Knowledge Base

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Set Descending Direction

Moderate Sedation

Very often the documentation for moderate sedation says that it was administered by an interventional nurse or nursing staff. We are billing for radiologists. In order to bill for moderate sedation, does it have to be administered by our physicians?

Neurovascular Intervention and Imaging 36224

Coil embolization was done for the known left internal carotid aneurysm at the intracranial segment. 3D reconstruction at the separate work station, angiogram during the intervention, and the follow-up angiogram were done at the same session. The description of code 61624 says any method and does not mention S&I. Can I add codes 75894, 75898, and 76377 with codes 61624 and 36217?

36246

Do we still report code 36246 if a catheter approaches from the radial artery instead of transfemoral artery to the internal iliac artery?

36593 Declot by Thrombolytic

Why can we not bill code 36593 on the professional side?

35883 or 35876

"#4 Fogarty was passed into the profunda, then passed easily and well into the profunda for a distance of at least 30 cm, and minimal thrombus was extracted. Clot was easily extracted from the femoral-femoral bypass graft; normal pulsatile arterial inflow was restored. At this point, this is thoroughly irrigated and inspected, and then bovine pericardial patch brought to the field and cut to the primary size and sewn in using two separate CV 7 Gore-Tex sutures. Excellent Doppler signals were noted outflow right profunda and at the right peroneal artery post procedure." I am thinking of reporting code 35876, while the doctor states it should be code 35883. What's your opinion?

Central Dialysis Segment vs. Peripheral Segment

"Doctor performed a thrombectomy via transverse incision. After thrombus was removed, a fistulogram was performed, which showed a moderate stenosis throughout most of the fistula up to the deltoid level where the vein became more normal appearing in caliber. The outflow was examined all the way through the subclavian level, and there was no evidence of central vein stenosis. Guidewire was advanced through the fistula, and a 6 mm balloon was used to iron out areas of narrowing readiness. Completion fistulogram showed improvement." Would we only report code 36831? I am confused about central vs. peripheral. I don't know when it would be appropriate to report code 36907.

Office Hysteroscopy

How would you code ultrasound guidance for a hysteroscopy that is done in an office? Would you use unlisted code 76999? This is a facility charge done by hospital US department staff.

IVUS of the Thoracic Aorta

I have a patient who had suspected thoracic aortic aneurysm due to spinal pedicle screw penetration. Patient underwent aortography, and, due to the potential nature of the screw threads catching the aorta (since they were touching), they performed IVUS, which showed the screw juxtaposing the aorta but no penetration. No intervention was decided this session. How do I report IVUS with no qualifying procedure? Or is this just a courtesy we performed? Also is the PCS code for aorta IVUS B240ZZ3, single coronary artery IVUS? We have to add both codes at our facility.

Occlusion of vessel appropriate for angioplasty?

Just seeking a clarification to make sure we are not barking up the wrong tree. If hemodynamically significant stenosis is documented, this is justification for angioplasty. If the physician documentation is "the superior vena cava is completely occluded", does that support that this vessel is essentially severely stenotic? Or would the physician truly have to document severity of stenosis as opposed to the vessel just being occluded?

Transposition or Direct Anastomosis

"We started procedure with a longitudinal incision of 3 cm at level of axilla. A subcutaneous tissue was dissected until we identified neurovascular plexus. Axillary vein was dissected free and encircled with vessel loop proximally and distally total 3 cm. We started to tunnelize the graft in the subcutaneous tissue. Through the tunneler we performed a loop of 20 cm from axilla to antecubital fossa. We started fashioning arterial anastomosis end-to-side and performed 6-0 prolene on a running suture. At the end we checked flow inside the graft, which was excellent. Should I code a transposition (36820) or direct anastomosis (36821)?

32557 or 32550

"After administration of local anesthesia and using ultrasound guidance, a 19 gauge needle was advanced via posterior approach into the previously demonstrated right pleural collection. A specimen of thin amber fluid was obtained for lab for studies. The tract was dilated to 8 French, and an 8 French pigtail catheter was inserted. The catheter was connected to a Pleur-evac. Follow-up chest radiograph was scheduled." Should we report code 32557 or 32550?

Angioplasty of Fontan Fenestration

What is the appropriate CPT code for angioplasty of the Fontan fenestration? The note states, "The wire was positioned into the right atrium. Through this wire, we advanced the balloon and inflated it on two occasions across the Fontan fenestration."

Coil Embolization

For coiling of right superior and inferior gluteal arteries, should we bill codes 37242 and 37242-59?

Upper Arm Dialysis AV Fistula

One of our doctors routinely accesses the brachial artery on upper arm AV fistulograms. With the 2017 changes, is there a way to charge for brachial artery access, either by CPT code or modifier?

Billing for 77001

In the 2017 edition of the Interventional Radiology Coding Reference, example 2 in the "Vascular Access Device Placement" section of chapter 7 states: "Patient presents for central catheter. Ultrasound is used to determine suitability of the jugular veins. The right jugular vein is determined to be too tortuous to use. The left jugular is suitable for the placement. Ultrasound is used as guidance for needle placement (76937). Hard copy images (permanent recording) and reporting are documented. The non-tunneled central venous catheter is placed without difficulty and secured with suture (36556). After catheter manipulation and injection of contrast, confirmation of tip placement in the superior vena cava (77001) is documented on a stored image." In this example, how do you know that tip placement was confirmed by fluoroscopy? In this same section you state, "Some catheters may be placed without any guidance. The use of these guidance codes requires specific documentation to support utilization of the access guidance codes." If they do not state fluoroscopy was used, how can you code 77001?

US Guidance with LE Revascularization

You have previously stated that the SIR confirmed that ultrasound guidance is allowed for arterial access. My question has to do with usage of ultrasound during lower extremity revascularization and the CPT definition of these codes. When I started coding vascular cases, I was told that ultrasound with codes 37221-37235 is not allowed because of CPT guidelines and descriptions. Per the CPT Codebook, codes 37221-37235 include the work of accessing the vessel. The CPT Codebook describes ultrasound code 76937 as "ultrasound guidance for vascular access". Since the ultrasound is used to access a vessel, and accessing of the vessel is included in codes 37221-37235, then you don't code it. This has come up again with a new practice, and the physicians feel they should be able to use code 76937. I only use the code with arterial access for non-occlusive procedures like 37236, which actually states in the CPT Codebook that ultrasound guidance can be used when performed. I would like your opinion on this. 

Transvenous Biopsy of IVC/Right Atrial Mass

I need some direction on how to code this case. I came up with 37200 (transcatheter biopsy) along with 75970 and 36010. "Procedure: Transvenous biopsy of IVC/right atrial mass under fluoroscopic and ultrasound guidance. Clinical indication: Mass in the intrahepatic IVC and right atrium. Right groin was prepped and draped in usual sterile fashion. Under direct ultrasound guidance, the right common femoral vein was accessed with a needle. After series of exchanges, a 0.035" wire was advanced centrally into the IVC under fluoroscopic guidance. A 9 French sheath was placed over the wire. Venogram was obtained, re-demonstrating the mass at the intrahepatic IVC and right atrium. A 5 French angled catheter was advanced through the sheath, and the venogram was repeated with similar results. A 0.035" wire was advanced through angled catheter into the right atrium, then a 14 gauge transjugular stiff cannula was placed over the wire. A 19 gauge biopsy needle was advanced through the 14 gauge stiff cannula. Anterior upper abdomen core samples of IVC/atrial mass were obtained."

93463

I am wondering if, in this scenario, it would be correct to report code 93463 with the cath and stent placement. "Patient was given 200 mg of nitroglycerin to evaluate the mid LD lesion. However, that made the lesion appear worse. Then, 400 mcg of nitroglycerin was used and finally 150 mcg of Nicardipine was used, which made the lesion even worse. Hence, I decided to proceed with angioplasty/stent."

Superior Vena Cavogram and Angioplasty

Patient had a stricture of about 80% in the superior vena cava. Patient underwent a superior vena cavagram, angioplasty of the superior vena cava, removal of vascular catheter, and insertion of new vascular catheter under fluoroscopy. How would you code this?

Pulmonary Vein Venoplasty/Stent

Could you please clarify (Interventional Radiology Coding Reference, P242-12): "Use codes 35476 and 75978 for venoplasty of pulmonary vein stenosis and 37238/37239 for stent placement across a pulmonary vein stenosis. Catheter placement codes are included." Does it mean that codes 36013-36015 are included in 35476, 37238/37239 and shouldn't be coded separately? Is it specific to pulmonary vein intervention? It seems that catheter placement in splenic vein (36011) can be coded with splenic venoplasty (35476). 

77001

Is this enough documentation to bill code 77001? "We now brought a 28 cm tunneled dialysis catheter onto the field, and we made a stab incision in the infraclavicular left chest. We anesthetized a tunnel between this puncture incision and the access site to the left jugular vein. Of note, the access site to the jugular vein as well as the infraclavicular puncture site and tunnel were separate from the patient's recently removed catheter. We now brought the catheter between the puncture incision and the access site to the jugular vein. We sequentially dilated the tract into the jugular vein and placed a sheath into the jugular vein. We then passed the catheter through the sheath and placed at with the tip at the junction between the right atrium and superior vena cava. The sheath was removed and a pull away fashion. Following sheath removal fluoroscopy demonstrated no kinking of the catheter."

Basilar part of vertebral 36226

I wanted your opinion on whether I can charge code 36226 when the physician selectively catheterizes the vertebral artery and describes diagnostic results of the vessels beyond the vertebral (PCA, basilar, etc.) but no diagnostic information on the vertebral. Can you still submit code 36226 with no mention of the vertebral artery diagnostic information? Does the physician need to do an addendum to submit code 36226, or it is that not necessary?

IR Coding 75710, 75630, 37222, 37225, 37221

"Right common femoral accessed and threaded into AA. Aortogram was performed with findings documented. Wire was passed into left external iliac, and lower extremity arteriogram was done with findings of stenosis. Rubicon cath was passed over wire into superficial femoral on left side. Repeat arteriogram was done for intervention. I performed thrombectomy of left fem pop segment. After this, atherectomy of fem pop segment was done on left. A drug-eluting balloon was passed over wire, and angioplasty was performed of fem pop segment. Arteriogram confirmed excellent results. Balloon was removed and sheath pulled back to right iliac. Following this, a balloon was brought up on right side into proximal right common iliac, and balloon mounted stent was brought up on the left side. Stent was deployed in proximal left common iliac. This done as right-sided balloon brought up for support." Provider wants to bill 37221, 37225, 37220, 37184, 75710, 75625. Im not sure when to bill 75710 & 75725 with the procedures. Would I bill 36247?

93458 with 36140

Would it be appropriate to report code 93458 with 36140 in this case? "Local anesthesia was obtained to the right radial region with lidocaine 1%. Able to cannulate the right radial artery three times with good pulsatile flow, but not able to pass wire due to spasm and pain. Therefore, the right groin received local anesthesia. Using a micropuncture needle, a 6 French sheath placed into the right common femoral artery. The appropriately selected catheters were advanced through their respective ostia and injected with contrast, obtaining selective coronary angiograms in multiple views. The LV pressure was measured while accessing the left ventricle."

Lymphatic Malformation vs. Lymphocele

My providers are performing sclerotherapies over a 3-day period for lymphatic malformation. The first day they place a drain in the RLQ, then they sclerose with doxycycline, let it sit for an hour, and then drain. The next two days they inject the sclerosing solution. On the first day, where they place a drain, would you code for both the drain placement (49406) and LM sclerotherapy (37241)? I've gotten a denial for code 37241 saying it's included with another procedure.

Interatrial Angioplasty with Mitral Clip

"Physician entered the left upper pulmonary vein and removed the sheath…Then, after using dilators, attempted to advance the guide cath but could not advance it across the interatrial septum. During attempts lost access to the left atrium and had to re-access using transseptal sheath. We positioned the super stiff Amplatz wire in the left upper pulmonary vein and performed balloon angioplasty with a Mustang 8 x 2 sequentially in the interatrial septum. Then they were able to proceed with the mitral clip." When questioned, the physician indicated this was an anatomy issue not a blockage. Is the angioplasty included in the clip (33418) procedure? If not, what code(s) would be reported?

61645, Recanalization

Patient had occlusion on right MCA. Acute stroke intervention was done. Using stent retriever, MCA was recanalized, but the clot did not come with retriever when retriever was removed. There was active plaque at the occlusion site. Can I report code 61645?

PA stent placement 37236 along with RHC

"Patient presents with right main pulmonary artery stenosis due to external compression by mass. A RHC is performed through the right femoral vein; pressure measurements are documented. Multiple pulmonary angiograms are then taken; the stenosis is measured. A stent is advanced but becomes dislodged as it is advanced through the sheath. The stent is seen in the right femoral iliac vein; it continues to be over the wire. The wire is snared, the stent taken back into the sheath, and the stent and sheath are removed as a unit. Subsequently a stent is successfully placed using multiple pulmonary angiograms." What is the appropriate CPT coding for this case? Would this be reported with codes 93451, 93568, 37236, and 37197?

Cervical Carotid Dissection

Status post distal internal carotid artery embolization for superior hypophyseal aneurysm, patient developed a dissection of the proximal internal carotid artery that was treated with a Xact stent with embolic protection. I understand the codes for the coil embolization (61624, 36224, 75898.26, 75894-26), but I'm unclear what to use for the repair of the dissected vessel. Should it be code 37215? If so, then how would the coding look for the embolization since so much is bundled with code 37215?

Native arterial AV access

Since access has changed for 2017, I am not sure how AV fistula native arterial access and angioplasty should be coded when AV fistula is not used for access. "Left native artery cannulated. Access made of the native radial artery, J wire passed, retrograde brachial artery angio done. Ulnar artery patent-high grade native radial artery stenosis (60%) noted 6cm proximal to anastomosis. Angioplasty resolved native artery stenosis. Fistulogram showed forearm cephalic stenosis (70%) 4 and 6 cm from anastomosis. PTA successfully resolved stenosis. No central vein stenosis." I have chosen codes but would like clarification of this different type of access. 37246,36901-52?, 36120?, 75710, or 75658?

Bilateral Venography at Access Sites

My physician wants to report code 75822 for his diagnostic and intervention venous procedures. Could you give me some clarity if he can or cannot report this code in this case? "Bilateral IVUS-guided access was obtained to the right and left common femoral veins. Simultaneous injection of both right and left common femoral veins was used to image IVC and pelvic veins via digital subtraction angiography." Am I able to report code 75822 for this? Or does he need to move both his caths to different vessels and then perform injections in order to report it? Does this differ between a diagnostic and therapeutic/intervention procedure?

Angioplasty Subclavian Vein with Selective venogram

"Venogram was done by selective cannulation of right subclavian vein from right basilic approach. Apparent stenosis found. Left subclavian vein was then cannulated and contrast injected for left venogram. IVUS was done of both right and left subclavian veins. Provider proceeded to perform angioplasty of right subclavian vein stenosis." Is the venogram coded in addition to the angioplasty? If so, isn't this considered "non-selective" since it was from a basilic vein approach (36005, 36005-59) and not reported? Can the venogram of the left subclavian vein be reported since intervention was done on the right subclavian vein?

Test Occlusion of Fenestration

Would a test occlusion of a fenestration be reported with an unlisted code (93799)? "INTERVENTIONS: Test occlusion of the fenestration. A 014 Mailman guidewire was passed through the right Judkins, which was passed through the fenestration and advanced into the descending aorta. Over this guidewire, a pre-prepared 10 x 20 mm mini Tyshak balloon was advanced. This was then pulled back near to the atrial baffle. After partial inflation, the balloon was pulled across the fenestration and held straddling the fenestration. The balloon was left in situ for about 5 minutes, and saturations and hemodynamics were repeated. Following this, the balloon was deflated and removed. An angiogram was performed, and the balloon was inflated to confirm complete occlusion of the fenestration."

PCI on variant coronary artery

One of my cardiologists performed a PCI on variant coronary artery in a patient who had no prior interventions or grafts. He first placed a BMS in the LD, finding normal anatomy there. He then documented an anomalous LC that “originates from the right coronary artery”, and placed a BMS in the mid to distal anomalous LC to treat an 80% stenosis. Would the LC intervention be coded as a major vessel equivalent with 92928-LC? Or would it be coded as part of the RC distribution with 92928-RC since he had to separately select the ostia of the RC to reach the LC?

Swan-Ganz vs. Right Heart Catheterization Criteria

There is a discrepancy between the coders and techs regarding the use of codes 93503 and 93460 when a patient has a Swan placed for pressures during a LHC and it is left in after the procedure is complete for prolonged monitoring. Some believe thats if any right heart pressures are taken in the cath lab we cannot charge 93503 and that it is an automatic RHC in addition to the LHC. Some believe that if there aren’t RA/RV pressures it isn't a full diagnostic RHC and therefore 93503 should be charged. For example, a patient comes into the cath lab in cardiogenic shock and has a LHC performed, pulmonary artery pressures and wedge pressures (no RA or RV pressures), and the Swan is left in for prolonged monitoring. Is this 93458 and 93503? Or does this count as a right heart catheterization and therefore we should charge 93460 only? 

Complete Runoff

What is meant by a complete runoff? Does the imaging have to be to the toes in order to bill for the complete runoff? "Both groins were prepped right common and left common femoral arteries were accessed; a 5 French sheath was placed into each vessel. There was high grade stenosis in the left common iliac artery and multiple stenosis in the external iliac artery, common femoral artery, and beginning of the SFA. On the right there was high grade stenosis of the RCA and occlusion of the RSFA and CF . We performed angioplasty across these areas using a 5 mm balloon x 200 in length and then deployed 8 mm x 57 in length expandable stents across the CIAs. We then deployed a stent across the ext iliac, CF, and the beginning of the SFA on both left and right sides and post-dilated these areas. After this, repeat contrast study revealed a widely patent iliac arterial system as well as common femoral arteries, SFA, and profunda femoris." Would the correct codes be 37226-50, 37221-RT, 37223-RT, 37221-76-XU-LT, 37223-XU-LT, and 75716-26-XE? In this case would it support the runoff?

CT Guidance PERCUNAV CT/US

"The lesion was not directly visible under UL imaging. Therefore PERCUNAV CT-US imaging was used to help position the targeted lesion. A preprocedural low contrast dose exam was performed to delineate the lesion. Under CT-UL fusion guidance, a suitable site for access of the right liver dome lesion was localized. A small dermatotomy was made. Under intermittent CT and Perkin guidance, a 19 gauge needle was advanced to the targeted lesion in the right liver dome. Repeat low contrast dose CT was performed to confirm appropriate position. Multiple core biopsy samples were then obtained utilizing the supercore biopsy device. Following specimen collection, all needles were removed. Hemostasis was achieved with manual compression." Would we bill codes 47000 and 76499-26, or would we also add code 76942-26? 

Venogram LE with 37252

In follow-up to question ID #8381, there is an NCCI edit that says I can't bill 36005 and 37252. Does 75822 become my primary?

Percutaneous staining of pulmonary nodules with Methylene blue

Is there a CPT code for percutaneous injection of methylene blue into pulmonary nodules? Or do we use unlisted code 32999? This will be performed under CT guidance (77012).

Chemical Cardioversion

"Patient was brought to the cardiac cath lab. Ibutilide was administered in 250 mcg increments over 5 minutes. After roughly 30 minutes the patient was converted to NSR." I'm coding for the hospital, not the physician. Do we use code 96374 or 93799? Or something else?

ONYX to Treat EVAR Endoleak

In researching the product ONYX liquid embolic system LES, the FDA has it listed with a classification name of "Agent, Injectable, Embolic". However, in the approval statement, this is noted: "Device is indicated for presurgical embolization of brain AVM." That being said, if an embolization is performed with the ONYX system to treat an EVAR endoleak, is this considered "off label" and therefore should be coded with a UPC? Or, would it be appropriate to utilize code 37242?

Radial Approach

When radial approach fails and LHC is ultimately performed via femoral approach, should we code radial access 36215-59, followed by LHC 93458 (of course, without femoral access since it included in the LHC code)? If so, are specific diagnosis codes required for radial access to be reimbursed?

93452 and 93462 during EP Ablation

"Transseptal puncture was done using Baylis needle at central fossa under ICE and hemodynamic guidance. Entry to left atrium was verified, and left heart catheterization was performed. Mean LAP was 30 mmHg. Agilis sheath was then inserted to the left atrium and tip deflected into the mid-MV. Pentary cath was deployed to the left ventricle, whose geometry was acquired. The other EP catheters were inserted into the CS, right ventricle, and left ventricle. 3D maps of right atrium and left ventricle were created with CARTO. HIS bundle was located and labeled. EP study was performed to assess AV and VA conduction and sinus node recovery time. Clinical PVCs were seen with infusion of Isuprel. The ablation cath was then positioned to the respective cardiac chambers, and activation and pace mapping was performed using PASO software. Ablation was performed targeting the respective sites, and complete disappearance of PVCs was seen following ablation." Can we report codes 93452 and 93462 during this EP ablation? Encoder specifies that code 93452 is allowed but with modifier -59. Are these two typically coded/billed together for EP ablations?

US Liver Ablation with US and CT Guidance

Please advise on proper coding of the following procedure. "TECHNIQUE: Informed consent was obtained. The patient was placed in supine position and placed under general anesthesia by the anesthesiology service. Utilizing ultrasound and CT guidance, a 17 gauge RF needle was advanced right hepatic lobe masses. RF ablation of the liver masses was performed. Tract ablation was performed. The needle was removed. A sterile dressing was applied. The patient was taken to recovery in stable condition. INTRA-PROCEDURE MEDICATION: Contrast agent Omnipaque 300 50 ml 100 milliliter. INTRAVENOUS IMPRESSION: Successful ultrasound and CT-guided ablation of right hepatic lobe hepatocellular carcinoma." Both US guidance and CT guidance were utilized for the liver ablation. Should this be coded as 47382, 77013-26, and 76940-2659 OR 47382, 76940, and 74160?

Ablation

"Patient presents for hydrodissection followed by ablation. A small incision was made in the RUQ. Under ultrasound guidance, a Hawkins needle with a blunt tip was advanced into the peritoneum from a subcostal approach. A Benson wire was advanced into the peritoneum under CT fluoro guidance. Then, a 6 French pigtail catheter was placed over the wire toward the dome of the liver, and 2L of 5% Dextrose was infused into the peritoneal cavity. Periodic CT fluoro was used. As fluid was infusing, the lesion began to separate from the liver. A non-contrast scan of the liver was performed, which confirmed that the lesion was, in fact, a diaphragmatic implant, not an exophytic liver lesion. Given the risk of diaphragmatic paralysis and other complications if we were to ablate the lesion, the decision was made to terminate the procedure. The intraperitoneal fluid was drained and the catheter was removed." Had liver ablation been performed, would we code both the ablation 47382 and 49084??

Mild regurgitation ICD-10

If the provider states "there is/was mild aortic regurgitation" in the report, can that be coded or does it need to be moderate? In our office we have had a difference of opinion on this. If it can be used, would you use I35.0 as the dx code?

ICD-10 f/u after pacemaker

If a patient is coming into the office one year post pacemaker for CHB, would you still code the CHB with status post PPM as the diagnosis code?

ICD Changeout for FDA Advisory

Patient presented for an ICD generator and lead that are under advisory from the FDA. There is no supporting information to state that the generator was showing an ERI status now or that there were any lead failures noticed in the device checks. Device was placed for secondary prevention and patient is solely reliant on the ICD, so decision was made for a complete removal/replacement. The provider is coding the procedure as a mechanical breakdown of ICD generator and ICD electrode (T82.111A and T82.110A). Is this appropriate without evidence to support any actual complication? Is there another ICD-10 code that is more appropriate to report when changing out due to an FDA advisory or recall, or do we simply revert to the Z45.02? Is there anything else we should be doing on facility or physician side to make sure the claim is processed smoothly when there is an FDA advisory/recall?

Iliac Stent

We are seeing several denials for iliac stenting with diagnosis of iliac arteriosclerosis. We are using I70.8 for iliac stenosis. We have WPS Medicare, and this is not a covered diagnosis. Is there a different diagnosis code we should be using?

ICD-10 use follow up visits after coiling ruptured aneurysm

If a patient had a ruptured aneurysm that was treated prior (coiling couple years ago) and now comes in periodically for follow-up, would we code the diagnosis of the ruptured aneurysm still as I60.7? Or would we code the aneurysm non-ruptured (I67.1)? My thinking on this as to why I question it... the aneurysm is always there, but it is not ruptured anymore, so would that be more specific to use the non-ruptured? Or would we just keep the ruptured aneurysm code for the SAH I60.7 even though it is already treated and no longer hemorrhaging?

Rheumatic vs. NonRheumatic

In ICD-10, if a patient has mitral regurgitation without mention of it being non-rheumatic in the report, would we use the rheumatic diagnosis code? My colleague is taking the AAPC CPC coding class and was told this is the correct way to code with the rationale that if the documentation does not specify rheumatic nor non-rheumatic that you would assign the unspecified code, which is also the rheumatic code. Other coders in our office have always been taught to code as non-rheumatic unless stated otherwise. Any assistance would be appreciated.

93784 and Acceptable DX Codes

Patient already carries diagnsis of HTN (I10) and comes in for an office visit for an ABPM 93784. Research shows the acceptable code to use is R03.0, but if patient already carries HTN diagnosis, that code cannot be used. What are others doing to get the ABPM 93784 paid?

37246

"With ultrasound guidance, left radial artery was micropunctured and sheath placed. Guidewire navigated retrograde into the axillary artery. Angiogram was performed, identifying stenosis of proximal anastomosis of the axillofemoral bypass and dissection of axillary artery. More angiograms were performed for the rest of the grafts. Keeping wire access, the proximal anastomosis was balloon angioplastied. This was followed by readjusting the wire into the axillary artery, which was balloon angioplastied as well." Is it appropriate to report codes 37246, 76937, and 75710? Do I need to add codes 36120 and 37247? Is non-selective catheterization included in 37246-37249 and 37236-37239? 

Shared Visits

Our cardiologists will see the same patient, but after the midlevel for a shared visit. The MD will document within the midlevel's note, but document his/her own exam findings, HPI, assessment, and plan. If the exam information isn't comprehensive enough, do you agree with assigning the lowest CPT E/M level?

Y90 mapping and sirsphere therapy on same day

Our hospital is being asked by referring physician more frequently to do the Y90 mapping and then the SIR-Spheres treatment on the same day. This would be done several hours apart, but still with the same date of service. Is it appropriate to report code 37242 for GDA embolization during the mapping and then 37243 later that same day for the embolization of the tumor?

Physician Planning of FEVAR

My surgeon wants to bill code 34839 (planning of a patient-specific fenestrated visceral aortic endograft). Medicare does not have fee for this procedure. Can you tell me if this is Carrier priced or not just payable at all?

Pneumothorax Induced During Liver Tumor Ablation

I have a case where they first placed a catheter in the pleura to induce a pneumothorax and then injected saline to displace the lung from the liver edge. Then, they performed a liver tumor ablation. Would I add code 32960 for the pneumothorax creation, or would this be an inclusive procedure to the liver ablation and therefore not separately billable?

Declot CV Catheter

In H&P, nurse documents the following: "Attempted to flush port with medallion, which flushed well, but would not aspirate. Then instilled with 2 mg tPA with a dwell time of 30 minutes. Port still would not aspirate. Patient had removal/replacement." I'm billing for hospital. There is no separate physician procedure note for tPA. Can we report code 36593? Only 30 min infusion done by nurse?

93655

Regarding your answer to question ID #8809 from 1/18/17, your answer in part: “Only if after the first ablation is done a second arrhythmia is identified and treated can it be reported.” Now I am more confused by the use of code 93655. If a patient presents for ablation with a documented diagnosis of atrial fib and atrial flutter, and ablation is performed for both without any induction of or spontaneous atrial flutter post PV isolation, code 93655 cannot be reported? Procedure example: "Patient has documented atrial fib and prior atrial flutter ablation. Atrial flutter was seen on ECG pre PVI ablation. Pulmonary veins are isolated, and, post PVI, given the history of typical flutter and prior challenging CTI ablation, bidirectional block across the CTI was checked, and this was found to be conducting in both directions. A Tacticath was positioned along the 6'0 clock position of the CTI, and several RF lesions were applied." In this case would code 93655 also be reported along with 93656?

BM aspirate > stem cells>...PCS Root term?

CPT was previously addressed. This refers to the PCS codes: Patient had chronic, nonhealing leg ulcer and deemed a stem cell candidate. H&P states: "The only option is stem-cell injection to facilitate neovascularization." Operative report: "Procedure: Bone marrow aspirate with injection and delayed primary closure of left distal leg wound. We accessed the right anterior superior iliac spine with a bone marrow aspirate and aspirated 240 mL of bone marrow from the right iliac bone marrow. We spun this down to stem cells and then implanted the autograft proximal to the wound in healthy tissue to effect late closure or delayed closure, closure by secondary intention. The procedure was staged in two parts. The bone graft was removed and created a bone autograft to seal, fill, and replace lost tissue. This was injected at multiple locations around the wound and proximal to the wound in healthy tissue in order to facilitate neovascularization and facilitate healing of the wound." What is the PCS code for aspiration? For placement, is it Introduction or Supplement?

Heart Catherization

Can you please tell me the CPT code for left heart catheterization with ascending aortogram?

Repair of type 1 endoleak

Can you help with this procedure? I am not sure what the physician did here. "OPERATION: Repair AAA Endovasc, ENDOVASCULAR REPAIR OF ENDO LEAK (PROXIMAL CUFF). angioplasty OR STENT PERCUTANEOUS , RT RENAL ART PTA, STENT, PLUS LT BRACHIAL CUTDOW. Pt taken to OR. From the femoral artery and the brachial artery, catheters were placed in the aorta. The aortic cuff was advanced into the abdominal aorta through the 18 French sheath. We cannulated the lower pole renal artery. Working over the wire, a 5 mm x 59 mm Atrium/iCast stent was advanced approximately 2 cm into the lower pole right renal artery. The precise position of the proximal renal artery was marked, as was the SMA. The aortic cuff was then deployed with its cranial tip at the level of the proximal right renal artery. The icast stent was then balloon deployed by inflating the balloon. The iCast balloon and Coda balloon were simultaneously inflated in the aortic cuff. Repeat angio, no endoleak."

Fistulogram of Upper Arm and PTA of the SVC

"Patient has a basilic ulnar artery fistula. Needle is placed in the basilic vein in the right forearm. An arteriogram was performed of the right upper arm. A second study is done of the SVC, showing 95% stenosis of the SVC/possible stenosis of subclavian vein at its branch of the SVC. PTA is done of the SVC. A fistulogram is then performed. Another PTA is done of the SVC. The subclavian vein and the SVC were then given PTA. Venogram showed improvement." Should this be reported with codes 36902 and 36907? Or 36901 and 36907?

Access for Endovascular Procedures

When an endovascular procedure has the femoral artery accessed percutaneously, how is this coded? We are not exposing the femoral (34812).

Documentation requirements for peri-procedureal device evaluation

Can you please help me with what documentation is required to report codes 93286, 93287 during a procedure? A chart note reads: "PROCEDURES PERFORMED: 1) AV node ablation. 2) Device programming pre and post procedure (dual chamber internal cardioverter-defibrillator: was stated in HPI). The patient's pacemaker was reprogrammed to DDD 90 bpm. Device thresholds checked pre and post procedure (RV was at 0.75 volts @ 0.4 milliseconds)." Would this be adequate documentation to report these programming codes? If not, will you let me know what is needed?

Observation Place of Service

What is the correct place of service and CPT codes to bill when the hospital labels the patient in observation on the date that our cardiologist was called in for a cardiac consult?

62323 Multiple Site Injections

If ESI is performed on L4-L5 and L5-S1 and both are injected using fluoroscopy, can we report code 62323 twice?

PVI for patient not in atrial fibrillation

Our patient has a history of atrial fibrillation, for which PVI was scheduled. When the patient presented for the procedure, he was found to have a supraventricular tachycardia at the start of the case. The arrhythmia did not appear to be A-fib. After mapping, the focus of the tachycardia was suspected to be at the right pulmonary vein. The EP physician performed PVI. Entrance and exit block were confirmed. Attention was turned to the initial tachycardia, which could not be re-induced. Is code 93656 appropriate for this PVI since the patient was not in atrial fibrillation at the time of the procedure? Or would it be more appropriate to report code 93653 for ablation of the SVT at the right pulmonary vein?

Open Thrombectomy

Patient was in for open thrombectomy of AV fistula followed by angioplasty and stent insertion. Is there an additional code for the stent placement if it was done via open approach? Would code 36903 in addition to 36831 be appropriate? If not, what code do we report, if any? “An incision was made in the medial side of the arm where the patient had an arterial revision in the last week, and then a graftotomy was made in this position and a #4 Fogarty was used to thrombectomize both the arterial and venous limbs. Once this was done, a 7 French introducer sheath was placed into the graft in the venous limb, and a fistulogram was performed. There was a very tight stenosis at the AV graft AV fistula anastomosis and at the venous anastomosis. So, an 8 x 5 cm Viabahn stent was then deployed at both locations. Then, an 8 x 4 balloon was placed over the wire in this position and angioplastied several times to 26 atmospheres."

Lexiscan- rest and stress portions done on different days

Occasionally the rest and stress portions of the Lexiscan (nuclear stress test) are performed on two different days, usually in patients who have a larger body mass. Would it be appropriate to bill codes 78451 and A9500 for the DOS that the rest portion was done and codes 78451, A9500, 93015, and J2785 (if the patient is unable to walk on the treadmill) for the stress portion and bill with the DOS this was done? Would we bill the same for Medicare and commercial? Or for commercial plans would we bill codes 78452 and A9500 on the rest day and then codes A9500, 93015, and J2785 (if applicable) on the day the stress portion was performed? Also, to confirm, should the DOS each portion was done be the DOS used as the billing date? And would you suggest two reports (each dated accordingly), or would one report documenting the date each portion was performed be sufficient?

Intercostobrachial Supplemental Nerve Block

What would be the correct nerve injection code for a intercostobrachial supplemental nerve block? The physicians are performing this in conjunction with a brachial plexus/interscalene single-shot block (64415) for post-op pain management. Would 64420 be appropriate for the supplemental intercostobrachial block? Or would 64450 be more appropriate since the intercostobrachial nerve is a cutaneous nerve off of the T-2 intercostal nerve?

93623

My provider is performing an SVT ablation (93653). Drug infusion is inducted (93623), patient goes into a different arrhythmia, and an ablation is performed after adding the infusion. Can we bill for the drug infusion (93623)?

Left Atrial Appendage Exclusion

Atrial clip inserted during sternotomy for repair of cardiac injury to right ventricular outflow tract. Would I use code 33340 or 33999 for atrial clip? With good exposure of the left atrial appendage, the left atrial appendage was excluded with a 35 mm atrial clip and then vented.

Midline Catheter Insertion

Your Diagnostic Radiology books says: "A 'midline' catheter (placed in the arm and advanced with the tip in the subclavian vein) is a central catheter (PICC) for coding purposes. Use code 36569 to describe this procedure." The other note says we can capture 36569-52 if the PICC cannot be advanced from the extremity centrally due to subclavian occlusion. If this occurs, and the tip is in the axillary vein, we would report the lesser service. Our radiology staff have said that the midline catheters are too short to reach the subclavian vein, so they would never qualify a midline catheter as a central catheter. Can you comment on this for us? I need to clear it up for us. It is as clear as mud to us right now.

Endo-Anchors

From previous Q&As it appears that the endo-anchors placed during the initial stent graft deployment cannot be coded. Since there is significantly more work/risk/time involved in placement of the anchors, do you have an opinion on justification for a -22 modifier? Also are you aware of any movement to create a CPT code for this procedure that is becoming ever more common?

Preservice Work, Interservice Work, and Postservice Work

I was wondering if you need to have the documentation of preservice, interservice, and postservice in the operative notes, or is it okay to have this documentation listed in other parts of the record?

Infected port catheter site follow-up wound care code

Patient had infected port catheter removed and will be coming weekly for wound check, irrigation, and repacking of wound with Iodoform gauze. No anesthesia is involved. Is there a CPT code for this, or is it just E&M?

Cuff shave of peritoneal dialysis catheter cuff

I'm unsure of the appropriate code for this procedure. Operative report reads: "A small ellipse of skin was created around the exit site and dissection taken down around the cuff. The entire cuff was exposed, and a rim of soft tissue was created around the exit site where skin had heaped up and grown onto the cuff. I removed 1-2 mm rim of epithelium as well as the cuff. I shaved the cuff from the catheter, taking great care to remove only the cuff and not to injure the catheter."

Pelvic Doppler Studies

What has to be mentioned when coding 93975?

Recurrent pelvic congestion syndrome

"The previous supraumbilical transverse incision was created with a #10 blade. The muscle layers were divided with a bovie cautery. The abdominal cavity was explored and no abnormalities were appreciated on exam. The Omni tract retractor was placed in position. The small bowel was eviscerated to the right side. The aorta, vena cava, left renal vein and superior mesenteric artery were dissected. All lymphatic tissue encountered were ligated with hemoclips and divided. It was noted that the juncture of the left renal vein previously transposed to the vena cava was examined and found to be patent. The ovarian vein was still patent and very large. It had a common trunk proximally but quickly bifurcated into two smaller branches which then came together to form a common trunk in the pelvis. The ovarian vein was clamped in the pelvis and then transposed to a partially occluded vena cava above its bifurcation. The anastomosis was constructed with 7-0 prolene. The anastomosis was hemostatic." The doc has dropped the code 34510, but I don't think this is correct. What are your thoughts?

Thyrocervical Trunk Angiography

I'm wondering how to report catheterization of the subclavian artery followed by catheterization of the thyrocervical trunk, as well as angiography of both. I'm thinking of code 36225-52. Thoughts?

Define Complete Doppler

I am faced with a group of doctors who want to charge for a complete Doppler study for every transesophageal echo that they perform. I know that when Doppler measurements are documented for one or two valves, that is a limited Doppler study (93321). However, the doctors are wanting me to define a list of the sites measured in a complete Doppler TEE (93320). I believe a complete Doppler should include measurements at all four valves and the left ventricular outflow tract. Is there anything else that needs to be documented? What measurements do you personally look for before you apply 93320 to a TEE?

Can we bill 76881 with 20610, 77002?

I am seeing charges for 76881 come in with 20610, 77002. I don't feel we should be able to charge for this because I'm not sure if its medically necessary. They do aspiration/injection frequently without knowing/checking how much fluid is actually there. Can you give me your thoughts? Provider note states: "Survey view of the right hip was performed using real time grayscale ultrasound to determine if sufficient joint effusion was present for ultrasound-guided aspiration. No significant joint effusion was seen and the procedure was then performed fluoroscopically. The right hip was sterilely prepped in the usual fashion and anesthetized with approximately 4 mL locally infused 1% lidocaine solution. Under direct fluoroscopic guidance, a 22 gauge spinal needle was advanced into the right hip joint. A small amount of Omnipaque solution was injected to confirm intra-articular needle position. A combination of 2 mL Kenalog (40 mg/mL) diluted in 5 mL 1% lidocaine solution was injected." I would code this as 20610 and 77002. What are your thoughts?

Gastrostomy Button Exchange

"The balloon of the MIC-KEY gastrostomy button was deflated. The button was removed, and a new 14 French low-profile MIC-KEY gastrostomy button with a 1.2 cm stomal length was placed. The balloon was inflated with 2 mL saline. Gauze was placed between the tube and the skin." Would we use code 49450 for the g-tube exchange? Or do we add a -52 modifier to 49450 or use an unlisted code?

Closure Device G0269 and C1760

When a closure device is used during a uterine fibroid embolization, when would it be appropriate to assign G0269 and/or C1760 in the following locations: 1. Global - office (POS 11), 2. ASC (POS 24), and 3. Outpatient (POS 22)? When does the facility get to code, and when does the physician get to code for it?

Right Gastric and Left Hepatic

Based on previous responses it has been noted that the right gastric is commonly a branch of the left hepatic, which I can see in the "Celiac Arterial" anatomy chart in your publications. My question is about coding when both of these vessels are catheterized in the same case. If the left hepatic is catheterized distal to the origination of the right gastric, would you consider it to be a separate placement (36247, 36248)? I would have this same question about a scenario involving the right hepatic and cystic.

Venous Lower Extremity Intervention

For venous lower extremity angioplasty and stents, do they follow the same territory rules as lower extremity arteries (iliac, femoral/popliteal, and tibial/peroneal territories)?

Billing drugs and supplies for IR group in office setting

Can you provide us with guidelines or resources in regards to what supplies (if any) and/or drugs can be billed for an IR group within an office setting? What drugs or supplies would be inherent to the reimbursement within the procedure code, and/or what drugs can we additionally bill for?

Fluoroscopy with Pacemaker

Can I use code 76000 with codes 33217 and 33225? "Using a 0.014 whisper wire, through an inner and outer sheath, the appropriate branch was cannulated, and the wire was advanced distally. The lead was then delivered to this branch. Satisfactory sensing and pacing were confirmed, without diaphragmatic stimulation at 10 V on the proximal poles of the quad lead. No diaphragmatic stimulation was seen on the minimal vectors tested during implant. The proximal poles unfortunately had limited capture, but the distal pole actually had the latest activation. Next, using the splitter, the inner and then the outer sheath were successfully split. Next, the short introducer sheath was split. The lead was tied down with 0 Ethibond suture. Attention was next turned to the atrial lead. Another 7 French sheath peel way introducer was inserted over the second wire. This was used to position the atrial lead. The atrial lead was positioned into the appendage were was screwed in place. Satisfactory thresholds were measured. The sheath was split. The lead was tied down with 0 Ethibond suture."

Spinal Cord Neurostimulator

According to the new Pain Management boo,k fluoroscopic guidance for the initial electrode array placement (63650 and 77003) may be reported separately, but there is an NCCI edit in place. Should these be billed together?

76642 vs. 76882

Can you use code 76642 when ultrasound is performed on the axillary tail only? Is this considered a compliant use of this code?

Moderate Sedation Facility

I work for a hospital (IVR), and I am looking for guidance on how to bill the new moderate sedation codes. When we have a case, a nurse administers the meds and monitors the patient. The doctor does not. He is performing the procedure only. Would codes 99155 and 99156 be the correct codes to use?

Mitral Line after PVI

I see this pretty often and am unsure every time. For this particular case the physician completed a PVI. After this the patient's afib converted to left-sided atrial flutter (in other cases flutter is induced after PVI). Mapping was performed that showed mitral reentry, therefore a mitral line was performed. In this case that terminated the arrhythmia to afib. The impression states: "Left-sided mitral flutter was ablated with the mitral line joining the left inferior pulmonary vein." Is the mitral line just an extension of the PVI, or is it a separate ablation (93655)? I often see a similar account with a roof line joining the pulmonary veins. I've seen some direction that says the mitral line and roof lines are included in the PVI since they are done so often, and I would like your opinion please. 

Regarding Coronary CTA

If patient has had a coronary CTA and is now in the cath lab, can we still do the coronary angio? I know with CTA legs it is a prior diagnostic procedure.

Remote Heart Monitoring

While performing an internal audit of remote heart failure, I noticed several services not billed dating back to 2016. Can I bill these services now, as I can download reporting for the specific DOS? Would the tech service 93299 reflect the actual date of service? What DOS would be used for 93297, the professional component? 

KX Modifier

Is the -KX modifier still in effect to report for billing on the physician coding side?

Left Dorsalis Pedis an additional artery on Left Anterior Tibial?

A PTA was performed on the left dorsalis pedis. A PTA with atherectomy was done on the left anterior distal tibial. Is the left dorsalis pedis PTA an add-on to the 37229? Or part of the 37229? 37229, 37232 or 37229?

List of tunneled and non tunneled catheters

Do you have a list of names of types of tunneled catheters and non-tunneled catheters? I used to have a great list to refer to, and in an office move I cannot find it.

POP TO POP BYPASS FOR TRANSECTED ARTERY D/T TRAUMA

Saphenous vein was harvested to bypass the transected portion of the popliteal artery (above knee to below knee bypass). The damaged section of artery was ligated distal to the proximal anastomosis and proximal to the distal anastomosis. Would you use code 35571 or an unlisted procedure code?

Moderate Sedation

When the providers are performing a procedure that now has the moderate sedation billed separately, does the moderate sedation documentation have to be in the body of the report or can we use the nurse notes to bill it?

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