If we went through the whole process of performing a lumbar puncture after anesthetizing the area and could not obtain any fluid, do I have to modify the procedure as attempted but failed?
How does one properly code for a failed/unsuccessful procedure to recanalize (cross a CTO) an obstructed peripheral artery (e.g., lower leg)?
If a warranty credit is received in 2014 for a procedure that took place prior to January 1, 2014, do we still use the -FB/-FC modifiers? Following is an extract from MLN Matters® Number: "MM8572 No Cost/Full Credit and Partial Credit Devices Effective January 1, 2014, CMS will no longer recognize in the OPPS the FB or FC modifiers to identify a device that is furnished without cost or with a full or partial credit. Also effective January 1, 2014, for claims with APCs that require implantable devices and have significant device offsets (greater than 40%), the amount of the device credit will be specified in the amount portion for value code “FD” (Credit Received from the Manufacturer for a Replaced Medical Device) and will be deducted from the APC payment for the applicable procedure."
My physician completed a right fem-pop bypass using saphenous vein. As the right external iliac was not clampable for an endarterectomy, he instead balloon angioplastied the stenotic segment and placed a stent through a micropuncture needle in the common femoral artery. I would only code for the bypass, as I would consider this part of localized inflow and outflow. My provider disagrees and thinks this should be billed in addition to the bypass. Can you please provide your thoughts?
"Patient had a CTA with run-off showing AV fistula at the fem-pop bypass graft and came to IR. Bilateral run-off was done, catheter was placed in the graft, and embolization occurred with many coils. PTA was done in the popliteal artery at the anastomosis." I believe I should report code 37242 for the embolization and code 37224 for the PTA of the popliteal. The vascular surgeon wants to code the bilateral run-off plus catheter placements. Would you verify for me please?
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?
Greetings, I have a physician completing a femoral arteriovenous fistula for a pedicle free flap to the lumbosacral area. They tried a iliac artry exposure first but due to scar tissue they had to expose the femoral vessels. The physician harvested the entire greater saphenous vein,then anastomosted the vessel to the common femoral artery. This was then tunneled to the lumbosacral area. While tunneling the illiac vein was injured. How would I code this? A fistula tranposition code with a 36818- 22. The unlisted code 37799. Do you have any advice? Thanks, LW
How do I code for a common femoral to profunda bypass using a Dacron graft same leg?
I am hoping you can help with the following case. I don't believe that code 35879 should be billed at the same time as code 35566, but I am considering the use of a -22 modifier. "Once femoroperoneal bypass was completed, ultrasound Doppler was used to evaluate graft, and the graft was found to have relatively low velocities of 15cm/sec in the thigh. There was a significant flow difference noted with velocities of 80 cm/sec in comparison to adjacent velocities of 15cm/sec. Incision was made over the graft, graft was mobilized, and it was decided to proceed with patch angioplasty since abnormality was likely a frozen valve. A segment of residual GSV was harvested and opened longitudinally for patch purposes. Arteriotomy was made through the valve and fibrotic tissue debrided away from the wall. Standard onlay vein patch angioplasty was then performed. Repair was complete, flow restored, and duplex showed no abnormalities with significantly improved velocities. Total procedure time was 7 hours."
My question is regarding the new codes for fenestrated grafts for repair of the visceral aorta. Am I assuming these codes apply to grafts from the manufacturer and ones that are custom made by the surgeon in the OR suite?
Our practice just performed their first fenestrated EVAR. They used a fenestrated aortic cuff with a bifurcated stent graft. They also stented both renal arteries with iCAST stents and used an extension on the right iliac and used an iCAST stent on the left iliac. From what I have researched, I believe the codes would be 0078T, 0079T, 0080T, 0081T for the fenestrated cuff with bifurcated EVAR graft, and codes and 34825, 75953-26 for the extension on the right iliac. Are the renal stents included in the fenestrated graft codes, or can they be coded additionally? And can the iCAST stent for the left iliac be coded with 37221? A stent was done because 'there was only 4-5 mm of available iliac artery to extend the graft and there was noted to be poor apposition of the stent wall due to tortuosity of the proximal iliac artery'.
We've just done our first fenestrated repair of an aortic dissection, and we are needing help with coding it. Can you help us? Here is what was done: 1) Successful balloon-assisted juxtarenal and infrarenal aortic fenestration. 2) Unchanged SMA occlusion. Patent celiac axis, IMA, and bilateral renal arteries. 3) Occlusion of right common iliac artery successfully treated with bare metal stent.
Is it okay to report code 93580 (fenestration closure) and 93568 (pulmonary angiography) when the angiography is done after the fenestration closure when documentation states that "angiography revealed complete occlusion of fenestration in right atrium"? It is my understanding that codes 93580 and 93568 are bundled and should not be billed separately.
One of our doctors will soon begin doing fetal cardiac interventions (aortic valvuloplasty, pulmonary valvuloplasty, ASD creation, pacing) in conjunction with doctor from Maternal Fetal Medicine for the access to the fetus. Any idea how both doctors would bill for these procedures? Please help.
Pediatric cardiologists bill codes 76825, 76827, and 93325 for fetal echos. They also look at the umbilical artery. They want to bill code 76820 in addition to the three above codes. Looks like there is a bundling issue with codes 76820 and 93325, but 76820 pays more. I can't seem to find anything about billing these codes together. I'm assuming code 76820 cannot be billed in addition to these codes, but I would like to confirm.
The doctor did a FEVAR (with the graft covering the entire abdominal aorta) with placement of stents into bilateral renals and bilateral femoral exposure. One side was inserted through the "scallop" and the other through the fenestration. Is this reported with code 34846? Or with codes 34845 and 37236?
When choosing the code for repair of an AAA with a fenestrated device, is the code determined by the number of fenestrations or the number of stents placed in visceral arteries? The CPT code description says "including 1, 2, 3, or 4 visceral artery endoprostheses", which leads me to think the code is determined by the stents... but then how would I code a graft with four fenestrations and zero stents? My physician has done several cases where there are four fenestrations, and he only places stents in one, two, or three arteries.
Can I bill surgical cutdown codes 34812 and 34834 along with fenestrated aortic stent graft with three visceral artery endoprostheses?
We are hitting an edit whenever we code an FFR 93571 with a drug-eluting stent procedure. We are told that we need a primary procedure code with 93571 and that C9600 is not acceptable. (Note, this is a hospital.) The acceptable codes for 93571 are the heart catheterization codes and the bare metal stent codes. I would appreciate you help.
Dr Z ~ Now that we can charge for individual vessels for PCI (LAD, diagonal) can we also charge separately for Radi wire diagnostic, per vessel (93571 and 93572)?
Would there be anything separately reportable on FFR performed on a renal artery, or would that be part and parcel of "including pressure gradient measurements when performed" in the description of CPT procedure codes 36251-36254?
Hi Dr Z, One of our physicians recently performed a bilateral renal angiography, and placed a FFR wire in the left renal artery. It is my understanding that the FFR is not separately billable with a non coronary angiography. Thank you
The patient first had a left heart catheterization with angiography at his doctor's office owned by our hospital (93458). The patient then was sent over to the hospital for FFR of the LAD and RCA. Our hospital cath lab charged code 93454 for the coronary angiography and codes 93571, 93572 for the FFR. When computing, we are getting an edit stating that code 93454 is a component of 93458 (because the charges for the two facilities are being combined). Is it acceptable for the hospital cath lab to charge for the coronary angiography once again (with the -59 modifier) since it was already performed by the physician office during the heart cath the same day? Or should the hospital cath lab only charge for the FFR? Current charges are: 93458, 93454, 93571, 93572.
IFR is now being performed regularly in the cath lab. The difference between it and FFR is that there is no pharmacological agent being given (adenosine). As the CPT for FFR (93571) specifically states “including pharmacologically induced stress”, is there another code that can be used for IFR, or can it perhaps be modified? It is performed using the exact same wire and control module. Any suggestions?
Distruption of fibrin sheath with angioplasty balloon 2011 Z Health Vascular & Endovascular Coding Reference lists 36595-52 & 75901-52. Distruption of fibrin sheath with angioplasty balloon 2012 Z Health Cardiovascular Coding Reference lists 36595-52 & 75901 without the 52 modifier. Why the difference in 2011 & 2012?
Do you have guidance when it comes to disruption of a fibrin sheath with a CVC diaylsis catheter exchange (not a Tessio catheter)? If a fibrin sheath was disrupted in the SVC and another fibrin sheath in the innominate vein, would codes 36595-52/75901 be assigned twice (once for each vessel) or just once (similar to guidelines of coding only one central PTA)?
Can you please explain why when fibrin sheath PTA is done via the same access in a hospital facility modifier -52 is not utilized only on the physician side? This modifier is used in other outpatient hospital coding and is approved per the CPT Manual (where modifiers are listed). I know this is in your literature but not the explanation behind it.
Is the following coded as a fibrin sheath (36595-52), a PTA (35476), or both? "A pull-back SVC venogram was then performed, revealing a fibrin sheath and stenosis at the superior cava/right atrial junction. The existing catheter was exchanged for an 11 French vascular sheath. Balloon angioplasty was performed using a 12 mm balloon, followed by a 14 mm balloon for fibrin sheath disruption and stenosis dilation. Follow-up venogram demonstrated satisfactory results with disruption of the fibrin sheath and slight improvement in the SVC stenosis."
Prior to TIPS, a fiducial marker is placed into the liver. "Under real-time CT fluoroscopic guidance, a 3 cm x 3 mm coil was placed to mark the portal vein bifurcation. FINDINGS: Archived images demonstrate excellent positioning of the fiducial marker at the portal vein bifurcation. IMPRESSION: Successful marker placement." Following, TIPS was attempted. "Access the right internal jugular vein using US guidance. A multipurpose angiographic catheter was used to select right hepatic vein, accessory right hepatic vein, and left hepatic vein. Hepatic venography was performed in each vessel. I tried several times to pass a working sheath into the occluded left hepatic system, and was unsuccessful each time. Due to hepatic venoocclusive disease, no invasive pressure measurements were obtained. IMPRESSION: Hepatic venoocclusive disease." I am unsure of how to code the coil. It's not being used for radiation, so I don't believe code 49411 is correct. It is not an embolization either. Also, would the hepatic venography be reported with codes 75891 and 36011 x 2?
Is a biopsy performed at the same time as a fiducial/vesicoil placement inclusive? So, if the physician performed a vesicoil placement in the chest under CT guidance and performed a biopsy at the same encounter, I would report codes 32553 and 77012 only, correct?
I had previously submitted the question, if a biopsy and a fiducial placement were performed at the same encounter, could they both be billed. You answered that they COULD both be billed. My compliance department wants to make certain they can both be billed if the biopsy and fiducial marker placement are performed from the same access point with the same needle.
We have multiple opinions flying around on this one, so I wanted to run it by you. Patient has/had DVT of the lower extremities and had a filter placed. She is seen now to have a lower extremity venous ultrasound done prior to removing the filter to check the status of the DVT. On the left it looks to have resolved, but on the right it's undeterminable if it has completely resolved. Would you use the DVT diagnosis (453.41/453.42), a follow-up (V58.81/V58.89), or a pre-op (V72.83) diagnosis code? I'm leaning towards the DVT, but a few do not agree, so I was hoping to get your opinion on it.
Dear Dr. Z: IVC filter migrated into the right lower lobe pulmonary artery requiring removal. Would 37203, 75961, 36014 be reported or would we report the standard filter retrieval 37193? Thank you. mlb
I apologize for my last question: It should have read what is the coding difference between a flow wire/pressure wire (93571-26) and a filter wire. I do not have a code for the filter wire.
Can we report both codes 93655 and 93656 for FIRM (focal impulse & rotor modulation) and pulmonary vein isolation catheter ablation to treat atrial fibrillation? Usually these rotor ablations are done in both the right and left atrium prior to PVI. If reportable, should we assign code 93655 twice for left and right no matter how many rotors/lesions were ablated? Or do we code based on the number of lesions ablated? Here's an example: "The 60 mm basket catheter was deployed in the left atrium and Epoch 3 created, which appeared to show rotors on the mitral annulus just anteroinferior and posteroinferior to the left lower vein. These rotors were ablated and ablation lesions connected. Epoch 4 showed a posterior wall rotor, which was over the esophagus and was difficult to ablate extensively due to heating. Epoch 5 and epoch 6 were created after adjusting the basket to better contact the posterior wall. These revealed rotors in similar areas as the prior rotors. Ablation lesions were delivered extending the prior lesions along the mitral isthmus and on the posterior wall. During ablation, atrial fibrillation terminated."
Is the fistula anastomosis considered an arterial anastomosis or a vein anastomosis? I have been coding a stenosis in the fistula anastomosis (like a brachiocephalic fistula) with codes 35475/75962.
Will code 36833 cover the following procedure? Or are codes 36147 and 36148 also needed? Please advise. "Patient with aneurysmal left brachiocephalic AV fistula with aneurysmal stick site, skin ulceration over upper stick zone. Micropuncture needle was inserted into proximal portion of fistula with wire advanced under fluoroscopy into upper fistula beyond aneurysmal stick zones. Sheath inserted up into subclavian vein and parked there with fistulogram done. Long segment of high grade stenosis (80%) began just beyond aneurysmal upper stick zone. Stenoses were balloon-dilated with good result and puncture site sutured. Attention turned to aneurysmal site in upper stick zone. Ulcer was excised with elliptical incision back to healthy skin on both sides, down to fistula. Inflow portion of fistula into stick zone was dissected and clamped. Patient was heparinized. Part of aneuyrsmal fistula was excised, revealing ulcer had penetrated into fistula with layer of thrombus between scabbed area and fistula. This was excised including excessive thrombus. Opening was oversewn in two layers, clamps were released, and suture line was hemostatic. Subcu and skin sutured."
Dr Z, we had an interesting case in which a patient with a brachio-cephalic AVF was complaining of severe arm swelling. Fistulogram was performed revealing the fistula to be widely patent, so an upper extremtiy arteriogram was performed revealing an occluded brachial (just distal to the anastomosis) and ulnar artery, as well as occlusion of a previouslly placed stent in the left subclavian. At this point the sheath is pulled and hemostatis is achieved. Vascular surgery consult is obtained. Later the same day, they re-access the AVF, but this time a diagnostic exam is not performed, just thrombectomy and restenting. How do you recommend we code the re-accessing of the AVF on the same day, should we use 36148 even though it is a separate session? Thank you
"Operative report: The catheter was placed in the fistula located in the left abdomen near the lap band adjustment port. Next, contrast was administered during fluoroscopy observation. Contrast is administered, which demonstrates a fistulous track between the skin and the implantable port. There was a contrast leakage along the catheter to the skin surface. No intraperitoneal extravasation or fistulous connection is seen." Code 76080 has been billed for this procedure, but shouldn't a surgical code such as 10030 or 20501 also be reported in this case?
The following case was coded with 35476, 36870, 75978, 36147. We were asked to add codes 37212 and 75791 by our HIMS dept. Not sure if this would be appropriate. "The graft was accessed with a micropuncture needle in an antegrade fashion. A fistulogram was then performed from the right atrium to the level of the fistula. Two improve visualization of the central stenosis a Kumpe catheter was advanced to the subclavian vein and subsequent venography performed. Fistulogram demonstrated a large thrombus within the fistula distal to the venous anastomosis. Thrombolysis was performed and this thrombus was laced with 6 mg of TPA. After a short waiting period a catheter and wire were advanced beyond the thrombus. Another 6 mg of TPA were used to lace the venous outflow thrombus. Mechanical thrombectomy was performed through the outflow vein and the fistula thrombus. The above described conduit and venous outflow stenosis was negotiated with a glide wire. Subsequent balloon angioplasty was carried out without significant residual. Brisk flow was acheived."
Hello. My question is regarding C1874 stent coated/covered with delivery system. Is the flair stent inserted in this example a drug eluting stent? Does the HCPCS code C1874 necessarily equal a drug eluting stent? thanks for your help! Utilizing 2% lidocaine as local anesthesia a 21-gauge needle was corrected into the arterial limb of the AV dialysis graft directed towards the venous anastomosis. Subsequently, a AV shuntogram was performed demonstrating a high-grade focal stenosis involving the venous anastomosis. A 6 French sheath was placed and the anastomosis crossed. This was then dilated to 7 mm which appeared to improve flow, however, residual intimal regularity remains. As a result, a 7 mm x 5 cm fluency stent was deployed across the venous anastomosis. This was then dilated to 7 mm. The graft also demonstrates mild diffuse intergraft stenosis. This was also dilated to 7 mm. A post procedure shuntogram demonstrates no significant residual stenosis, however, the thrill was suboptimal following this procedure. As a result, the arterial anastomosis was evaluated. This demonstrates a high-grade arterial anastomotic stenosis. A 21-gauge needle was then directed into the venous limb of the graft directed towards the arterial anastomosis. A 5 mm x 2 cm balloon was then inflated across the anastomosis. A post procedure fistulogram was then performed demonstrating no significant residual stenosis. A nice palpable thrill was achieved within the graft. As a result, the access guidewires, vascular sheath, and balloon catheter were removed.
Dear Dr. Z, Thank you for taking the time to consider my question. Our facility treated a patient who they suspected as having Brugaga Syndrome so a flecainide challenge was done. The patient had a base EKG done then was given 400mg of oral flecainide. EKGâ€™s were then done after one half hour, one hour, two hours, three hours and four hours. My question is what CPT code (if any) would be appropriate for this procedure? I have reviewed the Noninvasive Physiologic Studies and Procedure section of the CPT book and 93799 â€“ unlisted cardiovascular service or procedure is the only one I feel can be used. The other option I have considered is to only code the EKGâ€™s and not apply a code for â€œflecainide challengeâ€. Thank you in advance for your input. Debra Patterson, RHIT
Can we use 93463 for the evaluation of pulmonary hyperetnsion reversibility using intravenous Flolan (epoprostenol)during a right and left heart cath?
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 am coding a case of a dissecting aneurysm of the supraclinoid left internal carotid. The physician used a Y-stenting technique without the use of coils to divert flow and "occlude" the aneurysm. One stent was placed in the supraclinoid ICA and A1 segment. The M1 segment was selected through an open cell of the previously deployed stent, and a second stent was deployed in the supraclinoid ICA and M1 segment, bridging the aneurysm. This created aneurysm occlusion through flow diversion. Would this be coded as an intracranial embolization with code 61624, or should I use an unlisted code? I have read that this is a new technique used for wide-necked aneurysms, aneurysms where the emanating branches are incorporated in the sac, or it's a giant aneurysm causing mass effect.
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.
Can we charge for fluoroscopy guidance (77003) when the fluoroscopy is provided by a radiology tech and the procedure is performed by a surgeon? The surgeon dictates fluoroscopy guidance was used in the operating room procedure. An example is code 62311, epidural injection (myelogram, epidurogram, and arthrogram are not performed in the OR procedure).
Dr. Z, If a patient recieved an epidural injection along with a facet injection, can I add a modifier 59 to 77003 (fluoro guidance for the epidural)? Patient has right lower back pain radiating to the right lateral thigh. Impingment of right L3 and L4 nerve roots seen on recent MRI. Patient also has moderate central canal stenosis and facet arthrosis per the CT done 9 days earlier. Thanks for any help you can give me. Michelle
One of our IR docs is taking a spot image after removal of a port and cath, and we are trying to determine if it is appropriate to bill code 77001-26 in this circumstance (pro fee side). What are your thoughts?
Here is a brief synopsis: the patient is having prolonged post-transplant hospital course with persistent pericardial effusion and persistent mild respiratory distress. The patient presents to cath lab for fluorscopic evaluation of the diaphragm as well as her routine post-transplant RHC and biopsy. The eval of the diaphragm is a fluoroscopically saved image which demonstrated that the left hemidiagphragm is paretic with evidence of paradoxial motion of the diaphragm. The existing pericardial drain and 350 ml of straw-colored fluid was removed. Oximetries & hemodynamics of the RH were done pre and post pericardial drainage. Endomyocardial biopies were done X5. I wanted to bill 93451-26-59, 93505-26, 33010, and 76000-26. However,76000-26 hits an edit with 93505 as bundled and no modifier is allowed. Is there another code I should be using or is the evuluation of the diaphragm non-billable? Thanks so much for your help with this scenario!!!
Could you please tell me if unlisted code 43499 should be used in this scenario, or can code 43453 be used? I am thinking of the unlisted but need help. "A 5 French Berenstein catheter, in combination with a 0.035 inch Amplatz guidewire, was advanced through the oropharynx and cervical esophagus across the anastomosis and into the thoracic stomach. A 14 mm Atlas balloon was advanced over the guidewire and into appropriate position. The balloon was inflated. The waist resolved with inflation to 20 atmospheres. The balloon was left inflated for 1.5 minutes. The balloon was then deflated and removed. Repeat dilation was performed using a 16 mm balloon and inflated to 20 atm for 1.5 minutes. A repeat esophagram was performed. This demonstrated improvement in luminal caliber. There was no extravasation demonstrated."
What are the appropriate facility codes for the fluoroscopic insertion of spinal fiducial markers for a spinal tumor? If the patient is a medicare outpatient, would HCPCS C9728 and 77002 be the correct codes for this type of case?
Dr.Z, Since code 27096 now includes fluoro, does G0260 follow the same rules and include Fluoro? Thanks so much Henri
Dr. Z, a facility wants to charge 76001 for a tech and a fluoro machine being in the OR for more than an hour even though the documented time for use of the fluoro is less than an hour. There is a physician in the room for more than an hour but the fluoro machine is not being used for the whole time. What is the correct way for the facility to code for the fluoro when the OR procedure does not involve an S&I code and the documented time is less than time in the room. Thank you.
Is it enough to dictate that 6 minutes of fluoroscopy was used to support the use of the code 77001 or 49440? If not, what would be the appropriate documentation? For example, if the dictation stated that the wire was advanced under fluoroscopic guidance, is that enough? Or should the use of the fluoroscopic guidance be matched up with the final placement of the catheter?
I code cases for a hospital, and we are needing clarification regarding epidural steroid injections. Your 2015 Interventional Radiology Coding Reference, page 511, #1, states, "Per CMS, do not use code 77003 with codes 62310-62319." What is the specific CMS guideline/regulation stating not to report code 77003 with 62310-62311?
Hi Dr. Z We were discussing the fluorscopy code (76000) vs the cineradiography code (76120). If the doctor uses fluoroscopy to check on a valve or a lead, takes some images and that is all....which code is appropriate or can both be used? Thanks for your help!
Original Question: Will you please address the issue of tunneled catheter removal since it now has its own code (32552)? Is it appropriate to code a fluoro guidance code, 76000 or 77002? I don't get an edit, but the your IR book states S&I is N/A. In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter. The catheter could have been compromised because of infection. Why is this? Thank you! Additional Information: In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter. The catheter could have been compromised because of infection.
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 have a question regarding FNA of thyroid nodules. We have a physician who mentions in his report that he is doing a capillary and suction technique, but never mentions FNA. When we say we need documentation for FNA versus core, his reply is "capillary and suction technique" is FNA. Can we assume and code these as FNA? Please advise.
I have a radiologist who has told me whenever he does a biopsy of the thyroid it is always core; however, he never dictates "core" in his reports... he always just says "tissue". Pathology from the hospital always says FNA. So my question is, do I report code 60100 because that's how he instructed me to code, or do I go with the pathology and report code 10022?
I need to know when I can code both a fine needle aspiration and a core biopsy. Sometimes our physicians do not say why they go on to obtain a core after an FNA has been done. If a reason is not documented, should I just code for the core biopsy? Following is an example: "Ultrasound of the neck revealed 2.5 cm of right cervical lymph node/mass. A 25 gauge needle was advanced into the mass with ultrasound guidance, and an FNA was obtained and given to pathology. The needle was removed, and a total of six core biopsies were also obtained. Post ultrasound demonstrated no hematoma or complication."
We have a patient who had an IR px for insertion of a Foley balloon into the pleural space with injection of calcium channel blocker to stop a massive hemothorax. Once bleeding was controlled, it was determined that the intercostal artery was punctured from a previous chest tube placement. Do you have a suggested CPT code and ICD9 px code?
Can we code/charge for foley catheter placement in Cath lab or EP lab? It's done prior to long procedures in EP. It's done in the Cath lab if the bladder is too full or patient will have difficulty using bed pan after procedure. As always, we appreciate your assistance! Thank you!
Dr. Z, Our radiologist does Discectomies, vertebroplasties, and kyphoplasites quite a bit. He always has a follow up CT/MRI in 2 weeks to 1 month. These procedures have a 90 day global, can I charge for the follow-up CT/MRI? Thanks
Follow Up to Question ID #5966, it states: ‘A caveat would be if two physicians are in same group and use same billing number then code as usual, as add-on code 93571 would be okay with the heart cath.’ Can you further clarify what is meant by ‘code as usual’? Do you mean first physician can code and bill add-on code since second physician is in the same group even though first physician didn’t perform add-on procedure? CPT manual, p. xiv outlines: “The add-on code concept in CPT 2014 applies only to add-on procedures or services performed by the same physician. Add-on codes describe additional intra-service work associated with the primary procedure…Add-on codes are always performed in addition to the primary procedure and must never be reported as stand-alone code.” CMS 1/1/14 policy outlines the same principal. Also, if FFR/IVUS is performed on same day as heart cath but by two physicians in different groups then do you recommend each physician code their part with second physician utilizing unlisted code 93799 to capture the stand alone px of FFR/IVUS.
Our physician recently attended a conference where he was told that you can now bill all of the following: 4-vessel diagnostic angio done (36226-50 & 36224-50), emergent crani done for aneurysm clipping (61697), and follow-up angio done in internal carotid (36224) to make sure the clipping was complete. This is done all in one operative session. MUEs previously had 36224 as one, so we have only been billing code 36224-50 in these cases. But I see the MUE table for April 1, 2015 now is showing three per day for code 36224. (Looking at the January 1, 2015 MUE table on your site the MUE for code 36224 is still at 1.) So with that in mind, is it acceptable after April 1, 2015 to then bill codes 36226-50, 36224-50, 61697, and an additional 36224?
For follow-ups post infusion/embo (75898), I know it's to be done once (other than for intracranial procedures), but my physician asked about doing multiple AVM's (right and left lung), if they embo there, is that still just one follow up? or would it be two, one for each lobe? Same for multiple hepatic tumors? one follow up even if they embo multiple tumors through different cath. placements? thanks!
Please do NOT include any actual patient medical records with your question. DR Z I have a general question about Follow-Up (75898 ) charges. We coiled a cerebral aneurysm. Nine coils were placed into the aneurysm but only the last 2 were deployed.The other seven were removed because the DR did not like their placement. After each placement a follow-up angio was performed. Do you charge 9 follow-up's or only 2 for the 2 coils that were leftin for the embolization? I say you only charge Follow-up for the coils that actually embolized not the ones that were removed. TY
A question came up as to whether or not it is appropriate to charge for CAD when performing "spot compressions" on a follow-up diagnostic mammogram. Is there a requirement for the type/number of images on a diagnostic mammogram in order to charge CAD?
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?
"Patient had right-sided carotid cavernous fistula and upon imaging before embolizing the right they discovered that a left carotid cavernous fistula was present, so they came back two days later to embolize the left. They performed a bilateral cerebral angiography from the common carotids prior to the embolization, which was performed from the left cavernous sinus via femoral vein access. After embolizing, the physician came back and performed cerebral angiography as a follow-up from the bilateral internal carotids, the bilateral external carotids, and the left vertebral." So my question is, can I code the extrernal carotids as angiography? Or do I have to consider those a follow-up? Also since the catheter went further and since we code to the highest catheter placement, I am unsure if I should code the highest order and use the internal carotid code 36224 instead of the common carotid code 36223... or should it be 75898?
Does a separate report need to be created to support the filing of both codes 76380 and 76377 when a cone beam CT hepatic artery injection and 3D reconstruction are performed in conjunction with diagnostic hepatic arteriography in Y-90 planning? Alternatively, in reporting codes 76380 and 76377, is it sufficient to only note that the cone beam CT was completed during the angiographic procedure? Findings are reported as a single discussion without specifically noting what modality (angio or CT) was used, both having been completed. Reference is made to the angio and CT in the conclusion. How much documentation is required to support these codes?
Dr Z, What is the appropriate code for balloon angioplasty of a Fontan fenstration? " we then turned out attention to the Fontan fenestration. We crossed the Fontan fenestration with a coronary wire and glide catheter. We then exchanged the Glide catheter for an Apex RX 4.5 mm x 20 mm balloon. We advanced the balloon over the wire, across the Fontan fenestration and made a total of 3 inflationsfor a total of 6 seconds each. We then repeated the IVC angiogram and this revealed much improved shunting throught the Fontan fenestration and a slight drop in arterial saturations." Cath lab is using 92992, however I don't think that's correct. Is this an unlisted 93799 or would it code to a valvuloplasty code? Thanks!
I’m not sure what to do with this one. Patient came to cath lab to have an angioplasty of his AVF. While ballooning the subclavian and innominate vein, the balloon ruptured. Due to aspiration of blood from the inflation port of the balloon, the surgeon decides to take the patient to the OR for emergent surgery. In the OR he opens the arm, creates a venotomy in the fistula, and removes the balloon. It is noticed that there is some thrombus, so he removes the small amount of clot present and closes the venotomy. I don’t like code 37197 since this is open instead of percutaneous. I was thinking of reporting the exploration with code 35761 (which includes foreign body removal) (or possibly 35860 since there was bleeding) with modifier -XU or -59, as well as the open thrombectomy with code 36831 since they shouldn’t have had to do a thrombectomy as well. My other thought was unlisted code 37799. What are your thoughts?
After a PFO closure procedure (93580) the occluder device was seen to be floating in the left ventricle. During a second procedure, on the same day, the same doctor retrieved the device. To capture the device he actually pulled it back into the ascending aorta and there successfully pulled it into the sheath. Can I use code 37197 for this procedure or go to an unlisted procedure code?
We have physicians who have been given the direction, by company reps, to use code 37197 when snaring a wire advanced from an access site in the foot and exteriorizing it though a sheath placed in the common femoral artery. Is that an appropriate use of code 37197? I code for the facility and have never reported code 37197 in that scenario. I don't believe it is an appropriate use for code 37197, and I am being questioned by the physicians. If you could clear that up for me, I sure would appreciate it!
"1st lesion intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the 1st obtuse marginal 2nd intervention: A successful stent with balloon angioplasty was performed on the 99% lesion in the 2nd obtuse marginal 3rd intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the right posterior descending artery. 4th intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the mid RCA." I am reporting codes 92928-RC, 92929-RC (right posterior descending), and 92929-LC (1st obtuse). Can you code for the 2nd obtuse (92929-LC)? Per CPT: Additional PCI in a third branch of the same major coronary artery is not separately reportable. Since there are two PCI in one branch and one PCI in another, could you use code 92929 three times? I understand that Medicare considers the add-on code bundled into the base code.
Would placement of the FRED (Flow Re-Direction Endoluminal Device) be coded as an embolization or a stent? It looks like a stent, but it is used to occlude an aneurysm.
In the main radiology department, the tech will inject the gtube with contrast but then not use fluoro. they use regular xray instead. would we still charge a 49465 or something else?
Initial percutaneous placement of G-tube into the jejunum or duodenum is reported with codes 49440 and 49446. Using that same logic, would it be incorrect to report codes 43752 and 43761 for G-tube placement into the duodenum via nasal approach for enteral nutrition? The description of code 44500 in the Coder’s Desk Reference does not seem to describe what was actually done. Example: "Under fluoroscopic guidance, a 10 French nasoduodenal/jejunal feeding tube was advanced using real-time fluoroscopic guidance as well as a 0.035 stiff Terumo Glidewire and positioned in the proximal jejunum."
Is it correct to report code 76000 for an injection of room air into a gastrostomy tube under fluoroscopy to evaluate the tube? No contrast is used, so I don't think code 49465 would be appropriate.
How would you code a clogged G-tube clearance using soda water with follow-up contrast injection to confirm patency?
Please do NOT include any actual patient medical records with your question. For 2011, would the G0269 code still be coded with heart catheterizations for hospital side coding? The CPT coding notes say that closure device placement is inherent to the catheterization and not separately reportable, but we were not sure if that applied to this code. Also, if the patient came back and just had stent or angioplasty(no heart cath)would the G0269 code be used then? Thank you.
Dr.Z: I'm confused to when we can code for 75710 when doing diagnostic angiograms? Example:Right Common femoral artery was selected.AP views showed to have normal caliber and branching. The puncture site was appropriate for Angio Seal device deployment. They then continue with the diagnostic angiogram. thank-you for your help.
Is use of a closure device included if only a cardiac intervention is performed & not a diagnostic cath? Thanks
Dr. Z, At a resent conference, the speaker said that CMS wants us to charge for the closure device procedure, G0269, even if it is bundled in the procedure. The speaker said they want to know when the closure device is used for statistical reasons. Do you know of this being true with CMS? Thanks!
Is code G0269 bundled with the 2014 new embolization codes? It's not showing that it is on NCCI CodeManager. When would this code be applicable for billing with embolization?
Hello Dr Z! I was wondering regarding the renal codes for 2012, 36251, 36252, 36253 and 36254, all thou it does not say it in it's description, but is the closure device to be included in the charge as they were for the cardiac cath /endovascular revascularization codes for 2011?
Hi there-- In the facility setting as of 2011, I know that we are no longer supposed to bill G0269 in conjunction with diagnositc cardiac catheterization procedures. But is it still ok to bill G0269 if the only procedure performed is a PCI Procedure? (ie. a stent, PTCA, or atherectomy)?
I am trying to put together a list for my IR department that contains information regarding occlusive device placement charges. Do you have a list of the procedures that bundle the charges for the placement, as well as a list of procedures where the charge is allowed to be added? The devices have C-codes, so I want to have the appropriate charge on the accounts.
Our end coder, Code Correct, is advising that code G0275 has been deleted for 2014, but that G0278 is still active. Is it true? And if so, is MCR accepting any other code? I could only find a vague reference to it on MCR under Part A.
Dr. Z; I am torn on this report with the proper code assignment. In all honesty I am not sure that code G0275 is correct on this account and the Cath lab assigned 75625. I am in total disagreement with assignement of 75625 also I am not sure that G0275 is supported by this limited documentation. I am only giving infomration related to the abdominal aortography section of the report. Procedures Preformed: Left heart cath with ventriculography, selective imaging of the coronaries. Abominal aortography. Indications: Angia/MI: stable angina. Coronary artery diesase: suspected and abnormal stress test. Cardiac: arrhythmia. History: The patient has hypertension and medication-treated dyslipidemia. Coronary Bypass abdominal Aortography: A catheter was placed and contrast was injected. Aorta: There was medium-sizwed, localized(saccular) aneurysm formation. Infrarenal location. The root exhibited normal size. Thanks in advance for your help.
You have written much about G0278 amd G0275. I understand how to code for these and when to use it. However, I have an MD that codes for this but the indication for Cath does not address PVD. Wouldn't you have to mention this in the indication for Cath?
Please do NOT include any actual patient medical records with your question. Can selective catheter placement be reported when documentation states: A4Fr JR 4.0 catheter was advanced to the aorta and positioned at the vessel origin(common iliac) under fluoroscopic guidance. Right and left side. Cardiologist documents R/L heart cath with cors in addition to bilateral iliac angiography for arteriosclerosis. Department reported 93460. Look forward to your response.
Please do NOT include any actual patient medical records with your question. My physician have started doing abdominal arteriogram (75625) on patients who come in for LHC and RHC for possible TVAR procedures.Here is the preop diag. and the finding below. preoperative diag: The pt has moderate to severe aortic stenosis by suface echo and present for evaluation of his coronary arteries and aortic valve for consideration of possible percutaneous aortic valve replacement vs tranditional repair. Findings: Abdominal Aortography: The patient was found to have calcified iliac vessels..diameter 1.6cm lt and rt iliac. My question is should I code G0278 or 75625 or can you code for this procedure when there is only a possible of a TVAR?
I know that the code for non-selective iliac angiography done at the same time as 93452-93461 is G0278. However I ran into a situation. A patient was admitted to an outside hospital for NSTEMI, had a left heart cath with coronary angiography, and was transferred to our hospital for intervention because the lesion was complex. My physician did a coronary angiography and placed three drug -luting stents in addition to performing a non-selective peripheral angiography of the iliacs. However, since the patient had a coronary angiography three days prior, the compliance department advised against billing the coronary angiography since we had the imaging from the procedure done at the outside hospital and were intervening on lesions identified during that procedure. How can I bill for the peripheral procedure if I am unable to bill code 93454? My understanding is that code G0278 has to be billed with 93452-93461. Please advise.
I need help coding this report. The procedures were left heart catheterization, selective cornonary, saphenous vein and IM angiography, ventriculography, RAO view, aortography, AP view, right iliac angiogram, and primary stenting of vein graft to RCA with use of spider. Closure of access site using Mynx grip. Here is the part of the note that I don't know how to code: "Aortography was performed in the AP view, as patient was complaining of discomfort in his right leg. This shows significant stenosis of 60-70% in the right common iliac, which with the placement of the catheter was obstructing flow. Following this, selective right iliac angiogram was performed, and this iliac appeared to be diffusely diseased with 60-70% narrowing, but I felt I could get the procedure done and bring him back for elective intervention of his iliac vessel." I am new to cardiac coding, so I'm feeling very lost. The patient has Medicare.
The CPT code book lists one CPT code for coronary stent initial and one CPT code for additional - no reference to type of stent used. There are G codes for CMS patients and those state drug eluting stents. My question: do we charge differently based on bare metal stent placement or drug eluting stent placement? We have been told to have charge codes for bare metal stent placement at one price, and another charge code for drug eluting stent placement at a different price for non-CMS patients. Is this correct?
DR. Z, The patient came in for AV fistula creation and in the same setting it states 'using ultrasound, the upper extremity was mapped. Based on the findings from the ultrasound decision was made to proceed with a left basilic vein transposition.' Not sure if this is good enough to code 'G0365'along with the creation of AV fistula? Is this ultrasound mapping included in the AV fistula performed in the same setting? Sometimes we see an order stating vein mapping or pre op for AV fistula creation and the procedure is bilateral venogram, please clarify when and what kind of documentation suports 'G0365'? Thanks