Knowledge Base

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Set Descending Direction

MRI of the Spine

Our office has been experiencing a new problem when billing HAP insurance. We had a patient who had MRI of the thoracic spine and an MRI of the right shoulder on the same encounter, which was billed using CPT codes 72146 and 73221-RT. HAP paid only on the MRI of the shoulder and not the MRI of the thoracic spine. HAP informed us that the MRI of the thoracic spine was denied based on CMS cutbacks. The same happened with another instance when a patient came in for an MRI of the thoracic, cervical, and right shoulder on the same encounter; HAP only paid for the MRI of the right shoulder and denied the thoracic and cervical due to CMS cutbacks. Am I missing an additional modifier that needs to be appended, or is it that the MRI of the spines should be done on a different day than the MRI of the extremities??

Blood Patch After PTX

During a CT biopsy of the lung, the patient had a pneumothorax. The doctor performed "autologous intrathoracic administration of blood product for treatment of pneumothorax". Is there a code we can bill for this? 

Y90 and Post NM Scan

Now that there is an edit in place between C2616 and any of the liver/spleen NM scans, should we no longer report the NM scan following a Y90 embolization procedure? 

ECA Branches and Embolization

"Intractable idiopathic epistaxis. Selectively cathed the right and left CCA to view neck and face vessels, selectively cathed the right ECA, and selectively cathed the right and left internal maxillary arteries confirming no undesired collaterals. Embolized the right and left internal maxillary artery with PVA and gelfoam. Post angio was done to confirm no residual nasal mucosal stain. Then a right facial artery was selected, and angio proved no significant supply to the nose from this artery." Please let me know if you would code this differently and why. I'm looking at codes 36222-50, 36227-50, 61626-RT, 61626-59LT, 75894-RT, 75894-59LT, and 75898. Is there another code for catherization of another branch off the ECA?

LIMA Separate Session

I'm not sure how to code this. Patient was in our facility as an IP from 11/20-11/29. We do charge our cath codes on IP, but they don't "go out the door on the bill"... we use them for revenue tracking in the facility. Patient had diagnostic cath with angios on 11/20 and was then brought back on 11/25 to evaluate the LIMA for potential graft as a stand-alone procedure. Then, on 11/27, they decided to do high risk PCI because patient was not a candidate for CABG due to lung issues. So, since the LIMA was evaluated on a different day and not in correlation with a cardiac cath procedure, should I use code 75756? I don't think it's appropriate to code/charge the LIMA evaluation as a coronary angio on 11/25, and for the 11/20 DOS I don't think it's appropriate to change that to a bypass angio because only native arteries were looked at. What are your thoughts?

Attempted Pulmonary Vein Recanalization

Can we report 35476/75978 (x3) with a -52 modifier for ATTEMPTED recanalizations if no angioplasty is performed? "Procedures performed: Right and left heart catheterization. Attempted recanalization of LUPV, RMPV, and RUPV using radiofrequency (Nykanen RF wire). Several rounds of RF were placed at the pulmonary vein sites, but were unable to gain access to a vein. At this point, we did not feel that there was a feasible transcatheter approach to recanalize the stenotic/atretic pulmonary veins. This was the end of the interventional portion of the case."

Congenital Heart Caths

I’m having a bit of an issue with our physicians documenting crossing the septum (when performed) during some of our congenital heart caths (93532 and 93533). I’ve encouraged them to document whether or not the septum was crossed and also to document if it was through an existing opening or transseptal puncture. In some cases they have documented “patient underwent a prograde right and left heart catheterization” or “the atrial septum was crossed” and then charged 93533. Is that sufficient? If the patient has an ASD, VSD, or PFO, can I assume if they say they crossed the septum if it was through one of those openings? In hopes of clearing this issue up, can you share your recommendation of what the documentation should reflect in order to properly charge CPT codes 93533 and 93532? I've been taught never to assume anything.

Renal Angiography

"Right common femoral artery was accessed utilizing micropuncture technique. A Bentson wire was advanced into the abdominal aorta, over which a 5-French vascular sheath was placed. A 5-French Contra 2 catheter was then used to select the right renal artery and digital subtraction angiography was performed in the PA and RAO projections. The catheter was repositioned into the left renal artery and digital subtraction angiography was performed in the PA and LAO projections. Decision to intervene was made based of these images. The vascular sheath was exchanged for a new 6-French sheath. A 6-French guiding catheter was then advanced into the proximal renal artery. A 0.018 inch McNamara wire was advanced into the upper pole artery of the kidney, and a 0.016 inch fathom wire was advanced into the lower pole. Angioplasty of the proximal aspect of the upper pole renal artery was then performed utilizing a 5 mm x 2 cm balloon. The balloon was deflated and post angiography angiogram was obtained." Unilateral or bilateral renal angiogram? Which is correct: 36254 OR 36251-RT, 36253-LT with 35471/75966?

Cerebral Embolization

"INDICATION: 36 year old female with a family history of ruptured intracranial aneurysms, who underwent clipping of an unruptured right anterior choroidal aneurysm in 2003, was recently found to have growth of a right posterior communicating artery aneurysm over the past several years. Embolization of this aneurysm with a biplane embolization device was therefore recommended. COMPARISON: Cerebral angiogram dated 11/18/15 LVA catheterization and angio RCC and RICA catheterization and angio 3D angio transferrred and processed on separate workstation. Embolization of right PCA anuerysm using pipeline embolization device. Post-embolization right ICA, RCCA, left vertebral." Is this reported with codes 61624, 75894, 75898 x 3, 36217, and 76377? 

Attempted Revascularization of CTO

"Patient with stable angina and abnormal nuclear stress test has a left heart catheterization with LV pressures measured and coronary angiograms. Then proceeded to PCI of RCA chronic total occlusion. Tried wires using an over-the-wire balloon, but never could cross due to bridging collaterals and inadequate support from radial access in addition to poor visualization due to obesity." Will chronic total occlusion require coding C9607-74RC/92943-74RC even though there was no combo of the three (3) revascularization techniques attempted? If only angioplasty were used rather than a combo of angioplasty, stent, and atherectomy techniques, would codes C9607-74RC/92943-74RC still be reported? Or would angioplasty 92920-RC be reported instead?

Embolization of Aneuysm with Stent and Coils

"Patient has a known MCA aneurysm associated with a left occipital AVM (previously coiled M1 segment of aneurysm now with a neck remnant). Angiography is done with catheter in the left ICA in order to obtain optimal working projection for treatment of the known aneurysm. They deployed a stent across the aneurysm neck and proceeded with coil embolization of the aneurysm sac. Post embolization angio was performed and demonstrated near complete obliteration of the aneurysm sac." These are the codes I am considering: 36217, 61624, 75894, and 75898. I would appreciate your thoughts on coding the cath placement of the MCA. And, is the stent placement just part of embolization code 61624?

MR lymphangiogram/extremity, MR venogram, Extremity lymphedema pre op planning

Multiplanar T1 & T2 images were obtained with pre & post contrast. Images were obtained sequentially after the intracutaneous inj. Of 4ml of Multihance mixed w/lidocaine & sodium bicarb. 19 ml of contrast was injected IV w/o complication. Sagittal, axial, and MIP images are provided. Precontrast T2 weighted images show a mild amount of edema along the plantar & radial forearm. Max thickness of adipose tissue in forearm is 1.4 cm Max thickness upper arm is 6.6cm. Multiple enhancing channels are seen on sequential images performed after intracutaneous inj. Majority of these are smooth w/ increase in size on the MR venogram single channel on the dorsum of forearm extends from level of radial styloid proximally 3 cm. terminates at level of dermal backflow etc. MR lymphangiogram and venogram show probable lymphatic channel along the dorsal distal forearm. Is the lymphangiogram an unlisted 76498 & MR venogram extremity 73225.

62311 and 64483

I think these back injections are based on substance injected and location of injection. When would we choose codes 62311 and 64483? I think the office used codes 62282 and 62311, but code 62282 is injection of a neurolytic substance, and the examples given in CPT for the medications don't seem to line up with the medications used in these injections.

Procainamide Challenge Test for Brugada Syndrome

A 19 year old male was recently evaluated for Brugada syndrome. The procedure was done while he was an inpatient. The physician generated the following report: "Resting EKG normal. 17 mg/kg procainamide given over 30 minutes. No significant ST changes, RV delay patterns w/ T V1-V2 ; ST normal. Evidence does not suggest Brugada or other await genetic testing, no specific intervention at this time." I apologize for the gaps, this was a hand-written report, and I am unable to copy. I am having difficulty finding the proper code for this procedure. While this procedure is not performed often, there is the chance it may be done again. Would it be appropriate to code an infusion code versus 93017 for hospital tracing of an EKG, the miscellaneous cardiology code 93799, or would it simply be part of E/M services for that day? 

Closure of Diaphragm After Cyst Removal

"A metal port was placed, and a 10 mm 30 degree scope was introduced. The pleura showed many areas of white plaque and some areas of asbestosis. The white plaque was biopsied. A 3 cm incision was then made overlying the 4th interspace starting at the anterior axillary line and extending posterior. The soft tissue was dissected with cautery, and the pleural space was entered under direct vision and dissected. A small Alexis wound retractor was placed into wound and tightened. Using ring forceps, the lung was pushed off the diaphragm. On the medial posterior portion, we found a 2 cm cyst coming off the diaphragm. There were no masses visible or palpated in the LLL. The cyst was grasped and resected with cautery taking the entire cyst with rim of diaphragm. There was a second smaller cyst just anterior to the first. It was grasped and resected with portion of diaphragm. These were sent for frozen section. Preliminary path shows benign mesothelial cells. There were two small 0.5 cm holes in the diaphragm from the resected cysts right next to each other. These were closed with suture." What code(s) would you recommend for this?

Tendyne Valve for MV Replacement

"The left ventricular apex was then exposed utilizing a small anterior thoracotomy, French delivery mechanism was placed into the left ventricular apex and into the central orifice of the mitral valve, just above the closure plane of the valve. A 20 mm Tendyne transcatheter mitral valve was then successfully deployed in a supra-annular position utilizing transesophageal echocardiographic guidance. Once proper position of the valve was confirmed and lack of left ventricular outflow obstruction also verified, the valve was released and apical pad was secured to the apex of the heart."  What would be the correct codes: 33999 only or 33418 and 93462?

Multiple Endartectomy in Femoral

When is it appropriate to bill codes 35302, 35371, and 35372 together on the same side? If the physician states an eversion or deep in the profunda, can it be billed with modifier -59?

Dacron Shunt of LT Subclavian for TAVR

How should we code the following? We have reported code 33363-62 and nothing else. Is that appropriate? "DX: Significant left ventricular failure with a need for transarterial aortic valve. Procedure: Placement of Dacron shunt to anterior surface of the left subclavian artery to facilitate placement of a transarterial aortic value. Procedure Note: Traverse incision in the left infraclavicular. Longitudinal arteriotomy was made in the vessel with a 15 blade and extended with Potts scissors. 10 mm Dacron graft was then anastomosed end of graft to side of the subclavian artery. Clamps were removed from the vessel, and two leaks in the suture line were controlled with interrupted 6-0 Prolene simple suture. Procedure was then done to implant a trans Dacron graft aortic valve."

VAD with ECMO Support

I am coding a case for insertion of a CentriMag bivad device "with ECMO support". The provider places a cannula in the left atrium and then an additional cannula in the right atrium via femoral vein insertion. He then places a 10 mm Hemashield graft in the pulmonary artery and one in the ascending aorta. After tunneling all grafts out to the chest wall, he states, "The patient was then converted to biventricular support with inflow for the RVAD from the right femoral venous cannula and outflow to the pulmonary artery cannula, and to the LVAD with inflow from the left atrial cannula and outflow to the ascending aortic cannula with ECMO support." This note reads exactly like a standard bivad insertion with the placement of the cannulas. I know ECMO circuits are sometimes used as temporary VADs, but the CentriMag does appear to be a VAD device per the manufacturer's website. Given the mention of ECMO support here, though, I wanted to ensure the coding should still be 33978 for implantation of an extracorporeal BIVAD. 

Documentation Guidelines for 72114

I was needing some information on how my physicians should dictate certain x-ray reports. Is it appropriate for them to only dictate 6 views of the spine, or should they include bending or flexion views in their documentation? The same with reporting codes 73510 and 72170... If they give me two separate reports, can I bill for both or only for one?

MRI Enterography

We work in a hospital where MRI enterography is performed. We code these studies with 74183 and 72197. What terminology needs to be included to support the use of code 72197? Our radiologist feels that stating "no significant retroperitoneal lymphadenopathy seen" would suffice. Please advise. 

50435 and 50693

I have a physician who did a left nephrostogram, ureteral stent insertion, and a nephrostomy tube exchange at the same setting. With the new 2016 codes there is no scenario with a pre-existing nephrostomy tract tube exchange and a placement of ureteral stent. I am getting an NCCI edit for code 50435 saying it shouldn't be billed with code 50693. Am I missing something or misinterpreting something? Would you bill codes 50693 and 50435-XU? The payer is Medicare.

Catheter Placements with Revascularization of Leg

Can codes 36245-36247 be billed when performing diagnostic angiography for a lower extremity exam on the same day of intervention if no previous imaging exists (or if condition has changed since previous imaging)?

Ureteral Stent Placement via Existing Access with Ureteroplasty and PCN

In 2016, what are the appropriate CPT codes for the following? "Patient was placed prone on the table. Contrast was injected via left nephrostomy tube and nephrostogram performed. This revealed complete obstruction of distal left ureter at the UVJ. Nephrostomy tube was removed and cath was placed at the UVJ. After multiple attempts, sheath was placed at distal left ureter and dilated with a 6 mm balloon. Next, internal left stent was placed. 10 French safety nephrostomy tube was placed and capped. Impression: 1) Complete obstruction of the distal left UVJ. 2) With difficulty, obstruction was crossed and dilated. An 8 French left ureteral stent was placed. 3) A 10 French safety nephrostomy tube was placed and capped."

Non-Target Vessel Embolization

What is the appropriate coding for coil embolization of the GDA? Are the caths included? Procedure performed: 1) Selective SMA, hepatic angiography. 2) Coil embolization GDA. 3) Tc-MAA infusion right hepatic artery and left hepatic artery. 

Percutaneous Paravalvular Leak S/P TAVR

I know that, in the past, paravalvular leaks that were repaired with Amplatzer plugs have been coded with unlisted codes. I was wondering, since TAVR procedures are becoming more frequently done, are the percutaneous repairs of paravalvular leaks of repairs still reported with the unlisted codes? Since the TAVR procedure has more defining charge codes I was hoping that these repairs would have been given codes for 2016. Also, do these codes include the heart cath procedures and TEE monitoring done during this repair?

Coil embolization of a pica aneurysm

"Patient presented with a Hunt and Hess II, Fisher grade III subarachnoid hemorrhage concentrated in the 4th ventricle with hydrocephalus. Eleven coils were deployed in the vertebral artery to the V4 segment to remove a right pica aneurysm." How do I code this? 

Arterial and Venous Access with Heart Cath

"The right groin was anesthetized using 1% Lidocaine. Intravascular access was established via the right common femoral artery under ultrasound guidance. A 6 French sheath was placed. Similarly venous access was established under ultrasound guidance. A 4 French sheath was placed. Venous access was established due to the underlying malfunctioning left antecubital IV. A 5 French JR4 diagnostic catheter was used to cross aortic valve. Left ventriculography was not performed. Next, the same catheter was used to engage the native right coronary artery. Next, JL4 diagnostic catheter was used to engage the left main. Arterial and venous access was established under ultrasound guidance via the right common femoral artery and vein with direct visualization of the needle entering the right common femoral artery as well as the right common femoral vein. Images of the arterial access established with the ultrasound guidance were acquired and recorded in the permanent document." Should I code separate access?

Access Attempt Using Fluoroscopy

Can we report code 77001 (fluoro guidance) for attempted access prior to the start of heart catheterization? "Venous access was obtained in the left femoral vein with ultrasound, and a permanent record was stored with a 4 French sheath. It should be noted that we used ultrasound for the LFV, but could not enter the vessel initially despite blood return. We then advanced a JR catheter and angled glide wire from the RFV sheath and retrograde down to the LFV. This was used as a target for LFV access under fluoroscopy with success."

ASHD with Angina

What information and/or situation can be documented by the physician to code angina? Does the physician have to specify angina to code angina or WITH angina? What if the patient also has chest pain? Does the physician have to specify ischemic chest pain?

Critical Care

We are looking for an industry standard (based on CPT rules) for how to correctly code critical care (99291 and 99292) for more than one provider. Per rules in the CPT Codebook (on page 25), what should be coded if MD1 spends 30 mins with the patient and MD2 spends 40 minutes?

Left Renal Vein to Vena Cava Transposition

"A supraumbilical transverse incision was created with a #10 blade. The muscle layers were divided with a bovie cautery. The Omni tract retractor was placed in position. The small bowel was eviscerated to the right side. The aorta, vena cava, left renal vein, and superior mesenteric artery were dissected. All lymphatic tissue encountered was ligated with hemoclips and divided. It was noted that the juncture of the left renal vein and vena cava was unusually high, at or slightly above the level of the SMA, such that the renal vein was as a sling around the base of the SMA contributing to its compression. The vena cava was clamped encompassing the left renal vein juncture, and the left renal vein transected at that level. The vena cava was closed in 2 layers using 5-0 prolene. The closure was hemostatic. The vena cava was then clamped further down from this point (approximately 4 cm) and then incised. The left renal vein was mobilized and anastomosed to the vena cava." My physician wants to charge code 35450 for this procedure. Is there another code to best describe this?

CVC Guidelines, Failed Access Site

For Permcath placement, should I be billing for failed access site as well as the procedure36558, 36000? "The right internal jugular vein was noted to have a prominent valve. There was hematoma present between the jugular and carotid. The right internal jugular vein was accessed using an 18 gauge needle with one stick using ultrasound guidance. A wire was not able to traverse the right innominate vein. The wire was exchanged for a Glidewire and Berenstein catheter; however, this combination could not successfully traverse the occlusion. The access was removed, and manual pressure was held. Hemostasis was achieved without complications. Attention was then turned to the left neck. The left internal jugular vein was accessed with one needlestick using ultrasound guidance."

EP Ablation with Transseptal Puncture

We have a new EP doctor coming to our facility. Recently he did an SVT ablation (93653) that was right- and left-sided, pre/post isuprel, 3D mapping, placed a catheter in the CS, utilized ECHO, and performed a transseptal puncture. He is stating that he does not need LA pressures to prove he was in the atrium so that we can charge for code 93462. I disagree. I feel like he should have established proof for charging and record purposes. Also he is charging and reporting that he did both LA and LV recordings via the CS. So to recap, 93653, 93662, 93462, 93621, 93622, 93623, and 93613. Is he correct?

LHC vs. Coronaries with Grafts

I am having a hard time coding this one. I am having trouble finding an appropriate code for SVG angio. I'm assuming that the other codes are 93458, 93567... "CAD Presentation: Angina cath. Post Procedure Diagnosis: Single Vessel Coronary, 70% Ostial RPDA. Occluded SVG to RPDA. Mechanical Aortic Valve. Severely Dilated Aortic Root. Procedure Performed: Coronary Angiography, LHC, Aortic Root Angiogram and SVG Angiogram. Findings: L-Main-OK LAD-OK LCX-OK RCA-70% Ostial RPDA. SVG to RPDA. Aortic Root-Severely Dilated SVG to RPDA." 

Stent with IVC Filter Removal and Placement

"1. IVC gram 2. New filter deployment in the suprarenal position 3. PTA of the infrarenal IVC within the area of stenosis in the occluded IVC filter 4. retrieval of the infrarenal IVC filter 5. stent IVC in the infrarenal portion 6. retrieval of the suprarenal IVC filter and redeployment of this filter in the infrarenal position above the stent. Patient has CTO IVC. She underwent thrombolysis and now has a tight stenosis of the IVC in the area of the IVC filter. Plan is to remove this filter, stent it, and then redeploy a filter higher. Because the filter could have clots, the plan was also to put a filter in the suprarenal position temporarily to make sure she did not embolize. Venogram of the IVC performed. PTA the IVC within the filter to allow smoother passage. Deployed new filter in the suprarenal position. I then retrieved the old filter. Residual stenosis that had grown within the filter, so I stented it and then put a 12mm balloon within this stent. I then retrieved the suprarenal filter and re-deployed it in the infrarenal position above the stent." What would the appropriate codes be?

Angiography and Embolization

Can you please help clarify when to code diagnostic angiography? Since we know that patient has cancer, and arteriography and embolization were planned, would these codes be correct: 37242, 36245, 36247, 36248 x4, 72726 x2 (59), 75774 x3 (59)? "CLINICAL HISTORY: Female with hepatocellular carcinoma and hypersplenism presents today for planned arteriography and embolization in preparation for planned radioembolization. PROCEDURE PERFORMED: 1) Selective superior mesenteric artery angiogram. 2) Selective celiac artery angiogram. 3) Selective proper hepatic, right hepatic, left hepatic, and middle hepatic artery angiograms. 4) Infusion of Technicium-MAA into the right hepatic artery. 5) Selective splenic artery angiography with embolization."

Endo AAA with Femoral Endarterectomy

Patient underwent endo AAA Endurant II. Provider said two docking limbs with no extensions. We coded 34803, 75952, 36200-50, and 34812-50. After all performed, they discovered a problem in femoral artery, placque removed, and required femoral artery endarterectomy. I'm a little confused as to when we can bill for problems such as this. Do you consider the femoral endarterectomy billable as well? AAA aneurysm and PVD diagnoses given.

Seroma Aspiration and Fibrin Glue Instillation

"Patient is post-op ventral hernia repair with aspiration of multiloculated fluid collection. After as much fluid as possible was removed, 8 cc of fibrin glue was instilled." Is this separately reportable? If so, what code would be reported?

Cardiac IV Drug Infusion

"PROCEDURE: IV drug infusion Clinical Summary: This is a 40 year old male with idioventricular rhythm, VT and PVCs all coming from the same source. These are gith bundloid with an interesting transition. There are negative in I and aVL; positive in the inferior leads. DESCRIPTION OF PROCEDURE: I brought him in. He was not having any PVCs and that was despite stopping flecainide and beta-blockers, so we put him IV drug. We put him on Isuprel and got his sinus rate up to 150 beats per minute or there abouts, and he had no PVCs. We let it wash out. There were no PVCs. He was never sedated. He then received an IV infusion of caffeine 500 mg IV, and he had a total of 2 PVCs, and that was only when we gave Isuprel combined with the caffeine. FINAL IMPRESSION: This patient has scant ventricular ectopy despite prolonged IV drug infusion of multiple agents." My question is, would you bill this with codes 37202 with 75896? Someone stated that only the meds used can be billed. I am new to cardio, so I am in need of your advice. 

73540: Radiologic examination, pelvis and hips, infant or child, minimum of 2 views

73540: Radiologic examination, pelvis and hips, infant or child, minimum of 2 views In 2016, CPT parenthetical notes state "73530, 73540 have been deleted. To report see 73501, 73502, 73503). Note that the previous bilateral code stating hips (plural), which in 2015 had a bilateral status indicator “0” (Indicator "0" in the Bilat Surg Column on the MPFSRVU means that the bilateral concept does not apply for this code), is now “cross referenced” to unilateral replacement code sets (73501, 73502, 73503). I am not able to find a reference that explains this conversion to my satisfaction, as I feel we should instead use the appropriate 2016 bilateral hip code sets 73521, 73522, 73523 dependent on the number of views. I would appreciate your insight on correct reporting in 2016 for imaging a child bilateral AP hips & pelvis on the first view along with a frog lateral bilateral hips & pelvis on the second view.

Accidental "Lacerations"

"After single attempt of manual aspiration thrombectomy, there was extravasation noted of the right middle cerebral artery. The vessel was successfully embolized with Onyx liquid agent with resolution of the extravasation. Can you bill for both the thrombectomy and the embolization? I thought that if in the process of one procedure the physician accidentally punctures a vessel that you cannot bill the patient for fixing that error. Or is that a known risk of thrombectomy that can be billed? 

Split/Shared visits for Medicare

The PA sees a patient in the ER department and performs an initial visit and determines that surgery is necessary. He documents his service while the supervising provider is in a case. When the surgeon is available he has a face to face visit with the ER patient on the same day. The surgeon performs a physical exam agrees that surgery is necessary and documents his portion of the E&M service appropriately. Can the E&M shared between surgeon and PA from the same group practice be billed to Medicare under the physicians number? Does it matter that the PA has made the decision for surgery and orders have been started since this is a shared visit?

Thrombectomy and revision of femoral-popliteal bypass

Is the following reported with codes 35876 and 35304? "Thrombectomy of the fem-pop bypass was performed with vein patch angioplasty, and flow was successfully restored through the vein graft; however, it reclotted within minutes of restoring flow. After multiple attempts to restore flow, it was felt that there may be an issue with the vein graft, so the graft was removed from the proximal and distal anastomoses. The popliteal artery arteriotomy was closed with a vein patch. A 6 mm thin-walled, ringed gore PTFE graft was tunneled through the previously created tunnels. The ends were spatulated and anastomosed in end-to-side fashion with 6-0 gore suture. Flow was then restored. Doppler interrogation demonstrated excellent flow-through graft. The distal outflow sounded somewhat high resistant. This point dissection was carried down the distal popliteal artery to the tibial/peroneal trunk. There was significant calcification noted at the origin of the tibial/peroneal trunk and anterior tibial artery. A longitudinal arteriotomy was made, and a limited endarterectomy was performed." 

AICD Removal and Implantation at a Different Site

I could use some help in this interesting situation. "History: Patient had a dual AICD implanted on the left side. Patient's treatment plan included radiation on the left. The left dual AICD was removed and the leads capped with a single AICD implanted on the right. Treatment was discontinued." Also need help with this procedure: "The single AICD on the right is removed along with the leads (33241 & 33244). A dual AICD was implanted on the left, and the existing leads that were previously capped were uncapped and attached to the dual generator (33230)." I reported codes 33241, 33244, and 33230, but there is a hard edit with 33241 and 33230. CPT indicates code 33263 should be used, but the same type of system was not used (single removed and dual implanted); therefore, I don't think 33263 is correct. Is it correct to code this procedure with 33230 and 33244? I thought the implantation was more important to code than the removal.

Vasospasm

"Six vessel diagnostic cerebral exam was performed. Decision was made to treat vasospasm of RICA and LICA." Discussion is whether or not the catheter selections for the bilateral ECA vessel selections are still chargeable since the catheter selections of the RICA and LICA are bundled into code 61650. I don't feel they are since, they are add-on codes to 36224 bilateral in this case. 

Vagal Nerve Stimular Removal with DICD Implant

"Patient underwent a DICD implant. Patient had an existing vagal nerve stimulator where the physician wanted to implant the DICD. The physician removed the VNS and capped the lead. Pocket was then revised to accommodate a DICD and atrial and ventricle leads. The VNS was not re-implanted and was discarded." In this scenario can you code only the DICD implant (33249), or can you also code the VNS removal (61888)?

Brachytherapy ICD-10

Is there an ICD-10 procedure code available for coronary brachytherapy?

Lower Extremity ABI/PVR Complete

"Bilateral lower extremity arterial duplex scans were performed with evaluation of the infrarenal abdominal aorta. The infrarenal abdominal aorta measures 2.3 cm proximally, 2.1 cm in its mid portion, and 2.1 cm in its distal portion. The waveform is biphasic, and the peak systolic flow velocity is 74cm/sec. Ankle-brachial indices were measured in both LE. They are 0.96 or greater bilaterally. Waveforms are biphasic in both lower extremities down to the level of the dorsalis pedis artery. Peak systolic flow velocities are within normal range. Conclusions: 1) Resting ankle-brachial indices and pedal Doppler waveform suggesting no evidence of significant arterial insufficiency of either lower extremity. 2) Continuous wave Doppler waveforms of both lower extremities are within normal range. 3) No evidence of infrarenal abdominal aortic aneurysm." We reported codes 93925, 93978, and 93923. Is this correct?

Iliofemoral Bypass Graft at Time of EVAR

"Patient with AAA aneurysm and critical vascular occlusive disease with claudication presents for endovascular repair. Vascular and IR co-surgeons: the vascular surgeon performs bilateral cutdowns, RCI to femoral bypass (used as access for delivery of Endologix main body device and to bypass critical occlusive disease on the right), and right femoral endarterterectomy." I'm thinking that the bypass could be coded separately and that it would include the cutdown on that side and the endarterterectomy as inflow-outflow...34804-62, 36556, 34812-XS for the vascular surgeon? Please advise.

Baclofen Pump Insertion

Is 62360 the correct code for a Baclofen pump insertion?

Guidance for a Liver Biopsy

If ultrasound and fluoroscopic guidance are used for a liver biopsy, should we report code 76942 or 77002? Or both?

NCCI Edits - Guidance for CPT 50200 - Renal Biopsy

We just noticed that guidance codes 76942, 77001, 77012, and 77021 were added as column 2 codes for CPT 50200 effective 1/1/16. There has been no change to the CPT description or to the notes following the CPT code regarding radiological S&I. Are you aware of the CMS rationale for implementing these edits? Any insight you could provide would be appreciated. 

76377

How many times may CPT code 76377 be used in a single encounter? Bilateral internal carotid arteries and the left vertebral artery were imaged. 

THROMBECTOMY/ANGIOPLASTY AV FISTULA

Hi Dr Z, Coding Open and Catheter use procedure? Senario: Discected upper ext. graft and performed graftotomy. Thrombectomized venous end graft which inadvertently thrombectomized arterial limb. Arterial limb clamped. Patient heparinized with 3000 units. After thrombectomy performed, then contrast inj, show residual thrombus at venous outflow of graft. Using clot catheter removed residual thrombus. Inj. contrast. Balloon angioplasty 7mm Armada balloon, then deployed 7x50 mm Viaben stent graft. Resulting arteriography demonstrated wide patency, no residual stenosis and nice luminal surface. We then utilized balloon to perform contrast inj centrally which demonstrated in-stent stenosis of innominate vein stent. Therefore use a 12mm x 60mm Armada balloon angioplastied innominate vein stent. Removed catheter, wire and sheath, locally heparanized and performed contrast inj. through arterial limb of graft, demonstrating wide patency. Closed graft with running 6-0 Prolene suture. Verified homstasis, irrigated wound and close wound with deep layer closer.

Endarterectomy w/fistula

I have an interesting case, and I'm wondering if you may have some insight. The patient was to undergo brachiocephalic arteriovenous fistula creation for dialysis access and required a brachial endarterectomy with a bovine patch angioplasty, to which the cephalic vein was then attached to create the fistula. I know in lower extremity bypass procedures the inflow/outflow would be inclusive, but this is not technically a bypass procedure. It has no NCCI edit per Craneware. However, since code 36821 has a "separate procedure" designation, I hesitate to bill these together, as they are in the same anatomic site at same session. If only one code is determined to be billable, could I bill the endarterectomy since this is more extensive (higher RVUs) than the fistula creation (36821), even though the intent of the operative session was for creation of the fistula?

35907

"In order to excise the infected abdominal graft at a later date, patient was scheduled for axillary bi-femoral bypass. However, he developed hemorrhagic shock with hemoptysis and was emergently taken to the operating room 10 days ago to endovascularly cover the pseudoaneurysm with placement of two 28 x 28 x 49 extension prosthesis and Amplatzer plug. He then underwent axillo-bi-femoral bypass 7 days ago and came back to the OR to remove the infected aorta bi-femoral bypass graft (35907-58). Surgeon also removed the endografts and the Amplatzer plug that were placed 10 days ago emergently, which he encountered while removing the aorta bi-femoral graft." Do we separately code for removal of endografts and the Amplatzer plug? If so, do we bill an unlisted CPT code with a -58 modifier? 

Bundled Sedation Narcotic Billing

If sedation is bundled into the procedure code(s), can the physician-owned facility still invoice for the narcotics used?

Retrograde Urogram

I am billing for the radiologist who is interpreting images from an intraoperative retrograde urogram. The report is as follows: "Images from an intraoperative retrograde urogram demonstrate opacification of the ureters and collecting systems. No filling defects on these images. A left nephroureteral double-J stent is identified. Please refer to the operative report for further details." Can I report code 74420-26? Many of these types of reports give less detail and only mention seeing a stent in place, such as: "Two fluoroscopic spot images were submitted for review and demonstrate wire and stent placement within the ureter. For complete findings see the procedural report."

Dynamic infusion cavernosometry and cavernosography

Would the following be coded as a 54230-74445 and 54231, or 54235? "23 gauge butterfly needles were inserted into the right and left corpora caverosa just behind the glans penis. Small contrast injection with fluoroscopy confirmed secure intracavernosal location of both needles. While occluding cavernosal outflow with umbilical tape placed around the base of the penis, papaverine 60 mg followed by phentolamine 1 mg was injected into the right needle. The drugs were distributed between the two corpora with massage. Ten minutes later, infusion of half strength contrast material was done through the right cavernosal needle at 1 mL/second for over one minute while pressure was continuously recorded from the left cavernosal needle. Radiographs were saved. Because of markedly abnormal response, redosing was done with papaverine 60 mg and phentolamine 1 mg with one minute of cavernosal occlusion and manual drug distribution. Five minutes later, infusion cavernosometry and cavernosography were repeated. Needles removed."

Conversion of Antegrade Ureteral Stent to Nephroureteral Stent

"Nephrostogram and nephrostomy. Catheter was removed. Using snare, existing antegrade ureteral stent was removed. Glidewire was advanced and a 10 French nephroureteral stent was placed." Should this be reported with codes 50384 and 50433?

Thoracic Outlet Procedures

"Patient underwent left first rib resection and scalenectomy for thoracic outlet syndrome. Following this, due to significant tightness at the inferior level and to give complete relief, excision of left subclavius muscle and left pectoralis minor muscle was performed." My thought is to use codes 21615 and 21700 for the excision of the first rib and scalenectomy, but I am not sure how to code for the excision of the subclavius and pectoralis muscles, and I would appreciate any direction you could give.

Pacemaker Relocation

"Patient has a right subclavian pacemaker and is going for radiation to that area and has to have the device relocated. Decision was made to move the device to a subcostal location. Previous device was removed, subcostal abdominal pocket was created, and leads were tunneled to the abdominal pocket and connected to a new generator." Is this just a change out (33228) with the relocation included in code 33228, or is this an instance when we can report the relocation with code 33222?

Repair of Atrial Lead

"Patient had her atrial lead protruding up and tenting the skin. We were afraid it would rupture through. The lead was pulled out as best as it could. We cut it and then pulled the inner core and put an O suture around the end and sutured it to a deeper layer of the epidermis." CPT Assistant, October 1996, page 9 states that code 33218 "includes services like splicing a fracture and/or modifying a terminal pin". Would you consider coding this "repair" with 33218?

Median Arcuate Release

Is there a CPT code for the division of the median arcuate ligament? Also, can you bill for this separately with the bypass?

Blebectomy

I need clarification on blebectomy/bullous disease. "26 year old male with spontaneous pneumothorax due to small bleb. Physician does VATS wedge resection of small bleb and pleurodesis." Is it okay to use codes 32666 and 32650 for blebectomy vs. 32655? Is it ever okay to use code 32666 for VATS wedge resections of bullae, even small ones, including another pleural procedure? The physician feels he should be able to use code 32666 and pleural procedure like 32650, as he is doing the same work as 32655 but getting less RVUs for 32655. 

Chronic Total Occlusion

A patient had an intervention on the right coronary artery. The distal RCA had a chronic total occlusion, and only an angioplasty was performed there (93943). The proximal RCA had an 80% lesion, and a drug-eluting stent was placed there (C9600). I have two questions: 1) Would you suggest coding 93943 or C9600? 2) If only the proximal lesion had been intervened on, would we have to code C9600 since that part of the vessel did not have the CTO, or could we code C9607? (This is for a hospital.) 

Multiple Embolectomies in the Upper Extremity

Can you bill more than one CPT code for embolectomies done on the brachial, radial, and ulnar arteries via the same incision? I understand that, if they are contiguous, you can only bill one CPT code, but what if there are more than two vessels?

Right Popliteal, Tibial/Peroneal,and Posterior Tibial Artery Exploration with Unsuccessful Thrombectomy

"Due to adherent veins it took physician two hours to expose the tibial/peroneal trunk. Both arteries were very calcified. Both were opened longitudinally. Fogarty cath was attempted, but neither artery would allow passage. Incision was extended with exposure down the leg to isolate the posteriort ibial, and arteriotomy was made. Lumen of the artery would not allow any thrombus to be removed. Slight backbleeding from posterior tibial was not enough to proceed with bypass." The physician reported codes 34201 and 34203. I added a -22 modifier to 34203 and a -53 modifier to 34201. Can you please give me directive on this procedure? I felt as though both needed a -53 modifier, but I felt the -22 modifier would not pay, and since it took him so long to isolate that artery I did not feel it appropriate for his sake not to append the -22 modifier. I also wondered if there should just be exploration billed with a -22 modifier. Many questions are running through my head on this one.

Ligation of Popliteal Aneurysm and Bypass

Provider performs a fem-pop bypass due to popliteal aneurysm and also ligates the popliteal aneurysm. Can you bill code 37618 with 35583?

LHC and FFR

"Patient with a prior MI 20 years ago with a scarred calcified anterior wall. He had a worsening EF down to 20% with increasing SOB and, therefore, had a heart cath with Physician A one month ago. He was found to have LVEDP of 13 at that time, as well as 70% left main lesion. The LAD was diffusely diseased. The circumflex had no obstructive disease, and there was some disease in the calcified ramus. Physician B reviewed the films, and he was concerned that the left main may be hemodynamically significant and that ischemia may be causing the patient's fall in EF. Patient was requested to come back in for an FFR of the left main. During the FFR they also performed a LHC." My question is, since the patient had a previous heart cath a month earlier, can we report the LHC with the FFR? If not, then how do we code the FFR, as it is an add-on code? 

93975 and 96976 Documentation

Related to pelvic, abdominal, and retroperitoneal ultrasounds, we understand that code 93975 or 93976 should not be reported in addition to the base ultrasound code when used for a quick assessment of blood flow or to simply identify a structure. Could you help us clarify for our physicians what elements should be seen in the report in order to substantiate these codes? This is an example of what we often see: "Technique: Transabdominal and transvaginal imaging, 2D gray scale, color Doppler, spectral waveform analysis. Findings: Uterus measures XX, uterine fundus circumscribed hypoechoic structure measuring XX. Another located in the posterior fundus measures XX. Endometrial measures XX. No endometrial fluid seen. Overlying bowel gas structures obscures right ovary. Left ovary measures XX. It demonstrates normal color flow Doppler and spectral waveform analysis. No free fluid seen." Could you please review and clarify if there is sufficient documentation to report codes 93975/93976 in addition to pelvic and transvaginal ultrasound codes?

Thrombectomy

Can code 37186 be reported twice when performed on bilateral lower extremities at time of angioplasty also performed bilaterally, since these are different vascular families?

Use of CO2 rather than contrast media

Can angiogram and angiography CPT codes be reported if CO2 is being used rather than contrast media due to the patient having CKD?

Brachial Cutdown with Embolization

I have a facility that needs to do a brachial artery cutdown for a splenic artery embolization with coils (37242). The codes for embolization/occlusion do not specify open or percutaneous. Would you charge unlisted code 37799 for the cutdown procedure? Or is it included as part of the overall catheterization access?

Four Biliary Catheter Exchanges

Exchange of 1 internal/external biliary catheter in the right posterior inferior intrahepatic biliary duct and exchange of 3 internal/external biliary catheters in the right intrahepatic biliary duct. Can we code 47536 x 4 or just 2?

Pacemaker System Implanted, Followed by Lead Being Broken During Procedure

What code(s) are appropriate when an initial pacemaker system is being implanted and the lead is broken or damaged and has to be replaced?

Embolization Cholecystostomy Tract

Is there a code for embolization of a cholecystostomy tract with coils when removing the tube?

Viabahn Stenting of Right Popliteal Aneurysm

Patient underwent AFRO with Viabahn stenting of a right popliteal aneurysm via left common femoral percutaneous access. I am unsure how to code this since popliteal artery aneurysm is not a valid diagnosis for 37226 per LCD. Is there another code you might suggest for this scenario?

Iliac Endarterectomy and Fem-Fem Bypass

Can we bill for an iliac endarterectomy along with the fem-fem bypass here? "CFA was exposed through left groin incision. The femoral artery was not pulsatile, and the incision was extended proximally splitting the inguinal ligament until the ileal femoral segment was exposed. The artery was calcified but pulsatile, and a spot was identified for clamp placement. The artery was dissected and side branches were controlled with loops. Loops were placed around the inflow artery as well as the superficial and deep femoral arteries on the left side. A second vertical incision was made in the right groin, and the fem bifurcation was exposed. At this point there was some lateral plaque but the vessel was generally soft. A suprapubic tunnel was created from the left groin to the right groin. Arteriotomy made in the left CFA and extended up the circumflex iliac artery. An endarterectomy of the vessel was then done with a clean break achieved in the deep femoral artery. Proximally the endarterectomy was blindly extended into the EIA to the point of clamp placement. The graft was anastomosed end-to-side to the endarterectomy. Graft passed into the right groin and anastomosed to CFA."

Dictating CPT Codes

Years ago I went to a seminar (unfortunately not yours), and I remember the consultant mentioning that it is not good for a doctor to add the actual CPT and ICD-10 (was ICD-9 at the time) codes into the dictation of an operative note. I currently see a doctor who is doing this, and I'm wondering if it is appropriate. Can you tell me if this was just an opinion brought forth from a Medicare auditor or if there is a general rule or guideline on this? For the most part the coding is correct, but some of it is not, and I fear there may be a compliance issue. When I try to find documentation on the subject, I cannot locate much of anything, so I would like to know how you feel about this. Is there is any kind of guideline that states a doctor should or shouldn't? If you feel that dictating the codes into the operative report is a good idea can you explain why? 

Pressures Taken in Ascending Aorta

My surgeon billed for a right retrograde left heart catheterization, but pressures were only taken in the right atrium and in the ascending aorta. Can we bill for that? Or is it just 93530?

Penumbra Device for DVT in the Legs and IVC

Our reps are pushing the Penumbra device to be used in the legs for DVT. If this device is like a thrombectomy device, wouldn't I use venous thrombectomy code 37187 even if we don'tt use tPA? According to what Penumbra is saying we don't need to use tPA with this device like we do with AngioJet or EKOS. That is their selling point. Can you please help?

RV Lead and Tricuspid Valve Replacement

"A patient has a tricuspid valve replacement and develops a complete heart block. A dual chamber pacemaker is placed with an atrial lead, and the RV lead is placed in the coronary sinus to avoid damaging the replaced valve." Would this be reported with 33206, 33225, or 33208?

AAA with Chronic Occulsion of Iliacs

I have been looking for a code for AAA and iliac repair. The device is "TriVascular Ovation Prime Bifurcated Device". I have read some info, but I can't figure out what code to use... or is this an unlisted one? What is different is there is Polymer injected and has a cure time (i.e., 20 min) on this patient. I have never seen this before. Any advice would be greatly appreciated.

Neph Stent Placement with Nephrostomy Tube Change

How do you code a ureteral stent placement using an existing nephrostomy tube tract and nephrostomy tube change? Are codes 50393 and 50435-XS appropriate?

Selective Coding

If the right subclavian artery is selected and the right vertebral artery is selected, would the coding be 36225 and 36226? Or just 36226?

Visceral/Renal Angioplasty

If the documentation states the doctor performed a selective renal unilateral or bilateral (36251 or 36252) diagnostic angiogram and catheter placement, can this be billed with code 35471 (angioplasty)?

Bundled Guidance Codes, 76942

If an ultrasound-guided needle biopsy is done on a superficial lymph node (38505, 76942), and a clip is placed at the same site (10035), should we be reporting ultrasound code 76942? There is an NCCI edit for codes 10035/76942. Are there specific guidelines I can reference for this situation?

Closure Device

We have a professional billing client that performed "angiogram through existing left groin sheath and removal of femoral arterial sheath with deployment of closure device". What, if anything, could we bill for this? This patient had a complex IR procedure embolizing multiple bleeding arteries 7 days prior, which I presume is why they did not place a closure device at that time.

61645 and 36224

Could you please confirm if we to bill 61645 and 36224 for the procedure performed below: "1. Diagnostic cerebral angiogram demonstrates acute vessel occlusion at the right M1 segment. TICI 2B revascularization was achieved with 1 deployment of the Solitaire stent retriever device. 3. Successful endovascular stroke therapy for treatment of right M1 occlusion with a TICI 2B revascularization." Please let me know if you need additional information.

Percutaneous Transluminal Balloon Angioplasty and Stenting of the Left ICA

My provider submitted codes 37215, 35475, 75898, and 75962 for percutaneous transluminal balloon angioplasty and stenting of the left ICA. This does not seem correct to me, as they bundle, and also the description of code 35475 says "brachiocephalic or branches" (and this is the left ICA). Can you help me with this scenario please?

Iliac Aneurysm Treatment with Bifurcated Aortic Stent Graft

"Unibody AAA Endologix placed at bifurcation to treat right iliac aneurysm. Extension placed in right common and external iliac. Left common iliac stent in left limb of graft to treat kinking of the left limb. The patient has a left iliofemoral bypass graft as well. Impression: Successful treatment of the right common iliac aneurysm with placement of an Endologix body endograft into the distal abdominal aorta and then placement of the stent graft into the right external iliac artery followed by placement of right iliac bridging prosthesis. A suprarenal aortic extension could not be placed due to lack of sufficient length between the lowest renal artery and the aortic bifurcation." Should we code the graft as unlisted? Or use code 34804 or 34900 plus extensions? 

End-to-end venous anastomosis

"During a Whipple procedure part of the portal vein is resected. Vascular service comes in and performs an end-to-end anastomosis between the portal vein and superior mesenteric vein." I believe this should be reported with unlisted code 37799, but I'm not sure what code to compare it to.

Second Stage Vein Transposition

It is my understanding that if, after the creation of an AV fistula, a vein transposition is performed at a later surgical session on the same fistula, that this should be reported with code 36832 (revision of AV fistula) instead of codes 36818-36820 for vein transpositions. My physicians disagree, stating that performing the vein transposition requires significantly more work than other, more simple revision procedures, and they believe the work RVU is more consistent with codes 36818-36820. They don't agree that the description in the CPT Codebook correlates to a one- or two-stage procedure and think they should use it in either scenario. I am hoping you can shed some more light from a clinical perspective that can assist me in explaining to them why this procedure should be coded this way.

OCT in Periphery

Is OCT separately billable when performed in conjunction with peripheral interventions? If so, is it reported with an unlisted code?

G-Tube Replacement, Multiple Aspects

I have an ED physician who performed dilation of old tract with cervical dilators and inserted a 4 cm Mickey G-tube. He sent patient off to Radiology Dept to complete the Gastrograffin injection and abdominal x-ray for tube confirmation. Code 49440 includes ALL of the above. Because this is a facility coding/charging issue, HOW do I report when multiple physicians and multiple departments performed different aspects of the procedure? Because, of course, they all want their revenue. 

93640

Could you please clarify the use of code 93640? "Patient here for biventricular generator change due to ERI. Patient was brought to the lab; all of the leads worked well. The old device was removed. The leads were inspected, and they all worked well. They were attached to the new device and placed into the pocket. Three layers were used to close the wound. High voltage resistance was checked. Patient left in stable condition. Patient was in complete AV block. No shocks on previous device." We are told the physicians test the leads when they place/change/upgrade an ICD and we should therefore report code 93640. We report code 93641 when they test the generator and the patient is induced into an arrhythmia and joules back into sinus rhythm. Can you clarify on implantation/change/upgrade regarding what the report has to indicate to report code 93640? Or is code 93640 considered inherent to the procedure and not coded if the report doesn't document an arrhythmia being induced? Does the report have to indicate that an arrhythmia was induced, or can it be assumed? We (hospital) reported the above with codes 33264 and 93640.

Balloon Maceration of Clot Induced by Catheter in Coronary

"Patient has right and left heart cath with coronary angio to dx reason for SOB. Minimal CAD is found, but not hemodynamically significant, as in impression he refers patient to pulmonary (has history of exposure to asbestos). During the coronary angiogram, an acute thrombus was angioplastied (likely source dx catheter)." Since there was no hemodynamically significant stenosis, can we code/charge for the angioplasty since it looks like it was caused by the catheter? 

Occluded EVAR graft

"Access via left CFA. Glidewire was negotiated into left external and common iliac artery stent occlusion. AngioJet percutaneous thrombectomy catheter was serially advanced through the long iliac occlusion rmoving 180 mL defibrinated thrombus. Retrograde angio revealed severe in-stent stenosis. Angioplasty of left CIA and EIA was performed; there were residual stenoses, so a 17 French AFX Endologix sheath was advanced into the AAA Afx graft. An Afx iliac ext cuff endograft was deployed at the flow divider of the previous placed Afx bifurcated endograft. Baloon angioplasty post-stenting noted resolution of proximal CIA stenosis, but residual mid-ext iliac artery stenosis remained. A second iliac balloon-expandable Omni link stent was deployed. Next a left fem arteriotomy was created and critically stenosed profunda was endarterectomized." Would this be reported with codes 37184, 37221, 37223, and 35372? Or are we to look toward an endograft extension limb even though the stent was placed for graft occlusion (rather than an endoleak)? AAA repair was 4 months earlier. 

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