closure was removed. Fibrillar and packing were removed. There was no compression of the superior vena cava. Right ventricular systolic function by inspection was depressed. Multiple felted 3-0 Prolene sutures were placed in the aorta and the right atrium for cannulation purposes. A 20 French arterial cannula and a 32 French venous cannula were then inserted into the ascending aorta and the right atrium. These were then connected to the ECMO tubing. ECMO flows were initiated at 2 L/kg/min without difficulty. The chest tubes were cleared of clot and placed back in the mediastinum. Hemostasis was achieved. A new IV bag was cut to appropriate shape and then sutured to the skin edges in a running fashion."

FFR/IVUS Hospital

I have read all the Q&As posted for FFR/IVUS that you have listed; however, I have another scenario for you. Patient is transferred from another hospital after having LHC, CORs, and LV. The cardiologist is unsure of the % of stenosis found in the mid LAD. He has the patient transferred for FFR and possible intervention. The cardiologist is not an interventional cardiologist, which is why the patient was transferred. The FFR shows 0.86%, which is stated as physiologically insignificant. Your instruction for stand-alone FFR or IVUS is to report code 93799. Does this also apply to the hospital setting? If yes, would you please explain why this is appropriate for the hospital setting so that I can educate staff and physicians? 

3D Rotational Imaging

Although you have stated that 76377 may only be charged once per encounter I cannot find it clearly stated in the CPT Codebook or any other source. I need to provide something to the facility that supports this statement. MUE is listed as 2 per day. Also when charging, as with all radiology, the images must be stored, but shouldn't there also be a separate report before charging 76377 (not just documented in the body of the physician operative report)?

Redo Exposure of Femoral Arteries

Our vascular surgeon believes that there is a different code for a redo exposure of the femoral arteries for EVAR. He states that the cutdown is much more difficult and requires more work. Is there a different CPT code that should be used, and/or would you recommend using a -22 modifier on code 34812?

37236 vs. 37242

If an AVM or perforation of a vessel is caused during a lower extremity intervention (in this case an SFA), can we code for fixing the AVM with 37242 (a covered stent was used)? Would we be allowed to code 37236 for placing a covered stent to fix a vessel that was perforated? 

Documenting Medical Necessity

Does medical necessity need to be documented in the operative report? For example, AHA states guidelines for screening of peripheral vascular disease include: 65 and older, claudication, lower extremity wound/ulcers, 50 and older who smokes, or with diabetes. So if any of these things are documented in the H&P/Consult/Admission note prior to an angiogram of head and neck, is that sufficient to support a diagnostic iliac angiogram? Or does the medical necessity need to be documented in the operative report?

Lead Testing for Epicardial Leads

Every time a cardiothoracic surgeon performs epicardial pacemaker generator change our EP attending will be in the OR during the entire procedure. He also interrogates/reprograms epicardial leads during procedure. Can we bill for his service as the co-surgeon?

Replacement of Pacemakers End-of-Life

I understand the new requirements for the -KX modifier on new pacemakers. We have recently been denied on replacement pacemakers (33228) for not having the -KX modifier. Are the requirements the same for the replacements?

Helix-FX EndoAnchor System Coding

Our vascular surgeon informed us on this new endovascular treatment (Helix-FX EndoAnchor System), and we were wondering if it is able to be billed, along with the other codes he has always used. He gave us some information on it and it is saying to use unlisted procedure code 37799 and use it comparable to 34825. What is your opinion on this?? In one case, he billed 34825 already for an extension cuff. Is this new system something that is separately billed? 

Fistulogram, Angioplasty, Embolization

I want to make sure this documentation is sufficient for billing the four 36011 codes. "Sedation was done. Access obtained in AVF in proximal aspect of the fistula close to the arterial anastomosis. Contrast was injected, and cephalic arch was angioplastied due to stenosis. Decision was made to approach branches from the other end of fistula. Sheath was removed, and fistula was accessed in proximal arm with the sheath towards arterial anastomosis. The side branches were selected. The selected side branches, 4 in total, were coil embolized using Cook Tornado coils. Result was acceptable and coils were in good position, and coil branches were totally occluded. Fistula was widely patent with no residual stenosis in cephalic arch. Procedure well tolerated." I would code 36147, 35476, 75978-26, 36011 (36148, deleted), 36011-XS x 3, and 37241. As always, I appreciate your input!

SVG Stent and RCA Stent

We have a case where the patient comes in having an MI. The doctor had to stent the totally occluded bypass saphenous vein graft, and from there he went to the native right coronary artery distally (as the proximal portion of the RCA was previously occluded, hence the bypass) and stented a distal lesion. A culprit lesion is not noted in the report, and we are trying to determine if we should code for C9606 and C9600, or if stenting the lesion in the SVG was integral to stenting the RCA and instead only code C9606-RC. Your thoughts?

Bilateral Lower Extremity Venogram

"The left popliteal vein was accessed. An advantage Glidewire was advanced through the catheter and directed into the femoral vein. A venogram demonstrated patency of the left popliteal and superficial femoral veins and left common, external, and common iliac veins. A 5 French straight flush catheter was advanced over the Glidewire into the left common iliac vein. A venogram demonstrated occlusion of the inferior vena cava in the mid abdomen. Prominent intrahepatic collaterals were noted providing drainage into the right atrium via a left hepatic vein. A C1 catheter was then used to select the right common iliac vein. A venogram demonstrating somewhat diminutive, but patent left common iliac, external iliac, and common femoral veins. A 2.8 French program microcatheter was advanced through the C1 catheter into the left superficial femoral vein. A venogram demonstrated tiny venous collaterals throughout the left thigh." Codes used were 88.66 and 88.51 with 36012 (left SFA) and 36011-XSRT (right common iliac vein), and 75822 (bilateral extremity), and 75825 (inferior vena cava).

Follow-Up Angiography After Embolizations

I need some guidance on how many times can I use 75898 for embolization of intracranial (CNS). Is it still as often as necesary to complete procedure? Six coils were placed with multiple angiographic views to ensure occlusion basilar tip aneurysm. Then two coils were placed posterior inferior cerebellar aneurysm with multiple angiographic views to ensure occlusion. Would this be 75898 x 8? For non-CNS/head and neck, SIR recommends coding only one follow-up angiography per embolization surgical site. Clarification on how to bill for CNS and Non-CNS would be helpful.

Aborted ASD closure

I had another attempted VSD closure that was aborted for technical reasons. Much effort went into closing it, but it was unsuccessful. In this situation, are we billing it as VSD closure with a modifier, or as 93531 and add the angios?

Nephrostomy Tube Conversion to Internal Drainage

Would code 50688 be correct for this procedure? "Placement of retrograde right ureterostomy catheter. Distal right ureteral dilatation. Following preparation using maximum sterile barrier technique and infiltration of the soft tissues with local anesthetic, the indwelling right nephrostomy tube was exchanged over a guidewire for an 8 French sheath. The sheath was negotiated into the ureter. A 5 French catheter was negotiated into the distal right ureter. A high-grade right ureteral stenosis was again identified. A guidewire was eventually negotiated through the stenosis into the ileal loop. The stenosis was dilated using a 6 mm balloon. This allowed passage of a guidewire out the ostomy. The guidewire was engaged in both entry sites. A 14 French x 45 cm catheter was advanced in retrograde fashion with the retention loop in the renal pelvis at completion of the procedure. The catheter protruded well enough to the ureterostomy bag. Successful placement of right retrograde ureterostomy catheter to allow "internal drainage" of the right kidney."

Extremity Venography for Venovenous Collateral Evaluation

If my surgeon documents that an initial angiography was performed and catheter positioned in the innominate vein with contrast injection demonstrating a large venovenous collateral arising from the base of the innominate vein, does this support the venography since the angiography was of the innominate vein?

93503, 93458, and 36556 on same day

Physician performed left heart cath via right common femoral (93458). He then placed a Quinton catheter per nephrologists’ request (36556) via the left common femoral and sutured in place. He then placed a Swan-Ganz catheter via the internal jugular and sutured in place (93503). Can I bill these codes together? Of course, we know there is some direction per the CPT Codebook stating we shouldn't bill 93503 with other diagnostic caths. However, when checking NCCI edits it is allowed. Your thoughts?

Vascular Surgery Bundled Component

My physician used bovine pericardial patch for a profundaplasty all the way up to the iliac. He calls this a patch angioplasty. I typically think of a balloon being used for an angioplasty. Would I use the repair codes for "other than vein" for this procedure (i.e., 35286, bovine pericardial patch)? Also, since the entire region from the profunda up to the iliac was repaired, do I report only one CPT code? At the same session he also performed endarterectomy of the same region and then went on to place stents in the iliac. Can I code all three procedures? Patch angioplasty, endarterectomy, and stent? This procedure was performed for severe atherosclerosis and stenosis in one extremity.

Breast Bracketed Seed Localization

"Using mammographic guidance, a bracketed approach using two I-125 seeds was chosen to localize the microcalcifications. Using aseptic technique, a small amount of 1% lidocaine was instilled for local anesthesia. The first18 gauge pre-loaded needle occluded with bone wax was then advanced into the posterior, superolateral aspect of the microcalcifications, and an I -125 seed was deployed. Same aseptic technique. A second site was chosen at the anterior, inferomedial aspect of the microcalcifications. A second pre-loaded needled occluded with bone wax was advanced into an anterior, inferomedial aspect of the microcalcifications, and an I-125 seed was deployed." Do I report this with a single code (19281-RT) because it's a bracketed approach, or do I treat this like I am coding a second lesion and add 19282-RT? Please advise because I feel like I should code this with a single code because it's bracketed. 

Ablation of coumadin ridge/ligament of marshall

Following a PVI ablation for atrial fibrillation, I will occasionally see documentation of a coumadin ridge/ligament of marshall ablation. The report reads, "Post ablation of the pulmonary veins, left atrial appendage as well as the coumadin ridge/Ligament of Marshall region were ablated with slowing and organization of the atrial fibrillation to atrial tachycardia at 180ms cycle length." I know that a roofline ablation is considered inherent to a PVI procedure, but I'm not familiar with the coumadin ridge/ligament of Marshall. Would this be coded as a second atrial fibrillation ablation, 93657?

36147

Because there were no diagnostic findings for this procedure, I am questioning whether or not I should add 36147 to the account. "Informed consent was obtained. Patient was placed in the supine position, and the left arm was prepped and draped. 1% lidocaine was used for local anesthesia. The graft was accessed. A 6 French vascular sheath was inserted over guidewire directed towards the venous anastomosis. A 5 French catheter was advanced over guidewire into left subclavian vein. Heparin was infused into thrombosed graft. Thrombectomy was performed. Injection showed a 2 cm intragraft stenosis along the venous limb cannulation zone near the apex. The stenosis was dilated with an 8 x 4 balloon at 6 ATM for 2 min. The balloon was used to iron the stents in the outflow vein and macerate residual thrombus. Sheath was removed from access site and redirected towards atrial anastomosis. Thrombus was removed from remainder of graft. A completion fistulogram was performed, which showed excellent flow. Central venogram was performed and found no stenosis." How would you code entire procedure?

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