Knowledge Base

Items 1601 to 1700 of 1929 total

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Set Descending Direction

36200, 75710-26, 36221, 36216

"Patient has known subclavian stenosis and was brought to the cath lab for an angiogram. Procedures performed: Left radial access, right common femoral artery access, thoracic aortogram, left subclavian angiogram. Multipurpose catheter imaged the left subclavian artery. Vertebral artery was also imaged. Sheath inserted into right common femoral artery. A pigtail was used to perform a thoracic aortogram concurrent with an injection on the left subclavian artery to map the entire subclavian stenosis." The report then goes into details of the findings of the left subclavian artery (which is occluded) and also the left vertebral artery (found to be enlarged). There is diffuse atheromatous disease of the aortic arch. The right common femoral artery has no significant stenosis. There was no more information on catheter placement, and the physician wants to bill codes 36200, 75710-26, 36221, and 36216 for this. I do not agree. What do you think?

Coronary Embolization

Physician performed coiling and placement of 18 mm cribiform occlude device in the large bilobed aneurysmal SVG to diagonal artery. LIMA graft and root angiography performed in conjunction. Would you use codes 37242 and 93455? For the root angiography there's nothing specifically documented other than catheter was placed and root injected. Would you add 93567?

Bilateral Ureteral Obstruction

After prepped, draped, skin anesthetized w/ 1% lido w/o epi, placed in prone position under gen’l anesthesia. Using fluoro guidance a 21-g needle was advanced into RT kidney collecting system in single pass. Contrast inj 74425-RT showed hydronephrosis & hydroureter to level of bladder. 4 Fr cath was placed, 8 Fr sheath placed, 4 Fr angled cath used to gain access into bladder. 8 Fr x 24 cm ureteral stent was deployed w/ distal pigtail in bladder, proximal pigtail in RT renal pelvis, noted to function. Using fluoro guidance a 21-g needle was placed into LT kidney collecting system in single pass. Contrast inj 50390-50-XU, 74425-LT showed hydronephrosis & hydroureter to level of bladder. 4 Fr cath was placed, 8 Fr sheath placed, 4 Fr angled cath used to gain access into bladder. A long 10 Fr peel-away sheath was placed, 8 Fr x 24 cm ureteral stent placed through sheath, sheath removed w/distal pigtail in bladder, proximal in LT renal pelvis, noted to function. 50393-50, Bilateral percutaneous accesses were removed. Any other codes or modifiers needed?

Coronary CTA

I have had two cases now where one physician has performed a complete cardiac CT angio showing non-cardiac and cardiac findings including coronaries and LVEF. The next day, a complete LHC with LV angio is performed by another physician. There are similar findings on both reports, but of course the LHC has the pressures and % of blockage in each vessel. I raised the question to the department, and they said it was because they needed views that can only be obtained with the cath. Will you please advise on the indications required to perform both procedures in the same visit and confirm that we are not "double billing"? What am I missing? Why do the CT first? I have never seen this done until just recently. As always, I appreciate your guidance and expertise.

73530

When 73530 is done at time of hip surgery with films and interpretation by radiologist, would code 73530 be billed as views or as diagnostic?

Upgrade from Dual Pacemaker to Biventricular AICD

The upgrade to a biventricular AICD from a dual pacemaker leads me to codes 33230, 33233, and 33225. But this scenario is very confusing because the descriptor for 33230 says "with existing dual leads", so should I use code 33231 instead because now with the addition of the LV lead that was implanted along with the biventricular generator I have 3 total leads?

May-Thurner Syndrome in ICD-10

Would you agree that May-Thurner syndrome would be coded as I87.1 in ICD-10? Also, would other acute conditions that result from the compression be considered integral to MTS?

Coding for CAD

My physician saw a patient with atherosclerotic heart disease of native coronary artery without angina pectoris, as well as atherosclerosis of coronary artery bypass graft(s) without angina pectoris. In the ICD-9 world we were instructed to code 414.00 for this scenario. With the increased specificity in ICD-10 would it be appropriate to code both conditions, I25.10 and I25.810, when known? Another scenario: Patient has known atherosclerotic heart disease of native coronary artery without angina pectoris with a history of CABG. Patient has not undergone a heart cath since the CABG procedure, so the cardiologist does not know if the atherosclerosis has advanced into the bypass grafts or not. Would the correct codes for this scenario be I25.10 and Z95.5?

AARO with Lower Extremity Revascularization

3M Nosology is stating S&I is inclusive to lower extremity revascularization per 2015 AMA CPT Codebook, page 238, so even if a true diagnostic procedure is performed prior to intervention it is not separately coded. What would the codes be for this AARO with intervention? "The right femoral artery was entered with US guidance and permanent recording was made. An Omni flush catheter was placed in the abdominal aorta and aortography performed with runoff. The catheter was placed into the left external iliac artery and additional angiography performed, showing occlusion of the left common femoral artery. The catheter was placed into the distal SFA, and atherectomy device was utilized. Multiple runs were made of the vessel. Next, the sheath was retracted, and runoff of the RLE was performed." Would the correct code assignment be 76937, 75625, 75716, 75774, and 37225?

Subclavian Stent with Thoracic Aortogram

Does the documentation that follows support the following codes: 75600, 36140, 75710, and 37236? "Sheath left radial artery, retrograde catheter left brachial, left axillary, left subclavian point of high-grade stenosis. Hand injection was performed, demonstrating the 99% left subclavian stenosis. Combination angled glidewire/glide catheter traversed the stenosis and was able to get into the descending thoracic aorta. Injection performed thoracic aortogram. Passed magic torque wire through angled glide catheter then removed angled glide catheter, passing ansel sheath across the obstruction. Then advanced a balloon expandable stent into position extending out into the thoracic aorta."

77012 vs. 77013

Based on the below operative note, could 77012 and 77013 be coded together using an unbundling modifier? "The patient was placed on the CT table in the prone position. After obtaining general anesthesia, local anesthesia was obtained with 1% lidocaine. CT guidance was utilized for placement of an 18 gauge needle guide into the 2.5 cm heterogeneous mass within the upper pole of the left kidney. Once confirming satisfactory placement, multiple 18 gauge core biopsies were obtained and placed in the proper container for disposition. The needle guide was removed. Utilizing CT guidance, a radiofrequency ablation probe was advanced into the left renal mass. After confirming satisfactory placement, ablation was initiated. Radiofrequency ablation was performed, 2 separate burns for 8 minutes each. The probe was removed, and hemostasis was obtained with direct manual pressure. Post ablation CT was performed to document hemostasis."

Spinal Angiogram

How do you code for a patient who has received spinal angiograms on 10 levels (T8-L4) for a total of 20 units?

Pacemaker Lead Replacement and New Generator

Patient had a dual chamber pacemaker placed in 2009. He has had noise in his RV lead, as well as ERI of his generator. His generator was removed and a new generator inserted, and his current RV lead was capped and a new RV lead inserted. His existing RA lead was reused and attached to his new generator, as was his new RV lead. There is confusion as to whether 33207 should be coded vs. 33208, 33233. It is my understanding that 33207 should be coded based on the lead that was replaced, not on the generator (single vs. dual) system. Others feel 33208 should be coded because the patient has both an RA and an RV lead system implanted. In addition, can you please clarify if the -KX modifier should be appended to both the CPT code and the HCPCS supply code?

Upgrading a Pacemaker to a Biventricular Pacemaker

When upgrading to a biventricular pacemaker, do I charge for a new pacemaker with LV lead insertion and put a -59 modifier on the code for removal of the old pacemaker? Or do I charge for removal and replacement with biventricular pacemaker with a -59 modifier on the code for LV lead insertion? And with the second option, can I charge for the removal of the device?

Coils Looped Around Pacemaker

The doctor states he did a pocket revision, but technically he had to go in and un-wrap coils around the pacemaker. Would you consider this a lead reposition? As code 33222 has changed in definition to pocket relocation. 

Cooling Catheter

Should a cooling catheter be billed with code 36556 or an unlisted code?

Carotid endarterectomy with diagnostic carotid angiogram

"Patient came in for a right carotid endarterectomy with patch angioplasty. After completion, closure, and arousal from anesthesia, the patient was noted not to be able to move her upper extremities and had significant weakness in the left leg. Decision was made to re-explore the carotid artery. Wound was reopened and vessel examined. There was a pulse in the common, internal, and external carotid arteries, and decision was made to perform an angiogram. Contrast was injected through a butterfly needle placed in the CCA just below the patch to obtain a carotid angiogram. The CCA and ICA, as well as anterior and middle cerebral arteries, were patent. Decision was made not to reopen the patch. Incision was closed." I know to report the endarterectomy with code 35301. I am uncertain about the diagnostic carotid angiogram since it is open and there was no catheter selectively placed – just a needle directly placed in the CCA. What are your thoughts?

Peri-splenic and peri-renal abscess drainage

The patient has a peri-splenic abscess located around the spleen beneath the left hemidiaphragm. Would code 49406 be correct, as the abscess is not located within the splenic organ itself? Also, some consultants are recommending that a peri-renal abscess drainage be reported with code 49405. Since the abscess is not within the organ, wouldn't 49406 be correct? Are there any AMA references that address "peri" conditions for drainages?

WPS and Popliteal Aneurysm

With the new LCD for ICD-10, popliteal aneurysm I72.4 is not covered for 37236. It also is not covered for 37226. What do you recommend if a patient has a popliteal aneurysm and is MCR or MCR replacement in our area? The particular patient I have now is having thrombosis due to the aneurysm, but by coding guidelines it would be covered for intent, which is the aneurysm. The thrombosis is covered under 37226 if it is ok to code for thrombosis and not aneurysm. We do these all the time, this is just the first one that came up since ICD-10 and I need to be able to educate my physicians on coverage. 

Dual chamber pacemaker extraction and implantation

How would you code a dual chamber pacemaker extraction, including the leads from the left subclavian site, and reimplantation of new dual chamber pacemaker to the right subclavian site?

Stress Echo and Full Routine Echo Same Day

Can you bill a full echo (93306) and a stress echo (93351) done on the same day? We are doing a full echo, then we are stressing the patient and doing a stress echo. NCCI states a modifier is allowed. Do you have any documentation requirements for doing both on the same day? Also, would you have to have separate unique diagnosis codes for each? 

Coding for Penile Angioplasty

One of our new physicians has scheduled a case in the cath lab for penile angioplasty for erectile dysfunction. How would we code that procedure? He plans to do angiography first, then the plasty.

Two Stent Placements, Iliac Territory

I'm trying to sort out when I can charge for two stent placements in the iliac territory. Scenario 1: Patient has bridging lesions in the common and external iliac arteries. Two overlapping stents are placed. Scenario 2: patient has two non-bridging lesions in the same vessels. Two non-overlapping stents are placed. Can I report codes 37221 and 37223 for both of these scenarios?

93456 vs. 93460

This patient has CM and facility wants to bill RHC & LHC. I do not see they did an LV or crossed the Aortic Valve. Do you see something that indicates this was done? "Under ultrasound guidance a #5 French sheath was placed in the right radial artery, a #6 French sheath in the right brachial vein. Right heart catheterization was undertaken utilizing a 5 French Berman catheter. Oximetry performed. Coronary arteriography was then undertaken with multiple angulated views utilizing #5 French L 3.5 and R 4 Judkins catheters. After reviewing the films to ensure an adequate study, the catheter and sheath were removed. RESULTS: HEMODYNAMICS: Normal sinus rhythm, rate of 82. RA mean of 11. RV 41/14. Pulmonary complete wedge pressure 22. PA 41/19, mean of 30. Aorta 132/68, mean of 90. SvO2 75.1%. SaO2 92.8%. Cardiac output 6.85 L/minute. Cardiac index 3.75 L/minute/m sq. CORONARIES: He states - no atherosclerosis. Patient has Mild biventricular elevation of filling pressures with mild pulmonary HTN & preserved cardiac output."

IVUS with Two Access Points

Could you please clarify the use of 37250/75945 and 37251/75946 when two accesses are used? In the case where right and left femorals were punctured and IVUS performed of both left and right femoral veins, would both accesses allow the use of 37250/75945? Or should we use 37250/75945 for the first puncture and 37251/75946 for the additional? We do understand that in 2016 these codes are deleted and combined to a bundled code. 

CPT Codes for Insertion of Cardiohelp VAD

What would be the correct CPT code for this procedure? "Decision was made to place Cardiohelp device. Patient was undergoing CPR intermittently during this part of the procedure. Left subclavicular incision was made, and left subclavian and axillary artery was identified. This was dissected free from soft tissue attachments. Needle was inserted into the artery, and a wire was placed under fluoroscopic guidance. Wire was placed in descending aorta. Axillary artery was then dilated, and arterial cannula was placed over wire. This was positioned in the thoracic aorta. Tip was positioned in thoracic aorta under fluoro. Separately, a venous cannula was placed in the right femoral vein. This was placed percutaneously over the guidewire and placed in the right atrium under fluoro. The cannulas were then hooked up to the Cardiohelp device, and the device was turned on. Cannulas were then secured to the skin." From my research this seems more like an ECMO than a VAD. What are your thoughts?

Right Subclavian Atherosclerosis ICD-10

I am unable to locate a good ICD-10 code for right subclavian atherosclerosis. I have looked under atherosclerosis, but I'm unable to find a code that truly fits.

93458 vs. 93454

Is documentation of "no gradient across the aortic valve on pullback" sufficient to support coding a left heart catheterization? The only other documentation is "catheter placement in LV" and "LVgram deferred". No systolic, ventricular, atrial, or end-diastolic pressures are documented. Are we to assume that pressures were performed since he was able to evaluate there is no gradient? The physician documented coronary angiography as well, so the question relates to whether this should be coded as 93454 for coronaries only or 93458 coronaries with left heart cath. 

MRV and MRA

Can you report code 70544 twice if you perform an MRA and MRV of the head on the same date of service, if they are performed at two different times?

Bilateral Outflow Venograms

This one is confusing me. How should I code the following? "PROCEDURE: Outflow venograms of the upper extremities. TECHNIQUE: Using ultrasound guidance, superficial veins in the wrists bilaterally were accessed with 22 gauge Angiocath cannulas bilaterally. Segmental venograms were performed of each arm bilaterally, including forearm venograms with and without tourniquet placement cephalad to the elbow joints bilaterally. Additionally venograms were performed of the thoracic inlet during bilateral contrast injections for evaluation of the subclavian and brachiocephalic veins. On the left there is a mild to moderate small segmental narrowing underlying the left clavicle, most likely related to extrinsic compression by the overlying bone. No collateral vein formation is seen; however, minimal reflux into the left axillary veins is identified."

TIPS Insertion with Thrombectomy

Our physician did a TIPS insertion followed by venous thrombectomies in the inferior, superior, and splenic veins. Can these thrombectomy procedures be reported in addition to the TIPS procedure? I'm looking at codes 37187, 36011, and 36012 in addition to 37182. 

Single ICD Upgrade to Biventricular System

Indications CSHF, NYHA Class III, EF 10%, Chronic RV Pacing, Sustained VT. Existing single chamber ICD, placed in 2013, is replaced/upgraded with CRT-D. From your Q&A and book I understand that I should code this with 33262 and 33225, but how do we code for the added right artrial lead? 

Angiography Left Ophthalmic Artery

What is correct code for this angiography? "After informed consent the patient was brought into the angiography suite and placed supine on the angiographic table. The right groin was prepped and draped using sterile technique. Ultrasound guidance was used to evaluate the right groin site, and patency of the right femoral artery was noted. Using a 5 French micropuncture kit with ultrasound guidance under real-time visualization, the micro-puncture needle was advanced into the right femoral artery, and intravascular location of the needle tip was confirmed on ultrasound and documented in PACS. Then the provided micropuncture dilator was placed, the inner stylet removed, and the outer dilator was connected to an RHV. Multiple attempts using a 0.008" Mirage microwire and Standard Magic Microcatheter to catheterize the left ophthalmic artery were unsuccessful. The left ophthalmic artery was successfully catheterized utilizing a Synchro 10 microwire and Marathon microcatheter."

Sheath Insertion into Atrium

Is there a code for insertion of a sheath into the atrium? The surgeon performed this in preparation for the interventional folks to place a stent in the pulmonary venous confluence. "...We introduced a vascular sheath into the right atrium (open chest). The vascular sheath was secured, and the patient was transferred to the cath lab for placement of the stent in the pulmonary venous confluence. Following the placement of the stent, the chest was closed..." The reasoning was due to lack of alternative access to this area after Fontan procedure. 

Removal of FFBPG at Same Time as ABF

A patient has a fem-fem bypass graft that keeps clotting. Doctor wants to “take down” the fem-fem graft and put in an aorto-bi-femoral graft. I cannot find a code for the take-down of the graft other than removal of infected graft. This fem-fem graft is not infected. Is the take-down included in the aorto-bi-femoral graft, or would a -22 modifier be appropriate? Any suggestions?

Repair of Ventricular Perforation, S/P TAVR

How would you code the following? "A small subxiphoid incision was made and carried down in the chest. The pericardium was opened and the tamponade released with several hundred mL of red blood in the pericardium. I tried to see where this bleeding was from, but I could not see it. Therefore I opened and did a median sternotomy and explored the chest. The main perforation appeared to be on the posterior wall of the left ventricle near the second obtuse marginal artery. It was repaired with 5-0 pledgeted prolene suture. Two mediastinal chest tubes were placed. I then closed the chest with interrupted sternal wires. She was stable and taken back to ICU."

ICD-10 Status Diagnosis Z-code Z76.82

When doing a cardiac cath for pre-evaluation for organ transplant, would it be appropriate to report code Z76.82 (awaiting organ transplant) as the primary diagnosis? There is conflicting information that shows it should not be used as a PDX, but on the professional side there is nothing concrete to back that up. Understanding that patients over 40 with history of heart disease or significant smoking history are required to have this done. For example, a patient awaiting lung transplant for J60 (Coalworker's pneumoconiosis) and pulmonary fibrosis. Would you report code Z76.82 primary, or use the reason for lung transplant?

ICD-10-CM, Gunshot Wound

Our coders are trying to decide which ICD-10-CM code(s) would be best to describe a gunshot wound, and the x-ray shows the bullet or bullet fragments. If we use "open wound" there is no option for "with foreign body". Some coders are thinking "puncture" or "laceration" because they both give the option of "with foreign body". I can't find any written guidance (other than external causes). Can you please advise?

37238

Physician stents the bilateral common and external iliac and removes IVC filter using US guidance. I'm reporting codes 37238-50, 37239 x 2, 37193, and 76937. Codes 37238 and 37239 have MUEs attached. Code 37239 can only be reported twice and code 37238 can only be reported once, so I'm appending modifier -50 to code 37238. Am I doing this correctly?

Billing Chemotherapy with Fluoroscopy 96450/77003

Since we have the chemotherapy nurse administer the chemotherapy, I have not billed the chemotherapy charge on physician billing side. Is this incorrect, and I should bill the chemotherapy administration?

Tumor Imaging

We have patients who come in for tumor imaging spanning 3-4 days. Day 1 is the injection, day 2 is the first image, day 3 is the second image, and day 4 is possible third image. We are currently reporting code 78802 per image and 78803 for the SPECT. Should this be billed with code 78804?

Lariat Procedure

Is there a CPT code for left atrial appendage closure (not with implant) – Lariat procedure? Is this reported with unlisted code 33999?

Mitral Valve Replacement

Is there any new direction that has been identified regarding Q&A #6584? The physician used Sapien XT 29 valve to repair aortic valve and another to repair mitral valve. Found two more dehiscience sites after mitral valve procedure and placed two Amplatzer ductal occluders. He describes "off label utilization of valve for ting placement with possibility of pugging dehisced 2 areas around mitral valve". What is the correct coding for this case?

Uterine Artery Embolization for Placenta Accreta

If a pregnant woman has a bilateral uterine artery embolization immediately prior to a C-section/hysterectomy due to placenta accreta or placenta percreta and high risk for hemorrhage during surgery, would this be coded with 37244 or 37242?

Removal of Graft

"Patient has thrombosis of aortofemoral bypass graft. Physician performed excision of PTFE femoral-femoral bypass graft with vein patch angioplasty and repair of right common femoral artery. Then he redid right to left femoral bypass graft using cryopreserved femoral vein. The patient does have some persistent drainage from the resent surgical wound in her right thigh, therefore a decision has been made to use cryopreserved femoral vein." Can I bill code 35903 for removal of infected graft with code 35661? Please advise.

Failed CTO Crossing

In a lower extremity endovascular revascularization of a chronic total occlusion, does a device like the Crosser™ Catheter fulfill the requirements as an atherectomy device? Also, in a procedure where a Crosser™ Catheter was utilized and the occlusion could not be crossed, does the physician report the procedure with code 37225 with a -52 modifier appended, or should it be reported with code 37224?

CPT Code 35721

Can you report codes 35721 and 27364 together? Another coder thinks that because the description of code 35721 says if you do a more comprehensive procedure through the same incision site to code the more comprehensive procedure that this means the original surgical incision site. I think this means the same incision site of the femoral artery. To me, if it was the surgical incision, all codes would bundle with it and only vascular codes bundle with. Plus everything I have read says you can code them together and CPT guidelines are for more comprehensive VASCULAR procedures, not any procedure. 

Selective Catheter Placement of the T4-L3

My doctor did a selective catheter placement on the left for T4-T7 and L4. He then did a selective catheter placement on the right for T8-T12 and L1-L3. How should I code this?

Drug-Eluting Stent to RCA, OM1, and OM2

The RCA, OM1, and OM2 were all stented. Would it be appropriate (because the CIRC was not treated) to report code C9600 x 3? The descriptor states "main vessel OR branch of".

Leg Shunt Angioplasty

Please advise on the CPT codes applicable to this procedure. "Operation: Patient has had problems with dialyzing on the right groin graft and is undergoing AV fistulogram. Procedure performed is right groin fistulogram, PTA, stenosis of arterial and venous anastomoses. Patient heparinized. A 6 mm x 4 cm balloon was used to dilate arterial anastomosis. Second sheath in venous limb and performed angioplasty of venous anastamosis with 6 mm balloon and then with 7 mm ballooon. After completing, fistula appeared widely patent. Sheaths were removed and direct pressure applied." 

Coronary Artery Bypass Grafts

Our surgeon assisted on a CABG, and primary surgeon coded CABG (3+1) 33533 and LIMA 33519. Our surgeon thought it would be CABG (x4) 33536 and Lima 33522. "Procedure: Coronary artery bypass grafting x 4 with LIMA to LAD, vein graft to the diagonal artery, vein graft to the second obtuse marginal artery and vein graft to the LV branch of the right coronary artery. Saphenous vein graft harvested in L leg. Simultaneously, sternotomy was performed..Bypass was initiated. Target vessels identified and marked. Aorta was cross-clamped...The LV branch was nice target over 1.5mm in diameter. Vein graft was anastomosed end-to-end; R coronary artery and posterior descending aorta was severely and diffusely calcified. The vein graft to LV branch of R coronary artery anastomosed to aorta..Marginal vessel was exposed. Vein graft was anastomosed to this vessel which on small side, 1.5cm. Vein graft was then anastomosed over diagonal vessel, also small, 1.5cm LIMA was anastomosed to LAD beyond its midportion. LAD was again quite small, 1.5 cm...anastomosis sewn, etc..."

Infrarenal aortic resection with graft reconstruction

Physican performs infrarenal aortic resection with aortic reconstruction with homograft (end-to-end anastomosis) and IMA reimplantation for indication of infrarenal aortitis due to Clostridium septicum infection. Since the indication is infection, rather than aneurysm, pseudoaneurysm, or other occlusive disease, I'm thinking of using code 33330 for the reconstruction (insertion of graft), along with add-on code 35697 for the IMA reimplantation, but I'm having trouble locating a code for the resection. Procedure: "Aorta was clamped just below the renal arteries and at the common iliac vessels. Aorta was divided 3 cm from the left renal artery and 2 cm from the aortic bifurcation distally. The homograft was cut to length just below the renals and an end-to-end anastomosis created. Distally the left and right iliac anastomoses were completed. 4 mm punch used to create an opening in the ant wall of the aorta. 6-0 Prolene used to create an anastomosis between the IMA and the side of the aortic homograft." 

IVUS Study

Two interventionists performed separate interventions during the same case; one did 92941-RC and the other 92928-LD. Each performed IVUS on the artery they intervened on. Can each bill for an initial vessel IVUS for professional billing? 

Wire Localization of Neck Mass

Would codes 21899 (unlisted procedure, neck or thorax) and 76942 be correct to bill for a wire localization of a neck mass? The payer (UHC) has denied twice, even with the operative notes were sent, for reason "CPT code inconsistent with provider". They paid on code 76942, but not 21899. Do you know if there is instruction somewhere saying these are the appropriate codes that could be sent to insurance company that might get them to consider paying on code 21899? 

Intracranial Thrombectomy, 61645

When looking at reimbursement for 2016 codes we are finding that code 61645 (intracranial thrombectomy/thrombolysis) is showing no reimbursement for outpatient. This code is not listed on the inpatient-only list (that we could find). Is there a different CPT code we should be using for this procedure, or are we missing something?

CABG with Incomplete Documentation

"CVT SURGERY OP note Dx ASHD Angina pectoris, CAD, NSTEMI Diabetes Hypertension Hyperlipidemia Morbid Obesity Sleep apnea OP CABG x 5 Vein graft to diagonal to OM to PDA IMA to diagonal to IMA Endoscopic vein harvest right thigh Findings Good LV, vein and IMA Morbidly obese Aorta OK Moderate distal disease thin walled vessels Tolerated well Off bypass easily No inotropes very bloody counts correct. This is all my surgeon has documented can i code based on this documentation." How can I explain to my manager that I need more documentation to correctly code? Where can I find the minimum documentation requirements for procedures in CMS? Your expertise will be a great help in this.

Stent in PA Conduit

How do you code stent repair of distal artery to pulmonary artery conduit (5 mm x 15 mm Genesis bare metal stent)?

AV fistula intervention with selective catheterization and angiogram of radial artery

I'm not sure if this is reported with codes 36147, 35475, and 75962, or if there is more to code for the radial artery cath and imaging. What are your thoughts? "Percutaneous retrograde puncture of the left forearm arteriovenous fistula was then performed at the level of the upper forearm with a single wall arterial entry needle. A fistulogram was then obtained. There was a focal stenosis at the arteriovenous anastomosis. This was crossed with a Glidewire. A Bernstein catheter was advanced selectively into the radial artery, and a selective radial artery angiogram was obtained. A 3 x 30 mm eV3 EverCross balloon was advanced over the wire and positioned across the arteriovenous anastomosis. The balloon was inflated to its nominal pressure, and the inflation was maintained for 2 minutes and repeated twice. Completion angiogram showed an excellent result with a widely patent arteriovenous anastomosis."

76937 Documentation

Our physicians use a variety of wording when it comes to the permanent recording and reporting of code 76937. Evaluating the access site, documenting patency, and real-time needle entry is usually not an issue; however, they will document things like "a permanent still image of wire position was archived", "ultrasound documented wire position", or "I advanced wire and documented wire position". Wire placement/position?? "Documented" doesn't necessarily mean saved and stored in my opinion. Are these acceptable examples of permanent recording and reporting?

Frequency Guidelines for Cardiac Rhythm Evaluation

We have been told by the pacemaker rep that, if we see the patient in the office and provide a pacemaker or AICD check and make changes, we can still bill the remote check every 91 days. However, we are receiving denials for one of the checks for frequency issues. Can you clarify if we can bill the mix of device checks in person with remote device checks, or will each check bump out a new time frame that the next check can be done?

Pacemakers/ICD's, Bi-Vent, and Venography

I have some physicians who insist on billing code 33224 along with codes 36005, 75820, and 75860. My understanding is that you have to use venography to see the proper placement, so it would be inappropriate to code additionally. I have also explained that code 75860 is not intended for the "coronary sinus", but I still hear arguments. Can you clarify please?

Hypogastric Coil Embolization and Stenting

Please advise if codes 37242, 34900, 75954, and 36200-50 are appropriate for the following: "Sheath was inserted into the right SFA and left SFA. Pre-operative imaging demonstrated two primary outflow branches from the right hypogastric aneurysm. We were able to advance a wire from the ipsilateral groin into the right hypogastric artery aneurysm, and, fortunately, this wire passed easily into the primary outflow branch. Nine 8 mm x 4 cm Tornado coils were deployed into the branch. Completion angiogram showed small type II endoleak. Left hypogastric aneurysm was stented into primary outflow branch. There was another small endoleak, so we chose a Gore Excluder limb stent from right common iliac to the external iliac, past the origin of hypogastric artery. Second stent was placed slightly above aortic bifurcation to complete perfect seal."

His Bundle Lead in CRT-D Devices

I have a physician who is wanting to know how to report His bundle lead in CRT-D therapy cases. He is placing three leads: 1) RA in RA port, 2) RV in RV port, and 3) His Bundle lead in the LV port. Codes 33225 and 33224 both describe insertion of pacing leads for left ventricular pacing, but these codes do not seem to fit our physician's situation, as he is inserting leads into the His bundle. What are your thoughts?

Separate reporting of external iliac stent with endovascular AAA

If the physician places a stent in a 50% external iliac artery narrowing because the narrowing is causing difficulty passing the AAA endograft, can the stent placement in the external iliac be reported?

Mechanical Thrombectomy, Intracranial

We've noticed that on the 2016 APC file, new code 61645 for intracranial mechanical thrombectomy/infusion for thrombolysis is assigned status indicator E (non-covered for Medicare). It is on the 2016 physician fee schedule, so it seems like an error on the APC file. Also, would 03CG3ZZ be the correct ICD-10-PCS code for intracranial thrombectomy?

2016 CPT Codes 61650 and 61651

How do you report the new codes for a nitroglycerin spasmolytic procedure? The description is for prolonged service and does not fit what we are doing.

CPT 93050

What can you tell us about code 93050?

MR Lymphangiography

Is there a separate code for billing an MRI lymphangiogram? The radiologist performed an MRI with and without contrast, along with MIPS. Exam is being performed for pre-surgical planning (patient has left leg lymphedema).

Excision of Forearm Venous Aneurysm

I'm having a hard time locating an exact CPT code for this procedure, and I am wondering if I should use unlisted code 37799. "The patient's venous aneurysm was marked in the erect position. The skin overlying the venous aneurysm was infiltrated with 1% lidocaine with epinephrine. It was incised with a #15 blade. The aneurysm was dissected from the surrounding soft tissue. The branch of the basilica vein, from which the aneurysm emenated, was ligated with 2-0 silk ties proximal and distal to the aneurysm. The skin was closed with 3-0 vicryl suture in a subcuticular fashion. The incision was reinforced with steri strips, and the wound was dressed." If the unlisted code should be used, what procedure is it comparable to? For pricing purposes?

E&M for Purse-string Suture

Consultation was requested regarding patient with prolonged bleeding from AV fistula after dialysis. Patient was seen in the ED – persistent bleeding from fistula’s single puncture site. There was no ulceration or infection. Physician placed a single purse-string suture to control bleeding. Is there enough here to code a simple wound repair, or would you code an E&M visit?

Right Lower Extremity Angiogram and 3rd Order Catheterization Right SFA

What codes would l use for a right lower extremity angiogram and a third order catheterization right SFA? Patient also had an angioplasty of right lower extremity vascular graft with a follow-up angiography.

Endovenotomy

Please advise on the proper codes for this procedure. "Operation performed: Open exploration, left common femoral vein, femoral profunda, femoris vein with endovenectomy of femoral vein. Construction of arteriovenous fistula between the left SFA and femoral vein with reversed anterior accessory saphenous vein. Bilateral lower extremity venogram and inferior vena cavogram. Open angioplasty of the left common femoral vein, external and common iliac veins, and inferior vena cava. Double-barrel stent placement of the para renal inferior vena cava with Palmaz open stent placement from the left and percutaneous stent placement from the right." So far I'm thinking I will need to use an unlisted code for the endovenectomy. I'm not sure about the AVF since there was no bypass performed. Any advise and help would be greatly appreciated.

3D Mammography

Will you please review the documentation below and advise on appropriate coding? "Patient is positioned in Selenia Dimensions Affirm stereotactic biopsy system (this is an attachment that goes on our Selenia Dimensions Tomosynthesis Mammography system). A tomosynthesis image is taken and target confirmed. Biopsy needle put into position in the patient’s breast. Stereotactic 2D pre-fire images acquired. Biopsy device is advanced further into the breast (fired). Stereotactic post-fire images acquired to confirm position of biopsy needle. Tissue specimen was obtained. Specimen imaging was performed (as indicated) on separate mammography unit. Biopsy clip was deployed. Post biopsy image was taken to confirm clip has deployed. This is done either 2D or 3D. Two-view tomosynthesis combo (2D + 3D) mammogram (full field image) performed to confirm clip placement, and area of target was biopsied."

Excision of AVF

We have a patient who had an ulcerated left AVF. We ligated the fistula, and she had further issues with the wound healing after the ligation surgery. She came in for her new access in the right arm and had foul smelling drainage from the open wound in the left arm. Decision was made to debride the wound and excise the portion of the AVF that contained the infected hematoma and to create the new AVF in the right arm. We did the AVF creation in the right upper extremity. My concern is how to code the excision/debridement. This was an AVF, not graft, so I don’t feel as though code 35903 would be accurate. I also don’t feel as though a debridement code or 10180 would cover the amount of work actually done. I don’t think I like a revision code either, because they don’t intend on using the AVF. I would appreciate your input!

Can I bill a femoral cutdown , aortogram w/ bilateral iliofemoral arteriogram with the placement of stent femoral artery?

I believe I can only bill code 37226 with 75630 if decision to perform intervention after iliofemoral arteriogram. No other codes. Is this correct?

50390 with 74425 in 2016

I just completed your 2016 updates webinar, and I understand that there are new nephrostogram and pyelogram codes that bundle diagnostic imaging. However, I noticed that in the 2016 codebook, under code 50390, it still directs the coder to add code 74425 (urography) to the 50390 injection code. I assume this is not for a diagnostic study. Under what circumstances or in what scenario in 2016 would you use code 50390 with 74425?

Aspiration Thrombectomy

"The physician performs a diagnostic angiography of the left lower extremity (75710-59) and then decides to place stents in the mid, distal, and proximal SFA (37226-LT). After this he performs a confirmatory angio and determines there is thrombus material in the posterior tibial and peroneal arteries. He then performs a suction thrombectomy, which removes the thrombus." I am unsure how to code the thrombectomy, as it was not mechanical and it is in a different vessel territory than the SFA stents. Is unlisted code 37799 my only option here, or is this not even billable?

Pocket Relocation

If an electrophysiologist performs an ICD removal from the left side, moves it to the right side, and then tunnels the lead from left to right and reattaches the lead to the right-sided defibrillator, is there a reportable code the physician can use for the work involved in the tunneling?

Procainamide Challenge

Patient was admitted and 1 gm IV procainamide was given in an outpatient setting. My doctor dropped the charge of 93623 (the add-on code) and nothing else. This was done alone and not part of an EP study. What code should I use to bill for this?

Monitored Anesthesia Care

The use of MAC is being done more frequently within hospitals during EP studies as well as other diagnostic services. Both G-codes currently available are G-codes assigned status indicator M. Per AMA, this should only be done when medically necessary or potential for adverse reactions to the procedure. Our OR currently charges this a regular anesthesia for all EP studies, but I'm not sure this is appropriate. Code G9654 will be new for 2016 (also status indicator M). Any advice?

Billing angioplasty with stent placement in same session

This Q& A below was in the ZHealth coding newsletter of December 2011. Does this still apply, or has there been changes to billing angioplasty with stent placement based on intent? Original Question: "Can you bill angioplasty code 35476 and stent placement code 37205 in the same venous (SVC-IVC) or pulmonary artery (92997, 37205) when angioplasty is not just for inflating a stent that is placed?" Original Answer: "Depends. There needs to be an intent to only perform balloon angioplasty, with a suboptimal outcome requiring stent placement to code for both. If this is not documented, I would only code the stent placement."

Unsuccessful Outcome

The intended procedure was to place a coronary stent, but, after much time and many attempts with various caths, the lesion was not crossed. How should this be billed?

Diagnostics at Time of Intervention

I'm getting denials for codes 75716 and 75625 billed with 37221/37224 or intervention codes billed on same encounter. The CPT Codebook indicates that for lower extremities the radiological S&I directly related to intervention is included. In the past we have billed these S&I codes with a -59 modifier. Are they still eligible to code?

Attempted Port placement

I have an attempted port placement: "Right internal jugular vein was accessed with a needle under ultrasound guidance with angiography of the right internal jugular vein. Catheter was removed. Left internal jugular vein was accessed with needle under ultrasound guidance. Needle was advanced to the brachiocephalic and imaged obtained of the left jugular and brachiocephalic veins." Since the SVC could not be accessed via either of the jugular veins due to central occlusion, the port catheter placement was aborted. Are codes 36000, 36000-76, 75860, and 75860-76 appropriate?

Billing 36010 with 93531

Can I bill for both codes 36010 and 93531 for the following, since it comes up as bundled in the NCCI edits and needs a modifier? "Catheter Course: The right femoral vein and right femoral arteries were percutaneously entered under ultrasound guidance, and a 4 French sheath was placed in each vessel utilizing the modified Seldinger technique. The right femoral vein was pre-closed with three (3) Perclose devices. The 4 French sheath in the right femoral vein was eventually upsized to a 16 French Gore DrySeal sheath. A 4 French pigtail catheter was inserted into the 4 French right arterial sheath and subsequently advanced retrograde to the ascending aorta and into the morphologic right ventricle (systemic ventricle). A 7 French GL catheter was inserted in the right femoral sheath and advanced in the usual fashion to the IVC, inferior and superior baffles, and SVC. Pressures and saturations were taken, and an angiogram was performed of the IVC." 

Venous Mechanical Thrombectomy

In your endovascular surgery book it states that venous code 37187 is used once per day per vascular territory. Is the venous vascular territory the same as arterial iliac, fem-pop, and tibial-peroneal territories? If a physician is doing a thrombectomy in the iliacs (common, external) and femoral (common, SFA, and popliteal) would code 37187 be reported twice or just once? I just want clarification on the initial day.

Documentation to Charge 76937

Is the following documentation enough to support charging code 76937? If not, can we down-code it to 76942? Physician is placing a bedside non-tunneled CVC. He uses US guidance. Here is a copy from the note: "Preparation: Sterile preparation of site (in usual fashion, with 2% chlorhexidine gluconate, with full drapes, gown, gloves and mask). Vessel was identified with ultrasound guidance. Technique: Seldinger technique used, location (left, femoral vein, 1 attempt), anterior approach used, catheter type 4 lumen catheter, location confirmed via flashback, catheter flushed with saline, dressing applied (catheter secured, semi-permeable transparent dressing applied), monitoring during procedure (blood pressure, cardiac, continuous pulse oximetry). Procedure tolerated: well."

Clarification of an Acute MI in Reference to C9606

I am coding for the hospital cath lab services. We have a large percentage of patients who are admitted with an acute MI, and the intervention is performed the next day. My understanding is that code C9606 is appropriate if the patient goes to the cath lab within 90 minutes [e.g., patient presents with NSTEMI and 24 hours later goes to the cath lab for a left heart cath with V-gram, coronary and graft angiography, and two drug-eluting stents in the LCx (95%)].

Right Heart Cath with LV Injection

What would we report when only a right heart catheterization was performed in addition to an LV injection?

Sitz Markers

I'm not sure if I can bill separately for the Sitz marker placement. I'm thinking unlisted, but what are your thoughts on this case? "The lower abdomen and current cecostomy site were prepped and draped in the usual sterile fashion. Initial fluoroscopic image identified the pigtails of the current Chait tube to be within the region of the cecum. A stiff Glidewire was introduced through the Chait tube and advanced into the ascending colon. The current Chait tube was removed in its entirety. A 12 French vascular sheath was inserted over the Glidewire with tip positioned within the ascending colon. A C-wire was placed through the 12 French vascular sheath with tip positioned in the ascending colon. The 12 French catheter sheath was then removed and replaced over the Glidewire. The Glidewire and inner dilator of the vascular sheath were removed. The external portion of the gastric sheath was cut. Under fluoroscopic guidance, 72 Sitz markers were placed through the vascular sheath and into the cecum. The sheath was then removed. A new 28 Chait tube was replaced."

Renal Angiography and Stent Placement

"Femoral access gained. Cath to infrarenal aorta, aortogram performed showing high grade stenosis in right main renal artery and on left 3 renal arteries. Left renal cannulated and angiogram performed, confirming 3 renal arteries and no significant stenosis. No intervention on left. On the right catheter placed at the level of the right renal ostium and crossed this with a wire. Obtained an angiogram to confirm placement and then placed a stent across the lesion. Post treatment angio showed widely patient right renal artery." Would you report codes 36251, 37236, and 36245?

34502 vs. 37799

I know in past years renal vein transposition was unlisted, and it is what I have always used. I have a physician asking if we can use code 34502, but I am not sure I agree with that code, as the only IVC repair/reconstruction completed is where the renal vein is taken down. I am just wondering if there is something I am missing somewhere of any new codes that can be used, or if it truly is just unlisted. 

TEE

We did a Mitraclip with TEE (93355) guidance. I noticed that medical records coded this as "B244ZZ4 - ULTRASONOGRAPHY OF RIGHT HEART, TRANSESOPHAGEAL". When I asked about it, I was told the following: "The cardiologist needs to state 'right and left TEE' in the procedures performed or description of findings. The coders cannot assume.” However, the report has the supporting findings of right/left chambers, all valves and measurements, pressures, etc. Before I speak with the cardiologists on this request, what is the appropriate documentation for ICD-10 coding on inpatients? HELP!!

Echo ICD-10 Dx

The way things are in the book is confusing. When looking in the index, both "insufficiency, aortic" and "insufficiency, mitral" go to the I3x codes (nonrheumatic), but the "insufficiency, tricuspid" leads you right to code I07 (unspecified). If you are coding aortic stenosis (with or without insufficiency), you are brought to the I35 codes (nonrheumatic), yet mitral stenosis (with or without insufficiency) brings you to I08 (rheumatic) codes. ICD-9 was clear, as the codes were specific to either being rheumatic or NOS. With ICD-10, the description in the tabular section of the book for the rheumatic codes includes conditions whether specified as rheumatic or not. How would you diagnosis code a patient with aortic, mitral, and tricuspid insufficiency?

MRI of the Spine

Our office has been experiencing a new problem when billing HAP insurance. We had a patient who had MRI of the thoracic spine and an MRI of the right shoulder on the same encounter, which was billed using CPT codes 72146 and 73221-RT. HAP paid only on the MRI of the shoulder and not the MRI of the thoracic spine. HAP informed us that the MRI of the thoracic spine was denied based on CMS cutbacks. The same happened with another instance when a patient came in for an MRI of the thoracic, cervical, and right shoulder on the same encounter; HAP only paid for the MRI of the right shoulder and denied the thoracic and cervical due to CMS cutbacks. Am I missing an additional modifier that needs to be appended, or is it that the MRI of the spines should be done on a different day than the MRI of the extremities??

Blood Patch After PTX

During a CT biopsy of the lung, the patient had a pneumothorax. The doctor performed "autologous intrathoracic administration of blood product for treatment of pneumothorax". Is there a code we can bill for this? 

Y90 and Post NM Scan

Now that there is an edit in place between C2616 and any of the liver/spleen NM scans, should we no longer report the NM scan following a Y90 embolization procedure? 

ECA Branches and Embolization

"Intractable idiopathic epistaxis. Selectively cathed the right and left CCA to view neck and face vessels, selectively cathed the right ECA, and selectively cathed the right and left internal maxillary arteries confirming no undesired collaterals. Embolized the right and left internal maxillary artery with PVA and gelfoam. Post angio was done to confirm no residual nasal mucosal stain. Then a right facial artery was selected, and angio proved no significant supply to the nose from this artery." Please let me know if you would code this differently and why. I'm looking at codes 36222-50, 36227-50, 61626-RT, 61626-59LT, 75894-RT, 75894-59LT, and 75898. Is there another code for catherization of another branch off the ECA?

LIMA Separate Session

I'm not sure how to code this. Patient was in our facility as an IP from 11/20-11/29. We do charge our cath codes on IP, but they don't "go out the door on the bill"... we use them for revenue tracking in the facility. Patient had diagnostic cath with angios on 11/20 and was then brought back on 11/25 to evaluate the LIMA for potential graft as a stand-alone procedure. Then, on 11/27, they decided to do high risk PCI because patient was not a candidate for CABG due to lung issues. So, since the LIMA was evaluated on a different day and not in correlation with a cardiac cath procedure, should I use code 75756? I don't think it's appropriate to code/charge the LIMA evaluation as a coronary angio on 11/25, and for the 11/20 DOS I don't think it's appropriate to change that to a bypass angio because only native arteries were looked at. What are your thoughts?

Attempted Pulmonary Vein Recanalization

Can we report 35476/75978 (x3) with a -52 modifier for ATTEMPTED recanalizations if no angioplasty is performed? "Procedures performed: Right and left heart catheterization. Attempted recanalization of LUPV, RMPV, and RUPV using radiofrequency (Nykanen RF wire). Several rounds of RF were placed at the pulmonary vein sites, but were unable to gain access to a vein. At this point, we did not feel that there was a feasible transcatheter approach to recanalize the stenotic/atretic pulmonary veins. This was the end of the interventional portion of the case."

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