Knowledge Base

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Fluoro Guidance during Operating Room Procedure

Can we charge for fluoroscopy guidance (77003) when the fluoroscopy is provided by a radiology tech and the procedure is performed by a surgeon? The surgeon dictates fluoroscopy guidance was used in the operating room procedure. An example is code 62311, epidural injection (myelogram, epidurogram, and arthrogram are not performed in the OR procedure).

Fluoro guidance for epidural and facet injections

Dr. Z, If a patient recieved an epidural injection along with a facet injection, can I add a modifier 59 to 77003 (fluoro guidance for the epidural)? Patient has right lower back pain radiating to the right lateral thigh. Impingment of right L3 and L4 nerve roots seen on recent MRI. Patient also has moderate central canal stenosis and facet arthrosis per the CT done 9 days earlier. Thanks for any help you can give me. Michelle

Fluoro Guidance with Port Removal

One of our IR docs is taking a spot image after removal of a port and cath, and we are trying to determine if it is appropriate to bill code 77001-26 in this circumstance (pro fee side).  What are your thoughts?

Fluoro of the diaphragm with heart cath and biopsy

Here is a brief synopsis: the patient is having prolonged post-transplant hospital course with persistent pericardial effusion and persistent mild respiratory distress. The patient presents to cath lab for fluorscopic evaluation of the diaphragm as well as her routine post-transplant RHC and biopsy. The eval of the diaphragm is a fluoroscopically saved image which demonstrated that the left hemidiagphragm is paretic with evidence of paradoxial motion of the diaphragm. The existing pericardial drain and 350 ml of straw-colored fluid was removed. Oximetries & hemodynamics of the RH were done pre and post pericardial drainage. Endomyocardial biopies were done X5. I wanted to bill 93451-26-59, 93505-26, 33010, and 76000-26. However,76000-26 hits an edit with 93505 as bundled and no modifier is allowed. Is there another code I should be using or is the evuluation of the diaphragm non-billable? Thanks so much for your help with this scenario!!!

Fluoroscopic insertion of spinal fiducial marker

What are the appropriate facility codes for the fluoroscopic insertion of spinal fiducial markers for a spinal tumor? If the patient is a medicare outpatient, would HCPCS C9728 and 77002 be the correct codes for this type of case?

Fluoroscopy and G0260

Dr.Z, Since code 27096 now includes fluoro, does G0260 follow the same rules and include Fluoro? Thanks so much Henri

Fluoroscopy and room time

Dr. Z, a facility wants to charge 76001 for a tech and a fluoro machine being in the OR for more than an hour even though the documented time for use of the fluoro is less than an hour. There is a physician in the room for more than an hour but the fluoro machine is not being used for the whole time. What is the correct way for the facility to code for the fluoro when the OR procedure does not involve an S&I code and the documented time is less than time in the room. Thank you.

Fluoroscopy to check a valve or a lead

Hi Dr. Z We were discussing the fluorscopy code (76000) vs the cineradiography code (76120). If the doctor uses fluoroscopy to check on a valve or a lead, takes some images and that is all....which code is appropriate or can both be used? Thanks for your help!

Fluoroscopy with Tunneled Catheter Removal

Original Question: Will you please address the issue of tunneled catheter removal since it now has its own code (32552)? Is it appropriate to code a fluoro guidance code, 76000 or 77002? I don't get an edit, but the your IR book states S&I is N/A. In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter. The catheter could have been compromised because of infection. Why is this?  Thank you! Additional Information: In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter.  The catheter could have been compromised because of infection.  

FNA Thyroid

We have a question regarding FNA of thyroid nodules. We have a physician who mentions in his report that he is doing a capillary and suction technique, but never mentions FNA. When we say we need documentation for FNA versus core, his reply is "capillary and suction technique" is FNA. Can we assume and code these as FNA? Please advise.

FNA vs. Core Biopsies

I have a radiologist who has told me whenever he does a biopsy of the thyroid it is always core; however, he never dictates "core" in his reports... he always just says "tissue". Pathology from the hospital always says FNA. So my question is, do I report code 60100 because that's how he instructed me to code, or do I go with the pathology and report code 10022?

Foley Balloon Placement in Pleural Space

We have a patient who had an IR px for insertion of a Foley balloon into the pleural space with injection of calcium channel blocker to stop a massive hemothorax.  Once bleeding was controlled, it was determined that the intercostal artery was punctured from a previous chest tube placement. Do you have a suggested CPT code and ICD9 px code?

Foley catheter placement in the cath lab or EP

Can we code/charge for foley catheter placement in Cath lab or EP lab? It's done prior to long procedures in EP. It's done in the Cath lab if the bladder is too full or patient will have difficulty using bed pan after procedure. As always, we appreciate your assistance! Thank you!

Follow up CT MRI during 90 day global

Dr. Z, Our radiologist does Discectomies, vertebroplasties, and kyphoplasites quite a bit. He always has a follow up CT/MRI in 2 weeks to 1 month. These procedures have a 90 day global, can I charge for the follow-up CT/MRI? Thanks

Follow-up angiography

For follow-ups post infusion/embo (75898), I know it's to be done once (other than for intracranial procedures), but my physician asked about doing multiple AVM's (right and left lung), if they embo there, is that still just one follow up? or would it be two, one for each lobe? Same for multiple hepatic tumors? one follow up even if they embo multiple tumors through different cath. placements? thanks!

Follow-up angiography following cerebral aneurysm embolization

Please do NOT include any actual patient medical records with your question. DR Z I have a general question about Follow-Up (75898 ) charges. We coiled a cerebral aneurysm. Nine coils were placed into the aneurysm but only the last 2 were deployed.The other seven were removed because the DR did not like their placement. After each placement a follow-up angio was performed. Do you charge 9 follow-up's or only 2 for the 2 coils that were leftin for the embolization? I say you only charge Follow-up for the coils that actually embolized not the ones that were removed. TY

Follow-Up Diagnostic Mammography with CAD

A question came up as to whether or not it is appropriate to charge for CAD when performing "spot compressions" on a follow-up diagnostic mammogram. Is there a requirement for the type/number of images on a diagnostic mammogram in order to charge CAD?

Follow-up on Carotid Cavernous Embolization

"Patient had right-sided carotid cavernous fistula and upon imaging before embolizing the right they discovered that a left carotid cavernous fistula was present, so they came back two days later to embolize the left. They performed a bilateral cerebral angiography from the common carotids prior to the embolization, which was performed from the left cavernous sinus via femoral vein access. After embolizing, the physician came back and performed cerebral angiography as a follow-up from the bilateral internal carotids, the bilateral external carotids, and the left vertebral." So my question is, can I code the extrernal carotids as angiography?  Or do I have to consider those a follow-up? Also since the catheter went further and since we code to the highest catheter placement, I am unsure if I should code the highest order and use the internal carotid code 36224 instead of the common carotid code 36223... or should it be 75898?

Follow-up to Cone Beam CT coding (Question 2143)

Does a separate report need to be created to support the filing of both codes 76380 and 76377 when a cone beam CT hepatic artery injection and 3D reconstruction are performed in conjunction with diagnostic hepatic arteriography in Y-90 planning? Alternatively, in reporting codes 76380 and 76377, is it sufficient to only note that the cone beam CT was completed during the angiographic procedure? Findings are reported as a single discussion without specifically noting what modality (angio or CT) was used, both having been completed. Reference is made to the angio and CT in the conclusion. How much documentation is required to support these codes?

Fontan Fenestration dilation

Dr Z, What is the appropriate code for balloon angioplasty of a Fontan fenstration? " we then turned out attention to the Fontan fenestration. We crossed the Fontan fenestration with a coronary wire and glide catheter. We then exchanged the Glide catheter for an Apex RX 4.5 mm x 20 mm balloon. We advanced the balloon over the wire, across the Fontan fenestration and made a total of 3 inflationsfor a total of 6 seconds each. We then repeated the IVC angiogram and this revealed much improved shunting throught the Fontan fenestration and a slight drop in arterial saturations." Cath lab is using 92992, however I don't think that's correct. Is this an unlisted 93799 or would it code to a valvuloplasty code? Thanks!

Foreign Body Removal of Occluder Device

After a PFO closure procedure (93580) the occluder device was seen to be floating in the left ventricle. During a second procedure, on the same day, the same doctor retrieved the device. To capture the device he actually pulled it back into the ascending aorta and there successfully pulled it into the sheath. Can I use code 37197 for this procedure or go to an unlisted procedure code?

Four Coronary Artery Stents

"1st lesion intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the 1st obtuse marginal 2nd intervention: A successful stent with balloon angioplasty was performed on the 99% lesion in the 2nd obtuse marginal 3rd intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the right posterior descending artery. 4th intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the mid RCA." I am reporting codes 92928-RC, 92929-RC (right posterior descending), and 92929-LC (1st obtuse). Can you code for the 2nd obtuse (92929-LC)? Per CPT: Additional PCI in a third branch of the same major coronary artery is not separately reportable. Since there are two PCI in one branch and one PCI in another, could you use code 92929 three times? I understand that Medicare considers the add-on code bundled into the base code.

G tube check without fluoroscopy

In the main radiology department, the tech will inject the gtube with contrast but then not use fluoro. they use regular xray instead. would we still charge a 49465 or something else?

G-Tube Unclog

How would you code a clogged G-tube clearance using soda water with follow-up contrast injection to confirm patency?

G0269

Please do NOT include any actual patient medical records with your question. For 2011, would the G0269 code still be coded with heart catheterizations for hospital side coding? The CPT coding notes say that closure device placement is inherent to the catheterization and not separately reportable, but we were not sure if that applied to this code. Also, if the patient came back and just had stent or angioplasty(no heart cath)would the G0269 code be used then? Thank you.

G0269

Dr.Z: I'm confused to when we can code for 75710 when doing diagnostic angiograms? Example:Right Common femoral artery was selected.AP views showed to have normal caliber and branching. The puncture site was appropriate for Angio Seal device deployment. They then continue with the diagnostic angiogram. thank-you for your help.

G0269

Is use of a closure device included if only a cardiac intervention is performed & not a diagnostic cath? Thanks

G0269 and procedures CPT says it is bundled into

Dr. Z, At a resent conference, the speaker said that CMS wants us to charge for the closure device procedure, G0269, even if it is bundled in the procedure. The speaker said they want to know when the closure device is used for statistical reasons. Do you know of this being true with CMS? Thanks!

G0269 with 36251-36254

Hello Dr Z! I was wondering regarding the renal codes for 2012, 36251, 36252, 36253 and 36254, all thou it does not say it in it's description, but is the closure device to be included in the charge as they were for the cardiac cath /endovascular revascularization codes for 2011?

G0269 with 92980

Hi there-- In the facility setting as of 2011, I know that we are no longer supposed to bill G0269 in conjunction with diagnositc cardiac catheterization procedures. But is it still ok to bill G0269 if the only procedure performed is a PCI Procedure? (ie. a stent, PTCA, or atherectomy)?

G0269/93799 Occlusive Device Placement

I am trying to put together a list for my IR department that contains information regarding occlusive device placement charges. Do you have a list of the procedures that bundle the charges for the placement, as well as a list of procedures where the charge is allowed to be added? The devices have C-codes, so I want to have the appropriate charge on the accounts.

G0275 in 2014

Our end coder, Code Correct, is advising that code G0275 has been deleted for 2014, but that G0278 is still active. Is it true? And if so, is MCR accepting any other code? I could only find a vague reference to it on MCR under Part A.

G0275 vs 75625

Dr. Z; I am torn on this report with the proper code assignment. In all honesty I am not sure that code G0275 is correct on this account and the Cath lab assigned 75625. I am in total disagreement with assignement of 75625 also I am not sure that G0275 is supported by this limited documentation. I am only giving infomration related to the abdominal aortography section of the report. Procedures Preformed: Left heart cath with ventriculography, selective imaging of the coronaries. Abominal aortography. Indications: Angia/MI: stable angina. Coronary artery diesase: suspected and abnormal stress test. Cardiac: arrhythmia. History: The patient has hypertension and medication-treated dyslipidemia. Coronary Bypass abdominal Aortography: A catheter was placed and contrast was injected. Aorta: There was medium-sizwed, localized(saccular) aneurysm formation. Infrarenal location. The root exhibited normal size. Thanks in advance for your help.

G0278

You have written much about G0278 amd G0275. I understand how to code for these and when to use it. However, I have an MD that codes for this but the indication for Cath does not address PVD. Wouldn't you have to mention this in the indication for Cath?

G0278

Please do NOT include any actual patient medical records with your question. Can selective catheter placement be reported when documentation states: A4Fr JR 4.0 catheter was advanced to the aorta and positioned at the vessel origin(common iliac) under fluoroscopic guidance. Right and left side. Cardiologist documents R/L heart cath with cors in addition to bilateral iliac angiography for arteriosclerosis. Department reported 93460. Look forward to your response.

G0278 for iliac imaging during heart cath

Please do NOT include any actual patient medical records with your question. My physician have started doing abdominal arteriogram (75625) on patients who come in for LHC and RHC for possible TVAR procedures.Here is the preop diag. and the finding below. preoperative diag: The pt has moderate to severe aortic stenosis by suface echo and present for evaluation of his coronary arteries and aortic valve for consideration of possible percutaneous aortic valve replacement vs tranditional repair. Findings: Abdominal Aortography: The patient was found to have calcified iliac vessels..diameter 1.6cm lt and rt iliac. My question is should I code G0278 or 75625 or can you code for this procedure when there is only a possible of a TVAR?

G0290, DES

The CPT code book lists one CPT code for coronary stent initial and one CPT code for additional - no reference to type of stent used. There are G codes for CMS patients and those state drug eluting stents. My question: do we charge differently based on bare metal stent placement or drug eluting stent placement? We have been told to have charge codes for bare metal stent placement at one price, and another charge code for drug eluting stent placement at a different price for non-CMS patients. Is this correct?

G0365

DR. Z, The patient came in for AV fistula creation and in the same setting it states 'using ultrasound, the upper extremity was mapped. Based on the findings from the ultrasound decision was made to proceed with a left basilic vein transposition.' Not sure if this is good enough to code 'G0365'along with the creation of AV fistula? Is this ultrasound mapping included in the AV fistula performed in the same setting? Sometimes we see an order stating vein mapping or pre op for AV fistula creation and the procedure is bilateral venogram, please clarify when and what kind of documentation suports 'G0365'? Thanks

Gastrostomy Tube Explant

"Deflation of the balloon was unsuccessful with slip-tip syringe. Using a 25 gauge lidocaine needle, the gastrostomy balloon was ruptured for complete decompression. Gastrostomy tube was then pulled with traction. A sterile dressing was applied."  Is there a CPT code for gastrostomy tube explant?

Graft interventin 37225

Dr Z: My surgeon performed an atherectomy of the distal right popliteal artery. At the same session, he performed an atherectomy of the proximal portion of a right femoral-tibial bypass vein graft near its origin from the common femoral artery. Do we only bill 37225 once since we are in the femoral/popliteal area on both the vein graft and native artery and on the same side or can we bill 37225 and 37225-59 with the vein graft being considered a separate vessel? Thanks for your help.

Graft Thrombecomy with revision

Hello, I need help :) The surgeon did a Graft Thrombecomy with revision (36833). He then did a fistula gram (36147) and because of stenosis in the venous outflow did an PTA (35476 & 75978-26). And a segmental incisiion of graft & overlying skin with primary closure??? Separate incision and closure.. Diag: End-stage renal disease, thrombosed graft fistula with recurrent bleeding from the false aneurysm of arterial limb of the graft with skin erosion. After revison/thrombecomy proc; The inflow was then tapered due to the incision..sheath removal of the graft was clamped proxiamally and distally, sheath withdrawn and sheath hole closed with sutures. Clamps released and palpable thrill was present along the graft, hemostasis was obtained. Counts ere correct x2. The wounds were closed in layers with Vicryl & Monocryl for teh skin Dermabond waa applied to seal wounds. This is what I am not sure about: Incision was then made to excise the sutured skin at the site of graft bleeding. The skin was excised as well as the underlying graft. No evidence of infection. The wound was reapproximated with nylon suture. Because this was a separate incision and it was done after the revision was completed, he feels he should get credit for the work. Since the graft was no infected, I am thinking this is still a part of the revision but not 100% sure. Your advice would be so appreciated! Thanks you!

Gray zone 37204

Dr. Z: Would following be consider one operative field or two separate operative fields?: Following removal of an existing nephrostomy tube and placement of a new tube through a separate access site, active bleeding was noted from the lower pole of the left kidney to the posterior abdominal wall from the old nephrostomy tract. Embolization was performed on a segmental branch of the left kidney. Followup angiograms confirmed adequate occlusion of the vessel. A small focus of contrast extravastion was seen in the hematoma in the left posterior abdominal wall, fed by the left T12 intercostal artery. The T12 artery was embolized. Thank you for your assistance!

GTube exchange w/angioplasty of tract for stenosis

This is my first ever case where the physician is doing an angioplasty of the tract of a gastrostomy because of stenosis.  Wouldn’t I code for the angioplasty?  If so is this considered an open angioplasty or an unlisted code? Your feedback is greatly is appreciated.

Hard copy documentation for ultrasound

Hello, I recently heard a rumor that the Radiologist has to state within the report that hard copy sonographic images were obtain for us to be able to bill out 76942. Is this correct? Your feedback is greatly appreciated.. Thanks so much for all your help....

HCPCS 2014

Do you have any information on what code will be replacing deleted HCPCS code G0275?

Heart Cath Question

We are in discussion with the hospital about billing for intervention on a branch of a major artery. We have a situation where the physician intervened on the LAD (92928, not during an MI), and there was some plaque shift into the diagonal branch of the LAD. Physician then did angioplasty (92921) on the diagonal branch. Can we show that this was performed? (I know we, as physicians, don’t get paid, but we need to show it was performed.) The hospital says no because the physician caused the shift of the plaque.

Heart Cath with Intent to Place Closure Device

For example, 93458 done, and femoral angio performed with the intent of placing a closure device. Decision made not to place the device. How should this scenario be coded? Also, same scenario and closure device was placed how should that be coded? Within our cath lab we have debated this round and round and I would like the clearest guideline. 

Heart catheterization and 36010

Dr. Z, Question#4. If the physician perform a congenital or a non-congenital heart cath can the code 36010 be assigned along with 75827 or 75825 if the documentation supports? I think thing this can be used with a -59 but then again if the physician already has the catheter within the parameter of the heart/headed towards the SVC or IVC to take a picture then it seems that it can be an inclusive code.??

Heart catheterization documentation

Hi Dr. Z and Dr. Dunn, I have a couple of questions regarding required documentation. If a report lists hemo measurements, including systolic and end diastolic LV pressures, does the note also have to have specific verbiage stating 'the catheter crossed the aortic valve' or 'the catheter was pulled back (out of the valve)'? Wouldn't the documentation of those measurements be sufficient enough to bill for a left heart cath? On a similar note, does the report have to specifically state 'the coronary arteries were selectively injected' if the purpose of the exam is to evaluate CAD and the coronary vessels and any disease is described? CPT states that 'catheter palcement(s) in coronary arteriy(ies) involves selective engagement of the origins of the native coronary artery(ies)for the purpose of coronary angiography.' I would interpret this as catheter placement in the coronary artery itself or in the aorta at the origins of the left and right arteries. Your thoughts? Thank you so much.

Hematoma AV Fistula

Hi! I'm hoping to get some insight on coding this procedure. Some think it could be a exploration, a repair of a vessel, or a revision. BRIEF HISTORY: The patient is a 42-year-old gentleman who has had multiple AV access operations performed on his right arm. He presently appears to have a hybrid access with a vein to artery anastomosis but a more distal graft. He came to the hospital with this access thrombosed. He underwent percutaneous intervention for opening of the access and this was successful; however, the procedure resulted in a large hematoma in the antecubital fossa. This has been painful. It has not shown any sign of resolution. We studied it in the vascular laboratory yesterday because it was pulsatile. We did not find a false aneurysm. However, I reasoned that the hematoma had sealed or at least was causing intermittent sealing of the puncture site. Given the size of the hematoma, the patient required evacuation and exploration. He comes to the operating room at this time for this purpose. DETAILS OF PROCEDURE: The patient was brought into the operating room and placed on the table in the supine position. His right arm was placed at his side on an armboard and was prepared with ChloraPrep and sterilely draped in the usual manner. Supplemental oxygen was given. Vital signs were monitored. Sedation was induced. Timeout was performed. Operation was initiated with the infiltration of 1% lidocaine and 0.5% Marcaine solution into the skin and subcutaneous tissues of the antecubital fossa. Then, a transverse incision was made incorporating the puncture site. Incision was carried into the subcutaneous tissues. The hematoma was encountered and there was some bright red blood within the hematoma. I evacuated the hematoma and as soon as I did, I was met with pulsatile bleeding. I put my finger on the source of bleeding and then opened the incision wide enough to gain access. At the depths of the hematoma, the AV fistula had a puncture site that appeared to be about 8 French in size. Suction was held to control the stream of blood flow and the puncture was closed with 4-0 Prolene suture. Approximately 200 milliliters of blood was lost during this maneuver. Once the puncture site had been sutured, the wound was irrigated and the hematoma and walls of the false aneurysm were further evacuated. Then bleeders were controlled with electrocautery. Subcutaneous tissues were closed in 2 layers of interrupted and then running 3-0 Vicryl. Skin was closed with a running 4-0 Monocryl suture reinforced with skin sealant. A sterile compression dressing was applied. The patient tolerated the procedure well. As noted, blood loss was about 200 milliliters. No blood replacement was required.

Heparinization and 93458 and not 93463

Good morning, After checking national CCI edits we have a question. When billing for a cardiac cath 93456 is the heparinization inclusive (CPT 93463) or billable separately? We ask because the description of 93456 says includes contrast imaging. Thank you, Jackie

Hepatic artery to right hepatic artery bypass

How would you code a proper hepatic artery to right hepatic artery bypass with a reversed greater saphenous vein?

Hepatic biopsy with pressures

Hello, Could you please tell me if a first order or second order should be billed when doing a liver bx with pressures? The catheter is in the selected Right Hepatic Vein. Contrast is injected. The catheter is put in the Wedge position for pressures. Then core bx is performed. Also, can the venogram w/pressures be billed 75889.59 with 52 for the pressures? Thank you so much.

Hepatic venous sampling after arterial infusion of calcium gluconate, visce

Is there a code for the calcium stimulaton? thanks! PROCEDURE: Following informed consent, and verification of the appropriate patient identification and procedure be performed, the right groin was sterilely cleaned, prepped and draped. Local anesthesia was achieved with lidocaine 2%. Via a right common femoral vein a 5-French vascular sheath was placed.  Through this a 5-French Simmons-2 catheter (modified with two extra side holes 0.5 cm from the tip) was advanced over a wire into the right hepatic vein (second order). Selective right hepatic venography was performed confirming location.  Subsequently via a right common femoral artery puncture a 5-French vascular sheath was placed. Through this a 5 French RC-I catheter was advanced into the celiac artery and celiac arteriography was performed. Subsequently the catheter was advanced to 5 super selective vessels. These included A: The distal splenic artery just proximal to the pancreaticomagna artery, B: The proximal splenic artery just proximal to the dorsal pancreatic artery, C: Proximal common hepatic artery,  :  The gastroduodenal artery proximal to the superior pancreaticoduodenal arcade and E: The superior mesenteric artery proximal to the inferior pancreaticoduodenal arcade. In each super selective site catheterized, selective arteriography was performed. Following selective arteriography the patient was administered calcium gluconate, 10%, 5 cc (0.025 mEq of calcium/kg) intraarterially and right hepatic venous blood samples were drawn 0 seconds, 30 seconds, 60 seconds, and 120 seconds following administration of the intraarterial calcium. This resulted in 20 samples obtained from the right hepatic vein sent for insulin level analysis. The catheters were removed and hemostasis obtained at the puncture sites. FINDINGS: There is classic celiac anatomy. The dorsal pancreatic, pancreaticomagna, gastroduodenal artery, superior pancreaticoduodenal arcade and inferior pancreaticoduodenal arcade are normal. The superior and mesenteric artery and its branches are normal. The right hepatic venogram is normal. No hypervascular tumor was identified angiographically. IMPRESSION: Super selective mesenteric angiography with calcium stimulation and simultaneous selective hepatic venous sampling for insulin levels.  

HERO

Hi Dr. Z, we appreciate your knowledge and expertise, and we can sure use it on the following scenerio. I think we are ok on how to code all the procedures here except for the removal of the HERO. It would stand to reason that if the insertion would be 36558 and 36830-52, then the removal would be 36589 and then a code for a revision/removal/ligation of the AV fistula graft, but I don't see this described here, are we missing something? Did he just simply disconnect the catheter portion from the fistula portion? Thank you so much for your help PREOPERATIVE DIAGNOSES: 1. Chronic kidney disease, stage V, presently dialyzing with dysfunctional right femoral TCC and thus for removal of the same: 2. Thrombosed left jugular HeRO device for removal of same. 3. No further need for IVC filter and thus for removal of same. POSTOPERATIVE DIAGNOSES: 1. Chronic kidney disease, stage V, presently dialyzing with dysfunctional right femoral TCC and thus for removal of the same: 2. Thrombosed left jugular HeRO device for removal of same. 3. No further need for IVC filter and thus for removal of same. NAME OF PROCEDURE: 1. Cutdown exposure of the HeRO catheter at the left jugular insertion site with removal of the HeRO catheter. 2. Removal of IVC filter through the left jugular approach. 3. Replacement of a left jugular tunneled cuffed catheter, 23-cm precurved Palindrome catheter. 4. Removal of right femoral TCC catheter. DESCRIPTION OF PROCEDURE: The patient's left neck and chest were prepped and draped in the usual sterile fashion after adequate satisfactory general endotracheal anesthesia was obtained. The left jugular HeRO catheter insertion site incision was reopened and the HeRO catheter isolated at this location. The catheter entrance tract was encircled with a 3-0 Prolene pursestring suture. The HeRO catheter was then divided and a guidewire passed down into the vena cava through the HeRO catheter followed by complete removal of the HeRO catheter and replacement with a 13-French sheath. The sheath was then replaced with a Cook IVC filter retrieval kit which was passed through the wire and used to remove the IVC filter without any difficulty. The filter retrieval kit was then exchanged once again for a 13-French sheath followed by placement of 22-cm precurved Palindrome catheter which was tunneled subcutaneously and delivered out over the course of the guidewire insertion site. The large dilator and introducer assembly were then passed over the guidewire after removal of the 13-French sheath and positioned in the right heart under fluoroscopic guidance. The guidewire and dilator were then removed and a 23-cm Palindrome catheter passed through the introducer and positioned in the right heart under fluoroscopic guidance. The peel-away introducer was then removed. The pursestring suture was then tied at the catheter insertion site and the catheter insertion incision was closed in layers using 3-0 and 4-0 suture. The catheter was then secured at the exit site to the chest wall using nylon suture. Sterile dressings were then applied. At this point, the patient's right femoral TCC catheter was prepped and draped and then removed. A sterile dressing was applied at the right groin. The procedure was then completed and the patient awakened, extubated and taken to the recovery room in stable condition.

HeRO catheter embolectomy

Could you please help? I have searched data base and can't find examples of the HeRO catheter embolectomies (only placement 36830-52 and 36558-51). Have two operations that incision is made and fogarty catheter was then used to perform embolectomy of the venous end of the graft and the arerial end of thegraft to removed organized blood clot(only one 36831). Then the HeRO catheter was embolectomized with a fogarty catheter also. Following this good flow was noted throughout the catheter. Venogram of the AV graft was perfromed on the vnous end and arteriogram was performed in the subclavian artery (no charge??) Following this the graft was repaired with suture and incision was closed with sutures and staples. Does the HeRO embolectomy qualify as a seperate 36831-5951 charge? Thanks, Kim.

Hero Device

Have you heard of the Hero Device? Can we bill 36558 and 36830 for implanting the device? I don't think so but I need clarification. Thank you,

HERO device

Greetings A physician is placing a HERO graft. He angioplasties a stenosis in the vessel to place the HERO. Can we charge for the angioplasty, or is it part of the Hero placement. Thanks, LW

Hero device 36830

Dr. Z. What codes would you use for the radiologic services provided in the O.R. for a Hero graft placement? Basically, the tech is providing fluoro and saving pertinent images for the vascular surgeon. Thanks, Judy A.

HERO graft insertion and device code

What should we charge for HERO Graft insertion? Unlisted or is there a code to discribe the procedure? Thank you!

High Grade Stenosis Adjacent to the Arterial Anastomosis

I have a physician dictating angioplasty of a high grade stenosis of the fistula adjacent to the arterial anastomosis. He does not state that he's actually doing the plasty of the arterial anastomosis, just the high grade stenosis adjacent to it. For the angioplasy of the arterial anastomosis (35475), I need the doctor to state that is what was plastied as opposed to a stenosis proximal to the arterial anastomosis or adjacent as this one is dictated... am I correct?

Hip/Knee Drain with Catheter Placement

Drainage and catheter placement in hip and/or knee. Should you report code 20610 or 10160 with imaging code?

Holter monitor

Please do NOT include any actual patient medical records with your question. Hi Dr. Z, If we used 93230 cpt in 2010 for the holter monitor, which code would we use in 2011 to replace 93230? If we used 93224 cpt in 2010 for the holter monitor which code would we use in 2011 to replace 93224? Thank you so much for your help Geri Elliott Norva Medical Billing, Inc. geri@norvamedbill.com

How to use anatomical drawing to code selective catheter placement

I am writing to request an explanation for the answer given to a test question in the Basic Catheter Selection module exam. The question was exactly as stated: Correct code(s) for left femoral access with catheter placed into the right superficial artery for angiogram is (are: 36247, 36246, 36245 36247, 36200 36247 36247, 36140 The correct answer was indicated as 36247. I cannot see how that was selected. Is the cath placement in the right superficial FEMORAL artery (femoral was not in the test question, but I assumed that was the vessel in question); if so, the access was on the left and the diagram Lower Extremity Arterial Anatomy Right Transfemoral Approach leads me to 36245 for the right leg in this diagram. 36247 is the code for the left leg. I think the left approach is starting me off on the wrong diagram and I need to choose the code based on the Order of the vessel selected (3rd order, initial, lower extremity) and the fact that it is a selective (placed) catheter. Please explain how to use the diagram to simplify Basic Catheter Selection. Thanks so very much for your extremely helpful webinars, but I do want to be sure I get the basics down pat now.

Humana denying catheter placements

Greetings Dr. Zeilske or Dr.Dunn, We have lately started receiving denials from at least Humana, Cigna, and Tricare, maybe others, when reporting 36140, 36200, 36245-36248 when submitted with 75710 or 75716. We have recently found on the Humana website that on June 24, 2011 Humana has published an edit that "36140, 36200, 36245-36248 will not be separately reimbursed when submitted with 73706, 75635, 75710 or 75716". Are you familiar with any such edit or coding change that would support the insurance denials not to pay the cath placement with the diagnostic study? Our surgeons regularly perform the diagnostic angiograms and we of course report the catheter placement as well as the radiological supervision and interpretation. (of note, no cath is reported with interventions, of course. Cath only reported with the diagnostic studies). Thank you for any insight you may have to how / why the insurance carriers have developed this edit to deny the catheterization with 75710 / 75716. Thank you

Hybrid AV Graft Case

My physician performed a cutdown thrombectomy on PTFE dialysis graft arterial and venous anastomosis. Then he angioplastied the venous stenosis (severe recoil) and then placed a stent. The problem is, when he closes the graft he patch angioplastied, does this make it a revision of a dialysis graft? I know if we code this to a revision then the angioplasty and stent code are bunded. So do I code this as either: A) 36833/75791-2659, or B) 36831/75791-2659, 35460-51/75978-26, 37207-51/75960-26?

Hybrid Congenital VSD Repair

"Patient with congenital VSD is brought to cath lab for transcatheter VSD closure. They are unable to properly place the device, and the device and catheters are removed. They then make a small thoracotomy incision and place a sheath through the RV and deploy the closure device from there. Sheath is removed, and the RV and thoracotomy incisions are closed." Would this be reported with code 33999 (unlisted cardiac surgery), or could it be reported using code 33681 (closure, VSD with/without patch)?

Hypoplastic Left Heart Syndrome

Hypoplastic left heart syndrome consists of several defects - mitral and aortic valve, aorta, and left ventricle. The question came up about whether other related conditions should be separately coded out with ICD-9 codes (mitral stenosis/atresia, aortic valve stenosis, coarctation of the aorta/aortic arch) or if all of these conditions associated with hypoplasty left heart syndrome would fall under the one ICD-9 code.

Hypothermia 37799

Dr. Z, How do we charge intercool insertion, an invasive catheter that stays in the body for hypothermia done in cath lab? Since it is CVC can we charge 36556 77001? Thanks

I-131 administered through gastric feeding tube.

Hello, Please clarify cpt coding for iodine 131 administered through the gastric feeding tube for papillary thyroid cancer (thyroid surgically removed). Is it unlisted? Thank you

IABP

Codes 33970/ 33967... Can we charge these codes more than once on the same patient with the same date of service?

IABP and Impella

If a pt comes to the cath lab with a IABP in place and it is taken out and Impella is put in and then in the same setting the Impella is taken out and a IABP is put back in, can I code for IABP removal and another insertion?

IABP Insertion and Removal Same Day

When IABP insertion and removing on the same day, Medicare has '0' edit.  However, recent cardiology coding alert suggested using a -59 modifier to charge both. Can you please clarify?

ICA Stent Placement

If we have a stent placement in the cervical ICA, we use codes 37215/37216.  Do we use code 61635 if the stent is placed in the intracranial portion of the ICA?

ICD 33249

I need some help coding the following. The patient was brought to the heart catherization laboratory and draped in the usual sterile fashion. Consent was obtained prior to the procedure. IV conscious sedation as given using Versed and fentanyl thoughout the case. Next we attempted to cannuulate the left subclavian vein.We then took a venogram of the left subclavian vein and it was found to have diffuse collaterals and no good discrete subclavian vein to proceed with the implant on that side. Therefore, we went to the right side of the patient and we took a venogram and this time there were good images seen of the right subclavian vein. Next approximately 15Ml of lidocaine were used to anesthetize the planned pacemaker pocket on the right side of the patient.Next using Seldinger techinique two subclavian access sites were obtained and then the pacemaker pocket was created using a scapel and cautery. At this point over a 7-French introducer sheath the right ventricular lead was positioned into place near the lower RV septum. This sheath was torn and peeled away and another 7-French introducer sheath was inserted and the lead was then placed at the right atrial appendage. RV pacing leads were kept on the patient due to the fact that he had a baseline left bundle branch block. Next the coronary sinus sheath was inserted and a specific sheath for the right-sided coronary sinus was inserted and using a J-tipped guidewire we able and contrast we were successfully able to cannulate the coronary sinus. Tehre was found to be a mild lateral vein though small which was used as our planned placement for the LV lead. At this point the LV was positioned over a coronary guidewire into the mid lateral vein and successfully wedged into that position. The sheath was then slit appropriately and the lead was kept in place. At this point pacing thresholds were also checked here and they were within normal limits. Next the sheath was torn and peeled away and all 3 leads were sutured using 0 silk to the left pectoral muscle. Next antibiotic solution with consisting of Bacitracin and gentamicin was used to flush the pocket at this point. At this point 2-0 and 4-0 Vicryl sutures were used to close the pocket. Steri-strips were applied on the skin level. The estimated fluoro time would be 25 minutes. Implanted Device: Boston Scientific Guidant Contact Renewal CRT pacemaker. the patient had a heart cath with grafts: 93459-26 ICD Insertion: 33249 33225 71090-26 Is this correct codes to use?

ICD and pacemaker

Dr. Z,               I attended the course in Nashville as well as the one in Vegas the year before. We are having issues with the CPT code 33224 LV lead placement. In the past, we have charged for the generator removal (pacemaker usually) 33233, place the LV lead and put in the new ICD (usually) generator. So, we would have had 33233, 33224 and 33249 (because they would put in an ICD lead also), as well as fluoro. We didn’t realize that 33224 last year included the removal and replacement of the generator, which was always a new generator because the old generator couldn’t hold all three leads. My problem is that we were charging for the old generator to be removed and a new one placed and didn’t realize it was included in the code 33224. So our cost was much more than what it should have been, we are now realizing. One thing that might have kept us not getting any edits or have any other type of issue, is that the coders probably didn’t code that for payment(generator removal.) Our finance department can’t understand why the cost for an ICD placement is higher than a pacemaker placement. We are trying to stay budget neutral until this budget year is over. Ours runs from June 1 to May 31. Is it normal for the ICD implant cost to be higher? I don’t have anything to do with setting cost, but need to try and help make this correct from here on out. Again, we didn’t have any issues with the bills or payments, so I feel that the coders were correcting the bill before it dropped for billing. Any insight would be very much appreciated. Hope to attend the Nashville seminar again this year. Thanks,

ICD diagnosis coding

Hi Dr. Z, I am having a problem with coding an ICD case. The paient had a single chamber ICD put in for primary protection in 2003. He is back for replacement of his depleted generator, and also an upgrade to a Bi-v ICD due to his worsening CHF (class 111), EF of 29% conduction delay on ekg, with QRS duration of greater than 120. He is an out patient. He received a Bi-v ICD generator, atrial lead and a bi-v lead. I coded 33249, 33241, and 33255. I did not use the Q0 modifier because of the existing ICD and I thought the Q0 was only for new ICD inserts. MR coded 428.22 as the diagnosis code. 33249 hit an edit for a modifier, or addd't diagnosis code. " 33249 requires a modifier, or a diagnosis (per CR3604) must be present if the AICD is for secondary prevention of sudden cardiac arrest. I was told that V53.32 could not be used because of the upgrade. Should I use Q0 to bypass the edit? Thanks, Dr. Z Diane

ICD downgrade to pacer 33229

Patient received a "down grade" in a device. Patient had a BIV ICD and we replaced it with a BIV PPM. We coded 33229, removal and replacement of a BIV PPM, is this correct?

ICD generator exchange with lead movement subcutaneously (33263)

Good morning DrZ...I was wondering if you could help with this case. Procedure Performed: 1)Explant of a BiV ICD, 2)Tunneling of the right ventricular ICD and a left ventricular paciong lead from the left subclavian to right subclavian 3)Placement of a new biventricular cardioverter defibrillator. I coded it, 33241, 33215, 33226, 33240. However, 33226 includes removal and insertion and moving the pacer to the right was more work then just repositioning LV lead. Can you help me? Thanks, Melissa

ICD Implants

Dr. Z, I am being told that when coding ICD implant (33249)and DFT testing (93641) to use a diagnosis code of 427.41 for 33249, because during DFT test the patient was induced into V-fib. My understanding of NCD 20.4 number 1, is that v-fib is used when the patient has a documented episode of cardiac arrest due to V-fib not due to a transient or reversible cause.No where in the medical record can I find where the patient has had cardiac arrest due to V-fib and there fore I have been using what the report says and assigning 414.8 with QO mod and assigning 427.41 for the DFT test (93641). Is it appropriate to assign 427.41 to 33249 because the patient was induced into v-fib for the DFt test? Thankyou

ICD Lead

A patient has an existing biventricular ICD that was previously repositioned into the abdominal area from its original location in the pectoral region. The old ICD lead was capped and left in the pectoral pocket. Now the patient presents with the abandoned lead ”externalized” (a small portion of the lead having made its way outside of the body). The patient was taken to the OR and placed under sedation by anesthesia. The surgeon made an incision parallel to the externalized (old abandoned) lead. Then the surgeon dissected the lead out to where the yoke of the old trifurcated defibrillator lead rested. The ”externalized” lead was cut down as far as possible and then also capped. The pocket was freed up of extensive scar tissue, but no sign of infection was present in the pocket or tunneled areas. At that point, the surgeon placed as much of the leads as possible back in the pectoral pocket in an antibiotic sleeve and the pocket was closed. What would be the appropriate CPT code(s) to report?

ICD NIPS

What are the appropriate codes for a NIPS study (EP study performed through a patient's exisiting device) and termination of an arrhythmia through a patient's pre-exisiting device? Is it code 93724 (pacer) and code 93642 (ICD)?

ICD upgrade 33263 vs 33249

Hello Dr Z. Question on new 2012 Rhythm Device Coding. The patient has a ICD (single lead) and presents for a Upgrade to BiV ICD (dual lead)Would it be coded as: Removal of ICD generator (33241) Insert ICD generator, multi(33231) Insert BiV lead (33225) Insert New lead (atrial) (33216) Thanks for your help Melissa

ICD-10

Will your 2014 live seminars discuss ICD-10-CM and/or ICD-10-PCS coding? If so, in how much detail?

ICD-9 code for endocarditis of the aortic, mitral and tricuspid valves

Please do NOT include any actual patient medical records with your question. We use ICD9 Code 424.0 for Mitral Valve disorder, 424.1 for Aortic Valve disorders and 424.2 Tricuspid Valve disorder., But our doctors want Endorcaditis of the Aortic, the Mitral and Tricuspid.Is theres such a ICD9 code for Endocarditis of the Aortic Valve, Endocarditis of the Mitral Valve and Endocarditis of the Tricuspid. Please Help. Thank You!

ICD-9 for follow-up angiogram post placement of coils

DR. Z or Dr. Dunn: I have a follow-up arteriogram post placement of coils. Diagnosticly speaking would we use the V58.73 and the current disease process that necessitated the placement of coils for this follow-up exam? Such as V58.73 and V12.59 or V58.73 and 437.3 Thanks for your in put.

ICD-9-CM for postoperative compliction

I have question that maybe Ruth can help with concerning ICD 9 post op codes. I am not sure how long we can code for 997.1 post op complication. I see our physcians dictate post op afib after many procedures/ For Example: Pt has surgery by a "another" surgeon.. different practice. Develops post op Afib. Seen at hospital for post op Afib by one of our MDs. Placed on anti arrhythmic meds. Pt is seen a couple times over a couple month period while pt is on these new meds. 8-9 months after the initial hospital visit, the patient is seen back in office. MD has been trying to wean patient off the anti arrhythmic. Are we still using post op Afib at that 8-9 month visit?

ICY Catheter

Is there a specific code for placement of ICY catheter for patients who have had cardiac arrest and are being treated per the hyperthermia protocol?

Iliac angioplasty and atherectomy

Dr. Z, I am having difficulty understanding the bundling and reporting for code 0238T. 1. In the case of an atherectomy in conjunction with a PTA in the iliac artery territory, would you add code 0238T to the primary code 37220? 2. In the case of an atherectomy in conjunction with a stent in the iliac artery territory, would you add code 0238T to the primary code 37221? Thank you for your time!

Iliac angioplsty with EVAR placement

Dear docs-I was hoping you could help with when can you charge ballooning the iliac for an EVAR placement (and anything else I might be missing)Can I charge 37220 for stenosis when I am not sure that this isn't just for the clearing the way for deployment? And is there really an extension being placed? (including preop discussion, hopefully that helps) In the office in the preoperative area, we had a discussion with the patient regarding the difficult nature of the aneurysm including poor iliac access, high-grade stenosis of the iliac and the need for fem-fem bypass graft. We explained the creation or placement of an aortomonoiliac bypass graft with a fem-fem crossover. Bilateral groins were opened in a vertical fashion. We dissected down to the common femoral, profunda femoris, superficial femoral artery junction. 34812-50 I cannulated the right common femoral artery without complications or difficulty and inserted a wire into the aorta. This was followed by a sheath, flush catheter and then the wire was switched out for stiff wire. Catheter and wires were removed as needed to perform angiography. Please recall that the left common iliac artery is completely occluded. 36200-59RT We performed balloon dilatation of the external iliac artery prior to deployment of the stent graft. 37220-LT The patient was heparinized prior to any ballooning and we planned for the placement of a distal extension and this was carried out by placing a 1610 limb with 124 length in the aneurysm sac and out into the common iliac artery through preexisting stents. 34825/75953-26 A 20 20, 82 limb was then placed with sufficient overlap with the 10 16, 124 graft and finally an Endurant cuff, which was a 32 32 x 49 was placed in an infrarenal location. 34802-75952-26? Completion angiography demonstrated patent renal arteries bilaterally, no evidence of endoleak and widely patent aorto-mono-iliac bypass graft. Having this in mind, we removed the wires, catheters and sheaths and tunneled a piece of 8 mm ringed Gore-Tex from one incision to the other, created arteriotomies on the common femoral arteries and performed anastomosis of the end of the 8 mm bypass graft to the side of the common femoral artery with 6-0 Prolene suture. 34813 thank you so much for your expert opinion!!

IlIac bone biopsy

Dr. Z, Patient came in with bony lesion iliac for bone biopsy. After administering anesthesia bone biopsy needle was advaced into the iliac bone. Satisfactory position was confirmed with CT. Approximately 3cc of bloody fluid was aspirated too. Multiple core biopsies were performed thorugh the 13-gauge cannula. Samples sent for both culture and cytology. Not sure what else we can charge for the aspiration along with bone biopsy? Please advice. Thanks

Ilioplasty

How do you code for an ilioplasty (bone).  Would you think this is unlisted or do the T codes apply?

IMA injection for graft

I just want to clarify what I read in this Q/A in the Jan 2011 newsletter please: Q: In 2010 I would code 93539 to check IMA for suitability for CABG. What would be used in 2011? A: Codes 93455, 93457, 93459, and 93461 describe coronary angiography(the blockages you found)and arterial/venous grafts (even if for evaluation of subsequent use as a graft, such as the IMA before it is a graft) by itself, with RHC, LHC,and RHC w/ LHC. So, it will just be part of the larger code. If this were a congenital case, then consider code 93564 for the IMA evaluation. In this answer, if a LHC is done + imaging the IMA for patency before CABG but the patient has no grafts at all. You would code the ungrafted IMA as if it were already grafted? CPT 93459 Thank you

Imaging guidance and EP

Dr Z, Is guidance bundled in with an EP study? we have heard several different things. Also, If our doc. uses ultrasound guiance and flouroscopy during an icd or PPM placement can we bill 71090-26 and 76998-26? Thank you for your help Traci

Imaging of the Lower Extremity, 73592

Would you consider the following a reference to determine the age of an “infant”? CPT 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year). If hip and lower extremity can be imaged on one film and the patient is 15 months old, would you code CPTs for hip and LE for tech component opps?

Imaging with stent placement coronary

When can you code 92980 and 93508, and 93556 together?

Impella

Good morning! Our cath lab is going to be using the Impella Device in a case today and we were woundering how to go about coding it. We have seen a lot of different ways to go about coding it but are not sure what to go with. We saw where the website said to use 33999, 93799, 92970 but the actual package for the device says to use 33975 or 33975-52. Also is there HCPCS code that goes with it? Any help would be greatly appreciated! Thanks!

Impella (2.5) Inserted during PTCA/Stent

Our physicians are wanting to schedule patients who may need an Impella 2.5 to assist during cardiac stent procedures as outpatients. Code 33990 is an inpatient-only procedure. 3M Encoder and CPT Assistant still lead to code 33999 for this type of intervention. Will there be updates to CPT Assistant or the 3M Encoder to relay the new 2013 codes, as we are in May 2013 now and still no updates? Does code 33990 cover any situation that an Impella 2.5 would be used including during a coronary stent procedure and removed at the conclusion of the procedure?

Impella 33990

Is there more information on the coding of the Impella Heart Assist Device, if we should use 33990 vs. 33999? The Encoder still specifically directs the use of 33999 with the keyword Impella even with a 2013 date of service. Your advice in 2012 was 33999, but you mentioned code 33990 would be available (which it is in 2013 CPT now). I'm hesitant to change the code without verification and contradicting the encoding system. Thanks for your help!!

Impella Use for Procedures

There are many different scenarios in which we have used the impella lately and would like clarification as to when we can charge the removal on the same day as insertion.  (Also trying to clarify definition of separate distinct session.)  For instance: Impella inserted in cath lab for procedure that would be done in different department later in the day.  At the end of the procedure in the other department, the Impella is removed. Impella inserted in cath lab for procedure in cath lab, but patient goes back to his room, and a few hours later when the MD is available, it is removed.  Impella inserted in EP procedure room by cardiologist for a left heart catheterization by cath lab staff, followed by an EP procedure by EP staff.  Hours later after the ablation, the Impella is removed by the cardiologist while still in the EP lab.  The IABP is a different class of assist device but curious as to when it's appropriate to bill removal on the same day as well.  We understand if put in for a procedure and removed at the end of a procedure, the removal is not billable.  However, when put in for a procedure but left in for continued support (for a few hours) and then removed, can the removal be charged?

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