Knowledge Base

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Set Descending Direction

49451 vs. 49452

This seems like a simple question, but we get these all the time and I have not seen it addressed anywhere. When replacing only the jejunostomy portion of a GJ tube, should that be billed as 49451 or 49452 since what is left at the end of the procedure is a GJ tube? 

Right Heart Cath with Pulmonary Artery Angio and CardioMems Implant

I searched the archives and found that you suggest to use (for the physician) unlisted code 93799 for CardioMems implant. Our doctor documented a right heart cath (93451-26) also and left pulmonary artery angiogram, as well as left pulmonary descending inferior posterior artery angiogram selectively. Is all of this included in the CardioMems implant, or should the pulmonary artery angiograms also be coded? 

Using QO Modifier with TAVR

I have been told that I need to use the -QO modifier with all TAVR procedures. However, the claims manual says it is required if patient is part of a clinical study. So which is true? Or is it similar to using primary prevention ICDs that are part of an ongoing registry?

Brachiobasilic Fistula Creation and Basilic Vein Transposition, Same Session

I have a provider that does the brachiobasilic fistula creation and the basilic vein transposition all in the same operation. How would this be coded? "The brachial artery was identified and encircled with a vessel loop, and control over the brachial artery was prepared for with vessel loops proximally and distally, and any branches were also controlled. The basilic vein was then tunneled along the anterior-lateral aspect of the arm. An arteriotomy was created. The basilic vein was then allowed to lie over the arteriotomy without a significant amount of slack. The end of the vein was spatulated to match the size of the arteriotomy. The anastomosis was then performed using a 6-0 Prolene running suture. At the completion of the suture line, the brachial artery and basilic vein were forward flushed and then allowed to back bleed. The sutures were tied, flow restored, and the fistula noted to have palpable thrill." This was done in one operation. I am not sure if I need one code or two codes for this.

Device Interrogations

Can you tell me for device checks does it have to be an EP provider that signs off and approves these, or can a cardiologist approve these also? We have general cardiology, interventional, and EP in our practice, and I just need to see if any of them can sign off on device checks.

Graft Intervention 92937 and 92938

A lesion was found in the venous graft of the RCA with a clot and another lesion in the distal RCA into the PDA. Both were treated with a bare metal stent. Can you bill codes 92937 and 92938 if a stent extended into the branch? Or in this case just 92937? How about if the stent didn't extend and there was a lesion in both the RCA and PDA stented; can you bill for two interventions or only one?

IVUS for Vessel Sizing

A physician uses IVUS for vessel sizing only before and after placement of a coronary stent. The only documentation in terms of IVUS findings read, "IVUS pre and post stent deployment shows adequate apposition of the stent struts with adequate lumen areas." Is this enough to bill an IVUS procedure? If the physician provides more detailed information regarding the vessel measurements, would IVUS be billable when used strictly for stent sizing?

Coil Embolization with Varicose Veins

We have a question about coil embolization for varicose veins. We have found the information that we cannot use code 37241, but we can’t find what we can use. The doctor images the greater saphenous vein, chooses the area to be coiled, and then drops a Medusa embolization coil. The doctor has previously tried ablation therapy (36478) and sclerotherapy (36471), and now the patient has recurring varicosities. What code should we use?

Transcatheter Thrombolytic Infusion and Relook

Can we bill anything for the relook in this case? "Sheath was placed in the left femoral artery. Catheter was inserted and advanced into the right EIA and angiography performed with unilateral run-off. Infusion catheter was inserted into the right EIA and infusion initiated (37211, 37246, 75710-26-59). Later the same day, patient is brought back to the cath lab for a relook. Infusion catheter was removed. Catheter was inserted into the existing sheath (in left femoral artery) and advanced into the right SFA and angiography performed with unilateral run-off. Catheter and sheath were removed." 

Microcystic Lymphangioma Embolization

Please provide the CPT codes with an explanation. "12 month old with large dominant macrocyst. Sclerotherapy of the left neck lymphatic malformation. In supine position, using ultrasound guidance, a 20 gauge angiocath needle was initially directed into the lobular posterolateral collection. Only a small amount of fluid could be aspirated, likely due to collapse of this smaller cavity. The catheter was removed. Using direct ultrasound guidance, a 20 gauge Angiocath needle was then used to access the large anechoic cyst more anteriorly. The needle was removed and a total of 10 ml of amber colored fluid was aspirated. The pocket of fluid again collapsed around the Angiocath, and access to the cyst was lost. After aspiration, on ultrasound, the large cyst was noted to be significantly smaller in size. No additional fluid was aspirated. The needle was removed from the sheath. Through the Angiocath, 100 mg of doxycycline (10 mg/mL) was injected under fluoroscopic guidance. Even filling of numerous adjacent microcysts. Sheath was removed."

Retrograde Approach for a Selective Common Femoral Angio

Can you please explain a retrograde approach for a selective common femoral angio? The physician directly accessed the popliteal artery. I feel like I am missing something. Here is the dictation: "Access was obtained in the right popliteal artery with micropuncture kit. Next NaviCross was placed over a wire into the right common femoral artery, and angiogram of the right iliac arteries as well as the right common femoral artery was performed." I coded for second order, but have a gut feeling I'm wrong.

Ax-Fem Bypass Graft

Physician states graft was accessed (does not state where) and contrast injection performed through micropuncture sheath, showing complete thrombosis of the graft proximally and distally. Due to volume of clot the patient was taken to the OR. How would you code this?

Selective Catheter Placement

I have been reviewing documentation for a new neurointerventionalist. The documenation states, "Through the sheath, a 5 French Davis was introduced and was navigated over a Glidewire for catheterization of the vessels as listed above. The arteriotomy was closed with Star close." In the heading of the report it lists: "VESSELS INJECTED: Left common carotid artery, left internal carotid artery, right common femoral artery. VESSELS STUDIED: Left CCA, cervical views; left ICA, intracranial views; right common femoral." The findings are listed clearly at the end of the report. With the impression, I am just wondering if this is enough documentation regarding the catheterization for each vessel.

75630 vs. 75716

My physician documents using "table step imaging" to perform abdominal aortography with bilateral runoff (results include iliacs, femoral, and sometimes popliteals). Would this documentation be considered appropriate for code 75630 since there is only one cath position vs. 75716?? "RCFA access with catheter advanced to abdominal aorta and bilateral lower extremity runoff was performed using table step imaging. On the right, severe common iliac, mild external iliac, and mild common femoral stenosis. Patent popliteal artery with three vessel runoff to the right foot. On the left, mild common iliac artery, mild external iliac artery, and mild common femoral artery stenosis. Patent popliteal artery with three vessel runoff to the left foot."

50688 vs 50387

For the following case, I am being advised that this is not 50688 but should be 50387. Can you clarify? "Clinical indication: Hematuria. Tube pulled back. Informed consent was obtained. The patient was prepped and draped in the usual sterile fashion. The existing nephroureteral catheter was injected with iodinated contrast. It shows opacification of the pyelocalyceal system and proximal to mid ureter. The intrarenal pigtail has pulled back into a lower pole calyx. The distal pigtail has uncoiled partially. Contrast is not seen extending into the ileal loop. A 0.035 guidewire was advanced through the existing catheter, and exchange was made for a new 8.5 French x 26 cm nephroureteral catheter. The proximal pigtail was coiled in the renal pelvis, and the distal pigtail was coiled in the ileal loop. Contrast was injected showing flow of contrast through the catheter into the ileal loop. There is minimal left-sided pyelocaliectasis."

FFR with Acetylcholine Challenge Test

Is FFR included in the Acetylcholine challenge or coded separately? "After diagnostic LHC/COR was completed, attention was turned to coronary reactivity testing. A Volcano FloWire was then placed into the proximal portion of the LAD. The following interventions were then performed in sequence according to protocol. 18 mcg of adenosine was given, 0.36 mcg of Acetylcholine was given, 36 mcg of Acetylcholine was given, 108 mcg of Acetylcholine was given, and 200 mg of nitroglycerin was given. The catheter was then removed, and the patient was taken to the holding area in stable condition. Baseline QCA was 2.2. Following high-dose Acetylcholine, was 2.1. Following nitroglycerin, was 2.6. The intracoronary response to Acetylcholine was negative 4.5, percentage saturation was positive 18%. Coronary blood flow was increased to 67%. Of note, following the 108 mcg dose of Acetylcholine, there was greater than 90% diffuse spasm of the LAD associated with 5/10 chest pain but no electrocardiographic changes."

Embolization Nephrostomy Tract

I am trying to find a CPT code for the embolization of a percutaneous nephrostomy tract. "The patient presented for a nephrostomy tube change. After replacing the tube, the contrast injection revealed abundant filling of the venous system and frank blood coming from the catheter. They tried to reposition, but this was not successful. Decision was made to embolize the nephrostomy tract. A coil was deployed within the collecting system followed by gelfoam along the tract." My understanding of the embolization codes is that they are for an endovascular procedure. Is this correct? If so, then I think I need to use an unlisted urinary system CPT code; do you agree with this?

Pulmonary Thrombolysis

Patient at first facility had echo and CT (they called it CTA, but it wasn't), which showed bilateral main branch pulmonary embolism. Two days later patient gets transferred out and goes to cath lab at major facility and has RHC with pressure measurements documented by Swan, pulmonary angio by pig, and bilateral thrombolysis is started. My coding is 93451, 93568, 37211-50. Patient assessed on unit next day and is clinically improving, so catheter is pulled out on unit. No trip to cath lab or any imaging done, based on symptoms and vitals. I do not believe 37213 and 37214 can be used for the visits to the unit when the MD goes up to assess patient and depending on day of cath removal, use these codes because it "includes ongoing E&M". Patient does not go back to cath lab at all. Would that not be part of the subsequent hospital care E&Ms and for procedures, only the 37211 code day 1?

Thyroid Biopsies

The patient has two thyroid nodules on the right side. The patient underwent ultrasound-guided FNA of the right upper pole thyroid nodule and the right mid/lower pole thyroid nodule. Are codes 10022, 10022-59, and 76942 correct?

Bone Biopsy, Bone Marrow Biopsy, and Bone Marrow Aspiration

Bone biopsy, bone marrow biopsy, and bone marrow aspiration are done. How do we code this? Can they all be reported together? "The patient was referred from ortho oncology for biopsy of known lesion of the right tibia with history of positive bone scan and bone marrow abnormality of magnetic resonance imaging at the mid-distal right tibia. Single pass of the 11 gauge Cook Osteo Site bone biopsy needle was made through the cortex of the tibia; additional three sites of core needle biopsy of the marrow with this needle were attempted; the specimen of needle biopsy of the right tibia was sent to surgical pathology. An aspirate of 3 ml of bone marrow was also obtained from the site and was placed in a CytoLyt and sent to cytology. Additional aspirate of 5 ml of bone marrow was obtained from the site, and this aspirate was sent to microbiology."

CT Abscess Drainage Tube Check

How do you code contrast injection of abscess drainage tube under CT? Tube injected followed by CT limited scan. Can it still be coded 49424/76080? Or 49424/76380?

35761 vs. 37799

"Pre-op diagnosis: 1) ESRD on HD. 2) Stenosis of left cephalic-axillary venous junction. Procedure: Left cephalic-axillary stenosis repair via venolysis. LT supraclavicular, aberrant cephalic vein at its axillary vein confluence was dissected circumferentially via an oblique incision.Venolysis of the entire 4 cm length cephalic-axillary vein segment was performed with tenotomy scissors. Markedly improved AVF flow was immediately noted. Vicryl 3-0 suture coapted the subcutaneous tissue, while the dermis with 4-0 Monocryl." We would much appreciate guidance on appropriate coding for this procedure. Would this be in the direction of a repair code? 

May-Thurner Syndrome

We have been unable to find a great example of a case covering May-Thurner syndrome interventions in any of the various resources. Are there any pointers you could provide when approaching these cases? Our physicians usually perform IVUS from the IVC through the common femoral, and usually multiple stents are performed. Assuming there are IVUS findings for all the vessels, should we be using them all? Does anything change when bilateral interventions are performed? On the surface it seems like many of these cases are fairly straightforward, but when you end up with so many codes the doubt creeps in.

Common Iliac Artery Thrombectomy with Stent

I know we typically would not report a thrombectomy of the common iliac (34201) with a stent of the common iliac (37221) together during the same case, as both interventions are in the same vessel and a thrombectomy is an inflow/outflow procedure typically. I have a case though where the provider passes a Fogarty three times to remove clot in the common iliac artery in the area of a prior Nellix device. The thrombectomy is the intended intervention in this case. He then shoots a completion angio, which reveals a patent common iliac artery, but there is an area of dissection distal to the prior Nellix device but still in the common iliac artery, and he deploys a 10 x 5 mm Viabahn stent that extends from the prior Nellix stent into the external iliac artery. In this case since the stent is distal to the area of thrombectomy and extends into the external iliac and is used to treat a dissection. Would you report both 34201 and 37221? I should mention the point of access for the thrombectomy is a CFA arteriotomy. 

Arcuate Ligament Syndrome, CTA, Catheter-based Angiography

I know if a patient has prior CTA that angios are only billable if diagnostic in nature. I am asking for a little more detail on this concept. For example, patient in for abdominal pain has CTA with findings of potential arcuate ligament syndrome. Patient is taken to cath lab and found to have high grade stenosis of celiac, exacerbated by arcuate ligament syndrome. No treatment performed at angio. Would the angio be billable? And the other way around... if CTA shows stenosis and patient is taken to cath lab for intervention, but then no stenosis found and just angio/cath placement performed, is angio billable since it showed no stenosis?

Fistulagram with Retrograde Access via Left IJ

How would an AV fistula case be coded with initial fistulogram (36147) performed from fistula? But to treat the arterial stenosis access was obtained via the left IJ, catheter advanced to left subclavian, and then glidewire was used to access the fistula retrograde and catheter brought across the arterial anastomosis. The arterial anastomosis and juxta arterial outflow were treated with angioplasty along with the remainder of the venous outflow. The graft is only described as a left UE bovine graft. I am stumped on coding for the retrograde access from the IJ approach and would appreciate your guidance. 

Visceral Angiography Pre Treatment Chemo Embolization Liver

Could you please advise coding of the following visceral angiography? "OPERATIONS: 1. Ultrasound and ultrasound-guided micropuncture of the right common femoral artery. 2. Selective catheterization of the SMA followed by angiogram 3. Selective catheterization of the celiac artery followed by angiogram. 4. Selective catheterization of the common hepatic artery followed by angiogram. 5. Selective catheterization of the proper hepatic artery followed by angiogram. 6. Selective catheterization of the right hepatic artery followed by angiogram. 7. Selective catheterization of the left hepatic artery followed by angiogram. 8. Selective catheterization of the medial division of the left hepatic artery followed by angiogram. 9. Selective catheterization of the lateral division of the left hepatic artery followed by angiogram."

CardioMems HF System

For hospital coding, we use C9741 for insertion of CardioMems, which includes a right heart cath. If a right and left heart cath were done at the same time of the CardioMems insertion, can we use code C9741 as well as left heart cath 93458? Or does code C9741 include both a right and left heart cath? 

37250 and 36200

I need a little guidance with this procedure: "Thoracic aortic aneurysm, s/p endovascular aortic aneurysm repair with small endoleak. Procedure: Bilateral groins accessed, catheter into aorta (36200). Aortogram was performed with cath in the ascending aorta (75605-26). This showed patent innominate artery, left carotid artery to subclavian bypass. Endograft in good position. No type I or II endoleaks. However, there is delayed filling of the pseudoaneurysm. I performed IVUS (37250/75945-26) of the aorta and the aortic endograft. The endograft was well approximated to the aortic wall. Findings: Small endoleak." Can you have non-selective cath placement with IVUS? Is this coding correct?

Transposition and Plication of AV Fistula

Would you bill 34819 only for this procedure (as I would think the plication would bundled)? "PROCEDURES PERFORMED: 1) Transposition of the brachiobasilic arteriovenous fistula in the right arm. 2) Plication of an area of 1 cm in the basilic vein proximal to the anastomosis. The basilic vein was then ligated at the most distal end after applying a clamp to the vein at the distal arm. The vein was flushed with heparin saline and noted to expand nicely without any evidence of stenosis or obstruction to the flow. The vein was then passed through the tunnel and brought out to the inflow vein. The end of the vein was spatulated to allow creation of a spatulated end-to-end venous to venous anastomosis. The anastomosis was then performed using 7-0 Prolene running suture. At the completion of the suture line the inflow vein was forward flushed. Attention was then turned to the Doppler signals and plication of the inflow vein to a diameter of 6 mm using running 5.0 Prolene suture for a distance of 1 cm." 

Non-selective Venous Catheterization

What is the proper code to bill for a non-selective venous catheterization of the lower extremity when a thrombolysis or venous angioplasty is being performed with no diagnostic venography? Code 36000 hits NCCI edits with 37212 and 35476.

Medical Necessity vs. Screening

I know we have asked a question similar to this one before; however, my compliance department wants me to ask this specifically. When a physician is treating patients for a surgical intervention for a different primary reason (i.e., stroke, carotid stenosis, etc.), would it be appropriate to perform and bill a diagnostic iliac angiogram based on the AHA guidance below? We want to confirm this guidance meets medical necessity. 2011 American Heart Association Guidelines for the Management of Patients with Peripheral Vascular Disease: The guidelines detail that screening for peripheral vascular disease is recommended for the following patient populations: age 65 or older • claudication • lower extremity wound or ulcers • age 50 or older AND smoking (active or history) • age 50 or older AND diabetes

Common Femoral Endarterectomy

Provider performed left common femoral endarterectomy with patch angioplasty, then a right external iliac balloon angioplasty. Can I report the iliac angioplasty, or is it included?

Coding for Subclavian, Innominate, and Brachiocephalic Trunk

I see the charging staff reporting 36225 when there is a shot in the innominate artery as the catheter is on its way up to the common carotids for selectivity there. I would consider this a "drive by" and only report the 36222 or 36223 depending on the cerebral angiography documentation. If the physician selects the common carotids first, then stops at the innominate on the way out, I would not code the 36225 then either. The confusion is also fueled with the description of the code 36225. It states '"selective catheter placement, subclavian, or innominate" etc. To me, this description reads that the subclavian and innominate are the same when using 36225. Can you help us understand the proper reporting of code 36225 and if the innominate artery can be reported with 36225 when shot in conjunction with a common carotid, etc.?

CTA Prior to Neurointerventional Procedure

Coding guidelines state that if a prior diagnostic imaging service is performed before an interventional procedure, such as a CTA, we cannot code diagnostic imaging for the procedure (only catheter placements). Our CTA studies are read by radiologists, and then the neuro IR physician reviews these prior to intervention; however, he is not the provider who did the CTA or initially read and interpreted the report. Do we still consider this a prior diagnostic study for the purpose of the procedure and only code cath placements such as 36217 instead of 36224? Your clarification would be very much appreciated! 

Hip Aspiration with Injection of Contrast and Methylene Blue

"With the needle in place, aspiration was performed. No fluid or pus was aspirated; however, there is minimal aspirate was obtained, which was sent to the lab for culture and sensitivity. With the needle in place, 10 cc of Omnipaque 350, as well as 5 cc of methylene blue, were injected into the joint. CAT scan was performed after the injection as well as a delayed scan after two hours. Most of the contrast is seen within the hip joint. No definite contrast is seen outside the hip joint (77012, 20610)." Is there a code to use for the Methylene blue injection, or do I use unlisted?

Retrograde Left Heart Cath

Our physician documents in the cath report that "patient underwent a prograde right and retrograde left heart catheterization obtaining hemodynamic pressure and saturation data" with no LVEDP, no left ventriculography, no LV hemodynamics; however, left atrium hemodynamic data is documented. Can we report code 93531? This is a patient with Tetralogy of Fallot. Is left atrium hemodynamic data enough to justify a retrograde left heart?

TEE Guided RFA

TEE-guided RF ablation. Adult 3D probe was passed. Goes on to give findings in the LV, RV, RA, LA, AV, atria, MV, TV, pericardium, and under the PV it says, "Impella RP visualized crossing the pulmonary valve." Does this meet 93355, or would this be the interpretation of the 93662? I have no clue WHO performed the RFA either. So if it was the same provider I know I can't code the 93355, correct? Maybe I'm reading too much into this and it's just a 93312.

Steroid/Anesthetic Injection Post Laser Endovenous Ablation of Saphenous Vein

"Patient comes in for pain relief post laser endovenous ablation of the saphenous vein. Under ultrasound guidance, a needle was inserted around a short segment of the medial thigh greater saphenous ablated segment. Marcaine and Celestone steroid were injected into the site." Would this injection be unlisted code 20999, or do you have another suggestion?

Upper Extremity Intervention/Cath Placements

"PROCEDURES PERFORMED: 1) Left upper extremity angiography. 2) Successful percutaneous recanalization of a chronically occluded left subclavian artery utilizing the Frontrunner and Pioneer catheter was followed by IVUS-guided angioplasty and stenting with an Omnilink balloon expandable stent. Left radial access with cath placement into the aorta. Right common femoral access with cath placement into the left subclavian. Performed balloon angioplasty of the subclavian from the radial access. Performed stenting of the subclavian from the right femoral access." Please advise on the proper codes for this procedure including cath placements.

Removal of Retained Filter Fragments

"Patient with prior IVC filter removal, now for removal of two retained filter fragments. Via right CFV, venacavogram and 3D rotational venography are performed to assess fragments. A sheath was passed and positioned in the infrarenal IVC. Alligator forceps were used to retrieve both fragments under biplane fluoroscopic guidance, with both fragments retrieved intact." We know 37193 is used for IVC filter removal, but question if the retained fragments should be reported as foreign body removal 37197 rather than 37193. What are your thoughts?

Coil Placement in Tract of CVC

Please check my coding of the following procedure and let me know if I'm correct. I've just given a description of what was done. 1. Tunneled dialysis catheter placed via translumbar approach under fluoroscopic guidance, final catheter position at inferior right atrium (36558, 77001) 2. Removal of previously placed transhepatic tunneled dialysis catheter (36589). 3. Hepatic vein embolization of exit tract (two 8 x 140 mm coils placed to ensure hemostasis). Should this be reported at all? 

Wire and Sheath Lower Extremity Venous Recanalization

How would we code a case where a recanalization was done but with no balloon? "The Nitrex wire was exchanged for a stiff angled glidewire, and the Greb set was exchanged for a 6 French x 23 cm sheath. A 4 French x 90 cm Cxi catheter and stiff angled glidewire were used to recanalize the left posterior tibial vein." The payer did not reimburse for the procedure due to the fact that there were no balloons used for the device-to-procedure Medicare edit. This case was coded with 35476, 75978. 

ICD Lead Removal with Abandoned Lead Removal

If a physician is extracting leads attached to an ICD device he would use CPT code 33244. What if during the same case he has to remove capped leads from the same side (abandoned leads) that were previously attached to a pacemaker? Would that now add CPT code 33235? Would we code differently if the leads were capped on the opposite side?

Coding for Unsuccessful Procedure

Please let me know how you would code the professional services for the following procedures: "1) Iliac angiogram. 2) Bilateral extremity runoff. 3) Left SFA selective angiogram. 4) Unsuccessful crossing of the CTO of the peroneal artery. The right groin was prepped using sterile technique. 2% lidocaine was used for anesthesia. A 5 French sheath was inserted into the right common femoral artery. Omni Flush catheter was positioned above the iliac bifurcation. Iliac angiogram was performed. The catheter was advanced to the contralateral left SFA. Selective angiogram was performed. Attempt to cross the occlusion in the peroneal was unsuccessful, as the wire was unable to cross. The procedure was aborted. Right lower extremity angiography was performed through the sheath, and a Mynx was deployed. Hemostasis was achieved." Would you apply the -53 modifier to code 37228 to identify unsuccessful crossing of the CTO of the peroneal artery? 

33418/V70.7

In the NCD for 33418 it is required to have the secondary diagnosis of V70.7 listed. There is concern from some that since these patients are not clinical trial patients, but are required to be placed on the TVT registry, does the national clinical trial number support V70.7? Or do we need to be documenting additional information? Can you clarify the NCD guidance; we are on the hospital side of this.

Modifier 80 vs. 81 vs. 62

Two interventional radiologists in the same practice participated in a procedure to treat pelvic congestion syndrome. Both were scrubbed in on the case. One performed the majority of the procedure, and the other assisted. Which modifier should be applied, and how? Do each of the interventional radiologists need to dictate a separate report, or can one radiologist dictate and indicate that another physician assisted?

MRI of the Thyroid

We had a patient who was referred over to us for an MRI of the thyroid. An MRI of the neck soft tissues without contrast was performed. What is the correct CPT code?

Dialysis Access Creation Clarification 36818, 36819, 36820

In reference to question #6577: Is it the location and vessels used that determine use of 36818, 36819, and 36820? Or is it the technique that the surgeon uses to create the anastomosis? I find that lay descriptions of these codes are much more involved (2 incisions, tunneling, 2-part surgeries) than the simple single incision, mobilizing the vein and attaching to the artery that I read in reports. Is mobilizing the vein considered transposition because the surgeon is moving from its origin, or is it more involved? Also, can US evaluation of the selected vessels (76998) prior to the incision be separately reported in these cases?

Generator Change and RV Lead Replacement

Due to end-of-life on generator and RV lead malfunction, we replaced the RV lead and generator. I know the codes to bill are 33207 and 33233 with diagnosis codes 996.01, V53.31. The new Medicare guidelines do not include these diagnosis codes as covered. Please advise.

Ureteral Stent Placement Via Ostomy

Patient presents with obstructive uropathy (has ostomy/ileal loop in place). Physician performs loopogram and decides to place ureteral stents from the retrograde approach. Is the correct coding for the ureteral stent placement 50393/74480, even if the access was not percutaneous/via an antegrade approach?

TTIF Surgery

If my doctor does a TTIF, we have been using code 22899 since there isn't one for the thoracic area. I was wondering, do we use 22899 for each additional level at a lower cost?

Aneurysmal Arteriovenous Fistula

What CPT code is appropriate for the following example? "The larger of the two aneurysms was the venous cannulation site. Micropuncture kit was used to cannulate the fistula, which appeared to be brachiocephalic. Fistulogram was performed, which turned down to the axilla rather than showing the usual cephalic vein outflow. Glidewire was advanced with a Dorado balloon parked across the stenosis of about 85%; it was inflated at 10 atmosphere. Fistulogram showed improvement of stenosis. The catheter was then removed, and the hole in the fistula was closed with a clamp. A clamp was applied across the inflow of the fistula. The aneurysm was squeezed to remove most of the blood in it, and then the outflow was clamped as well. A longitudinal incision was made on the anterolateral aspect of the fistula, and a large amount of excess fistula wall was excised. The lumen was irrigated with heparinized saline, and the fistulotomy was closed longitudinally using running 5-0 Prolene. Flow was restored."

Peripheral vs. Centrally Placed Catheter

Regarding the placement, replacement, and removal of femoral tunneled dialysis catheters, would this be considered centrally or peripherally inserted? I've been coding a tunneled femoral permacath placed as 36558, and after training at another facility it was brought to my attention that the femoral vessels are actually peripheral. For a replacement of a tunneled femoral catheter, would that be coded with 36584 then?

36215 and 36870

"The graft the cannulation zone was accessed with a micropuncture set directed towards the venous outflow. A Kumpe catheter/Glidewire combination was then advanced to the central veins and a central venogram was performed, showing wide patency of the SVC and left innominate vein. A pullback venogram was then performed, showing widely patent cephalic arch and cephalic vein over the humerus. Clot was then noted throughout the cannulation zone of the loop graft. Next, an additional access within the cannulation zone of the graft was performed with a 21 gauge micropuncture needle directed towards the arterial inflow. The Trerotola device was then advanced through this vascular sheath into the brachial artery. It was gently pulled back to the level of the arterial anastomosis, and then mechanical thrombectomy was performed throughout the cannulation zone. A PTA of the venous anastomosis was performed for stenosis." How would you code this? Would you code 36215 since the Trerotola was placed in the brachial artery before being pulled back to the AV fistula?

36228 with Pipeline Embolization

"Following diagnostic cerebral angiogram with bilateral internal carotid artery catheter and 3D angiogram requiring separate work station, angle projections for treatment of the cavernous segment of the right internal carotid artery aneurysm were obtained. Navien catheter was positioned within the intracranial segment of the right internal carotid artery, and Marksman catheter was navigated into the right middle cerebral artery. Then pipeline embolization was done on the right cavernous carotid segment. At the completion of the coiling procedure, cerebral angiogram was performed via the right internal carotid artery." Besides 36224-50, can I add 36228 in this case even though the embolization was at cavernous carotid? I also coded 61624, 75894, 75898, and 76377. Are these the right codes for this case?

Saphenous Vein Graft Embolization

Our physician did a CTO revascularization of the RCA. There is a bypass graft going to the RCA, and the physician decides to coil embolize the vein graft in order to maintain patency of the native RCA. How would you code the coil embolization of a saphenous vein graft to a coronary artery?

Femoral Embolectomy

I am new to coding for our vascular surgeon. Is there a code for left femoral cutdown when performing a left femoral embolectomy?

Occlusion of the LSVC

One of my providers did an ASD closure (93580) and an occlusion of the LSVC, for which I can't find a specific CPT code other than unlisted 93799. Thoughts?

92987

Is code 92987 (mitral valvuloplasty) an all-inclusive code? Does it include 93452 or 93462 if performed?

Other uses for 37221

In a couple of ‘Ask Dr. Z’ cases this year (#6923 and #7038) you and Dr. Dunn have recommended use of code 37221 for Viabahn stenting for something other than occlusive disease in the Iliac arteries. One of these cases was a dissection, and the other was a Type II endoleak. Both patients had prior AAA repair, and there was no mention of stenosis or atherosclerosis in either case, and there was no mention of prior treatment of occlusive disease. Could you please cite something or explain your use of the revascularization code 37221 in this way? I am wondering if your code choice was due to the type of stent used. Also, could you please define the difference between a “stent graft” and a “covered stent?”

76377 vs. 76376

We typically utilize cone beam CT with post processing on a separate workstation and bill 76377. Now, a new angiography system has come out that has bundled the post processing workstation and the angiography system controller into one PC (even though they use separate boards and programs on the same PC). So everything is in one PC tower now. Would you agree that 76376 is now the only thing that can be coded with any cone beam CT from this system?

Embolization Coils

Is there a pass-through code that is to be used for embolization coils or other embolizing agents such as glue? I have found a company that recommends using code L8699. Is this correct?

Cardiac Stress, 93017

I have been seeing charges from our cardiology department for non-invasive physiologic study LE rest and treadmill stress testing 93924 and for 93017 cardio stress test; tracing only. The operative reports ABIs and EKG status, BP, and if any ST changes have occurred. Indication for exam is for leg claudication with no mention of CP in the H&P. Is it common to charge for 93924 and 93017 at the same time? I'm afraid these procedures are being charged incorrectly.

Facility Charging CPT 93355

For facility billing, if the anesthesiologist for a heart procedure also places a TEE probe, monitors the TEE, and dictates a separate report for an intraoperative TEE procedure while a cardiologist performs the transcatheter heart procedure (i.e., TAVR, MitraClip, Lariat, etc.), is the facility justified in billing 93355 for the intraoperative echo?

ICD-10 Coding for Device Checks

In the past we have used V53.31 to indicate a patient with an implanted device having a routine device check (programming). It now maps to ICD-10 Z450.010 (battery) and Z450.018 (other parts). Which is the correct ICD-10 code to use when performing a routine device check? And when would you use the other V-code?

KX Modifier Appendage to Hospital Claims

Pertaining to facility claims regarding the recent pacemaker NCD/LCD... Is there specific documentation or guidelines which state that the -KX modifier needs to be appended to the CPT code, rather than HCPCS? Several of our facilities are wanting to attach to the HCPCS code, while others want to attach to the CPT code. 

LVAD 33990 and High Risk Indication

For 33990, used for Impella assist during high risk stent placement, is coronary artery disease sufficient for medical necessity? What about current or old MI? 

Neuroprotective Device to Prevent Stroke During TAVR

Would placement of the Claret Medical Sentinel neuroprotective device under clinical trial be considered inclusive in the TAVR procedure codes for ICD-9-CM and ICD-10-PCS? Or should we be assigning a separate code for it? If it is to be coded separately additional information as to location of the device will be requested. "Using, micropuncture technique the right and left femoral arteries and right femoral vein were accessed. Heparin was given. A sheath was placed, and a Claret neuroprotective device was placed. Then, a 26 mm SAPIEN 3 was passed through the sheath into the descending aorta. The balloon was docked on the valve, and the valve was then passed across the aortic annulus and positioned using aortic root angiogram, fluoroscopy, and transesophageal echo. We deployed the valve under rapid ventricular pacing. Post deployment there was excellent hemodynamics, trivial regurgitation, and minimal gradient. We then removed the Claret neuroprotective device and then protamine was given. The patient will be returned to CICU in stable condition." 

Multiple Interventions Performed on Femoral Popliteal Arteries

We understand that we are to code only one intervention per side for femoral popliteal arteries. And, we would code the "most extensive" procedure. What would you do in the case that, say, an atherectomy and angioplasty were performed on the SFA (37225) and a stent was placed in the popliteal (37226). Would you "add" the interventions up and use a 37227? Or just use 37225 for the atherectomy?

Tunneled Peritoneal Catheter Exchange

Would the following example be reported with unlisted code 49999? If not, how would this be coded? "Patient with malignant ascites is in for a fluoro-guided tunneled peritoneal catheter exchange due to cuff being exposed. Patient is prepped, draped, and anesthetized. Using fluoroscopy, existing cath was exchanged for a guidewire, and over the guidewire a new tunneled peritoneal drainage cath was placed with distal tip in the pelvis. Fluid was easily aspirated from the new cath." 

Removal of Infected Patch

My physician performed/coded a surgery and needed help with a code for the removal of the infected graft. The patch was placed 13 years prior by another physician. 1) Removal of infected Hemashield patch on carotid artery with a vein patch angioplasty (right proximal saphenous vein harvest). 2) Reoperative carotid artery operation greater than 1 month,  35390 (however, I'm not sure if 35390 is appropriate since he was not the surgeon who performed the original surgery). 3) Resection of carotid artery wall and partial endarterectomy for completion of procedure, 35301 (since this was partial should we add modifier reduced services?). Any help would be appreciated. 

37233 with 37230

I had a patient with atherectomy/PTA of right anterior tibial, PTA with DES stent of right tibial peroneal trunk, and PTA of right posterior tibial and right peroneal. I have 37230 for posterior tibial and tibial peroneal trunk (which is considered part of tibial territory) PTA and stenting done and 37232 for PTA peroneal... I want to assign 37233 for atherectomy/PTA of right anterior tibial, but the code only says can be used with 37229 and 37231. What am I missing?

MR Guided-HIFU ablation

How would you code MR guided-HIFU ablation of thigh desmoid tumor or sites other than fibroids?

Billing 33241 and 33216

A question has been raised whether or not it is appropriate to bill for the removal of the generator at the time of insertion of a new RV lead. The patient did not have a new generator replaced; they used the existing generator. The codes in question are 33241 and 33216. Although these codes pass NCCI edits, is it assumed that the physician needs to remove the generator in order to place the new lead and, therefore, the generator removal cannot be billed?

37193-74 vs. 36011, 75825

Would you bill this with 37193-74 or with 36012, 75827, 75820? "Under direct ultrasound guidance, the right internal jugular vein was accessed utilizing micropuncture technique. An Amplatz wire was advanced into the IVC, over which a 5 French Berenstein catheter was placed. Digital subtraction cavogram was performed in the PA projection. An 11 French coaxial sheath was then placed over the wire and catheter and was advanced to the top of the existing IVC filter. Several attempts were made to traverse the IVC filter utilizing a combination of wires. The Berenstein catheter was exchanged for a Crosser support catheter. The catheter was advanced coaxially with the wire below the level of the IVC, and digital subtraction venography was performed from multiple locations. Digital subtraction cavogram was also performed via the sheath side arm. The catheter was then manipulated into the right femoral vein, and digital subtraction venogram was performed. Based on these findings, the decision was made to abort filter retrieval at this time."

Multiple 76937s and Billing

This case had ultrasound access (76937) used for right CFA access, left CFA access, and left brachial artery access. Our billing system keeps kicking the last 76937-59 out as a duplicate code. Any suggestions on how to get around this?

BRTO with TIPS Placement

BRTO is currently being used by our doctors, but I don't see a CPT code on VASCULAR, sclerosing agents selective injection followed by balloon occlusion of the gastrorenal shunt; the technique being done by our doctors also includes metallic coil embolization of the feeders/shunt. How would we code a balloon-occluded retrograde transvenous obliteration (BRTO) if done with a TIPS placement?

TPA into Both Ports of Dialysis Catheter

If tPA is injected into both ports of a dialysis catheter, can code 36593 be reported twice? 

Ethanol Ablation Renal Cyst

I thought at one time I had seen where you stated to use 53899 for ethanol ablation renal cyst, but someone said to use 20500 and 76080. Which is correct?

3D Interpretation During Mitraclip

I understand that 93355 should not be billed by the interventional physician performing a Mitraclip placement (33418). What if the guidance TEE is performed by a physician not performing the intervention and the interventional physician is performing the 3D interpretation? Would the interventionalist then be able to bill for this 3D interpretation (76376)?

Pacemaker Complication

"Patient was admitted with infected pacemaker pocket, had explantation of old transvenous pacemaker in the left subclavian region and removal of pacemaker generator and atrial and ventricular lead with antibiotic irrigation and closure of the pocket, and placement of a new temporary transvenous lead. The next day he had fever with positive blood culture for staph aureus, assumed pacemaker pocket infection." My question is, can the MD bill for a critical care service (99291) for this next day in which the patient had fever due to a pacemaker complicationt? I believe that is part of the global service period, but not sure. Please clarify.

93970 and 93965

I am finding codes 93971 (93970) and 93965 filed together and having difficulty understanding the difference and if they can, in fact, be filed together at the same session (e.g., leg swelling). 

Foley Insertion in the Cath Lab

A patient comes from ED or the floor (observation) to the card cath lab, and a Foley catheter is inserted in CCL. Can this Foley insertion be coded and charged? If not, why not? The cath lab is insisting it should be charged.

10160 vs. 10030

I see that this question was answered in 2014, but I did not know if the rules have changed since then. "Catheter needle was used to aspirate thigh seroma with sclerosing injection. No catheter was left in place." What is the appropriate code? Should I report 10160? Or 10030 with 20500?

Fluoroscopy

When a diagnostic tech is in the OR with the portable fluoroscopy unit, but does not use the fluoroscopy because it was not necessary, can we still charge for the time the equipment and tech were in the OR?

Multiple Stent Placements from Different Access Sites

A patient has a left common iliac stent placed via a right internal jugular access site and has a left external iliac stent placed via the left femoral access site. Since the work is being done from two separate access points would the codes be 37238/37238-59, or would you use 37238/37239? I chose 37238/37238-59 because my understanding is that with a different access site the coding starts over. Is that correct? 

External Carotid Angioplasty at Time of Carotid Stent

Patient has severe stenosis on both ICA and ECA. With EPD, stent was placed in cervical ICA (37215). Then, left external carotid artery was gently angioplastied. What code should I use for the ECA angioplasty?

Cyst Aspiration and Ethanol Ablation

HIM coding 10030 and 58999. Is that correct? I would like to avoid the unlisted, if possible. Prepped -draped anesthetized etc.... Under CT guidance a 5-french multi-side-hole drainage catheter was advanced into the colleciton. A 0.035 wire was passed through the 5-french catheter and the drainage catheter was moved and an 8-french pigtail catheter was placed. From this catheter a total of 150 ml of clear yellow fluid was removed. The cavity was completeley collapsed. Next, 20 ml of ethanol were injected into cavity. the drain was capped. The pt was placed supine for 15 minutes, left lateral decubitus for 15 min, prone for 15 min, and right lateral decubitus for 15 min. Alcohol was aspirated and the drain was removed. Thanks

Permacath exchange with venous angioplasty of fibrin sheath

I'm trying to determine whether I should use 36595 and 75901 or 37187 for the angioplasty of the fibrin sheath. I prefer 36595 and 75901 due to them indicating it is due to the device and not just the vein but but Coding Clinic for HCPCS - Second Quarter 2012 Page: 5-6 indicates to use 37187. Can I get your take on this? Thank you! "The skin surrounding the indwelling left jugular permacath as well as the external portions of the catheter were prepped and draped using maximal sterile barrier techniques. Lidocaine 1% was infiltrated for local anesthesia. The catheter was freed from the subcutaneous tissues using gentle traction. The catheter was removed over two stiff glidewires. A 10 mm x 4 cm balloon was advanced the brachiocephalic vein for SVC venogram. Balloon dilatation was performed throughout the left brachiocephalic vein and superior vena cava. A 28 cm BioFlow DuraMax permacath was placed to the right atrial/SVC junction. The catheter easily aspirated and flushed."

Rupture of Foley Balloon of a Broken Foley Catheter

Would we use unlisted code 27086 for rupture of Foley balloon of a broken Foley catheter? "Under ultrasound guidance, a 25 gauge needle was placed into the Foley balloon. The balloon broke and the Foley catheter was easily removed."

Impella Device

When coding the insertion of an Impella device in ICD-10, one of the choices to be made is continuous vs. intermittent. Can you tell me when an intermittent device would be used and how to identify which device was inserted? Does the physician need to include the word 'continuous' or 'intermittent' in his documentation?

E/M and Carotid Stent Placement

The physician did carotid angiography two weeks prior to stent, and no E/M was done by the doctor. Research was directed by doctor to see if the patient would qualify for a carotid stent trial, and patient was not able to participate. Two weeks later the doctor did E/M the same day as the stent and explained the goals, risks, potential complications, and limitations, and the patient wished to proceed. We are getting a denial on codes 99223-57 and 37215. Insurance does not want to pay admit/consult because they want to bundle to procedure. Can the physician bill the E/M, or is it bundled? I have tried to find guidelines on this, but I am unable to find any.

Congenital vs Non Congenital Post Heart Transplant

It's my understanding that when a patient with CHD receives a heart transplant, if all aspects of the disease are removed due to the transplant, the patient is no longer considered congenital and therefore cath codes 93451-93461 should be used. What if a patient with hypoplastic left heart syndrome receives a heart transplant and disease remains in the aorta? We should use the congenital cath codes 93530-93533, correct? I was a bit confused because the example on page 152 (#4) of the Diagnostic & Interventional Cardiovascular Coding Reference shows a patient with HLHS and the non-congenital codes are used. Wouldn't disease in the aorta still be present for a HLHS patient post heart transplant? Or is that not always the case? Should the physician always document when disease is still present post heart transplant? These congenital pediatric patients can be a challenge. 

62284 vs. 62305

Please confirm if 62305 is correct for facility billing. "Myeolgram inj and images in X-ray, patient then sent for CT. HIM is stating 62284 is correct. Spinal needle into the L4 level under fluoro guidance Contrast injected into thecal sac. AP and lateral views show good contrast opacification of the lumbar thecal sac. There is myelographic block at T12-L1 . After extended time head down in prone and supine positions contrast does pass into the thoracic levels. Limited contrast visualized in the cervical levels, however patient did have pain from headache suggesting contrast of passage into the cervical levels. Successful myelogram demonstrate myelographic block at T12-L1. Separate CT dictation for complete details. The patient is tilted, etc., in X-ray."

Cath placement during and angioplasty for stenosis while replacing a central venous device

Patient comes in to have the central venous catheter replaced. When they removed the catheter they noticed stenosis in the SVC, so they angioplastied it and replaced the catheter. My question is, does catheter placement need to be reported with 35476/75978, 36581/77001? 

Wire Removal as "Foreign Body"

"Patient had occluded fem-pop graft. Operator attempted to cross native SFA, but due to stent complication and occlusion he proceeded with a retrograde crossing via the distal posterior tibial artery. MD inserted a micropuncture pedal access sheath in the posterior tibial artery and advanced a guide wire in the posterior tibial artery through proximal posterior tibial and tibial peroneal trunk and in the occluded fem-pop graft. Wire was retrieved through sheath. A support catheter was 'back loaded' over wire through the right femoral sheath and down into distal posterior tibial artery. Wire removed as foreign body." The operator used code 37197 to describe this separate and distinct procedure. Although there was work expended, I am questioning if this is a separately billable procedure that can be coded. Thoughts?

34812

Condensed version of AAA 2 providers involved - bilateral femoral cutdowns were made on common fem, Seldinger tech. wires and sheaths were introduced in to each groin. Initially an aortogram was performed to delineate anatomy. the main body graft was placed via Rt. fem artery was Medtronic 28x16x124 graft, contralateral limb was placed via Lt fem artery 16x24x156 and then Rt. limb extension was placed via Rt. groin 16x28x93 which was a flare type graft. balloon angioplasty was then carried out. A second arteriogram was then performed for an endoleak. No endoleak all catheters & sheaths withdrawn fem artery repaired with 5-0 prolene suture. I have coded 34802,62 / 34825,62 / 34812,50,62,XS,51 / 75952,26 / 75953,26 / 36200, XS,51/ 36200,XS,51 - Am I coded this right my surgeons never say placed the catheters in aorta for aortogram simply say aortogram x 2 and do I coded the cutdown part correct with modifiers since cvt surgeon and cardiologist both doing this. I really thank you for your expertise.

Biopsy-Vocal Cord Mass

Could you please help with the code for the procedure below? Code 38510 is what we assigned. Is this correct? "The patient was placed supine in the CT scanner. The patient's anterior midline neck was prepped and draped in a sterile manner. A hard stop time-out was then performed to verify the patient's identity, the planned procedure, and procedure location. After proper patient identification and verification of the planned procedure, the procedure continued. Local anesthetic was applied. Under CT guidance without the use of contrast, a 20 gauge, 15 cm Chiba needle was placed into the right vocal cord mass. The mass was difficult to access through the cartilage. The needle was continuously agitated in the lesion to obtain fine needle aspiration samples. Several biopsy specimens were obtained, which were immediately handed to cytology for evaluation. Samples were then sent to the laboratory as per the requesting physician's orders."

Open thrombectomy dialysis AV fistula with PTA & fistulogram

"The patient has outflow stenosis around the elbow with flow through the perforator vein into the brachial vein with stenosis there. The fistula was opened, and a large amount of thrombus was evacuated. A Fogarty was passed proximally and retrieved clots from there as well. After this the fistulotomy was repaired, and the fistula was then punctured with a needle wire and sheath, and fistulogram was performed. This demonstrated high-grade stenosis of the brachial vein down the perforator, which is the sole outflow of this fistula. We crossed the lesion with a wire and noted that we were in two different perforator systems and ultimately engaged each. These were treated with 6 mm balloon angioplasty. We then also treated the proximal fistula lesion with 8 mm balloon angioplasty. Repeat injection demonstrated improvement. The sheath was removed and the puncture site repaired." Can we report codes 36831, 35476, and 36147 for the same encounter/same physician? There is an NCCI edit on codes 36831 and 36147. Would it be appropriate to assign modifier -59 or-XU to 36147 in this scenario?

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