I just recieved a referral on code 20600 small joint/bursa. The Doctor injected the navicular cunieform joint space of the foot with Kenolog and they would like me to chance the coding to intermediate joint/bursa injection. I was always taught that only the ankle joint was concidered an intermediate joint so the only intermediate joint on the foot would be the Calcaneus bone I'm I correct in my thinking?
Hi! One outpatient department performs this procedure. The patient comes in with a previously placed pleural catheter. The catheter is attached to a drainage system to drain fluid. Since the catheter was already in place, it does not seem appropriate to report CPT code 32556. Should the hospital report a low level E/M code or 32556 with a 52 modifier? Thanks in advance!
Question: Is the cephalic arch considered separate central venous zone for coding 37238? If so would this case be coded 37238 and 37239? 1. Multifocal short segment cephalic arch stenoses treated with angioplasty and telescoping stents. 2. Intra-stent venous limb restenosis treated initially with angioplasty and restenting with markedly improved luminal flow and post intervention venogram.
I have a question regarding -51 modifiers. I am billing out a 37229, 37233, 37224 for charges. Is it neccesary to add a -51 modifier to the 37224? If so, why? We are having some debate in our office.
Would it be appropriate to code 35371, 35372, 35741 for this case? Incision left groin, exposing the distal external iliac artery, entire common femoral artery, several centimeters of superficial femoral artery and well down into the profunda femoral artery as well- extensive endarterectomy of the entire common femoral artery extending well down into the profunda femoral artery. The superficial femoral was totally occluded - We divided that beyond its origin, the SFA, about 6cm distally and divided it, over sewed the distal SFA. The proximal and then the 6 cm stump was opened on its inferior surface, endarterectomized and this was used as the patch for the profunda endarterectomy. We then opened up the profunda femoral artery for several centimeters, did extensive endarterectomy of the profunda. The vessel of course was opened here and we did an extensive endarterectomy of the common femoral artery through this same access. He also did an exploration of the popliteal artery for possible by-pass but found that it was a non-bypassable vessel
Patient has a draining sinus tract from a non healing abdominal wound. Patient taken to the operating room where the sinus tract was then probed with forceps. It went about 4-5 cm deep and was narrow. An incision was made with a scalpel through the old midline suture surgical scar spanning the mouth of the sinus tract. Essentially this sinus tract was split all the way down to it's base. Halfway down we encountered the first piece of ethibond suture which was barely incorporated and easily removed. Then using electrocautery, the scalpel and Kocher clamp the subcutaneous scar was cored out and circumferentially around the sinus tract saw more fibrous material at the base and pulled on this and removed another piece of unincorporated ethibon suture. Palpating the wound we could not feel anymore scar. It was healthy tissue thoughout the entire wound bed now. The wound was irrigated, no further bleeding identified and no foriegn bodies were seen. All the tissue was healthy. Sutured deep cavity and skin. Excision and repair?
We are uncertain of the appopriate code to use when the provider describes the use of a bifurcated graft placed at the aorta with one leg of the graft anastomosed to the right common iliac artery and the other leg anastomosed to the left common femoral artery. There are three anastomoses (Aorta, RT CIA, LT CFA) thus we are unsure if two separate bypass codes would be appropriate in this case or if this may necessitate an unlisted code (which comp code would be appropriate?) Your guidance would be greatly appreciated. Thank you .
Our surgeon performed a cephalic vein thrombectomy and later performed a internal jugular vein end-to-end venous anastomosis ot the cephalic vein. How would I code the venous throbectomy and anastomosis? see below op note The microscope was brought into the field, and after the placing vascular loops to stop the blood flow through the internal jugular vein, a venotomy was created. Then, utilizing of Synovis 2.5 mm venous coupler ring, an end-to-side venous anastomosis was created from the cephalic vein into the internal jugular vein. There was excellent blood flow, and we placed a little bit of Gelfoam to bolster the vein to prevent kinking.
After the hemodynamic data were obtained, an aortogram was performed using a 4F Pigtail catheter in the standard PA/LAT projections and the fractured coarctation stent was identified and appropriate measurements made. Using a 4F angle glide catheter a super stiff Amplatz wire was parked in the distal right subclavian artery. The catheter was removed and the sheath was exchanged over the wire for a 14F x 80-cm Check-Flo sheath. An 18 x 30-cm Gore graft was mounted onto a Palmaz 4010 stent and then the entire stent system was mounted on an 18-mm x 4-cm BiB balloon catheter. The balloon was inserted over the wire and centered within the previously placed, now fractured, coarctation stent. The BiB balloon was deployed in the usual fashion, first by inflating the inner balloon, checking position, the finally inflating the outer balloon for definitive stent deployment. The outer balloon, unfortunately, burst before reaching nominal pressure but the stent was expanded enough that it did not migrate or embolize on balloon deflation.
According to your reference and previously asked questions, codes 47805 and 74305 are reported for a cholecystostomy tube check. I'm coding for a "follow-up of post gallbladder drainage" in which "scans are obtained through upper abdomen without contrast and after injection of the drainage catheter. After injection there is filling of the gallbladder." The impression was "after injection of contrast through the drain there is a small amount of leakage into the pericholecystic region." So I am told by the IR coder that in this case code 74150 should be used. However, could code 47505 also be used for the injection into the catheter? Or is code 47505 only to be used for a specific check of the tube functioning?
A stereotactic breast biopsy was attempted but on the stereotactic localization images of the breast the lesion could not be found so the biopsy was not performed. What if anything can the physician bill for?
Our neurointerventionalist performed a coil embolization of the ophthalmic artery. After the coils were placed there was a protrusion of two loops that required emergent stenting which was accomplished with a neuroform EZ stent. The doctor is trying to bill for both the embolization (61624) and the stent placement (61635). It's always been my understanding that any complications that arise during the procedure that were caused by the physician are not billed when corrected. Can you point me to something to give back to the provider regarding this? Is he correct that, in this scenario, both the stenting and the embolization are billable? Any insight on this would be greatly appreciated.
What do you suggest for the cardiologist who is performing the ECHO guidance during a TAVR? I see a code for 2015, but what do you suggest for 2014 and what type of documentation is needed.
What CPT code or codes would you use if we are performing an IR prostate artery embolization?
Please provide the correct catheter selection code for this procedure: Left groin prepped & draped & a 4 French sheath placed. Flush catheter introduced in the proximal abdominal aorta. An aortogram revealed normal aortoiliac system. Bilateral patent renal arteries and the SMA well visualized with the catheter selected into the distal right external iliac artery. Right femoral angiography revealed patent common femoral, deep femoral, and superficial femoral artery with the superficial femoral artery selected. The distal superficial femoral artery was widely patent. All 3 tibial vessels were patent with direct runoff into the foot. The catheter was removed.
The pt had Bentall procedure 2mo ago with Magna valve and Valsalva graft.Now has returned due to pseudoaneurysm of the ascending aorta.CP bypass was initiated. His previous median sternotomy incision was opened.I crossclamped ascending aorta.We entered the rt coronary button and a thrombus around the graft.Thrombus was removed.There seemed to be bleeding coming up from underneath the right side coronary button,coronary sinus and rt/lt commissure area. We then performed a transverse incision thru the previously placed Dacron graft, above the sinus of Valsalva section of the graft. There was no evidence of injury of the valve.I then cut alongside the rt coronary button down thru the Valsalva segment of the graft.It was difficult to find hole where the bleeding was coming from. I then decided to reinforce the whole area with sutures. These were placed thru the prior sinus segment, LVOT, and back up thru the sewing ring of the valve and the rt coronary sinus segment. I then repaired the sinus of Valsalva graft segment with Prolene. Then graft incision was closed.
Our hospital/neurosurgeons use fluoro in all their spinal cases. What is the instruction for charging/billing for fluoro done in the OR for these cases? It seems that cpt codes for open procedures 63001 and on, do not include fluoro. The minimally invasive/percutaneous procedures 0274T and 0275T seem like they do include the fluoro charge. If we do charge for the fluoro, would we use 77003 or 76000. Thank you very much.
What is the correct coding for a femoral acetabular impingement (FAI) exam? In our protocol, we perform a CT through the bony pelvis and proximal femurs, 3D reconstructions are created of both hips. In addition we obtain axial CT imaging through the knees to evaluate for femoral anteversion. Since this exam is primarily focused on the hips it seems most appropriate to code this as a Bilateral CT Lower Extremities (which covers the hips and knees) and include a 3D post processing component (76377). We also considered billing it as a CT Pelvis with 3D post processing component however that seems to ignore the added imaging through the knees?
All of the following is through one SVG: Physician stents the body of the SVG to RCA and also a spot in the RCA - one charge 92937. In the same setting he also stents the PDA branch of that RCA, still through that same SVG. Can I use 92921 with the 92937?
One of our doctors marked his rounding with VT ablation (93654) and another arrhythmia (93655) for the second PVC that he treated. The doctor describes these as two entirely discrete PVCs but he was aware of them from a prior outpatient study. When code 93655 was introduced we were taught that the doctor could not be aware of the arrhythmia prior to the procedure..that the other arrhythmia had to emerge during the procedure in order to get credit for the 93655. Is that correct? Should we give him the 93654 only for treating both PVC's or should he get the 93654 and 93655? The doctor also states that the source of the PVCs would be the mid LV and that PVC1 was spontaneous and that PVC2 was triggered and that Isoproterenol was infused to facilitate increased frequency of PVCs.
How would you code additional venography if MUEs for 75820/75822 is one? Do we code additionals with 75820/75822 with 59 modifiers, or use 76496? Venography below performed with heart cath. RT/LT arm venograms: Injections via peripheral IVs revealed patent axillary veins, with complete occlusion of RT/LT subclavians. SVC: complete occlusion of SVC. RIJ peripheral: Injection reveals complete occlusion at clavicle, with a network of collaterals. LT cephalic: Selective injection via left brachial sheath. Left cephalic vein enters collateral network that drains to left paravertebral plexus. There is complete occlusion of communication into subclavian vein. LT subclavian vein: With catheter in LT subclavian vein shows complete occlusion of LT subclavian vein as it passes between first rib and clavicle. Lt innom vein: Catheter advanced to LT innom vein, it is diminutive and completely occluded at SVC connection. RT innom vein: With catheter in RT innom vein it is found to be diminutive from caudal aspect of the RIJ into SVC.
I have a scenario where one cardiologist did a lhc and then during the same operative setting, another cardiologist stepped in and did a rhc. Would I bill these out separately as they were performed? Or bill as 93460-26 for both? If 93460, what modifier would I use? They have both dictated their own portion but modifier 80 doesnt seem to fit and modifier 62 isn't allowed for this px.
I was hoping you could shed some light on a case for me. A patient is brought in for an ICD battery replacement due to end of life. Prior to ICD replacement, the physician performs DFT testing with the old device to check the lead integrity. The results are normal and the physician proceeds with ICD replacement. Once the new device has been placed, the physician performs DFT with the new device. I know that CPT 93641 would be used for DFT after the replacement, but what can we use for the testing prior to the replacement? Is it appropriate to use CPT 93642 or is it possible to use CPT 93641 and 93641-59 or 93641-76?
ESRD pt w/hx of coiling of a branch vein originating from immature AV fistula w/coil migration to the RT heart. RT CFV was punctured w/ placement of 7 French sheath, pigtail cath advanced over Bentson guidewire into descending branch of LT pulmonary artery (36014), contrast injected & imaged showing coil lodged at bifurcation of descending pulmonary artery branch. A 9-15 mm EN-snare was used to capture end of coil & retracted into RT iliac vein & as it was pulled into the sheath began to unravel. Sheath removed, unraveled wire clamped w/hemostat. Maln coil mass was still in iliac vein. CFV was punctured a 2nd time, slightly higher than initial puncture. 7 French sheath was placed & coil mass then easily captured with snare & removed. (36000-59) The other guidewire fragment was cut at the skin & removed through the 2nd venotomy. Imaging confirmed complete removal of the coil. (37197) Will codes 37197, 36014, and 36000-59 accurately represent this procedure? Clinic says 36005 should be charged, not 36000-59. Which do you advise?
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? ?????
Our institution will start implanting the CardioMEMS HF System. What codes do we use for implanting the device and remote monitoring?
Need assistance with coding an excision of paranganglioma of the vagus nerve. I'm thinking 64771, but possibly needs to be an unlisted procedure. Procedure: A transverse incision was made from the midline laterally approximately 2 fingerbreadths above the clavicle. Dissection was deepened. The platysma was divided and platysmal flaps were raised. Dissection was deepened and jugular vein was dissected along it's medial edge and retracted laterally. The paranganglioma was identified and it was clearly not only adjacent to, but part of the vagus nerve. We carefully dissected this trying to ascertain whether or not the paranganglioma could be resected and the vagus nerve preserved, however, it was apparent that the lesion was actually part of the nerve itself. For this reason, we resected the paranganglioma with a section of vagus nerve proximally and distally. Pathology was obtained and sent for exam. Careful inspection for any other areas of neoplasm was carried out and none were seen. Closing began.
I'm looking for the appropriate cpt code(s) for repeated angioplasties in the left dorsalis pedis artery and distal anterior tibial along with repeated angioplasties proximal and origin of left anterior tibial artery for severe ischemia of the left lower extremities.
RT groin, under ultrasound guidance, RT common femoral vein accessed. a vascular sheath was advanced over a guidewire. then advanced in the rt external iliac vein with venogram. next, using a catheter the confluence of the bilateral iliac veins were catheterized w/subsequent inferior venacavogram. next cath was advnced beyond the area of narrowing along the infrarenal IVC and a ssuperior venacavogram was done. At this point all cathes and wires were removed. The codes I think should be 36011, 75825-26, 75827-26 and 75822-26
Since the co-surgery surgical indicator is "0" for the new FEVAR codes, how do you suggest coding a procedure when two vascular surgeons (partners) work together equally on a case?
Here is the procedure: 1. Right common iliac artery (end-to-side) to right renal artery (end-to-end) bypass with 7-mm PROPATEN graft. Right renal artery proximal ligation. 2. Left external iliac artery (end-to-side) to left renal artery (end-to-end) bypass with 7-mm PROPATEN graft. Left renal artery proximal ligation. Question: Are these ligations part of establishing flow and included in the bypasses?
For this case, is it possible to bill 33853 with 33854? The physician actually extended the graft to the distal arch because it was hypoplastic, so I wanted to know if I could bill both codes under these circumstances. Procedure performed open repair of coarctation PROCEDURE NOTE: A left-sided posterolateral thoracotomy was made. The distal aortic arch and proximal descending thoracic aorta were mobilized. The Control of the distal aortic arch and subclavian artery was obtained. CPB was utilized. The coarctation was then resected and sent to pathology. In order to sew a larger graft to the distal arch, the arch was opened up into the left Subclavian and a 22 mm graft was then sewn to the distal aortic arch and subclavian. The graft was then trimmed to size and sewn to the descending thoracic aorta distal to the aortic coarctation Interposition graft was approximately an 4 cm long. FINDINGS: His distal aortic arch was hypoplastic measuring approximately 18 mm between the carotid and the left subclavian. The aortic coarctation was distal to the left subclavian in the isthmus area. We resected the coarctation area and performed an end-to-end anastomosis with interposition graft and 22 mm Dacron graft.
What CPT code is appropriate for ligation and excision of venous aneurysm? The left upper extremity was prepped and draped in the usual sterile fashion. He received intravenous antibiotics preoperatively, and an appropriate time-out was performed. There was a dilated mass overlying the forearm distally in the mid forearm basilic vein. Local anesthetic was infiltrated in this area. A small longitudinal incision was made. The venous aneurysm was exposed, and it was quite dilated, but the more proximal and distal veins were completely normal. The forearm basilic vein was then ligated proximal and distal to the venous aneurysm which was then excised and handed off the field as a specimen. Hemostasis was ensured, and the wound was closed in layers.
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?
The physician initially attempts a right radial approach and documents that he has difficulty and brings the catheter up to the aortic arch and into the ostia right subclavian and documents that the patient has an anomolous takeoff of the right subclavian off the aortic arch. The doctor then takes a femoral approach and performs a standard left heart cath. No vertebrals were mentioned. I'm thinking 36215-59 (separate takeoff of the right would make this a 1st order, correct?) and a 75710-RT-59 as well as the 93458 for the garden variety LHC and a 93567 as he does discuss the aortic arch but that was after with the LHC approach. I considered 36225 but no vertebrals were mentioned and it didn't seem like this was really the intent of the angiography. I'd really appreciate your thoughts on this. Thank you.
Closure of perivalvular regurgitation of bioprosthetic mitral valve using Amplatzer VSD occluder. Patient had severe perivalvular bioprosthetic mitral valve regurgitation in the lateral sie with congestive heart failure symptoms. TEE probe placed and 3D images were obtained. Identified area close to the left atrial appendage and the perivalvular mitral valve regurgitation occurred was severe. Access from right groin, RCFA & RCFV followed by transseptal puncture . Notes are not clear as to what happened next? It appears d/t an inability to cross the perivalvular space he used a balloon to open then he was able To pass a shuttle inside the left ventricle, but still unable to advance the sheath in the perivalvular space. At this point a wire was placed in the ascending aorta. Using a large EnSnare he was able to snare the wire from the ascending aorta and brought into the RCFA. He was able to deploy the Amplatzer closure device into perivalvular space. Repeated procedure 2 more times. Uncertain if 93799 or 0343T x 1 & 0344T x 2
When using bilateral procedure codes and separate S&I codes, ie. 50394/74425, 50398/75984 or 50390/74470 etc, how would you report the S&I? Would it be: 1)50394-50 and 74425 and 74425-59 2)50394-50 and 74425 x2 3)50394-50 and 74425 x1 ??? I seem to remember reading somewhere that you would code the 2nd one with a 59 but I can’t find it now...
50398 vs 50387? And why. Contrast material was then instilled through the bilateral nephroureteral tubes, and the images obtained show appropriate positioning and bilateral hydronephrosis/hydroureter. A Bentson wire was inserted through both of the existing 8 French nephrostomy tubes. While maintaining the guidewires in place, on each side the previously placed nephroureteral tubes were removed, and new nephroureteral tubes were advanced over the wire. New 8 French 26 cm tubes were introduced over the wire under fluoroscopic observation. The proximal loops were formed in the renal pelvis and the distal loops formed within the bladder. Contrast material instilled through these new tubes, and films obtained show adequate contrast opacification of the collecting systems. The nephroureteral tubes were then secured to the skin with revolution devices and sterile dressings were applied.
I coded 36247 Rt & 75716-26, is this right? What am I missing? REASON: Nonhealing rt leg wound. PROCEDURE: 1. Distal aortic angiography w/nonselective bilateral iliac angiography. 2. Rt femoral angiography w/runoff (via third order). 3. Lt femoral angiography w/runoff. 4. Successful atherectomy of mid right SFA using TurboHawk. 5. PTA of femoral popliteal artery.
Is it appropriate to add an extra cpt code of 36248 for the proper hepatic when a diagnostic arteriogram if performed? The celiac was selected,type 1 celiac anatomy, selected common hepatic, , The G.D. was selected. To prevent reflux and nontarget embolization in the GDA. The cath was positioned in the proper hepatic artery, an arteriogram was performed. The r. gastric artery was identified arising from the r. hepatic artery. This was selected microcath, arteriogram done. To prevent reflux & nontarget embolization into the RGA, the RGA was occluded with coils. The cath was directed deeper in the r. hepatic artery, arteriogram was performed. 1.5 mCi of tech 99 MAA was infused into the r. lobe. The cath was then directed into the l. hepatic artery. 2.5 mCi of tech 99 MAA was infused in the l. lobe. Codes used: 37242,36247(G.D.),36248X4(proper hepatic, r. gastric, r. hepatic, l. hepatic) & 79445. My understanding is we can add a 36248 for the proper hepatic, because they stopped at this level to do a diagnostic arteriogram. If the cath was going from the proper to the hepatic, not stopping to do an arteriogram of the proper hepatic, then we would pick the highest cath placement?
Can these two codes be billed with the diagnostic codes for 36221-36228? What kind of information should be documented? Are the words as described above enough or should there be more? I have searched everywhere for documentation guidelines and have been unable to find. I was under the impression these codes were only to be billed with just the other 70,000 code series(e.g CT or MRI).
Pt. came in as a stemi. Pt. had previous grafts and the physician stented the native circumflex,not going through svg.In the final impression he stated that the svg to the om was the culprit lesion. I'm assuming, due to years working in the cath lab, and not what the physician stated in his dictation that he opened the native circumflex to get flow to the om. If the pt. comes in infarcting but he doesn't do the culprit lesion, can we still charge AMI-92941?
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?
Patient admitted with an acute myocardial infarction. Procedure note documents that a stent was placed in the diagonal vessel of the left main which was presumed to be the culprit vasculature. They then redirected the wire down the left anterior descending artery and in the proximal left anterior descending artery, stented an eccentric lesion that was 85% stenosed. The wire was redirected down the circumflex system and a stent was deployed across the circumflex marginal vessel. The physician is billing 92941, 92938 and 92944. I don't agree with this code selection.
Right arm fistula procedure. Normal access of the fistula and imaging (36147). There was a stenosis present in the innominate branch. Multiple attempts were made to cross this lesion from the inital access site. This was unsuccessful. The decision was made to obtain groin access and address the lesion from below. This attempt was successful. Now comes the question you've been waiting for... What on earth do I charge for the groin access and the venoplasty of the brachiocephalic? I did give a good ole college try...this is what I billed: 36147,36011, 35476 and 75978. i'm hoping that I wasn't too far off.
If a patient has a congential heart defect such as a PFO and they are coded as congenital 745.05 and we perform a congenital Echo 93303. Then the patient comes back a year later and the PFO has closed and the Echo is now showing normal would you still code them as congenital?
Coding Clinic states that a diagnostic left heart cath may be reported with the TAVR (ICD-9), but states that sampling or monitoring of heart pressures is included in the TAVR procedure. What would indicate that a left cardiac cath is done for a diagnostic purpose? Is the physician's statement that it is a "diagnostic left heart cath" enough? He gave indications (acute on chronic dias heart failure from aortic stenosis) and only provided the LEDVP. It seems to me that all patients who require a TAVR probably have some degree of acute or chronic heart failure. Would this scenario be sufficient to code the CPT for the diagnostic left heart cath in addition to the TAVR? I am hoping this will provide some insight into my ICD-9 coding.
My doctor is checking the activated clotting time and post stent placement, and sometimes does this two or three times. Is this something that would be included with the stent placement procedure, or is it something that we should be billing for? I am confused as to what code to use, if indeed we can bill.
What are the correct surgical CPT codes for lateral branch blocks in the sacrum? The orthropaedic physician says he is injecting bilaterally the lateral branches S1-S4. The radiology guidance reports seeing four needles into the SI joints; however, the physician says he is not injecting the joints, rather he is performing lateral branch blocks. The physician also confirms he used four needles for the injections, and he advises the codes for this are 64493-50, 64494-50, and 64495-50. My question is, if he is using four needles, would three levels be injected bilaterally? Also, I am seeing on some pain management websites recommendations to use code 64450 for lateral branch blocks, as they are considered peripheral nerves in the sacral area. Please advise.
If a CHD patient receives a heart transplant, are heart cath and echos coded as congenital or non-congenital? Physicians insist on congenital, but problem then is what congenital diagnosis can we use if it no longer exists? Also, see the following example of patient with post transplant complex anatomy. Should this patient be coded as congenital? Patient's native IVC and SVC were left-sided; complex re-routing of the systemic veins was performed at the time of his transplant. A flap of atrial tissue was used to redirect the IVC to the right atrium, while the donor innominate vein was anastomosed to the recipient left-sided SVC to the right atrium. Instead of using a congenital code, should we be adding a modifier -22 for this patient?
Thank you for the information on this drug test and the information included in my cardiology book. I have been working on getting this procedure code added to our system for our EP physicians to use in ordering and performing the tests. Code 93799 (unspecified code) would be used for this study. I need to provide the closest code to this unspecified code. I felt the ergonovine provocation test (93024) would be closest. I also see in the guidelines for the ergonovine test that it would include the drug used. Would this be the same case for the procainamide drug challenge? Any and all information regarding this is appreciated.
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."
Our physician replaced a pacemaker generator. He removed a single chamber device and replaced it with a dual chamber device; however, there is still only one lead in the ventricle. He pinned the atrial lead port. Would this be reported with code 33227 or 33228?
Our hospital started doing CardioMems HF system in 2014. We see that there is a new HCPCS code for OP coding as of October 1, 2014: C9741 (RHC with implantation of wireless pressure sensor in the PA including any type of measurement, angio, imaging supervision and interpretation report; includes provision of patient home electronics unit). Would it be appropriate to code a diagnostic right heart cath when pressures are taken in the RA and RV if it is done for diagnostic purposes since the CardioMems itself includes a RHC? Can you touch on IP vs. OP vs. physicoan coding (CPT and ICD-9 px)? We know what the vendor is suggesting as far as coding, but we are lacking official coding guidance. Also, do you know of any medical necessity ICD-9 diagnosis requirements?
I am unsure about how to code a TAVR procedure where subclavian artery access was used (cutdown). Do I need to use an unlisted code, or would I be able to use code 33363 (TAVR open axillary approach)?
The pre-operative embolizations are sometimes confusing because they are done for varying reasons. When embolization is arteries supplying tumor, would this be considered "tumor embolization"? Patient has metastatic renal cell carcinoma to femur. "Title of Procedure: Transarterial particle embolization of left femoral metastasis. Indication: Preoperative embolization. Impression: Large hypervascular lesion in distal left femur, receiving blood supply from multiple branches of superficial femoral artery. Successful embolization of 3 branches of left SFA with approximately 90% of tumor vascularity embolized using 500 um and 700 um particles." I would appreciate your input.
Could you please let me know if the we are coding correctly (50398, 50394, 74425)? "A preprocedure fluoroscopic image was obtained. Contrast was injected through the right percutaneous nephrostomy tube. The tube was cut and removed over a Bentson wire. A completion fluoroscopic image was obtained. A sterile dressing was applied to the site. Removal of the right percutaneous nephrostomy tube was completed."
Regarding Q&A #6213, in review of your diagram of the Pulmonary Arterial System, the left pulmonary artery is a first order vessel (36014, and the diagram is color coded as first order down to where there are branches off). Because documentation referred to the vessel as "descending branch of left pulmonary artery", without further specification of location of cath tip, could you please explain what indication makes this a second order vessel (36015)?
The instruction under code 77003 says, "Injection of contrast during fluoroscopic guidance and localization  is included in 22526,...., 62310-62319." And yet there is no NCCI edit. We have not been coding for the guidance since discovering this note. Does this note mean that we can charge code 77003 if it is for localization but not if contrast is injected? How should this note be interpreted?
I would appreciate you help with this scenario. We did a drug-eluting stent procedure on the LAD (C9600-LD). Later in the day, this patient developed pain and returned to the cath lab. The diagonal was closing down, and the same physician put a drug-eluting stent in the diagonal. For the second encounter, would I report code C9600-76-LD, or would I report code C9601-LD?
"Patient with history of congenital aortic stenosis who had valvuloplasty done at 3 days old followed by Ross procedure with bioprosthetic valve in 2009. Now comes in with severe stenosis of the bioprosthetic valve. Doctor performed a balloon angioplasty with bare metal stent placement in the bioprosthetic valve (Palmaz 3110 XL stent inflated to 20mm) and a transcatheter placement of a Melody valve on a 20 mm Bib balloon within the stent complex." I am thinking of using code 37236 for the stent placement, but I'm not sure about the placement of the Melody valve within the stent.
"Patient with metastatic gallbladder cancer to the right lobe of the liver and segment 4. This procedure is being performed to increase the size of the future liver remnant in preparation for extended right hepatectomy. Patient presents today for right portal venous embolization for future extensive hepatic resection. Puncture of a branch of the right portal vein via intercostal approach. Catheter was then reformed and positioned in the main portal vein (36481) with portography and evaluating suitable portal veins for embolization (75887-59). Catheter was manipulated into the left portal vein, subsegment 4A and 4B branches of the left portal vein, and selective portogram was performed followed by embolization with plug and coils." We are hoping to get your thoughts on selected codes please. Should we report code code 37241 or 37243 for embolization in this case?
"Left arm fistula was accessed and diagnostic fistulogram performed. Venous outflow stenosis was identified and angioplasty performed. The result was a focal rupture of the fistula requiring placement of a bare metal stent. Attention was then turned to the arterial anastomosis where a web-like stenosis was identified. Arterial anastomosis angioplasty was performed." I believe codes 37238 and 36147 would be correct, but I wondered about the PTA of the arterial anastomosis (35475, 75962). Is that considered inclusive to venous stent code 37238, or is it separately reported?
Would you mind telling us how you would code the following? "Initial scout imaging demonstrated a peroneal dialysis catheter coiled within the right lower quadrant. Gentle contrast administration demonstrates patency of the catheter and positioning in the peritoneum. Under fluoroscopic guidance, a 0.035-inch stiff glide wire was advanced to manipulate the catheter. A tip deflecting wire was also used. These were unsuccessful. Then, a 5.5 French Fogarty balloon catheter was advanced into the distal end of the peroneal dialysis catheter, and attempts to reposition the catheter were unsuccessful. The stiff guidewire was used to push the tip of the PD catheter into the right upper quadrant. A 5 mm x 2 cm Mustang balloon was advanced over the wire into the distal end of the PD catheter, and manipulation was attempted. This was followed by the Fogarty balloon. All of the attempts to reposition the PD catheter into the pelvis were unsuccessful."
We have a new piece of equipment that is being used to assist in guidance. The doctors each dictate the use of it a little differently, but in essence it looks to me like it might be most accurately coded with 76377. Here is a sample of the technique description: This case was performed using the I-guide feature of the Siemens artist Q. fluoroscopy suite. Guidance was performed using rotational cone beam, the 3D reconstruction, with extensive use of a workstation 2 project and then confirm the needle trajectory." Is this description adequate to capture CPT code 76376 or 76377? Can we even code for the use of this type of guidance?
Please help with coding this report. Would codes 33320, 36010, and 75827-26 be appropriate? I was also thinking about codes 36597and 76000 since they had to reposition it back in place. Do I separately code for thoracotomy? I am really lost on the coding for this one! "Fluoroscopy was used, demonstrating that the proximal port was in the SVC and the distal port was within the pleural space. Completion venogram showed distal port was now in the right atrium. Once the cath was originally determined to be in the pleural space, the patient was placed in the left lateral decubitus position, sterilely prepped, and sterilely draped. A thoracotomy incision was made. Entry was through the fifth intercostal space. Lung was retracted and cath identified. Purse-string suture in position, and cath was then pushed back into the SVC and placed into the right atrium. Suture was tied. There was no hemorrhage from suture, and the chest was closed. Chest tube in place. Fluoroscopy was brought back into position and distal tip in the RA."
For the following, would you use codes 49424 and 76080-26 for the evaluation, code 49999 for repositioning the catheter, and code 49082 for the paracentesis? "Right abdomen and pleurx site were prepped and draped. A short multiside hole seroma catheter was used to access the pleurx, followed by contrast administration to evaluate the pleurx drain. Using a combo of glide catheter and Amplatz guidewire, the pleurx catheter was slowly repositioned from the pelvis to the contralateral left lower quadrant and superiorly along the left abdomen. A repeat contrast evaluation was performed. At this point, the pleurx was accessed for a therapeutic paracentesis. The entire site was then sterilely dressed."
Can you clarify something for me? This relates to question 5222 where you said if injections were done of the L2, L3, and L3 facets that you would only code two injections (L2-3 and L3-4). If my physician dictates that he did facet injections of the L2-3, L3-4, and L4-5, would you then code three injections because he is giving the levels?
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."
Are codes 36011, 36590, and 77001 correct for the following case? If not, what do you advise? "Known thrombus associated with the central line of port. RUE prepped amd draped. With ultrasound guidance, a small caliber needle was directed into the right basilic vein. Guidewire was directed centrally, needle was removed, and dilators were passed until a 5 French cath could be directed into right subclavian vein. Contrast was injected under fluoroscopy with digital images recorded. Cath was then directed into upper aspect of SVC and advanced into the left innominate vein. Repeat injections of contrast agent performed. Cath was removed and hemostasis achieved. The right anterior chest wall was prepped and draped and anesthetized with local anesthesia. A transverse incision was made over the port and was then removed in its entirety with the attached central line. Pocket was closed, as was skin. Findings: Superior vena cava is chronically occluded with reversal of flow into the azygous system, which is now capacious. A port, which is no longer functional, was removed."
I have a case in which they had a GJ, and they repositioned it and now it is a G-tube. I have code 49465 for the injection, but I am not sure about the repositioning. "Dysphagia displacement - gastrojejunostomy tube injection, gastrostomy tube repositioning. Person with need for long-term enteral nutrition. Tube was pulled back and then readvanced. Please evaluate positioning. Impression: 1) Contrast material was injected into the indwelling 14 French Shetty gastrojejunostomy feeding tube, confirming appropriate positioning of the distal tip in the proximal jejunum. The catheter is patent and amenable to immediate use. 2) Contrast material was injected into the indwelling pigtail gastrostomy. The gastrostomy tube had migrated into the proximal small bowel. For this reason, the catheter was slightly retracted and repositioned into the gastric lumen."
In light of the July 2014 NCCI edit update, we (hospital staff) have been debating whether or not it is appropriate to append a -59 modifier to existing myelography codes when a CT scan of the same area is performed on the same date of service. We routinely perform a full and complete conventional myelogram with a separate report amd then send the patient to CT. Bottom line - can we bill separately for the conventional myelogram, or is it now considered bundled with the CT study performed in the same patient encounter?
We billed unlisted code 17999 for this. Can you suggest a valid CPT code that would most closely describe the following procedure? "A Kopan needle was advanced with intermittent CT guidance into the left flank tumor. Position was confirmed, and Kopan wire was positioned and needle partially withdrawn. CT confirmed needle and Kopan wire position. The needle was then completely removed over the Kopan wire. Kopan wire was secured to the skin."
If a lumbar puncture (62270), myelogram injection (62284), and blood patch treatment (62273) are all done at the same level (i.e., L3-L4), is the blood patch billable? Current NCCI edits allow the -59 modifier if appropriate. Does that mean only if done on a different level?
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."
If you were to approach this physician on his documentation of the below generator changeout, what would be your exact verbiage? There is no documentation of work done, nor info on implanted device (only intraprocedural measurements). "PROCEDURE PERFORMED: Generator replacement of a dual chamber biventricular cardiac defibrillators, fluoroscopy of device and lead, and capsulectomy pocket revision. Explanted device is a Guidant CRT-D model D224TRK. Existing leads: Atrial lead is Medtronic model 5076, length 45 cm in the right atrial appendage. The ICD lead is a Medtronic model 6947, length 58 cm in the right ventricular apex, and the CS lead is Medtronic 4196, 78 cm long in the lateral branch. Tachy detection at 300 millisecond. Tachy interval for ventricular fibrillation, first therapy 35 joules then 35 joules x 5. Bed rest for 4 hours. Antibiotics used."
My surgeon approaches this like an endovascular AAA repair; however, it is for severe atherosclerotic disease (not aneurysm), so I know we need to use lower extremity stent codes. My problem is deciding what is bundled due to inflow/outflow. HELP! "Bilateral fem exposures were made, and embolectomy was performed on one side just to get to aorta to take grams, which revealed patency of renal arteries and abdominal aorta to just inferior IMA, then occluded. Right external iliac is occluded. Large amount of thrombus both chronic and subacute from aorta and right iliac arteries retrieved. Flow was established and majority of clot burden removed. Good flow down the right iliac with multiple areas of stenosis and dissection. Neither internal iliacs filled, nor did the left common or left external iliacs. Angioplastied aorta, bilateral common iliacs, and bilateral external iliacs. Bilateral femoral embolectomy performed with severe residual stenosis. Bilateral stents from IMA into origin each common iliac. Two more bilateral common iliac stents. Two bilateral external iliac stents. On the right, common iliac residual disease beyond the stent at site of initial femoral incision required full endarterectomy with large core removed."
The cath lab would like to charge codes 11983, C1781, and 33263 when a dual chamber AICD is replaced and an antimicrobial envelope is used. Is code 11983 appropriate in this case?
Our physicians state they are performing a facet joint injection and a nerve root block. If both of these procedures were performed at the same session, are we allowed to report both codes 64483 and 64493-50? "Utilizing sterile technique, fluoroscopic guidance, and local anesthetic, 22 gauge spinal needles were advanced into the bilateralL4-L5 facet joints. After injection of dilute contrast into the joints, confirming the needle position, 1 ml mixture of 0.25% bupivacaine and 20 mg of Kenalog were injected into each joint space. Utilizing sterile technique, fluoroscopic guidance, and local anesthesia, a 22 gauge spinal needle was advanced into the perineural space of the left L4 nerve root. After injection of dilute contrast into the perineural space, confirming needle position, 1 ml mixture of 0.25 bupivacaine and 20 mg of Kenalog was injected."
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?
Our surgeon performed a cephalic vein thrombectomy and later performed an internal jugular vein end-to-end venous anastomosis ot the cephalic vein. How would I code the venous throbectomy and anastomosis? See operative: "The microscope was brought into the field, and after the placing vascular loops to stop the blood flow through the internal jugular vein, a venotomy was created. Then, utilizing of Synovis 2.5 mm venous coupler ring, an end-to-side venous anastomosis was created from the cephalic vein into the internal jugular vein. There was excellent blood flow, and we placed a little bit of Gelfoam to bolster the vein to prevent kinking."
Can you help me code this (selective renal transplant arteriogram with embolization). Report excerpt: "Micropuncture was performed of the right common femoral. A 0.018 wire was inserted, followed by placement of 5 French micropuncture set and subsequently a 5 French sheath. A 5 French Kumpe catheter was then advanced into the iliac artery, and injection was performed in the right external iliac artery, opacifying the feeding vessel to the transplant kidney. This was then superselected with a Kumpe catheter and formal arteriogram performed, showing evidence of renal cortical thinning. There is normal arterial blood flow. A 3 French microcatheter was then advanced selectively into the distal vascular bed of the transplant kidney. n-Butyl Cyanoacrylate (1 mL mixed with 4 mL of ethiodol) was then subsequently injected under fluoroscopic control, withdrawing the catheter and filling the entire vascular bed of the transplant kidney. The microcatheter was then subsequently removed. A follow-up injection was then performed with a Kumpe catheter in the right external iliac artery, showing complete occlusion of the transplant renal artery and no evidence of residual arterial flow."
How would you code aspiration and embolization of facial macrocystic lymphatic malformation? "US 20 gauge needle into neck/facial lymph malformation. Aspiration of fluid sent to pathology. Injection of contrast for lymphangiogram under fluoroscopic guidance was performed, confirming isolated cystic structure. Contrast was aspirated, and we performed infusion of doxyclcline with sterile water and contrast under fluoroscopy. No evidence of non-target embolization. Catheter tract was plugged with collogen matrix."
"A 5 French micropuncture sheath was advanced into the cephalic vein, followed by an exchange to a 7 French Pinnacle sheath. Next a 5 French puncture sheath was placed into the reverse saphenous vein graft and the patient’s DRIL bypass. Initially the arterial anatomy was scrutinized: widely patent anastomoses of DRIL graft. Axillary and brachial arteries were moderately calcific but patent. Then a venogram of the cephalic vein was performed: critical stenosis of the LT subclavian vein just distal to its subclavian and innominate confluence. This finding is consistent with venous TOS. Through the sheath, a glidewire with a 5 French Kumpe catheter traversed the tandem venous stenoses. A superior venacavagram was performed. Next, serial venoplasty with Armada 8 x 40 cm balloon, followed by ConQuest 10 x 40 cm balloon, was performed. Post venogram revealed widely patent venous segments." Here are our coding thoughts: DRIL access (36120, 75710-26), venacavagram with venous access (36005, 75820-26), venoplasty (35476, 75978-26). Provider is asking for fistulogram. Is the DRIL part of AV fistula?
I have a doctor who is an interventional cardiologist, and he has recently asked me about his specialty being considered a separate specialty/sub-specialty of cardiology, which has been the case for EP. He states that he heard CMS has now officially recognized "Interventional Cardiology" as a separate specialty. He wants to know if this is true, and if so did it start in January 2014 or is it to begin in January 2015?
I thought I read something about a change. The patient has known CAD, and the only procedure done is an IVUS of the left main and LAD. "Patient's groin was prepped, and a 5 French sheath was placed and guide advanced. Wire was placed down to the LAD, and IVUS of the left main and LAD was done." I have documentation of the IVUS findings. Catheter as well as sheath were removed. IVUS would be reported with codes 92978 and 92979, but current edits indicate a base code is needed. We don't have a base code. Was there a change so this can be coded, or is there another code that we are to add? Or is the claim going to be denied?
"Patient has aneurysmal development of the distal SFA in above- and below-knee popliteal arteries. Doctor performed left distal superficial femoral artery to below-knee popliteal artery bypass using non-reversed transposed greater saphenous vein, ligation of below-knee popliteal artery, and ligation of above-knee popliteal artery with plication of popliteal aneurysm." Would code 35556 be more appropriate than 35151 due to involvement of SFA and popliteal? The physician also advised ligation would not normally be included. Do we need to report code 37618 x 2?
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.
Patient with duplicated right kidney has a bilateral nephrostogram and nephrostomy tube change in addition to a nephrostogram and nephrostomy tube change on the right duplicated kidney (two on right, one on left) because of poor drainage from the catheters. Initially we reported codes 50394-50, 50394-59RT, 50398-50, 50398-59RT, 75984-50, and 74425, but we got an MUE of 1 on 50394-59RT, 50398-59RT. What's the correct way to code this?
I have a situation where there is a question about what CPT codes can be billed together with a PICC line insertion. I have a charge for the insertion of the PICC (no pump > 5) and ultrasound charges for US-guided vascular access (76937) and duplex UE/LE unilateral (93971). Can codes 76937 and 93971 be billed together for PICC line insertion? There is documentation by the radiologist that "US evaluation was performed of the left UE to evaluate vessel patentcy and the basilic vessel was deemed patent. During real time sonographic imaging, access was gained into the basilic vein utilizing micropuncture technique. Sonographic imaging obtained for confirmation." The documentation for the duplex states to "please correlate with the PICC line placement." If both ultrasound codes cannot be billed, which is the appropriate one to use?
Do we use code 34802 or 34203 for an Endurant 2 stent graft for AAA?
Is there a CPT code specifically for thoracic aortic angiogram?
The CPT Assistant article from November 2013 states embolization of liver tumor in two separate lobes may be reported with codes 37243 and 37243-59. Does this update your response to question ID #5157 from 10/22/13 that stated the liver is one surgical site? Our patient had radioembolization of right and left hepatic arteries for bilobar hepatic metastases, so we are using codes 37243 and 37243-59.
Does the hospital charge for the contrast material itself with a cardiac cath procedure, or is it considered included?
Our physician did an external iliac-popliteal bypass with graft. I am not seeing a CPT code for this procedure. Since the popliteal is included in the femoral family for percutaneous intervention, would it be correct to report code 35665, or should we use an unlisted code for this procedure?
Patient has a left to right femoral-femoral bypass with a PTFE graft. Using the same graft, the physician does a left femoral-popliteal bypass graft. Can I use both codes 35656 and 35661, as two bypasses were done but only one PTFE graft used?
I researched prior questions along with your cardiovascular coding book and could not locate an answer to my question. Patient has a biventricular ICD in which the left ventricular lead is repositioned in the anterior cardiac vein, the dislodged right atrial lead is repositioned, and adequate slack was added to the right ventricular coil. I want to report this with code 33215 along with 33226, but I am encountering an NCCI edit. Please advise.
Could you please indicate how to code this case? A stent was placed in an AV graft venous outflow while an angioplasty was performed on arterial anastomosis.
I'm looking at using an unlisted code for this procedure (37799): renal vein reimplant to the IVC/renal vein transposition (being done for nutcracker syndrome on one case, and renal vein entrapment with pelvic congestion syndrome on another). I wasn't sure if you were aware of something better to use.
Can I bill surgical cutdown codes 34812 and 34834 along with fenestrated aortic stent graft with three visceral artery endoprostheses?