Knowledge Base

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Set Descending Direction

IABP Placement at Same Session as Removal

Is it appropriate to code intra-aortic balloon during a cardiac catheterization and/or PTCA when the balloon is inserted and removed during the procedure?

TAVR with Insertion of Intra-Aortic Balloon Assist Device

Can code 33967 (insertion of intra-aortic balloon device) be billed with code 33361 (TAVR procedures)? "Through the 18 French left femoral sheath, an al1 diagnostic catheter was advanced into the ascending aorta. After wire exchange, a straight wire was advanced across the aortic valve into the left ventricular chamber. Catheter was advanced and again exchanged over a J wire for a pigtail catheter. Simultaneous pressures were then measured and hemodynamics were summarized. An Amplatz super stiff wire with its distal tip coiled was then advanced through the pigtail catheter positioned optimally in the left ventricular apex. An 18 x 40 z Med II balloon was then advanced across the aortic valve orifice, and, during rapid pacing at 160 paces per minute, the balooon was inflated to nominal dimensions. Balloon was deflated. Pacing was terminated, and the patient tolerated the procedure well. Balloon was removed in favor of corevalve transcath aortic valve implant advanced across the valve."

Cerebral Vasospasm 61650

Per the CPT Codebook, code 61650 is for the prolonged therapeutic administration of non-thrombolytic agents of at least 10 minutes continuous or intermittent duration. Is there authoritative guidance from the AMA or SIR on how to code when the duration is less than 10 minutes?

Tunneled Catheter Exchange via Same Access

For purposes of catheter exchange, is "same venous access" considered same vein (RIJ to RIJ)? If catheter is removed from RIJ and inserted in RIJ but with creation of new tunnel/exit site, does that make it a removal/insertion since it is not the same "entry site"? I have a physician disagreeing with me and just want clarification if possible.

Intracranial Thrombectomy Territories

My doctor selected the left vertebral and then accessed the basilar trunk and performed thrombectomies within the left basilar trunk and PCA. My reference states that the PCA is part of the left carotid territory. If the PCA is accessed like it is a branch off of the basilar artery, is it coded as the vertebro-basilar territory? Or is it appropriate to code thrombectomies for both the left vertebro-basilar and left carotid territories?

Cholecystostomy Tube Check and Removal

I've been using the new biliary tube check code 47531 as shown on page 395 of your Interventional Radiology Coding Reference for cholecystostomy tube checks. However, if the cholecystostomy tube is removed after the check, should I report code 47537? The example states (no code, watch for errata), but I do not see a errata listed on the website either. So, has there been further discussion on the new biliary tube removal code? And would I use it in this case, or just code it as a biliary tube check?

Prevention of Atrial Flutter

"Patient had ablation for atrial fibrillation with ICE, 3D mapping (93656, 93662, 93613). The subeustachian isthmus was then ablated for prevention of right atrial flutter." Can we also report code 93655? Patient did not have flutter in history; this was simply preventative.

Anti-Embolic Protection Filter Wire Lower Extremity

Patient undergoes lower extremity endovascular revascularization for arterial occlusive disease (angioplasty and atherectomy) of the popliteal artery. A left popliteal anti-embolic protection filter wire (4 mm Spiderx EV3) is placed via right common femoral artery approach. For PCS I coded as 04HNDZ. However, I could not find an appropriate CPT code or CPT coding guidelines.

Debridement of AV Fistula

"For an area of infection in midpoint of AV fistula, incision was fashioned proximally over basilic vein and of distal basilic vein. The vein was dissected free. Once dissected free it was clamped proximally and distally at the arterial limb of basilic vein, divided, and oversewn with sutures. Then ligated the venous outflow tract to prevent back bleeding. Wound irrigated and closed in layers with sutures. Attention was turned to midpoint of fistula, where obvious infection was. An elliptical incision was fashioned and deepened down to the skin and subcutaneous tissue. The anterior wall of the fistula was completely resected involving the area of obvious infection. Was irrigated and sutured." Is this enough documentation to only use code 36832 as a fistula revision, or should this be reported with codes 37607 and 37799?

Entrapment of Percutaeous Wires

Patient had a CTO done and the wires became stuck. It was stuck entering the left common femoral artery, traveling through the heart, and exiting the right common femoral artery. Surgeon was called to do coronary bypass (saphenous vein taken from left thigh and internal mammary), extraction of the wires, and repair of the left femoral artery. The codes I came up with so far are 33533, 33517, and 35226, but I'm not sure about the wire extraction. Can you help me with this?

Selective Coding

If you selected and imaged the left common iliac from the right common femoral and then backed out to select and image the superior mesenteric artery, would you report code 36246 for the iliac and code 36245 for the mesenteric?

Cerebral Stent

Is there a CPT code for removal of a migrated microcoil stent from the middle cerebral artery?

Catheterization of Occipital Artery

During a cerebral angiogram the provider documented that he selectively catheterized the following arteries: left vertebral, left common carotid, left internal carotid, left external carotid, left occipital, right common carotid, right internal carotid, and right external carotid. My codes so far are 36224-50, 36227-50, and 36226. Is there a code for the selective catheterization (and imaging) of the left occipital artery? It is my understanding that it is a branch of the left external carotid.

Carotid Angio and MobiusHD Implant

What CPT codes do you recommend for this procedure? "The patient presented to the cath lab for resistant hypertension. Sheath was inserted into the right femoral artery. Angiography was performed in the right femoral artery. The 5 French Bernstein catheter was positioned into the right CCA. Angiography was performed in the right CCA. MobiusHD size B 6.25-8 mm was inserted into the right internal carotid artery. Angio performed in right internal carotid artery. MobiusHD deployed in right internal carotid artery. Post angiography was performed in the right CCA. Sheath was removed. Diagnostic: Intracerebral Arteries: The right intracerebral arteries are normal. Carotid Artery: The right bifurcation of the carotid is normal. Right Common Carotid Artery: The right CCA is normal. Summary/Post-Operative Diagnosis: The device was successfully deployed in the right carotid bulb. Position of deployment confirmed angiographically."

Percentages on Coronary Angiogram

We are wondering if the below documentation is enough to bill out a coronary angiogram. Or do we need to have documentation that the provider selected the coronary arteries? "Left circumflex: The left circumflex is a large but non-dominant vessel. This vessel gives off a large prominent obtuse marginal with multiple sub-branches. This vessel is calcified. There is a proximal stenosis of 90% in the AV groove portion of the vessel prior to the takeoff of any branches. The obtuse marginal is diffusely diseased with a 70% stenosis in the distal portion of the obtuse marginal main branch. An upper tertiary branch of that obtuse marginal, which is distal, has an ostial stenosis of 80%. There is diffuse distal disease. A more proximal branch of this obtuse marginal has an ostial stenosis of 80%."

Aortic Angioplasty of Two Separate Areas

If aortic angioplasty for ascending aortic stenosis was performed, as well as angioplasty for coarctation at the aortic isthmus, can I report codes 35476 and 75978 twice? Is billing per vessel or per lesion in this case?

Revision/re-do fem-pop bypass

"The patient had a previous fem-pop bypass using an in situ vein. He has now developed a tight stenosis in the segment of the vein from the knee down into the anastomosis and has had two catheter interventions, so that part is pretty much stented all the way into the native artery. Decision is made to revise this with a new bypass from the old bypass down onto the native posterior tibial artery. Cephalic vein is harvested for the bypass." We are unsure how to code the new bypass that is attached to the old (fem-pop) bypass down onto the native posterior tibial. Revision or new bypass? Can you please help with the codes?

Intraoperative TEE during AVR

The question has been asked if it is appropriate for Cardiology to charge for a TEE during AVR surgery. A cardiovascular surgeon requests the cardiolgy echo tech to come up to the OR and perform a TEE after patient is prepped. This is because sometimes it has been a month or two since last echo. Then post procedure still in OR TEE is performed to evaluate function of valves. The surgeon states Intraoperative TEE Performed: His TEE dictation is included in surgical op report. It is often stated like this: "Intraoperative TEE was performed, which revealed stenotic aortic valve leaflets with mild aortic insufficiency, no significant mitral regurgitation, and mildly diminished ventricular function." Later it is stated: "Repeat TEE revealed satisfactory function of the aortic valve leaflets, no significant aortic insufficiency, or perivalvular leak. After adequate de-airing was confirmed by TEE, the patient was weaned from bypass." This is the only information documented for TEE. Can Cardiology report code 93312 for their revenue, or is this included in the main surgical procedure?

Discontinued Bone Marrow Aspiration

I am questioning the use of a -74 modifier for an unsuccessful bone marrow aspiration during a bone marrow biopsy/aspiration procedure. The report states: "After informed written consent was obtained, the patient was brought to the fluoroscopy suite and placed in the prone position. The patient's right posterior pelvis was prepped and draped in the usual sterile fashion. 2% lidocaine solution was used to anesthetize the skin and subcutaneous tissues, and a dermatotomy incision was made. Initially, a 15 gauge needle was advanced into the posterior left iliac bone under fluoroscopic guidance. Marrow aspirates could not be obtained. Per protocol, three separate 11 gauge core needle biopsy specimens were obtained under fluoroscopic guidance. The samples were submitted to the pathology technologist. The 11 gauge needle was removed and hemostasis achieved following two minutes of manual compression." Would the correct codes be 38221, 77002, and G0364-74? Or would you only code the completed procedure of the biopsy with 38221 and 77002?

TPA to Unclog a PleurX Catheter

How would you code a case where they infuse tPA to unclog a PleurX catheter? I do not think a lysis code (37211-37214) is appropriate. Here is the documentation: "Existing PleurX catheter is plugged and wire could not be advanced. Eventually the wire was advanced up to the tip of PleurX catheter. tPA was diluted with saline and left in situ for 1 hour. After 1 hour, significant improvement in clearance of fluid. 700 cc of bloody fluid could be aspirated from PleurX." Any suggestions would be appreciated.

TPA in Drainage Catheter

What codes would you recommend for coding tPA injection into a drainage catheter?

Breast Cyst Needle Aspiration Followed by Biopsy

Could you please clarify the coding of this procedure for me? "Limited ultrasound performed to locate and measure abnormality. A 16 gauge needle was advanced into the cyst with aspiration yielding thick brown nonbloody cyst fluid. This was placed into Cyto-lite solution for cytology. A small skin incision was made, and a 12 gauge vacuum-assisted core biopsy needle was then advanced into the partially collapsed cyst. Four biopsy passes were made through the cyst wall, yielding multiple tissue fragments, which were placed into formalin. A T-shaped titanium pellet was deployed at the cyst location with postbiopsy cc and ML views showing marker placement at the site of the known nodular asymmetry at the 4 o'clock position, which is now significantly decreased in size." I want to report codes 76642, 19000, 19083, and 77055; however, I remember there being some guidelines about coding an aspiration with a biopsy, and I'm wondering if reporting code 19000 is really allowed? Also, I didn't add code 76942 with 19000 because of the 19083. 

Supreme Intercostal Artery Imaging

What code should I use when the supreme intercostal is imaged after selective imaging of internal carotids and vertebral arteries?

Fistulogram with Arterial Anastomosis Balloon Angioplasty

I am very new to IR coding, so I am not real sure on how to code this report, which reads as follows: "Under ultrasound guidance the left upper arm dialysis access graft was catheterized. Images of the graft were recorded. Subsequently under fluoro guidance a catheter was placed in the graft, and fistulogram was obtained. A questionable stenosis at the arterial anastomosis was dilated with a 5 mm angioplasty balloon. FINDINGS: Ultrasound shows markedly thickened wall of the graft consistent with mural thrombus. The fistulogram shows very slow flow through the graft with very small lumen. There was a questionable stenosis at the arterial anastomosis, but there was really no change with the angioplasty. The distal anastomosis at the venous end is unremarkable. Central veins are patent." I was going to report codes 36147, 35475, and 75962 because he stated "at the arterial anastomosis". However, another coder thinks we should only code for fistulogram (36147) because the doctor did not give the percentage of the stenosis. What is your opinion?

Thoracic Duct Leak

How would you code a thoracic duct leak? "The radiologist performed bilateral lymph node injections in the groin area with Lipiodol. A guide wire was advanced into the thoracic duct, and the leak was embolized." How would I charge for the supply of Lipiodol used? Do you have any recommendations on HCPCS/revenue codes?

Cardiac Cath Documentation

I was wondering if there are specific requirements for what needs to be in the documentation of a cardiac cath. An outside resource disagrees with documentation requirements, and we are asking for your help to clarify. The physician includes the pre-procedure diagnosis, the findings and plan, contrast used, blood loss, fluro time, etc. This is an example of the main part of the procedure dictation: "Catheter: JACKY, JL4, PIG, 3DRC Sheaths: 5 FR, right radial artery Closure device: TR Band Dominance: right Pressures: Aorta: 136/75/101 LVEDP: 21 Coronaries: Left Main: Large caliber. Free of obstructive disease. LAD: Heavy proximal calcified plaque but no significant obstructive disease. Moderate caliber Diagonal. Free of obstructive disease. LCX: Moderate caliber, nondominant LCx. Moderate caliber OM. Free of obstructive disease. RCA: Moderate/large caliber. Dominant. No obstuctive disease. Moderate caliber PDA. Free of disease LVG: EF: 65% Findings: Calcified but nonobstructive coronary atherosclerosis Normal LV systolic function. EF 65% Mildly elevated LVEDP."

Endurant IIs

Would you still use code 34802 for the Endurant IIs for AAA repair?

PPM Generator as Temp Pacing

A physician implanted a generator with a ventricular lead externally as a temporary pacing system, in which he intends to implant a permanent pacemaker system within the next 10 days. Should we code for only a temporary pacing procedure (33210), or do we code for the implantation of the generator with a ventricular lead (33207)? If we use code 33210, then we would not be able to recoup the cost of the devices used. "Dictation: The skin was infiltrated with mepivacaine, and a single venipuncture was made in the left axillary vein using the modified Seldinger extrathoracic approach. A ventricular lead was advanced in the central circulation over a tear away sheath. The ventricular lead was placed in the RV septum, and the active fixation mechanism deployed normally. The ventricular lead tested well and was sewn to the skin. The generator was connected to the lead with good contact ensured by visual inspection and manual tugging. The pacemaker and excessive lead was placed on the skin and tegadermed in place."

AV Fistula/Graft Interventions Open vs. Percutaneous

When dealing with an AV fistula/graft, what constitutes open vs. percutaneous as it relates to the various interventions? Does the graft/fistula need to be incised for it to be considered open? In a recent case an incision was made to ligate a collateral, then access through the collateral with a micropuncture needle was obtained into the AV fistula where angioplasty and stent placement occurred.

Revision of Collateral Vein, Angioplasty, and Stent

Can you tell me if this would be considered an open procedure and if you would only report code 36832? "DuraPrep and sterile draping of the left upper extremity in the routine manner. Using the SonoSite, the location of the collateral vein arising from the left brachiocephalic arteriovenous was identified. An axial incision was made over the fistula at this location. Sharp dissection down to the fistula and the collateral vein, which was controlled by circumferential dissection and secured with 0 silk ties. Access through this large collateral vein with a micropuncture kit into the left upper arm brachiocephalic arteriovenous fistula. Insertion of a 6 French sheath. Wire exchange, which was advanced across the stenosis. Viabahn stent graft was then deployed across the stenosis. Post deployment balloon angioplasty conquest balloon up to 18 atm with 0% residual stenosis. The large collateral vein was then triply ligated with 0 silk. Irrigation and hemostasis. Wound closure in layers dermal closure staples."

Fluoroscopy in Surgery

How should fluoroscopy use with angiography in surgery be coded for use during open lower extremity revascularization? AAA repair? A/V fistula revision? Should angiography codes be used or 76000, 76001?

Catheter Code with 75791

If the AV fistula was accessed through a cutdown, and the provider performed imaging (without the catheter really getting all the way to the cava or any branches or any artery), would you also report code 36005 with 75791? The provided performed a cutdown of the brachiocephalic AV, did the imaging, followed by venoplasty of the cephalic and then thrombectomy. I was thinking of using codes 36832, 35460, 75978, and 75791, but I am not sure if I should add 36005 for the cath portion. Or would code 75791 include non-selective cath access already? Please advise.

Coding for Diagnostic Angiogram at Closure Site

"VESSELS INJECTED: Right CCA, right ICA, and right common femoral. VESSELS STUDIED: Right CCA, cervical views; right ICA, intracranial views; right common femoral, RAO. PROCEDURE: The arteriotomy was closed with 8 French Angio-Seal. I was present and participated in the entire procedure as described above. The right common femoral arteriogram is normal with no significant atheromatous disease or dissection." Based on this documentation would it be appropriate to code a diagnostic study? The provider is a neuorinterventionist. He feels these angiograms should be coded, though I am not seeing the medical necessity qualifying for this... it looks like it is access the closure site. What if there was some disease noted? Would that make a difference? I just want to be sure I am not missing an opportunity. 

Embolization of C1 branch of Right Vertebral and Embolization of Right Posterior AuricularArtery

Would the following be reported with codes 61624, 75894, 61626-59, and 75894-59? "We then identified a C1 branch of the right vertebral artery and proceeded with coil embolization of this pouch of goal to decrease flow to the fistula using the above-mentioned coils. At the conclusion of the vertebral artery branch embolization, we manipulated the 6 French Envoy catheter into the right external carotid artery, which was evaluated using multiple projections. We then selected right posterior auricular artery branch #1  with superselective catheterization, which was accessed using an SL10 straight tip over a Synchro II standard microwire, and we embolized this feeding artery using the above-mentioned coil for branch number #1."

Nephrostomy Tube Removal under Fluoroscopy

I code for a hospital. We have cases where the doctor removes a nephrostomy tube under fluoroscopic guidance. Can we bill for this service? I am being advised we can bill for the fluoro (76000) or for a nephrostogram (50431). Or, is there an E&M charge for the hospital (not the doctor's office) I can use? The CPT Codebook states the following: "Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent)". I read that eg means "for example", thus this only being a description of one option; ie means " in other words" and is used for further clarification. As a biller for the hospital, could I bill an E&M code if fluoro isn't used, or is that just for the physician's office? "History: Postpartum with neph tube in place. Evaluate for obstruction and for urolithiasis. Antegrade nephrostogram shows excellent position within the lower pole calyx. There is no hydroureteronephrosis. There is brisk flow of contrast into the collecting system down the ureter into the bladder. No evidence of obstruction or filling defect. PCN removed."

Modified Lymphangiography for Chylous Leak

Is unlisted code 38999 appropriate for the following case? "Sterile prep of the chest, abdomen, and bilateral groins was performed with patient under general anesthesia. Using ultrasound guidance, a 25 gauge needle was advanced to the cortical medullary junction of a right inguinal lymph node. This was repeated on the left side. Approximately 5 ml of lipiodol and 10 ml of saline flush were injected into both lymph nodes over 30 minutes using intermittent fluoroscopy to opacify the lymphatic system. Lymphangiogram clearly demonstrated the lymphatic channels of the pelvis ascending into the abdomen with two large lumbar lymphatic channels. Overlying the upper right L5 vertebral body, just inferior to the L4-L5 disc space, there was a focal area of contrast extravasation into the right peritoneum and retroperitoneum. This was confirmed by fluoroscopy and Dyna CT, demonstrating free lipiodol in the right retroperitoneal space collecting along the right psoas muscle and posterior abdominal wall. Additional lymphangiography demonstrated drainage of the cisterna chyli and ascending to the thoracic duct."

75736 & 75774

How would you code the following? The radiologist performs and documents pelvic arteriogram (contrast injection at the distal aorta) (not codeable), bilateral selective internal iliac arteriograms (75736-50), and bilateral external iliac arteriograms (?). I have no findings for the bilateral common iliac or femoral arteries. This was done for a possible bleeding from a postoperative total abdominal hysterectomy. Would I use codes 75774 and 75774-59 for the bilateral external iliac arteriograms? Or not code this at all?

61624 or 61626 or BOTH

"Indication: Laryngeal tumor encasing and eroding carotid artery. Procedure: Patient had a diagnostic head and neck angiogram with balloon test occlusion one week prior. PX slim microcatheter was advanced into right petrous (intracranial) internal carotid artery after right common femoral artery access. Intracranial carotid sacrifice was then performed with Pkpc2enumbra Ruby 4 mm x 35 mm standard coil into the right internal carotid artery." Should I report code 61624 or 61626? Or should I report both?

Graft Intervention CPT Code

To use the graft intervention CPT code, does the documentation need to state the lesion was in the graft area in order to use? Can you use it if they had to go through the graft, but the lesion was in the native vessel instead? Example: A lesion was discovered and stented in the PDA, but the graft was in the RCA.

Embolization for Excessive Bleeding - Placenta Increta

"Physician performed a bilateral internal iliac artery embolization on a patient who had placenta increta. During the attempt to remove placenta, excessive bleeding was noted. Catheter was placed in the right groin and advanced into left internal iliac artery, and angio was done. Gelfoam slurry was injected. The catheter was removed from the left side and advanced under fluoroscopic control into the right internal iliac artery. Angio was done. Metallic coils were placed. Catheter was pulled back into the left internal iliac artery, and coils were placed into the distal main segment of the anterior division. Final images showed bleeding slowed. Emergency embolization for severe hemorrhage from the uterus was performed with embolization of the anterior division of both internal iliac arteries." Would this be reported with codes 37244, 36246, 36245, and 75736-26 (x 2)? 

36556 for Meds during PAD Intervention

Can a physician report code 36556 (central venous catheter) for introduction of meds during an intervention? I first do not see supporting documentation in the attached report to support a CVC. Also, shouldn't injection of meds be part of the surgical package? Is there source documentation to support/refute billing CVC for drugs during an intervention? "There is no significant aorto-iliac inflow disease. Right common femoral artery, profundus femoris artery, and superficial femoral artery are patent. Popliteal artery is patent. The anterior tibial artery is patent and runs to the foot. There is significant blunting of arborization in the foot itself. The tibial/peroneal trunk has a high-grade proximal lesion present. The main tibial/peroneal trunk is patent. Posterior tibial artery is diminutive. Peroneal artery is patent and does run into the foot with cross-filling of the posterior perimalleolar segment. The patient was heparinized. Venous sheath was placed. Atherectomy of tibial/peroneal trunk and peroneal artery was performed."

Balloon Tamponade Hemorrhagic Carotid Artery

Balloon was used to tamponade the hemorrhage. Is there a code for the tamponade, or do we just get codes 37615 and 36215 for ligation? "We then placed a 6 French 70 cm sheath into the proximal brachiocephalic artery. We utilized contrast injections from the brachiocephalic artery sheath to visualize the area of bleeding. Once this was performed, I then utilized a 6 mm x 6 cm balloon and carefully inflated this to a nominal pressure within the right common carotid artery. Once this was performed we had adequate hemostasis. The vascular surgery team then went ahead and performed the right carotid artery ligation. At this point in time, neurosurgery was available and performed cerebral angiography, which they will dictate in a separate note."

Attempted EVLT

"The right greater saphenous vein was cannulated under ultrasound guidance, and a 4 French sheath with dilator was introduced and advanced into the vein. I was unable to advance the dilator past the midportion of the vein due to venous spasm. The sheath was pulled back into the distal portion of the vein, and a total of 2 mL of 1% polidocanol mixed with 8 mL of air was injected into the vein. An ultrasound performed after the procedure revealed no flow in the treated vessel. Patency of the deep venous system." Would this be reported with codes 36478-53 and 36470? Also, how would you code if only the ultrasound-guided sclerotherapy was performed?

Upper Extremity Angiography with Thoracic Aortography

"Using direct ultrasound guidance, the right common femoral artery was accessed with a micropuncture needle. Through this access, a 5 French sheath was placed. A flush catheter was advanced into the ascending thoracic aorta. Aortography was performed. 5 French catheter and wire were advanced into the left subclavian artery, and then into the left axillary artery. Arteriography was performed. There was poor visualization of the arteries beyond the fistula anastomosis." Should I report 36215-59 for axillary/subclavian and 36221 for thoracic aortogram?

Aortopulmonary Shunt Reduction

What code should be used for the following? "I took a silastic patch and wrapped this around the proximal part of the aorta pulmonary shunt, securing it with sutures, reducing it from a 5 mm shunt to a 2 mm shunt." 

AVF

For coding purposes, is the brachial artery included in the fistulogram (36147), or can we report code 75710 as well if a brachial angiogram is performed during the fistulogram?

Registry for Carotid Stents

Do you know if CMS currently requires the use of Z00.6 on a claim for carotid stenting, indicating that the patient is a registry?

TEE 2D Color Doppler

TEE with 2D color Doppler was done. Are codes 93312 and 93325 correct for this procedure?

Hypothermia Protocol

My physician is taking the patient to the cath lab and introducing a catheter into the inferior vena cavas to cool a patient presenting with cardiopulmonary arrest. It is time consuming. Is it just billed with critical care codes, or is there a CPT code for hypothermia protocol?

Trans-Baffle Approach

Our EP physician documented that he performed the following during EP study with ablation procedure. Is this something that may be separately billed, or is this included in the ablation services codes (93653, 93654, 93656)? "A trans-baffle approach was used to access the pulmonic atrium (PA) for mapping. The entailed advancing a SL-1 sheath with dilator into the superior vena cava and directing both (monitoring multiplane fluoroscopy and tip pressure) with the tip oriented toward the baffle. The systemic atrial (SA) pressure was 22 mmHg. During advancement of the SL-1 sheath, the baffle was engaged. PA access required a single pass with the brockenbrough needle extended; PA pressure was 23 mmHg. The SL-1 sheath, through which the mapping catheter was passed, was advanced over the dilator and positioned in the PA. The sheath was slowly aspirated to remove all air before infusing saline/inserting a catheter. A catheter was placed through the sheath into the PA. Heparin was administered after groin sheaths were situated."

Endovascular Repair of Descending Thoracic Aorta

How will you interpret the initial endoprosthesis in 33881? Since there is no subsequent endoprosthesis code in the CPT Codebook, does the “initial” not mean first? Does it mean first to the extensions? Could you please code the following surgery also? "A male patient has an 8 cm descending thoracic aneurysm. The right common femoral artery was accessed with a 7 French sheath, and diagnosis aortogram was performed, which revealed a large thoracic aneurysm as predicted by the CT. A 39 mm device was deployed just distal to the left subclavian artery, a 43 mm device was telescoped into the 39 mm device, and finally a 44 mm device was deployed just above the diaphragm. The surgery was uneventful; all the devices were removed." Since there are three different sizes of the devices were deployed, would they be considered a single endoprosthesis if all of them were from the same manufacture? However, if the 39 mm is Alpha thoracic cook device, and the 43 mm and 44 mm are Gore Tec devices, would they still be coded the same ways?

Venography

Can you please help me code this venography case? "The catheter was maneuvered from the right common femoral vein to the right jugular bulb to select the right transverse sinus, where venogram was performed. Then the catheter was manipulated into the superior sagittal sinus. Venographic views were obtained. The catheter was then maneuvered down to the torcula and then into the left transverse sinus, where further venographic views were obtained, then back to the right jugular bulb."

Abscessogram for ICD-10-PCS Procedures

"Reason for Exam: Drain injection x 2. Examination: Abdominal and pelvic drainage catheter injections under fluoroscopy. Clinical History: Follow-up of abdominal and pelvic collections. Procedure: The indwelling left abdominal and presacral pelvic catheters were injected with contrast material under fluoroscopic control." What would be the ICD-10-PCS codes for these procedures? 

Device Occlusion of Fontan Baffle Leak

What are the appropriate procedure/diagnosis codes for device closure of a Fontan baffle leak? Would that be the same as closure of a Fontan fenestration (93580)? Fontan baffle leak (T82.897A, Other complication of cardiac prosth dev/grft, initial)

Arterial Line and Monitoring, 36620

Arterial line was placed during a heart catheterization. Physician coder is suggesting that it be billed since it was left in place for ICU transfer. It's my understanding that arterial line is part of the main procedure (heart cath), even if it's left in place for patient transfer. The only time I would bill for it is if it's placed AFTER completion of the heart cath for continued critical care/monitoring. Procedure note: "The arterial line was left in place and sutured and secured in place for continued arterial access in the CVICU." What are your thoughts?

Brain Death Study

Is there is a specific CPT code to use for a cerebral perfusion angiogram (brain death study)? The physician performs bilateral carotid angiogram catheter placement in common carotid (right, left). Righ vertebral imaged, catheter placement brachiocephalic, left vertebral selective cath placement. Is it appropriate to report codes 36223-50 or (36222-50) and 36225-RT/36226-LT, or are there codes specific for a brain death study?

Documentation guidelines for imaging guidance used for thoracentesis and paracentesis

We have been discussing the documentation for these two codes with HIM. They want us to use 49082, 76705 and 32554, 76604 when the radiologist doesn’t state that the needle was imaged entering the fluid collection. They are saying that the documentation for guidance wasn’t met. We disagree with the diagnostic imaging; since the condition is usually known we don’t believe the diagnostic exam is supported here. We have not been able to find any specific reference and need clarification regarding appropriate billing for the “guidance” – does the needle entry need to be imaged to code image guidance? If ultrasound was used to locate a safe entry point, but it was not stated that the needle was imaged entering the collection, is it acceptable to consider the localization as guidance and bill 49083 or 32555? 

76937 with Cardiac Caths

Can code 76937 be reported with heart caths (if it meets the documentation requirements of 76937)?

Echo followed by a bubble study on the same date of service

Patient presents with an order for an echo, and it is performed and billed with code 93306. The results are sent to the physician, who then sends the patient back with an order for a bubble study to be performed on the same day. How should the subsequent bubble study be reported?

SC and KX Modifiers

I was wondering if you could clarify something. Do CPT codes 33227, 33228, and 33229 or 33233 fall under the group 3 conditions and require a -SC modifier? Or should I be using the -KX modifier? I believe I should be using the -SC modifier, but I need to try to verify that. 

DFT Testing Documentation

At the time of ICD insertion, the physician documents the following in his procedure report: "ICD was tested with successful defibrillation threshold testing at 25 joules, 35 ohms impedance." The Witt Log (which is signed by the physician) says, "ICD generator tested for VT/VF VT/VF converted with ICD @ 25J." Is this sufficient documentation to submit code 93641?

50431 Bilateral

"Bilateral antegrade nephrostogram via existing percutaneous nephrostomy tubes using total 35 mm Isovue-370 intravenous contrast. Digital subtraction imaging utilized to evaluate UVJ at site of prior leak. Across the time 1.4 minutes. 12 exposures obtained. Bilateral antegrade nephrostogram including with digital subtraction demonstrated widely patent bilateral pelvicalyceal and ureteral collecting system without hydronephrosis obstruction or suspicious filling defect." Is it appropriate to submit code 50431-50? I'm receiving the following edit: "Modifier -50 is approved for HOPD use, but may not be appropriate for use with this code." 

Assistant Surgeon

When performing a cerebral angiogram, and the doctor has another doctor assisting in the procedure, what is the proper way to bill? Would we use modifier -80? Is it applicable with the INR procedure codes?

Fluid Drainage - 10160 vs. 49405/49406

How would the following be coded? My docs are saying that code 10160 should be used for the fluid drainage, based on a reference where you indicated that 10160 should be used when the catheter is removed prior to patient leaving the procedure area. But the same catheter was used to instill the erythromycin and left in place for 2 hrs. CDR for 49405/6 says catheter 'may' be left in. Please advise. "Using u/s guidance, an 8.5 Fr drain was placed into the largest pocket of the SQ collection located in the RLQ. Vigorous aspiration was then performed with approximately 30 cc removed. U/S demonstrated complete collapse of the cavity. Then, 30 cc of 4 mg/mL of erythromycin was placed into the cavity and the drainage catheter was capped to facilitate sclerosis. Then, the patient was instructed to turn every 30 minutes 90 degrees for 2 hours. This allowed contact of the erythromycin to the walls of the cavity. After this time had elapsed, vigorous aspiration was performed demonstrating collapse of the cavity and the drain was removed."

47532 when performed via separate access site than that of 47532

Please provide your interpretation of the following: "An anterolateral lower intercostal approach selected for the PTC and a complete dx cholangiogram performed. Multiple common duct stones were identified with complete occlusion across the ampulla. A more favorable approach was targeted for catheter placement via a separate access. A second 12g needle was directed into the biliary duct via a separate puncture and after several injections, an internal-external biliary catheter was placed into the duodenum." The dictation clearly states that the PTC was performed via one access and the catheter placed via a separate access. In this scenario, would it be acceptable to file for 47534 and 47532-XU or -XS? The CPT Codebook states, "Do not report 47532 with 47534 when performed via same access." The catheter was not placed via the same access as the initial diagnostic PTC for this procedure.

Peripheral Bypass with eEndartectomy

The surgeon performed a superficial femoral to anterior tibial artery bypass graft after eversion endarterectomy, followed by removal of residual plaque from the profunda artery. Per the CPT Codebook: “Primary vascular procedure listings include establishing both inflow and outflow by whatever procedures necessary.” I am using code 35666 for the bypass. Am I correct in the assumption that the endarterectomies fall into the circumstance of establishing inflow/outflow and are therefore not separately billable? I have always felt like they were included in bypass, but I really don’t have access to any quality vascular reference material, and I'm not sure if there is a situation where these endarterectomies would be separately billable.

35082

Patient has history of AAA repair with Gore excluder stent graft four years prior. The physician is stating open repair type 2 endoleak. Can code 35082 be used if no graft insertion is used and only sutures are used to reclose after the AAA rupture is evacuated?

Amputation Via Elbow Disarticulation

The patient was involved in an MVA resulting in a mangled, non-salvageable distal right upper extremity (crush injury). The doctor performed an amputation via a right elbow disarticulation. What CPT code do I use for this?

Billing Modifier 50 with 51

I have a question about modifiers -50 with -51 being billed together. I know that we do not have to apply modifier -51 to the codes, but for our reports we use it for RVU purposes. We apply a -51 modifier, and the clearing house will take the -51 off. Our charge is already reduced when we apply modifier -50 (150%), but do I apply modifier -51 to the second code even though it is already reduced? I am unable to locate any information that talks about billing these two modifiers together. (Example: 36226-50, 36223-50-51)

Acceptable Documentation for Coding Cerebral Atherosclerosis

When coding for a carotid stent procedure, on the rare occasion when the physician does not specifically say the words "cerebral atherosclerosis" in his findings, is it reaching too far for us to code it as such if he describes the internal carotid artery as "70% stenosis ulcerated", "80% stenosis with string sign", "60-80% stenosis with plaque", "95% stenosis, extremely calcified" for example? One corner is stating that it must specifically state "cerebral atherosclerosis" in order for it to be coded as such, but after some discussion they said that a description of calcified stenosis or ulcerated plaque (ulcerated must include plaque in the description) would be acceptable. The other corner feels that understanding anatomy and the pathology of the disease makes any of the descriptors in the opening paragraph sufficient to be led to cerebral atherosclerosis as the disease. Will you please give us some insight regarding this?

TAVR and Endartectomy

We had a patient who had a TAVR, and after the TAVR the provider removed the drapes and found that the patient had no pulse in one of the legs. So they did an aortography of the pelvis with bilateral lower extremity runoff, which showed that the patient had an occlusion in the right common femoral arteriotomy site, which required cutdown and an endarterectomy and patch revision. Would you code the aortography, the bilateral lower extremity, and the endarterectomy?

Left Ventricle Aneurysm Repair

The patient is undergoing a CABG, and during the service the physician discovers a left ventricular aneurysm. He decides to repair it by entering the left ventricle and suturing a pericardial to the inner part and healthier part of the left ventricle. How would we code the ventricle repair?

Pre-Op Arteriogram, Compliance Risk?

I am well aware of your warnings about repeat angios being a huge compliance risk. The physician performed a CTA of the leg and found occlusion of the patient’s vein bypass and native arteries. He then performed a complete percutaneous arteriogram of the leg. Can this second study be billed? The only reason given in the report for the repeat study was: “He was recommended an arteriogram to assess potential for new bypass.” This reason does not explain why the prior CTA was inadequate, but I am wondering if it will pass muster in an audit. Would pre-operative exam Z01.818 be the primary diagnosis for the arteriogram even though they have not yet definitely decided to replace the bypass?

Toba II Clip Insertion

How would the insertion of a Toba II Clip placed on the SFA be coded? The procedure was percutaneous with angioplasty of the SFA performed, with dissection of the artery noted. The patient was then enrolled in the Toba II trial, and a clip was placed. I appreciate your help with this, as I am so far unable to locate any coding advice, and I'm thinking this is an unlisted code.

Atherectomy RCA and PTCA with Vision Stent Posterolateral Branch

Can you help verify if I understand the coding hierarchy for the cardiac intervention codes? The patient had a diagnostic heart cath (93458), followed by: 1) successful orbital atherectomy with balloon angioplasty to the heavily calcified right coronary artery, 2) successful balloon angioplasty and stenting to the right posterolateral branch by deploying one bare metal stent. Should I report code 92924 for the RCA atherectomy and code 92929 for the vision stent and PTCA of the posterolateral branch?

Creation of Brachiocephalic Fistula with Patch Repair due to No Pulse in Fistula

If a surgeon creates a fistula (32821) and there is no pulse, and he therefore does a revision and repairs it with a harvested vein and does vein patching, can you code the revision as well (36832), even though both codes are separate procedures?

Smart Needle for Needle Insertion

Can you please advise as to whether code 76942 or 76937 is appropriate to report the "smart needle" for the needle insertion documented in the referenced report? We do not believe either is appropriate; there's no permanently recorded images. The physician is stating that the smart needle is being used "for needle insertion". The report reads as follows: "Femoral areas were prepped and draped in the usual sterile fashion. Smart needle with fluoroscopic guidance was used for needle insertion. A 6 French sheath was placed in LF artery using the modified Seldinger technique. Angiogram of the femoral artery was obtained through the sidearm of the sheath. A 7 French sheath was placed in RF vein using the modified Seldinger technique. A Swan-Ganz catheter was advanced through the venous sheath and into the chambers of the right heart. Pressures were obtained in the right atrium, right ventricle, pulmonary artery, and pulmonary capillary wedge..."

CT-Guided ALcohol Ablation

What code can I use for CT-guided liver alcohol ablation?

Revascularization Hierarchy

Perhaps you can help us understand a dilemma we’re having in our coding unit. Beginning with the 2013 CPT guidelines, the PCI codes for revascularization (both in coronary and lower extremity vessels), the atherectomy CPT codes have a lower CPT code number than the stent placement codes, yet the RVUs for the atherectomy codes are higher. In the past, the higher CPT code number reflected the higher RVU value since it included all the work done in the preceding CPT codes. Why did they break formula for these procedures in 2013?

61635 vs. 37238

It is unclear whether to bill 37238 or 61635 for transverse sinus stenting. Can you help? I cannot locate anything specific. Patient has stenosis.

Left Heart Cath from Two Approaches

"Via the right radial artery, cath passed to LV, pressures obtained, LV-gram performed, attempted diagnostic cor angiogram but unable to engage RCA, exchanged cath, axillary artery went into a spasm, which was angiogrammed. RT femoral artery then accessed and used to obtain bilat coronary arteriograms." We have assigned code 93458, but I wonder if the two approaches affect code selection, and if so, what additional code will be appropriate?

Pipeline Stent Intracranial Aneurysm Separate Encounter

When we place the intracranial/neuro Pipeline stent for aneurysm and perform the coil embolization at a separate encounter, how should the stent be coded? Both Medicare and non-Medicare?

Codes for Right Carotid Angiogram

What are the correct codes for this procedure? "Right carotid stenosis procedure. The right common femoral artery was accessed. A JB2 cath and glidewire were used to engage the innominate artery and right common carotid. From this position a selective right innominate and common carotid angiogram was performed. This showed a widely patent right subclavian artery and right common carotid artery. The bifurcation was identified; the external carotid artery was identified. A glidewire advantage was placed into the external carotid artery and advanced into the common carotid artery. A carotid and cerebrovascular angiogram was performed. This showed a widely patent carotid bifurcation and widely patent external carotid artery. The internal carotid artery had an area of ulcerated severe stenosis, several centimeters beyond the bifurcation. Distally the internal carotid artery was somewhat hypoperfused and smaller. The middle and anterior cerebral arteries were completely occluded. It was decided to treat patient medically." 

93531 and 75743

I have a congenital cath (R/L 93531) case were my provider documented doing a selective injection into the left and right pulmonary artery (75743). I'm also coding RV injection (93566), LV injection (93565), descending aorta injection (93567), and SVC injection (75827). However, I'm getting an NCCI edit with codes 93531 and 75743. Can you please advise on the reason for that edit?

Sinogram vs. Drain Injection

How would you code a procedure where they inject contrast into a previously placed drain (diverticular abscess) to see if there is a fistula? Example: "Patient has diverticular abscess for which a pigtail drainage catheter was previously placed. Sinogram requested. Contrast gently instilled. Flowed freely into the vaginal cuff. It did not fill any further pelvic soft tissues and did not opacify bladder or colon. Images were stored. Impression: Sinogram demonstrated fistulation from the patient’s abscess cavity to the vagina." Because the report states “sinogram”, do we use code 20501? Or should it be injection into drain (49424)?

Angioplasty Zones

When performing angioplasties, my physician will state in his dictation "intra access and outflow and inflow". Are these separate areas/zones, or are all considered one?

Repair of LV Apical Pseudoaneurysm with VSD Occluding Device

"TAVR procedure two days prior. Patient then found to have a contained apical pseudoaneurysm. By way of the left axillary artery surgical access, we delivered a 9 French Torque Amplatzer delivery system into the left ventricle. Successful closure of left ventricular apical pseudoaneurysm with an Amplatzer Muscular VSD device." What are the correct CPT codes? Does this qualify for assistant surgeon?

Drugs used to induce arrhythmia for 93623

What are the names of the drugs used to induce an arrhythmia during cardiac ablation procedures that we would code CPT code 93623? Would adenosine be one of them?

Attempted Pleural Catheter Exchange

How would you code for a tunneled pleural catheter that is removed and attempted to be replaced? Dictation states, "Multiple attempts were made to place a new catheter, but they were all unsuccesful." They ended up just removing the catheter. Is this still just 32552? 

Right external iliac artery injury with arterial bleeding

"Emergent intraoperative vascular surgery consult. Ultrasound-guided retrograde access right common femoral artery. Intra-arterial angioplasty balloon inflation for temporary control arterial bleeding. Diagnostic right iliac and lower extremity angiogram. I-CAST covered stent repair of right external iliac artery injury. StarClose hemostasis right common femoral artery." Are codes 37244, 37236-51XE, and 36140-51XE appropriate for this?

61645

How would this be coded? Should I report codes 37216 and 61645, or just 61645? "Patient presented with an acute left hemispheric infarct, acute cervical carotid occlusion likely from dissection, and intracranial carotid thrombus. A Solitaire stent retriever was deployed across the area of thrombus in the left internal carotid and removed with vacuum aspiration applied to the guide catheter after 5 minutes. Angiogram demonstrated restoration of flow in the carotid siphon and into the anterior and middle cerebral artery territories. Angioplasty was then performed in the upper cervical internal carotid and in the mid cervical region. This was followed by stents placed in the upper cervical internal carotid adjacent to the skull base and extending proximally. Angiography demonstrated excellent flow." 

Stenting internal iliac artery and superior gluteal artery

"Bilateral lower extremity angiography was performed, showing 60% left internal iliac artery stenosis and 60% left superior gluteal artery stenosis. I placed a sheath over the super stiff wire, and wired the internal iliac artery and the superior gluteal artery. I primary stented the origin of the left internal iliac artery with a 5 mm x 16 mm stent. It responded very well. I then primary stented the left superior gluteal artery with a 4 mm x 26 mm drug-eluting stent, opening both vessels up nicely with 0% residual stenosis." Would it be appropriate to report both codes 37221 and 37236?

92937 and 92938

"We first took a 3.5 x 32 mm Synergy drug-eluting stent, positioned across the area of stenosis in the distal OM1 branch of the vein graft, and deployed it at intermediate to high pressure. There was a size mismatch between the vessel proximal to the stent. So we went in with a 2.25 x 16 mm Synergy stent, positioned it across the area of stenosis more proximally, and deployed it overlapping with the proximal edge of the other stent. Next, we turned our attention to the other branch of the vein graft. We took a 3.5 x 24 mm Synergy stent, positioned it across the area of stenosis in the more midvessel, and deployed it at intermediate high pressure. Next, we took a 3.5 x 28 mm Synergy drug-eluting stent, positioned it across the area of stenosis more distally, and deployed it overlapping with the distal edge." Would the two interventions through the bifurcated graft be reported with codes 92937 and 92937-59? Or codes 92937 and 92938?

Covered Stent Used As Bridge Between Vessels

Do you have any suggestions on the best way to bill for this complex procedure? "Viabahn PTFE covered stent graft was placed between the right pulmonary artery at the hilum and the left atrial appendage, traversing the inside of the right and left atrium, and, in the process of doing so, also occluded the baffle leak that was traversed. This was an extremely complicated procedure given the patient’s unusual anatomy and complexity of the planned procedures. In addition, the placement of a covered stent in this case was really very similar to placing a surgical graft because it was used as a bridge between one vessel and another vessel much like a surgical graft (it was only anchored at each end rather than being within a vessel throughout its course)."

Lung Biopsy with Chest Tube Placement

I've asked the following question of several seasoned IR coders and received different answers. I hope you can clarify. "Procedure: CT-guided lung biopsy resulting in hypotension. Repeat imaging demonstrated hemothorax. At the request of the referring physician, a chest tube was placed under CT guidance." Since code 32405 includes CT guidance, is code 77012 separately billable for the chest tube placement (32557)? Or is this considered within the same session?

CPT 50435 and 75984

In the CPT Codebook under 50435 it states not to report code 74425 (but it does not mention 75984). Under 75984 it states to report exchange of percutaneous nephrostomy as 50435. If you look at coding instructions in the 3M Encoder under nephron tube check and change (75984) #4, it says, "Do not report 75984 with 50435. Use code 76000 for fluoro." Coding instruction #6 states, "Do not code fluoro imaging with 50382, 50384-50387, 50432-50435, 50693-50695." These two instructions (#4 and #6) seem to contradict each other, and the CPT Codebook (under 50435) doesn't say that 75984 can't be used. Can you please verify?

Thrombolysis, Extensive Procedure

I need help with the following case: "Patient has DVT left lower extremity and thrombosis of IVC. Day one the doctor did catheter placements into the IVC from both left and right popliteal veins. He did a diagnostic left leg venogram and diagnostic IVC prior to placing EKOS catheter(s) into the IVC for overnight infusion." Would this be reported with codes 37212, 36010-50, 75820-26XU, and 75825-26XU? On day 2 his report indicates, "Subsequent day with cessation of thrombolysis in left external iliac vein, left common iliac vein, and IVC." Is this all "one surgical field?"

Thrombus Maceration

Our IR docs do this procedure quite often, and I am wondering if you would use an unlisted code or bundle with the catheter placement. He goes into upper and lower bilateral pulmonary arteries and does administration of 4-6 mg of tPA in each artery. He calls it "thrombus maceration". What is your recommendation for charging for the maceration part of the procedure?

CPT 61645

I'm wondering if there has been any rationale for the status change to non-coverage with the new CPT by Medicare (61645) or if the status will be changed from E to C status. There also does not appear to be an additional code applicable if more than one area treated: Left vertebral/basilar and right ICA/MCA.

Thrombectomy Before Lysis Catheter Placed

"Patient with left leg DVT with CT showing May-Thurner syndrome. Accessing the left popliteal vein a venogram was performed. The thrombosed portion of the left lower extremity was recanalized in the femoral, external iliac, and common iliac vein. Thrombosis throughout all these veins. Catheter to the IVC with an Inferior Cava venogram demonstrated no caval thrombus. AngioJet thrombectomy in the left leg with tPA performed. After swelling time of 20 minutes AngioJet again. Good results to the origin of femoral vein but partial occlusive thrombus in CFV and common iliac without inflow from profunda or internal iliac. So an infusion catheter overnight to be placed. However, since the flow was completely stagnant and there is only a mild amount of thrombus inline, we decided to perform angioplasty, as the risk of PE would be low and we wanted to have some flow through this segment, preventing re-thrombus. Angioplasty of left common iliac vein. Infusion catheter placed from prox fem through com iliac vein. Then infusion catheter placed." Would you report codes 36010, 75820-59-LT, 75825-59, 37187, and 37212-59?

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