Knowledge Base

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Set Descending Direction

Documentation

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

Documentation concerning selective

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

Documentation for Catheterizations

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

Documentation for Double Contrast UGI

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

Documentation for Endarterectomy

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

Documentation for Right Heart Catheterization

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

Documentation guidelines on performing biopsies

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

Documentation IVUS

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

Documentation of aorta for use of 75630

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

Documentation of Cerebral Angiography

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

Documentation of induction of arrhythmia and mapping

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

Documentation of mapping

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

Documentation Required for CVC Cath Placement to code CPT 36556

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

Doppler of Aorta

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

Doppler prior to tunneled central venous catheter placement

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

Dottering of iliac artery angioplasty stent placement aorta

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

Downgrade of ICD Generator to Pacemaker Generator

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

Doxorubicin Beads

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

Drainage Catheter Advancement

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

Drainage Catheter and Sclerotherapy

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

Drainage Catheters

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

Drainage of Bakers Cysts

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

Drainage of chest wall collection

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

Drainage Pseudoanerysm During AV Graft Stenting

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

Drains

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

Dual Chamber AICD Replacement with Insertion of a Subcutaneous Coil

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

Dual Chamber ICD Generator Replacement with Lead Insertion

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

Dual Isotope Nuclear Stress Test - 78452 Problem

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

Dual to Biventricular, Unsuccessful Placement of the LV Lead

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

Dual to Single Pacemaker Generator Change

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

Duplex Scan of arterial Inflow and Venous Outflow Breast Lesion

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

Duplex scan of upper and lower extremities

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

Duplicated IVC with filters

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

Duplicated Nephrostomies

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

Duration Requirements 37211

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

DynaCT coding

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

Dynamic CT Myelogram of the Cervical and Thoracic Spine

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

E&M

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

E&M

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

E&M codes and diagnostic angiography

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

Echo and fluoroscopic guidance 77002 and 76930

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

Echo Dictation 93306

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

Echo requirements

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

Echocardiography

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

ECMO

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

ECMO

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

ECMO

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

ECMO Device

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

Edits with new cardiac catheterization codes

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

Ekg abnormal findings

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

EKG and cardiac catheterization

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

EKG with cardiac catheterization

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

EKGs and cardiac catheterization

I am auditing the CCL of one of our smaller system hospitals that hasn’t been audited since before I joined the audit department a few years ago.  I have discovered that they are CPT 93005 (with and without modifier 59) performed with CPT codes 93458, 93459 & 93460.  The EKGs are ordered as part of the standard pre-procedure routine.  From my understanding, charging for the EKG is not allowed because it’s an NCCI edit.  I discussed this issue with other auditors who agreed that the hospital should not be charging, as our other hospitals that I have regularly audited do not charge for them; but I pulled the “National Correct Coding Initiative Policy Manual for Medicare Services” from the CMS website and in Chapter 11, Section I, Point #14 it states: “A cardiac catheterization procedures or a percutaneous coronary artery interventional procedure may require ECG tracings to access chest pain during the procedure.  These ECG tracings are not separately reportable.  Diagnostic ECGs performed prior to or after the procedure may be separately reportable with modifier 59.” This makes me think that the diagnostic EKG that is performed prior to the cardiac catheterization IS billable/reportable as long as it has modifier 59.  What is not billable is any EKG taken during the procedure.  If this is the case, then I need to instruct all of my hospitals to start reporting/billing this charge.  Do you agree?  I looked in your Cardiology reference guide but it only referenced that EKGs should NOT be billed with EP studies and doesn’t address cardiac catheterizations. Thank you,

EKOS

What is an EKOS considered? We infuse TPA and use ultrasound to break up the clots. We bring patient back between 6 and 24 hours for a recheck. Is it a mechanical thrombectomy because of the ultasound or infusion for thrombolysis?

Embolectomy in AV graft

If a dr enters a arteriovenous graft for embolectomy with a scalpel then performes an embolectomy with a catheter into the preexisting HeRO catheter, and then the Fogarty catheter was then passed to the arterial end with similar retrieval of arterial flow with brisk arterial bleeding. Can we charge 36831 for the arterial and 36831-59 for the HeRO catheter embolectomy? Thank you for your help!!

Embolic protection device

Good Morning Dr. Z, Yet another question, Our physician did a Fox Hollow atherectomy of the distal superficial femoral artery. There was a significant amount of atheramatous debris in the spider EX filter device. The filter was retrieved. Does this constitute a thrombectomy also??? Thank you and Happy Friday!! Tina Pihlainen

Embolization and Angioplasty

I have a case were a chemoembolization was performed in the hepatic arteries and an angioplasty was performed on the left external iliac artery. The angioplasty was not planned; stenosis was found when trying to cannulize the artery for the embolization. The problem is that I have to use codes 37243 and 37220 for two different vascular families, and due to the fact a diagnostic angiography was performed on the external iliac I have catheter placements for both areas of treatment, so codes 36247 and 36248 x 3 for the hepatic embolization and 36249 for the diagnostic angio in the external iliac. Due to code 37220, codes 36247 and 36246 both require a -59 modifier, but code 36247 overrides 36246. How do we address that so that both catheter placements are paid?

Embolization and diagnostic angiography

Dear Dr. Z: More CCI edits- eff 4/1/2011 75726 and 75774 bundles into 37204, 75894 and 75898. Can the pre-procedure angio no longer be billed when hepatic embolization is performed? Do the guidelines for angio performed at the time of a therapeutic intervention apply to this procedure, as stated in the instructional CPT notes in the Radiology section for Vascular Procedures? Thank you. mlb

Embolization Arteriovenous Fistula Head

I have a simple question that probably you can address. I have a case that I am auditing that involves an embolization of an AV fistula brain. I am recommending code 61624, but my question is regarding the catheter access. The radiologist punctures the arterial side and the venous side for proper embolization. I know to only code the embolization code once, but can I code the catheter placement for both vascular systems (36215 series and 36011 series), as he accessed the femoral artery and femoral vein? This case would follow CPT coding guidelines of 2012.

Embolization Fields

Patient has colorectal liver metastases. Yttrium 90 mapping arteriogram performed. Documentation indicates that left gastric artery microcoil embolization performed with post coil embolization arteriogram, right gastric artery embolization with post embolization imaging, medial branch gastroduodenal artery embolization with post embolization imaging, and lateral branch gastoduodenal artery embolization with post imaging are all performed. I am thinking this is one surgical field and would be reported with codes 37204 x 1 and 75898 x 1 (2013 case). The facility wants to report the embolization x 3 for the three separate vessels. Would this be considered one surgical field or more? 

Embolization for Adrenal Artery/Renal Artery

I have a case that the physician accessed the right renal artery, and right renal arteriogram was performed, demonstrating filling of the adrenal artery with supply up in to the right lobe liver mass. The right adrenal artery was selective along with an adrenal arteriogram (the adrenal artery comes off the renal artery). Chemotherapy was then infused into the right adrenal artery slowly over 20 minutes. Embolization was then performed with a combination of 100-300 and 300-500 micron particles of biospheres. Because the renal code 36251 includes the renal arteriogram, how would I code for the adrenal artery that comes off the renal artery? Would you report codes 36246 and 75731-26, or just code 36251?

Embolization later in day

I have a patient who had an Embolization of GDA in the morning (9:00 am) but after subsequent flow study there was evidence of extrahepatic flow with MAA injection. On correlation with prior angiogram and CT, it was evident that a unusual branch arising from the cystic artery was supplying extrahepatic omentum;therefore, a decision was made to bring the patient back for embolization of this small branch. In the afternoon (15:00 same day) embolization of an extrahepatic branch arising from the cystic artery was performed. Are we able to bill this additional embolization/cath placements/angio's? I am trying to locate information about how to do this if it is allowed. If so, would we use modifier 59 on these or 76? It is a repeat embolization but of a different area and many hours later. Any suggestions would be most appreciated! Thank you, Additional information received subsequently: I should have inquired about cath placement/imaging as well.  As it turns out this patient did have the sheath still in, so there was not a new access. Would we be able to bill the cath’s and angio’s for the afternoon procedure? I really appreciate your assistance!  My co-worker and I are really looking forward to your conference, but it looks like we won’t be scheduled until early next year.  

Embolization of a Single Site

This patient had renal artery embolization for a large renal metastatic mass. There are two left renal arteries. The vascular surgeon does an angiogram and embolization of the left UPPER pole renal artery in a third order branch, as well as an angiogram and embolization of the left LOWER pole renal artery in a second order branch. Does this represent one surgical site? And therefore only one 36253, 37204, 75898 set of codes? In your Interventional Radiology Coding Reference, I see that the right and left kidneys represent two surgical sites. But I don't know about two arteries on the same side. And would code 75894 only be reported once for follow-up? Thank you very much.

Embolization of AV fistula collateral

Dr, Z, Patient has AV fistula with a complication for dialysis. With two AV graft punctures and intervetion was performed using both accesses. Additonally a large accessory vein was seen arising from the venous outflow from the arteriovenous anastomosis. Using a catheter the accessory vein was selectively cathterized and was subsequently embolized using multiple coils. My question is can we assign 36217 36148 and 36299 for the accssory vein access? I understand we can't use more than two punctures for the AV fistula however this was an accessory vein so not sure of this, please advice. Thanks

Embolization of Gastrocutaneous Fistula Plug

What is your code recommendation of this case? "Upper abdomen was prepped and draped in usual sterile fashion. Contrast was injected into patient's indwelling percutaneous pigtail type gastrostomy tube, confirming intragastric location. Catheter hub was cut, and the catheter was removed over Amplatz superstiff wire. A 12 French sheath was advanced into the stomach in order to facilitate fistula brushing, which was performed with 3 mm bristle Cellebrity Cytology Brush over Amplatz wire as sheath was retracted from fistula. Next, Cook enterocutaneous fistula plug was deployed through 24 French sheath within the fistula. Inner disc was in appropriate position along gastric staple line, as confirmed with fluoroscopy and radiography in multiple obliquities. External portion of the plug was secured to abdominal wall with Molnar disc and trimmed. There were no immediate complications."

Embolization of Gastroduodenal Artery, Left Gastric Artery, and Thoracic Arteries

Initial Question: We have a physician who does embolizations on the gastroduodenal artery, left gastric artery, and thoracic arteries (normal anatomy), and I was wondering if we could not charge two embolizations since one is above the diaphragm and one is below the diaphragm and in two different coding family sets? I know it is once per surgical field and have heard if you make one puncture it is considered one surgical site, but if you do two different abdominal areas (e.g., liver, pancreas, spleen) it is considered two different surgical sites even though you go through one puncture site. Could you please clarify when charging two would be acceptable billing? Additional Info Provided Following Inquiry from Dr. Z: Most of the dx are a primary cancer (rectal, colon, etc.) metastatic to the liver and he says intercostal on the thoracic arteries. It looks like most of them are evualating suitability for Sirtex radioembolization. Please let me know if there is additional information I need to supply; I know nothing is ever black and white in coding.

Embolization of GDA and Inferior Pancreaticoduodenal

I have a question on embolization. I have a report where we went through the celiac artery, advanced in the common hepatic, ended in the gastroduodenal artery, and did coil embolization. The radiologist then went into the superior mesenteric artery and found additional bleeding went into the pancreaticoduodenal artery and did an additional embolization. My question is, can I code for both embolizations?

Embolization of ICA

Greetings, Pt had a coil embolization of the rt internal carotid at the cavernous and the supraclinoid. Am I correct in letting the physician know he can only code one embolization as it is in the same vessel. LW

Embolization of inferior epigastric branch artery

Dr. Z, I am having a bit of a dilemma over a procedure that was done in our IR lab. The patient presented with bleeding to the abdominal wall post op hernia repair. The radiologist did a distal aorta and bilateral iliac angiogram. He then selected the lt internal iliac ( to"confirm its position"). He then selectively catheterizes a branch of the lt inferior epigastric and proceeds to embolization. No mention of an angiogram for the internal iliac. He does perform an angiogram of the inferior epigastric artery branch. He then catheterizes the inferior epigastric (lt), does an angiogram, embolizes it and finally, a LIMA catheterization with angiogram. I have 2 concerns--1. What, if any, diagnostic angiogram code should I use? From his report, it would seem like I could use 75756 and 75716 with possibly 75774 but i am hesitant about the 75716. 2. For the selective catheterizations, would it be 36456 (inferior epigastric branch, 36246-59 (lt internal iliac), and 36215? I know that I need 75894, 37204, and 75898 for the embolization and follow-up. Thanks for any help. Chris

Embolization of kidneys

Hi Everyone, Embolization of the kidneys to we bill 37204 once or twice? Also emboliztion of an ovarian artery for abnormal bleeding should we use 37204 or 37210?

Embolization of Lower Pole and Midportion of the Left Kidney

"CFA is accessed. SOS catheter is used to selectively catheterize the LRA. Following review, decision is made to embolize two of the three branches of the left renal artery using ProGreat microcatheter, and coil embolization is performed. Following embolization, the percutaneous neprostomy catheter is removed. During removal of this, the existing double-J was also inadvertently pulled through the tract. Removal of the double-J was not intentional and was accidental."  Would we charge codes 37204/75984 twice? Also, would we charge for the accidental removal of the double-J tube? Not sure what all codes would be valid with this report.

Embolization of scrotal varices

Good afternoon to you all, My patient has scrotal varices and presented for embolization. We were unable to locate the left renal vein after injection in the IVC, therefore we did a selective renal artery injection to locate the renal vein. The arterial injection was not done for diagnostics only localization, would you still code 36245 for the catheterization? Appreciate your comments, jb

Embolization of superior and inferior left throcervical, internal mammary

Dr. Z, Coil occlusion of superior and inferior left thyrocervical artery, right internal mammary artery and right innominate vein, would these be coded with 37204 or 61626? Thank you

Embolization of Uterine Artery Punctured During Uterine Fibroid Embolization

While performing uterine fibroid embolization, an accidental puncture of the uterine artery was made. This required an additional coil embolization. Is there any way to code this separately?

Embolization Surgical Site

I understand that embolization is based on surgical site, so all embolizations done in AVF would only be billed one time. However for pulmonary AVMs, what is considered the surgical field when multiple lobes are treated? Are the entire lungs considered one surgical field? Per embolization? Any guidance is greatly appreciated.

Embolization with Diagnostic Angiogram

I hope you can help with this case: "Female patient with excessive post-partum bleeding presents in IR for eventual embolization of the bleeding vascular source. No previous diagnostic study performed. Bilateral selective (internal iliac arteries) pelvic diagnostic angiograms, complete (75736 x 2) and bilateral supraselective (uterine arteries: 36247 x 2) diagnostic angiograms, complete (75774 x 2) from left groin access were performed. Diagnostic angiograms reviled sources of bleeding resulted in decision for embolization. Embolization was performed, bilateral, with follow-up angiograms post embolization (37244)." Can we code and bill diagnostic angiograms along with embolization in this coding scenario?

Empyema Drain 2014

Initial Question: Can you please clarify whether an empyema drain would be reported with code 49405 or 32557 for 2014? Follow-Up Question: I have a question about your response I received. Code 49405 lists lung/mediastinum in parenthesis in the CPT Codebook, and I have heard this is the way to bill for an empyema drain. If not, when would it be appropriate to bill code 49405 for the lung/mediastinum?  Thoughts? 49405   Image guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous

Endarterectomy and Stent Placement

Original Question: Where can I find documentation on billing or not billing codes 35301 and 37215 on the same day in the same vessel? Follow-Up Information Provided Upon Request: The doctor performed an endarterectomy of the carotid bifurcation into the internal carotid and also did one of the external carotid and did a patch angioplasty. Then he punctured the patch and placed a stent in the origin of the common carotid.

Endarterectomy Procedures

If a patient has endarterectomies performed in the common femoral, profunda femoral, and superficial femoral, can all three be coded? Do the territory rules apply for the PTA/stent/atherectomy rules to the endarterectomy procedures (35301-35372), which only allow one intervention in the fem/pop region?

Endarterectomy vs. Stent Placement

I cannot locate information for coding femoral endarterectomy and stent placement. "Operative Note: After completion of the endovascular stent graft, the external iliac, profunda femoris, and SFA were clamped and the sheath removed. A longitudinal incision was created in the common femoral artery, and extensive plaquing was noted, necessitating endarterectomy of distal external iliac, common femoral, and profunda femoris origin. Additionally, a stent was placed in the proximal superficial femoral artery to tack down the plaque at this level. This was performed, and then a patch angioplasty was used to close the arteriotomy." Would it be appropriate to code for the endarterectomy (35371) or the stent (37226), as I don't feel you can code for both procedures since they are within the same vessel.

Endarterectomy with Open Bypass Surgery

The physician performed left common femoral endarterectomy (35371), left axillary artery to common femoral artery extra-anatomic bypass (35621), and left femoral to below-knee popliteal artery bypass (35656). I run the NCCI edits, and all codes can be billed together. However, my confusion comes with your coding tips that when a new bypass is performed the inflow/outflow includes thrombectomy and endarterectomy related to the bypass. So, can I bill these three codes together?

Endo Leak Status Post EVAR

Can you take a look at this case for me? I have seen a few of these, and I am not sure if I am coding these correctly. The codes that I am coming up with are 76937 (ultrasound), 36246 (left internal iliac), 75736 (left internal iliac), 37204, 75894, 75898 (embolization), G0269 (Mynx), 36245 (right L3 lumbar artery), 36245, and 36248 (left L3 artery including 2 feeding ascending lumbar pathways). Please let me know if I am close and thank you for your help.  Here is the procedure: Reason for Exam: Abdominal aneurysm.  Findings Exams: Abdominal aortogram with selective left internal iliac arteriogram disease (3rd order), embolization non-neuro, placement of vascular closure device. History: Abdominal aortic aneurysm, status post EVAR with type II endoleak and enlarging aneurysm sac Technique: Intravenous conscious sedation with Fentanyl and Versed was administered in my presence. The patient was continuously monitored by a special procedures nurse for a duration of one hour and 30 minutes. Fluoroscopy time: 28 minutes. The left groin was prepped and draped with the maximum sterile barrier technique. Ultrasound was used to identify a patent left common femoral artery and image recorded in PACS. Using ultrasound localization, sterile technique, and lidocaine anesthesia, a 21 gauge needle was placed into the upper left superficial femoral artery and exchange made for a 5 French sheath. Aortogram, selective arteriography, and intervention is as detailed below. Findings: Abdominal aorta: AP aortography shows no evident type I endoleak, however delayed imaging shows prominent flow through the left ascending lumbar artery with retrograde flow into the left L3 lumbar artery and perfusion to the endoleak cavity. The inferior mesenteric artery fills via the marginal artery, but does not course back to the aneurysm sac and is not felt to be a contributor to the endoleak. Both renal arteries show mild stenoses with some irregularity of the main renal arteries which may be due to fibromuscular disease. Left internal iliac artery: Selective injection shows prominent ascending lumbar artery which bifurcation shortly after its origin and filling of a large L3 lumbar artery which is patent to the endoleak cavity. This felt to be the etiology for the endoleak. Catheterization of the ascending lumbar artery with negotiation of the multiple turns required to catheterize the endoleak cavity was quite difficult, but eventually was achieved with a Progreat catheter. Injection within the endoleak cavity confirms appropriate placement with outflow via the right L3 lumbar artery. The endoleak cavity was then filled with multiple 8 and 10 mm Nester microcoils. Catheter was negotiated into the proximal right L3 lumbar artery and occlusion done with 6 mm microcoils. The left L3 lumbar artery as well as 2 feeding ascending lumbar pathways were occluded with multiple 2 mm to 4 mm Nester microcoils. Completion and spot films show no residual filling to the endoleak cavity. The left femoral access site was assessed and closed with the Mynx closure device. Good hemostasis was achieved. Impression: 1. Type II endoleak via the left ascending lumbar and retrograde flow in left L3 lumbar artery. Successful coil occlusion of the endoleak cavity and feeding arterial pathway was done as detailed above.

Endograft Abdominal Aorta Bifurcated Modular, with No Docking Llimbs

Our physicians placed an abdominal modular bifurcated endograft, but they did not place the contralateral iliac docking limb. Instead they went through the brachial artery (due to left iliofemoral disease) and placed three iCast stents sequentially in the left common iliac artery. Should we charge code 34802 for all the work, or should we charge code 34805 and an iliac stent placement (37221)?

Endoleak Repair with Endostaples

"A patient had an AAA repair approximately 10 years ago. He developed a type 1 endoleak and presents to the endovascular suite for repair. There was a cutdown on the right side with placement of a catheter into the aorta. A percutaneous approach was done on the left side with a catheter into the aorta. The endoleak was located and repaired with the Aptus endostapler to seal the leak at the top of the stent graft." Since this is not a repair using an extension, we were not sure how to code this. Would it be an unlisted code? Any guidance would be appreciated.

Endoleak treatment with 37205

Please do NOT include any actual patient medical records with your question. Hello again, If a patient returns for endoleak a few days after AAA repair, and two Palmaz stent are deployed in the AAA neck and two more additioanal extensions in the common iliacs can I charge for the stents (37205 & 37206). I am heading more for a "NO" as this were done for anchoring purposes not for stenoses.. Please Advise...

Endologix AFX Device

The IRs are recently using the Endologix AFX device, but dictation is very poor, making it difficult to decide if I should be using codes 34804/34825 or 34845. I am leaning towards code 34845 because, in their reports, they state they are placing the main body device and then placing a proximal device in the infrarenal location without comprising the renal arteries.

Endoscopic Vein Harvesting

Physician harvested saphenous vein endoscopically (33508). Vein is no good, so same procedure is performed on the opposite leg. Can he bill code 33508 two times?

Endovascular Aneurysm Repair with Aortic Cuffs

"Patient has history of end-to-side aorto-bi-femoral bypass and has developed a large AAA anastomotic aneurysm at proximal aorto-bi-fem bypass anastomosis. Aorto-bi-fem limbs are patent. After right fem incision, sheath was advanced up right iliac system. Surgeon placed aortic cuffs starting distally from old aorto-bi-fem bypass and building proximally up to infrarenal aorta utilizing 5 aortic cuffs overlapping. Proximal, distal, and junctions were ballooned. Angiogram revealed junctional leak. Reballooned. Persistent junctional leak. Two more cuffs were placed overlapping in midportion of previously placed cuffs and then ballooned. Leak improved, but was still faintly present. Patient not candidate for open repair. Surgeon feels that with heparin reversal and time this faint leak will seal." Is aneurysm repair with tube prosthesis 34800 and one cuff 34825? Or is the initial code 34825 since he used cuffs and it is for aneursym repair? I see the cuff code descriptions are for inital vessel and each additional vessel. This was all done in the aorta, so only one vessel had intervention. Seven aortic cuffs in all.

Endovascular Reconstruction for Occlusive Disease (not AAA)

What codes would you recommend for endovascular reconstruction of the aorto-bi-iliac vessels for occlusive disease? Exact same technique as an AAA repair, but not for aneurysm. Bilateral cutdowns. Bifurcated endoprosthesis deployed in aorta and bilateral iliacs, and iliac extender. Would you recommend unlisted? Or code it with the new stent codes (37236/37237)? According to the CPT Codebook, 348XX codes are exclusive to aneurysm repair.

Endovascular Repair of Popliteal Aneurysm

What code should I use for a Medicare patient with popliteal aneurysm when the physician plans to repair with percutaneous placement of a covered stent graft?

Endovascular Thoracic Aorta Stent Graft Procedure

I've got a couple of questions regarding the below patient. Is femoral cutdown (34812) always performed with these procedures? Our provider didn't document an open cutdown, only that 5 french sheath was placed into the common femoral arteries. "Following deployment of the endograft with intentional partial left subclavian coverage (33880-62) he attempted to close the left femoral arteriotomy using the Perclose Prostar sutures; however, they prematurely knotted in the subcutaneous tissue because of vessel depth in this obese patient. In order to control bleeding without vascular control of the artery established, he used a balloon in the iliac artery so he could surically repair the left common femoral artery with placement of a bovine pericardial patch." I'm thinking I should code this part of the procedure as 37204, 75894, and 35286, but I wanted your expert opinion. Here are the codes I came up with: 36200-50, 33880-62, 75956-26, 37204, 75894-26, 35226.

Endovascular Thoracoabdominal Aneurysm Repair

Patient with a stent graft in the proximal to mid descending thoracic aorta who is 8 months out s/p. Now with enlargement of not stented area (thoracoabdominal aneurysm repair). Physician performed the repair with stenting thoracic and abdominal aorta with total of four stents starting from abdominal aorta bifurcation and last one overlaps the previous stent in thoracic aorta. Is this correct to code aneurysm repair in the thoracic aorta (36200, 33881, 75957) with proximal extension (33883, 75958) and abdominal aorta aneurysm repair (34800, 75952) separately? Does the way the physician builds the grafts in thoracic aorta (proximally or telescopic way) affect coding (e.g. in this case the main body first in distal thoracic with one extension proximally to overlap with previous stent)?

Endovenectomy with Patch Angioplasty

"Procedures performed: Bilateral groin cutdown with common femoral vein exposure. Extensive left  common femoral vein endovenectomy followed by patch angioplasty. Focal right common femoral vein endovenectomy with primary closure. Kissing stents from IVC into the iliac system... Left groin venotomy was made and extended. An extensive amount of scarring was saline(?) as typical of chronic thromboses with recanalization and anatomy was seen. Extensive endarterectomy of the common femoral into the profunda and also the femoral vein and distal external iliac vein was performed. A bovine pericardial patch angioplasty with 6-0 prolene running suture was performed." We were unsure if open thrombectomy code 34421 would be appropriate in this case without findings or removal of thrombus. Is the reference to the scarring typical of chronic thromboses sufficient? We were unable to locate a venous equivalent to an endarterectomy. Your guidance is greatly appreciated.

EP Ablation Components

I know this has been addressed many times, but I'm still not totally clear on the requirements of the new ablation codes. The errata says to document the reason any components might not be performed in order to use code 93656, which doesn't seem logical to me since the new descriptor states "when possible". I would think the reason for not performing would be needed on 93653 and 93654 instead. Do you recommend including the reason for not performing on all three ablation codes? I realize that would seem to be the easiest fix; however. I'm still struggling to get my physicians on the bandwagon and don't want to ask for more than I need.

EP Ablation Procedures

Is it appropriate to assign EP codes 93620, 93653, and 93656 when it is not necessary to induce an arrhythmia? In some cases, the patient presents for the procedure with an arrhythmia, such as atrial flutter, already present.

EP and echocardiogram

Dr Z I would really appreciate your assistance in the EP case below. The intended procedure was EP ABL w/ 3D mapping for A-fib. However all that was done was 93662 intracardiac echocardiogram which is an add on code with 93651 which did not take place. I have searched your database extensively and the only example I can come up with is for a PFO in which you suggested to use a 74 modifier for the intended procedure along with the add on code. Based on this would I charge 93651-74 and 93662. Or charge for possibly TEE 93318 as a completed procedure? Thank you for your expertise, Terri DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the electrophysiological laboratory in a fasting state. The patient's oropharynx was anesthetized using aerosolized lidocaine spray. Once sedation was achieved, I manually advanced the echo probe passed the oropharynx into the lower esophagus. Limited echocardiographic images were obtained in multiple views. FINDINGS: Left ventricle size is grossly normal. There appears to be left ventricular hypertrophy. Global left ventricular systolic function is normal. Ejection fraction is visually estimated to be 60-65%. There are no regional wall motion abnormalities. Right ventricular size and systolic function within normal limits. The mitral valve is morphologically normal. The tricuspid valve is grossly normal. The left and right atria both appeared mildly dilated, both measuring approximately 4.5 cm. The intraatrial septum is intact to 2-D imaging. There is a mass in the tip of the left atrial appendage thrombus highly suggestive of thrombus. Doppler velocities in the left atrial appendage are less than 0.4 meters per second. CONCLUSIONS: 1. Normal left ventricular size and systolic function. 2. Biatrial enlargement. 3. Left atrial appendage thrombus. PLAN: Based on this study, we will defer on left atrial ablation. His anticoagulation will be restarted and we can consider restoring sinus rhythm in approximately 1 month.

EP codes

Dr. Z, I have a couple of questions on 2013 codes. For 93656 I have heard that HRS is trying to get clarification or re-wording on the code so it does not read like all components must be done and if this is not accomplished a 52 modifier will be needed for professional billing. What are your views on this? And have you heard if there is to be any clarification of the code? Second question, there is no reimbursement on the SICD T codes is there? Thank you, Debbie Grant Follow-up Question: Dr. Z,   Thank you for your answers.  I know that you are recommending not charging for 93623 now and was wondering about 93621.  It is still an add on code to 93620 and causing an edit with 93653 and 93654 due to no primary procedure code.  What are your recommendations for this?   Thank you,   Debbie  

EP Possible Parent Coding 93653 and 93654

Below is a report from one of our physicians. Both coders disagree on the coding, and I would like your input, as it involves parent codes 93653 with 93654. Coder #1 reported codes 93654 and 93623. Coder #2 reported codes 93653 and 93621. PREPROCEDURE DIAGNOSIS Supraventricular tachycardia. POSTPROCEDURE DIAGNOSIS Typical atrioventricular nodal reentrant tachycardia. PROCEDURES PERFORMED 1. Comprehensive electrophysiology study with coronary sinus pacing and recording. 2. Arrhythmia indJction. 3. Drug infusion with isoprotereno~ 4. ~electroanatomic mapping. 5. Radiofrequency ablation of typical AV nodal reentrant ta~rdia with modification of the AV nodal slow pathway. HISTORY OF PRESENT ILLNESS This is a 61-year-old female ~.~tmedical history significant for recurrent frequent episodes o~dpalpitations. The patient had a recent visit to the hospital at Flagler where she was noted to have heart rate of approximately 200 beats per minute, which terminated with adenosine. The patient now presents to electrophysiology laboratory for further evaluation and management. DESCRIPTION OF PROCEDURE The patient was brought to electrophysiology laboratory and appropriately identified on the table. Twelve-lead ECG electrodes were placed in the patient and vital signs were recorded at baseline. A conscious sedation was administered by the nursing staff with intravenous fentanyl and Versed. The patient was prepped and draped in standard sterile fashion. Sheaths were inserted using modified Seldinger technique as indicated below. Catheters were then subsequently advanced to the sheath and placed in the heart under a cardiac fluoroscopy. Baseline intracardiac recordings were obtained followed by standard EP study. During the entire procedure, the patient's vital signs were continuously monitored, remained stable. Details of the EP study and subsequent ablation were outlined below. The patient remained hemodynamically stable and com£ortable throughout the en~ire procedure. At the conclusion of the procedure, all catheters were removed from the heart and woa~d sites were then dressed and the patient wls transferred to t~e Recovery Room '£~ea in stable condition. The postoperative orders were wfitten at that t~e. ; SUPPLIES < Diagnostic catheters were placed at the level of the high right atrium, His, right ventricular apex. A diagnostic catheter was also placed in the main body of the coronary sinus. A 4-mm radiofrequency ablation bidirectional catheter was used for right atrial mapping and ablation. BASIC EP STUDY FINDINGS 1. The AH interval was 101 msec, the HV interval was 39 msec. 2. The VA Wenckebach cycle length was 360 msec at baseline. The right ventricular effective refractory period while pacing from the right ventricular apical catheter was 220 msec at a pacing cycle length of 600 msec. 3. The AV Wenckebach cycle length was 400 msec while pacing from the high right atrial catheter. 4. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec. ARRHYTELl\,fIA AND ABLATION The patient presents to the electrophysiology laboratory in normal sinus rhythm. Following administration of conscious sedation, we proceeded with a basic EP study. The patient had normal EP study findings at baseline. Upon insertion of the catheter, she immediately went into a spontaneous supraventricular tachycardia. The tachycardia was typical AV nodal reentry for the following reasons. 1. The septal VA t~~e during SVT was approximately 0 msec, making typical AV nodal reentry the likely diagnosis. 2. The SVT tachycardia cycle length was 410-420 msec. 3. During a right ventricular apical pacing, the atrial activation sequence in the coronary sinus catheter was concentric, making left lateral pathway and AVRT unlikely. 4 .. During SVT, entrainment from the right ventricular catheter revealed a VAHV response to pacing, making atrial tachycardia unlikely. 5. During supraventricular tachycardia, right ventricular entrainment revealed a post-pacing interval minus tachycardia cycle length of 145 msec, making AV nodal reentrant tachycardia the likely diagnosis. 6. His-synchronized ventricular premature depolarizations during SVT did not reveal the presence of a septal bypass tract and was not able to the atrium. The patient had easilY sustained episodes of supraventricular tachycardia, which were spontaneous and also reproducible with both ventricular and atrial extrastimuli from the high right atrial, coronary sinus, and right ventricular catheters. We observed both echo beats and sustained tachycardia. At this t~~e, we proceeded with modification of the AV nodal slow pathway. The ablation catheter was positioned across the posterior septum just posterior t{ i the coronary sinus ostia. 3D electroanatomic mapping prior to this was used to identify the dehisced as well as the coronary sinus ostia. Ablation catheter was positioned across the tricuspid valve annulus with an A-V ratio of approximately 1-4. Using power controlled settings of 50 watts and 55 degrees under temperature, serial ablation was performed in this area. We monitored the AH and HV intervals during this time and a junctional ectopy was observed throughout the duration of these lesions. At final conclusion of my ablation, I rechecked the patient for dual AV nodal physiology. No sustained tachycardia was observed. Isoproterenol w~started up to 2 mcg per minute and no evidence of inducible SVT was no~ecr. With frequent atrial and ventricular extrastimulus pacing, the patient did have 1 echo beat with atrial extrastimuli; however, with continued decremental pacing on our extrastimulus beat, the patient would block on the subsequent beat. At this time, this was considered an acceptable endpOint as the patient previous to my ablation had easily inducible SVT. After waiting period, we attempted arrhythmia induction again and SVT was no longer observed. At this time, the procedure was terminated. AH and HV intervals remained stable and comparable to baseline. The postablation AH and HV intervals were 85 and 42 ITsec respectively. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec at this time. The catheters and the sheaths were then removed from the heart and body. Hemostasis was achieved. The patient made a complete neurologic and hemodynawic recovery. CONCLUSIONS 1. Normal EP study findings. 2. Typical AV nodal reentrant tachycardia. 3. Successful ablation of typical AV nodal reentrant tachycardia with modification of the AV nodal slow pathway.

EP repeat study

Hello Dr. Z, In your book you mention that a repeat EP study should not be coded â?oon a subsequent date unless there is documentation of a new arrhythmiaâ?. What types of circumstances would this include? VT vs. SVT? Same type of arrhythmia in a new location? Examples of when it would be appropriate to code an EP Study on a subsequent date due to a new arrhythmia would be especially helpful. I would appreciate any input you can provide. Thank you for your time. Jill Paul CPC-San Diego

Epicardial Ablation

I have never coded for the epicardial access for EP ablation and have not been able to find information. Would you give your insight on what the following procedure coding would look like? The patient was brought to the EP lab. The ICD was reprogrammed and interrogated. Both groins were prepped in the usual fashion. Local anesthetic was applied to the skin. Following a modified Seldinger technique, one 8 French sheath and one 11 French sheath were placed in the left femoral vein. A 4 French sheath was placed in the right femoral artery. Via the subxiphoid approach, epicardial access was obtained with an epidural needle and an 8 French flexible steel Arrow sheath. Mapping and ablation catheters were placed in the 9 French sheath and 9 French Arrow sheath. A 3D map of the epicardium was created. The 4 French arterial sheath was exchanged for an 8 French Arrow sheath due to the torturous nature of the aorta. During epicardial mapping an IBI HIS catheter was placed in the right and left ventricles for pacing. There was a patent foramen ovale present. The mapping and ablation catheter was advanced through the aorta to the left ventricle via the retrograde approach. Left ventricular pacing and recording were performed, a 3D map of the endocardium was created. Ventricular stimulation was performed and programmed ventricular stimulation was performed. Several different VT morphologies were induced by ventricular pacing. All of the VTs were mapped to an area posterior to the mitral valve. RF energy was delivered with termination of the VTs from within the left ventricle, epicardially, and from the anterior cardiac vein. Aspiration of the pericardial space was performed throughout the case. At the end of the procedure, protamine was given, Solumedrol 125mg was given via the epicardial sheath, the sheaths and catheters were removed, and good hemostasis was achieved with direct manual pressure.

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