Knowledge Base

Items 1301 to 1400 of 2014 total

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Set Descending Direction

Drainage of Gluteal Seroma with Ablation

Which code (49406 or 10030) should be used for drainage of a gluteal seroma followed by alcohol ablation? And would code 20500 be correct for the ablation? Procedure details (partial): "Following preparation of the right gluteal region and administration of 8 mL, 2% lidocaine local anesthesia, a 12 French pigtail catheter was introduced into the collection using serial CT guidance and Seldinger technique. A total of 480 mL of turbid dark brown fluid was aspirated, and CT scan was performed to confirm coaptation of seroma capsular membrane. Next, 50 mL of absolute alcohol was introduced into the collection. The alcohol was allowed to dwell within the cavity for 5 minutes, during which time the patient was repositioned, and the cavity was compressed externally to distribute the sclerosant CT-directed, catheter drainage, alcohol ablation of pelvic, seroma..."

Indwelling Stent Exchange through Urostomy

What is the correct coding for this case? "The urostomy site was prepped and draped in the usual sterile manner. A scout image demonstrated ureteral stents in place. A 0.035 Coons wire was advanced through the indwelling ureteral stents, which was subsequently removed. Bilateral 7 French Bander catheters were placed over wire. Impression: Fluoroscopic-guided retrograde bilateral ureteral stent exchange for 7 French Bander catheters."

100% in-stent restenosis: Can this be coded as a chronic total occlusion?

The patient had a "100% total occlusion without thrombus in-stent" of a coronary artery stent. The doctor described it as a CTO/chronic total occlusion, and an angioplasty was performed. Would you recommend using diagnosis code 414.2 to describe the CTO and procedure code 92943 for the angioplasty? I am confused as to whether an in-stent restenosis can be coded as a CTO or whether that description can only be used for a chronic total occlusion in a coronary artery that has not been stented.

Renal Vein to IVC Bypass Using Cryovein

A previous question answered to use unlisted code 37799 for renal vein transposition; however, my physician did a renal vein bypass to the IVC using cryrovein. Does this fall under code 37799, or could you use code 35281 intra-abdominal repair with other than vein (for nutcracker syndrome)? "Procedure: I was able to expose the renal vein back towards the left kidney. Meticulous dissection was performed with blunt sharp dissection, and I was able to expose the renal vein to level of both gonadal vein and adrenal vein. I placed Satinsky clamp on the inferior vena cava where renal vein joined. Also placed Satinsky clamp on the left renal vein at level of adrenal vein . The renal vein was divided at its junction with IVC. The IVC was oversewn with 5-0 prolene. We then did end of renal vein to end of cryopreserved vein anastomosis, as we did not have enough mobility in renal vein itself. We brought this down more distally on the IVC and placed a second clamp. We performed longitudinal venotomy, beveled the cryovein, and performed end to cryovein to side of vena cava anastomosis."

Three Acute MIs C9600

Patient has severe coronary artery disease to left main, LAD, and circumflex. Stents were placed in each vessel during myocardial infarction. Patient expired. Can code C9606 be reported three times?

Revascularization of Chronic Total Occlusion (CTO)

I have patient with CTO of the LAD and left circumflex. To bill out to Medicare Advantage plan, would I use codes 92943-LD and 92943-59LC? Or should I bill codes 92943-LD and 92944-LC?

Lower Extremity Stent Placement When Performing TAVR

I am finding several of our TAVR procedures where a stent is being placed to access during the TAVR procedure. In the following example, would this be separately coded? Procedure: "We then directly stented with a 9 x 38 mm Atrium covered stent in the right common iliac and a x 59 mm Atrium covered stent in the left common iliac extending into the left external iliac. Of note, the internal iliac on the left was occluded. The stents were deployed at 10 atmospheres. We post-dilated with a 10 mm balloon in the left iliac. We performed another pelvic angio and had an excellent result. We then used the serial dilators, and after applying Rotaglide to the 18 French Edwards E sheath we advanced it into the abdominal aorta. It advanced without significant difficulty. We then crossed the aortic valve, utilizing an AL1 diagnostic catheter and a Terumo Glidewire. We then upgraded to an Amplatz extra stiff J-tipped wire. We performed balloon aortic valvuloplasty with the 23 mm balloon from the Edwards kit. We performed an aortogram to help 'balloon size'."

Epidural Plasma Rich Protein Patch

For the following example, is it appropriate to report codes 62273 and 0232T? "Patient with suspected CSF leak. L1-2 level was localized with fluoroscopy. Needle was then placed in the posterior epidural space under fluoroscopic guidance. Contrast was injected to confirm epidural position. 60 mL of peripheral blood was withdrawn from the IV catheter, which was then centrifuged to obtain 7 mL of platelet rich plasma that was slowly injected into the spinal needle. The patient maintained normal motor function in both feet and denied significant radicular symptoms throughout the injection."

Congenital Echo

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

TAVR with Sentinel Device Embolic Protection

Our physicians have begun using a research device called Sentinel for embolic protection, placed in the right brachiocephalic and left carotid arteries during TAVR procedures. The use of embolic protection is not separately reportable with various other coronary and revascularization procedures, but would an additional code (93799) for the placement of the device be allowed when it is performed as part of a TAVR?

50393 vs. 50395

I am leaning towards code 50395 for this example, but I have read conflicting opinions that code 74485 should/should not be reported. Could you provide your guidance and opinion? "Indications: Pre-op access for lithotripsy; nephrolithiasis. After injection of 1% subcutaneous lidocaine, an 18 gauge x 15 cm Hawkins needle was used to access a right posterior, inferior calyx under fluoroscopic guidance (after inflation of a proximal ureteral balloon and injection of approximately 5 cc contrast). The stylet was removed, and reflux of urine was confirmed. A 0.035" stiff Glidewire, with the aid of a 5 French Berenstein catheter, was placed in the urinary bladder to maintain access. The Berenstein catheter was then exchanged for an 8.5 French nephroureteral stent. A small amount of contrast was injected to confirm placement. The wire and stylette were then removed. Final sonographic image was obtained to confirm placement. The catheter was sutured into place using a 2-0 silk suture,and it was then capped. Sterile dressings were applied."

Transverse Process Biopsy

Which is the appropriate code for needle biopsy of T9 transverse process? 20220 or 20225?

75710 with 36147

Patient has AV fistula, and physician documents medical rationale for advancing the fistula beyond the anastomosis (i.e., steal/embolus). I am comfortable in the concept that code 36147 includes imaging of the adjacent fistula. However, the question came up that if the physician evaluates only one other artery, is that sufficient for code 75710? Or does it have to be multiple arteries? It's a weird question, but the physician has it in his head that to qualify for 75710 beyond 36147 there should be at least three vessels visualized, but that seems to imply that there is a minimum to use the code. Thanks for any insight.

Conversion of PCN to PNU

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

Graft Angiography, 93459

How do I code left heart catheterization, left ventriculogram with LVEDP measurement, selective coronary angiography, and non-selective LIMA angiography?

ICD9 Code for Chemoembolization

When performing chemoembolization, do you use V58.11 (encounter for antineoplastic chemotherapy) as your primary dx? These encounters are not your typical “chemotherapy”, but I believe they would qualify as antineoplastic chemotherapy. If that is true, then would you also use V58.0 (radiotherapy) when performing a radiofrequency ablation?

Doppler Edits

I get an NCCI edit for code 93976. When a female patient comes in for pelvic pain, we do a pelvic ultrasound (76856). If nothing is found, we check for arterial and/or venous flow through the ovaries. Can I add modifier -XU if done on the same encounter?

Hepatorenal Bypass Graft + Addition of Synthetic Bypass Graft

"During the procedure the physician harvested the GSV and attempted to create a proper hepatic to right renal artery end-to-end bypass. The anastomosis was completed, but failed once, and following a revision and re-attempt was found to be too diminutive on arteriography and was removed and abandoned. A 6 mm PTFE bypass graft was then used as the conduit." My question is, with PFTE graft vs. 35535, should I report code 35535 alone with a -22 modifier (assuming documentation states as such) and/or another code for the PTFE graft that was ultimately left in place? (It appears that code 35535 only covers vein, and I cannot find a synthetic.) I would also like to code the arteriography (75726). What are your thoughts?

Biopsy vs. FNA

When a patient is seen for biopsy and "core biopsies" were not possible due to nearby vessels, would it be appropriate to bill biopsy if report calls it such? In this example, the title of report is "Image-Guided Biopsy of 1 cm Left Common Iliac Lymph Node Lesion". "Using a lateral approach under CT guidance, an 18 gauge needle was advanced down to the lesion of interest. A 22 gauge needle was used to obtain samples for cytologic assessment. The lesion is not amenable to core biopsy because of the close proximity of the arterial vessels and ureter." Would this be billed as an abdominal biopsy (49180), a lymph node biopsy (38505), or an FNA (10022)? It is titled "Biopsy", yet the report states "core" not collected, rather a needle "biopsy" was. Is this a needle biopsy or an FNA? If it is a biopsy, would "common iliac lymph node" be reported with code 49180 or 38505? It would seem that the work of accessing an area that is deep (such as abdominal or visceral) would be more involved than just an FNA. I would really appreciate your input!

Cerebral Angiogram via Internal Carotid Artery and Embolization of Middle Cerebral Artery

For the following scenario, can I report code 36244 along with codes 61624, 36217, and 75894? "Cavernous carotid artery aneurysm was found on CTA. Therefore, selective catheter was placed in right internal carotid artery, and cerebral angiogram confirmed aneurysm. Catheter was then navigated into the right middle cerebral artery, and Pipeline embolization device was placed across the neck of the aneurysm. Angiogram showed endoleak, so the second pipeline embolization device was placed."

19287/19288 vs. 19287

For the following example, would you report codes 19287 and 19288? Or just code 19287? "Pre-operative MRI-guided bracket 2-wire localization of the right breast, with the target R1 (a 4.1 cm linear clumped non-mass enhancement at the 8:00 position in the anterior to middle depth, 7.4 cm from the nipple) located between the two wire tips and their distal segments."

Congenital vs. Non-Congenital Heart Cath Codes

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

35475 vs. 35476

When the report states that the anastomosis was treated with PTA, are we to assume that this graft is a direct anastomosis between vein and artery (which is reported with code 35475)?

Vertebral Occlusion

For the following example, we assigned codes 36216-LT, 75894, and 75898.  However, I'm questioning if this should be 61626 or 61624. Please advise.  "Previous recent angiogram showed sluggish flow within distal left vertebral artery concerning for thromboembolism. Via right CFA, a 5 French straight guide cath over a guidewire selectively catheterized proximal left subclavian artery. DSA showed proximal LVA occluded approximately 15-20 mm from its origin. Microcath over microwire through guide cath was advanced into left subclavian, then LVA just proximal to the occlusion. I then advanced a TruFill DCS Orbit Complex Fill 5 mm x 15 cm coil into the LVA just proximal to the occlusion. After confirming stability with fluoroscopy, coil was successfully detached. Embolization continued with additional coils, and stability was confirmed prior to successful detachment. DSA showed occlusion of LVA approximately 10 mm distal to its origin with no filling of the more distal LVA and no filling defect in left subclavian to suggest thromboembolism. Cath withdrawn and closed with a Mynx."

Contralateral SFA with Ipsilateral Iliac Stent

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

Mammogram Post Axillary Lymph Node Biopsy

For the following example, would you charge as a lymph node biopsy or breast biopsy? If lymph node biopsy, is it appropriate to charge for post procedure mammogram? "52 year-old with newly diagnosed right breast malignancy and prominent right axillary lymph node. The procedure and risks of ultrasound-guided core biopsy and ultrasound-guided metallic localizer clip placement for a right axillary lymph node were discussed in full with the patient. Both oral and written consents were obtained. With ultrasound guidance, aseptic technique, and 1% lidocaine and lidocaine with epinephrine as the local anesthetic, the mass of concern was sampled 3 times with a 14 gauge Achieve biopsy needle. Immediately thereafter, a metallic localizer clip was placed within the mass. Direct pressure was applied to the site immediately post procedure, and hemostasis was achieved. The site was bandaged with antibiotic ointment. POST PROCEDURE MAMMOGRAM was performed in a separate room: The localizer clip is in the expected location of the axillary lymph node."

36002, 76942

If the patient has two separate pseudoaneurysms in the CFA, and the physician does two separate punctures to treat each, can we bill codes 36002/76942 twice?

Kommerell Diverticulum and Medical Necessity

I have never seen a procedure like this, so I am in need of your advice! The procedure is a left subclavian bypass and endograft covering of the original of subclavian and diverticulum with Kommerell and orgin of the left subclavian artery. A graft was deployed just at the distal margins of the origin at the right subclavian artery and completely covered the origin of left subclavian artery and diverticulum Kommerell. I am looking at codes 33880 and 35621.

Esophagram

I hope you can help with this unique request. The patient’s condition warranted a bedside esophagram. Fluoroscopy was NOT used. Instead, the tech used a digital portable x-ray machine with cassette placed behind and on the side of the patient to take 11 or so images in the AP and lateral projections in the chest area. This was done before, during, and after ingestion of contrast material, which was injected via GI tube at the level of mid esophagus by the patient’s physician (not the radiologist). What is the appropriate way to code this? Scout film demonstrates evidence of pneumomediastinum and soft tissue emphysema in the neck and supraclavicular regions. No pneumothorax is evident. Extensive bilateral pulmonary parenchymal disease is noted with diffuse infiltrates. Administration of contrast opacifies the mid to distal esophagus, which demonstrates no evidence of obstruction or extravasation of contrast. We are concerned if we need to report this as a chest x-ray or as an esophagram.

FIRM and PVI Catheter Ablation

Can we report both codes 93655 and 93656 for FIRM (focal impulse & rotor modulation) and pulmonary vein isolation catheter ablation to treat atrial fibrillation? Usually these rotor ablations are done in both the right and left atrium prior to PVI. If reportable, should we assign code 93655 twice for left and right no matter how many rotors/lesions were ablated? Or do we code based on the number of lesions ablated? Here's an example: "The 60 mm basket catheter was deployed in the left atrium and Epoch 3 created, which appeared to show rotors on the mitral annulus just anteroinferior and posteroinferior to the left lower vein. These rotors were ablated and ablation lesions connected. Epoch 4 showed a posterior wall rotor, which was over the esophagus and was difficult to ablate extensively due to heating. Epoch 5 and epoch 6 were created after adjusting the basket to better contact the posterior wall. These revealed rotors in similar areas as the prior rotors. Ablation lesions were delivered extending the prior lesions along the mitral isthmus and on the posterior wall. During ablation, atrial fibrillation terminated."

Transcaval Aortic Access

Physician is doing a transcaval aneurysm sac embolization for an endoleak after an abdominal aortic aneurysm endovascular repair. He is accessing the vena cava, placing a TIPS needle, and gaining access into the aortic aneurysm. How should I report catheter placement? Should I just report code 36200 since that is where the catheter ultimately landed? Or do I report both codes 36200 and 36010?

Echo Guidance for Temporary Pacemaker Insertion

A cardiologist recently asked for echocardiography to assist with a temporary pacemaker insertion. My understanding is that transthoracic echo guidance was utilized for intracardiac RV lead placement. How would you suggest this be reported? Is a UPC the most appropriate? Thank you for your expertise.

Angioplasty of Vein Graft Stenosis

Patient is status of femoropopliteal bypass for his critical limb ischemia, resulting in the setting of a thrombosed popliteal artery aneurysm. He has had some increased claudication symptoms of difficult-to-heal wounds that appear to be primarily of venous nature in the right leg. So, the physician performed an angioplasty of the proximal vein graft stenosis. My question is, should I use the code for venous angioplasty of the fem-pop bypass graft for lower extremity? Or the arterial angioplasty code?

36147, AV Shunt Studies

I have a physician who wants to limit radiation dose in patients with frequent dialysis interventions, therefore he is considering limiting the shunt study to the region of concern. The physician is wondering if he does not discuss findings of ENTIRE outflow, will this be a reduced service? Does code 36147 require discussion of findings of entire outflow to the vena cava to substantiate billing the charge?

Unsuccessful Biventricular Upgrade

We attempted to upgrade a dual ICD to a biventricular ICD; however, the physician was unable to implant the CS lead after multiple attempts. He implanted the biventricular ICD and plugged the CS port. Can we still report code 33264 since the biventricular ICD generator was implanted even though it's only with the existing atrial and ventricular leads? Would we use a -52 or -74 modifier on code 33225 for the facility bill?

TAVR Via Carotid Artery Access

Would a TAVR px via left common carotid artery cutdown for placement of CoreValve be reported with code 33363?

Cauterization

I have case where the physician opened up a PPI pocket and cauterized a bleeding vessel. No mention of a hematoma. Any ideas if there is a code that might apply here?

Code 37218 in 2015

In 2014 we used code 37236 for subclavian, etc. stenting. In reading new code 37218 for 2015, is this code taking the place of 37236? If not, what is your interpretation of this new code, and what is it to be used for?

37241 vs. 37243

Is code 37241 or 37243 appropriate in the following scenario? "Patient with advanced gallbladder cancer presenting for right portal vein embolization prior to possible future right hepatectomy. 1) Contrast enhanced C-arm CT on injection of the main portal vein. 2) Portal venogram. 3) Right portal vein posterior division venogram. 4) Glue embolization of the posterior division of the right portal vein. 5) Right portal vein anterior division venogram. 6) Glue embolization of the anterior division of the right portal vein. 7) Completion fluoroscopic image. Successful embolization of the right portal vein ANTERIOR AND POSTERIOR DIVISIONS with histoacryl and lipiodol."

Hepatic Wedge Pressure

For the following example, would the wedge pressure be reportable with codes 36012 and 75889? "Patient has a right heart cath with hemodynamic measurements via right internal jugular (93451). Through a separate femoral vein approach, catheter is advanced through the vena cava to the hepatic vein, and a hepatic wedge pressure is taken. No contrast was used for procedure."

Dottering and Thrombectomy During STEMI

I'm not sure what I can bill here. I know thrombectomy isn't separately billable, and the dottering was done with a wire, so I'm thinking that isn't either. It seems to me the physician should be able to bill something for the work. Acute MI is documented in report. Interventions: "Given bolus and started on infusion of angiomax. Prowater wire advanced beyond PLB occlusion, but distal vessel very small and tortuous. Two aspirations with Pronto thrombectomy catheter, restoring TIMI-1 to TIMI-2 flow. Wire then pulled back and advanced to distal PDA occlusion. Vessel very tortuous and occlusion very distal, so no thrombectomy. Floppy wire then used to dotter the PLB occlusion again, restoring TIMI-2 flow. Elected not to do PTCA or stenting, given how distal both occlusions were and how small the vessels were at that point. Considered integrilin, but small hematoma at right groin (patient practically jumped off table with lidocaine at beginning of case) and concerns about bleeding risk (with effient on board as well). Angio-seal deployed right FA."

Category III Codes for PTA Abdominal Aorta

Is code 0236T correct for aortogram, iliac angiography with closure device, PTA? We are getting claim denials even with records sent.

36595

Are codes 36595/75901 correct for PTA of a fibrin sheath through the same access site (via the CVC) as the CVC during a replacement of the existing CVC without port? Or is this included in the replacement procedure (36581)?

Repositioning peritoneal catheter

What code do you suggest for repositioning of a peritoneal drainage catheter? CT abdomen shows drainage malpositioned catheter. Using a stiff guidewire, it is brought to position.

Failed Attempt for LHC

Would you report the following example with code 36140? "Access from the right groin with multiple attempts and radiological guidance was unsuccessful, and the left side was also unsuccessful. The patient is extremely corpulent, and access was not possible. The patient had the radial artery used during surgery, so we are going to need to go from the left arm brachial or radial in order to access her arteries, and this will be rescheduled."

External Iliac Angioplasty Performed to Stop Bleeding, NOT for Stenosis

One of our cardiologists was assisting another surgeon, and our cardiologist performed an angioplasty in the external iliac to stop bleeding below the iliac so the surgeon could perform repairs. Since the angioplasty was done for bleeding and not disease, I don't think code 37220 would apply. I'm thinking of using code 37799 (unlisted procedure, vascular surgery), but I would appreciate your opinion on this one.

Accuracy of Coding

I was brought into an organization due to concerns regarding loss revenue, lack of clinical documentation, and poor procedure charging. I am new to this facility. I have used your resources for a long time now in my role roles of a radiological technologist in cath lab, IR, and EP. In my new role I am required to become more aware of Medicare reimbursement. My main issue I have had in the short time I have been at this new facility is that when reviewing cases there are many small coding mistakes that are taking place. Examples being 77001, 76937, 75625, 75630, 75716. In the last year, no CVC cases had code 77001 attached to procedure when they were all done with fluoroscopic guidance. Code 76937 is charged with no documentation of recorded image, and codes 75625 and 75716 are being charged without documentation of catheter placement, which should have been coded as 75630. When asked about these practices I am told we have almost 100 percent Medicare patients and we get reimbursed the same no matter how we code it. How do you overcome this mentality? I'm so frustrated.

AV Shunt Placement

Patient has 403.90 and 585.9. Patient comes in for AV shunt. The MD plans to create the AV shunt at the wrist area. He makes his incision and explores the area and decides the vein is too small. He closes here and then moves to the upper arm and creates the AV shunt there. I did refer to your Q&A # 6128, but this was for two unsuccessful attempts.

Billing 72265-59 with 72132

Would you consider this documentation sufficient for billing a lumbar myelogram (72265-59) with LS spine CT (72132)? The physician orders a CT spine and lumbar myelogram. Documentation for the myelogram in the first example states: "Myelogram without significant compression on the thecal sac or exiting nerve roots, osseous structures are unremarkable." In a second example the documentation states: "Conus/Cauda: Tip of the conus is typical at L1. Individual nerves of the cauda equina are unremarkable. There is no evidence of arachnoiditis or other pathology." All elements of the LS CT are well documented in both instances. In either instance, can the lumbar myelogram be separately coded?

Arterial Thrombectomy

I have a case where the physician did a primary percutaneous mechanical thrombectomy of the following areas (right common femoral approach): left common iliac, left external iliac, left common femoral, left superficial femoral, left popliteal, left anterior tibial, and the left posterior tibial/tibioperoneal trunk. How many times should codes 37184 and 37185 be submitted in order to cover all these areas?

Biopsy of Leg Mass

For the following example, I'm not sure what to code for this because it is not muscle or bone.  What are your thoughts?  "Physician performed a venogram of the right common femoral vein, that had been previously stented. The venogram showed limited flow from a mass pressing on the stent. With percutaneous access, a biopsy guide for 16 gauge core biopsies were then placed through the stent into the mass. Three good core biopsies of the mass were obtained and placed in formalin."

Foreign Body Removal - Open

I’m not sure what to do with this one. Patient came to cath lab to have an angioplasty of his AVF. While ballooning the subclavian and innominate vein, the balloon ruptured. Due to aspiration of blood from the inflation port of the balloon, the surgeon decides to take the patient to the OR for emergent surgery. In the OR he opens the arm, creates a venotomy in the fistula, and removes the balloon. It is noticed that there is some thrombus, so he removes the small amount of clot present and closes the venotomy. I don’t like code 37197 since this is open instead of percutaneous. I was thinking of reporting the exploration with code 35761 (which includes foreign body removal) (or possibly 35860 since there was bleeding) with modifier -XU or -59, as well as the open thrombectomy with code 36831 since they shouldn’t have had to do a thrombectomy as well. My other thought was unlisted code 37799. What are your thoughts?

Billing 93286 or 93287 twice

When billing code 93286 or 93287 twice, for before and after another procedure (such as an ablation), Encoder Pro states we should bill the code x 2, but I have seen it also billed on two lines with either a -76 or -59 modifier. Which way is correct?

AV Fistula Transposition

Does your previous answer to a question from years ago regarding code 36818 still apply - must this procedure still require two incisions to code for it? "Procedure: We made incision a fingerbreadth above the elbow crease where the vein and artery had been mapped. We dissected first the cephalic vein circumferntially and exposed at least a segment of around 5-6 cm both proximal and distal to our incision so that we could swing it over. We divided a little part of the biceps muscle to allow for no compression with the transposition of the vein towards the brachial artery medially. The brachial artery was exposed proximally and distally. She had some scarred valves in the vein walls which were trimmed at the level of the anastomosis to allow no problem with the venous anastomosis for the future. We then clamped the artery distally and proximally and made an incision with 11 blade and dissected with micro Potts in oblique fashion. The vein was then anastomosed using 6-0 prolene in a running fashion." What code would you use if not 36818? Unlisted?

Code 93623

Patient comes in for EP study in arrhythmia. Physician administers isuprel. Is it appropriate to bill code 93623 if the patient is already in an arrhythmia BEFORE drug infusion?

Internal Biliary Stent, No Safety Catheter Left

How do I code this report? "Technique: The internal/external biliary drain was prepped and draped. Contrast was injected, and a cholangiogram performed. This revealed a malignant obstruction of the distal CBD. No contrast enters the duodenum. Guidewire was advanced through the drain and into the duodenum. Sheath was placed at the insertion site. Under fluoroscopic guidance, a biliary covered stent was deployed at the level of the malignancy. It was then dilated with a balloon. Excellent result with brisk flow into the duodenum. No safety catheter was left. Impression: Successful internal biliary stent placement. No safety catheter was left."

Congenital Saturation Study

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

Heparin Infusion

Would heparin infusion be considered a continuation of infusion therapy (37213) even thought it’s not a thrombolytic agent? On 2/7 patient’s thrombolytic infusion catheter was injected, removed, and replaced with a sheath, in which heparin infusion was initiated. On 2/11, sheath was injected for follow-up venogram and heparin infusion continued. Should we report code 37213 or 37214 for the 2/7 exam? And for the 2/11 exam should we report code 37213 or 75898? Patient undergoing thrombolytic therapy. Infusion catheter injected, catheter removed, AngioJet placed with several passes, and angioplasty performed. Sheath left in placed and heparin infused through this access (35476, 75978, 37187)... but what I'm not clear on is 37214 or 37213 (does heparin infusion qualify for continued therapy?) - A report a couple of days later reads sheath injected, stent placed, heparization continued (37238). Again, not clear on this, 37213 or 75898 (because heparin is not thrombolysis?)?

Injection of Left Innominate Vein

When the physician says “hand injection in the left innominate vein”, is the correct CPT code 75820? If not, what is the appropriate code for that? And is it appropriate to charge for this with a congenital heart catheterization?

ICD Implant

A patient had a CABG, and during that procedure an LV lead was placed for future use. Previously the patient had an infected pocket and the ICD generator was removed along with the lead. Now the patient is back in the OR to implant an ICD with leads and also to attach the LV lead that was previously placed. Would you report code 33249? DFT was done, so we'd use code 93641-26. Code 33249 states single or dual chamber, but patient did have three leads attached.

VSD Stent

How would you code a VSD stent with LV and RV angiograms with no heart cath performed?

Arch Aortogram (36221)

Looking for clarification on what findings need to be documented in order to bill code 36221 in conjuction with a congenital heart catheterization. If the physician report does not describe any findings of the great vessels, ONLY findings of the arch, can code 36211 be billed?

36010 with Open Thrombectomy

In the 2015 Vascular & Endovascular Surgery Coding Reference, page 384, example #2, you included code 36010. Can you explain why? I didn't know you could bill a catheter placement during open procedures.

CHD and Heart Transplant

I received your February 2015 Q&A answer regarding coding a patient non-congenital once they've had a heart transplant. I have your Diagnostic & Interventional Cardiovascular Coding Reference, and it states that once a patient is diagnosed as having congenital heart disease he/she should always be coded as such, even if the patient receives a heart transplant. My book version is a couple of years old, so I was not sure if your new version has the opposite of what this version has.

Dual Venous Outflow Tracts

This patient has dual venous outflow tracts of his AV fistula in right upper extremity and outflow into the basilic vein and cephalic vein. When both venous outflows are accessed for AV fistulogram, will code 36147 cover both? Or will we need an additional 36147-59? Or do you have a different code recommendation?

Kyphoplasty of T12 and L1 levels

Our physician performed a kyphoplasty of the T12 level and the L1 level. The 2015 guidelines are confusing, and reading the instructions #5 and #6 from the Dr. Z Interventional Radiology Coding Reference, it appears that we would report code 22513 for initial level and 22515 for the additional level. Is this correct? The example given #2 shows 22513 and 22514 for T10 and L2 levels, but there is an NCCI edit that does not allow the use of two initials together.

34900 with 34825

I have a patient in whom we are treating bilateral iliac aneursyms with an AAA endograft. The graft we are using has one docking limb. We placed the endograft with the docking limb on the right side, and then extended both sides with extensions. Would you suggest codes 34900-62, 34900-62-59, and 34825-62 along with the S&I and catheter placements?

KX Modifier

What is going on with the delay on the use of the -KX modifier on pacemaker procedures? I know the ruling to use it was delayed in July 2014. Has there been any further development on whether or not it should be applied?

G-tube check using room air and fluoro

Is it correct to report code 76000 for an injection of room air into a gastrostomy tube under fluoroscopy to evaluate the tube? No contrast is used, so I don't think code 49465 would be appropriate.

Peripherals with Cath

"Common femoral artery was cannulated, and a sheath was placed. Because resistance was met, right iliofemoral arteriography was performed via the sheath. A glide wire was advanced beyond the common iliac artery, and the sheath was exchanged; the tip of sheath was in the distal abd aorta. Through this, abdominal aortography was performed. A catheter was advanced into the ascending aorta and aortic pressures recorded. Catheter was then used to engage the left main, and selective left coronary angio was performed. Catheter was then disengaged and exchanged, which was used to engage the right coronary artery and each of two aortocoronary bypass grafts. Selective right coronary and bypass angio performed. A catheter was then used to engage the innominate artery. Selective innominate angio was performed. Prior to this, limited aortic arch angiogram was performed via the catheter, which was placed immediately proximal to the innominate artery." I reported codes 93459, 75625, 75710, and 36222. Does this sound right? Sorry not enough room to put all specific but included the main points.

Device Pocket Revision

How would a pacemaker pocket revision be coded when the pocket is not relocated? Since code 33222 is now only for relocation of the pocket, I am not sure how this should be coded. "The patient had a pocket revision due to painful movement of the pacemaker within the pocket. The device was removed from the capsule, and the capsule was enlarged laterally and superiorly. A Parsonnet pouch was placed over the device and excess leads. The device within the pouch was placed back in the pocket and fixed at 5 points to the underlying pectoral muscle a few centimeters lateral and superior to the original position."

G0278 not with PCI

I know that the code for non-selective iliac angiography done at the same time as 93452-93461 is G0278. However I ran into a situation. A patient was admitted to an outside hospital for NSTEMI, had a left heart cath with coronary angiography, and was transferred to our hospital for intervention because the lesion was complex. My physician did a coronary angiography and placed three drug -luting stents in addition to performing a non-selective peripheral angiography of the iliacs. However, since the patient had a coronary angiography three days prior, the compliance department advised against billing the coronary angiography since we had the imaging from the procedure done at the outside hospital and were intervening on lesions identified during that procedure. How can I bill for the peripheral procedure if I am unable to bill code 93454? My understanding is that code G0278 has to be billed with 93452-93461. Please advise.

Additional Ablation

Documented AF and atrial flutter. Physician goes on to describe pulmonary vein isolation and then states: The RIPV could not be occluded with the balloon but was electrically isolated post ablation. There was no phrenic nerve injury demonstrated during the lesions. Block was demonstrated in each vein. Exit block was demonstrated. Using Carto 3D mapping a voltage map (0.3-1 mV) was performed in the LA. Using Carto, 3D mapping of the RA and the CTI was targeted for ablation. An Ablation line was performed with RF at 6 o'clock using the 3D map and Intracardiac Echo map. Block was obtained. There was a prominent Eustachian ridge and both the RA and RV leads were crossing the isthmus. IMPRESSIONS: Successful isolation of pulmonary veins CTI ablation RHC with pressure measurement of RV/PA 3D mapping Trans-septal cath Intracardiac Echo Mapping Normal AVN and HP function Would this be enough documentation to add CPT 93655 to 93656? Thank you!

Creation/Closure of New Generator Pocket

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

Y-90 with GDA Embolization

"Initial placement of the microcatheter (by IR) into the right hepatic artery resulted in decreased antegrade flow and reflux into the small, patent gastroduodenal artery. The decision was made to embolize the GDA prior to the Y-90 treatment by the AU." In this case, can the IR bill for the GDA embolization since the AU is billing the Y-90? If so, would that be reported with code 37242?

Catheter Placements

If an angio is done during an intervention that is NOT a diagnostic study, would you code and bill the catheter placement? For example, embolization of a liver tumor. "The physician selectively catheterizes the cystic artery, right hepatic artery, and branch of right hepatic artery. Findings: Location of cystic artery confirmed, both the main right hepatic artery and branch of right hepatic artery were confirmed to supply the tumor. Intervention: The catheter was advanced into the right hepatic branch, and embolization was done." The codes I am using are 37243 and 36247. Would you also report code 36248 for the cystic artery cath placement?

Placement of a Loop Recorder (33282) and Fluoroscopic Guidance (76000)

Can you bill fluoroscopic guidance with the placement of a loop recorder for hospital based billing? I can't find anything that states you can't bill it, but yet I can't find anything that states that you can bill it.

Sheath Removal

My patient had a splenic embolization done, and the sheath was left in place for possible use in the following splenectomy. The following day the patient was brought back into IR for subsequent removal of the sheath. "DESCRIPTION OF PROCEDURE: The right groin was cleaned and prepped in the usual sterile fashion. Local anesthesia was then injected into the skin and subcutaneous tissues. An angiogram of the right common femoral artery was performed through the existing 5 French sheath. The 5 French vascular sheath was seen within the midportion of the right common femoral artery. The sheath was then removed, and hemostasis was achieved using 6 French Angio-Seal device. The patient tolerated the procedure without difficulty or immediate complications. IMPRESSION: Successful Angio-Seal device deployment in the right common femoral artery." How would you code the pro fee for this, if at all? I was considering reporting code 75710. Is there anything else you would suggest?

Performing More Procedures Than Initially Intended

Our physician performed a redo open thrombectomy, right limb of aorto-bi-femoral bypass graft. Then a stent placement, right limb of proximal aorto-bi-femoral bypass graft, followed by another stent. Those were successful. There was then brisk flow through the right limb of the graft. Because of the patient's small, poor outflow, it was felt best to perform a fem-pop bypass with vein, as the SFA was occluded. The physician wants to bill all services performed. Can we bill everything or just the bypass?

34812 with 34803

When billing code 34803, would I also report code 34812 if that is done? In our Encoder pro software it says that code 34812 is included in code 34803. "34803 - INCLUDES: Balloon angioplasty/stent deployment within the target treatment zone; introduction, manipulation, placement, and deployment of the device; open exposure of femoral or iliac artery/subsequent closure (34812)." Not sure if I should be billing code 34812 with a -59 (-XS) modifier or just not using it at all.

Dialysis Access

Can you please explain the difference between codes 36818, 36819, 36820, 36821, and 36825? Perhaps with examples of each? I've been reading through my new book, Dr. Z's Vascular & Endovascular Surgery Coding Reference, but I am still as confused as ever.

Modifier for Same Day Stent and Cardioversion

My cardiologist did a cardioversion and a stent on the same day. Do I use modifier -59 on both the stent and cardioversion since they are in the same CPT code set?

Echo Documentation

I would appreciate your guidance on documentation. It has been proposed that the CPT guidelines before a section are technical requirements that need to be performed, but are not necessary to be documented in the professional report unless they are “clinically relevant”. For instance, for a complete echocardiogram (93306), the guidelines state the structures that need to be evaluated or the reason that they can’t be visualized needs to be stated. If, for instance, the right atrium was not referenced in the report because it was not deemed to be clinically relevant, could a complete echocardiogram be billed if all of the other elements were on the professional report? In your opinion, have we met the requirements for documenting a full echo (without including all the elements in the professional report) because we have the supporting tape to show that the service was rendered completely? Secondly, would a statement indicating that “the structures were visualized” suffice? In other words, must it be an interpretation of what is seen?

Temporary Device Interrogation/Programming

A critically ill neonate with coarctation of the aorta with multiple ventricular septal defects s/p CoA repair, patch closures of membranous and mid-muscular VSD, and PAB placement, who is in complete heart block with temporary pacemaker. A plan is in place by a cardiothoracic surgeon to place permanent pacemaker when patient stabilizes. In the meantime, our EP doctors do temporary device interrogations. Can we bill for temporary device interrogations? If so what codes can we use?

ICD-9 Coding, Sick Sinus Syndrome

We have been audited by an insurance carrier and told we can not use the diagnosis of sick sinus syndrome if the patient has had a pacemaker placed and it is working properly. They have instructed us to only use the dx code for status post pacemaker placement. Do you agree with the above information? If not can you please provide me with sources that I can use to back up that information?

Follow-Up Angiogram with Aneurysm Clipping and Diagnostic

Our physician recently attended a conference where he was told that you can now bill all of the following: 4-vessel diagnostic angio done (36226-50 & 36224-50), emergent crani done for aneurysm clipping (61697), and follow-up angio done in internal carotid (36224) to make sure the clipping was complete. This is done all in one operative session. MUEs previously had 36224 as one, so we have only been billing code 36224-50 in these cases. But I see the MUE table for April 1, 2015 now is showing three per day for code 36224. (Looking at the January 1, 2015 MUE table on your site the MUE for code 36224 is still at 1.) So with that in mind, is it acceptable after April 1, 2015 to then bill codes 36226-50, 36224-50, 61697, and an additional 36224?

Conversion of Inferior Vena Cava Filter to Stent

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

Lower extremity catheter placement and angiogram

"Right common femoral artery was accessed, and a 5 French sheath was placed. Omni flush catheter was advanced to the abdominal aorta using the support of a Glidewire. A flush catheter was placed in the abdominal aorta, and angiogram was performed. Next, the Glidewire was advanced to the common femoral artery on the left. Next, Omni flush catheter was exchanged for straight flush, which was advanced to the proximal left common iliac artery. Next, run-off was performed. Next, the catheter was removed and right groin sheath was used to perform right lower extremity angiogram." I reported codes 36245-LT, 75625, and 75716. Are those the correct codes for this scenario? Glidewire was up to left common femoral artery, but catheter was placed at left common iliac artery.

Mitral Valve Prosthesis Repair

Would code 33418 be appropriate for repair of regurgitation of an existing mitral valve prosthesis? The physician used an Amplatzer device.

Ultrasound for Inguinal Hernia

What is the best CPT code to use for an ultrasound of the abdomen/lower extremity for ingunal hernia? 76705 or 78881/78882?

Atherectomy of Left Arm

Could you please clarify the uses of code 0234T. The CPT description states "transluminal peripheral atherectomy". Since there is a separate code for the brachiocephalic trunk and branches (0237T) on the right side of the body, does this mean that code 0234T may be used for atherectomies in the left arm, as well as renal atherectomies?

Venography and PICC Line

Please let me know if I can code venography and PICC line together on this type of case. "Clinical History: Needs improved central venous access, poor peripheral access. A small amount of contrast was injected, confirming chronic occlusion of the right upper extremity central venous system. Therefore, right internal jugular central venous catheter placement was pursued. Access to the right internal jugular vein was gained by sonographically-guided puncture. A permanent sonographic image was obtained. The vein was confirmed to be patent. Under fluoroscopic guidance, a dual lumen peripherally-introduced central venous catheter was placed with the tip at the junction of the superior vena cava and right atrium at completion. A permanent radiographic image was obtained. Fluoroscopy time was 3.1 minutes. Successful placement of right internal jugular central venous catheter." Please let me know if I can report codes 75820 (not sure), 77001, 76937, and 36556 for this case.

Mofidifer for 93287

When a patient with a biventricular defibrillator comes in for an EPS study (93620, 93621, 93623), and his/her defibrillator is turned off before the EPS procedure, then turned back on and reprogrammed after the procedure, we have been placing a -59 modifier on the second instance of 93287. Will that still be the most specific/appropriate modifier in this scenario, or will modifier -XU or -XS be more appropriate?

19083-50, no longer

I took a webinar for the CIRCC exam by Dr. Z, and I think Dr. Z mentioned that we no longer would apply modifier -50 if -LT and -RT breast lesions are biopsied. Instead we would use add-on code. Could you let me know where I can find the AMA article about it. I was just reviewing 3M Encoder Pro, and they still recommend using modifier -50 for a bilateral procedure. Could you clarify?

62311 with CT Guidance

I know fluoroscopic guidance is included with code 62311, but our IR people almost always use CT guidance for this procedure. Would you use code 77012 with this procedure, or are all types of guidance included?

Modifier 52 on Nuclear Medicine Study

I have a question on using a -52 modifier. Patient comes in for a nuclear medicine stress test (78542). The rest portion is performed with images, and for various reasons the stress portion is not completed. Should this be reported with code 78452-52 or 78451 for what was actually performed? The interpreting physician does not want the code to be changed, but to code what was originally ordered. Documentation is there to describe that the test was not completed. I have some advice that says to code the original order with a -52 modifiier, with the example that the patient could not cooperate for the complete study. My thought is if there is a code for what was performed that is what should be coded. Any help would be appreciated.

Aspiration Thrombectomy of Lower Extremity

Can aspiration thrombectomy of the lower extremity be considered a mechanical thrombectomy and reported with codes 37184-37186? Or does an AngioJet need to be used to report for these codes? The patient had tPA for 18 hours (second and final day) and was brought back for a re-look. Infusion catheter was removed. The thrombus was still present in the popliteal artery. Aspiration thrombectomy was performed, still not sufficiently removing the thrombus. The physician then performed balloon angioplasty. I am thinking of reporting code 37214 for the final day of tPA infusion, code 37184 for a primary thrombectomy of the popliteal, and code 37224 for the PTA of the popliteal. Am I reporting the correct codes?

Post-op EKG

The patient had an external cardioversion for atrial fibrillation. Case end was called and patient was transferred to "holding". An EKG was performed at this point. Is this EKG (93005) considered included/during the procedure and not separately chargeable? Or is this chargeable, as it was performed after procedure ended and patient was transferred to a different area?

Inflow, Outflow Procedures

I would like to know if the physician does a fem-pop bypass with reversed transposed gsv, iliofemoral thromboendarterectomy, and profundoplasty, can I bill codes 35556, 35572, and 35355?

Foreign Body Retrieval

We have physicians who have been given the direction, by company reps, to use code 37197 when snaring a wire advanced from an access site in the foot and exteriorizing it though a sheath placed in the common femoral artery. Is that an appropriate use of code 37197? I code for the facility and have never reported code 37197 in that scenario. I don't believe it is an appropriate use for code 37197, and I am being questioned by the physicians. If you could clear that up for me, I sure would appreciate it!

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