Would you report codes 92928-LD and 92928-59LD for the following case? "Right femoral access: Stent to the LD with subsequent angio showing excellent results. Removed wires and started to close groin when patient went into cardiac arrest. Angio showed thrombosis of LD. Could not access left femoral for IABP. Had to pull wires from right to insert IABP. With chest compression and IABP support we were finally able to access left common femoral and place a stent across LD thrombosis."
I was reading an article published in an endovascular magazine. They had several examples, one of which was a peripheral intervention. We understand that if a true diagnostic study was done prior to an intervention in the leg, we can code it, however, not to show the catheter placements. In the example we are questioning is the following quote: "Code 36246 is reported in addition to the stent placement because the higher degree of selective catheter placement was performed for the diagnostic study, not the intervention." Is this true? If so, then would then the reverse be true on greater selectivity for interventions that don't include catheter placements (say diagnostic cerebral imaging and then greater selectivity to do the intervention)?
Can we bill this stent placement even if they had to remove it? Physician angioplasties two areas in the venous portion of an AV graft. In one of these areas there still remained a lot of dz, so it was decided at that point to place a stent. In deploying the stent, because of the narrowing, it created a "pumpkin seed" and migrated into the subclavian vein. They had to remove it by accessing the common femoral vein and used a snare device to remove it. They did not place another one after this. Would I code for the stent placement and/or code for the retrieval?
We have a scenario that is frequently encountered in IR, and we need clarifications for coding the number of surgical fields and if diagnostic imaging is warranted. It is my understanding that billing for bilateral ovarian vein embolization is a grey zone, and we see difference in the recommendations regarding coding one time embolization (37241) or two separate surgical fields (37241, 37241-59). "Catheter was advanced into left renal and left and right ovarian veins with imaging (36012, 36011-59, 75833). Selective catheterization of ovarian veins and coil embolization with post imaging. Left ovarian venography showed reflux of contrast into the deep pelvic venous plexus with multiple para-uterine varicosities. Varicosity also extends into the vulvar region. Initial hand injection into the right gonadal vein demonstrated no reflux of contrast towards the pelvis. The patient was therefore placed in 15 deg of reverse. Injection revealed reflux of contrast into the deep ovarian vein with opacification of small para-uterine varicosities."
Can I use regular CPT codes (CT without contrast) 72125, 72128, and 72131 to report intraoperative CT guidance with spinal procedure? Or would you recommend use of an unlisted code? "68-year-old woman undergoing L2-S1 revision of posterior spinal fusion. Non-contrast axial images of the lumbar spine were obtained intraoperatively for surgical guidance. Coronal and sagittal reformatted images were reviewed. There has been interval placement of a clamp on the T12 spinous process. Post-surgical changes are again demonstrated with posterior fusion hardware in the lower lumbar spine, extending from the L4 level to at least the L5 level. Note that the inferior extent of the hardware is incompletely included in the field-of-view on this exam. A soft tissue defect in the posterior midline soft tissues is compatible with the intraoperative state. Curvilinear, metallic structures within the posterior soft tissue defect may represent packing material/gauze. Multi-level degenerative changes are again identified with anterior and posterior osteophyte formation, disc space narrowing, and vacuum disc phenomenon at multiple levels. Additionally, there are facet joint degenerative changes in the lower lumbar spine."
The provider performed a diagnostic angiography of the right lower extremity accessed through the ipsilateral CFA and stopping in the SFA (billing 36245-59, 75710-26-59). Then tried to cross the SFA to treat occlusion and was unable to. Closed this access up. Accessed the posterior tibial artery and advanced catheter to the SFA occlusion and did an atherectomy through this access (billing 37225). There was spasm in the posterior tibial artery, and the provider proceeded to balloon angioplasty the posterior tibial artery spasm (provider would like to bill code 37228). Can we bill code 37228 for treating the vasospasm?
"Complications: After completion of left heart catheterization, a right iliac angiogram was done for closure device deployment. A small perforation was noted from needle stick in the inferior epigastric artery, which was successfully sealed off/tamponade by 7.0 x 20 Mustang over the wire balloon, with two inflations of 10 min at nominal pressures. Angiogram was repeated, which showed normal inferior epigastric artery with extravasation of contrast." This was recently performed in the heart cath lab. My question is how would you code this to reflect the procedure performed? The first iliac angio was done for closure device evaluation. The second was done to evaluate the perforation. A balloon was used to seal the perforation until hemostasis was achieved. I spoke with the cardiologist, and the balloon was inflated in the femoral/iliac artery area, and at no time did he enter the epigastric artery. Are codes 36245, 75710, and 37244 appropriate?
When a patient has a left heart catheterization, followed by percutaneous intervention, both are considered necessary and can be billed. I'm not sure how to bill services provided when the patient emergently arrives to the hospital and requires this sequence: coronary angiography, percutaneous intervention, and left heart catheterization last. Is the catheterization still billable even though it was done second since there wasn't time to do it prior to the intervention? Or is it not supposed to be billed since it was not done to determine if the intervention should be put in? If not, can I bill for the coronary angiography since that was done prior to the intervention?
Our surgeon treated an iliac aneurysm using a unibody bifurcated endograft that was deployed on the aortic bifurcation and two Iliac extension grafts (same side). Can code 34804 be used in this type of situation, even though the patient does not have an aortic aneurysm? Code 34900 is only for tube endografts. But can we use it anyway, because of the extensions? Or should we use an unlisted code? If yes, what code should we use for the extensions?
Should we report code 37242 or 37241 if the anomalous venous drainage of an arteriovenous malformation is sclerosed without treatment of the arterial portion of the malformation?
Would you code separately for drainage of the pseudoaneurysm during the following AV graft stenting case? Would you use code 10030? "Through the existing sheath an 8 mm x 10 cm Viabahn covered stent was subsequently deployed with post-deployment venogram revealing excellent exclusion of aforementioned pseudoaneurysm. Under fluoroscopic guidance a percutaneous angiocatheter was introduced into the pseudoaneurysm sac at a separate site in the pseudoaneurysm and was drained after exclusion. Antegrade access was then acquired, being careful to avoid the recently placed stent. A 9 French sheath was introduced over wire and a 9 mm x 5 cm via bond stent was deployed at the cephalic origin into the innominate. Post deployment venography reveals exclusion of the primary collaterals and no significant intrusion centrally. Balloon angioplasty was subsequently performed with an 8 mm balloon within and adjacent to the more central stent."
I have a neuro angiogram where the bilateral vertebral arteries were selected (36226 -50), the bilateral ascending cervical arteries were also selected, and angio was performed. They were selected via the subclavians and thyrocervical trunk. My question is should this be reported with code 36228-50 or something else? I'm confused because this is not a common case for me. They are performing the angio for a tumor at the C2 spinal vertabre.
"Our physician did a complete diagnostic study of left and right internal carotid and external carotid arteries, right vertebral artery, and left superficial temporal artery. Embolization was done on the superficial temporal artery all from bilateral inguinal access. Following embolization he did the same studies left and right internal carotid and external carotid arteries, right vertebral artery, and left superficial temporal artery. The patient was then taken to surgery where the physician did a resection of the left superficial temporal artery pseudoaneurysm." Would codes 36224 x 2, 36226, 36227, and 61626 be correct? I'm not sure any of the post angiograms can be charged. The resection was billed with OR time. Our CEO is concerned we are not charging correctly for all the biplane procedures.
The physician opens common femoral artery at the groin and performs a thrombectomy, then opens medial calf at the tibials and performs additional thrombectomy. Can I report codes 34201 and 34203?
Can code 20500 be utilized when, at time of abscess catheter placement or exchange, the cavity is debrided of necrotic material using normal saline (500 ml, in this case)? This is time-consuming and goes above and beyond just placing or exchanging the catheter.
I need your perspective on this one. At conclusion of study the provider mentions that the patient will need an aorto-bi-femoral bypass. "Operative Synopsis: Pigtail catheter placed first at renal artery and then pushed down to distal abdominal aorta. Then after completing peripheral angiogram, cardiac catheterization was decided." The provider mentions findings for abdominal aorta, common/internal/external iliacs, and bilateral SFAs. Report states that they were "unable to visualize clearly the below-knee vessels due to slow flow". I'm thinking this needs to be reported code 75625 only. My rationale is that the statement of slow flow to see below-knee vessels is not acceptable to also capture code 75716. I did not go with code 75630, as the catheter is not in one spot. With conclusion of statement that patient needs bypass, is this study then considered screening (G0278)?
"Patient was brought into the electrophysiology laboratory in the fasting, non-sedated state. The patient was prepped and draped in the usual sterile fashion. 1 percent lidocaine was used for local anesthetic. An incision was made in the left infraclavicular region. The tissues were dissected down to the level of the ICD pocket. A redundant lead was extending just beyond the device with stretched skin and impending erosion. That lead was dissected free and turned into the pocket. The lead was sewn to the pocket floor with 0 silk. The pocket was irrigated with a combination antibiotic solution." We know this was not a pocket revision or move. How would this be coded?
Can you please help with the correct diagnosis code for the following scenario? The patient has CRF and is coming in for creation of an AV fistula (36821). In my opinion the primary diagnosis would be for the CRF. Per our in-house auditor, the primary diagnosis should be V56.1. What are your thoughts?
Our doctors have started using stereotactic technology to perform certain EP ablation procedures. Is there a CPT code for this?
Will code 36833 cover the following procedure? Or are codes 36147 and 36148 also needed? Please advise. "Patient with aneurysmal left brachiocephalic AV fistula with aneurysmal stick site, skin ulceration over upper stick zone. Micropuncture needle was inserted into proximal portion of fistula with wire advanced under fluoroscopy into upper fistula beyond aneurysmal stick zones. Sheath inserted up into subclavian vein and parked there with fistulogram done. Long segment of high grade stenosis (80%) began just beyond aneurysmal upper stick zone. Stenoses were balloon-dilated with good result and puncture site sutured. Attention turned to aneurysmal site in upper stick zone. Ulcer was excised with elliptical incision back to healthy skin on both sides, down to fistula. Inflow portion of fistula into stick zone was dissected and clamped. Patient was heparinized. Part of aneuyrsmal fistula was excised, revealing ulcer had penetrated into fistula with layer of thrombus between scabbed area and fistula. This was excised including excessive thrombus. Opening was oversewn in two layers, clamps were released, and suture line was hemostatic. Subcu and skin sutured."
"11 year old male status post pacemaker for sinus node dysfunction, with a recent change to ERI mode. He presents for elective replacement of the generator. In pre-procedure discussion with the surgery team, it seems that the post-rectus device had possibly migrated upwards and centrally. We thus elected to have surgeon scrub in to the procedure to assist in removal of current generator. After removal, leads were tested and found to be stable in function. We thus proceeded to create a new pocket (33222) in the left-sided abdomen under the anterior rectus sheath above the rectus muscle. The existing leads were attached to a new device. Testing confirmed stable thresholds and impedences. The new device was placed in the new pre-rectus pocket (33228) on the left and closed in three layers. The old pocket was also closed in three layers. Patient tolerated procedure well." NCCI edits do not allow codes 33228 and 33222 to be reported together, no modifier allowed. Do you have any suggestions on an appropriate code combination that would allow reporting of pocket relocation?
Would codes 49424, 20500, and 76080 be supported for this procedure? "Contrast was instilled into the patient's indwelling right groin catheter/fluid collection under direct fluoroscopic guidance. Overall, the fluid pocket appeared similar in size compared to previous exam with no external communication. Contrast was aspirated and replaced with ethanol solution. Patient was repositioned into right and left decub positions. Alcohol was left in place for 30 minutes and then removed. Impression: Stable appearing fluid collection in the right groin with successful alcohol sclerotherapy of patient's lymphocele."
Day One - Patient has a percutaneous thrombectomy, common and external iliac stents, and starts thrombolysis. Patient has a left iliofemoral thrombosis (37187, 37212-59, 37238, 37239). Day Two - Follow-up venogram shows residual thrombus in the left external iliac vein. The residual thrombus in the iliac vein was macerated using a pigtail catheter and 10 x 4mm balloon. Thrombolysis was completed (37214). Would you code the venoplasty (35476, 75978) for maceration of the residual clot?
Would I report codes 64483 and 64484 or codes 64493 and 64492 for the following case? These can be confusing at times. Please let me know how these can be easier. "History: Right L3 and L5 radiculopathy Summary: Uncomplicated right L3 and L5 fluoroscopic guided transforaminal epidural selective nerve root block. A combination of 2 mL 0.25% bupivacaine, 1 mL 1% lidocaine, and 40 mg Kenalog were injected at each level. Procedure: Using fluoroscopic guidance, a 22 gauge spinal needle was inserted into the right L3 and L5 neural foramina. Position within the nerve root was confirmed with small injection of contrast and digital fluoroscopic image. Medication was injected as above. Needles were removed. Total fluoroscopy time 2.3 minutes. 15 minutes intravenous conscious sedation with Versed and fentanyl were administered by sedation nurse under my supervision with continuous monitoring."
I'm only adding the procedures and not the actual description. I know the codes for the thoracic and lumbar etc., but I'm not sure what to use for the superselective injections. "Questionable spinal vascular pathology. POSTPROCEDURE: No vascular pathology identified. OPERATION/PROCEDURE: 1) Diagnostic cerebral angiogram 2) Right common femoral artery selective 3) Complete aortic survey 4) Left intercostal selective injection 5) Right bronchial superselective injection 6) Left bronchial superselective injection 7) Left T8 selective injection 8) Left T9, left T10, left T11, left T12, left L1, left L2, left L3, right T8, right T9, right T10, right T11, right L1, right L2, right L3, right vertebral artery, right subclavian, left vertebral artery, left thyrocervical, superselective injections 9) Personal review and interpretation of angiogram."
Patient with jaundice presents for biliary evaluation. Physician performed: percutaneous transhepatic cholangiography (47500-59, 74320-59), cholangioplasty with stent placement (47556, 74363), and internal/external drainage catheter placement at the initial presentation. Would you please give us your insight on why the drainage catheter (47511, 75982) is not coded in addition to ductal dilation with or without stenting when the procedure was not staged?
Should I report the following with codes 36200, 34825, and 75953? Please advise. "The flush catheter was positioned in the proximal visceral segment of aorta. Aortography was performed. This identified some suggestion of a type 1 endoleak. Pre-close technique was used to fire two perclose devices in the right femoral artery and facilitate introduction of a 14 French sheath, which was done over a stiff Lunderquist wire after administration of systemic heparin to the therapeutic level. With the 14 French sheath in position, a 40 x 10 Palmaz stent was mounted onto a Coda balloon. This was advanced up to the level of the perirenal aorta, and the balloon mounted stent was then inflated and appropriately positioned."
In your "Ask Dr. Z" knowledge base forum, you previously recommended the use of unlisted code 93799 for percutaneous treatment of a paravalvular leak instead of code 37242. Would you please elaborate on why this is the case? I am assuming that since code 37241 is for venous embolization and 37242 is for arterial embolization you would not be able to use these codes, as a paravalvular leak treatment is used to treat a valve. The reps have also pointed us to the embolization codes (37241-37244), but I am reluctant to bill these out for treatment of a paravalvular leak. I am hoping you can shed some light on this relatively new procedure.
If the physician just states that the RCA is totally occluded without saying "chronic total occlusion", can we report code 92943, or should we report code 92928 instead?
How can we tell if this procedure is performed as a "pulsed" radiofrequency procedure? The term "pulsed" is never used in the report. Report states the target point at the ipsilateral, lateral, inferior border of the sacrum, just lateral to the S4 sacral foramen was identified. "The probe was advanced over the sacral periosteal surface to the level of the sacral such that its active contact points overlapped the exit points of the S1-S4 sensory nerve fibers. RF lesioning performed with pre-programmed protocol at 80 degrees centigrade for 60 seconds per segment and/or contact point (total duration 5 minutes). RF probe was then removed, and hemostasis was promptly obtained using hang compression. Then the L5 primary dorsal ramus RF lesioning was performed. The curved RF needle was advanced under fluoroscopic guidance. RF lesioning was performed at 80 degrees centigrade for 60 seconds. Successful R sacral RF neurolysis at S1, S2, S3, S4, and L5."
Is there a CPT code for tissue Doppler imaging, or would this be inclusive to the echocardiogram?
How would we code for contrast injection into the ileostomy with imaging? Is code 49465 appropriate, or would codes 20501 and 76080 be reported? Brief Report: "Fluoroscopic evaluation of abdominal ostomy after cannulation of bowel ileostomy openings and administration of water-soluble iodinated contrast. Left ostomy opening demonstrates opacification of distal ileum, which extends to the ileocecal valve and inferior cecum. Mild blush of contrast outside small bowel surrounding small segment prior to the ileocecal valve is seen. Right sided ostomy demonstrates slight more proximal segment of small bowel opacification overlying the left mid pelvis."
Can we use code 76775 when just an AO is being scanned or just renals without bladder (retroperitoneal limited), or do we need to use code 76705? Can we use code 76770 for renal with bladder or for retroperitoneal complete that includes everything?
Scenario: ER physician orders a CT abdomen/pelvis, CT lumbar, and CT thoracic due to trauma. The patient is taken to the CT Department for scans. A “whole body” CT scan is obtained. The technologist manipulates the films, and the radiologist separately reports on each orderable. Please validate if it is appropriate to charge separately for a CT abdomen/pelvis, CT lumbar, and/or CT thoracic... or if the CT lumbar and CT thoracic would be considered “2D rendering”.
The procedures I am auditing are performed by an interventional cardiologist (who is also dictating the reports for the procedures). The co-surgeon is the cardiovascular surgeon. Cutdowns are being performed by the vascular surgeon. Is there any coding I can do for them? I want to be sure I am looking at these procedures correctly.
How would you code this scenario? PTCA in the diagonal for chronic total occlusion and PTCA with drug-eluting stent to the mid LAD (no total occlusion). I want to report code 92943 for the CTO and 92929 for the drug-eluting stent; however, code 92929 states in the descriptor that it is for a branch of the major coronary artery, not the major coronary artery itself. So then it is code 92928 for the major coronary artery and 92944 for the CTO... but that is also not coding by the guidelines since it states you code by the hierarchy of services based on the intensity of the service. Thoughts?
I need to know when I can code both a fine needle aspiration and a core biopsy. Sometimes our physicians do not say why they go on to obtain a core after an FNA has been done. If a reason is not documented, should I just code for the core biopsy? Following is an example: "Ultrasound of the neck revealed 2.5 cm of right cervical lymph node/mass. A 25 gauge needle was advanced into the mass with ultrasound guidance, and an FNA was obtained and given to pathology. The needle was removed, and a total of six core biopsies were also obtained. Post ultrasound demonstrated no hematoma or complication."
I am having an issue with denials when reporting code 93580 with codes 93568 and 93567. Do you have any suggestions on how we can get this paid when billed?
Follow Up to Question ID #5966, it states: ‘A caveat would be if two physicians are in same group and use same billing number then code as usual, as add-on code 93571 would be okay with the heart cath.’ Can you further clarify what is meant by ‘code as usual’? Do you mean first physician can code and bill add-on code since second physician is in the same group even though first physician didn’t perform add-on procedure? CPT manual, p. xiv outlines: “The add-on code concept in CPT 2014 applies only to add-on procedures or services performed by the same physician. Add-on codes describe additional intra-service work associated with the primary procedure…Add-on codes are always performed in addition to the primary procedure and must never be reported as stand-alone code.” CMS 1/1/14 policy outlines the same principal. Also, if FFR/IVUS is performed on same day as heart cath but by two physicians in different groups then do you recommend each physician code their part with second physician utilizing unlisted code 93799 to capture the stand alone px of FFR/IVUS.
For the following case, are codes 36012-50, 36005-59, 75822, and 75825 correct? Using US guidance, a micropuncture needle access attempted into small irregular LT CFV (36005-59). Several attempts were made to pass a wire up through left iliac stents but were unsuccessful. Then access was from the right IJV down into the left SFV and right CFV with catheter placement (36012-50). We traversed entire length of existing iliac venous stents. Contrast injection digital subtraction LLE and left pelvic venogram were performed. Could not traverse beyond region of proximal left thigh due to significant venous irregularity. Catheter was pulled back and positioned in distal aspect of left iliac vein stents, and contrast injection pelvic venograms were performed to evaluate stent patency. Next, access was gained into right iliac vein with glide catheter and with resistance in expected region of right CFV. Could not advance beyond level of right femoral head. Contrast injection digital subtraction right pelvic venogram performed with catheter in right CFV (75822). Catheter was pulled up into central right common iliac vein, and then IVC venogram was performed (75825).
I am not sure if this unsuccessful AV fistula placement should be reported with 36821-53 x 2 or some other code. What are your thoughts? A longitudinal incision was made to wrist between the cephalic vein and the radial artery. The cephalic vein was exposed proximally and distally along the incision, and after inspecting the vein, it appeared to be less than 2 mm and appeared inadequate for fistula placement. Because of that, this incision was closed with 2 layers of absorbable suture. A second incision was made in the upper arm, above the elbow crease, over the cephalic vein. Again, the vein was then inspected for adequacy and the vein was sclerotic and again not adequate for fistula placement. This incision was then closed in 2 layers. After discussion with the nephrologist, it was felt not to place an AV graft at this point.
We have a case where we placed a subcutaneous ICD lead and then placed the ICD generator in the retroperitoneum. What would you recommend coding for this? Code 0319T, even though the generator is in the retroperitoneum, or possibly code 33999?
Would I use code 75625 for this procedure? I understand if just the distal abdominal was performed I would not use code 75630. I am not sure when to use code 75625 vs. 75630. Can you tell me how to distinguish the difference? Right lower extremity angiography with run-off to the foot was then performed with hand injection of dye. A 5 French Omniflush catheter was advanced to the distal abdominal aorta, and abdominal aortography with iliofemoral run-off was then performed with hand injection of dye. The catheter was then advanced over a Glidewire to the left common femoral artery using standard crossover technique, and left lower extremity angiography was performed with run-off to the foot with hand injection of dye. The catheter was then advanced over a Glidewire to the left common femoral artery using standard crossover technique, and left lower extremity angiography was performed with run-off to the foot with hand injection of dye.
I need help coding this report. The procedures were left heart catheterization, selective cornonary, saphenous vein and IM angiography, ventriculography, RAO view, aortography, AP view, right iliac angiogram, and primary stenting of vein graft to RCA with use of spider. Closure of access site using Mynx grip. Here is the part of the note that I don't know how to code: "Aortography was performed in the AP view, as patient was complaining of discomfort in his right leg. This shows significant stenosis of 60-70% in the right common iliac, which with the placement of the catheter was obstructing flow. Following this, selective right iliac angiogram was performed, and this iliac appeared to be diffusely diseased with 60-70% narrowing, but I felt I could get the procedure done and bring him back for elective intervention of his iliac vessel." I am new to cardiac coding, so I'm feeling very lost. The patient has Medicare.
A patient had a biventricular AICD with a right atrial lead. They brought the patient to the EP lab and did an AV node ablation. Then they added a His bundle lead and capped the right atrial lead. They replaced the generator with a biventricular pacemaker generator. I am unsure of how to code this. I was thinking of reporting codes 93650, 33207, and 33241. What are your thoughts?
Can codes 36598 and 36597 be charged together? Here are the highlights of the report: "Spot image of tunneled CVC shows tip flipped superiorly into left brachial cephalic vein. Saline injections attempted to move catheter were unsuccessful. Access was gained into right common femoral, and catheter was advanced into SVC. Catheter used to hook the CVC catheter tubing and reposition the tip into the SVC. Contrast injection into the CVC catheter demonstrates rapid flow through CVC with tip in SVC." My thought was to report codes 36598 and 36010-59, but now I'm questioning if we should also add code 36597, as I don't see any edits for coding the repositioning and the evaluation together.
Is it CMS guidance that separate reporting of 93623 is never appropriate with EP ablation procedures? Or is it appropriate to report code 93623 if the service is performed during diagnostic programmed stimulation and pacing or after ablation is delivered?
"Patient has paracentesis. Then, right common femoral vein is accessed and catheter advanced to thoracic aorta. Pressure bad with continuous saline flush started. Then, right jugular is accessed and catheter is advanced to IVC where a pressure bag with continuous saline flush is also started." Are the selective catheter placements and the "flushes" considered part of the paracentesis?
Would there ever be a circumstance in which suction thrombectomy and atherectomy could be performed together? Physician insisting that suction thrombectomy of CFA, SFA, popliteal, and anterior tibial was performed after atherectomy "with removal of debris" after an SFA atherectomy. My understanding is if thrombectomy is performed (even with different device) it is part of the atherectomy itself unless there is a distal thrombus being treated in an entirely different vessel. Is there some source documentation I can supply to the physician to indicate we cannot bill a separate thrombectomy?
What is the recommended CPT code for placement of a leadless pacemaker? "A pigtail catheter was then advanced into the right ventricle and a hand injected RV gram showed normal RV function and the RV apex was nicely visualized. Subsequently with serial dilation over an amplatz super-stiff wire, the 8F sheath was upsized to an 18F delivery sheath.The Leadless pacemaker delivery apparatus was then assembled with appropriate flushes and was then advanced under flouroscopic guidance carefully into the RV. A suitable spot in the mid RV septum was chosen to deliberately avoid the apex, given a very small heart. A contrast injection showed good septal wall apposition on both LAO and RAO projections. The pacemaker helix was then torqued in 1.25 turns. The sheath was then released and a vigorous tug test showed no lead dislodgement."
Is it okay to report code 93580 (fenestration closure) and 93568 (pulmonary angiography) when the angiography is done after the fenestration closure when documentation states that "angiography revealed complete occlusion of fenestration in right atrium"? It is my understanding that codes 93580 and 93568 are bundled and should not be billed separately.
Pt had a positive finding for traumatic retro bleed found on CTA. Selective cath plmnts 2nd & 3rd lumbars, contralat. common, internal & ext iliacs w/embo of 3rd lumbar. dr also comments that in order to "locate" the lumbar artery's he also selected splenic, lt gatric, lt renal, and IMA. I feel those would be considered roadmapping or guiding shots so I did not code them. I've coded the following-37244,36245x2 for lumbars, 36246 for ext common iliac and 36248 for internal. No S&I's since CTA. Would this be correct or should I code what I think to be the guiding selective catheter plmnts also? Thanks in advance for your help!
Technique: After informed written consent was obtained, the patient was prepped and draped in the usual sterile manner. Access was obtained using CT fluoroscopic guidance. An 8 French catheter was advanced into the distended bladder. Subsequently, as the patient drain uterine the bladder contracted. The pigtail catheter utilized was unable 2 remain within the lumen of a contracting bladder. The referring urologist was notified. The patient left the department in the same condition. Once the bladder had retracted a window through the lower pelvis was not identified for replacement. The bladder capacity was an inadequate target for a replaced catheter. The patient tolerated the procedure well. The patient left the department in the same condition. Unsuccessful attempt at placing a super pubic catheter with an 8 French pigtail drain. The catheter was placed within the lumen and the bladder was drained. As the bladder retracted the pigtail catheter sideholes were eventually excluded from the smaller capacity bladder. The referring urologist was notified.
If order states ultrasound pelvis, and the radiologist does only TV, but does all the elements of the pelvic ultrasound (and documents), are there any concerns on passing that as a valid order? I have asked that they also document why they did the TV approach.
I received this new code in an October 2014 OPPS new service update from Med Assets. Will this new C-code (C9741) go with the existing right heart CPT codes (93530, 93460, etc.), or will it have one of its own (primary or add-on)? Or is this a stand-alone code? I thought that C-codes were only on supplies and sometimes needed in conjunction with a CPT code. I am personally very confused about this new code. Any clarification that you can offer in regards to this would be much appreciated.
We had a patient who was referred over to us for an MRI of the right clavicle. The right clavicle was imaged. Which modifier should I addend to code 71550? Should I use -RT, or should I use -52? What is the correct coding with modifier usage if modifier(s) are applicable?
Would you agree with the following joint injection assigments? Subtalar joint injection: Intermediate Talonavicular joint injection: Intermediate 1st or 2nd Tarsometatarsal joint injection: Small
How do we code for saphenous vein transposition as thigh AV fistula?
We have a case were the vascular surgeon placed a TAA and AAA graft with iliac coil embolization and also placed a renal stent. Are we allowed to bill an open femoral exposure (34812) and/or a brachial exposure (34834)? Or are they considered bundled due to the other procedures done during the case?
Do you have guidance when it comes to disruption of a fibrin sheath with a CVC diaylsis catheter exchange (not a Tessio catheter)? If a fibrin sheath was disrupted in the SVC and another fibrin sheath in the innominate vein, would codes 36595-52/75901 be assigned twice (once for each vessel) or just once (similar to guidelines of coding only one central PTA)?
We have an ESRD patient who ran out of dialysis access options. Two surgeons worked on her. Physician #1 (thoracic surgeon) did an incision of RT anterior chest wall, entered pleural space, excised pericardial fat pad, incised pericardium and dissected the RT atrial appendage free from aorta & SVC. Physician #2 (vascular surgeon) created a tunnel across anterior chest wall, brachial artery was fragile & injured requiring a bovine patch. He then made an arteriotomy on the patch & anastamosed a Goretex graft to the ptach and tunneled the graft across the anterior chest wall. Next the other end of the graft was anastamosed to atrial appendage by Physician #1. Chest tube was place in the RT pleural space and attached to Pleur-Evac suction. There are three billers involved in the coding. One biller states it can't be an AV dialysis graft, as no vein is involved. However, the RT atrium is acting as the venous anastomosis, according to the vascular surgeon. How would you code this case? We are considering codes 36830-22 and 32551, but we really are out of our comfort zones.
CT Physician created open drainage via a thoracic window. Starting posteriorly the 7-8th rib space was identified and using cautery the intercostal muscle was removed from the top of the rib. Dissection of pleural space, encountered extremly thick rind, frozen section of pleural was sent to check for malignancy. Resected through the 7th rib to gain more access to the chest cavity. A rongeur was used to removed 5cm segment of rib. Rind was entered and was almost 3 cm thick and was removed to the size of the incision. Debris was sent for cultures. Removed calcified purulent debris. Performed open drainage via a thoracic window. The 8th rib was resected in a similar fashion. Skin edges around the rib resection were marsupialized, muscle was closed and then deep dermis and skin stapled around the window. I think this would be a 32036 except for the fact that this is Thoracotomy. Would it be more descriptive to bill unlisted procedure?
Bilateral groin cutdowns (34812-50) were made. Rt CFA accessed and catheter advanced to the ascending aorta, Lt CFA accessed and positioned at L1 (36200-50) Main body deployed (34803, 75952-26). Angiogram done which showed 90% stenosis of rt renal artery. Using lt groin access angiogram obtained and contralateral limb deployed proximal to the bifurcation of CIA. Rt docking limb deployed above bifurcation and limbs were dilated. Post dilation angiogram revealed good flow in stent but proximal aspect was found to have migrated more distal than what was the initial placement. There was concern so Dr elects to proceed with placing a cuff to obtain a more proximal seal. Aortic cuff placed and post dilated (34825, 75953-26). Angiogram shows significant stenosis of Rt CIA. Stent placement done in rt CIA (37221) post dilation angiogram revealed excellent results, but there was impingement of the lt CIA, so Dr placed stent in the lt CIA (37221-59). Post stenting angiogram revealed good results. Does this look correct? The common iliac artery stents have me confused.
I have a question about coding using modifier -59. Scenario is patient receives SIJ injection with fluoroscopic guidance (27096) and at the same session has TP injections at a separate body area under fluoroscopic guidance (20552/77002). Would it be appropriate to add a -59 modifier to code 77002 since the guidance was provided at a separate body area from the SIJ?
"Patient had a CTA with run-off showing AV fistula at the fem-pop bypass graft and came to IR. Bilateral run-off was done, catheter was placed in the graft, and embolization occurred with many coils. PTA was done in the popliteal artery at the anastomosis." I believe I should report code 37242 for the embolization and code 37224 for the PTA of the popliteal. The vascular surgeon wants to code the bilateral run-off plus catheter placements. Would you verify for me please?
A question has come up from a Radiology bill. The radiologist coded 76870 and 93976, the hospital coded just 76870. My question is what documentation is needed to be able to code the 93976? An example of the documentation, "Color and duplex doppler interrogation of both testicles confirms normal testicular vascular flow bilaterally" or "Color Doppler and spectral waveform analysis demonstrates normal arterial waveforms within both testicles". My understanding was that "inflow and outflow" needs to be included or "Arterial/Venous flow" must be documented. I want to code correctly but not to over code.
"Patient presents for ablation of atrial flutter. They are post MAZE/MV replacement procedure for a-fib at another facility and has since had continued issues with a-flutter. EP and ablation today show patient to have reconnection of one pulmonary vein with LA, which is causing the a-flutter. Another a-flutter mechanism is also identified in the RA." Should this situation be reported using codes 93656/93655 or using codes 93653/93655?
How would you report a percutaneous ultrasound-guided fine needle aspiration biopsy right axilla with post-biopsy metal marker placement? "Six aspiration passes were made with a 21 gauge needle. A cytopathology technologist was present to confirm adequacy of the samples. A spring-shaped Hydromark MRI compatible stainless steel marker was deployed through an incision under direct ultrasound visualization into the biopsied area." We have billed codes 10022 and 76942. Do you agree? Would we code for post biopsy metal marker placement? If yes, what code we could use?
95% of the patients my practice sees have chronic total occlusions. This is shown through CTAs prior to the patient being presented for the operation. The doctors thus pre-plan thrombectomies for the occluded vessels. After performing an aortagram, sometimes transluminal angioplasty, stent placement, and atherectomy are required in the femoral artery. We use 37227 for this. My question is this: Can we perform 37184 and 37185 in addition to 37227 if the thrombectomies are pre-planned? The most common vessels they perform thrombectomies on are the CFA, SFA, Popliteal, and Peroneal.
Common femoral with advancement of diagnostic catheter. Selective catheter placements second order RT common carotid artery, third order RT internal carotid artery, third order RT external carotid artery, superselective greater than third order RT ascending pharyngeal artery. We use cpt code 36224. Please help!
I have an exam that the physician selects the left renal vein for a venography and then advances the cath to the left gonadal vein. I know the selection will be a 36012, but what code whould I use for the interpretation of the gonadal vein?
When access is made in LCFA to REIA 36246 with 75710 of the Rt lower extremity. A second access is made in RCFA and angioplasty is done of the RATA 37228 from the second access site. Do we bill for the catheter placement from the first access (LCFA)? Since the procedure was done on same extremtiy as catheter placement but (sep access) I wasn't sure if billing catheter would be correct.
The radiologist states in the dictation that contrast was infused after catherization by gravity (following placement of a tube)Does that satisfy the requirements to bill 51600 CPT? Does the infusion "by gravity" change anything in regards to the coding the injection CPT 51600?
We are a group of cardiologists, we have one interventionalist. we have situations were our cardiologists consult on a patient and then on occassion call in our intervention cardiologists and 2 consults are done the same day. Is there a way we can get paid for both the interventionalist and the managing cardiologists the same day when they are trying to determine need for surgery AND surgery is not needed.
Would a balloon occlusion of the distal thoracic aorta just above the diaphram for the purpose of temporizing be coded when a stent graft is placed in the SMA for a hemorraging pseudoaneurysm d/t pancreatic carcinoma. The balloon in the aorta was deflated just before the stent was placed in the SMA. I've coded 37236 for the stent but am not sure if the balloon is included in this case since.
I thought I had this figured out but I need to clarify. I always coded a fistula anastomosis plasty to an arterial. But then reading up in your book, you state that there are both venous anastomosis and arterial anastomsis in a graft. You also state we should code arterial anastomosis or perianastomotic region angioplasty to an arterial 35475/75962. If the physician states that the angioplasty is of the anastomosis,how do you know if it was arterial or venous anastomosis? Does it matter? Do all anastomotic strictures of the fistula automatically get an arterial angioplasty code assigment?
I just recieved a referral on code 20600 small joint/bursa. The Doctor injected the navicular cunieform joint space of the foot with Kenolog and they would like me to chance the coding to intermediate joint/bursa injection. I was always taught that only the ankle joint was concidered an intermediate joint so the only intermediate joint on the foot would be the Calcaneus bone I'm I correct in my thinking?
Hi! One outpatient department performs this procedure. The patient comes in with a previously placed pleural catheter. The catheter is attached to a drainage system to drain fluid. Since the catheter was already in place, it does not seem appropriate to report CPT code 32556. Should the hospital report a low level E/M code or 32556 with a 52 modifier? Thanks in advance!
Question: Is the cephalic arch considered separate central venous zone for coding 37238? If so would this case be coded 37238 and 37239? 1. Multifocal short segment cephalic arch stenoses treated with angioplasty and telescoping stents. 2. Intra-stent venous limb restenosis treated initially with angioplasty and restenting with markedly improved luminal flow and post intervention venogram.
I have a question regarding -51 modifiers. I am billing out a 37229, 37233, 37224 for charges. Is it neccesary to add a -51 modifier to the 37224? If so, why? We are having some debate in our office.
Would it be appropriate to code 35371, 35372, 35741 for this case? Incision left groin, exposing the distal external iliac artery, entire common femoral artery, several centimeters of superficial femoral artery and well down into the profunda femoral artery as well- extensive endarterectomy of the entire common femoral artery extending well down into the profunda femoral artery. The superficial femoral was totally occluded - We divided that beyond its origin, the SFA, about 6cm distally and divided it, over sewed the distal SFA. The proximal and then the 6 cm stump was opened on its inferior surface, endarterectomized and this was used as the patch for the profunda endarterectomy. We then opened up the profunda femoral artery for several centimeters, did extensive endarterectomy of the profunda. The vessel of course was opened here and we did an extensive endarterectomy of the common femoral artery through this same access. He also did an exploration of the popliteal artery for possible by-pass but found that it was a non-bypassable vessel
Patient has a draining sinus tract from a non healing abdominal wound. Patient taken to the operating room where the sinus tract was then probed with forceps. It went about 4-5 cm deep and was narrow. An incision was made with a scalpel through the old midline suture surgical scar spanning the mouth of the sinus tract. Essentially this sinus tract was split all the way down to it's base. Halfway down we encountered the first piece of ethibond suture which was barely incorporated and easily removed. Then using electrocautery, the scalpel and Kocher clamp the subcutaneous scar was cored out and circumferentially around the sinus tract saw more fibrous material at the base and pulled on this and removed another piece of unincorporated ethibon suture. Palpating the wound we could not feel anymore scar. It was healthy tissue thoughout the entire wound bed now. The wound was irrigated, no further bleeding identified and no foriegn bodies were seen. All the tissue was healthy. Sutured deep cavity and skin. Excision and repair?
We are uncertain of the appopriate code to use when the provider describes the use of a bifurcated graft placed at the aorta with one leg of the graft anastomosed to the right common iliac artery and the other leg anastomosed to the left common femoral artery. There are three anastomoses (Aorta, RT CIA, LT CFA) thus we are unsure if two separate bypass codes would be appropriate in this case or if this may necessitate an unlisted code (which comp code would be appropriate?) Your guidance would be greatly appreciated. Thank you .
Our surgeon performed a cephalic vein thrombectomy and later performed a internal jugular vein end-to-end venous anastomosis ot the cephalic vein. How would I code the venous throbectomy and anastomosis? see below op note The microscope was brought into the field, and after the placing vascular loops to stop the blood flow through the internal jugular vein, a venotomy was created. Then, utilizing of Synovis 2.5 mm venous coupler ring, an end-to-side venous anastomosis was created from the cephalic vein into the internal jugular vein. There was excellent blood flow, and we placed a little bit of Gelfoam to bolster the vein to prevent kinking.
After the hemodynamic data were obtained, an aortogram was performed using a 4F Pigtail catheter in the standard PA/LAT projections and the fractured coarctation stent was identified and appropriate measurements made. Using a 4F angle glide catheter a super stiff Amplatz wire was parked in the distal right subclavian artery. The catheter was removed and the sheath was exchanged over the wire for a 14F x 80-cm Check-Flo sheath. An 18 x 30-cm Gore graft was mounted onto a Palmaz 4010 stent and then the entire stent system was mounted on an 18-mm x 4-cm BiB balloon catheter. The balloon was inserted over the wire and centered within the previously placed, now fractured, coarctation stent. The BiB balloon was deployed in the usual fashion, first by inflating the inner balloon, checking position, the finally inflating the outer balloon for definitive stent deployment. The outer balloon, unfortunately, burst before reaching nominal pressure but the stent was expanded enough that it did not migrate or embolize on balloon deflation.
According to your reference and previously asked questions, codes 47805 and 74305 are reported for a cholecystostomy tube check. I'm coding for a "follow-up of post gallbladder drainage" in which "scans are obtained through upper abdomen without contrast and after injection of the drainage catheter. After injection there is filling of the gallbladder." The impression was "after injection of contrast through the drain there is a small amount of leakage into the pericholecystic region." So I am told by the IR coder that in this case code 74150 should be used. However, could code 47505 also be used for the injection into the catheter? Or is code 47505 only to be used for a specific check of the tube functioning?
A stereotactic breast biopsy was attempted but on the stereotactic localization images of the breast the lesion could not be found so the biopsy was not performed. What if anything can the physician bill for?
Our neurointerventionalist performed a coil embolization of the ophthalmic artery. After the coils were placed there was a protrusion of two loops that required emergent stenting which was accomplished with a neuroform EZ stent. The doctor is trying to bill for both the embolization (61624) and the stent placement (61635). It's always been my understanding that any complications that arise during the procedure that were caused by the physician are not billed when corrected. Can you point me to something to give back to the provider regarding this? Is he correct that, in this scenario, both the stenting and the embolization are billable? Any insight on this would be greatly appreciated.
What do you suggest for the cardiologist who is performing the ECHO guidance during a TAVR? I see a code for 2015, but what do you suggest for 2014 and what type of documentation is needed.
What CPT code or codes would you use if we are performing an IR prostate artery embolization?
Please provide the correct catheter selection code for this procedure: Left groin prepped & draped & a 4 French sheath placed. Flush catheter introduced in the proximal abdominal aorta. An aortogram revealed normal aortoiliac system. Bilateral patent renal arteries and the SMA well visualized with the catheter selected into the distal right external iliac artery. Right femoral angiography revealed patent common femoral, deep femoral, and superficial femoral artery with the superficial femoral artery selected. The distal superficial femoral artery was widely patent. All 3 tibial vessels were patent with direct runoff into the foot. The catheter was removed.
The pt had Bentall procedure 2mo ago with Magna valve and Valsalva graft.Now has returned due to pseudoaneurysm of the ascending aorta.CP bypass was initiated. His previous median sternotomy incision was opened.I crossclamped ascending aorta.We entered the rt coronary button and a thrombus around the graft.Thrombus was removed.There seemed to be bleeding coming up from underneath the right side coronary button,coronary sinus and rt/lt commissure area. We then performed a transverse incision thru the previously placed Dacron graft, above the sinus of Valsalva section of the graft. There was no evidence of injury of the valve.I then cut alongside the rt coronary button down thru the Valsalva segment of the graft.It was difficult to find hole where the bleeding was coming from. I then decided to reinforce the whole area with sutures. These were placed thru the prior sinus segment, LVOT, and back up thru the sewing ring of the valve and the rt coronary sinus segment. I then repaired the sinus of Valsalva graft segment with Prolene. Then graft incision was closed.
Our hospital/neurosurgeons use fluoro in all their spinal cases. What is the instruction for charging/billing for fluoro done in the OR for these cases? It seems that cpt codes for open procedures 63001 and on, do not include fluoro. The minimally invasive/percutaneous procedures 0274T and 0275T seem like they do include the fluoro charge. If we do charge for the fluoro, would we use 77003 or 76000. Thank you very much.
What is the correct coding for a femoral acetabular impingement (FAI) exam? In our protocol, we perform a CT through the bony pelvis and proximal femurs, 3D reconstructions are created of both hips. In addition we obtain axial CT imaging through the knees to evaluate for femoral anteversion. Since this exam is primarily focused on the hips it seems most appropriate to code this as a Bilateral CT Lower Extremities (which covers the hips and knees) and include a 3D post processing component (76377). We also considered billing it as a CT Pelvis with 3D post processing component however that seems to ignore the added imaging through the knees?
All of the following is through one SVG: Physician stents the body of the SVG to RCA and also a spot in the RCA - one charge 92937. In the same setting he also stents the PDA branch of that RCA, still through that same SVG. Can I use 92921 with the 92937?
One of our doctors marked his rounding with VT ablation (93654) and another arrhythmia (93655) for the second PVC that he treated. The doctor describes these as two entirely discrete PVCs but he was aware of them from a prior outpatient study. When code 93655 was introduced we were taught that the doctor could not be aware of the arrhythmia prior to the procedure..that the other arrhythmia had to emerge during the procedure in order to get credit for the 93655. Is that correct? Should we give him the 93654 only for treating both PVC's or should he get the 93654 and 93655? The doctor also states that the source of the PVCs would be the mid LV and that PVC1 was spontaneous and that PVC2 was triggered and that Isoproterenol was infused to facilitate increased frequency of PVCs.
How would you code additional venography if MUEs for 75820/75822 is one? Do we code additionals with 75820/75822 with 59 modifiers, or use 76496? Venography below performed with heart cath. RT/LT arm venograms: Injections via peripheral IVs revealed patent axillary veins, with complete occlusion of RT/LT subclavians. SVC: complete occlusion of SVC. RIJ peripheral: Injection reveals complete occlusion at clavicle, with a network of collaterals. LT cephalic: Selective injection via left brachial sheath. Left cephalic vein enters collateral network that drains to left paravertebral plexus. There is complete occlusion of communication into subclavian vein. LT subclavian vein: With catheter in LT subclavian vein shows complete occlusion of LT subclavian vein as it passes between first rib and clavicle. Lt innom vein: Catheter advanced to LT innom vein, it is diminutive and completely occluded at SVC connection. RT innom vein: With catheter in RT innom vein it is found to be diminutive from caudal aspect of the RIJ into SVC.
I have a scenario where one cardiologist did a lhc and then during the same operative setting, another cardiologist stepped in and did a rhc. Would I bill these out separately as they were performed? Or bill as 93460-26 for both? If 93460, what modifier would I use? They have both dictated their own portion but modifier 80 doesnt seem to fit and modifier 62 isn't allowed for this px.
I was hoping you could shed some light on a case for me. A patient is brought in for an ICD battery replacement due to end of life. Prior to ICD replacement, the physician performs DFT testing with the old device to check the lead integrity. The results are normal and the physician proceeds with ICD replacement. Once the new device has been placed, the physician performs DFT with the new device. I know that CPT 93641 would be used for DFT after the replacement, but what can we use for the testing prior to the replacement? Is it appropriate to use CPT 93642 or is it possible to use CPT 93641 and 93641-59 or 93641-76?
ESRD pt w/hx of coiling of a branch vein originating from immature AV fistula w/coil migration to the RT heart. RT CFV was punctured w/ placement of 7 French sheath, pigtail cath advanced over Bentson guidewire into descending branch of LT pulmonary artery (36014), contrast injected & imaged showing coil lodged at bifurcation of descending pulmonary artery branch. A 9-15 mm EN-snare was used to capture end of coil & retracted into RT iliac vein & as it was pulled into the sheath began to unravel. Sheath removed, unraveled wire clamped w/hemostat. Maln coil mass was still in iliac vein. CFV was punctured a 2nd time, slightly higher than initial puncture. 7 French sheath was placed & coil mass then easily captured with snare & removed. (36000-59) The other guidewire fragment was cut at the skin & removed through the 2nd venotomy. Imaging confirmed complete removal of the coil. (37197) Will codes 37197, 36014, and 36000-59 accurately represent this procedure? Clinic says 36005 should be charged, not 36000-59. Which do you advise?