Knowledge Base

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Fluid Drainage - 10160 vs. 49405/49406

How would the following be coded? My docs are saying that code 10160 should be used for the fluid drainage, based on a reference where you indicated that 10160 should be used when the catheter is removed prior to patient leaving the procedure area. But the same catheter was used to instill the erythromycin and left in place for 2 hrs. CDR for 49405/6 says catheter 'may' be left in. Please advise. "Using u/s guidance, an 8.5 Fr drain was placed into the largest pocket of the SQ collection located in the RLQ. Vigorous aspiration was then performed with approximately 30 cc removed. U/S demonstrated complete collapse of the cavity. Then, 30 cc of 4 mg/mL of erythromycin was placed into the cavity and the drainage catheter was capped to facilitate sclerosis. Then, the patient was instructed to turn every 30 minutes 90 degrees for 2 hours. This allowed contact of the erythromycin to the walls of the cavity. After this time had elapsed, vigorous aspiration was performed demonstrating collapse of the cavity and the drain was removed."

47532 when performed via separate access site than that of 47532

Please provide your interpretation of the following: "An anterolateral lower intercostal approach selected for the PTC and a complete dx cholangiogram performed. Multiple common duct stones were identified with complete occlusion across the ampulla. A more favorable approach was targeted for catheter placement via a separate access. A second 12g needle was directed into the biliary duct via a separate puncture and after several injections, an internal-external biliary catheter was placed into the duodenum." The dictation clearly states that the PTC was performed via one access and the catheter placed via a separate access. In this scenario, would it be acceptable to file for 47534 and 47532-XU or -XS? The CPT Codebook states, "Do not report 47532 with 47534 when performed via same access." The catheter was not placed via the same access as the initial diagnostic PTC for this procedure.

Peripheral Bypass with eEndartectomy

The surgeon performed a superficial femoral to anterior tibial artery bypass graft after eversion endarterectomy, followed by removal of residual plaque from the profunda artery. Per the CPT Codebook: “Primary vascular procedure listings include establishing both inflow and outflow by whatever procedures necessary.” I am using code 35666 for the bypass. Am I correct in the assumption that the endarterectomies fall into the circumstance of establishing inflow/outflow and are therefore not separately billable? I have always felt like they were included in bypass, but I really don’t have access to any quality vascular reference material, and I'm not sure if there is a situation where these endarterectomies would be separately billable.

35082

Patient has history of AAA repair with Gore excluder stent graft four years prior. The physician is stating open repair type 2 endoleak. Can code 35082 be used if no graft insertion is used and only sutures are used to reclose after the AAA rupture is evacuated?

Amputation Via Elbow Disarticulation

The patient was involved in an MVA resulting in a mangled, non-salvageable distal right upper extremity (crush injury). The doctor performed an amputation via a right elbow disarticulation. What CPT code do I use for this?

Billing Modifier 50 with 51

I have a question about modifiers -50 with -51 being billed together. I know that we do not have to apply modifier -51 to the codes, but for our reports we use it for RVU purposes. We apply a -51 modifier, and the clearing house will take the -51 off. Our charge is already reduced when we apply modifier -50 (150%), but do I apply modifier -51 to the second code even though it is already reduced? I am unable to locate any information that talks about billing these two modifiers together. (Example: 36226-50, 36223-50-51)

Acceptable Documentation for Coding Cerebral Atherosclerosis

When coding for a carotid stent procedure, on the rare occasion when the physician does not specifically say the words "cerebral atherosclerosis" in his findings, is it reaching too far for us to code it as such if he describes the internal carotid artery as "70% stenosis ulcerated", "80% stenosis with string sign", "60-80% stenosis with plaque", "95% stenosis, extremely calcified" for example? One corner is stating that it must specifically state "cerebral atherosclerosis" in order for it to be coded as such, but after some discussion they said that a description of calcified stenosis or ulcerated plaque (ulcerated must include plaque in the description) would be acceptable. The other corner feels that understanding anatomy and the pathology of the disease makes any of the descriptors in the opening paragraph sufficient to be led to cerebral atherosclerosis as the disease. Will you please give us some insight regarding this?

TAVR and Endartectomy

We had a patient who had a TAVR, and after the TAVR the provider removed the drapes and found that the patient had no pulse in one of the legs. So they did an aortography of the pelvis with bilateral lower extremity runoff, which showed that the patient had an occlusion in the right common femoral arteriotomy site, which required cutdown and an endarterectomy and patch revision. Would you code the aortography, the bilateral lower extremity, and the endarterectomy?

Left Ventricle Aneurysm Repair

The patient is undergoing a CABG, and during the service the physician discovers a left ventricular aneurysm. He decides to repair it by entering the left ventricle and suturing a pericardial to the inner part and healthier part of the left ventricle. How would we code the ventricle repair?

Pre-Op Arteriogram, Compliance Risk?

I am well aware of your warnings about repeat angios being a huge compliance risk. The physician performed a CTA of the leg and found occlusion of the patient’s vein bypass and native arteries. He then performed a complete percutaneous arteriogram of the leg. Can this second study be billed? The only reason given in the report for the repeat study was: “He was recommended an arteriogram to assess potential for new bypass.” This reason does not explain why the prior CTA was inadequate, but I am wondering if it will pass muster in an audit. Would pre-operative exam Z01.818 be the primary diagnosis for the arteriogram even though they have not yet definitely decided to replace the bypass?

Toba II Clip Insertion

How would the insertion of a Toba II Clip placed on the SFA be coded? The procedure was percutaneous with angioplasty of the SFA performed, with dissection of the artery noted. The patient was then enrolled in the Toba II trial, and a clip was placed. I appreciate your help with this, as I am so far unable to locate any coding advice, and I'm thinking this is an unlisted code.

Atherectomy RCA and PTCA with Vision Stent Posterolateral Branch

Can you help verify if I understand the coding hierarchy for the cardiac intervention codes? The patient had a diagnostic heart cath (93458), followed by: 1) successful orbital atherectomy with balloon angioplasty to the heavily calcified right coronary artery, 2) successful balloon angioplasty and stenting to the right posterolateral branch by deploying one bare metal stent. Should I report code 92924 for the RCA atherectomy and code 92929 for the vision stent and PTCA of the posterolateral branch?

Creation of Brachiocephalic Fistula with Patch Repair due to No Pulse in Fistula

If a surgeon creates a fistula (32821) and there is no pulse, and he therefore does a revision and repairs it with a harvested vein and does vein patching, can you code the revision as well (36832), even though both codes are separate procedures?

Smart Needle for Needle Insertion

Can you please advise as to whether code 76942 or 76937 is appropriate to report the "smart needle" for the needle insertion documented in the referenced report? We do not believe either is appropriate; there's no permanently recorded images. The physician is stating that the smart needle is being used "for needle insertion". The report reads as follows: "Femoral areas were prepped and draped in the usual sterile fashion. Smart needle with fluoroscopic guidance was used for needle insertion. A 6 French sheath was placed in LF artery using the modified Seldinger technique. Angiogram of the femoral artery was obtained through the sidearm of the sheath. A 7 French sheath was placed in RF vein using the modified Seldinger technique. A Swan-Ganz catheter was advanced through the venous sheath and into the chambers of the right heart. Pressures were obtained in the right atrium, right ventricle, pulmonary artery, and pulmonary capillary wedge..."

CT-Guided ALcohol Ablation

What code can I use for CT-guided liver alcohol ablation?

Revascularization Hierarchy

Perhaps you can help us understand a dilemma we’re having in our coding unit. Beginning with the 2013 CPT guidelines, the PCI codes for revascularization (both in coronary and lower extremity vessels), the atherectomy CPT codes have a lower CPT code number than the stent placement codes, yet the RVUs for the atherectomy codes are higher. In the past, the higher CPT code number reflected the higher RVU value since it included all the work done in the preceding CPT codes. Why did they break formula for these procedures in 2013?

61635 vs. 37238

It is unclear whether to bill 37238 or 61635 for transverse sinus stenting. Can you help? I cannot locate anything specific. Patient has stenosis.

Left Heart Cath from Two Approaches

"Via the right radial artery, cath passed to LV, pressures obtained, LV-gram performed, attempted diagnostic cor angiogram but unable to engage RCA, exchanged cath, axillary artery went into a spasm, which was angiogrammed. RT femoral artery then accessed and used to obtain bilat coronary arteriograms." We have assigned code 93458, but I wonder if the two approaches affect code selection, and if so, what additional code will be appropriate?

Pipeline Stent Intracranial Aneurysm Separate Encounter

When we place the intracranial/neuro Pipeline stent for aneurysm and perform the coil embolization at a separate encounter, how should the stent be coded? Both Medicare and non-Medicare?

Codes for Right Carotid Angiogram

What are the correct codes for this procedure? "Right carotid stenosis procedure. The right common femoral artery was accessed. A JB2 cath and glidewire were used to engage the innominate artery and right common carotid. From this position a selective right innominate and common carotid angiogram was performed. This showed a widely patent right subclavian artery and right common carotid artery. The bifurcation was identified; the external carotid artery was identified. A glidewire advantage was placed into the external carotid artery and advanced into the common carotid artery. A carotid and cerebrovascular angiogram was performed. This showed a widely patent carotid bifurcation and widely patent external carotid artery. The internal carotid artery had an area of ulcerated severe stenosis, several centimeters beyond the bifurcation. Distally the internal carotid artery was somewhat hypoperfused and smaller. The middle and anterior cerebral arteries were completely occluded. It was decided to treat patient medically." 

93531 and 75743

I have a congenital cath (R/L 93531) case were my provider documented doing a selective injection into the left and right pulmonary artery (75743). I'm also coding RV injection (93566), LV injection (93565), descending aorta injection (93567), and SVC injection (75827). However, I'm getting an NCCI edit with codes 93531 and 75743. Can you please advise on the reason for that edit?

Sinogram vs. Drain Injection

How would you code a procedure where they inject contrast into a previously placed drain (diverticular abscess) to see if there is a fistula? Example: "Patient has diverticular abscess for which a pigtail drainage catheter was previously placed. Sinogram requested. Contrast gently instilled. Flowed freely into the vaginal cuff. It did not fill any further pelvic soft tissues and did not opacify bladder or colon. Images were stored. Impression: Sinogram demonstrated fistulation from the patient’s abscess cavity to the vagina." Because the report states “sinogram”, do we use code 20501? Or should it be injection into drain (49424)?

Angioplasty Zones

When performing angioplasties, my physician will state in his dictation "intra access and outflow and inflow". Are these separate areas/zones, or are all considered one?

Repair of LV Apical Pseudoaneurysm with VSD Occluding Device

"TAVR procedure two days prior. Patient then found to have a contained apical pseudoaneurysm. By way of the left axillary artery surgical access, we delivered a 9 French Torque Amplatzer delivery system into the left ventricle. Successful closure of left ventricular apical pseudoaneurysm with an Amplatzer Muscular VSD device." What are the correct CPT codes? Does this qualify for assistant surgeon?

Drugs used to induce arrhythmia for 93623

What are the names of the drugs used to induce an arrhythmia during cardiac ablation procedures that we would code CPT code 93623? Would adenosine be one of them?

Attempted Pleural Catheter Exchange

How would you code for a tunneled pleural catheter that is removed and attempted to be replaced? Dictation states, "Multiple attempts were made to place a new catheter, but they were all unsuccesful." They ended up just removing the catheter. Is this still just 32552? 

Right external iliac artery injury with arterial bleeding

"Emergent intraoperative vascular surgery consult. Ultrasound-guided retrograde access right common femoral artery. Intra-arterial angioplasty balloon inflation for temporary control arterial bleeding. Diagnostic right iliac and lower extremity angiogram. I-CAST covered stent repair of right external iliac artery injury. StarClose hemostasis right common femoral artery." Are codes 37244, 37236-51XE, and 36140-51XE appropriate for this?

61645

How would this be coded? Should I report codes 37216 and 61645, or just 61645? "Patient presented with an acute left hemispheric infarct, acute cervical carotid occlusion likely from dissection, and intracranial carotid thrombus. A Solitaire stent retriever was deployed across the area of thrombus in the left internal carotid and removed with vacuum aspiration applied to the guide catheter after 5 minutes. Angiogram demonstrated restoration of flow in the carotid siphon and into the anterior and middle cerebral artery territories. Angioplasty was then performed in the upper cervical internal carotid and in the mid cervical region. This was followed by stents placed in the upper cervical internal carotid adjacent to the skull base and extending proximally. Angiography demonstrated excellent flow." 

Stenting internal iliac artery and superior gluteal artery

"Bilateral lower extremity angiography was performed, showing 60% left internal iliac artery stenosis and 60% left superior gluteal artery stenosis. I placed a sheath over the super stiff wire, and wired the internal iliac artery and the superior gluteal artery. I primary stented the origin of the left internal iliac artery with a 5 mm x 16 mm stent. It responded very well. I then primary stented the left superior gluteal artery with a 4 mm x 26 mm drug-eluting stent, opening both vessels up nicely with 0% residual stenosis." Would it be appropriate to report both codes 37221 and 37236?

92937 and 92938

"We first took a 3.5 x 32 mm Synergy drug-eluting stent, positioned across the area of stenosis in the distal OM1 branch of the vein graft, and deployed it at intermediate to high pressure. There was a size mismatch between the vessel proximal to the stent. So we went in with a 2.25 x 16 mm Synergy stent, positioned it across the area of stenosis more proximally, and deployed it overlapping with the proximal edge of the other stent. Next, we turned our attention to the other branch of the vein graft. We took a 3.5 x 24 mm Synergy stent, positioned it across the area of stenosis in the more midvessel, and deployed it at intermediate high pressure. Next, we took a 3.5 x 28 mm Synergy drug-eluting stent, positioned it across the area of stenosis more distally, and deployed it overlapping with the distal edge." Would the two interventions through the bifurcated graft be reported with codes 92937 and 92937-59? Or codes 92937 and 92938?

Covered Stent Used As Bridge Between Vessels

Do you have any suggestions on the best way to bill for this complex procedure? "Viabahn PTFE covered stent graft was placed between the right pulmonary artery at the hilum and the left atrial appendage, traversing the inside of the right and left atrium, and, in the process of doing so, also occluded the baffle leak that was traversed. This was an extremely complicated procedure given the patient’s unusual anatomy and complexity of the planned procedures. In addition, the placement of a covered stent in this case was really very similar to placing a surgical graft because it was used as a bridge between one vessel and another vessel much like a surgical graft (it was only anchored at each end rather than being within a vessel throughout its course)."

Lung Biopsy with Chest Tube Placement

I've asked the following question of several seasoned IR coders and received different answers. I hope you can clarify. "Procedure: CT-guided lung biopsy resulting in hypotension. Repeat imaging demonstrated hemothorax. At the request of the referring physician, a chest tube was placed under CT guidance." Since code 32405 includes CT guidance, is code 77012 separately billable for the chest tube placement (32557)? Or is this considered within the same session?

CPT 50435 and 75984

In the CPT Codebook under 50435 it states not to report code 74425 (but it does not mention 75984). Under 75984 it states to report exchange of percutaneous nephrostomy as 50435. If you look at coding instructions in the 3M Encoder under nephron tube check and change (75984) #4, it says, "Do not report 75984 with 50435. Use code 76000 for fluoro." Coding instruction #6 states, "Do not code fluoro imaging with 50382, 50384-50387, 50432-50435, 50693-50695." These two instructions (#4 and #6) seem to contradict each other, and the CPT Codebook (under 50435) doesn't say that 75984 can't be used. Can you please verify?

Thrombolysis, Extensive Procedure

I need help with the following case: "Patient has DVT left lower extremity and thrombosis of IVC. Day one the doctor did catheter placements into the IVC from both left and right popliteal veins. He did a diagnostic left leg venogram and diagnostic IVC prior to placing EKOS catheter(s) into the IVC for overnight infusion." Would this be reported with codes 37212, 36010-50, 75820-26XU, and 75825-26XU? On day 2 his report indicates, "Subsequent day with cessation of thrombolysis in left external iliac vein, left common iliac vein, and IVC." Is this all "one surgical field?"

Thrombus Maceration

Our IR docs do this procedure quite often, and I am wondering if you would use an unlisted code or bundle with the catheter placement. He goes into upper and lower bilateral pulmonary arteries and does administration of 4-6 mg of tPA in each artery. He calls it "thrombus maceration". What is your recommendation for charging for the maceration part of the procedure?

CPT 61645

I'm wondering if there has been any rationale for the status change to non-coverage with the new CPT by Medicare (61645) or if the status will be changed from E to C status. There also does not appear to be an additional code applicable if more than one area treated: Left vertebral/basilar and right ICA/MCA.

Thrombectomy Before Lysis Catheter Placed

"Patient with left leg DVT with CT showing May-Thurner syndrome. Accessing the left popliteal vein a venogram was performed. The thrombosed portion of the left lower extremity was recanalized in the femoral, external iliac, and common iliac vein. Thrombosis throughout all these veins. Catheter to the IVC with an Inferior Cava venogram demonstrated no caval thrombus. AngioJet thrombectomy in the left leg with tPA performed. After swelling time of 20 minutes AngioJet again. Good results to the origin of femoral vein but partial occlusive thrombus in CFV and common iliac without inflow from profunda or internal iliac. So an infusion catheter overnight to be placed. However, since the flow was completely stagnant and there is only a mild amount of thrombus inline, we decided to perform angioplasty, as the risk of PE would be low and we wanted to have some flow through this segment, preventing re-thrombus. Angioplasty of left common iliac vein. Infusion catheter placed from prox fem through com iliac vein. Then infusion catheter placed." Would you report codes 36010, 75820-59-LT, 75825-59, 37187, and 37212-59?

Diagnostic Selective Catheter Bilateral ICA and Vert

MD performed bilateral ICA 36224-50 and bilateral vert 36226-50. The findings for those vessels are documented along with findings in the left opthalmic artery without selective catheter being placed there. Can we include (or should we be including) a code just for the S&I of the left opthalmic artery? Or is it considered inclusive?

93613 and 93615

When the documentation supports it, is there any reason that we should not bill both codes 93613 and 93615 along with 93620, 93653, or 93656? NCCI has a bundle that can be by-passed with a modifier; however, coding is hesitant without more guidance.

Does a CTO 92943 have to be staged?

Since a CTO is a CHRONIC total occlusion, does it need to be staged? They would know about it ahead of time, since it is chronic. But what if the doctor finds a CTO upon first diagnostic angiography, and is able to treat it with some type of intervention at that same session? Would that be billed as a 92943 along with the cardiac cath code (w/59)? Or, because it is the first time it was found, is the PCI code just the 92928, 92920, 92924, 92933, etc. instead of 92943? Do we need to find prior documentation showing CTO was known about prior to intervention?

Portal Vein Branch Embolization

Portal vein branch embolization to stimulate hypertrophy of the opposite lobe of the liver is reported with code 36481 once for venous access to all selected intrahepatic portal vein branches, and code 37243 is used for embolization of this side of the liver to shrink it and cause hypertrophy of the opposite lobe. Do we need to report code 36481 since the non-selective catheter placement is bundled during embolization procedures?

TPA

Would you report code 37211 for the tPA? There is no time given, only the amount of tPA. "Under ultrasound guidance we obtained antegrade access to the femoral-popliteal bypass graft. With angled guidewire and angled glide catheter we were able to cross the area of thrombus in the popliteal artery and place the wire into the peroneal artery. We used a 4 x 40 mm balloon to angioplasty the popliteal artery with a reasonable result and now brisk distal flow. However there appears to still be a moderate to high-grade stenosis. We infused a total of 4 mg grams of tPA across the lesion. Repeat angiogram showed no significant resolution. It was then decided to stent that area."

Corpak Mechanical Disruption

Even though a CORPAK is not included in the CPT 49460 code description, is it permissible to code it for the case that follows? "CLINICAL INDICATION: ACUTE PANCREATITIS BEING FED THROUGH A CORPAK WHICH HAS BECOME CLOGGED. TECHNIQUE: A CORPAK WAS MANIPULATED WITH AN ANGLED GLIDE WIRE AND REPEATED FLUSHES OF SALINE AND THEN AFTER CONTINUED MECHANICAL DISRUPTION CANOLA OIL WAS INJECTED INTO THE CORPAK WHICH COMPLETELY RELIEVE THE OBSTRUCTED LUMEN. CONTRAST IS INJECTED TO CONFIRM THE POSITION OF THE CORPAK FEEDING TUBE. 1 MINUTES AND 36 SECONDS OF FLUOROSCOPY TIME WAS UTILIZED DURING THE PROCEDURE. FINDINGS: THE CORPAK LUMEN TOTALLY FILLS WITH CONTRAST AND CONTRAST EMPTIES INTO THE PROXIMAL JEJUNUM THROUGH THE TIP OF THE CORPAK."

Billing E&M on Same Day as Kyphoplasty

If a patient was admitted from ER for a fall and was diagnosed with "lumber spine (L2) compression fracture, severe pain, probably due to osteoporosis", can IR bill a consult (or in this case inpatient visit)? The order in the hospital computer from the referring MD says, "Reason for Consult: L2 acute compression FX." The IR does a complete HPI, ROS, Exam, and makes an assessment and plan to undergo kyphoplasty on the same day. I don't know if I should bill the inpatient visit code with a -25 modifier. I was told you can't use a -25 modifier for "decision for surgery". Can you please advise?

Fecal Transplants

I have a question regarding fecal transplants. We sometimes place the NJ tube (44500/74340) and do the fecal injection (unlisted 44799). Would you bill for both the tube placement and the fecal injection? Iif so, do you know which CPT code you compare the 44799 to for reimbursement? We cannot seem to find a good CPT code to compare it to for billing.

93657 for FIRM (Focal/Rotor Ablation) after PVI

"Left atrial FIRM mapping. Mapping of the left atrium was done with the aid of Navix electroanatomic 3D mapping and ICE. The 50 mm basket was now placed in the left atrium. FIRM Mapping results. 1) LA Site #1 – Mid roof (EF 2,3). 2) LA site #2 – Anterior to appendage (CD 3,4). Of note the patient had two left pulmonary veins and two right pulmonary veins. The pulmonary veins were checked for isolation, and the LSPV and the RSPV were isolated at the beginning. Using a Medtronic Advance cryoablation balloon catheter, the left inferior and right inferior pulmonary veins were re-isolated via an antral approach. The pulmonary vein signals on the Achieve catheter became isolated in less than 30 seconds with the first ablation of each vein. We then turned our attention to the areas of rotor activity. Using 3.5 mm tip F/J curve Thermocool catheter, the rotor sites were targeted for ablation. Patient spontaneously converted to sinus rhythm following ablation of the rotor sites, and patient remained in sinus rhythm for the remainder of the case." Can we report code 93657?

Biventricular Implantable Cardioverter-Defibrillator Change with Insertion of a New Right Ventricular Lead

This patient had a previous biventricular ICD in 2009 and is now having noise noted on the right ventricular ICD lead. "Patient presents today for insertion of a new right ventricular ICD lead and generator change from a D1-D4 device. The old right ventricular lead was cut and capped, and the old coronary sinus lead was also capped and left in place. The leads were attached to the new ICD generator, and the two old capped leads were also placed in the pocket. The old right atrial lead P waves measured 3 mv, RA lead impedance 490 ohms, and the old coronary sinus lead impedance was 690 ohms. ICD was programmed to its final setting. The final impression: 1) Successful implantation of a new RV St. Jude Medical ICD lead. 2) Capping of the old right ventricular Medtronic ICD lead and also old left ventricular lead. 3) Pulse generator change of a St. Jude Medical device from a DF-1 to DF-4 pulse generator. 4) Defibrillation threshold testing of less than or equal to 17 joules for ventricular fibrillation." How would this be coded?

Nephrostomy Tube Exchange x 3

We have a patient who has three nephrostomy tubes (two on theleft/upper and lower pole, and one on the right) that were exchanged at the same time. What would be the best way to list the 50435? Modifier -50 with the -59? Modifier -50 with the -LT? Or should we report 50435 three times? The patient has Medicare.

Rt heart cath and intra-aortic ballon pump placement.

"Under US and fluroscopic guidance an 8 French sheath was placed in the right femoral vein using modified Seldinger technique. A 7 French C-tip Swan-Ganz catheter was advanced in the right femoral artery and right heart pressures were measured. Then an 8.5 French sheath was placed in the right femoral artery using a modified Seldinger technique. Care was taken to access the common femoral artery above the bifurcation and below the access site from earlier this morning. Balloon pump was set to 1.1 augmentation. Sheaths were sutured in place." I reported codes 33967 and 93451, but I'm not sure if bundled. Do we have to code 93503? What are the appropriate ICD-10 codes?

Injection of Methylene Blue for Thyroid Nodule

Patient comes in for the injection of methylene blue to mark the area of excision, which will happen on the next day. "Under ultrasound guidance, a 25 gauge needle was advanced into the subcutaneous nodule. 0.2 cc of methylene blue was injected into the nodules." Would I use 38900, which is an add-on code, or should we use 38792? (Is the methylene blue radioactive?) If 38900 is the appropriate code, what would I use for the primary procedure? Or would this be an unlisted code? 

Is it appropriate to code 74485

Is it appropriate to code 74485 for the following? "The patient was placed prone on the fluoroscopy table. The skin was prepped and draped under sterile conditions and 1% lidocaine was used for local anesthesia. A posterior calix in the right kidney was accessed with a micropuncture needle using fluoroscopic guidance. A microwire was advanced centrally within the renal pelvis using fluoroscopic guidance. The AccuStick sheath was placed. Position was confirmed after injection of contrast. Contrast injection demonstrates large amount of calculus within the right collecting system. The wire was upsized. Using a combination of an angled catheter and Guidewire the wire was manipulated into the urinary bladder.  A 7 French sheath was then placed and a second safety wire was placed into the bladder. The large sheath for the nephrolithotomy was then placed into the urinary collecting system after tract dilatation. Nephrolithotomy was done per urology report. A catheter was placed into the urinary collecting system after the procedure as a nephrostomy tube."

Pulmonary Vein Isolation for SVT

Can code 93656 ever be reported for a diagnosis besides atrial fibrillation? If the physician performed a PVI, but the patient is in for atrial flutter and atrial tachycardia, would you report code 93653? If so, can codes 93462 and 93621 be reported as well for the transseptal puncture and left atrial pacing performed?

Catheter Placement Bundling

I have a question regarding coding for catheter placement along with diagnostic imaging and lower extremity bypass. Briefly, the patient had a previous MRA, which was considered inadequate and did not show whether or not the patient had a target for revascularization. MD performed an arteriogram to decide if a target was feasible for a bypass. I'm getting an edit for the catheter placement. Is it appropriate to bill for the catheter placement here (36140, 75710, and 35566)?

Contrast Enhanced Liver Sonogram

I have a question regarding the use of ultrasound contrast, Lumason, for hepatic lesions. Patient has lesions identified with CT or ultrasound. Recommendation is to have a contrast enhanced liver sonogram. The coding guidance I have found for a liver sonogram with contrast is 76705 (imaging), Q9950 (contrast), and 96375 (diagnostic injection). Would this be correct? As there are no "with and without" contrast codes for sonograms, would code 76705 cover pre-contrast scanning and post-contrast scanning? If a contrast enhanced liver sonogram was done on the same date of service as a complete abdominal sonogram (76700), would a modifier need to be appended to one of the codes? My radiologist tells me that he will utilize a contrast enhanced liver sonogram post CT-guided hepatic ablation. Will codes 76705, Q9950, and 96374 work for that exam along with ablation guidance code 77013 and surgical code 47382? 

Ultrasound Follow-Up CPT 76970

Have you ever seen code 76970 used? Could you provide any guidance in how it should be utilized? The scenario that was presented to me is... could it be coded for a follow-up ultrasound on a LT leg recently treated with EVLT on the same day as treatment is given on the RT leg with EVLT procedure or some other varicose vein treatments? I don't see any NCCI edits to disallow or bundle the service. I guess my concern would be medical necessity for the follow-up ultrasound and what the Carriers would expect for medical necessity. I have not found any payer specific policies yet on this code.

10160 vs. 10022

Using a Yueh catheter, 20 cc of pus was aspirated from a known subsplenic abscess with a sample sent for microbial evaluation (catheter was not left in place). My understanding is this would be reported with code 10160. However, it was brought to my attention that code 10160 is only appropriate if the abscess is drained and the fluid discarded, and that code 10022 would instead be appropriate in this case because a sample of the fluid was sent for evaluation. Does the drained fluid have to be discarded to use code 10160?

Event Monitors and ILR medical Necessity for Cryptogenic Stroke patients

We have recently been receiving patients from a neurologist ordering event monitors for patients with diagnoses of cryptogenic stroke, occult Afib. These are not appropriate diagnoses that meet medical necessity per WPS LCD. Private Payers show medical necessity for these patients. Are you aware of appropriate diagnosis codes to meet medical necessity for these patients with Medicare?

76377

Patient with acute SAH has head and neck CTA performed, which reveals a PCOM aneurysm, and NIR performs and bills for the professional component of the CTA. Same NIR takes the patient to the angio suite on the same date of service and performs a diagnostic angiogram with 3D recons. The payer is denying 76377-26 with the angiogram stating, "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed." Is it appropriate to bill for the 3D reconstruction during the diagnostic angiogram when a CTA has been performed on the same date of service by the same provider?

Post Biopsy Embolization

Is it appropriate to charge/code separately for an embolization done post biopsy via the same needle placement if it is being done as a precaution against bleeding?

Diagnostic RHC with tPA Infusion via EKOS Catheters in Bilateral Pulmonary Arteries, WITHOUT Pulmonary Arteriogram

As a follow-up to question #5393 from 3/3/14, if the physician states he did not do a pulmonary arteriogram, but did do a diagnostic right heart catheterization followed by overnight tPA infusion in bilateral pulmonary arteries, is it appropriate to report codes 93451 and 37211-50, without 93568? Or, is code 93568 still needed to cover cath placement and pressures in the pulmonary arteries? From the previous Q&A, it seems you either have a diagnostic RHC and pulmonary arteriogram (93451 and 93568), or you have cath placement in the pulmonary arteries (36014-50) without RHC, with/without pulmonary arteriogram (75743). 

Sclerotherapy Injections

How many times should I submit code 37799 for the following case? "HISTORY: Left neck lymphatic malformation for doxycycline sclerotherapy.  PROCEDURE: The left neck was prepared and draped in the usual sterile fashion. Using ultrasound guidance a 21 gauge Angiocath was advanced... five non-communicating cysts of the malformation... and Doxycycline was injected directly under ultrasound and fluoroscopic guidance. FINDINGS: Ultrasound of the left neck with greyscale and Doppler demonstrated a smaller macrocystic lymphatic malformation amenable to direct injection. Site 1 = 2 mls Doxycycline (20 mg). Site 2 = 2.5 mls Doxycycline (25 mg). Site 3 = 1 mls Doxycycline (10 mg). Site 4 = 1 mls Doxycycline (10 mg). Site 5 = 1 mls Doxycycline (10 mg). Permanent ultrasound and fluoroscopic images were obtained and stored in the PACS system. IMPRESSION: Successful 5 site direct instillation of Doxycycline for sclerotherapy of a smaller macrocystic lymphatic malformation."

CTO - 99% or 100% Stenosis

Is it appropriate to code angioplasty of a CTO (C9607/92943) when the physician documents CTO and 99% stenosis of the coronary artery? Per information found on the CDC website, CTO is typically described as greater than or equal to 99% stenosis. http://www.cdc.gov/nchs/data/icd/att1_CTO_mar06.pdf

Repair of the Brachial Artery after AVF Ligation

"Patient had brachial vein transposition and endarterectomy three days ago. He presented to the ED complaining of pain in her right hand. The patient was returned to the operating room. A dissection was performed to expose both the proximal and distal brachial artery; clamps were applied. The doctor made venotomy into the vein near the anastomosis, passing a Fogarty catheter distally until the clot was removed. He elected to repair the brachial artery using the vein that was present via the anastomosis from prior AVF. Therefore, AV fistula was ligated and divided without issues. The distal extent of the vein was used as a hood for the patch angioplasty." The physician wants to submit codes 34101, 34111, and 37607. Since he documents only one venotomy, is it appropriate to report code 34111 for a radial artery thrombectomy? Would the brachial artery repair be considered included with the ligation? 

36147-52

Would code 36147 require a -52 modifier if the patient had a previous fistulogram and returned for the intervention? "The patient returns today for interventions following a fistulogram that demonstrated high grade stenosis in the fistula and venous outflow tracts."

Hepatic Artery Dissection

The doctor was investigating lack of pulse within the hepatic artery. A small amount of thrombus was found; however, they ended up resecting a length of the artery because of a dissection and then connected the proper hepatic to the common hepatic artery. Can code 35121 be used for this? The description doesn't mention dissection like the EVAR codes do. Or would code 35221 be better?

AV Fistula Aneurysm Repair

We are receiving conflicting information on how to code AV fistula aneurysm repairs. Some coders are using code 35190, while some are using unlisted code 37799. What is the correct code for the following procedure? "The patient was taken to the OR. Left arm was prepped and draped in usual sterile fashion. A tourniquet was placed in the high arm. The aneurysm was appropriately marked with an indelible marker. An Esmarch was used to drain the arm, and the tourniquet was then insufflated to 250 mm of pressure. The anterior wall of the aneurysm was resected inclusive of the skin, subcutaneous tissue, and anterior wall of the vein. The vein wall was then reapproximated with running suture taken of 5-0 Prolene started at each end of the venotomy and tied at the midpoint of the venotomy. Antegrade flow was then restored by releasing the tourniquet. There was an immediate palpable thrill in the fistula. Hemostats were assured. The wounds were closed in layers with suture taken of 3-0 Vicryl at the subcutaneous tissue level. The skin was reapproximated with 4-0 Monocryl at the skin level."

93971

We are having a discussion about whether to use the -52 modifier on code 93971, when the study does not include both compressions and/or color flow. The description of 93971 says for "unilateral or limited study", so then why would a -52 modifier be needed? There is confusion on what limited for this study actually means. For example, if the patient has a 93971 on both the right and left without color flow on both, but with compressions on both, how would that be coded? Layman's terms would be much appreciated.

93005 vs. 93000

Currently we (hospital) report our EKGs with code 93005. Can a hospital report the EKGs with code 93000 instead to capture global billing? (Since we have cardiologists read all the EKGs, and they do not currently capture those reads.)

Post-procedure mammo with stereotactic guided breast biopsy

I have documentation from a few years ago from ACR.org stating that unless the patient is moved to a separate table for the post-procedure mammogram, it cannot be coded with a stereotactic-guided breast biopsy. Can you tell me if that is still currently correct? This has been a question here at our office, since the new NCCI edits allow post-procedure mammo to be separately coded, but now there is this notion that it cannot be coded if the patient is left on the same table and the same physician does the mammo. Please clarify.

Revision or Ligation and Thrombectomy

"Patient presented with massively dilated brachiocephalic AVF with discomfort. The left upper extremity of the patient was prepped. A skin incision one centimeter above the cubital fossa was made and deepened into the subcutaneous fat using electrocautery. After careful isolation of the arterial inflow to the aneurysm, the vein was encircled with vessel loop for traction. The inflow was ligated with 1-0 ethibond transfixion suture. An elliptical incision was made over the aneurysm, the outflow was also ligated with 1-0 ethibond, and aneurysmal sac was opened and partially excised. Doppler signal of the brachial artery was verified after skin closure, and radial pulses were still palpable." Should I report codes 37607 and 36831? Or 36833?

Right Carotid to Left Axillary Bypass Procedure

The doctor performed the following procedure: left axillary artery to right common carotid bypass. How it was done (in a nutshell): 1) Tunnel created between left axillary and left common carotid. 2) Tunnel created between left common carotid and right common carotid (anterior to spine). 3) One single graft threaded through both tunnels. 4) End-to-side anastomosis made between the graft and right common carotid artery. 5) End-to-side anastomosis made between the graft and left axillary artery. 6) The left common carotid artery was clamped, transected, and the distal stump was ligated while the free end was anastomosed end-to-side to the graft. The report reads as two separate bypass procedures, but they only used one graft, even though they anastomed it to three different arteries, but the end result is the right carotid to left axillary graft. Would this be reported with codes 35606 and 35601? Or code 35606-22? Or maybe something else altogether? 

MRI Shoulder Arthrogram

If an ordering physician orders an MRI shoulder arthrogram, what codes would we use? I am confused about when to use codes 77002 and 73040, also 73218 or 73219. "Patient comes to x-ray, and radiologist places a needle in the shoulder joint and injects contrast. The patient then goes to MRI for imaging."

34812-50 and 35371

When we have an EVAR with open exposure, then plaque is noted and is significant (preventing an easy closure), can we charge code 34812 on the same side with 35371 (CFA endarterectomy)? As you know, it requires a -59 (or -XS) modifier for NCCI, but is the bypass available thinking that it could be the other side? Like 34812-50 and 35371-59. I can't seem to find a definitive answer anywhere. 

Category III OCT 0291T

Some of our cardiologists are starting to use OCT over the IVUS, and it has been suggested that since it is a category III we should not bill it and write it off to medical necessity. However, it appears to have the same N status indicator as the IVUS, and we were questioning if Noridian would consider it as packaged or a medical necessity? Either way some of us strongly feel it should a least be billed to justify the work involved. Please share your expert advice.

Pulmonary Artery Band Adjustment

How would you code this? "Emergent mediastinal exploration, clot extraction of central aortopulmonary shunt, pulmonary artery (PA) band loosening, intracardiac Broviac placement, 4.2 French. A midline redo sternotomy was performed carefully. Subsequently a gentle dissection was made around the PA band and the shunt. The PA band was loosened after removing 2 clips and secured back with Prolene sutures over the MPA. The central shunt was opened with a vertical incision after securing it on each end with vascular clamps. The lumen of the shunt was occluded with clot and fibrin material. The shunt lumen was cleaned thoroughly and it was repaired back using 8-0 Prolene."

93566

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.

Percutaneous Tunneled Catheter 49418

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.

PFO

"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?

US Knee Aspiration

"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?

CT/CTA with Calcium Scoring

Does CT/CTA (i.e., 75572-75574) include calcium scoring? I know there is a separate code for CT without dye with calcium test.

ICD-10-CM code for in-stent stenosis - coronary artery

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?

Multiple Nodules on Thyroid

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.

Stenting Two Major Coronaries, Same Session

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.

CT Lung Screening - Registry

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?

Holter Monitor Recording

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?

Axillary Vein Repair

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?

Antegrade Ureteral Stent Placement

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."

Status Change after Intervention

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?

Catheter placement in the abdominal for diagnostic and embolization

"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?

ICD Generator Replacement RV/LV Leads Only

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?

Attempted FEVAR; converted to open repair AAA

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.

CT cystogram with insertion of contrast via foley catheter

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"?

Fibrin Sheath Stripping with Repositioning of CVC and Vena Cavagram

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."

Documentation Question

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?

Stereotactic core breast biopsy using tomosynthesis

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?

Ultrasound-Guided Muscle Injection

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?

Bilateral Renal Stents

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?

GI Bleed

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.

Myelogram 62304 vs Injection 62284 with bending views 72114 and Spinal CT 72132

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.

ABSORB Scaffold

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.

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