Can you let me know if this documentation supports reporting codes 93566 and 93568? "Biplane cineangiogram with a pigtail catheter positioned in the proximal right pulmonary artery demonstrates mild narrowing of the proximal right pulmonary artery with unusual branching pattern of the branch pulmonary arteries with both the right and left pulmonary arteries coming off very close to each other. The left pulmonary artery has a hairpin turn as it comes off and then makes an immediate 90 degree turn to the left. There is moderate to severe pulmonary insufficiency. The right ventricle does not appear significantly enlarged on this angiogram." I initially only reported code 93568; however, another coder believes we can also submit code 93566. The only documentation that I'm able to see of 93566 is showing on a final angiography. Can we code a final angiography even if the provider doesn't document one done prior to the stent placement? Please advise.
I have your Interventional Radiology Coding Reference (2016), and I'm looking at pages 415-416. In coding instruction #5, you indicate codes that 49083 and 49406 should not be billed at the same encounter, and I do see there are NCCI edits in place for this. How should we code if the doctor does a paracentesis (49803) and tunneled catheter (49418) at the same session? There are no NCCI edits on this, but it looks like he's using the initial puncture as part of the tract for the tunneled drainage catheter. I'm thinking I should only bill the tunneled drainage catheter. Please advise.
"Physician deployed a Gore Helex closure device for a PFO. The device became mobile, and he had to retrieve it from the aorta. He then proceeded to place a new closure device with success." Would it be appropriate to bill code 93580 as well as 37197?
"Patient comes to hospital for knee aspiration. Under ultrasound guidance no fluid is identified; no aspiration can be done." Do you charge for knee aspiration, as insurance has approved, and add modifier for reduced service? Or, do you charge for limited lower extremity ultrasound? Or perhaps cancel exam all together?
Does CT/CTA (i.e., 75572-75574) include calcium scoring? I know there is a separate code for CT without dye with calcium test.
What ICD-10-CM code would you recommend for an "in stent re-stenosis" in the coronary artery? Documentation indicates that the patient had a prior stent in the LAD and now has a 99% "in stent" re-stenosis. In most cases where I encounter this diagnosis of "in stent re-stenosis", the patient has had a prior PCI with stent placement and is undergoing CABG or a re-do PCI procedure of both the vessel with the in-stent stenosis and other coronary arteries during the same encounter. I have researched this diagnosis extensively, and it appears to be a subject of debate in the cardio community. The differential recommendations are to report either T82.857A for the in-stent stenosis as the primary diagnosis or CAD of the native arteries with the appropriate code from category I25.1 as primary (since the patient still has CAD and the CAD could be viewed as the reason for the stenosis in the stent, though that is not always the case clinically speaking). What is your opinion?
In ICD-10, if a patient has multiple nodules on the thyroid, and the physician is not calling it a goiter, do you code to single nodule (E04.1) or multinodular goiter (E04.2)? We are thinking we should code it to E04.2, but we're not sure since the physician is not calling it a goiter.
When two major coronary arteries are stented during the same procedure, is it necessary to add a -51 modifier to the second stent code? The coronary artery modifiers would, of course, also be present.
I have conflicting information about who reports to the registry when billing CT lung screenings. We are a hospital-based group, billing for the physician only. I was originally told the hospital reports to the registry. Now I'm hearing that both the hospital and physician have to report. Can you please provided clarification or guide me to some resources?
If the patient does not return to our office to have the monitor disconnected, can we still bill code 93225? We connect a Holter monitor in office for 24 hours on a patient, and at the end of the monitoring period the patient disconnects the monitor and sends it in to our monitoring service. We have been billing code 93225 for the initial connections on the day that it was connected, as well as code 93227 for the interpretation under the day the physician performed his/her interpretation. We are being told that we should not be coding 93225 because we are not performing disconnection. Is this correct?
Can you please help with codes for this situation? Our physician performed a repair of the axillary vein after another physician removed a right axilla mass. We did not perform the mass resection, a different physician did. We were only called in to repair the axillary vein. What codes would be appropriate for this?
At the risk of sounding stupid, I just have to ask because I'm still not grasping the difference between the twp separate sets of stent codes when they are not clearly spelled out in the report (that I can tell). How do you know which this is, 50695 or 50433? My guess is 50433? "A 5 French coaxial introducer was placed the dilated left renal pelvis using micropuncture technique. A nephrostogam was done. Antegrade ureteral stent placement: A 0.035 wire successfully advance into the bladder . A 5 French Angiocath then was advanced over the guide wire in the bladder. The glidewire was exchanged with super stiff guidewire. The needle tract was dilated to 9 French . A 6 French x 22 cm was inserted over stiff guidewire under fluoro into the bladder. The guide was pulled back out of the upper end of the stent but was kept in the renal pelvis. An 8.5 French nephrostomy catheter inserted into the renal pelvis and the stiff guide wire removed. The nephrostomy catheter was secured on the skin with adhesive tape. The final image showed a good position of the stent and nephrostomy catheter."
Patient comes into the cath lab and has a left heart cath with LV pressures, an FFR of the LAD, and also intervention with a stent placed to the LAD. The patient started to experience chest pain before leaving the cath lab. A left coronary angiogram was performed and showed thrombus of the proximal portion of the previously deployed stent, and aspiration thrombectomy was performed along with balloon angioplasty of the LAD. The procedures originally coded were 93458-26XU, 93571-26, and 92928-LD. Since the patient developed the symptoms before leaving the cath lab, it would not be appropriate to code another coronary angiogram with a PTCA of the LAD, correct?
"RCF was accessed advanced catheter into abdominal aorta. Catheter was then placed in SMA, celiac, left hepatic, medial branch of the left hepatic, left gastric, and right gastic; arteriograms were performed at each artery selected. Embolization of the right gastric artery (tumor)." I was thinking of reporting codes 36247, 36248 x 3, 75726 x 2, 75774 x 5, and 37242. Can you verify my codes?
I have a question regarding the removal and replacement of an ICD generator when the device has RV/LV leads only. My physician wants to bill code 33264 to signify this as a multi-lead device. However, I'm thinking this should be reported with code 33263 instead, since we technically have two leads only. What are your thoughts?
Our surgeon attempted to perform a FEVAR on the patient, but, due to graft rotation and multiple attempts to salvage the orientation, it was unsuccessful. Catheters were selectively placed into the renals, and bilateral renal angioplasty was done prior to FEVAR attempt. He then converted to open repair of AAA and assoc. iliac artery occlusive dz with aortobifemoral bypass (18 x 9 bifurcated Dacron graft). Cutdown on both groins over femoral arteries. Explant of proximal body of a Cook Zenith fenestrated graft. Open repair ensued of above stated procedure." Please tell me how you would code this.
If a CT pelvis is performed following insertion of contrast via Foley catheter, should code 72192 or 72193 be coded? Does the contrast administered via Foley count as "with contrast"?
Please advise whether repositioning of CVC (36597), CVC catheter stripping (36595), and vena cavagram (75827, 75825) can be reported on this case. "Indication: Porta-cath appears to be curled up in left jugular vein. A 5 French dilator was introducted through the right femoral vein into the iliac vein and also into the inferior vena cava. With injection of contrast, the superior and inferior vena cava were patent. Using multiple snares and graspers, it was not possible to bring the loop of the CVC down into the vena cava. With manipulation of the port and through the neck with external massage, the tip of the catheter was advanced into the superior vena cava. A snare was introduced, and the tip of the catheter was pulled down to the inferior vena cava, but it bounced back into the left subclavian. At this point the catheter was pulled down into the inferior vena cava, and, through manipulation the fibrin sheath, the loop was advanced into the base of the neck. The sheath was stripped and the cath pulled down in the vena cava."
I have a question about the ICD-10-CM guidelines for the physicians. Is an operative note required to be a stand-alone document for diagnosis documentation? Or can we obtain more details for the diagnosis from the hospital record? Could you point me to some written guidelines to help with our diagnosis documentation?
When the physician is performing a core breast biopsy using stereotactic guidance with the Affirm system tomosynthesis guidance, would we report unlisted code 19499? Or should we report codes 19081 and 77061?
I am wondering how we report the physician portion of an ultrasound-guided hip muscle injection. There is no mention of trigger point injection or tendon injection; it's specific to "left lateral hip muscle injection" for pain management. We were wondering about code 96372. However, that's a part A service only and not billable by the physician. Can you please direct me to the correct CPT code to use for this procedure?
If the physician places a stent in both the right and left renal arteries (he also did the angiography prior to stent placement), would I report codes 36252 and 37236-50? Or codes 36252, 37236, and 37237?
If a patient is brought to the IR department for an active bleed due to trauma or a GI bleed, occasionally the physician won't see active bleeding or extravasation, but will embolize the artery that was seen on the CTA bleeding. Can we still use code 37244? I know a lot of times, especially with GI bleeds, the bleeding will wax and wane.
Provider indicates, "Contrast is introduced into thecal sac and oblique views are obtained. Please see post myelogram CT for further details." I would report code 62284 based on the above documentation along with 72132 for the CT with contrast. However, bending views were performed. Do I bill code 72114 in this case with the above codes since we cannot bill for the full myelogram? Or if bending views are performed, does this mean we should bill for the lumbar myelogram 62304 with CT 72132? I don't think this matters either way, but my inquiry is for facility coding.
We are getting ready to implant ABSORB product. Per the rep, "Absorb is not a stent, so you need to differentiate what is different between drug-eluding stents and the Bioresorbable Vascular Scaffold." If this is not a stent, how should we code it (CPT and ICD-10)? Any suggestions would be appreciated.
I saw in your forum that code 36556 should not be used for a cooling catheter, but my physician states that he was told when hypothermia is being induced via catheter he should bill 36556 for catheter insertion, even though this is an insertion of non-tunneled centrally inserted CVC for patients age 5 years and older, and also bill 77001 for fluro. Please help.
I have a physician who is wanting to charge for ultrasound guidance for sheath placement during a RHC. The code is 76937, but it is an add-on code, and 93451 is not an appropriate add-on code. Can you help me with if he can charge for this and how you would bill it? I have an example of what he is doing: “PROCEDURE: 1) Ultrasound-guided percutaneous right internal jugular venous insertion of a 7 French sheath after routine prep and drape and Lidocaine anesthesia. Insertion of the sheath was performed using a micropuncture needle and modified Seldinger technique under direct visualization of the needle entering the right internal jugular using ultrasound guidance. A representative ultrasound image is being stored in the electronic medical record. 2) Right heart catheterization, mixed venous oxygen sampling, cardiac output by Fick and thermodilution, wedge pressure determination using a 7 French balloon tipped Edwards Lifesciences TD catheter.” Any help on how or if he can bill for this would be great.
We have a new physician starting at our facility who has a different approach for some VT ablations. If he finds that the VT is originating in the ventricle and from the epicardial space, he will ablate both areas. The epicardial space will be access from a pericardiocentesis type of approach, but without the fluid build-up in the pericardial sac, making the access that much more difficult. I am wondering if the charge for this type of approach would be included in code 93654. Is there an additional charge for this more specialized and more specific type of approach for VT ablation?
I need clarification of charging codes. Patient has dual chamber ICD and now needs upgrade to biventricular ICD and requires placement of LV lead. I believe the codes should be 33264-Q0 and 33225. Is this correct? Does code 33225 need a -59 modifier?
What code(s) would be appropriate for revision of peritoneal dialysis catheter, open?
Operative note states: "Fistulogram with angioplasty and revision of fistula with ligation of tributary. The patient has poorly functioning right radiocephalic fistula. Fistulogram was found to have stenosis just distal to the anastomosis up beyond a large tributary. This was angioplasited with 4 x 80 and 6 x 80 balloon, and large tribrutary was then ligated through separate incision. Wire was manipulated using a Bern catheter down into the radial artery. Angioplasty was performed of the stenotic area with good results. A large tributary was located and marked and the vein dissected free from surrounding tissue up to level of the fistula and ligated with 2-0 silk and divided." I am not sure if the ligation of tributary would be reported with code 37607, as it is not the fistula itself. Also, I do not believe this is a revision of the fistula. I am reading this as fistulogram (36147), angioplasty (35476, 75978), and the ligation. There really was no revision of the fistula. Your help is appreciated.
Patient with a biventricular ICD had a RV lead dislodged into RA. Patient had RV lead extracted and a new RV lead implanted. A stylette was placed down the RA lead after suture sleeve was freed up, given that slack on RA lead was significantly reduced after manipulation of the device and removal from the pocket. After addtional slack had been placed into the RA lead, suture sleeve was sutured to the underlying fascia, then reconnected to the existing ICD generator as was new RV lead. LV lead was never disconnected." How should this be coded? Will the RA lead be coded as a revision, repositioning, or something else?
One of our physicians has been told that using modifer -22 requires two seperate documentations. Can you tell me if a seperate statement on the operative report will suffice, or does there have to be a separate stand-alone document as well in order to use modifer -22? Where can I find some written guidelines on this?
If a patient has an ASD closure and is seen once a year, every year, for a routine follow-up visit (standard office visit, EKG, echo), would we still always code them as Q21.1? Or should we be billing the follow-up code Z09 and the personal history code for a corrected cong malformation Z87.74?
I realize that, for purposes of coding CPT procedures, an AV dialysis shunt (fistula or graft) is defined as beginning at the arterial anastomosis and extending to the right atrium. Procedures performed in any of those veins are considered shunt procedures. Based upon that definition I have assumed that problems with those same veins, all the way to the right atrium, would be reported with shunt diagnosis codes in ICD-10-CM. For example: I would use the shunt diagnosis code T82.868A for thrombus of the brachiocephalic vein in one of these patients. However, my auditor would use the regular venous thrombus code I82.290. Who is right, and where does the fistula or graft end and the vein begin for ICD-10 diagnosis coding?
I have a question about the use of code 77001. In your 2016 Interventional Radiology Coding Reference, page 185, example #2, upon the injection of contrast (no mention of fluoroscopy) code 77001 is added. In one of the Q&As from your website (question ID #5789), with use of C-arm you suggest the imaging modality should be mentioned. Bottom line: is contrast injection through the access site/catheter enough to use code 77001?
Am I going down the right path to coding this case with CPT codes 34831 and 34825? I was also considering codes 36246 and 37242. "Aorto-bi-iliac angiogram, open exposure of right common femoral artery, and repair of right iliac artery aneurysm and type 1B endoleak. In 2012, endovascular AAA repair and right iliac artery aneurysm were done. Aneurysm extends down to the bifurcation of the external and internal iliacs with a short neck and graft had pulled up, making a large type 1B endoleak (distal)." I have very little experience with interventional radiology cases, and I am overwhelmed at this point. The case was performed in an Ambulatory Surgery setting.
"PROCEDURE: Using real-time ultrasound guidance, the left brachial artery was accessed proximal to the anastomosis and fistulography performed from the anastomosis to the right atrium. A catheter was then placed in the brachial artery, and left upper arm arteriography was performed distally to the right hand to evaluate the patient's steal symptoms and identify a possible arterial stenosis. The transposed basilic vein was then accessed towards the anastomosis, and additional fistulography was performed. Based on the imaging findings and presenting symptoms, angioplasty of the proximal AV anastomosis was performed to 6 mm. Post treatment images were obtained, and both sheaths were removed. Pressure was held for hemostasis. Ultrasound was used for vascular access. Hard copies were retained for the patient's file. Sterile ultrasound gel and probe cover were used." What would be the appropriate codes for this procedure? I was considering codes 36147, 36120, 75710, 35475, 75962, and 76937.
"Four-legged Dacron graft was sewn into a patulous opening made in the aorta. The celiac, SMA, and bilateral renal artery origins were each ligated and transected off the aorta, and each attached to one of the limbs of the four-legged Dacron graft." I don't know if it matters, but the next day they are scheduled for EVAR. Would this be reported with code 35631 x 4?
Can you help with the CPT codes for this scenario? (This is professional billing.) Can I use 92928 two times here, one for the LAD and one for the LC? "1) Left main lesion: An 8Fr guide catheter was positioned at the ostium of the LM........A BMW wire was advanced across the LM lesion and positioned in the LAD. A 2.0x12mm balloon was used to pre-dilate the lesion. A 2.5x15mm Emerge balloon was then used to further predilate the lesion. Two 3.5x23 Alpine drug-eluting stents were then deployed as kissing stents from the left main into the LAD and LCx. Very sluggish flow was observed in the LCx after opening the LM. In the summary of the report, it says "Successful deployment of drug eluting stents to the LM and ostial LAD/LCx . . . ."
How would you code the transhepatic approach? The report includes: "Attention was first turned to gaining access into the hepatic venous system. Due to known complicated vascular anatomy, decision was made to perform direct stick hepatic vein venogram. Under ultrasound guidance, the middle hepatic vein was accessed using a Chiba 22 gauge,15 cm needle. Contrast was injected filling the right hepatic vein. A nitinol wire was inserted, and the Chiba needle was exchanged for the inner cannula of a 6 French AccuStick catheter. AccuStick catheter was advanced into the middle hepatic vein. Contrast was injected and a venogram was performed. This showed patent middle hepatic vein filling to the right atrium. Decision was made to perform rendezvous procedure through from right IJV access."
This patient had a brachiocephalic fistula. Excision of an aneurysm/aneurysmorrhaphy was performed on the "middle portion of the fistula". Stenting was performed for an 80% "outflow stenosis", specifically the axillary vein. The Dr. Z Vascular & Endovascular Surgery Coding Reference states that, if surgical revision is performed on a graft, we should not code angioplasty/stenting within the graft (anastomosis to anastomosis). How do we code when it's a fistula? In the case above, is it okay to code the stent as well as the revision, since the stenting was performed in the axillary vein and the revision was on the brachiocephalic fistula? Are we looking to see if different veins are worked on or for words like "outflow"? Or do you believe we should not code for both a revision and angioplasty/stenting for fistulae when done in the same zone?
Can you please tell me if there is a code for aortic paravalvular leak closure with Amplatzer vascular plugs? It's a bioprosthetic valve. I see the code for transcatheter mitral valve repair, but nothing for aortic. I'm assuming I need an unlisted code here?
"The left hepatic artery was catheterized, and diagnostic angiography was performed. One-third of the 5 mCi 99m-Tc-MAA dose was injected into the left hepatic artery. The SMA was then selected, and, using the Progreat microcatheter, the replaced right hepatic artery was selected and diagnostic angiography performed. The other two-thirds of the 5 mCi 99m-Tc-MAA dose was then injected." I reported codes 36247, 36248, and 36245-59, but the reviewer is insisting that code 37242 should also be reported. What do you think?
What code should I use for axillary conduit during endovascular procedure? Unlisted 37799 or 35266?
I was told by my trainer that if the physician states that "tachycardia cycle lengths" were measured, we could code 93609 mapping, since mapping measures cycle lengths. Can you clarify if this is accurate? I cannot find any documentation of this in my references.
Patient was here a week ago and had a LHC/RHC with angiography, and was found to have disease in his circ and is now back for stenting (no new symptoms). Physician did a LHC "to manage fluid status" before he placed the Xience stent. Would this be coded only with C9600-LC? Or would you also submit code 93452? There is a disagreement among our team. Also, does LHC follow the same rules as angiography for repeat serivces?
Please review and provide coding recommendations. "LC femoral artery cannulated using landmark technique. Bentson wire inserted into the aorta. Aortogram performed showing patent distal aorta, patent common iliac arteries bilaterally, patent external iliac arteries bilaterally, patent common femoral arteries bilaterally, no evidence of stenosis profunda femoris arteries. Right common iliac artery orifice selected. Angiogram performed of right lower extremity selectively showing an area of stenosis in distal SFA, chronic total occl of the popliteal artery w/ calcified plaque at that location & chronic total occl of the tibial/peroneal trunk with 90% stenosis of peroneal arteries. Peroneal artery was the dominant artery runoff to the foot with reconstitution distally of the posterior tibial artery. 6 French sheath, 55 cm placed in right common femoral arteries. These areas were traversed with a 0.018 wire under fluoroscopic guidance. These areas were balloon angioplastied from proximal to distal using drug-eluting balloon and Sterling non-drug-eluting balloons."
"Right arm prepped and draped in the usual sterile fashion. An elliptical incision was made at the base of this large venous aneurysm. Using electrocautery, the soft tissue around it was dissected free, and several small arterials were Bovied for closure. The base of the stalk was mostly fatty tissue with lymph and venous filling. These were controlled with electrocautery and Bovie as well. The aneurysm was excised and then sent to pathology. The wound deficit was extremely superficial and was closed with 2-0 Vicryl pops and 4-0 Moncryl for the skin and Dermabond." I am starting to get excisions of venous aneurysms from two of my doctors pretty often. When it's describe as being in an AVF/AVG, I usually lean toward the revision codes. But, what about this note where there is no mention of an AVF/AVG?
The surgeon did an embolization for a menigioma. He selectively catheterized the right CC, right ICA, right ECA, left CC, left ICA, left ECA, left MMA, left IMAX, and left accessory meningeal artery. He embolized the left MMA. Would you code the left MMA, left IMAX, and left accessory meningeal artery with 36228? Or are the IMAX and accessory meningeal artery bundled?
According to your cardiology reference book, you can report code 93623 for inducing or suppressing an arrhythmia using drugs isoproterenol, epinephrine, procainamide, dobutamine, and adenosine. A report that I reviewed this morning used aminophylline to induce the arrhythmia. Is that or other stimulants like caffeine acceptable when coding 93623?
If you pace the left side from the coronary sinus (CS) and not directly from the left atrium, can you still report code 93621? "A 7 French sheath and a 6 French sheath were placed the left femoral vein using the modified Seldinger technique. An 8 French sheath and two 6 French sheaths were placed in the right femoral vein using the modified Seldinger technique. Multipolar catheters were advanced to the high right atrium, His bundle recording position, the RV apex. A live-wire deflectable catheter was advanced into the CS. CS electrograms were recorded, and the catheter was subsequently used for left atrial recordings and evaluation. Programmed and incremental stimulation was performed in the atrium and ventricle at two times the diastolic threshold in the baseline state. Various diagnostic maneuvers were performed. AVNRT was diagnosed. An 8 French large curve 5 mm tip ablation catheter was advanced via the right femoral vein and positioned in the triangle of Koch posterior to the His at the level of the CS os."
We treat in patients with severe PDA. Lately a few cases the physician has had failed attempts for access. These patients have had a previous angiogram and were scheduled to come back to have an intervention performed on the lower leg. Unfortunately the physician was unable to gain access. The patients were given sedation. The only purpose for being in the procedure room was to have the intervention performed. The question is, do you code (charge) this as an attempted intervention (37224-74)? The current practice at this facility is to charge only for the supplies. I believe I have read that if the patient was brought into the lab for the intent to do the angioplasty and was given sedation the -74 modifier could be used. Can you clarify when to use modifier -74 (especially for this particular scenario)? Is there specific documentation to explain when it is appropriate to use in cath and IR procedures?
"PROCEDURE: The left axillary lymphatic malformation was examined with ultrasound and a suitable access site for needle placement was identified and the skin marked. The left axilla was prepared and draped in the usual sterile fashion. Using ultrasound guidance the first site (site #1) in the deep aspect of the axillary region was accessed with a trocar 6.3 French Dawson-Mueller pigtail drain. Next, using ultrasound guidance, the second, more superficial site (segment #2) was accessed with a trocar 6.3 French Dawson-Mueller pigtail drain. Finally, a superficial collection (site #3) was accessed with a 21-gauge micropuncture needle through which direct injection of 2 mL of doxycycline was performed. The predominant injection solution composed of a 4:1 dilution of doxycycline (10 mg/mL):Omnipaque 300 was injected under ultrasound and fluoroscopic guidance, according to the following outline: A total of 160 mg doxycycline in 16 mL saline was injected."
Recently our hospital has been having denials from commercial payers, Medicaid, and Medicare HMOs on ICD implants placed for cardiomyopathy where a -Q0 modifier was added. Our billing department has requested that we only add -Q0, when indicated, to straight up Medicare payments only. Could you please tell me if -Q0 modifiers should be added to commercial payers, Medicaid, and Medicare HMO payers as well when placed for cardiomyopathy? And, would a -Q0 modifier be necessary when Medicare is secondary insurance?
Radiologist injected sinus tract with contrast and then scanned the patient's abdomen in CT (74150). Would it be correct to charge the injection code (20501) along with the CT scan? Or would both codes 76080 and 20501 be appropriate? "Non-contrast abdominal CT scan performed prior to and following the injection of the patient's fistulous tract with contrast." The draining wound was cannulated with small Foley catheter to define the tract of the coloncutaneous fistula. Documentation includes location, size, length with detail.
"Incision was made between the basilic vein and the brachial artery. Dissection was carried down. Basilic vein was identified and mobilized proximally and distally. I then mobilized the brachial artery and anastomosed the basilic vein to the brachial artery in an end-to-side fashion." It says end-to-side, which is similar to 36819, but there are not two incisions, so it points me to code 36821, which is side-to-side. Which is correct? Does the side-to-side or end-to-side have to do with the code choice? What code would you use, and can you explain why you chose the code?
Are these billable using code 34812, or should I be using G0269? "1) An oblique femoral cutdown incision was made. A 6 French sheath was then placed and flushed, and this was replaced with a 10 French Prostar device, which was deployed and the sutures laid out in a radial orientation for later direct femoral arterial repair at the conclusion of the case. Attention was then turned to the right groin. Using ultrasound guidance, the right CFA was accessed, and a wire was advanced up into the aorta under fluoroscopic guidance. An oblique femoral cutdown incision was made, and a 6 French sheath was then placed and flushed. This was replaced with a 10 French Prostar device, which was deployed and the sutures laid out in a radial orientation for later direct femoral arterial repair at the conclusion of the case. 2) The right common femoral artery was cannulated using a 18 gauge needle. An oblique incision was made in the right groin and dissected bluntly down to the anterior wall of the CFA with a hemostat. Two Proglide sutures were then placed in the right CFA for direct repair."
What code should we use for trying to snare a catheter? "This is a 48 year old male with history of metastatic pancreatic cancer. A Portacath was placed in the right chest approximately three months ago. His Portacath is not working very well during chemotherapy infusions. Portacath study today showed retraction of catheter tip from SVC into right brachiocephalic vein and a full circle turn in the catheter. Contrast sudy of Portacath showed a fibrin sheath around the distal part of catheter, but otherwise no leakage or break in catheter was seen. Using right femoral approach the femoral vein was accessed and a snare was advanced into right brachiocephalic vein. However despite multiple attempts the tip of catheter could not be engaged with the snare. Portacath was left accessed for use the next day."
The MD is performing ERFA of the left lesser/greater saphenous vein. There were secondary varicosities involving the left calf and thigh that were treated with ultrasound-guided scleral therapy. Can we report these separately with codes 36475 and 36471?
"A patient has PVD with no pulse in the left leg and goes for a diagnostic angiogram with IVUS of the SFA, popliteal, and proximal tibial vessels. Physician finds extensive thrombus and performs a thrombectomy in the SFA and popliteal arteries, followed by placement of a stent in the popliteal artery, atherectomy and stent in the anterior tibial artery, and atherectomy and angioplasty in the posterior tibial artery." Can you clarify whether we'd use code 37184 or 37185? The reason for the visit was not of a known thrombus; however, once the angiogram/IVUS was performed the treatment was for the thrombectomy, with the other treatments for the additional stenosis in the anterior and posterior tibial arteries. Do you recommend reporting codes 37184, 37185, 37252, 37226, 37231, and 37233? Or do you recommend coding thrombectomy with 37186, 37252, 37226, 37231, and 37233?
A patient has stenosis of the proximal LD and is stented via the native LD, and a distal LD stenosis is stented via a saphenous vein bypass graft. Should you report both codes 92928-LD and 92937-LD?
For add-on codes 32668/32507, AMA's intent for these codes appears to be that they are reported when the intended procedure was therapeutic resection of the lung nodule/mass, but based on intra-op pathology a more extensive resection is needed and then performed, which causes the wedge resection to be "reclassified" as a diagnostic wedge resection (as per CPT Assistant, September 2012). That said, when I read the NCCI Policy Manual, Chapter 5, Section C.19, Medicare appears to be precluding payment for any diagnostic biopsy of the lung from a location that is removed in a more extensive procedure such as a lobectomy during the same encounter. However, CMS has assigned a fee to codes 32668 and 32507 on the MPFS, which seems odd if Medicare policy precludes payment for diagnostic wedge in the same area per NCCI and the only time you can report 32668/32507 is when they precede an anatomic resection in the same lobe/area. Do you know if the guideline in the NCCI Policy Manual is referencing codes 32668 and 32507, or are those exceptions to the rule based on the AMA definition?
Would it be appropriate to bill code 21825 when performing an open heart procedure? Due to bilateral sternal fractures and a significant amount of osteoporosis, each sternal table was repaired with vertical Robicsek weaves using # 7 wires. If reported, what do you look for to determine the reporting of this? If no, please explain why. All the information I have found points to not being able to report the 21825 with the open procedures due to if you created it you must fix it. Any guidance would be appreciated. We have a physician who routinely wants to report this code with bypass procedures.
For the following procedure, should I report codes 62305, 62284, and 72270? Or should I only submit code 62305? "Using fluoroscopic guidance, a 20 gauge needle was directed with a single puncture into the thecal sac until CSF was yielded. Subsequently, 10 cc of Omnipaque 300 contrast agent was instilled intrathecally. Afterwards, the tubing was removed and the stylet replaced. The needle was removed and pressure applied. No complications were evident. Maneuvers to facilitate distribution of intrathecal contrast were performed. The patient did not complain of any lower extremity symptoms. The patient was sent to CT for further scanning. Single fluoroscopic image demonstrated a needle directed towards the thecal sac from an interlaminar paraspinal approach at L4/L5 on the left."
"Patient was diagnosed with breast cancer, so she was referred to have her pacemaker moved to the upper abdominal area. No new generator was implanted, but the generator was explanted from the original location and relocated to a new pocket that was created in the upper abdominal area. A tunneling tool was used, and extenders were connected to the leads and brought to the new pocket, where the generator was connected and the upper abdominal pocket was closed." It seems to me that code 33222 is insufficient to cover this entire procedure. I believe it would it also be appropriate to code 33215 x 2 in this case. Do you agree?
I would appreciate some coding assistance. "Indication: Patient is a 61-year-old male with a successful kidney transplant who wants his AV fistula removed because of persistent pain. The area of the fistula was infiltrated with local anesthetic, and the skin was incised sharply. The dissection was carried down using electrocautery and sharp dissection until the level of the graft. The graft was dissected freely from the surrounding tissues from the level of the arterial anastomosis in the antecubital fossa to the level of the connection between the vein and the axillary vein at the level of the shoulder. The graft was then transected, and the proximal portion was tied with a silk suture. The distal portion was oversewn with a 5-0 prolene. It was removed and handed off the operation field. After hemostasis was achieved, the wounds were irrigated and then closed." How would you code this? I'm thinking it's got to be unlisted. The physician verified this was a large AV fistula that was excised, not a graft.
Could you please define what a surgical field is considered in the case where you have multiple aneurysms that are coiled in the intracranial arteries?
"Patient had bilateral stent grafts placed for a hemorrhage, after embolizations and stent were previously placed. Via right groin access, a 5 French marking pigtail catheter was advanced through the existing right common femoral artery stent graft into the abdominal aorta, and an aortogram was performed. The marking pigtail catheter was removed. A 13 mm x 10 cm Viabahn stent graft was advanced via the right groin access, and an 11 mm x 10 cm Viabahn stent graft was advanced via the left groin access. Both were positioned with the superior margins at the level of the mid L3 vertebral body and the distal extent above the iliac bifurcations. These stent grafts were subsequently simultaneously deployed and simultaneously molded with 9 mm x 80 mm Armada balloons. Successful deployment of kissing aorto-bi-iliac Viabahn stents (13 mm x 10 cm on the right, 11 mm x 10 cm on the left). No evidence of active extravasation before stent graft deployment." I was thinking code 37244 would be best to use since it was for the treatment of bleeding. Or should we use 37221, 37221-59 instead?
I'm having trouble finding the appropriate code for a bypass from anterior tibial to dorsalis pedis artery using a reverse greater saphenous vein? Would it be safe to use code 35570?
Physician performs a coronary artery evaluation (93454) and also does a cine evaluation of the valve. Is the cine of the valve separately reportable? 2016 NCCI narrative, chapter 11, section I, #17 states, “Fluoroscopy is not separately reportable with diagnostic coronary angiography or cardiac catheterization.” Would this directive also include cine?
A physician rotated an ICD device (only). Would you bill an unspecified code for this? Here is the report: "The patient was brought into the EP lab and was hooked up to an EKG monitor, pulse oximetry, and blood pressure monitor. He was sedated by anesthesia. His left shoulder was prepped and draped in the usual sterile fashion. Lidocaine was used to infiltrate the skin. Incision was made over the device using Bovie and blunt dissection, and the device pocket was entered. Device was removed and rotated more medially. The device was sutured in a very medial location away from the shoulder. The pocket was washed with triple antibiotic solution and closed."
What is the correct CPT code assignment for Cormatrix CanGaroo insertion? Documentation from Cormatrix seems to recommend coding 11043/11046 and 11042/11045 (depending on size); however, we get a medical necessity edit with these codes. Here is an excerpt from the operative report: "A new dual chamber pacemaker (Table 2) was connected to the leads and placed in the pocket. The device was sewn down with a silk tie to prevent migration of the generator. Cormatrix was placed in the pocket. The pocket was closed with multiple layers of Vicryl sutures. The final layer was closed with staples. Sterile dressing was placed with pressure dressing on top of the sterile dressing. Patient left the clinical electrophysiology laboratory in stable condition with the device functioning normally. Patient tolerated the procedure without any complications."
Can we bill code 93352 if the doctor states "intravenous contrast used" and doesn't state Definity, etc.? The doctors are stating that intravenous contrast was used, but not what was used. I just need some clarification.
My surgeon performed an open repair of a thoracoabdominal and left common iliac artery aneurysm with a bifurcated graft. Also, they performed a bypass to the left renal artery and common hepatic artery using another bifurcated graft. I think the bypass to the renal and hepatic are included in code 33877. My question is, since the bifurated thoracoabdominal graft treated the iliac aneurysm too, is the treatment of the iliac aneurysm also included in code 33877? Or should I bill a separate code for the iliac aneurysm?
I just would like some clarification on code 35650. Is this code for when a bypass is done from the right side to the left side? I have a case where he states, "Bilateral axillary arteries were exposed, a tunnel was created in a somewhat curvilinear fashion over the Manubrium, and a 6 mm ringed GORE-TEX was tunneled." It also states that the right-sided anastomosis was completed first, followed by the left side anastomosis. My concern is that the description of code 35650 does not state if left to right, etc. It states, "He then passes the graft around the blockage and sutures it to the other side." It's clear as mud to me. I just want to verify that this is NOT just for unilateral procedure.
Is there an additional code (or codes) that should be assigned if an AV fistulogram is performed by the radiologist (36147) and he decides to investigate the patient's hypotension and advances the catheter into the right atrium and transduces right atrial pressures? It was 0 mmHg. He then pulls the catheter back, and his venous pressures were between 0-1 mmHg.
Is there a CPT code for the exchange of a tunneled peritoneal catheter?
The doctor performed a left bronchial artery embolization (arterial access) and left pulmonary artery embolization (venous access). Although these are separate vascular systems and we can code the catheter placements and imaging as such, the question that has come up is whether we can code both of the embolizations or if this is considered one operative site and we should code for only one embolization?
Is it appropriate to use add-on code 50705 for non-permanent ureteral occlusion? "OP: Successful uncomplicated placement of a left modified 10.3 French nephroureteral stent with distal end, intentionally trimmed and occluded as described in detail above. The ureteral segment of this modified nephroureteral stent results in functional left ureteral occlusion by antegrade nephrostogram. The tube is in satisfactory position and placed to gravity drainage... Indication: Severe urethral erosion to the bladder neck with Resulting continuous urinary incontinence preventing the healing of chronic decubitus ulcers." I coded 50434 for conversion of a nephrostomy to a nephroureteral stent via the existing nephrostomy tube tract performed. Modification: utilizing methodology as published by Bush and Mayo in the Journal of Urology Volume 43, Number 5 (May 1994), a 10.3 French Boston Scientific nephroureteral stent was intentionally modified by..
"Right CFA was cannulated, and a 5 French sheath was advanced. Through this, a catheter was advanced to the distal abdominal aorta and angiography was performed, which showed a widely patent distal aorta and common external and internal iliac arteries, femoral arteries, and proximal SFA and profunda femoris arteries. Next an angled taper catheter was advanced to the left SFA after exchange over a wire, and left lower extremity runoff angiography was performed. This showed a relatively focal 95% stenosis of the distal SFA just above the adductor canal with patent popliteal artery and three-vessel runoff to the foot. After a series of catheter exchanges over a wire, a 6 French sheath was advanced to the left SFA and the patient was heparinized. The lesion was crossed with a wire, and the lesion was dilated with 5 and 6 mm balloons yielding dissection requiring stenting. Next a 7 x 80 mm self-expanding stent was deployed and post-dilated with a balloon with 0% residual stenosis and excellent result." Would you use codes 75630/75774 for imaging, or something else?
"LT brachiocephalic vein catheterization and venography via RT CFV access. Next, the LUE fistula was cannulated and a catheter was then advanced to the left axillary vein and venography performed from LUE access. Venograms demonstrated total occlusion of the left subclavian vein with large and tortuous draining collateral vein. A catheter and hydrophilic wire were then used thru the RT groin sheath in an attempt to negotiate thru the occluded left subclavian vein. A gooseneck snare was advanced thru the LUE catheter in attemtp to capture the wire from above, however this was unsuccessful despite multiple attempts. It was decided to perform radiofrequency wire recanalization. Appropriate grounding pads were placed on the patient's thighs and the radiofrequency wire was advanced thru a catheter from below and recanalization performed in the subclavian/axillary vein junction. The wire was snared with a gooseneck and removed thru the LUE. Balloon catheter was used to perform venoplasty of LT subclavian vein." Are codes 35476, 36147, 36012, 75820, and 75978 correct? Are there additional codes for radiofrequency wire recanalization?
"Patient with history of PVD and aortobifemoral bypass 35 years ago. He presents with a right leg pseudoaneurysm. After brachial cutdown, right limb of graft was accessed and injected, revealing a leak in the graft about 1 1/4 inches from the anastomosis to the common femoral artery. A 38 mm stent was deployed extending slightly into the common femoral. A second 38 mm stent was deployed to overlap the first and to cover the leak into the pseudoaneurysm." I reported codes 37236, 36246, and 75710-XU because the current indication is a leaky graft. However, the auditor says codes 37226 and 75710-XU are correct. Is she correct in using the revascularization code since the original indication for the graft 35 years prior was PVD?
If the physician did PVI for A-flutter, do we still charge PVI a-fib or SVT?
"Patient came to IR to have peritoneal dialysis catheter evaluated and manipulated, if needed. The radiologist injected the catheter and found the catheter in a small loculated cavity with no free spill and some adhesions. He used a wire to attempt to break up the adhesions and change the position of the catheter." Would it be appropriate to code this as 49400 and 74190 for the injection and 49999 and 76496 for the manipulation? A fibrinolytic was not used, so I am questioning if codes 49999 and 76496 should be reported for this procedure.
My physician has heard that, when doing spinal angiography, if he were to image the thyrocervical trunk and the costocervical trunk he could use code 75705 for the supervision and interpretation of these vessels. Would this be appropriate during spinal angiography?
Will you please advise on coding a Dobutamine stress test done during a cardiac cath procedure? MD states it was done to assess for transvalvular gradient and severity of aortic stenosis. Procedure is described as being done with a pigtail advanced across AV into the LV. Initially measured the baseling gradient and then up to 40 mcg of dobutamine was infused. The finding are as follows: "Good contractile reserve in response to dobutamine infusion with improvement in LVEF from 25% to 45% with increasing transaortic gradient from 25 to 49 mmHg at peak dobutamine infusion, suggestive of severe aortic valve stenosis."
Patient has SVT with an implanted loop recorder due to unsuccessful ablation and breakthrough SVT on medical treatment with atenolol. He presented for removal of loop recorder due to end of life of the battery with insertion of new loop recorder. Can we bill code 33282 with modifiers -52 and -59 appended, along with code 33284?
"The patient is brought to the operating suite for recanalization of an occluded left fem-pop bypass graft. A Destination sheath was placed at the left brachial artery and advanced to the distal aorta. The sheath was then directed into the left common iliac artery. Attempts to cross a severe stenosis at the common femoral artery in antegrade fashion were unsuccessful. Under US guidance, access was obtained via the dorsalis pedis artery, and a V18 wire was advanced in retrograde fashion all the way into the common femoral artery crossing the occluded fem-pop graft. The wire was snared and externalized at the left brachial artery, allowing advancement of a NaviCross catheter into the popliteal artery in antegrade fashion. A Pilot 200 wire was advanced into the peroneal artery. Multiple severe lesions at the common iliac, the entire fem-pop graft, and the common femoral artery were treated with balloon inflations." Can the access obtained via the dorsalis pedis be reported separately with code 36140-59? Or does this access also bundle with the intervention?
I am a little confused about when we can report code 93623. I know if they are just checking the efficacy of the ablation it cannot be coded, but I read somewhere that if they are looking for other arrhythmias then the code can be added. If the physician does an ablation and then administers isoprotenolol and notes that "no other inducible arrhythmias were found", would this be good enough documentation to support the separate reporting of code 93623 since they looked for additional arrhythmias?
Would you recommend using code 32553 for a 20 gauge hooked localization wire placed into a left lower lobe mass for planned surgical resection?
When billing for a TAVR case (i.e., CPT 33361 – TAVR with prosthetic valve; percu femoral artery approach), we have a cardiothoracic surgeon and two interventional cardiologists on the case. Would it be appropriate to report code 33361 with modifier -82 (assistant surgeon) appended if there is no qualified resident available, and there is a statement from the provider for medical necessity for the assistant surgeon for the second interventional cardiologist, in addition to 33361-62 for cardiothoracic surgeon and 33361-62 for the first interventional cardiologist?
Please help with the following scenerio: Patient had a diagnostic cath performed, and a thrombus formed as a consequence/complication of the cath in the RCA. Patient then had angioplasty for the acute total occlusion. Since an AngioJet wasn't performed, code 92973 wouldn't be appropriate, would it? Would we just code this to a plasty ? Or would we code it at all?
"The device was freed from the surrounding tissue and brought to the surface. A pocket was modified inferomedially using blunt dissection and electrocautery to accommodate for bigger device. The axillary vein was accessed two (2) times via the modified Byrd technique with the guidewires placed into the right heart. A 9.5 French sheath was placed in the axillary vein. However, the vein was dilated with serial dilators prior to this due to stenosis at the subclavian and brachiocephalic vein junction. The RV lead was advanced into the RA through the 9.5 French sheath with difficulty, as the sheath was kinked. I was not able to advance the RV lead into the RV due to difficulty in torquing the lead, likely due to stenosis in the SVC. At this point we had used almost 55 minutes of fluoroscopy. Hence the procedure was aborted on the right side. The old device and lead were placed into the pocket, and the wound was closed in layers. CONCLUSION: 1) Unsuccessful right-sided CRT-ICD upgrade. Plan for left-sided biventricular ICD upgrade." Codes 33212 and 33233 do not work. Do you have any suggestions?
When performing a full combined congenital right heart catheterization and transseptal left heart catheterization through intact septum (93532), my doctors feel that if the septum is then balloon dilated to allow for the sheath to pass through to get to the left atrium, we should also be able to bill for an atrial septostomy (92992). For example: “Transseptal needle puncture: The atrial septum was punctured with an adult transseptal needle through a 7 French long sheath. Injection of contrast confirmed placement in the left atrium, after which a 5 x 2 Maverick was inflated across the atrial septum, allowing advancement of the long sheath.” The doctor is billing codes 93532 and 92292. I believe the septum balloon dilation would be included in the transseptal puncture in this case, and that we should bill code 93532 only. I would greatly appreciate your input on this.
I am unsure whether the cath for the right side for the angiogram would be billable. There was intervention on both the right and left sides, but it was through the left access. "The decision to intervene was based on today's study, and there were no prior cath based studies to compare. Percutaneous 5 French RIGHT common femoral artery access. Cannulation of abdominal aorta. Pelvic arteriogram. Percutaneous 6 French LEFT common femoral artery access. 6 mm balloon angioplasty of the LEFT external iliac artery. Cannulation of RIGHT common iliac artery. Recanalization of chronically occluded RIGHT internal iliac artery. Primary balloon angioplasty to 4 mm of the origin of the RIGHT internal iliac artery."
If a patient has a soft tissue mass at a previous mastectomy site, and this soft tissue mass is biopsied, should I report code 20206, 76942, or 19083 for ultrasound-guided biopsy?
"A 10 mm x 2 cm Armada balloon was advanced into the biliary system for balloon sweep of both the segments 1 and 3 biliary ducts into the common bile duct." Can we use code 47542 for balloon sweep of biliary duct? Or not code it? This was done at the time of an internal/external biliary drain exchange (not really a dilation, but not 47544 either).
Selective coronary angiogram and IVUS of bilateral common iliac, external iliac, and common femoral arteries. One access in the right femoral artery. Physician performed coronary angiogram and then catheter from right common femoral artery into descending aorta. IVUS catheter from descending aorta into the common iliac, external iliac, and common femoral. Then crossed over into left common iliac, all the way to the SFA, and pullback from common femoral into the external and common iliacs. Physician gives IVUS interpretation of all vessels. Can we add codes 37252 and 37253 in addition to code 93454? Can we add cath placements as well?
"Patient with femoral pseudoaneurysm status post cardiac cath almost 2 months prior. Patient was taken to the cath lab, and manual pressure was applied to right groin area for 20 min." How would this be billed? There is no mention of US guidance. Is this even billable?