Knowledge Base

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Set Descending Direction

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. 

75630

I was reviewing the Case of the Month from August 2015, and I noticed that you used code 75630 to report the aorto-iliac imaging. Per the 2015 Interventional Radiology Coding Reference, the use of code 75630 "requires imaging of the abdominal aorta, not just the distal most aspect of the aorta". This is confusing because in this case the imaging was performed below the level of the renals. While I understand that this is higher than being at the bifurcation, the instructions from the reference would suggest that this would not be coded as such. Is the rationale that 75630 would be used since we had some portion of the aorta and then the runoff into the single leg from that one catheter position in the aorta, despite only imaging a portion of the aorta?

2016 Vertebroplasty

Vertebroplasty of T12, L3, and L5... By the old codes these would have been reported with 22520 (T12), 22521 (L3), and 22522 (L5), correct? So by the new 2016 codes, wouldn't these reported with codes 22510 (T12), 22511 (L3), and 22512 (L5)? But NCCI is showing that code 22511 is bundled with 22510 with no modifier allowed. I'm not understanding, because code 22510 is only for cervicothoracic. Wouldn't/shouldn't code 22511 be the primary procedure code for L3?

Right renal artery and right venous TPA thrombolysis discontinuation

"A patient has right renal arterial and right renal venous TPA thrombolysis done with two separate catheters. Follow-up with discontinuation of the right common femoral arterial sheath was then removed and hemostasis obtained with a star close vascular clip. Right common femoral venous sheath removed and hemostasis obtained with manual compression." Can I bill 37214 twice with a modifier -59 because both arterial and venous TPA thrombolysis were discontinued? I guess I want to know if I can code per type of vessel? Or do I treat this like one surgical field because anatomically it's all of the right kidney: right renal artery and right renal vein? I'm conflicted because of it being an artery and then a vein, because we have separate codes for arterial 37211 and venous 37212 thrombolysis... so should I code them as two separate surgical fields? I feel like I can only code this once because CPT 37214 applies to both arterial and venous thrombolytic infusions. Please advise.

Angioplasty or Primary Thrombectomy with No Stenosis Documented

Patient on subsequent day EKOS lower extremity. Re-visualized still heavy clot burden seen. Physician ballooned anterior tib, posterior tib, and peroneal artery plus aspiration catheter each vessel post balloon due to loose clot seen with in same vessel. There is no documentation of stenosis in these vessels. Restarted EKOS patient brought back next day for angiojet to PTA and peroneal and thrombolytic spray through AngioJet for 20 min to post tib plus stent placement to post tib due to dissection. Day two was coded by staff as 37213, 37228, 37232. Based on my understanding of what I read in your book it should be coded as 37213, 37184 (post tib), 37185 (anterior tib), 37185 (peroneal), 36247. Day three should be 37214, 37184, 37185, 37230. Is this correct? There is disagreement and confusion on what is an angioplasty and what is thrombectomy in cases like these.

Cancellation of Planned MitraCLip Procedure

The patient was brought into OR suite for a planned MitraClip insertion. Patient was prepped, equipment opened for "Clips", and patient was placed under anesthesia. Case began by TEE probe attempted passing several times but due to small/stricture of esophagus, but unable to pass probe and procedure was cancelled. What am I able to charge for this since she was an inpatient (-74 modifier not applicable??). She was made an inpatient per CPT guidelines .

Stress Echos

I am trying to determine whether or not to use code 93350 or 93351 for stress echos in our clinic. It seems to me that in order to bill 93351 the physician has to be in the room monitoring the test and performing the echocardiogram. We have a tech/nursing staff member in the room with the patient, and then the physician provides an interpretation and report. Which code is appropriate in this case?

Transforaminal Epidural Injection with a Ganglion Impar Injection

My provider performed an S2 transforaminal epidural steroid injection and clearly states he then "turned his attention to the cauda area and performed a ganglion impar injection". Would I be correct in billing code 64483 in addition to 64999? Even though it is an unlisted code that shouldn't make it an issue with bundling, right? Do you agree?

Open Thrombectomy and Percutaneous Thrombectomy of a Fem-Pop Bypass Graft

If open thrombectomy is performed on the proximal aspect of a fem-pop bypass graft and a percutaneous thrombectomy is performed on the distal aspect of the same fem-pop graft, can both codes 37184 and 35875 be reported (same DOS/encounter)? The physician then places two stents; one is fully inside the graft and the other is 1/2 outside the graft. Can either stent be coded?

Stereotactic Post Biopsy Mammogram

It is my understanding that, if the proper guidelines/dictation are met, a post biopsy mammogram to verify clip placement may be charged after a stereotactic guided breast biopsy. Is this correct?

Re-Implantation of AICD

Broken RV lead was removed and replaced. Existing generator was re-implanted. Are codes 33240, 33241, and 33244 correct for this scenario? "The pocket housing the existing pulse generator was entered and the device removed. The ICD lead was disconnected from the pulse generator. The lead was completely removed with gentle traction without difficulty. The cut end of Fidelis lead did not have a cap present, and this was replaced… The right ventricular lead was placed via this sheath into the right ventricular apical location. The lead was positioned superior to the abandoned Sprint Fidelis… previously implanted generator re-implanted. Generator connected to leads and generator implanted in pocket. Existing right ventricle lead was removed intact. Durata lead was removed. Additional RV lead remains."

PVI for PVCs

I am needing a second opinion on this case. "Patient had a previous PVI a few months prior. Brought back in for PVCs and was in a right to left flutter on the CS. Ablation: Biosense Webster catheter was used for the ablative procedure. The PentaRay catheter was used to assess the veins. Both inferior veins had reconnected. During PentaRay manipulation, the tachycardia terminated when the splines were around the left posterior carina. This was inferior to where the previous line was placed. Ablation was guided by the prior left atrial CT scan, geometry performed with Carto 3D mapping, electograms, fluoro, and continuous ICE with targeted areas those of high voltage within the previous lines. Ablation in this area immediately terminated the signals in the LIVP. A line was made in this region joining ablated areas of the superior vein to electrically silent areas in the inferior vein. Leions were placed on the ridge where there was activity. The PentaRay was placed into the RIVP and the vein isolated at areas of reconnection. All four pulmonary veins were isolated."

TEVAR through Open Sternotomy

I have an unusual case that I would appreciate your assistance with coding. The provider documented opening the chest through a median sternotomy, but he then accesses the ascending aorta, introduces a catheter, and then passes the catheter to the descending thoracic aorta. The rest of the case proceeds through an endovascular approach after that initial sternotomy (the provider deploys a thoracic endograft with a proximal extension that does not cover the subclavian origin). I have settled on codes 33881 and 33883 with radiology S&I codes 75957 and 75958 with modifier -26. For the approach and the catheter insertion directly into the aorta, I do not see established codes to report this part of the procedure. Would you agree with unlisted code 37799 in addition to the graft/S&I codes listed?

Dislodged Nephrostomy Tube

I work for a hospital. I have an account in which the patient had a dislodged left nephrostomy catheter. The procedure involved reinsertion of the nephrostomy catheter via an existing sinus tract. Should this be coded as a new placement (50432) or as an exchange (50435)? Since the reinsertion is via an existing sinus tract, how does this affect coding?

Removal of an Occluded Lower Extremity Bypass Graft

One of our physicians removed an occluded lower extremity bypass graft. Would code 35903 be correct to use? If not, what would be the correct code? There was no revision performed or a new graft.

Arteriogram of Lower Extremity

"Physician does an ultrasound-guided access of right common femoral. Complete abdominal aortogram, pelvic arteriogram, selective cath of left common femoral artery with select left lower extremity arteriogram, and selective right lower extremity arteriogram with interpretation. An Ansel catheter is used to select out the right external iliac artery as well as right common iliac artery. Ominiflush catheter was placed into the infrarenal abdominal aorta at L1-L2 interspace, and a complete abdominal aortagram was taken. The catheter was then brought down to the iliac bifurcation, and a pelvic arteriogram was taken. The catheter was then brought up and over the bifurcation, and then selective cath of the left common iliac, left external iliac, and left common femoral artery was taken. The catheter was then pulled back to the bifurcation down to the right external iliac artery and right common femoral artery, and a selective right lower extremity arteriogram was taken." I want to make sure my codes are correct: 36246 x 2, 75625, 75716, 75774, 75774-26-76-59, and 76937.

IVUS at Two Sessions

A patient came in for a diagnostic IVC-gram and bilateral lower extremity venograms. IVUS was used at that time. As we did not have large enough stents to treat the stenosis, the patient was scheduled to return for intervention. IVUS was used again at that time. I know I cannot recode the diagnostic venograms, but does IVUS follow the same rules? Is it non-billable roadmapping if it is used for precise placement of the stents, or is it a billable service at both encounters? 

37211 and 37212 in AV fistula

"Patient with thrombosed AV fistula was taken to Interventional Radiology. Ultrasound revealed a 5 cm segment of thrombus extending centrally from the arterial anastomosis. Venous limb of fistula is patent. Access was obtained directed towards arterial anastomosis, and infusion catheter was advanced to arterial anastomosis. tPA was pulsed into fistula under fluoro guidance, and tPA drip was started. Patient to return in one day for follow-up fistulogram. Impression: Successful initiation of thrombolysis therapy left upper extremity dialysis fistula." The department charged codes 37211 and 37212. Should this actually be reported with code 37211 only? In other cases by this radiologist he uses two infusion catheters in opposite directions, but in this case he uses only one. In an AV fistula, is it even appropriate to charge both codes 37211 and 37212 if two infusion catheters are used, one directed to the vein side and one to the arterial side?

Lynph Node FNA with Clip Placement, US Guidance

Patient comes in for US guided breast biopsy (19083) and FNA of the axillary lymph node (10022-59) under US guidance (76942). At the location of the FNA in the lymph node, a localization clip is placed (10035-59). Is it appropriate to charge the US guidance for the FNA (76942) separately when it is already bundled with the clip localization?

Device Codes

We are a physician office (place of service 11) that places PICCs, ports, etc. Can we charge separately for catheters and other supplies?

27096 and G0260

We are instructed to report code 27096 for commercial payers and G0260 for Medicare. Your book indicates that code 27096 can be reported with a -50 modifier when performed bilaterally. Can code G0260 be reported with a -50 modifier as well?

Rescue Thrombectomies

A Terotola thrombectomy of an AV fistula was attempted but resulted in the clot embolizing downstream in the radial and ulnar arteries. Rescue thrombectomies of the radial and ulnar arteries were then performed. Is this considered a "complication" and therefore only code 36870 should be reported? Or should codes 36870 + 37188 (or 37184 + 37185) be reported?

MUE for Cervicocerebral Imaging

I was wondering if there has been any discussion regarding an MUE of 1 for cervicocerebral imaging. Does this only reflect physicians as stated, or does this also apply to the facility setting? Does the "1" denote one line (with a -50 modifier), or just one period?

ZIO Patches

For code 0296T, who would be the billing provider? Example is we have a nurse in the cardiology department who will connect the ZIO Patch to the patient even though it was ordered by a different specialty provider. Do we bill under them or the cardiologist?

Bilateral Venous Studies for Upper and Lower Extremities

Our providers order venous studies of bilateral upper and bilateral lower extremities. We are billing them with codes 93970-26 and 93970-26XS. We place a box 19 comment on the claims to say what the exam was for, either bilateral upper or bilateral lower extremity studied. Insurance is denying them both. We appeal with notes and they are still denying, stating they are following MUEs. Do you have any suggestions for us? Should we use a different modifier?

Ascending Aortic Endoleak Repair

A patient has a type 1A endoleak with expanding thoracic aortic aneurysm. Thoracic dissection was previously repaired with Cook endograft as well as embolization of left subclavian by coverage of the left subclavian artery. "Current procedure: The physician placed aptus screws into the lesser curvature of the thoracic stent graft at the level of the fabric. There was improvement, but endoleak still there. There was approximately 5 mm between the leading edge of fabric to the left common carotid artery. Wire was placed within the ascending thoracic aorta, and stent graft was deployed under fluoroscopic guidance to ensure that the top of the fabric was at the level of the right common carotid artery." Should this be reported with code 33881? Or code 33886 perhaps? Was this performed in the ascending aorta or thoracic aorta? If ascending aorta repaired, do we still use descending codes? The previous procedure performed at another hospital. Also, is the screw placement included in repair, or do we report code 37799?

Nephrostomy Tube Placement with Double J Stent

Would you report both codes 50432 and 50433 for the following case? "The patient was placed prone. The skin was anesthetized with lidocaine, and a small needle was advanced into the inferior pole collection. Contrast injection confirmed location within the left kidney. Under fluoro, a guidewire was passed into right ureter. The tract was dilated and a sheath placed. A 22 x 8 French internal double J stent was then deployed with its distal tip in the urinary bladder and the proximal end in the left renal pelvis. Next, an 8 French nephrostomy tube was placed into the left renal pelvis. A locking mechanism was deployed. The line was sutured in place at the skin exit site. Successful placement of a nephrostomy tube and left-sided double J stent."

Placement of Fiducial Marker in Iliac Bone

I'm looking for the appropriate CPT code. No biopsy was performed, just marker placement in bone. "The patient was placed prone on the CT table. A preliminary, limited CT examination of the pelvis was obtained, localizing the left iliac bone. A suitable skin entry site was marked. The patient's left buttock was sterilely prepped and draped in usual fashion. 2% lidocaine was infiltrated into the subcutaneous tissues for local anesthesia. A small dermatotomy was created. Under direct CT guidance, an 11G bone marrow biopsy needle was advanced into the left iliac bone. Two fiducial markers were deployed at the inferior aspect of the iliac bone lesion. The 16G bone marrow biopsy needle was subsequently advanced into the superior aspect of the iliac bone lesion, and an additional fiducial marker was deployed at this site. The needle was removed. The site was sterile bandaged. No significant bleeding was noted. The patient tolerated the procedure well. IMPRESSION: Successful CT-guided percutaneous fiducial marker placement in the left iliac bone."

Diagnostic Imaging

In regards to coding diagnostic imaging at the same time as intervention, your vascular/endovascular book states to code separately if prior catheter-based angiography was not "recently" done. The CPT Codebook just states "no prior" catheter-based angiography. Is there a time frame attached to the "no prior" or "recently" performed CTA/MRA of the area of interest? I have seen no reference to this in your question database.

CPT 36200 for Co-surgeon

My thoracic surgeons did co-surgeon for AAA repair. Dr. A accessed from the left side and Dr. B accessed from right side. How should we bill for catheter placement? Should I report code 36200-LT for Dr. A and code 36200-59RT for Dr. B? And also for S&I code 75952 (34804) and ultrasound access code 76937, should I bill for each of the surgeons or just one of them? 

34812

We have a physician who was told that when he does a AAA procedure that the Perclose of the groins does count as a cutdown (34812), even though it is not a full cutdown. It is more like a partial, but suture is still used to close the artery. What are your thoughts on this, and what is the correct code? 

HCPCS Code for Turbo-Elite Atherectomy Catheter

Is a separately reportable HCPCS Level II code allowed when using an Excimer Laser System catheter when treating peripheral and coronary arterial disease?

34812

We are having a debate on billing code 34812. There are some that say code 34812 is just exposing the femoral artery, and vessel access can be done by a "puncture" or arteriotomy. Based on AMA Vignette and AMA KB 1585, both reference that exposure is done of the femoral artery, but the access must be done by arteriotomy. What are your thoughts?

Lymphangiography

The physician selected bilateral inguinal lymph nodes, then accessed the thoracic duct and embolized it because of a leak. Would he still get credit for both of the inguinal lymph nodes? If you have any additional info on this type of procedure it would be greatly appreciated.

36228 without contrast injection

"Patient had diagnostic cerebral angiogram on a right internal carotid artery and coil embolization on a ruptured right middle cerebral artery aneurysm. Catheter was placed on the right internal carotid artery, and contrast was injected. Cerebral angiogram was then performed in AP. 3D reconstructions were done on a separate workstation. Microcatheter was navigated in the right middle cerebral artery for coil embolization. Contrast injection was not used. Intermittent angiogram and post embolization angiogram were done." Can I report code 36228 along with codes 61624, 36224, 75894, 75898, and 76377?

Ureteral Stent Injecton and Nephrostomy Catheter Exchange

For the following, would the correct codes be 50431 and 50435-59? "The patient's indwelling Seidmon catheter was injected with contrast. It was noted to be within the mid ureter, and most of the side holes were outside the patient. This catheter was then removed, as it could not be cannulated with a guidewire due to calculus material within it. This was followed by injecting a ureteral catheter previously placed by the urologist, which demonstrated distal ureteral near complete obstruction secondary to two large calculi. The patient's nephrostomy tube was then attempted to be cannulated with a guidewire, which was unsuccessful, as the nephrostomy tube was obstructed secondary to calculus material. Next to the nephrostomy tube a Kumpe catheter with a glidewire was placed so that the renal pelvis was entered. Several attempts at entering the urinary bladder with glidewire were unsuccessful. It was elected to replace the nephrostomy tube at this time and no longer attempt to place a ureteral stent."

Nephrostomy Catheter and Seidmon Catheter Placed on Same Side

For the following, would the correct coding be: 50432, 50395-59, and 74485? "An upper pole calyx was punctured percutaneously and a antegrade pyelogram was done showing moderate hydronephrosis as well as a distal stricture in the left ureter. Within the left renal collecting system opacified with contrast, a Hinck needle was used to percutaneously puncture a lower pole calyx. Through the exisiting lower pole needle access, a 0.018 wire was placed and advanced into the renal pelvis. Over this, a Accustick catheter was placed. Through this, a glidewire was advanced down to the left ureter to the level of the distal stricture. The stricture was crossed with the glidewire, which was then advanced into the neobladder. The Berenstein catheter was removed, and a Seidmon cath was advanced over the wire with its distal end pigtailed within the neobladder. The external portion of the Seidmon was capped. A J-wire was advanced through the sheath into the proximal left ureter. Sheath was removed, and dilation and exchange were done resulting in a placement of a 10 French nephrostomy within the renal pelvis." 

Arm Pain

Would I report codes 36222, 36225, 36218, and 75774 for the following case? "A 5 French sheath was started in the right common femoral artery. A pigtail catheter was advanced to the thoracic aorta. Thoracic aortography was obtained. The catheter was exchanged and engaged the left common carotid artery. Angiography was obtained. Catheter engaged left subclavian with angiography. No thrombus was seen, and catheter was advanced to left axillary. Left arm upper extremity angiography was obtained. Findings: Type 1 aortic arch, patent left common carotid and left internal carotid. Left subclavian widely patent. Left vertebral artery widely patent. Left innominate without significant stenosis. Left radial and ulnar arteries patent." 

Left common carotid angiography and left middle cerebral cannulation only

If the physician performed left common carotid (with intracranial imaging) and also cannulation of left middle cerebral artery without imaging, would I use code 36217 for the cannulation of the left middle cerebral artery as well as 36223 for the cath placement and imaging of the left common carotid? He imaged the common carotid and found stenosis of the middle cerebral. At this point the plan was to perform intervention. He cannulated to the insular branches but could not pass guidewire through the occluded middle division, so the intervention was not performed. So my question is, do I only bill code 36223 for the carotid imaging? Or can I bill code 36217-59 as well for the cannulation of the middle cerebral artery?

Neuro Intervention

"Patient has a six-vessel cerebral angio and is found to have an aneurysm on the right internal artery. The next day, the patient has a repeat bilateral internal carotid and bilateral vertebral arteriogram, then has a stent-assisted aneurysm coiling where an aneurysm angio was performed. The patient has a complication of non-occlusive thrombus in the right middle cerebral, which was treated with thrombolysis." Do I code for the repeat angiogram before the embolization? And do I use code 37211 for the thrombolytic injection?

Lymph Node Resection

When using code 32674 or 38746, mediastinal and regional lymphadenectomy, what is the minimum number of lymph nodes resected? Is it allowed if only one or two nodes are taken, or does it need to be more than that?

Umbilical Node Biopsy

Would a core biopsy of an umbilical node be reported with code 38505 or 49180?

Contralateral cerebral imaging after ipsilateral cerebral imaging after a CTA obtained.

The patient presents for thrombectomy for known left MCA occlusion. Then, after left thrombectomy, the attending moves the catheter to the right internal carotid and performs imaging, documents findings (no stenosis seen), and ends the procedure. Would you report codes 61645 and 36217-59? It seems like 61645 and 36224-59 would not be appropriate since the condition was known and the contralateral imaging was after the therapy. The attending documented that no prior diagnostic angiogram was available and the decision to treat was based on this angiogram, but the patient presented for mechanical thrombectomy. Could the right-sided imaging still be diagnostic, or would it be considered follow-up imaging?

Primary AV Fistulogram Left Upper Arm

"An 18 gauge angiocatheter was used to cannulate the AV access. Contrast was injected to perform diagnostic fistulogram of outflow tract... The more proximal stenosis was addressed by 'redirecting' the guidewire and sheath into the fistula in the opposite direction under fluoroscopic guidance. The stenosis was angioplastied." I know that I can code 36147 for the catheter placement in the AV fistula. Can I code 36148 (second cannulation of dialysis access) for the ‘redirecting’ or ‘redirection’ of the guidewire/sheath to perform a PTA?

59 vs. 76 Modifier

I just started working for a client that used your company to do audits. They do internal audits, and they dinged me for using a -59 modifier on code 37211 for a bilateral pulmonary (they didn't have it set up for -50 in the system). They told me I should use a -76 modifier on the additional 37211. I explained that goes against any coding guidelines I have been taught. They stated your company does their auditing and has agreed with the use of -76 on all Carriers because it's based on Carrier policy. Can you please confirm that this correct?

PTCA with Drug-Eluting Stent

If a PTCA with drug-eluting stent to the LC is performed and extended slightly into the OM-2, is it reported with 92928-LC? Or 92929 also?

Right-Side Tandem Heart

"TTE demonstrated collapse of left atrium and dilalted right ventricle with patient on left-sided Tandem Heart Support. Therefore HTS requested right-sided mechanical circulatory support. A 6 French x 35 cm sheath was inserted into the right jugular vein. A 6 French x 110 cm wedge cath was inserted into the SVC. The 6 French x 110 cm wedge cath was repositioned into the right ventricle. A Tandem Set Up Kit was inserted into the right atrium. Counterpulsation was initiated. The Tandem Set Up Kit was sutured in. Right-sided Tandem Heart was initiated with Proteck Duo cannula inserted via right IJV." Would you report code 33991-52 (33991-74 for facility), or is there another code that is more appropriate for this procedure?

Chest Port Catheter Malfunction due to Fibrin Sheath

How would you code this procedure? "Left chest port catheter was accessed in a sterile fashion using a Huber needle. 2 mg of tPA was infused into the chest port catheter for a 3-hour span, followed by easy aspiration from the port catheter, which was then locked with Hep-Lock. The port is ready for use."

Removal of Aneurysmal Angioaccess Arteriovenous Fistula

Please advise if code 36832 is appropriate for the following scenario: "The patient has a functioning brachiocephalic fistula and presents for excision of a severely aneurysmal radiocephalic fistula. The radial artery proximal and distal to the anastomosis was dissected out and controlled with vessel loop. The radial artery proximal to the fistula was noted to be severely dilated. The excision was extended along the length of the fistula to the antecubital fossa, and the aneurysmal radiocephalic fistula was exposed. The fistula was then dissected out to free up its adhesions to the overlying subcutaneous tissue. There were multiple branches that were hypertrophied and were suture ligated. The cephalic vein was amputated at the antecubital fossa and oversewn proximally. The aneurysmal fistula was then freed up from underlying adhesions all the way to the wrist. There were multiple crossing veins, which were hypertrophied and required ligation. The aneurysmal anastomosis was taken down, and the radial artery was ligated."

Stent graft repair

1. Stent graft repair of lt common iliac artery aneurysm to preserve lt hypogastric artery utilizing an Endurant bifurcated graft with snorkeling of the lt hypogastric artery and stenting of the lt hypogastric artery using iCAST stents. 2. Ballon angioplasty of lt external iliac artery for residual stenosis. Endurant graft inserted from lt fem and positioned in the lt limb of the previously deployed endograft. Graft deployed so contralateral gate landed 1.5 cm above takeoff of lt hypogastric. The ipsilateral limb of graft was deployed in the lt external iliac artery. Proceeded to snorkeling of the lt hypogastric. Advanced an iCAST stent into contralateral limb of graft, directing it into lt hypogastric. The initial stent was deployed in the contralateral gate and extending into the origin of lt hypogastric. We advanced a 2nd iCAST stent into lt hypogastric. Allowed for 2 cm of overlap with the initially deployed iCAST stent. 2nd stent extended into lt hypogastric and landed prior to the takeoff of the 1st order sub branches of lt hypogastric.

93657 After PVI in Persistent Afib

I was explaining to a physician that he needs to clearly say that Afib remains after PVI ablation rather than/or in addition to speaking about potentials that remain. He wanted me to inquire about the following: Patient has persistent Afib but arrives in NSR. Post PVI ablation, the 4 veins are isolated and he measures potentials, and he finds it is necessary to do a posterior wall. After posterior wall, no potentials remain. Because of NSR, we can't say Afib remains after PVI but additional is done because of measured potentials. Can he use code 93657 anyway?

Resection of Mediastinal Tumor

Is code 39220 appropriate to report for the following case? "Procedure: Transternal resection of apical posterior mediastinal neurogenic tumor. Indication: Patient with large posterior mediastinal tumor in the apex of the left chest. Tumor entering spinal canal. Neurosurgery performed a laminectomy earlier and released the tumor from the canal. Patient was brought to the OR, and a C-shaped incision was made over the left sternocleidomastoid, down at the mid-sternum and around to the third interspace. The mass was evident towards the left side and was entirely extrapleural. The pleura at the reflection of the mass was incised with harmonic scalpel, and the mass was gently dissected of the chest. The area of the laminectomy was easily seen now, appeared undisturbed, and hemostasis was adequate. A chest tube was placed on the left pleural space. The sternum was closed." 

AV Fistula/Graft

Where is the "inflow" segment of the AV fistula? When treated with PTA, is it venous or arterial? Also, where is the "access" segment of AV fistula?

Popliteal Aneurysm

We are looking for a code for popliteal aneurysm (37236 perhaps?). This is what one of our physicians said: "Code 34900 is an aneurysm procedure code, and although it specifies iliac it is far more reflective of the procedure type and work, including large sheath placement that is involved with popliteal aneurysm repair. In fact, the two procedures are almost identical, except one is done at a more distal location." What code do you suggest we use for popliteal aneurysm and why?

PCI on Two Sub-branches of an Obtuse Marginal

"Patient had 80% stenosis of a main superior sub-branch of OM3 and also had 60% ostial stenosis of an inferior sub-branch of OM3. The 80% superior was treated with a drug-eluting stent across the lesion, jailing the inferior sub-branch. Angiogram then revealed a 90% inferior side branch stenosis, not improving after nitroglycerin administration. Plain balloon angioplasty then was performed at ostium of inferior branch. Then kissing balloon inflations were done in the superior sub-branch and ostium of inferior sub-branch, resulting in 0% residual in the main superior and 5-10% residual in the inferior sub-branches." Would it be appropriate to report codes 92928 and 92921? Or should I only report code 92928 since these were both sub-branches of the OM3?

Iatrogenic Procedures

If we are doing a procedure and cause a dissection that needs to be treated with a stent, can stent device and/or pro fee for placement be charged? Is there a CMS or ACR directive on billing an iatrogenic procedure caused during a procedure?

Transvenous Lead Extraction

We have started doing lead extractions, which are new to me. If we extract an ICD right ventricular lead (33244) and insert a new right ventricular lead, can we bill for both removal and insertion? Or is it all included in the insertion code?

Epicardial Lead and Generator

Procedures: 1) Epicardial lead implant x 1, 2) VVI pacemaker implant in LUQ, 3) Dual chamber pacemaker explant, 4) Pacing lead extraction x 2 with laser, 5) Right femoral a-line placement, 6) Exploratory left thoracotomy. Our coding tool bundles code 33212 (insertion) with 33233 (removal) with no modifier allowed; however, these were two different areas. Do you have any suggestions? (We reported codes 33202, 33212, 33233, and 33235.) 

Internal Carotid Embolic Filter

Patient has bilateral stenting and now there is evidence of narrowing in the left stent. The physician performed selective views of right and left cervical and cerebral (36223-RT), selective view of internal carotid (36224-LT), selective view of vertebral left and right (36226-50). He is also placing embolic filter device into the internal carotid. What code would I use for the filter? I only come across codes 37215-37218, but these include the stent.

Subclavian Vein Stenosis Treatment During AV Fistula Evaluation (36147)

If the subclavian vein is selected during an AV fistula exam evaluation of a brachial artery to axillary vein PTFE graft), and severe stenosis is found and treated with angioplasty, can you add selective code 36011 in addition to codes 36147, 35476, and 75978?

Code Edits with 76937

We use coding software that's showing OCE edit when reporting 76937 with any procedure outside of the 34001-37799 range. The edit is as follows: "76937 is an add-on code and must be reported in conjunction with 34001-37799." The CPT Codebook does not indicate what base code(s) would be acceptable to use with 76937. Do you have any current guidelines on the appropriate use of code 76937?

Thrombectomy of Graft and Native Artery

Would the following example be reported with codes 34201 and 35875? "11 blade was used to make a longitudinal graftotomy, which was extended with Potts scissors. A 4 French Fogarty balloon was used to perform a right graft limb thrombectomy with extensive clot burden retrieved. Next a 3 French Fogarty was used for SFA and PFA thrombectomy with excellent back bleeding, particularly from the PFA. After obtaining robust forward bleeding and excellent back bleeding, the graftotomy was repaired with 5-0 prolene sutures." 

Bridging Lesion LM-LC and Additional Lesion Prox to Mid First OM

Procedures: 1) Percutaneous coronary intervention of bridging lesion distal left main artery into proximal left circumflex artery with one drug-eluting stent, 2) Proximal to mid first obtuse marginal artery with two drug-eluting stents. For professional coding, would this be reported with codes 92928-LM and 92928-LC? 

C-codes

I am having a big debate over CPT code C2623. How is this code reported for the hospital and physician coding/billing?

Biventricular Upgrade of an Existing VVI Defibrillator

"The patient was prepped. The pocket was opened with sharp dissection followed by blunt dissection. The existing ventricular lead was dissected from the pocket, and the existing defibrillator was removed from the pocket and detached from the lead. Left subclavian vein access was obtained at two separate puncture sites, and peel-away sheaths were advanced over guide wires. The coronary sinus was cannulated, and a left ventricular sinus lead was easily advanced into a posterolateral vein. Difficulty was encountered in advancing the right atrial lead into the right heart, and venogram was performed through peripheral IV, which revealed a persistent right-sided superior vena cava connecting into the left superior vena cava with a markedly tortuous route. Subsequently the wire lead was advanced across into the left superior vena cava and down into the heart, and the atrial lead was then placed without difficulty. The sheaths were then peeled away, and the leads were sutured in the pocket." Will I charge for generator change out and two lead insertions?

92941 Clarification

Does the following documentation/example support the use of code 92941? Indications listed in the procedure note include known history of CAD, status post prior stenting of LC, typical chest pain, EKG suggestive of inferior wall ischemia, and cardiac enzymes that became positive. Because of her increase in enzymes and her acute EKG change, she was taken emergently to cardiac catheterization laboratory. Findings consist of 70% hazy lesion of the LC as the culprit lesion and is type A or low risk. Procedure performed was angioplasty of the circumflex artery. 

Diagnostic Cerebral Angiogram Pre and Post Hematoma Evacuation

A diagnostic angiogram was done prior to planned hematoma evacuation. The catheter was removed, and the sheath was left in place for performance of a completion angiogram after the evacuation of the hematoma. Can the angiogram be billed twice (pre and post)?

FB Retrieval of Fractured Neph Cath

"Neph tube is fractured. MD retracted tube for removal of the fractured fragment remains left in the renal pelvis. Using the strings which are attached to the fragment and blunt dissection and a hemostat the retained fragment was successfully retrieved. Under fluoro guidance a new neph tube was placed." Can anything be coded for the retrieval for the fractured cath, or is it considered part of the tube exchange code (50435)?

Percutaneous Paravalvular Leak S/P TAVR

We are having a discussion about which code to use for percutaneous paravalvular leak status post TAVR. According to a previous question posted on January 28, 2016, the code to use is 33399. Is this still correct, or have they created any codes for the closure of the leak for 2016?

Angioplasty in the Venous Outflow with Revision

Can you clarify the definition of "within the graft" as it relates to open surgical revision of an AV fistula/graft with balloon angioplasty in the venous outflow? Is the entire peripheral segment considered "within the graft" or just the anastomoses, graft material between the anastomoses, and the immediately adjacent areas? For example, a physician creates a surgical incision over the venous anastomosis of an AV graft. He opens the graft and retrieves thrombus using a Fogarty and places a patch angioplasty at the venous anastomosis to treat an area of stenosis there. He then performs a balloon angioplasty of an area of stenosis in the venous outflow in the cephalic vein through the same surgical incision (the stenosis is proximal to the venous anastomosis and not immediately contiguous with the anastomosis). Would you agree with 36833, 35460, and 75978 here? Or can I only report the angioplasty and radiology S&I (either 35460/75978 or 35476/75978) if these additional procedures are performed in the central segment?

Bone Biopsy, Deep vs. Superficial

Do you have a chart or document that identifies which bones would be considered superficial versus deep? The CPT book gives examples, but I’m looking for a bit more.

US in Emergency Department

Recently one of our facility has requested to implement ultrasound in the ED performed by the ED physician. This has been endorsed by ACEP, and the only argument I can defend is that revenue code 320 or 402 would not define the area where the service was provided. How medicine is practiced is evolving, so if a report is produced and images are stored in PAC system, would attaching revenue code 320 or 402 be appropriate in the ED? 

AVF Thrombectomy/Revision with PTA/Stent of the newly created anastomosis

I have a question regarding a thrombectomy/revision of a brachiocephalic AVF followed by PTA/stenting of the newly created anastomosis. "The surgeon performed a fistulogram, revealing occlusion/thrombus of the cephalic vein. He then removes the thrombus. Further occlusion was found near the shoulder. Incision was extended to dissect out more of the cephalic vein. A second incision was made in the axilla, and the basilic vein was dissected out. The basilic vein was then anastomosed to the cephalic vein. Another fistulogram was performed, revealing stenosis in the area of the end-to-end anastomosis. The surgeon then angioplastied and stented this." Would the correct coding for this be 36833 (thrombectomy/revision) and 36147 (fistulogram) only? I do not believe that I should code for the stenting (37238) due to it being done at the anastomosis just created. I was looking at it as an inflow/outflow type issue. Am I correct in my thinking?

93971

One of our vascular surgeons routinely orders 93971 for "swelling". The established protocol is to image both the upper and lower extremity on the same side (charging 93971 x 2). I have been adding the -59 or -XS modifier since it is a different extremity and it is not bilateral. Is this appropriate?

38792, Modifier Usage

We are coding for breast procedures where the surgeon is injecting the isotope and placing wires in a stereotactic suite. After the appropriate time frame the patient is then brought to the OR, where a lymphatic mapping injection is performed along with excision of sentinel nodes. We are currently applying the -XE modifier to CPT code 38792 for an edit with code 38900. We are being advised by our facility that this is not truly a separate encounter and therefore an -XU modifier should be used instead. We currently code for both facility and professional charges. Is there a difference in modifier guidelines? Can you please advise on which is the correct modifier usage?

Holter

If I'm billing codes 93225 and 93227, do they need to be billed on separate days? Or together on the same day the Holter is put in?

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