Knowledge Base

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CTO

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

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????

DFT TESTING

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?

Diagnosis

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.

Diagnostic nephrostogram

I have a guestion as to when a study is diagnostic in nature. We currently have a disagreement as to when to code for 47500 and/or 50390.The patient is referred to the radiologist for either a neprostomy catheter placement or a internal/external transhepatic stent placement . The report states that the patient has a stricture and needs a tube placement. The radiologist performs a 47500 or 50390 prior to placing the catheter with I want to code. In the sample below I am coding to 50390 as I see this diagnostic (Findings) and not just for localization. Any feedback would be appreciated.Would this be a diagnostic in nature? I guess my question is if the patient is scheduled for such procedure is any finding not codable? Will give an example: My CPT codes would be: 50390-59, 74425-59, 50392, and 74425 CLINICAL HISTORY: Reason: recurrent cervical cancer s/p posterior exenteration on 7/12/11 at LAMC, progressive right hydro with acute renal insufficiency, please place right percutanous nephrostomy tube, thank you OTHER MEDICATIONS: 1% lidocaine,1mg of Versed and 2mg of Morphine. CONTRAST: 20 ml of Visipaque 320. FLUORO TIME: 78 Seconds PROCEDURE TIME: 30 minutes of conscious sedation monitored by the radiology nurse J. Rigo, RN. FINDINGS: Following careful explanation of the potential risks and benefits of the procedure with the patient and/or family member , oral and written informed consent was obtained. The patient was placed prone on the angiographic table and RIGHT flanks were prepped and draped in the usual sterile fashion. Local anesthesia was achieved with 1% lidocaine. Under ultrasound guidance, a permanent image was recorded, a 22-gauge AccuStick needle was advanced into the lower pole calix of the RIGHT kidney. The stylet of the needle was removed and clear urine returned. Contrast was injected which demonstrated mild hydronephrosis. An 018 wire was inserted and the needle was exchanged with a 5-French dilator. The 018 wire was exchanged with a 035 wire. An 8-French nephrostomy catheter was inserted. The catheter was secured to the patient and connected to a drainage bag. Patient tolerated the procedure well and was discharged from the department in stable condition. IMPRESSION: Successful insertion of RIGHT nephrostomy catheter without apparent complications.

Diagnostic Nephrostogram When Doing Stent Placement and Tube Change

I have a chart where the doctor is stating procedure reason is "to place internal stent". The history says, "Patient returns for diagnostic antegrade pyeloureterogram and stent placement." The dictation says, "The contrast through existing tube. Cath was cut and removed. Fluoroscopy confirms uretral stone. Double J stent placed, new percutaneous catheter was placed, contrast confirmed position, and tube placed to gravity drainage." (I am shortening this a lot.) In the findings, doctor says pyelogram shows decompression and dilation of ureter, 1 cm stone that has migrated, ureter is obstructed at the level of the stone, and calcified uterine fibroid noted in pelvis. I know I can report codes 50393/74480 and 50398-59/75984, but is this enough info to also report codes 50394/74425?  Your book says it has to be diagnostic to be coded, and I feel this is diagnostic, but I'm not sure. Can you explain what I need to look for to be able to code diagnostic grams?

Diagnostic or screening mammogram when only one breast is symptomatic

Please do NOT include any actual patient medical records with your question. We have some confusion on how to charge for mammograms on patients where one breast is asymptomatic and the other breast is symptomatic. If physician orders a unilateral diagnostic mammogram and unilateral screening mammogram because a patient has symptoms in one breast and it is also time for the other breast to be screened should change the order to a bilateral diagnostic exam? I have always been under the impression if one breast is asymptomatic that the exam automatically becomes a diagnostic bilateral exam to compare breast tissue. Also, if a patient has had prior unilateral diagnostic exams for an area that is being watched or a past biopsy and that breast is due for a six month followup unilateral diagostic exam but, it is also time for a screening exam on the other breast can we then charge for unilateral screening mammogram and a unilateral diagnostic mammogram or should that also be a bilateral diagnostic exam? Thank you for your advice! Sorry if the

Diagnostic Test 75710, Medicare Guidelines

I thought that in your book you referenced Medicare guidelines regarding diagnostic test (75710) done the same day as an intervention. But I can't seem to find it. I need to show one of my doctors that it does indeed come from Medicare and not something I made up.

Diagnostic Venogram with IVUS and Stent across multiple Veins

Documentation shows both a diagnostic extremity venogram and venacavagram, as well as IVUS of the external iliac, common iliac, and vena cava. Can both be coded together? Also, he states a stent is placed across the external iliac, common iliac, and vena cava. The vena cava is normal, so I am thinking it's a bridging stent and to code only the stent for one common iliac vessel; although, he says he starts to see narrowing in the external iliac. "Duplex US to puncture the greater saphenous vein at the knee antegrade to place 10 French sheath. Catheter into the femoral vein, venogram with digitlal subtract tech fluoro contrast showed normal anatomy. Vena cava looked patent. IVUS up the femoral vein into the external iliac vein and started to notice some narrowing then in common iliac vein narrowing going down to 4 mm. Vena cava normal at 18 mm. Wall stent placed 12 x 90 into vena cava across common iliac vein into external iliac vein. IVUS shows resolution of narrowing."

Diagnostic Venography at Time of Venoplasty

My question is regarding the S&I codes for venography (75820) with venoplasty when both venography (75820, 76011) and venoplasty (35476, 75978) are performed in an outpatient acute care facility. We are coding for the facility. I have an edit for venography code 75820 being included in 35476. Is it appropriate to report code 75820 with a -59 modifier if no prior venography has been done?

Diagnostics at time of intervention

Hello! We listened to your 2011 IVR Updates webinar last week and heard that we cannot code diagnostic angios if the patient has had a prior catheter based angiogram. Our question is since CTA, MRA and vascular ultrasound are not catheter based, we're assuming that we can code for diagnostic angios even after these procedures. Would this be correct?

Diagnostics at Time of Intervention

I was taught that if an intervention was done after venography and access I should code only the intervention. I seem to have come across some confusion with this. I think I understand that if intervention was done on one leg, and just venography done on the other leg, I can bill the venography for the other leg separately, and just the intervention on the other extremity. Can you please give me some guidance as to how these are to be billed?

Dialysis Fistula

I am new to IR coding. I have an operative note for a fistula to the radiocephalic for dialysis. It looks like they did an anastomosis. Please help with the correct CPT and ICD-9 procedure codes.

Dialysis graft aneurysm repair

greetings, A Pt has a old dialysis graft not functional for over a year as it was ligated. It develops a aneurysm. The physician excises the aneurysm and ligates a posterior branch running alongside of the graft. Would this be 35011? Thanks, LW

Difference between a device interrogation and a device programming

Please do NOT include any actual patient medical records with your question. Could you please clarify the difference between a device interrogation and a device programming? When our Docs do a device check,93279-93281 and 93282-93284, I am being told that when the doc does the check he will make changes to the device, i.e. check the impedance level and parameters, to check it and then set the program back to the original setting, and this should be considered a reprogramming, CPT codes 93279-93281,93282-93284. I have also been told that these codes depend on whether or not the doc made changes to the final programming of the device, if he changed it from the original setting prior to the device check. I also was under the impression that If the doc did a check and made no changes to the device, "the final program" that this would be considered an interrogation of the device and to use 93288 or 93289.Your input on this would be appreciated. Thank you! Rick

Difference between codes 34201 and 35371 or 35372

I am wondering how this should be coded....we have had many a discussion on the difference between the two codes of 34201 and 35371 or 35372. We were hoping you would be able to clarify the difference. The procedure is as follows: 7 cm incision was made just below the inguinal ligament...dissection was carried distally to the deep and superficial branches of the common femoral artery. A puncture site was noted with clot coming out of it...arteriotomy made through arterial puncture site..clot was removed. Fogarty catheters were placed....no more clot was retrieved. The arteriotomy was closed with a Hemashield patch in both directions with 6-0 Prolene suture allowing backbleeding and forward bleeding before tying the last stitch.

Differences between 76937 and 76942

Can you elaborate please on when it is appropriate to report codes 76937 and 76942? Can these codes be reported by both the hospital and the physician when ultrasound is used to to locate vascular access? From the facility side, we report 76937 when placing central venous access devices, such as dialysis catheters. The Interventional Radiologists also frequently use the Sonosite ultrasound device to locate vascular access during lower extremity diagnostic and interventional cases and fistulagrams. Is it appropriate to report 76937 for the routine use of the Sonosite during cases other than central venous access cases? (Provided that images are saved and ultrasound use is documented in the dictation). The physician coders and the facility coders are trying to be sure that we have the correct practices in places in regards to these codes. Thank you so much!

Dilation of Tract for Nephrolithotomy

We need your help, as we are seeing conflicting guidance on the use of code 74485 on the day a lithotomy is performed. If the patient has existing access and the tract is dilated by the IR doc, but the nephrolithotomy is performed by a different physician, can code 74485 be reported? Or is that still bundled with the nephrolithotomy? Or is it more appropriate to report code 50398, 75984, or 50387 for the IR doc (depending on the position of the sheath) or if the tract isn't dilated?

Dilation of vein with sheath for PICC add -22 modifier

I researched the Q&A list. I would like to know if a venoplasty is appropriate under these circumstances? I know that in several non-vascular dilations, it is acceptable to use a balloon or a dilator. But is that true for vascular angio/venoplasty? He says, "A 7F dilator sheathe was then placed and the venogram performed via the sheath. Narrowing of the proximal subclavian vein was noted. A 7F dilator was then advanced over the .018 wire, through the level of narrowing. A 6F dual lumen PICC line, measuring 40cm in lentgh, was then advanced over the guide wire through the area of previously noted narrowing, with the tip positioned at the junction of the SVC and right atrium. Impression: Successful venoplasty, proximal right subclavian vein as discussed above. Coded as 35476,36569,75978, & 77001 Thank you for your consideration.

Dilation with fogarty balloon for fistula creation

The patient came for possible creation of AV graft. No prior mapping was done prior to arrival in OR. A venogram was performed via direct puncture. Venogram showed several areas of stenosis within the cephalic vein; however, decision was made to proceed with PTA of cephalic vein prior to creation of brachiocephalic fistula. Dissection was carried down to the cephalic vein and vessel exposed. A Fogarty balloon catheter was used to dilate the vein. Following successul angioplasty, the fistula creation was completed. Would it be appropriate to code the open PTA (35460) and the venogram (36005/75820) separately or are these considered part of the AV creation? Thanks in advance for your assistance.

Direct Access Sclerotherapy AV Malformations

Your February 2014 Q&A answer to the question on sclerotherapy for lymphatic malformation was not to use an unlisted code for this type of embolization in 2014. Would this also apply, for example, to direct access for sclerotherapy (i.e., facial AV malformation - 37799/37242)? Would I also report unlisted code 36299 for direct access if 37242 is to be used?

Direct Access Sclerotherapy AV Malformations, Face/Head

This is a follow-up question from Question ID# 5436. You mentioned in your answer that "we may still need to utilize an unlisted code 37799 for facial direct access venous and lymphangiomatous malformation therapy" for direct access sclerotherapy of facial AV malformation. You didn't like codes 37241 or 61626, but recommended code 37799. Have you heard different? Is your recommendation still to use code 37799? Also in the same coding scenario, would you use code 36005 or 36000 for venous access for AV malformation treatment of the face?

Direct needle stick into a non-vascular lymphatic system for treatment

Hi Dr Z, I need help with coding this case. The diagnoses are Lymphatic leak/cholothorax. Bilateral cutdowns were done on the dorsum of each foot, lymphatic channels were cannulated and Ethiodol was slowing injected for 1 hour with fluoroscopy used to observe lymphatic flow. Diagnostic lymphangiogram under fluoroscopy of the pelvic, abdominal, thoracic and neck areas was done. Extravasation was noted at the L1/L2 level. The abdomen was prepared. Using direct stick technique under fluoro guidance the area of extravasation was directly studied. Embolization was then performed using nBCA. Is 37204 appropriate here or should an unlisted lymphatic code be used?

Direct Puncture Embolization of AVM in 2014

Reading through your 2014 Interventional Radiology Coding Reference, you state to use code 37241 for treatment of a true venous malformation (via direct puncture or leg vein access). We are wondering if we can use code 37242 for direct puncture embolization of an AVM or aneurysm, or is it still an unlisted code in 2014?

Direct Puncture Embolizations

One of our doctors does a number of direct puncture embolization procedures under fluoroscopic and ultrasound guidance. I'm using code 37799, unlisted vascular surgery procedure, with codes 77002 and 76942 for the guidance. Is it appropriate to code both ultrasound and fluoroscopy with the unlisted procedure code?

Direct Puncture Therapy

Here is a procedure that was performed that I need some assistance in correctly coding. These unusual procedures can get very confusing.  DEVICES UTILIZED: Two separate 21 gauge micropuncture needles were utilized. PROCEDURES: 1. Ultrasound and fluoroscopically guided percutaneous access into the venous malformation in two separate areas. 2. Percutaneous venography of the venous malformation, times two. 3. Injection of Sotradecol into the lesion, three separate times, ten minutes apart. Using sterile technique, local anesthesia, general anesthesia, ultrasound and fluoroscopic guidance, two separate 21 gauge needles were placed within the lesion. Injection of contrast material was performed, demonstrating the extent of the filling of the lesion. The contrast material was then allowed to drain and the volume was replaced with Sotradecol. The Sotradecol was allowed to stand for ten minutes before attempting to remove it and reinjecting the same space with Sotradecol. This was performed twice from the first needle position and once from the second needle position. At the termination of the procedure the needles were removed, and band-aids were placed over the skin puncture site(s). The patient tolerated the procedure well, and no complications were encountered during or immediately following the procedure. FINDINGS: The first injection from the first needle placement demonstrated excellent filling of the lesion, representing the majority of the lesion, with a multi-lobulated appearance. The venous drainage was into an external jugular branch draining inferiorly. The second injection was in the most superior part of the lesion, filling the superior third. Venous drainage was as outlined above. IMPRESSION: Good filling of the lesion was achieved with Sotradecol, for purposes of sclerotherapy of the venous malformation within the substance of the left masseter, as described above.

Direct thrombin via needle into hepatic aneurysm

Dr Z. and all, wondering if you could recommend how I would code a CT guided percutaneous thrombin injection of a right hepatic artery pseudoaneurysm? Which was un-reachable via the common femoral artery. Thanks

Discontinued galactogram

If a patient comes in for a Galactogram (77053, 19030) and the radiologist cannot to get into the duct, can we charge due to the amount of room time, tech time and radiologist time and supplies. The biggest difference between these to me is that this patient has had invasive procedure done before they have to stop the exam. How would you code this?

Discontinued Procedure, PCI of CTO

When a patient is in for a planned staged intervention on a chronic total occlusion, and the physician is unable to cross with a wire after a prolonged attempt, do you recommend coding 92943-74 or 92920-74? The reason I’m asking is in the past you’ve recommended using the lowest level intervention when it’s aborted for this reason. The code for a chronic total occlusion is weighted much higher for the facility, the same as a stent or atherectomy. Should we use the lower weighted intervention code for an angioplasty instead?

Discontinued Stereotactic Breast Biopsy Procedure

Good afternoon. How would you code the following scenario? Would modifier -73 or -74 be appropriate to report in this instance since this is a radiology procedure? Would the modifier be applied to the RS&I or surgical component or both? "An attempt was made to perform a stereotactic biopsy. The calcifications could not be localized with stereotactic technique. The biopsy could not be performed. The patient understood the explanation. The microcalcifications may have to be biopsied with needle localization technique."

Discontinued TIPS procedure

I am not sure how to code this discontinued TIPS procedure. When I look at valid modifiers for 37182, I do not see -73, -74, or -52 modifiers as being okay to use. Should I code this as a diagnostic study and use codes 36011, 75889, 36481, and 75887? Condensed version of procedure: "Approach from right internal jugular. A 5 French multipurpose catheter was placed used to obtain pressures in the right atrium, after which it was manipulated into the hepatic IVC where another pressure was obtained, and then into the right hepatic vein for free and wedged pressures. Several passes into the liver were made with a needle wire and 5 French catheter. The right portal vein branch was entered, but the wire could not be manipulated peripherally into the left lobe. After exchanging multiple caths a stiff glidewire was placed into the more central right portal vein but was not able to cross into the main portal vein. Contrast injection showed filling defect within the main portal vein. Wire, catheter, and sheath were removed, and hemostasis was obtained."

Discontinued vertebroplasty

The patient was positioned for the procedure on the scanner, and scout images obtained for CT-guided vertebroplasty.After establishing pulse oximetry, BP and EKG monitoring by the radiology nurse, moderate sedation with Tordal and Fentanyl was administered. My intra-service time was less than 30 minutes. Despite the administration of IV pain medication as above the patient could not tolerate the positioning for the procedure. He demanded that we stop the procedure. It was therefore terminated, before any steps of the vertebroplasty were initiated. This is an outpatient. Could we use a modifier 74 for this?

Discrepancy between Order and Radiology Exam--hospital billing

I have run across a couple of situations (post-discharge) where the order and the radiological exam do not match exactly. For instance, a patient came in through the ED with pain that radiated from her abdomen down to left leg with history of pelvic fx last year. Pelvic x-ray was negative and lumbar x-ray w L3 fx indeterm age. So, the physician ordered MRI. The computerized order was for “MRI Lower Extremity Joint Left WO Contrast” (CPT 73721). It doesn’t look like the physician was actually looking for joint pathology. So, based on medical necessity, and the MRI report makes no mention of joints (mentions no fem neck fx or pelvic fx, etc.), it looks like the order should have been for non-joint (as in 73718 or 72195). Ideally, this order should have been corrected at the time of service. As this issue has been found after the procedure was provided and the patient was discharged, what is the best way to compliantly handle this situation? Code 73721 has been denied for medical necessity, and I would like to re-bill this with code3 73718, as this appears to be what the order should have been.

Disruption of left femoral-popliteal bypass graft and left femoral artery pseudoaneurysm

Propaten bypass graft placed from external iliac artery to fem-pop bypass graft at midthigh. All incisions closed. New incision to expose common femoral artery pseudoaneurysm. Lumen opened 1 liter of blood lost. Ligation ofcommon femoral, profunda femoris, superficial femoral. Proximal end of fem-pop bypass graft separated from previous patch graft. Patch graft resesected and sent for culture and suture ligated. The proximal portion of the fem-pop bypass graft avulsed from leg and proximal portion removed intact and sent for culture. 35665? 37618? ?????

Dissection and 37221

Does the dissection below justify 37221 ? I have 34802,34812-50, 75952-26, 36200-50 with no true extension? Could you please advise? Bilateral groin incisions were created and we dissected down to the common femoral artery. We gained proximal and distal control and heparinized the patient with the appropriate amount of heparin. We cannulated each artery with large bore needles and inserted wires into the suprarenal aorta. Wires were switched out appropriately with a guide caths and placement of a stiff wire. We planned for deployment of the Medtronic Endurant stent graft, main body through the right limb and contralateral limb being managed by Dr. Kunstmann. We performed angiography and identified renal artery orifices. We planned for deployment of the stent graft in an infrarenal artery location and using spot fluoroscopy, we deployed the stent graft in an AP cross limb fashion. The contralateral gate was cannulated from the left lower extremity. Left lower extremity was measured to length with pigtail and fluoroscopy and when we had appropriate length, the left lower extremity or contralateral limb extension was placed by Dr. Kunstmann and brought down to the internal, external iliac junction. We deployed the remainder of the main body and limb into the right common iliac artery. ** There was a small area of dissection with aneurysmal dilatation that we felt needed to be covered and, therefore, we brought an atrium stent into the case and placed it into the sheath and further into the common iliac artery and deployed the atrium stent which was 8 x 38 stent, but ballooned up to a 12 balloon proximally.** Once this was complete, we used a Reliant balloon and ballooned as usual the proximal and distal extensions and gait junctions. Then we performed completion angiography. Completion angiography was satisfactory and; therefore, we removed the wires, catheters and sheaths, repaired the common femoral arteries with 6-0 Prolene suture in a running fashion.

Distal Aortogram

"Procedures Performed: 1) Left groin access under ultrasound guidance. 2) Bilateral lower extremity angiography with distal aortogram. 3) PTA and atherectomy of right CFA and proximal SFA. 5) Intra-arterial nitroglycerin and Mynx device closure for left groin. 6) Selective catheter placement in the right CFA and angiography." I reported this with codes 76937, 75716-59, 37225, 36247-59, 37202, and 75896. I am not sure about distal aortogram. What code should I use for it?

Documentaion for left atrial pacing and recording

When billing for left atrial pacing and recording (93621) what documentation should be present? Is the mere mentioning that the wire is placed in the coronary sinus enough to bill this code, or should there be mention of the findings of the left atrium stimulation be present in the documentation? Thank you, Ana

Documentation

Got a question for you¦ I have a case here where the patient is coming in for angioplasty/stenting of the right common iliac artery (DOS 1-14-2010). The patient had a prior CT angiogram 11-13-2009 which was mentioned in the H&P and I did review the actual report. Essentially the same findings are seen in the prior study as what is seen in the current study; and there is nothing said by the MD that really gives medical necessity for a repeat study. I do believe that this is pretty cut and dry that the repeat study cannot be reported. However, my question is can the selective catheter placement still be reported even though the angiography is not going to be reported? In this case the right femoral was the puncture site. He takes the cath to the abdominal aorta for aortogram, then up and over to the left common femoral artery for left lower extremity angiography. At this point the cath placement is at 36246-LT. Then, he comes back to the right side, does injection for run-off, and performs angioplasty and stenting of the right common iliac artery. (If there had not been any angiography performed (or angiography of the right leg only), there would be no selective catheter placement; as the right side was the puncture site, and the right common iliac was the vessel intervened upon. The catheter placement code would be 36140-RT just for the puncture.) I am confused about whether to report the 36246-LT. Should this still be reported (even though the diagnostic study is not being reported)? I canâ?Tt find a specific resource to back that up. I looked in the Dr Z book and on the Q&A site. What do you think? Any guidance would be greatly appreciated! Pat  

Documentation

Do you have any material published or available that explains how the procedures need to be documented? Is there specific verbage necessary? Are there any CMS guidelines stating specifically what they are looking for in a cath lab procedure report? Thank You

Documentation

Dr. Z, In the description of Procedure portion of a Left Heart Cath an Abdominal Aortogram with runoff is described. But that's it. There is no description of the renals or legs. I've requested an addendum asking for the findings for the Abdominal Aortogram and runoff as well as the reason for it (medical necessity). In his addendum it only included the "uncontrolled hypertension" as the reason. For the purpose of any potential future audits, shouldn't there be 'findings' of the abdominal aortogram and runoff describing the condition of the renals, abdominal aorta, and legs?

Documentation concerning selective

DR Z, This may seem like a simple question but I have a physician that wants to charge a Selective Bilateral Renal Angiogram (36245-50) based on the following Documentation. What do you think? PROCEDURE PERFORMED: Aortic angiogram and bilateral selective renal angiography. INDICATIONS: History of PTA of the renal arteries bilaterally in the past along with resistant hypertension. PROCEDURE: After the patient was prepped and draped in a sterile fashion the left groin was infiltrated with 10 cc of 2% lidocaine. Access into the LSFA was done using 6-French arterial sheath. After images were obtained and hemodynamics were measured, an attempt was made to place a 6-French Angio-Seal. The artery was felt to be too hard and we had a little bit of trouble pushing the Angio-Seal so this was stopped. Manual pressure was applied. The patient tolerated the procedure well and left the cardiac catheterization laboratory without complications. FINDINGS HEMODYNAMICS: AO is 180/80. AORTOGRAM: An aortogram was done in an AP position. Diffuse atherosclerosis was noted. Both renal arteries were seen. LEFT RENAL ARTERY: The left renal artery shows moderate 30-40% proximal stenosis. RIGHT RENAL ARTERY: Right renal artery shows a 20% mild renal artery stenosis. SUMMARY: 1. Mild right renal artery stenosis. 2. Mild to moderate left renal artery stenosis. RECOMMENDATIONS: Medical treatment I only coded this as a non-selective aortogram (36200) and he says there is documentation based on the "Procedure Performed" listing. Please Advise.

Documentation for a LHC

To code a left heart catheterization there must be documentation that hemodynamic measurements were performed. If the doctor documents: HEMODYNAMIC DATA: The hemodynamic data obtained from the left heart was normal Is that sufficient to code the catheterization or does the doctor have to give the actual measurements?

Documentation for Catheterizations

For a left or right heart catheterization, my physician is currently documenting the following: "Access was obtained from the right femoral artery, and a left heart catheterization was done using standard guide wire approach using standard Judkins catheters." For correct coding guidelines, should the physician be more specific in stating where the catheter goes? Such as stating the complete path of the catheter through the femoral, iliac, aorta, and over the arch into the left marginal artery? Would this have anything to do with ICD-10 -PCS coming?

Documentation for Double Contrast UGI

A report for a UGI stated: "A normal swallowing mechanism was noted with free passage of barium through the esophagus and into stomach. There is a small hiatal hernia with trace gastroesophageal reflux. The stomach is distensible throughout. Visualized gas mucosal was unremarkable." Is this enough documentation to support code 74246 for a double contrast UGI? I was told the "visualized gas mucosal" indicates the air contrast.

Documentation for Endarterectomy

My doctor reported thrombectomy from beginning and throughout the report, but I think a couple of words at the very end of the report may have changed the coding from a thrombectomy to an endarterectomy. Does this limited documentation support reporting code 35371? "Incision overlying the femoral vessels... dissected out the common, superficial, and profunda vessels. Controlled vessels... arteriotomy extensively on the CFA and extended to the SFA. Fogarty catheter was placed, retrieving thrombus from the distal SFA out of the arteriotomy… thrombectomized the profunda vessel - flushed all the thrombus and clot out of the proximal CFA and actually endarterectomy of the CFA was also done with some degree of endovascular plaque disease, typical of atherosclerosis as well."

Documentation for Right Heart Catheterization

The cardiologist has reported a right heart catheterization (93451) for this procedure, and I'm not sure if his documentation is adequate. The report reads: "The right femoral vein was accessed using the modifier Seldinger technique. I then attempted to use the Edwards pulmonary catheter, but it would not cross into the pulmonary vein. I then switched to the 7 French Arrow catheter. After manipulating for about 5 minutes, I was able to cross into the pulmonary artery. At this point, this was placed in the pulmonary artery, but it would not wedge. I was able to get pulmonary artery pressures with this and then subsequently able to get PA and RV as well as SVC, IVC, and right atrial pressures." Can I assume he went through the tricuspid valve since he went from the pulmonary vein into the pulmonary artery?

Documentation guidelines on performing biopsies

Where can I find documentation guidelines on performing biopsies? For example, does the body and/or impression need to state whether a core biopsy or and FNA was performed? Can the decision to code either a core or FNA be determined from the size of needle used? If you can reply asap, I would very much appreciate it!! Thank you for the assistance!!  

Documentation Issue, Paracentesis with Catheter Not Removed

We would sure appreciate your advice. We have a physician who performs paracentesis with an angiocatheter. She does not feel that is necessary to document that the catheter was removed at the end of the procedure because she states that "it is common sense that an angiocatheter cannot be left in the belly". Can we report this to as a paracentesis with code 49083, or do we need to use code 49406 because the documentation doesn't reflect that the catheter was removed? We also have a similar situation with a thoracentesis. She doesn't document removing the catheter (angiocatheter), and she is tellling us that "if she doesn't state it was sutured to the skin then she removed it". Please advise.

Documentation IVUS

Good Morning Dr Z! My question has to do with documentation of IVUS. If the physician states that he passed the IVUS catheter thru the right common femoral vein, external iliac vein, and inferior vena cava and took images,but only reports what was found in the common femoral and external iliac, should I report 37250, 37251, 75945,75946 or 37250,37251 x2, 75945, 75946 x2?

Documentation of aorta for use of 75630

Please do NOT include any actual patient medical records with your question. Hello Dr. Z, I have a physician who dictates abdominal aortogram performed, along with unilateral or bilateral peripheral angiogram. However, findings start with the iliac arteries and proceed down the leg. Does a description of iliacs support 75625, or do I need to have a description of the abdominal aorta or renal arteries to support 75625? I have been coding 75710 or 75716 unless there are findings describing the abdominal aorta or renals, at which time I code 75625 along with 75710 or 75716. Thanks!

Documentation of Cerebral Angiography

We have a question concerning documentation. Is it enough to charge for fluoroscopy during a VAD insertion when the fluoroscopy is only documented in the list of procedures and not mentioned in the body of the operative report? Also, is the following sufficient to charge? Again, the actual selective vessels are listed at the top of the report, with the “select the above mentioned vessels” in the body of the report. The findings are documented. We do believe this documentation is sufficient, but I want to ensure it would hold up on an audit. "Vessels catheterized: 1) Right common carotid artery. 2) Right vertebral artery. Technique: Cerebral angiogram performed. Next, using a micro-stick singlewall puncture, the right common femoral artery was accessed and a 5 French sheath placed with a modified Seldinger technique. A 5 French DAV catheter and 035 Glidewire were navigated under fluoroscopic guidance to select the above-mentioned vessels. Multiple angiographic images were obtained. At the end of the procedure, all catheters and wires were removed."

Documentation of induction of arrhythmia and mapping

Hello Dr. Z- We're having difficulty coding EPS Studies and Ablations. Specifically we're having trouble determining if an induction of arrhythmia was performed and if the mapping that was done was 3D or not. We're being told that these things are being done but we don't see them in the documentation. If you would look at the following procedure note & tell us how it should be coded we would be very grateful! Procedure: The patient was brought to the lab in the fasting state, catheters advanced to the high right atrium and into the HIS bundle region and the RV apex. A catheter was left in the HIS region. There was a CS catheter advanced to the coronary sinus, his revealed proximal to distal atrial flutter. A mapping catheter was placed into the right atrium. He had a patent foramen ovale and the left atrium was mapped as well briefly. Catheter was pulled back quickly to the right atrium. The right atrium was mapped as well. He had a head meets tall counter-clockwise flutter which was typical flutter, energy applications along the cavotricuspid isthmus terminated flutter back to sinus rhythm. He had unidirectional block post procedure. He was in sinus bradycardia at the end of the case. He tolerated it well. There were no adverse complications.

Documentation of mapping

Is it always necessary to do mapping prior to the SVT ablation? I was told that even if the mapping isn't stated in the dictation, it is always required so I should code it. I disagree with this. Below is a dictation that I don't see "mapping" but was asked to add the 93609. The codes I used are 93620, 93621, 93462, 93651. PROCEDURE: This patient with a history of recurrent, symptomatic PSVT was brought in for an electrophysiologic study and/or ablation. The patient presented to the EP laboratory in sinus rhythm. Catheters were placed in the right atrium, His-position, coronary sinus, and right ventricle for pacing and recording. Baseline measurements were recorded. During PSVT, the fastest tachycardia cycle length was 380ms with eccentric atrial activation (CS 3-4 was earliest when CS catheter was in the coronary sinus). Transeptal puncture utilizing fluoroscopy was used to access the left atrium. The catheter was then placed at the position of CS 3-4, where there was noted to be a fusion of the ventricular and atrial potentials. Upon ablation, within 4 seconds, the patient's tachycardia broke, and the patient returned to sinus rhythm. Many ablation points were done at and around this area. Afterwards, when ventricular pacing was performed, whereas previously there was eccentric atrial activation, after ablation, there was concentric atrial activation. Also, after ablation, when performing AV Nodal ERP, there were no evidence of accessory pathway echos, whereas prior to the ablation, we saw many accessory pathway echos. We were not able to induce tachycardia after the ablation was complete. Ablation was performed in the left atrium, at the 5 o'clock, 5:30 o'clock position on the mitral annulus (in LAO view). After ablation was complete, post-procedure measurements were obtained. Attempts to induce the arrhythmia were performed with programmed stimulation or rapid pacing. Procedure went well without any complications. Thanks. Your assistance would be greatly appreciated.

Documentation Required for CVC Cath Placement to code CPT 36556

When a CVC is placed, is it necessary for the physician to document where the catheter tip terminates (i.e., sublcavian, brachiocephalic, etc.)? Our physicians document location: right femoral, ultrasound guidance used, successful placement, but not where the tip is. Our coding staff state that if the site the cath tip is terminated is not documented they must code to CPT 36000. Any guidance would be appreciated.

Dog Bone Stent in Atrial Septum

I can't find a code(s) for percutaneous transcatheter stenting of the atrial septum in a three-month old born with discrete coarctation of aorta, small left-sided structures, and pulmonary hypertension.  Here's an example dictation: "TEE probe was placed. ABG was performed and was reassuring. Swan catheter removed from pre-existing 5 French sheath. 5 French sheath in left femoral vein was exchanged for new, sterile 5 French sheath. JR 2.5 catheter was inserted in femoral venous sheath and advanced to the right atrium, and pressures were recorded. Baylis system was set up. Microcatheter followed by RF wire were advanced through JR catheter to tip of catheter. Guidance confirmed catheter in central location on the atrial septum, away from aorta and LA free wall. Wire was advanced and contact with atrial septum. Single application of energy was performed (10W for 2 sec), and bubbles were seen in the left atrium. Wire was advanced into left atrium, followed byt microcatheter and then JR catheter. Wire and microcatheter were removed and left atrium pressure recorded. Terumo Glide wire was placed through JR catheter 7 and advanced into LLPV. Catheter was advanced into PV, and wire was removed. 0.014" AllStar wire was advanced through catheter and catheter removed. Pre-mounted 3.5 mm x 12 mm stent was advanced over wire, and TEE was used to center stent in atrial septum. Stent was expanded under 5 ATM of pressure. Balloon was deflated and removed with wire."

Doppler

We are reviewing documentation for echocardiograms and are debating what needs to be dictated to prove spectral Doppler and what is needed to prove color flow Doppler. We are confused on how to prove/differentiate the two forms of Doppler spectral and color flow.

Doppler of Aorta

What comprises a complete aorta-only Doppler (93978), and what comprises a limited aorta-only Doppler study (93979)? My understanding is that code 93978 is for complete study of the aorta, IVC, iliac vasculature, or bypass grafts, while code 93979 is unilateral OR limited study of the aorta, IVC, iliac vasculature, or bypass grafts. 

Doppler prior to tunneled central venous catheter placement

Dr Z WHAT CODE CAN I USE WHEN MY DOCTOR DOES A NECK/JUGALUR VEIN DOPPLER EVALUATION. BEFORE PLACEMENT OF TUNNNELED 5 FRENCH DUAL LUMEN CENTRAL VENOUS CATH.

Dottering of iliac artery angioplasty stent placement aorta

On the following procedure we are questioning if we can code the stent and the angioplasty and also would you code abdominal aortogram and iliac? In your opinion did he do an angioplasty of the iliac? Another question?? Is this an Inpatient only procedure since he did cut down? DESCRIPTION OF PROCEDURE: With patient lying in a supine position on the operating table, a #16 Coude catheter was used to place in the urinary ostomy. Prior to the procedure by myself, I modified this catheter to cut the tip of it off very short since palpating the urinary bladder, it was only about 3 cm in depth. I placed a 5 mm balloon catheter in the stoma, by holding pressure on it and then cutting the end of this in 3 different places,I was able to get urine and irrigant with saline through this area from the stoma. This was then excluded from the field with an loban drape, and then the abdomen was sterilely prepped and draped. Another loban was placed over the entirety of the abdominal prepped area, after towels were placed and then a full draping. The operation was begun with a transverse incision right over the inguinal ligament. This basically was the same incision as previously, it is approximately 8 cm in length, and since this was exactly in the groin crease, I dissected upwards after dividing through the subcutaneous tissue and actually divided about 1 inch of the inguinal ligament in order to get control of the distal external iliac artery, which had not been dissected out preVioUsly. This was a small artery about 5 mm in size and so went ahead and dissected it out, and then dissected back on the extensive scar tissue over the common femoral, and in so doing, I was able to get control of about 2.5 cm of the distal external iliac and proximal commoril'emoral. There was 1trip branch that I had to tie off that was about a 2 mm collateral that took off laterally from the external iliac vessel and this was closed over with a figure-of-eight•.5-0 Prolene suture. Then, the patient was heparinized with a total of 7000 units of heparin. Seldinger needle was used to access the vessel and a .f-wire was placed through this and then a short 6-French sheath was placed over that into the vessel. Arteriogram revealed that the wire hung up at the distal stent graft'and th;tihe iliac was of narrow caliber. It appeared to be about a 5-6 mm vessel all way up to the common iliac. At any rate, Iwent ahead then and because the f-wire would not pass up through the stent, I went ahead and got a angled glide catheter (a Berenstein catheter) and then using this was able to advance the j-wire through the midportion of the stent. It went smoothly up into the distal thoracic aorta, and then the Berenstein catheter was rernoved'Ieavinq the J-wlre in place and then a 4-French angioplasty ealloon catheter was inflated and passed through this and then passed up with it being already inflated up the wire and it went smoothly through the stenotic lesion of the aorta and therefore I felt that the wire was through the midportion of the graft and had not gone underneath 1 of the stents. Then, the balloon catheter was advanced to the distal thoracic aorta and through this, I passed a Lunderquist wire to obtain stiff wire access through the lesion and then once that was accomplished, the Berenstein catheter was removed and then a 16-French long sheath was exchanged for the 6-French sheath, which was in the groin. This was passed up with some difficulty and went very slowly and with push-pull maneuver, was able to advance it through some areas, which felt like a stenosis but ifl fact this performed probably a Dotter dilatation of the iliac and once it was in place, it was advanced up to the distal to the level above the renal arteries. Then, a 40 diameter Palmaz stent approximately 3 cm in-lenqth was placed on a Coda balloon and then advanced through the long sheath and I neglected to say that an aortogram ha'd been accomplished through the sheath. A glow tape had been placed on the abdomen and I precisely identified the stenosis, which was right in the mid portion of the previously placed stent graft. I then pulled back on the long sheath, exposing the Palmaz stent, which was loaded on the Coda balloon and then deployed it by inflating the Coda balloon. Unfortunately, the Coda balloon was.not strong enough which with a low pressure balloon to dilate the lesion. The Coda balloon was removed leaving the stent in good position, and then a 14 mm diameter and 4 cm in length angioplasty balloon was exchanged for the Coda and placed in so that it extended on either side of the Palmaz stent and insufflated. There was an obvious waist on this where the in-stent stenosis had been, but it dilated nicely and dilated the Palmaz stent very successfully. This is a nice 14 mm lumen and a confirmatory arteriogram by hand injection through the long sheath, confirmed that the lesion was nicely dilated. Then, I removed the long sheath, slowly and pulled it back into the iliac and performed 3 hand injections as I pulled this back to confirm that there was no leak from the iliac artery, since I had felt that this had dilated the iliac considerably when it went in. Once it was back to the external iliac, and no leak from the iliac vessel was seen on the 3 arteriograms that I did and there was good flow all the way down and up across the bifurcation. The stent was then removed. Tapes were pulled up on the distal external iliac and common femoral vessel and then I closed the common femoral vessel with interrupted stitches of 5-0 Prolene and 6-0 Prolene suture. I used an interrupted closure so as to not create any stenosis of the femoral at that level. Once that was accomplished, a Doppler signal and palpable pulse was much stronger since the initial pulse was barely palpable in the groin and it was not palpable through the skin, but was barely palpable when the artery was exposed. It was much stronger and when hemostasis was felt to be secure, I closed the groin incision with 2 layers of running 2-0 Vicryl suture and skin clips were applied to the skin. An occlusive dressing with Betadine ointment and 4x4s were placed over the incision and then lastly the Foley catheters removed from the urinary stoma and an occlusive urinary stoma dressing was applied with Stomahesive and a small flange was placed over this and then attached to urinary drainage bag. The patient had a triphasic dopplerable signals in the foot at termination of procedure, and both right and left foot indicating much a very good result. The patient tolerated the procedure well and was extubated in the operating room, transferred to the recovery room in good condition.

Downgrade of ICD Generator to Pacemaker Generator

What would be the correct coding when changing out ICD generator, capping atrial lead, capping the charging part of RV lead thus leaving the pacing part of RV lead and inserting single pacer generator?

Doxorubicin Beads

I have a question about how to report the Doxorubicin beads 100-300 micron in size used for chemoembolization of a liver tumor? In the ZHealth online Q&A 2215 a similiar scenario is listed. You state the hospital should also report the J code for the drug. I have researched this and am only coming up with codes J9000 and J9001. My understanding is that these codes are to be used when the drug is administered via IV. What J code do you recommend to use for chemoembolization with Doxorubicin beads? Thank you.

Drainage Catheter Advancement

In a facility setting, how would the following procedure be coded? "The patient presents with a 10 French Malecot type catheter in a pelvic collection previously shown to be associated with a colocutaneous fistula. Catheter has been connected to a bag with minimal drainage. Aspiration of the catheter yields only 1 cc of serous fluid. The catheter was NOT injected with contrast material or saline. The suture material retaining the catheter is removed. The catheter is advanced out about 2 cm and resutured to the skin under local anesthesia. Total fluoroscopy time 0.6 minutes."

Drainage Catheter and Sclerotherapy

My IR physician are performing a new sclerotherapy procedure. A drainage catheter is placed into the lymphatic cavity (ie, axillary or thigh lymphocele) under ultrasound guidance, sclerosant agent is infused, and drainage is secured. Patient returns in a few days or week later. Next visit the contrast is injected in the drainage catheter for evaluation. Lymphocele has become infected in setting of obstructed catheter. Drainage catheter exchanged for new. Sclerosant therapy was infused into the collection and drained. How would this case scenario be coded?

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