Knowledge Base

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Coronary artery MRI

At our facility, we are coding C8909, C8910, or C8911 for imaging of the coronary arteries only; the radiologists are NOT evaluating diseases of the cardiac muscle. The patients' orders document the diagnosis of ARVD (Arrhythmogenic Right Ventricular Dysplasia). Are we correct with our coding or should we use CPT 76498? If we are not correct, can you explain why we are not?

Coronary Grafts via Root and Subclavian

I have a coronary CABG case where the cardiologist engaged the RC and LM then did root shot for venous graft info and subclavian shot for LIMA info (B.P. cuff blown up). Would you report a graft code because he selected the subclavian?

Coronary intervention

We have a difference of opinion among our coders regarding the correct coding of certain interventional procedures. The following is an example: "Percutaneous coronary intervention was carried out on a totally occluded saphenous vein graft. Initially a balloon was used but failed to open the vein graft. Next an Export extraction atherectomy catheter was used. Provider was able to suction out some of the clot. A balloon was used to pre-dilate a lesion in the distal vein graft allowing placement of a bare metal stent." Some coders coded an atherectomy while others coded an angioplasty. Apparently the physician's use of the term "atherectomy catheter" is prompting some of the coders to code an atherectomy. Can you provide our coders with some guidance regarding the appropriate codes for the procedure described?

Coronary Intervention, Codes C9600 and 92921

How would you code for a drug eluting stent to the obtuse marginal and an angioplasy to the left circumflex? Would you report codes 92920 and C9601 since the angioplasty was in the major coronary artery and the stent is in a branch? Or, would you report codes C9600 and 92921 based on the higher intervention per coronary vessel distribution regardless of whether it is a major vessel or branch?

Coronary IVUS

This question was brought up, and I would like to have your opinion. Prior to 2013 there were only three coronary arteries recognized by CMS. Therefore, prior to 2013, you could bill 92978 x 1 and 92979 x 2 for IVUS during PCI, if performed. Now that 2013 AMA and CMA both recognize five coronary arteries (LM, LD, LC, RI (if applicable), and RC) could it be possible to bill IVUS more than a total of three times?

Coronary Sinus Venogram

How would you code this? "The pacemaker was explanted. Using a modified Seldinger technique with extrathoracic approach, subclavian vein was accessed x 1. Guidewire was cannulated. Over the guidewire, a Medtronic long sheath to access the coronary sinus was placed. The standard sheath was unable to cannulate the coronary sinus; therefore, it was changed to a wider coronary sinus sheath. The coronary sinus did appear to be cannulated. Guidewire was advanced. The position of the guidewire appeared to be far more lateral on the lateral wall of the ventricle. Therefore, a venogram was performed. The venogram showed that the guidewire and the sheath were actually into the pericardium and it perforated the right ventricle. Therefore, the sheath was withdrawn. A STAT echocardiogram was ordered and showed the presence of approx a 2.5 cm pericardial effusion. An emergent pericardiocentesis was performed. This drained 250 cc of pericardial effusion. The pocket was extended and irragated, and the previous pacemaker was placed back inside."

Coronary Sinus Venogram with Embolization of Fistula from LAD to Left Ventricle

A coronary sinus catheter is placed via left subclavian vein for a CS venogram to locate site of a fistula from distal LAD artery to what appeared to be CS, found to actually be the left ventricle. Catheter was placed into the distal LAD, traversing the fistula to deploy coils and close off the fistula. Verified results with final angiography. We reported codes 37204, 93454, 75894, and 75898. How would the coronary sinus venogram be coded?

Coronary sinus venography

If a coronary sinus venogram during an EP study reveals that the patient has an abnormal takeoff or other anatomical abnormlaity of the coronary sinus, is there a set of codes that should additionally be billed to describe these services in conjuntion to the EP study codes (ie. 93620/93621)?

Coronary sinus venoplasty

Are there any additional charges that could be billed in a BIV ICD replacement case to describe a pta of a coronary sinus that was stenosed due to scar tissue buildup from multiple LV lead revisions/replacements?

Coronary thrombectomy must be performed with mechanical device

Is the most recent news letter that was sent this month "AMA Supports ACC Position on Use of Coronary Thrombectomy Code 92973" effective as of right now? we have a vender that is disagreeing with this and stating that it will not be effective until 2012. thanks so much!

Costocervical/Thryocervical Artery Imaging

When a cerebral angiogram is performed, and they catheterize and image the bilateral internal carotids, vertebrals, and external carotids, as well as the bilateral costocervical and thyrocervical arteries, do we code for the catheterization of the costocervical and thryocervical arteries? Right now I'm looking at reporting codes 36226-50, 36224-50, 36227-50, 36217 (right costocervical), 36218 (right thyrocervical), 36216 (left costocervical), 36218 (left thyrocervical), and 75774 x 4 (arterial imaging).

Covered stent in ruptured coronary artery after DES

We had a case in our cath lab the other day that I had not seen before and I would like your opinion on the codes we used. The patient came in and had a left heart cath with left ventriculogram. Then the physician placed drug eluting stents in the RC and LC. During placement of the RC stent, the vessel was perforated. They placed a JoMed Graftmaster covered stent to tamponade the perforation. We coded the diagnostic cath and G0290-RC and G0291-LC for the stents. We couldn't find any code to use for the covered stent since we had already used G0290 for the RC. Are we correct on this or is there some code we are missing for the use for the covered stent? Thanks for your help.

CPR with Heart Cath

If while performing a diagnostic or interventional heart cath the patient requires emergent CPR, do we code for the CPR separately in addition to the heart cath procedure? Or is it considered part of the procedure?

CPT 36832 for Collateral Vein Ligations

We are report code 36832 for ligation of collateral veins off the AVF. If we have multiple cut-down incisions with more than one vein ligated, can we bill code 36832 more than once per encounter?

CPT 93463

"Left heart catheterization with intraprocedural Nitroglycerin administration with hemodynamic monitoring. A 6 French JL4 catheter was advanced into the ascending aorta. Aortic blood pressure was measured. It was markedly elevated at 220/110. The patient was administered 0.4 mg sublingual Nitro. Hemodynamic monitoring was performed. Repeat blood pressure was obtained a few minutes after Nitro administration, and blood pressure had dropped to 160/100." Can code 93463 be billed for this part of the heart cath procedure? My physician needs clarification regarding the criteria for use of this CPT code.

CPT 93623 performed after the ablation

Typically, when our physicians perform CPT 93623, it is done during the EP study but before the ablation. We're seeing a case where it's documented as "post ablation testing" and IV isoproterenol was admininistered following the ablation. Is code 93623 billable in this circumstance?

CPT 96420 for Chemoembolizations

I was reviewing chemoembolization guidelines, and it says that code 96420 can be reported per the 2014 CPT Codebook, but I always understood that code 96420 should not be reported in a facility setting for physicians (only in an office setting). I work for a cath lab in a hospital where they perform these procedures. It is considered an outpatient department for billing purposes even though inpatients and outpatients are treated there. I do charge capturing for the facility side and coding for the physician side. The physicians note in their reports that "chemotherapeutic agents were prescribed and administered by (physician name)". I have not reported code 96420 in the past or currently based on guidelines. I do use code 79445 for the Y-90 cases we do. But I've had some of the business staff and physicians asking if I'm coding this because they are doing the work, so they think it should be coded. Am I correct not to report code 96420, or should it be reported? I need some clarification on the guidelines.

CPT 96450

How would you code the lumbar puncture if the puncture is by the interventionalist and the chemotherapy injection is by the oncologist through the same access?

CPT Changes for 2014 for Imaged-Guided Breast Procedures

I have a question regarding the 2014 NCCI narrative instruction Chapter 9, subsection D, #11, and I would like to get your opinion on what this means for outpatient radiology facilities. It is regarding post procedural mammograms and that there should not be a separate charge reported when the breast procedure is done with mammographic guidance. Does this mean that if the breast procedure (biopsy or needle loc) is done by ultrasound or MRI guidance that a post-procedure mammogram can be reported?

CPT code 35875, 35876

Greetings, Would a open thrombectomy of a fem pop bypass graft be coded as 34201 or 35875? LW

CPT code 36246 75716

Can you code 36246 and 75716 when an interventional procedure is not involved?

CPT Code 37607 vs. 36832

Is code 37607 used only when the AVF is completely ligated? Example: On page 363 of your Vascular & Endovascular Surgery Coding Reference, we are directed to use code 36832 for ligation of collateral veins that are preventing maturation. If the vein in the AVF is ligated due to steal of the flow, is 36832 still the correct code?

CPT code 93432 and 93581

Can 93463 be reported with 93581? Catheterization codes (93531, 93565) are included in 93581 but our cardiologist is repairing the VSD and then doing a nitric trial with documentation of R/L heart hemodynamics. Thanks

CPT code for injection into the symphysis pubis

Good evening Dr Z, Would the following be considered an unlisted injection? Following consent, following sterile prepping and draping and under fluoroscopic guidance 20 gauge needle is advanced into the symphysis pubis and steriod with local anesthetic injected. 20999 vs 27299 I'm leaning 20999, 77002 Appreciate your thoughts, Judy

CPT code for marking chest for subsequent thoracentesis

DR. Z, I am a coder having a disagreement with another department on coding a tunneled PleurX catheter for malignant pleural effusion. The doctor writes in the progress notes " 12 pleural cath via ultrasound guidence 1600m of fluid removed. He types up a report that states "ultsonography guided right pleurX catheter placement...Ultrasonography was performed at the bedside and revealed a large right pleural effusion which was echoic in nature, suggesting blood or thick fluid. A mark was placed in the patient's chest for proper needle placement. The patient was then cleaned with ... and a drape was placed. The right pleurX cahterter was placed in the right midaxillary line. It was tunneded under the skin to about 7 mm into the chest. There was good drainage of serosanguineous fluid which was removed without difficulity. I think the codes should be 32250 and 75989 but the department insist that 78989 should not be added because the ultrasound guidence is FOR LOCALIZATION: THis is the response representing the department: I have to ask whether the procedure was actually guidance vs. localization. To report ultrasound guidance I would expect documentation to support continuous ultrasound guidance as the following Thoracic Intervention Seminar demonstrates. This particular patients procedure note only describes using ultrasound to locate a large pleural effusion.The operative report does state Ultrasonography Guided Right PleurX Catheter Placement. It may be poor physician documentation but I would imagine that it was used only to localize. Thoracentesis under ultrasound guidance is usually performed with the patient in a sitting position on the edge of the bed, leaning forward with the patient's arms resting on a bedside table. When the patient is not able to be placed in a sitting position, the lateral decubitus or supine position can be used. Preprocedural ultrasound evaluation can localize the pleural fluid pocket and skin entry site at the posterior intercostal space, which is prepared and draped in a sterile manner. A skin entry site is then anesthetized using 1% lidocaine with epinephrine. The access site should be along the superior margin of the rib to avoid the injury to the intercostal artery, which runs along the inferior border of the rib. After making a small skin incision, an 18-gauge over-the-needle sheath is then advanced into the pleural fluid under continuous ultrasound guidance." What do you think should be coded for this procedure 33251 and 75989 or just 33251? I think they are getting 75989 mixed up with 76937. Thanks so much for your website and books. I could not do my job without them!! Kelly Hill Coder

CPT Code for Radiofrequency Ablation of the Sphenopalatine Ganglion

What is the correct CPT code for radiofrequency ablation of the sphenopalatine gaglion?  I am looking at unlisted code 64999, as there is not a specific code that names this group of nerves under the Destruction section 64600-64681.

CPT Code Question How To

How would you code the following?  Stent graft angioplasty of old cadaeric vein bypass, balloon angioplasty of right anterior tibial vessel, selective angiography of right lower extremity with third order catheter placement, and replacement of infusion cath for another 24 hours.

CPT Codes 93621, 93622, and 93623

AMA has clarified information on EP coding, but CMS Transmittal 2636 conflicts with the AMA's revision, so I'm questioning if we will continue to see issues with these codes until CMS updates their information. NCCI also lists a bundling issue with codes 93623 and 93653, and I'm not sure that it would be appropriate to append a modifier to unbundle. Thoughts?

CPT codes for embolectomy and iliac angioplasty

Hello Again, I am having a hard time with this case. I am debating between cpt codes 32401 with 75710-59,37220 or 35371,37184, 37220 and 75710-59. I am helding more on 32401 codes as i see the incision and repair and a catheter is also used. for the second pair of codes i really dont see the andarterectomy 35371 done as the surgeon states. Please help as the more i read it the more confused i get. Thanks for your help.... PROCEDURE: 1. Right common femoral artery exploration with endarterectomy. 2. Right SFA embolectomy. 3. Right common femoral embolectomy. 4. Right external iliac embolectomy. 5. Right iliac angiogram. 6. Right common iliac embolectomy with over the wire Fogarty, 4 French. 7. Right common femoral angioplasty with 8 millimeter x 60 millimeter balloon. 8. Right common femoral artery repair with patch angioplasty. - SURGEON: Kin-Man Lai, M.D. - ASSISTANT: John Beemer, Physician's Assistant. - ANESTHESIA: General endotracheal anesthesia. - ESTIMATED BLOOD LOSS: 50 cc. - ESTIMATED FLUID: A liter of normal saline. - COMPLICATIONS: None. - DISPOSITION: To the recovery room in stable condition. - BRIEF DESCRIPTION OF PROCEDURE: This is a 52-year-old gentleman with known peripheral vascular disease status post right common iliac angioplasty and stenting with double stent in the past and status post left common femoral artery endarterectomy and patch angioplasty repair 2 years ago who presented to the emergency room today with a four day history of right lower extremity numbness. The patient's symptoms progressively worsened with inability to walk and pain. - The patient was immediately evaluated with bedside ultrasound which noted there was little to no flow in the common femoral artery. The patient has flow in the SFA and profunda femoral artery via collateral. The patient also has no flow in the external iliac artery. Due to these findings and history of peripheral vascular disease and stenting, the patient was deemed to have evidence of acute on chronic ischemia. The patient was then given the option to go to the operating room to have this repair emergently. The risks and benefits of this procedure were carefully explained to patient and wife in full detail who wished to proceed. - The patient was then brought to the operating room, placed on the operating room table. After adequate anesthesia was achieved, the patient was appropriately prepped and draped. We made an incision approximately 3 inches above the groin crease. The subcutaneous tissue was then dissected with cautery device. With Weitlaner in place we dissected all the way down to the common femoral vein following the epigastric branch. We also ligated the epigastric branch and saved it for patch angioplasty repair at the end of the procedure. - We isolated the common femoral artery which has no pulse. A vessel loop was then placed around each one, the distal aspect of the common femoral artery. The patient was given 5000 units of heparin. When the heparin had been in for five minutes we opened up the arteriotomy with an 11 blade, extended it with Potts scissors. We then performed a Fogarty angioplasty with #3 Fogarty down the SFA and then #4 Fogarty at the common femoral and external iliac. We were not able to pass the Fogarty retrograde past 15 millimeters. Due to these reasons, I suspected a possible occlusion or stenosis of the previous atrium stent. We therefore placed a 6 French sheath in place and used 4 French over the wire Fogarty to open up a small passage. Under fluoroscopic guidance we were able to gain access to above common iliac artery on the right side. - Angiogram with Kumpfe catheter revealed no flow into the right limb of the iliac artery. We therefore proceeded to perform over the wire Fogarty with a 4 French system. We removed a small amount of clot. At this point we did not have good flow under completion angiogram. We therefore used an 8 millimeter x 60 millimeter Admiral balloon and performed angioplasty of this stent. This was performed successfully. Post procedure we had an open channel in the common iliac. We had good flow into the right iliac and retrograde flow into the aorta and the left iliac system. - At this point, after multiple angioplasty was performed, we elected to remove the sheath and proceeded to irrigate the arteriotomy and then we paired this arteriotomy with the epigastric branch saphenous vein. This was repaired with a 6-0 Prolene. This was repaired without any difficulty. We backflushed and foreflushed the conduit and irrigated the repair area with heparinized saline. The patient has good pulse at the end of the procedure. - We then proceeded to apply thrombin soaked Gelfoam for hemostasis. We then proceeded to close the wound with 2-0, 3-0, and 4-0 Vicryl and then Biosyn. The patient's wound was then carefully cleaned off and local anesthesia was infused. DermaFlex was then used as a sterile dressing. The patient tolerated the procedure well. No complications. The patient was then taken to recovery in stable condition. - -

Creation/Closure of New Generator Pocket

"Patient had a previous ICD that was infected and removed. Several days later we created a new pocket on opposite side. We attempted to access veins, and venogram with contrast was done, which showed everything to be occluded. Procedure was aborted and the new pocket was closed." Is there a code for just the creation/closure of the new pocket?


Hi Dr Z: I was informed that one of the hospitals across town is billing for an atherectomy procedure when using a Crosser device is used to make a path in a vessel. Should we bill for an atherectomy when the Crosser is used? Thanks

Crosser CTO Recanalization Catheter

Do you know if the Crosser Catheter system has been approved for use other than atherectomy? An issue has come up with the product being used for "recanalization of an occluded vessel" prior to proceeding with angioplasty. Product has a C-code of C1714, which is going to edit since documentation only supports the angioplasty procedure. Is "recanalization of occluded vessel" enough to justify changing this procedure to an atherectomy? I don't feel that it is.

Crossing a CTO

Can you please clarify what constitutes an atherectomy for crossing a CTO? Would I bill code 37224 or 37225 for the following? "A 12 gram Cook Advance CTO guidewire was then used to try to recanalize the occlusion of the right popliteal and tibioperoneal trunk vessels. It would not pass. A miracle Brothers 3 gram guidewire was substituted and met similar difficulties. A 6 French Cook ansel contralateral guiding sheath was then advanced over a Supracore wire into the right superficial femoral artery Viabahn. Angiography was then performed, and the Miracle Brothers 3 gram guidewire was then reintroduced with use of a Trailblazer catheter for support. The right popliteal artery occlusion was then treated with percutaneous transluminal angioplasty using a 4 mm x 40 mm balloon. This was followed by exchange for the Supracore wire, using a 4 French straight diagnostic catheter. At this point, the Supracore wire was successfully advanced into the peroneal artery."

Crossing occlusions

Dr. Z, we are seeing an increase in the use of "crosser" catheters for CTO use in peripheral vessels. We now have a plethora of such catheters being brought in by various vendors (Flowcardia Crosser, CTO Frontrunner, Quick-Cross Spectranetics, etc, etc). The physicians and the techs want to code the use of these catheters as angioplasties. Last year we had discussed with ZHealth and we had been advised that these are "glorified" catheters and not to code anything additional for their use. Today I happened to be in the IR Suite and one of the reps was telling the physicians that they recommended the use of unlisted cpt 37799. Have you any updated information on these catheters and their use? What would your recommendation be? Thanks for your insight, we breathe easier knowing we have ZHealth resources to help us!

Crossing occlusions

Dr. Z, we are seeing an increase in the use of "crosser" catheters for CTO use in peripheral vessels. We now have a plethora of such catheters being brought in by various vendors (Flowcardia Crosser, CTO Frontrunner, Quick-Cross Spectranetics, etc, etc). The physicians and the techs want to code the use of these catheters as angioplasties. Last year we had discussed with ZHealth and we had been advised that these are "glorified" catheters and not to code anything additional for their use. Today I happened to be in the IR Suite and one of the reps was telling the physicians that they recommended the use of unlisted cpt 37799. Have you any updated information on these catheters and their use? What would your recommendation be? Thanks for your insight, we breathe easier knowing we have ZHealth resources to help us!

Crossing Septum for Congenital Heart Catheterization

When we do a congenital right and left retro catheterization (93531) and take sats in the LV, then later in the case they go across the ASD to the LA (and don't take sats), but go on into the pulmonary veins for pressures or angio, how do you code the catheterization???  With code 93531 or 93533? Is going across the septum for any reason cause to change to code 93533?

Crossover is now atherectomy

Bard, Inc. has apparently received approval from the FDA in August to market the CROSSER Recanalization System as an atherectomy device, equivalent to the Diamondback and Turbohawk devices. Does this change your opinion that use of the crossover catheter should not be billed as atherectomy (at least for the Bard device)? Can we now bill for atherectomy when we use the Bard crossover catheter to cross a lesion? Thank you in advance.

Cryoablation of bone tumor 20999

Please do NOT include any actual patient medical records with your question. Our physician performed a CT guided core bone biopsy of a right tibia mass. Following the biopsy a 17 gauge cryoablation probe was inserted into the mass. Limited CT images were obtained at 2 minute and 6 minute intervals to evaluate the progression of the ice ball. These demonstrated circumferential coverage of the mass. Following removal of the cryoablation probe, limited CT was performed revealing hypodensity within the region of the mass consistent with the ice ball. Sterile dressing was applied. How would you code the cryoablation portion of this procedure? Would you use 20999 or 20982? Thank you.

Cryoablation of lung 32999

Dr. Z, In the area of cryoablation of the lung, I have suggested 32999 as the appropriate code, others are stating that microwave, radiofrequency and cryoablation would use the same code: 32998. Could you please clarify this as our hospital uses your guidelines but we do not have anything in writing on this issue. Another issue that has led to some confusion is that the physician used the RFA equipment but changed the needles on the equipment to perform the cryo? Documentation reads: Two 24L cryoablation needles were subsequently inserted into the lesion. Multiple adjustments in the position of the needles were made followed by limited CT scans in full expiration were performed until correct positioning was obtained. During this process, the patient developed a moderate volume pneumothorax for which an 8 French APDL pleural catheter was placed. Intermittent hand aspiration was performed to maintain lesion targeting. One run of 30 minutes was performed to ablate the lesion. The ablation needles were then removed and the tract was ablated. A sterile dressing was applied and the pleural catheter was left in placed to 20 mm Hg of wall suction. Thanks in advance for your help with this problem, Rhonda, Ancillary Manager

Cryoablation of Neck Mass

I need your help coding this procedure. "Serial CT images of the left upper neck and chest demonstrate a large soft tissue mass corresponding to area of suspected metastasis noted on outside MRI imaging. This area was targeted for ablation. The overlying skin was prepped and draped in normal sterile fashion. After local anesthetic was given intended needle tract, 4 x Ice Rod Plus probes were advanced with serial CT guidance. Confirmation was performed utilizing CT scan in multiple planes. After confirmation of appropriate positioning, ablation was commenced. Ablation commenced with two cycles of 10-minute freeze and 6-minute active thaw. At the conclusion of this, the Ice Rod Plus probes were removed. At the conclusion of the procedure, post-procedure CT of this region was obtained, which failed to demonstrate evidence of hematoma and appropriate coverage of the lesion with the ice-ball formation. Sterile dressings were applied."

CS Catheter

Dr. Z,  93621 is the bane of my existence! Below I have two separate excerpts which I would appreciate if you could tell me equal 93621. I can't recall any situation when I have specifically seen "LEFT atrial pacing/recording". (Well, maybe one.) Additionally, is there a specific phrase or wording I could suggest to the physician that would make it easier for everyone? Or, wording that I can specifically look for? Is coronary sinus cannulation sufficient? Because he almost always says that. He is very good about documenting comprehensive EP study. 1) Quadripolar catheter placed in high right atrium. Pacing septal and lateral to the isthmus. Rapid pacing in the atrium showed Wenckebach cycle.  Coronary sinus was also cannulated and mapped. 2) Quadripolar mapping and cryoablation catheter was placed in the right atrium and the right ventricle, and the coronary sinus.  Comprehensive EP study performed.  Patient had pacing, both septal and lateral.  Rapid atrial pacing.  Pacing in the RV. I have referred to your Q&A's from 7/30/10 and 12/28/09 as well as scrutinizing the CPT description for 93621, but I still wrestle with this. YOUR HELP IS GREATLY APPRECIATED.

CT Abdomen Multiphase

Dr. Z, A question has come up about charging for a CT Abdomen Multiphase. We are charging a 74170 CT Abdomen w+w/o contrast,but should we be charging a 74178 CT Abdomen+Pelvis w+w/o because the pelvis is included in the study? For renal multiphase, we scan the 1)abdomen+pelvis w/o 2)abdomen with contrast(arterial phase)3)abdomen with contrast(venous phase) 4)delay abdomen+pelvis(delay phase). We scan the pelvis with all multiphase-liver,pancreas,renal,except for adrenals. My physician thinks we are under charging because no pelvis charge in 74170. I think we should have a CT Abdomen+Pelvis Multiphase charge-74178 for liver, renal,pancreas and a CT Abdomen Multiphase charge-74170 for adrenals. The radiologists dictate the pelvis on these cases as well as the abdomen. I just got the Diagnostic Radiology E-book, it is really helpful!! Thank you, R Mercer

CT and CTA of the chest

Dr. Z Can I code a CT of the Chest w/contrast 71260 with a CTA 71275 if the reports evaluates the lungs as well as the non-coronary vascular structures of the chest?

CT brain w/o contrast with cerebral perfusion exam

Is a CT brain w/o contrast included in a cerebral perfusion analysis exam?

CT Cystogram

My question today is how to code for a CT cystogram. We have been charging CT pelvis with and without contrast, CPT 72194. In the 2013 Diagnostic Radiology Coding Reference, it says to charge the anatomy that is imaged, but does not mention using code 51600 for the delivery of contrast into the bladder. On the Z website there is a Q&A regarding this that says to add the injection code 51600 (but it is from 2008). We are getting more and more outpatients for this procedure, so I want to make sure we are charging correctly.

CT due to Trauma

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”.

CT Guided Breast Clip Placement.

We are reporting CT-guided breast clip placement with an unlisted code. Do you agree, and what is the reasoning behind not setting up a CT-guided code in the 19281-19288 code range? Was it lack of use? No one covers this in their references.

CT guided nephrostomy placement

Dr. Z This is a CT-Guided Nephrostomy Placement question. CT is used to direct entry into the left collecting system. Left back is sterily prepped and draped. There is placement of a 17-French introducer guide and the needle is removed. Bloody urine is obtained. 0.038 Benson wire is placed through the introducer guide and the needle is removed. Over the wire a 6-French dilator is placed. That is removed. Finally there is placement of an 8-French pigtail type catheter which is coiled in the left renal pelvis and its pigtail locked. Codes 50392 and 74475 were used but the question is can we also code the 77012 for the CT-guidance? Your interventional book mentions that fluoro and ultrasound are both included but is the CT?

CT Guided Nonvascular Alcohol Ablation Lymph Node

Would code 20500 be appropriate for this non-vascular alcohol ablation? What about code 77013? Thanks for your feedback. "Percutaneous ethanol injection into the portal enlarged metastatic lymph node PET positive lymph node. Under CT guidance, Chiba needle advanced into the target lymph node. Anhydrous ethanol was injected in small aliquots with intermittent scanning to observe the distribution and position of the needle. We injected approximately 17 mL of absolute ethanol intralesionally. Particular care was used to avoid needle entry and injection into the biliary and vascular structures."

CT Lumbar Spine with CT Abdomen/Pelvis

Is it appropriate to charge for both when doing a reconstruction-reprocessing of CT abdomen/pelvis to create a CT lumbar? Some of the hospitals are charging for CT abdomen/pelvis only, others for the CT lumbar spine only, and others for both.

CT Perfusion

At our institution, CTA brain and separate perfusion analysis with Diamox challenge is performed. We've referenced your 2014 Diagnostic Radiology Coding Reference, which states to code only non-contrast CT. We're performing CTA; how should we code the study? Can you explain to us why it is or is not appropriate to code 70496 and 0042T?

CT-Guided Needle Placement for Intraoperative Biopsy

CT-guided needle placement within an expansile mass in the lateral right rib for intraoperative biopsy (Note: Patient was brought to OR. The right eighth rib mass identified and biopsies were taken. However, more tissue was needed, so partial resection was done to provide more tissues.)

CTA of the chest, abdomen, and pelvis

Hello: I am coding for CTA of the Chest-71275-26, ABD-74175-26 & Pelvic 72191-26. For 2012 new code 74174 is for bundling of the Abdomen and Pelvis. The discription in CPT does not state anything about Chest. Have you heard of any problems in regrds of billing for the chest 71275-26 with the 74174-26? This is my 1st time using code.. Thank you

CTA or MRA with catheter based angiography

Is a CT angiogram now considered an equivalent study to a catheter based angiogram? Why am I asking this question?  Well, each year I print out the NCCI written instructions, place it in a binder in the MD reading room.  I highlight and flag the different practice areas for my physicians here. This is the version that releases in Oct."XX.3."  I was looking last week for this year's release, it is not being released until December this year.  I happened to glance through it and it stated that diagnostic angiography cannot be billed if the patient has had a CT angiogram or prior diagnostic catheter based angiogram.  (Unless of course those were suboptimal images or change in patient status/symptoms).  Has this changed then in the past year or so?  I attempted to find a clarification in your 2011 Diagnostic & Interventional Cardiology Coding book, but was unsuccessful. (I trust your guidance over others!)  Recently, I am seeing more patients coming in having had a CT angio now that suggested stenosis or aneurysm. NCCI Version 16.3 Chapter 9 CPT 70000-79999- D. 4.-- 4. Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59. If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier 52 to the angiogram CPT code. If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure. It appears that I am not able to charge for a diagnostic catheter based angiogram when  a  patient comes in for a diagnostic study and possible intervention if they have already had a CT angiogram that was a complete study and they have not had any changes in their symptoms.  Do you concur? Thank you so much for your time,guidance and patience.  Every day is a new day of learning!!!

CTA prior to catheter based intervention

Am I correct in thinking that if the patient had an outside CTA of extremities and then presents to our lab for intervention, we shouldn't report 75716 in addition to 33221? Thanks~

CTA/catheter based angiogram

I know that we cannot code angiograms if the patient has had a prior catheter based study to determine the need for intervention. We are doing more CTAs and MRAs in our institution. These images are obtained with a power injection into a IV. We have not been considering this catheter based, so if the patient is in the IR suite and angiograms are done to determine the need for intervention, we have been coding them. Is that correct?

CTA/PE 71275

It is my understanding the axial data set from which 3D images are created is insufficient for reporting of a CTA study. When reformatted images are acquired and interpreted in addition to the CT axial images, the reformatted images are part of the study. We have a customer indicating they perform CTA on all PE studies - they have a Philips scanner that has a MIP button to indicate - an axial MIP with 2D MPR in the coronal and sagittal plane - or - an axial MIP (but not 3D). The directive is to code these studies with 71275. The consultant for the customer is stating, "MIPS qualifies as 3D; so long as the physician includes that in their documentation you meet the requirements for CTA." The physicians are not documenting "MIPS" in their dictations. Should these representations (2D MPR) by the customer be coded as standard CT with contrast?


Does the physician have to specifically state "CHRONIC total occlusion" to use CPT code 92943? What if they only state 100% occlusion?

CTO with Dual Injections

At our facility we have started a new CTO program. These cases are, as expected, more complex. The technique that has been adapted here is bilateral access with dual injections of both the LMCA and RCA to assess the collateral flow for a potential retrograde approach. The physician who has been doing these procedures feels that we should be able to charge something in addition to code 92943 or C9607. I have been expressing my disagreement with him. I feel that the CTO charge already encompasses the additional access and greater procedure involvement. Please advise.

Cutting balloon

Greetings! Maybe you could clear things up with a quick question. If a cutting balloon is coded in the coronary arteries as Percutaneous Transluminal Coronary Atherectomy(92995) Can't you code a cutting balloon used within a dialysis graft as Atherectomy Brachiocephalic(0237T)? Thanks, Melissa

Cutting Balloon Angioplasty

If a cutting balloon is used to do an angioplasty, do we report an atherectomy?

CVC Evaluation and Repositioning

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.

CVC into Azygos Vein

When placing a CVC line from the subclavian with an occluded SVC into the azygos system, would this be considered a central line placement?

Cyst Drainages

Patient has a macrocystic venolymphatic malformation in the neck. Drainage catheters were placed in the two largest cysts, and sodium tetradecyl was injected into the cysts through the catheters. Bulb suction was applied, and then doxycycline was injected. The doxycycline was aspirated and the catheters left to suction drainage. What CPT codes would I use, and what is the ICD-9 code for a macrocystic venolymphatic malformation in the neck?

Cystic Lymphocele Ablation with Alcohol

I seem to have a hard time grasping these sclerotherapies. I get the 37241, but I dont know what else I can code with this case. "Using ultrasound, a Chiba needle was introduced through the skin and in between the pancreas and the kidney. Small amount of hydrodissection was employed to make a space between the kidney and the pancreas. After getting past the kidney and the pancreas, the lymphatic malformation was entered. Wire was then placed since the needle into the cyst, and a 3 French portion of the 3-4 dilator was placed into the lymphatic malformation over the wire. Contrast was injected through Touey, which showed filling of the lymphatic malformation. A Rosen wire was then placed into the lymphatic malformation, and a 5 French Yueh centesis pigtail was placed over the wire into the lymphatic malformation. 24 cc of 70% ethanol was injected through the catheter, filling the cyst. Unfortunately at the very end of the injection, the back end of the malformation ruptured. We waited five minutes for the alcohol to react with the lymphatic malformation wall."

D-Stat Topical Hemostat

We would appreciate recommendation for appropriateness of charging closure device C1760 for patients with radial artery access for cardiac catheterization.  (Femoral artery, usually Angioseal or Perclose, which we do charge C1760).  Our hospital is using a Vascular Solutions, Inc. D-Stat Rad-Band topical hemostat (model 3501).  The product description says this supply "uses the science and clotting power of thrombin to stop bleeding, and is designed to prevent compression of the ulnar artery".  If this does not qualify as a C1760 closure device (even at a different cost level than the Angioseal/Perclose), is there another category to which it would be appropriately charged?

Daily Management of VAD

I had attended the 2011 Cardiology Conference in Florida in December. Dr. Dunn was one of the guest speakers and he had given us information on how to code the Ventricular assist device (VAD). He provided us with the Initial 24 hours use of transseptal VAD (0048T), Prolonged use of VAD beyond 24 hours (33999) and Removal of percutaneous VAD (0050T). I had asked Dr. Dunn if there was a code for the Management of the VAD. He wasn’t sure if we were to bill 33999 so he had asked me to contact your office. He stated that Dr. Z performs this procedure more often than he does. Any information would help.

Date of service for event monitors

Dr.Z Could you tell me what date of service should be billed for 30 day event monitors (93268)? Would it be the date the monitor was put on, or the date that the report was read. Thanks

Date of service on operative report

I have an odd question and will understand if you choose not to answer. I have one physician who refuses to put the date of service on her dictated operative/procedure reports. She insists that the DOS is not required. When I review our hsp policy regarding all physician documentation it doesn't include any reference to DOS on op report either, nor apparently does the JCAHO reference on this. The manager of Medical Records said he figured it was assumed that a dos was a reasonable data element to expect. He too was surprised to see it not mentioned. Do you have any advice on this? Thanks

Debridement vs Excision and repair

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?

Declot with Trellis, 36870

Hello: I am hoping you can verify my coding and using code 37201 for Thrombolysis of AV loop graft, total of 15 mg of TPA used in isolated system. I am looking at coding 37201,35476,36147,75896-26 & 75962-26 A small incision was made to expose graft. there was no pulse in the looop graft at all. Access was accomplished through a pursestring and wire was passed up the venous end and then venou end fistulgram was performed showing the vein stopped right at the venous anastomosisi and it appeared that there was some stenosis at the venous anastomosis. Trellis 6 sytems was performed on the venous end for 2 treatments of each 10 cm long. Then Trellis of the arterial end was performed by micro puncture through the skin. Again, an additional 5 mg of TPA for total of 15 and arteriogrm showd fairly good resuts. There was one area in the very proximal end that showed stenosis, this was done with a 6 mm x 4cm balloone at 5 atmospheres of pressure for 3 minutes. Thanks for your assistance!!

Declot with venoplasty AV shunt 36870

Dr. Z Please tell me if I'm on the right track with the following code: 36147 1st access 36148 2nd access 36870 Mechanical Thrombolysis 35476 Angioplasty 75978 S&I for angioplasty thanks, :) The venous side of the patient's hemodialysis access graft was then cannulated in an arterial direction using a 21-gauge needle and a 0.018-inch guidewire is introduced in the graft. Over the guidewire, a Cook micropuncture system is used to place a 5-French catheter in the graft. The catheter is then steered in the left brachial artery. A left brachial arteriogram is then performed. A total of 70 mL of Visipaque-300 was used during the exam. Nonionic contrast media was used because of the patient's history of renal failure. 30 mL was wasted. The graft is seen to anastomose to a high takeoff of the radial artery. There is no evidence of stenosis in the radial artery. There is no flow identified from the radial artery into the graft. This is consistent with complete thrombosis of the graft. The arterial side of the graft is then cannulated in a venous direction using a 21-gauge needle and a 0.018-inch guidewire is introduced in the graft. Over the guidewire, a Cook micropuncture system is used to place a 5-French catheter in the graft. The catheter is then steered to the region of the venous anastomosis of the graft. A small amount of contrast media was then injected. This shows 90% venous anastomotic stenosis. There is also 90% stenosis in the venous side of the graft. Thrombus is seen to extend to the level of the venous anastomotic stenosis. A metallic stent is identified across the venous anastomotic stenosis. Both catheters were then exchanged for 6-French sheaths. The patient then received 5,000 units of intravenous heparin. Mechanical thrombolysis is then performed on the graft using the Arrow percutaneous thrombectomy device. A 6 mm diameter angioplasty balloon was then placed across the arterial anastomosis of the graft and gentle balloon embolectomy and angioplasty was performed of resistant thrombus and stenosis at the arterial anastomosis of the graft.This occurs within a previously placed metallic stent. An 8 mm diameter angioplasty balloon was then placed across the intragraft stenosis in the venous side of the graft and the venous anastomotic stenosis. Balloon dilatation was then performed at several levels. A left arm arteriovenous fistulogram and left upper extremity venogram were then obtained. There is no residual thrombus at the arterial anastomosis of the graft after angioplasty and balloon embolectomy. There is no evidence of intragraft stenosis. There is no residual venous anastomotic stenosis after angioplasty. There is no stenosis identified in the left axillary vein, subclavian vein, brachiocephalic vein or superior vena cava. Both catheters were then removed and hemostasis was achieved at both puncture sites using silk suture.

Deep Lymph Node biopsy

We have 49180 for deep lymph node biopsy for all peritoneal/retroperitoneal lymph nodes. What about deep axillary or intramammary lymph nodes? If unlisted, would you use 38999 even if a clip was placed at the biopsy site?

Defibrillator device edits

Dr Z, our facility upgraded a patient that had a single chamber defib to a dual chamber defib. The single ICD was removed and then implantation of new dual ICD and new RA lead. The old RV lead was fine and retained. The model for the new atrial lead corresponds with C1898. However, this is not a valid device code for Medicare. The doctor states that leads can be compatible with both pacer and defib. Does this happen often and is there a way to get this covered under the device to procedure or procedure to device edit? Also, if you can help me understand why we have different devices for pacer and defibs if some of the devices are compatible with both generators, I would appreciate any help!

Definition of ICD Replacement Codes 33262, 33263, and 33264

I think I have been misinterpreting the definition of ICD replacement codes 33262, 33263, and 33264. My understanding of these codes was that the number of chambers explanted had to match the number of chambers implanted. In the case of a dual chamber ICD generator only being explanted and a multi-chamber ICD being implanted with use of two existing leads and implantation of a left ventricular lead, we are being instructed to use code 33264. I thought it should be reported with codes 33241, 33230, and 33225. However, I see that the CPT parenthetical notes under code 33230 for implant generator only with existing dual leads instructs us to NOT report code 33230 with 33241 for removal and replacement of the ICD pulse generator and to use codes 33262-33264 when pulse generator replacement is indicated. Code 33241 is for removal only not replacement.  Is this a misprint in the parenthetical notes?  If we are to use codes 33262-33264 in this instance, am I understanding that it doesn't matter what we are explanting, we only code by what we are implanting?

Definition of subselective angiogram versus superselective

Hello, If you can please explain for me what Subselective angiogram actually means. Does subselective mean higher than first order? In the example provided below do I have enough documentation to support anything higher than a first order? Codes 36245 or 36247, 75726 and 75774 Thank you in advance for all your help and feedback.. Here is an example: The catheter was again used to gain access into the IMA and an angiogram revealed the vasospasm had been relieved. The microcatheter was again placed and a GT 018 wire was now used. Several other bouts of vasospasm slow progress however subselective angiogram of all the LEFT upper quadrant arterioles revealed no active extravasation.

Deleted Code G0275 (Renal Angiography with Cardiac Cath)

I've been told that as of 2014 that HCPCS G0275 is being deleted and the replacement code is 75625 (abdominal aortogram). I'm having a hard time believing this, but if it's correct, do I also charge for catheter placement (36200)? And what does the physician need to dictate for reimburse of code 75625 during a catheterization?

Deletion of Code 37201

I have two questions on the following case. The physician performed imaging of the cervical carotid and cerebral imaging from a cervical carotid catheter position. He then advanced the catheter into the MCA (no imaging) and initiated tPA infusion over a period of 2.5 hrs. Since we no longer have code 37201, would this infusion be reported with code 37799? And since there was no imaging of the MCA, would you report the highest catheterization (code 36224)?

Deployment of septal occluder right pulmonary artery/pulmonary vein fistula

Deployment of septal occluder for right pulmonary artery/pulmonary vein fistula. This was performed by IR radiologist and cardiologist. I am not sure about catheter selections and what imaging studies I can charge for the IR lab. I am going to condense the actual report below. Lt. common fem venous access obtained, Grollman cath and wire utilized to gain access to rt. superior pulmonary vein cath removed for exchange length wire that was left in place. Rt. common fem venous access obtained, Grollman cath utilized to gain access to rt. pulmonary artery. Cath exchanged by sheath and the sheath positioned in rt. main pulmonary artery with AP and lat PA-grams performed. Additional angiography of rt. lower lobe pulmonary artery performed. Could not identify definitively the fistula and used wire and catheter to negotiate the fistula tract and gain access to left atrium. Lt. atrial angiography confirmed access in the lt. atrium. At this point the cardiologist entered the procedure and you have already answered my coworkers question regarding the occluder. I was thinking of using 75741, 36015, 36015, and 75774? Thank you for your help on this unusual case!

Device checks pre and post MRI

We are doing more Device checks/monitoring before, during and after MRI. Indication: MRI of the heart is indicated to evaluate infilrative disease 1.Sensing, pacing, and capture atrium, and ventricle prior to MRI. 2.Monitoring the patient during the procedure. 3.A backup of external defibrillation and/or need for alteration of pacing outputs. (The doctor dicated baseline measuremnets, thresholds, battery life...During the procedure the pt had suprasternal notch discomfort. The MRI was stopped and pt was checked by cardiologist then proceeded with MRI.) Total time involved in the reprogramming and observation of the patient and monitoring the patient was one hour. Should this be billed with the peri-proceduraldevice check codes or should we be using E/M code? or both? Thanks for any information on this.

Device edit involving C1882

Question on the procedure to device and device to procedure edits. We inserted a new system for the first time (RA lead, RV lead, LV lead, & ICD generator). We billed for cpt 33249 and we are billing the device codes of C1882, C1900, C1777, and C1898. In looking at the procedure to device edits, we pass. However, in looking at the device to procedure edit, C1882 is failing as proc code 33249 was terminated as of 1/1/12, so is no longer listed as one of the procedure codes for the C1882 device. To me, this seems to be contradictory of each other. Any suggestions????

Device Pocket Revision

How would a pacemaker pocket revision be coded when the pocket is not relocated? Since code 33222 is now only for relocation of the pocket, I am not sure how this should be coded. "The patient had a pocket revision due to painful movement of the pacemaker within the pocket. The device was removed from the capsule, and the capsule was enlarged laterally and superiorly. A Parsonnet pouch was placed over the device and excess leads. The device within the pouch was placed back in the pocket and fixed at 5 points to the underlying pectoral muscle a few centimeters lateral and superior to the original position."


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?


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?

Diagnosis codes for cardiac cath following tetralogy of Fallot repair

Dr. Z, I need help with diagnosis question.  When the patient comes in for heart cath (TOF repair in 2009) now diagnosis are RPA stenosis, MPA stenosis and severe pulmonary regurgitation. Performed both PTA of pulmonary artery and Pulmonary valve.  Since pulmonary stenosis also part of TOF is this still considered TOF even though it is repaired? Sometimes the patch/Conduit has stenosis so is this complication -996.72? Or congenital Pulmonary valve stenosis? Can we code 746.09 and V13.65?

Diagnosis coding for left and right heart catheterization

Please help with this HTC. Here is what I was thinking: 416.8, 746.89, 424.0, 93531-26. Is there anything else I can code for this? What about the mention of congential heart? or what about "both by Fick and dermal dilution multiple times"? Thank you, PROCEDURE: 1. Insertion of 7 French sheath in right femoral vein. 2. Right heart catheterization with saturations and cardiac output check. 3. Based on the results of the right heart catheterization, we did put a 4 French sheath in the right femoral artery and did left heart catheterization with a pigtail catheter. 4. Simultaneous recording of left ventricle and right ventricle for the indication of suspected constriction. 5. Simultaneous recording of left ventricle and wedge pressure for the suspicion of mitral valve stenosis. 6. Fluoroscopy of the mitral valve done in the LAO position. PREPROCEDURE DIAGNOSIS: 1. Congenital heart disease. 2. Suspected Eisenmenger syndrome. 3. Persistent hypoxemia. 4. Mitral valve disease, status post a St. Jude mechanical mitral valve replacement. POSTPROCEDURE DIAGNOSES: 1. Moderately severe pulmonary hypertension although with severely elevated left ventricular end-diastolic pressure. 2. Evidence of a 20 mm or greater resting gradient on the mitral valve. Mitral valve area calculated to 1.35 sq cm consistent with severe mitral stenosis functionally. 3. Moderate elevation of right heart filling pressures appropriate to her degree of pulmonary hypertension. COMPLICATIONS IMMEDIATE TO PROCEDURE: None noted. MEDICATIONS: Medications given during the procedure include Fentanyl and Versed. The patient was taken off and put back on her oxygen by nasal cannula during this procedure. PROCEDURE IN DETAIL: The patient was informed and consented. She was brought to the cath lab in a fasting state. Her right groin was prepped and draped in a normal sterile fashion. Her Coumadin had been held and her last dose of low molecular weight heparin was well over 12 hours ago. INR was subtherapeutic. She received some conscious sedation. It was noted that hen we turned her oxygen off to do a saturation run she promptly drops her pulse oxygenation down to the range of 84 to 87% on room air. The patient received infiltration to the right groin after it was prepped and draped in a normal sterile fashion. A 7 French sheath was introduced in the right femoral artery and a Swan-Ganz catheter was introduced from this approach. Although she is a pulmonary hypertension workup patient, I was not able to go from above due to the presence of a dialysis catheter which we did not want to disturb. Although I was prepared to leave the Swan in, the findings were not consistent with isolated systolic pulmonary hypertension but rather with secondary pulmonary hypertension due to elevated left heart pressures. Therefore the Swan-Ganz catheter was not left in at the end of the procedure. Due to the finding suggesting that she has either constriction or mitral valve disease, we went ahead and put a 4 French sheath into the right femoral artery without difficulty and introduced a 4 French pigtail catheter into the left ventricle. Left heart pressures including simultaneous recordings during wedge pressure tracing and during right ventricular tracing with dual transducer system was performed. Cardiac outputs had been performed with a right heart catheter and cardiac index was obtained both by Fick and dermal dilution multiple times. At this point in time we did a fluoroscopy of the mitral valve from the LAO position and demonstrated what appeared to be reasonably good excursion of both leaflets to fluoroscopy. Results were reviewed, sheaths discontinued and pressure applied for hemostasis. RESULTS: 1. Hemodynamic findings: Again, the patient had severely elevated biventricular filling pressures. Right atrial pressure was 35, right ventricular pressure was variable with respiration ranging between 45 and 65 over 16 to 30. Pulmonary wedge pressure was a 45 aortic the left ventricular pressure was 92 over an end-diastolic pressure that ranged between 30 and 35. Again, PA pressure ranged between 65 and 75 systolic with diastolics in the 38 to 250 range. 2. Normal mitral valve leaflet excursion to fluoroscopy. 3. Dual transudate transducer measurements do not support constriction. The patient did have repeatedly splitting of the diastolic pressures between the right ventricle and left ventricle with gentle inspiration. 4. The dual transducer measurements did suggest that the patient has functional mitral stenosis with a mean resting gradient of 20 mmHg and a calculated mitral valve area of 1.35 sq cm. CONCLUSION: Severely elevated biventricular filling pressures, left greater than right, which suggests that the patient would benefit from volume reduction and possibly may benefit from further evaluation of her mitral valve function. I would like to see if with the use of a pressor we cannot effect more aggressive volume reduction with dialysis and otherwise consider a transesophageal echocardiogram. There certainly is some pulmonary hypertension but I suspect given the magnitude compared to the magnitude of left heart filling pressure elevation this is primarily secondary pulmonary hypertension. Pulmonary will be consulted and additional contributors to pulmonary hypertension such as sleep apnea, hypoxia and anemia should be addressed, as well.

Diagnositic Angiography and what is the correct code for the selection of the catheter?

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.

Diagnostic Angiogram with Thrombectomy and Stent

Is it appropriate to charge the cerebral diagnostic angio (no prior study) when a planned thrombectomy is done that resulted in the need for a stent by applying modifier -59, as the ipsilateral study is bundled with the stent? But in the case where the stent is not a planned event, can modifier -59 be used?

Diagnostic Angiography

From a claims review perspective for interventional radiology procedures that include angiography in the CPT description, would the procedure note include documentation to support billing a diagnostic angiography procedure? It's not always clear, especially if there is no prior angiography, change in the patient's condition, etc. referred to in the note and could result in non-reimbursement of a code (which is unfortunate considering the work that was done).

Diagnostic angiography and lower extremity revascularization

Greetings, I have a angio intervention on the illiac vessel with a stent. I know this is coded as 37221. The diagnostic angio performed at the same time is what I am having trouble with. The cath is placed in the aorta and a runoff is performed with no cath movement. Then,a diagnostic inturp through the tibials bilaterally is documented. How would you code this with the new code 37221? Can you also coded a 36200 as it is through the same femoral access? Thanks,

Diagnostic Angiography and Y90 Embolization

I have a physician who insists that the angiograms performed before and after embolization are diagnostic. I have provided the following indications as to when a diagnostic angiogram would be justified based on coding guidelines: 1) decison to perform intervention based on study, 2) change in patient condition, 3) inadequate visulaization of anatomy/pathology, 4) clinical change during procedure requiring new evaluation outside of target area of intervention. The rationale I received from the physician is as follows: "THE DIAGNOSTIC ANGIOGRAMS WERE NECESSARY, AS THERE IS A NEED TO EVALUATE FOR NEW COLLATERAL VESSEL FORMATION PRIOR TO THE ADMINISTRATION OF Y-90 SIRSPHERES TO PREVENT NON-TARGET EMBOLIZATION. WE ALSO NEED TO DOCUMENT ADEQUATE FORWARD FLOW BOTH BEFORE AND AFTER ADMINISTRATION OF Y-90 SIRSPHERES. FURTHERMORE, THIS PATIENT'S DISEASE HAS STEADILY PROGRESSED DESPITE NUMEROUS INTERVENTIONS." I do not see the requirements for diagnostic angiography being met, but I would like your opinion and rationale. Can you help me?

Diagnostic angiography at the time of an intervention

My docs have asked me two specific questions after I forwarded the latest Dr Z newsletter to them: “Diagnostic Angiography at the Time of an Intervention -- your ZHealth Online Newsletter for August 15, 2011”. 1) Does this apply to all interventions equally – Lower extremity, visceral, head & neck, etc.? 2) Does this apply to Part A and/or Part B or both  

Diagnostic angiography at time of intervention

Hey Dr. Z! In 2011, a DIAGNOSTIC lower extremity angio is codeable (with a modifier) prior to an intervention correct?

Diagnostic at time of intervention with prior color flow doppler study

Please do NOT include any actual patient medical records with your question. Your guide states that diagnostic imaging (when medically necessary) is separately billable when done at the same time as LE revascularization if not recently performed but not for confirmation of a known lesion seen on prior cath-based angiograpy,diagnostic CTA or MRA. My question is, since I am not familiar with alot of these tests, if the patient had a vascular study done about a month prior and imaging was obtained using gray-scale, pulse wave and color doppler, would the diagnostic imaging at time of revascularization still be seperately billable since they had the vascular study? Would it make a difference if patients symptoms had changed or condition worsened? I'm just unclear in these kinds of circumstances and would appreciate any assistance you may be able to offer.

Diagnostic cardiac catheterization with cardiac intervention NCCI edits

Hi, It seems I am asking a question every other week now. I thought I had a good grasp on the the new Cath codes for 2011, and for the most part I still do. However I have had some Medicare denials when billing a coronary stent placement (92980-RC) in the same setting as the left heart cath (93458-26) I know as of last year when we billed a STENT or PTCA, at the same time as the cath codes, we would have to put a 59 modifier on the 93555-26, and 93556-26, otherwise Medicare would deny those two codes as included with the intervention. Would billing 93458-26 with a 59 modifier be the way I should be billing? or would this be improper. The only other code that was billed the same day was a critical care E&M code 99291. What am I doing wrong, can you please help. Thanks Jene Anderson Central Fla Heart Center.

Diagnostic catheter placement followed by intervention that includes it

Dr Z and/ or Dr Dunn: I think I am confusing myself but want a little clarification. Cath placements for diagnostic purposes and then cath placements for the purpose of the intervention in the cerebral artey(s) can be billed/coded seperately correct? This would be in the same setting/time. I am getting conflicting information and want to check myself. Thanks

Diagnostic Cerebral Angiogram

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!

Diagnostic Cervical Angio

This is my first time coding for a diagnostic cervical angio. I've done thoracic and lumbar. Are there specific codes for the cervical?

Diagnostic imaging at time of an intervention

Dr.Z, Before a Kissing Balloon and Stent placements were performed Bilaterally on the Common Iliac Arteries, an Abdominal Aortogram with the catheter positioned above the bifurcation for a Bilateral Lower Extremity Run-off Angiogram. In a case like this with intervention in the Common Iliacs, would 75625 and 75716 still be reportable? There were findings and interpretation provided for the abdominal aortogram and extremity angiograms.

Diagnostic Imaging for Splenorenal Shunt Outflow Venography

Would you please guide us through coding this case?  What would be the correct diagnostic code for splenorenal shunt outflow venography? The report is included below: SPLENORENAL SHUNTOGRAM AND GASTRIC VARIX EMBOLIZATION (BRTO) CLINICAL INDICATION: Portal hypertension with spontaneous splenorenal shunt and large gastric varix. The patient has developed refractory encephalopathy. Right common femoral vein accessed. Selective catheterizations of the left renal vein were performed with a 5 French multipurpose catheter, which was ultimately manipulated into the splenorenal shunt outflow vein (36012), and venography was performed (75887) OR (75810). A 16 mm x 4 cm Atlas balloon catheter was then positioned across the splenorenal outflow into the left renal vein. The balloon was inflated, and contrast was injected. Venography revealed opacification of a gastric varix with a couple of small veins extending toward the gastroesophageal junction. The splenorenal shunt was occluded with the inflated balloon.with the balloon inflated, embolization was performed with foam (37204, 75894). A total of approximately 25 mL of foam was delivered until complete opacification and stasis in the gastric varix was noted at fluoroscopy.The inflated balloon and introducer sheaths were then fixed in the right groin, and a sterile dressing was applied. The patient was transferred to the PACU in satisfactory condition with no complication. FINDINGS: Balloon occluded shuntogram reveals opacification of the large gastric varix projecting over the medial aspect of the gastric body. No collateral flow into the IVC nor portal vein is appreciated. IMPRESSION: 1. Large gastric varix emptying into a spontaneous splenorenal shunt to the left renal vein. 2. Successful gastric varix embolization 3. Followup venogram will be performed in 4-6 hours. Following routine sterile preparation and local infiltration with 1% lidocaine around the indwelling 9 French right transfemoral venous sheath, injection of the occluded balloon in the splenorenal shunt demonstrate stasis alongside the gastric varix cast (75898).The balloon catheter was then slowly deflated and withdrawn, with no evidence of washout from the gastric varix. The left renal vein remains patent with brisk antegrade emptying into the inferior vena cava. IMPRESSION: Successful occlusion of gastric varix and spontaneous splenorenal shunt following BRTO.

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