Hello. My question is regarding C1874 stent coated/covered with delivery system. Is the flair stent inserted in this example a drug eluting stent? Does the HCPCS code C1874 necessarily equal a drug eluting stent? thanks for your help! Utilizing 2% lidocaine as local anesthesia a 21-gauge needle was corrected into the arterial limb of the AV dialysis graft directed towards the venous anastomosis. Subsequently, a AV shuntogram was performed demonstrating a high-grade focal stenosis involving the venous anastomosis. A 6 French sheath was placed and the anastomosis crossed. This was then dilated to 7 mm which appeared to improve flow, however, residual intimal regularity remains. As a result, a 7 mm x 5 cm fluency stent was deployed across the venous anastomosis. This was then dilated to 7 mm. The graft also demonstrates mild diffuse intergraft stenosis. This was also dilated to 7 mm. A post procedure shuntogram demonstrates no significant residual stenosis, however, the thrill was suboptimal following this procedure. As a result, the arterial anastomosis was evaluated. This demonstrates a high-grade arterial anastomotic stenosis. A 21-gauge needle was then directed into the venous limb of the graft directed towards the arterial anastomosis. A 5 mm x 2 cm balloon was then inflated across the anastomosis. A post procedure fistulogram was then performed demonstrating no significant residual stenosis. A nice palpable thrill was achieved within the graft. As a result, the access guidewires, vascular sheath, and balloon catheter were removed.
Dear Dr. Z, Thank you for taking the time to consider my question. Our facility treated a patient who they suspected as having Brugaga Syndrome so a flecainide challenge was done. The patient had a base EKG done then was given 400mg of oral flecainide. EKGâ€™s were then done after one half hour, one hour, two hours, three hours and four hours. My question is what CPT code (if any) would be appropriate for this procedure? I have reviewed the Noninvasive Physiologic Studies and Procedure section of the CPT book and 93799 â€“ unlisted cardiovascular service or procedure is the only one I feel can be used. The other option I have considered is to only code the EKGâ€™s and not apply a code for â€œflecainide challengeâ€. Thank you in advance for your input. Debra Patterson, RHIT
Can we use 93463 for the evaluation of pulmonary hyperetnsion reversibility using intravenous Flolan (epoprostenol)during a right and left heart cath?
The instruction under code 77003 says, "Injection of contrast during fluoroscopic guidance and localization  is included in 22526,...., 62310-62319." And yet there is no NCCI edit. We have not been coding for the guidance since discovering this note. Does this note mean that we can charge code 77003 if it is for localization but not if contrast is injected? How should this note be interpreted?
I am coding a case of a dissecting aneurysm of the supraclinoid left internal carotid. The physician used a Y-stenting technique without the use of coils to divert flow and "occlude" the aneurysm. One stent was placed in the supraclinoid ICA and A1 segment. The M1 segment was selected through an open cell of the previously deployed stent, and a second stent was deployed in the supraclinoid ICA and M1 segment, bridging the aneurysm. This created aneurysm occlusion through flow diversion. Would this be coded as an intracranial embolization with code 61624, or should I use an unlisted code? I have read that this is a new technique used for wide-necked aneurysms, aneurysms where the emanating branches are incorporated in the sac, or it's a giant aneurysm causing mass effect.
Our hospital/neurosurgeons use fluoro in all their spinal cases. What is the instruction for charging/billing for fluoro done in the OR for these cases? It seems that cpt codes for open procedures 63001 and on, do not include fluoro. The minimally invasive/percutaneous procedures 0274T and 0275T seem like they do include the fluoro charge. If we do charge for the fluoro, would we use 77003 or 76000. Thank you very much.
Can we charge for fluoroscopy guidance (77003) when the fluoroscopy is provided by a radiology tech and the procedure is performed by a surgeon? The surgeon dictates fluoroscopy guidance was used in the operating room procedure. An example is code 62311, epidural injection (myelogram, epidurogram, and arthrogram are not performed in the OR procedure).
Dr. Z, If a patient recieved an epidural injection along with a facet injection, can I add a modifier 59 to 77003 (fluoro guidance for the epidural)? Patient has right lower back pain radiating to the right lateral thigh. Impingment of right L3 and L4 nerve roots seen on recent MRI. Patient also has moderate central canal stenosis and facet arthrosis per the CT done 9 days earlier. Thanks for any help you can give me. Michelle
One of our IR docs is taking a spot image after removal of a port and cath, and we are trying to determine if it is appropriate to bill code 77001-26 in this circumstance (pro fee side). What are your thoughts?
Here is a brief synopsis: the patient is having prolonged post-transplant hospital course with persistent pericardial effusion and persistent mild respiratory distress. The patient presents to cath lab for fluorscopic evaluation of the diaphragm as well as her routine post-transplant RHC and biopsy. The eval of the diaphragm is a fluoroscopically saved image which demonstrated that the left hemidiagphragm is paretic with evidence of paradoxial motion of the diaphragm. The existing pericardial drain and 350 ml of straw-colored fluid was removed. Oximetries & hemodynamics of the RH were done pre and post pericardial drainage. Endomyocardial biopies were done X5. I wanted to bill 93451-26-59, 93505-26, 33010, and 76000-26. However,76000-26 hits an edit with 93505 as bundled and no modifier is allowed. Is there another code I should be using or is the evuluation of the diaphragm non-billable? Thanks so much for your help with this scenario!!!
Could you please tell me if unlisted code 43499 should be used in this scenario, or can code 43453 be used? I am thinking of the unlisted but need help. "A 5 French Berenstein catheter, in combination with a 0.035 inch Amplatz guidewire, was advanced through the oropharynx and cervical esophagus across the anastomosis and into the thoracic stomach. A 14 mm Atlas balloon was advanced over the guidewire and into appropriate position. The balloon was inflated. The waist resolved with inflation to 20 atmospheres. The balloon was left inflated for 1.5 minutes. The balloon was then deflated and removed. Repeat dilation was performed using a 16 mm balloon and inflated to 20 atm for 1.5 minutes. A repeat esophagram was performed. This demonstrated improvement in luminal caliber. There was no extravasation demonstrated."
What are the appropriate facility codes for the fluoroscopic insertion of spinal fiducial markers for a spinal tumor? If the patient is a medicare outpatient, would HCPCS C9728 and 77002 be the correct codes for this type of case?
Dr.Z, Since code 27096 now includes fluoro, does G0260 follow the same rules and include Fluoro? Thanks so much Henri
Dr. Z, a facility wants to charge 76001 for a tech and a fluoro machine being in the OR for more than an hour even though the documented time for use of the fluoro is less than an hour. There is a physician in the room for more than an hour but the fluoro machine is not being used for the whole time. What is the correct way for the facility to code for the fluoro when the OR procedure does not involve an S&I code and the documented time is less than time in the room. Thank you.
Is it enough to dictate that 6 minutes of fluoroscopy was used to support the use of the code 77001 or 49440? If not, what would be the appropriate documentation? For example, if the dictation stated that the wire was advanced under fluoroscopic guidance, is that enough? Or should the use of the fluoroscopic guidance be matched up with the final placement of the catheter?
Hi Dr. Z We were discussing the fluorscopy code (76000) vs the cineradiography code (76120). If the doctor uses fluoroscopy to check on a valve or a lead, takes some images and that is all....which code is appropriate or can both be used? Thanks for your help!
Original Question: Will you please address the issue of tunneled catheter removal since it now has its own code (32552)? Is it appropriate to code a fluoro guidance code, 76000 or 77002? I don't get an edit, but the your IR book states S&I is N/A. In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter. The catheter could have been compromised because of infection. Why is this? Thank you! Additional Information: In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter. The catheter could have been compromised because of infection.
In light of the July 2014 NCCI edit update, we (hospital staff) have been debating whether or not it is appropriate to append a -59 modifier to existing myelography codes when a CT scan of the same area is performed on the same date of service. We routinely perform a full and complete conventional myelogram with a separate report amd then send the patient to CT. Bottom line - can we bill separately for the conventional myelogram, or is it now considered bundled with the CT study performed in the same patient encounter?
We have a question regarding FNA of thyroid nodules. We have a physician who mentions in his report that he is doing a capillary and suction technique, but never mentions FNA. When we say we need documentation for FNA versus core, his reply is "capillary and suction technique" is FNA. Can we assume and code these as FNA? Please advise.
I have a radiologist who has told me whenever he does a biopsy of the thyroid it is always core; however, he never dictates "core" in his reports... he always just says "tissue". Pathology from the hospital always says FNA. So my question is, do I report code 60100 because that's how he instructed me to code, or do I go with the pathology and report code 10022?
I need to know when I can code both a fine needle aspiration and a core biopsy. Sometimes our physicians do not say why they go on to obtain a core after an FNA has been done. If a reason is not documented, should I just code for the core biopsy? Following is an example: "Ultrasound of the neck revealed 2.5 cm of right cervical lymph node/mass. A 25 gauge needle was advanced into the mass with ultrasound guidance, and an FNA was obtained and given to pathology. The needle was removed, and a total of six core biopsies were also obtained. Post ultrasound demonstrated no hematoma or complication."
We have a patient who had an IR px for insertion of a Foley balloon into the pleural space with injection of calcium channel blocker to stop a massive hemothorax. Once bleeding was controlled, it was determined that the intercostal artery was punctured from a previous chest tube placement. Do you have a suggested CPT code and ICD9 px code?
Can we code/charge for foley catheter placement in Cath lab or EP lab? It's done prior to long procedures in EP. It's done in the Cath lab if the bladder is too full or patient will have difficulty using bed pan after procedure. As always, we appreciate your assistance! Thank you!
Dr. Z, Our radiologist does Discectomies, vertebroplasties, and kyphoplasites quite a bit. He always has a follow up CT/MRI in 2 weeks to 1 month. These procedures have a 90 day global, can I charge for the follow-up CT/MRI? Thanks
Follow Up to Question ID #5966, it states: ‘A caveat would be if two physicians are in same group and use same billing number then code as usual, as add-on code 93571 would be okay with the heart cath.’ Can you further clarify what is meant by ‘code as usual’? Do you mean first physician can code and bill add-on code since second physician is in the same group even though first physician didn’t perform add-on procedure? CPT manual, p. xiv outlines: “The add-on code concept in CPT 2014 applies only to add-on procedures or services performed by the same physician. Add-on codes describe additional intra-service work associated with the primary procedure…Add-on codes are always performed in addition to the primary procedure and must never be reported as stand-alone code.” CMS 1/1/14 policy outlines the same principal. Also, if FFR/IVUS is performed on same day as heart cath but by two physicians in different groups then do you recommend each physician code their part with second physician utilizing unlisted code 93799 to capture the stand alone px of FFR/IVUS.
For follow-ups post infusion/embo (75898), I know it's to be done once (other than for intracranial procedures), but my physician asked about doing multiple AVM's (right and left lung), if they embo there, is that still just one follow up? or would it be two, one for each lobe? Same for multiple hepatic tumors? one follow up even if they embo multiple tumors through different cath. placements? thanks!
Please do NOT include any actual patient medical records with your question. DR Z I have a general question about Follow-Up (75898 ) charges. We coiled a cerebral aneurysm. Nine coils were placed into the aneurysm but only the last 2 were deployed.The other seven were removed because the DR did not like their placement. After each placement a follow-up angio was performed. Do you charge 9 follow-up's or only 2 for the 2 coils that were leftin for the embolization? I say you only charge Follow-up for the coils that actually embolized not the ones that were removed. TY
A question came up as to whether or not it is appropriate to charge for CAD when performing "spot compressions" on a follow-up diagnostic mammogram. Is there a requirement for the type/number of images on a diagnostic mammogram in order to charge CAD?
According to your reference and previously asked questions, codes 47805 and 74305 are reported for a cholecystostomy tube check. I'm coding for a "follow-up of post gallbladder drainage" in which "scans are obtained through upper abdomen without contrast and after injection of the drainage catheter. After injection there is filling of the gallbladder." The impression was "after injection of contrast through the drain there is a small amount of leakage into the pericholecystic region." So I am told by the IR coder that in this case code 74150 should be used. However, could code 47505 also be used for the injection into the catheter? Or is code 47505 only to be used for a specific check of the tube functioning?
"Patient had right-sided carotid cavernous fistula and upon imaging before embolizing the right they discovered that a left carotid cavernous fistula was present, so they came back two days later to embolize the left. They performed a bilateral cerebral angiography from the common carotids prior to the embolization, which was performed from the left cavernous sinus via femoral vein access. After embolizing, the physician came back and performed cerebral angiography as a follow-up from the bilateral internal carotids, the bilateral external carotids, and the left vertebral." So my question is, can I code the extrernal carotids as angiography? Or do I have to consider those a follow-up? Also since the catheter went further and since we code to the highest catheter placement, I am unsure if I should code the highest order and use the internal carotid code 36224 instead of the common carotid code 36223... or should it be 75898?
Does a separate report need to be created to support the filing of both codes 76380 and 76377 when a cone beam CT hepatic artery injection and 3D reconstruction are performed in conjunction with diagnostic hepatic arteriography in Y-90 planning? Alternatively, in reporting codes 76380 and 76377, is it sufficient to only note that the cone beam CT was completed during the angiographic procedure? Findings are reported as a single discussion without specifically noting what modality (angio or CT) was used, both having been completed. Reference is made to the angio and CT in the conclusion. How much documentation is required to support these codes?
Dr Z, What is the appropriate code for balloon angioplasty of a Fontan fenstration? " we then turned out attention to the Fontan fenestration. We crossed the Fontan fenestration with a coronary wire and glide catheter. We then exchanged the Glide catheter for an Apex RX 4.5 mm x 20 mm balloon. We advanced the balloon over the wire, across the Fontan fenestration and made a total of 3 inflationsfor a total of 6 seconds each. We then repeated the IVC angiogram and this revealed much improved shunting throught the Fontan fenestration and a slight drop in arterial saturations." Cath lab is using 92992, however I don't think that's correct. Is this an unlisted 93799 or would it code to a valvuloplasty code? Thanks!
I’m not sure what to do with this one. Patient came to cath lab to have an angioplasty of his AVF. While ballooning the subclavian and innominate vein, the balloon ruptured. Due to aspiration of blood from the inflation port of the balloon, the surgeon decides to take the patient to the OR for emergent surgery. In the OR he opens the arm, creates a venotomy in the fistula, and removes the balloon. It is noticed that there is some thrombus, so he removes the small amount of clot present and closes the venotomy. I don’t like code 37197 since this is open instead of percutaneous. I was thinking of reporting the exploration with code 35761 (which includes foreign body removal) (or possibly 35860 since there was bleeding) with modifier -XU or -59, as well as the open thrombectomy with code 36831 since they shouldn’t have had to do a thrombectomy as well. My other thought was unlisted code 37799. What are your thoughts?
After a PFO closure procedure (93580) the occluder device was seen to be floating in the left ventricle. During a second procedure, on the same day, the same doctor retrieved the device. To capture the device he actually pulled it back into the ascending aorta and there successfully pulled it into the sheath. Can I use code 37197 for this procedure or go to an unlisted procedure code?
"1st lesion intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the 1st obtuse marginal 2nd intervention: A successful stent with balloon angioplasty was performed on the 99% lesion in the 2nd obtuse marginal 3rd intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the right posterior descending artery. 4th intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the mid RCA." I am reporting codes 92928-RC, 92929-RC (right posterior descending), and 92929-LC (1st obtuse). Can you code for the 2nd obtuse (92929-LC)? Per CPT: Additional PCI in a third branch of the same major coronary artery is not separately reportable. Since there are two PCI in one branch and one PCI in another, could you use code 92929 three times? I understand that Medicare considers the add-on code bundled into the base code.
Would placement of the FRED (Flow Re-Direction Endoluminal Device) be coded as an embolization or a stent? It looks like a stent, but it is used to occlude an aneurysm.
In the main radiology department, the tech will inject the gtube with contrast but then not use fluoro. they use regular xray instead. would we still charge a 49465 or something else?
Initial percutaneous placement of G-tube into the jejunum or duodenum is reported with codes 49440 and 49446. Using that same logic, would it be incorrect to report codes 43752 and 43761 for G-tube placement into the duodenum via nasal approach for enteral nutrition? The description of code 44500 in the Coder’s Desk Reference does not seem to describe what was actually done. Example: "Under fluoroscopic guidance, a 10 French nasoduodenal/jejunal feeding tube was advanced using real-time fluoroscopic guidance as well as a 0.035 stiff Terumo Glidewire and positioned in the proximal jejunum."
How would you code a clogged G-tube clearance using soda water with follow-up contrast injection to confirm patency?
Please do NOT include any actual patient medical records with your question. For 2011, would the G0269 code still be coded with heart catheterizations for hospital side coding? The CPT coding notes say that closure device placement is inherent to the catheterization and not separately reportable, but we were not sure if that applied to this code. Also, if the patient came back and just had stent or angioplasty(no heart cath)would the G0269 code be used then? Thank you.
Dr.Z: I'm confused to when we can code for 75710 when doing diagnostic angiograms? Example:Right Common femoral artery was selected.AP views showed to have normal caliber and branching. The puncture site was appropriate for Angio Seal device deployment. They then continue with the diagnostic angiogram. thank-you for your help.
Is use of a closure device included if only a cardiac intervention is performed & not a diagnostic cath? Thanks
Dr. Z, At a resent conference, the speaker said that CMS wants us to charge for the closure device procedure, G0269, even if it is bundled in the procedure. The speaker said they want to know when the closure device is used for statistical reasons. Do you know of this being true with CMS? Thanks!
Is code G0269 bundled with the 2014 new embolization codes? It's not showing that it is on NCCI CodeManager. When would this code be applicable for billing with embolization?
Hello Dr Z! I was wondering regarding the renal codes for 2012, 36251, 36252, 36253 and 36254, all thou it does not say it in it's description, but is the closure device to be included in the charge as they were for the cardiac cath /endovascular revascularization codes for 2011?
Hi there-- In the facility setting as of 2011, I know that we are no longer supposed to bill G0269 in conjunction with diagnositc cardiac catheterization procedures. But is it still ok to bill G0269 if the only procedure performed is a PCI Procedure? (ie. a stent, PTCA, or atherectomy)?
I am trying to put together a list for my IR department that contains information regarding occlusive device placement charges. Do you have a list of the procedures that bundle the charges for the placement, as well as a list of procedures where the charge is allowed to be added? The devices have C-codes, so I want to have the appropriate charge on the accounts.
Our end coder, Code Correct, is advising that code G0275 has been deleted for 2014, but that G0278 is still active. Is it true? And if so, is MCR accepting any other code? I could only find a vague reference to it on MCR under Part A.
Dr. Z; I am torn on this report with the proper code assignment. In all honesty I am not sure that code G0275 is correct on this account and the Cath lab assigned 75625. I am in total disagreement with assignement of 75625 also I am not sure that G0275 is supported by this limited documentation. I am only giving infomration related to the abdominal aortography section of the report. Procedures Preformed: Left heart cath with ventriculography, selective imaging of the coronaries. Abominal aortography. Indications: Angia/MI: stable angina. Coronary artery diesase: suspected and abnormal stress test. Cardiac: arrhythmia. History: The patient has hypertension and medication-treated dyslipidemia. Coronary Bypass abdominal Aortography: A catheter was placed and contrast was injected. Aorta: There was medium-sizwed, localized(saccular) aneurysm formation. Infrarenal location. The root exhibited normal size. Thanks in advance for your help.
You have written much about G0278 amd G0275. I understand how to code for these and when to use it. However, I have an MD that codes for this but the indication for Cath does not address PVD. Wouldn't you have to mention this in the indication for Cath?
Please do NOT include any actual patient medical records with your question. Can selective catheter placement be reported when documentation states: A4Fr JR 4.0 catheter was advanced to the aorta and positioned at the vessel origin(common iliac) under fluoroscopic guidance. Right and left side. Cardiologist documents R/L heart cath with cors in addition to bilateral iliac angiography for arteriosclerosis. Department reported 93460. Look forward to your response.
Please do NOT include any actual patient medical records with your question. My physician have started doing abdominal arteriogram (75625) on patients who come in for LHC and RHC for possible TVAR procedures.Here is the preop diag. and the finding below. preoperative diag: The pt has moderate to severe aortic stenosis by suface echo and present for evaluation of his coronary arteries and aortic valve for consideration of possible percutaneous aortic valve replacement vs tranditional repair. Findings: Abdominal Aortography: The patient was found to have calcified iliac vessels..diameter 1.6cm lt and rt iliac. My question is should I code G0278 or 75625 or can you code for this procedure when there is only a possible of a TVAR?
I need help coding this report. The procedures were left heart catheterization, selective cornonary, saphenous vein and IM angiography, ventriculography, RAO view, aortography, AP view, right iliac angiogram, and primary stenting of vein graft to RCA with use of spider. Closure of access site using Mynx grip. Here is the part of the note that I don't know how to code: "Aortography was performed in the AP view, as patient was complaining of discomfort in his right leg. This shows significant stenosis of 60-70% in the right common iliac, which with the placement of the catheter was obstructing flow. Following this, selective right iliac angiogram was performed, and this iliac appeared to be diffusely diseased with 60-70% narrowing, but I felt I could get the procedure done and bring him back for elective intervention of his iliac vessel." I am new to cardiac coding, so I'm feeling very lost. The patient has Medicare.
The CPT code book lists one CPT code for coronary stent initial and one CPT code for additional - no reference to type of stent used. There are G codes for CMS patients and those state drug eluting stents. My question: do we charge differently based on bare metal stent placement or drug eluting stent placement? We have been told to have charge codes for bare metal stent placement at one price, and another charge code for drug eluting stent placement at a different price for non-CMS patients. Is this correct?
DR. Z, The patient came in for AV fistula creation and in the same setting it states 'using ultrasound, the upper extremity was mapped. Based on the findings from the ultrasound decision was made to proceed with a left basilic vein transposition.' Not sure if this is good enough to code 'G0365'along with the creation of AV fistula? Is this ultrasound mapping included in the AV fistula performed in the same setting? Sometimes we see an order stating vein mapping or pre op for AV fistula creation and the procedure is bilateral venogram, please clarify when and what kind of documentation suports 'G0365'? Thanks
"Deflation of the balloon was unsuccessful with slip-tip syringe. Using a 25 gauge lidocaine needle, the gastrostomy balloon was ruptured for complete decompression. Gastrostomy tube was then pulled with traction. A sterile dressing was applied." Is there a CPT code for gastrostomy tube explant?
Indication for procedure was need for ICD generator replacement. Also, fluoroscopy was performed of the right ventricular lead because of its recall status. Fluoroscopy revealed externalization of the right ventricular cable. For this reason, a left arm venogram was performed that demonstrated patency of the left arm veins. Through the axillary vein, a wire and sheath were advanced. Right ventricular lead was advanced through the right ventricular septum and fixed in place. Old right ventricular lead was capped and a new generator placed after recreating the pocket in a better position. Codes 33263 and 33216 as well as 36005 were charged by the Cath Lab. I agreed initially with codes 33263 and 33216 until I saw a similar Q&A from last year that advised different codes but appear to need more clarification. Please advise. Also, would code 36005 be allowed separately with a -59 modifier?
I have an exam that the physician selects the left renal vein for a venography and then advances the cath to the left gonadal vein. I know the selection will be a 36012, but what code whould I use for the interpretation of the gonadal vein?
How do I code left heart catheterization, left ventriculogram with LVEDP measurement, selective coronary angiography, and non-selective LIMA angiography?
Dr Z: My surgeon performed an atherectomy of the distal right popliteal artery. At the same session, he performed an atherectomy of the proximal portion of a right femoral-tibial bypass vein graft near its origin from the common femoral artery. Do we only bill 37225 once since we are in the femoral/popliteal area on both the vein graft and native artery and on the same side or can we bill 37225 and 37225-59 with the vein graft being considered a separate vessel? Thanks for your help.
Hello, I need help :) The surgeon did a Graft Thrombecomy with revision (36833). He then did a fistula gram (36147) and because of stenosis in the venous outflow did an PTA (35476 & 75978-26). And a segmental incisiion of graft & overlying skin with primary closure??? Separate incision and closure.. Diag: End-stage renal disease, thrombosed graft fistula with recurrent bleeding from the false aneurysm of arterial limb of the graft with skin erosion. After revison/thrombecomy proc; The inflow was then tapered due to the incision..sheath removal of the graft was clamped proxiamally and distally, sheath withdrawn and sheath hole closed with sutures. Clamps released and palpable thrill was present along the graft, hemostasis was obtained. Counts ere correct x2. The wounds were closed in layers with Vicryl & Monocryl for teh skin Dermabond waa applied to seal wounds. This is what I am not sure about: Incision was then made to excise the sutured skin at the site of graft bleeding. The skin was excised as well as the underlying graft. No evidence of infection. The wound was reapproximated with nylon suture. Because this was a separate incision and it was done after the revision was completed, he feels he should get credit for the work. Since the graft was no infected, I am thinking this is still a part of the revision but not 100% sure. Your advice would be so appreciated! Thanks you!
Dr. Z: Would following be consider one operative field or two separate operative fields?: Following removal of an existing nephrostomy tube and placement of a new tube through a separate access site, active bleeding was noted from the lower pole of the left kidney to the posterior abdominal wall from the old nephrostomy tract. Embolization was performed on a segmental branch of the left kidney. Followup angiograms confirmed adequate occlusion of the vessel. A small focus of contrast extravastion was seen in the hematoma in the left posterior abdominal wall, fed by the left T12 intercostal artery. The T12 artery was embolized. Thank you for your assistance!
This is my first ever case where the physician is doing an angioplasty of the tract of a gastrostomy because of stenosis. Wouldn’t I code for the angioplasty? If so is this considered an open angioplasty or an unlisted code? Your feedback is greatly is appreciated.
Hello, I recently heard a rumor that the Radiologist has to state within the report that hard copy sonographic images were obtain for us to be able to bill out 76942. Is this correct? Your feedback is greatly appreciated.. Thanks so much for all your help....
Do you have any information on what code will be replacing deleted HCPCS code G0275?
We are in discussion with the hospital about billing for intervention on a branch of a major artery. We have a situation where the physician intervened on the LAD (92928, not during an MI), and there was some plaque shift into the diagonal branch of the LAD. Physician then did angioplasty (92921) on the diagonal branch. Can we show that this was performed? (I know we, as physicians, don’t get paid, but we need to show it was performed.) The hospital says no because the physician caused the shift of the plaque.
For example, 93458 done, and femoral angio performed with the intent of placing a closure device. Decision made not to place the device. How should this scenario be coded? Also, same scenario and closure device was placed how should that be coded? Within our cath lab we have debated this round and round and I would like the clearest guideline.
Dr. Z, Question#4. If the physician perform a congenital or a non-congenital heart cath can the code 36010 be assigned along with 75827 or 75825 if the documentation supports? I think thing this can be used with a -59 but then again if the physician already has the catheter within the parameter of the heart/headed towards the SVC or IVC to take a picture then it seems that it can be an inclusive code.??
Hi Dr. Z and Dr. Dunn, I have a couple of questions regarding required documentation. If a report lists hemo measurements, including systolic and end diastolic LV pressures, does the note also have to have specific verbiage stating 'the catheter crossed the aortic valve' or 'the catheter was pulled back (out of the valve)'? Wouldn't the documentation of those measurements be sufficient enough to bill for a left heart cath? On a similar note, does the report have to specifically state 'the coronary arteries were selectively injected' if the purpose of the exam is to evaluate CAD and the coronary vessels and any disease is described? CPT states that 'catheter palcement(s) in coronary arteriy(ies) involves selective engagement of the origins of the native coronary artery(ies)for the purpose of coronary angiography.' I would interpret this as catheter placement in the coronary artery itself or in the aorta at the origins of the left and right arteries. Your thoughts? Thank you so much.
I have a follow-up to question #5129. My surgeon is treating an endoleak for an AAA. The original surgery was done at an outside hospital, and now my surgeon is placing the Heli-FX to resolve the Type 1A endoleak. Any suggestions on what code should be used for this?
Hi! I'm hoping to get some insight on coding this procedure. Some think it could be a exploration, a repair of a vessel, or a revision. BRIEF HISTORY: The patient is a 42-year-old gentleman who has had multiple AV access operations performed on his right arm. He presently appears to have a hybrid access with a vein to artery anastomosis but a more distal graft. He came to the hospital with this access thrombosed. He underwent percutaneous intervention for opening of the access and this was successful; however, the procedure resulted in a large hematoma in the antecubital fossa. This has been painful. It has not shown any sign of resolution. We studied it in the vascular laboratory yesterday because it was pulsatile. We did not find a false aneurysm. However, I reasoned that the hematoma had sealed or at least was causing intermittent sealing of the puncture site. Given the size of the hematoma, the patient required evacuation and exploration. He comes to the operating room at this time for this purpose. DETAILS OF PROCEDURE: The patient was brought into the operating room and placed on the table in the supine position. His right arm was placed at his side on an armboard and was prepared with ChloraPrep and sterilely draped in the usual manner. Supplemental oxygen was given. Vital signs were monitored. Sedation was induced. Timeout was performed. Operation was initiated with the infiltration of 1% lidocaine and 0.5% Marcaine solution into the skin and subcutaneous tissues of the antecubital fossa. Then, a transverse incision was made incorporating the puncture site. Incision was carried into the subcutaneous tissues. The hematoma was encountered and there was some bright red blood within the hematoma. I evacuated the hematoma and as soon as I did, I was met with pulsatile bleeding. I put my finger on the source of bleeding and then opened the incision wide enough to gain access. At the depths of the hematoma, the AV fistula had a puncture site that appeared to be about 8 French in size. Suction was held to control the stream of blood flow and the puncture was closed with 4-0 Prolene suture. Approximately 200 milliliters of blood was lost during this maneuver. Once the puncture site had been sutured, the wound was irrigated and the hematoma and walls of the false aneurysm were further evacuated. Then bleeders were controlled with electrocautery. Subcutaneous tissues were closed in 2 layers of interrupted and then running 3-0 Vicryl. Skin was closed with a running 4-0 Monocryl suture reinforced with skin sealant. A sterile compression dressing was applied. The patient tolerated the procedure well. As noted, blood loss was about 200 milliliters. No blood replacement was required.
Good morning, After checking national CCI edits we have a question. When billing for a cardiac cath 93456 is the heparinization inclusive (CPT 93463) or billable separately? We ask because the description of 93456 says includes contrast imaging. Thank you, Jackie
Could you please clarify the proper coding of catheter placements in the hepatic arteries off the celiac artery? What we most commonly see is that the doctor will place the catheter in the common hepatic (36246), but after that, we have conflicting coding information. If the catheter is placed in the proper hepatic, left hepatic, and right hepatic, is it correct to report with codes 36247 and 36248 x 2 since these are all third order vessels? Or are the proper and right hepatics considered one coded vessel for some reason, and if the catheter is placed in both of these, it is only reported with code 36247? Also, where does the middle hepatic come into play? I often see this artery mentioned, but it's not listed in any reference book that I have.
How would you code a proper hepatic artery to right hepatic artery bypass with a reversed greater saphenous vein?
Hello, Could you please tell me if a first order or second order should be billed when doing a liver bx with pressures? The catheter is in the selected Right Hepatic Vein. Contrast is injected. The catheter is put in the Wedge position for pressures. Then core bx is performed. Also, can the venogram w/pressures be billed 75889.59 with 52 for the pressures? Thank you so much.
How would I code the NM study performed in conjunction with a pre-Yttrium MAA injection? We coded the following report as 78201. "NM liver imaging static hepatic shunt study. 3mCi of 99mTc MAA was administered into the hepatic artery by the staff. Subsequent images of the liver and lungs were performed with calculation of a lung to liver shunt fraction. It was calculated that 2.25% of the administered activity into the hepatic artery appeared in the lungs. The remainder of the activity visualized appears to reflect elution of pertechnetate judging from its biodistribution. Impression: Negative intrahepatic shunt study, shunt fraction calculated at 2.25%."
Would it be correct to use codes 93451, 36011, and 76942 for this operative report? "Right heart catheterization. Smart needle/site. Right hepatic vein venogram was prepped and draped in the usual sterile fashion. Under lidocaine 2% local anesthesia, an 8 French sheath was placed in the right internal jugular vein using the modified Seldinger technique under ultrasound guidance. A 7 French balloon-tipped catheter was advanced through the right atrium into the IVC. The catheter was positioned into the hepatic vein, and wedge hepatic vein pressure was obtained. Confirmation of wedge position was confirmed by hepatic vein venogram via hand injection of 5 cc of contrast. Multiple measurements of WHVP and FHVP were obtained per study protocol. Repeat FHVP measurement was obtained about 1-2 cm from IVC. IVC and RA pressures were recorded. Following the procedure, the sheath was removed and hemostasis obtained with manual pressure . There were no immediate complications."
Is there a code for the calcium stimulaton? thanks! PROCEDURE: Following informed consent, and verification of the appropriate patient identification and procedure be performed, the right groin was sterilely cleaned, prepped and draped. Local anesthesia was achieved with lidocaine 2%. Via a right common femoral vein a 5-French vascular sheath was placed. Through this a 5-French Simmons-2 catheter (modified with two extra side holes 0.5 cm from the tip) was advanced over a wire into the right hepatic vein (second order). Selective right hepatic venography was performed confirming location. Subsequently via a right common femoral artery puncture a 5-French vascular sheath was placed. Through this a 5 French RC-I catheter was advanced into the celiac artery and celiac arteriography was performed. Subsequently the catheter was advanced to 5 super selective vessels. These included A: The distal splenic artery just proximal to the pancreaticomagna artery, B: The proximal splenic artery just proximal to the dorsal pancreatic artery, C: Proximal common hepatic artery, : The gastroduodenal artery proximal to the superior pancreaticoduodenal arcade and E: The superior mesenteric artery proximal to the inferior pancreaticoduodenal arcade. In each super selective site catheterized, selective arteriography was performed. Following selective arteriography the patient was administered calcium gluconate, 10%, 5 cc (0.025 mEq of calcium/kg) intraarterially and right hepatic venous blood samples were drawn 0 seconds, 30 seconds, 60 seconds, and 120 seconds following administration of the intraarterial calcium. This resulted in 20 samples obtained from the right hepatic vein sent for insulin level analysis. The catheters were removed and hemostasis obtained at the puncture sites. FINDINGS: There is classic celiac anatomy. The dorsal pancreatic, pancreaticomagna, gastroduodenal artery, superior pancreaticoduodenal arcade and inferior pancreaticoduodenal arcade are normal. The superior and mesenteric artery and its branches are normal. The right hepatic venogram is normal. No hypervascular tumor was identified angiographically. IMPRESSION: Super selective mesenteric angiography with calcium stimulation and simultaneous selective hepatic venous sampling for insulin levels.
For the following example, would the wedge pressure be reportable with codes 36012 and 75889? "Patient has a right heart cath with hemodynamic measurements via right internal jugular (93451). Through a separate femoral vein approach, catheter is advanced through the vena cava to the hepatic vein, and a hepatic wedge pressure is taken. No contrast was used for procedure."
"During the procedure the physician harvested the GSV and attempted to create a proper hepatic to right renal artery end-to-end bypass. The anastomosis was completed, but failed once, and following a revision and re-attempt was found to be too diminutive on arteriography and was removed and abandoned. A 6 mm PTFE bypass graft was then used as the conduit." My question is, with PFTE graft vs. 35535, should I report code 35535 alone with a -22 modifier (assuming documentation states as such) and/or another code for the PTFE graft that was ultimately left in place? (It appears that code 35535 only covers vein, and I cannot find a synthetic.) I would also like to code the arteriography (75726). What are your thoughts?
Hi Dr. Z, we appreciate your knowledge and expertise, and we can sure use it on the following scenerio. I think we are ok on how to code all the procedures here except for the removal of the HERO. It would stand to reason that if the insertion would be 36558 and 36830-52, then the removal would be 36589 and then a code for a revision/removal/ligation of the AV fistula graft, but I don't see this described here, are we missing something? Did he just simply disconnect the catheter portion from the fistula portion? Thank you so much for your help PREOPERATIVE DIAGNOSES: 1. Chronic kidney disease, stage V, presently dialyzing with dysfunctional right femoral TCC and thus for removal of the same: 2. Thrombosed left jugular HeRO device for removal of same. 3. No further need for IVC filter and thus for removal of same. POSTOPERATIVE DIAGNOSES: 1. Chronic kidney disease, stage V, presently dialyzing with dysfunctional right femoral TCC and thus for removal of the same: 2. Thrombosed left jugular HeRO device for removal of same. 3. No further need for IVC filter and thus for removal of same. NAME OF PROCEDURE: 1. Cutdown exposure of the HeRO catheter at the left jugular insertion site with removal of the HeRO catheter. 2. Removal of IVC filter through the left jugular approach. 3. Replacement of a left jugular tunneled cuffed catheter, 23-cm precurved Palindrome catheter. 4. Removal of right femoral TCC catheter. DESCRIPTION OF PROCEDURE: The patient's left neck and chest were prepped and draped in the usual sterile fashion after adequate satisfactory general endotracheal anesthesia was obtained. The left jugular HeRO catheter insertion site incision was reopened and the HeRO catheter isolated at this location. The catheter entrance tract was encircled with a 3-0 Prolene pursestring suture. The HeRO catheter was then divided and a guidewire passed down into the vena cava through the HeRO catheter followed by complete removal of the HeRO catheter and replacement with a 13-French sheath. The sheath was then replaced with a Cook IVC filter retrieval kit which was passed through the wire and used to remove the IVC filter without any difficulty. The filter retrieval kit was then exchanged once again for a 13-French sheath followed by placement of 22-cm precurved Palindrome catheter which was tunneled subcutaneously and delivered out over the course of the guidewire insertion site. The large dilator and introducer assembly were then passed over the guidewire after removal of the 13-French sheath and positioned in the right heart under fluoroscopic guidance. The guidewire and dilator were then removed and a 23-cm Palindrome catheter passed through the introducer and positioned in the right heart under fluoroscopic guidance. The peel-away introducer was then removed. The pursestring suture was then tied at the catheter insertion site and the catheter insertion incision was closed in layers using 3-0 and 4-0 suture. The catheter was then secured at the exit site to the chest wall using nylon suture. Sterile dressings were then applied. At this point, the patient's right femoral TCC catheter was prepped and draped and then removed. A sterile dressing was applied at the right groin. The procedure was then completed and the patient awakened, extubated and taken to the recovery room in stable condition.
"Transverse incision was made in the antecubital fossa overlying a new area of the arterial end of the graft. The graft dissected and skeletonized. A separate incision made in the deltopectoral region just distal to where the HeRO graft connected to the outflow component. Both of these areas of the graft were resected and skeletonized. Kelly Wick Tunnel used to make a 7 mm tunnel between these two areas. A 6 mm Acuseal graft was brought to the field. It was pulled through these two incisions. The arterial end of graft was clamped and the other end ligated with a hemostat. Graft was then divided. An end-to-end anastomosis was done between the arterial end of graft using one 5-0 C1 suture under loupe magnification. Attention turned to the venous anastomosis. Again graft clamped just distal to the outflow component; graft was transected. Another end-to-end anastomosis was done between Acuseal graft and the old HeRO graft... with a 5-0 C1 suture under loupe magnification. Post anastomosis, clamps were released. There was excellent flow into graft with immediate thrill."
Could you please help? I have searched data base and can't find examples of the HeRO catheter embolectomies (only placement 36830-52 and 36558-51). Have two operations that incision is made and fogarty catheter was then used to perform embolectomy of the venous end of the graft and the arerial end of thegraft to removed organized blood clot(only one 36831). Then the HeRO catheter was embolectomized with a fogarty catheter also. Following this good flow was noted throughout the catheter. Venogram of the AV graft was perfromed on the vnous end and arteriogram was performed in the subclavian artery (no charge??) Following this the graft was repaired with suture and incision was closed with sutures and staples. Does the HeRO embolectomy qualify as a seperate 36831-5951 charge? Thanks, Kim.
Have you heard of the Hero Device? Can we bill 36558 and 36830 for implanting the device? I don't think so but I need clarification. Thank you,
Greetings A physician is placing a HERO graft. He angioplasties a stenosis in the vessel to place the HERO. Can we charge for the angioplasty, or is it part of the Hero placement. Thanks, LW
Dr. Z. What codes would you use for the radiologic services provided in the O.R. for a Hero graft placement? Basically, the tech is providing fluoro and saving pertinent images for the vascular surgeon. Thanks, Judy A.
What should we charge for HERO Graft insertion? Unlisted or is there a code to discribe the procedure? Thank you!
I have a physician dictating angioplasty of a high grade stenosis of the fistula adjacent to the arterial anastomosis. He does not state that he's actually doing the plasty of the arterial anastomosis, just the high grade stenosis adjacent to it. For the angioplasy of the arterial anastomosis (35475), I need the doctor to state that is what was plastied as opposed to a stenosis proximal to the arterial anastomosis or adjacent as this one is dictated... am I correct?
Drainage and catheter placement in hip and/or knee. Should you report code 20610 or 10160 with imaging code?
Please do NOT include any actual patient medical records with your question. Hi Dr. Z, If we used 93230 cpt in 2010 for the holter monitor, which code would we use in 2011 to replace 93230? If we used 93224 cpt in 2010 for the holter monitor which code would we use in 2011 to replace 93224? Thank you so much for your help Geri Elliott Norva Medical Billing, Inc. email@example.com
I am writing to request an explanation for the answer given to a test question in the Basic Catheter Selection module exam. The question was exactly as stated: Correct code(s) for left femoral access with catheter placed into the right superficial artery for angiogram is (are: 36247, 36246, 36245 36247, 36200 36247 36247, 36140 The correct answer was indicated as 36247. I cannot see how that was selected. Is the cath placement in the right superficial FEMORAL artery (femoral was not in the test question, but I assumed that was the vessel in question); if so, the access was on the left and the diagram Lower Extremity Arterial Anatomy Right Transfemoral Approach leads me to 36245 for the right leg in this diagram. 36247 is the code for the left leg. I think the left approach is starting me off on the wrong diagram and I need to choose the code based on the Order of the vessel selected (3rd order, initial, lower extremity) and the fact that it is a selective (placed) catheter. Please explain how to use the diagram to simplify Basic Catheter Selection. Thanks so very much for your extremely helpful webinars, but I do want to be sure I get the basics down pat now.
Greetings Dr. Zeilske or Dr.Dunn, We have lately started receiving denials from at least Humana, Cigna, and Tricare, maybe others, when reporting 36140, 36200, 36245-36248 when submitted with 75710 or 75716. We have recently found on the Humana website that on June 24, 2011 Humana has published an edit that "36140, 36200, 36245-36248 will not be separately reimbursed when submitted with 73706, 75635, 75710 or 75716". Are you familiar with any such edit or coding change that would support the insurance denials not to pay the cath placement with the diagnostic study? Our surgeons regularly perform the diagnostic angiograms and we of course report the catheter placement as well as the radiological supervision and interpretation. (of note, no cath is reported with interventions, of course. Cath only reported with the diagnostic studies). Thank you for any insight you may have to how / why the insurance carriers have developed this edit to deny the catheterization with 75710 / 75716. Thank you
My physician performed a cutdown thrombectomy on PTFE dialysis graft arterial and venous anastomosis. Then he angioplastied the venous stenosis (severe recoil) and then placed a stent. The problem is, when he closes the graft he patch angioplastied, does this make it a revision of a dialysis graft? I know if we code this to a revision then the angioplasty and stent code are bunded. So do I code this as either: A) 36833/75791-2659, or B) 36831/75791-2659, 35460-51/75978-26, 37207-51/75960-26?
"Patient with congenital VSD is brought to cath lab for transcatheter VSD closure. They are unable to properly place the device, and the device and catheters are removed. They then make a small thoracotomy incision and place a sheath through the RV and deploy the closure device from there. Sheath is removed, and the RV and thoracotomy incisions are closed." Would this be reported with code 33999 (unlisted cardiac surgery), or could it be reported using code 33681 (closure, VSD with/without patch)?
Can you help clarify this vascular case? "An open endarterectomy is performed of the iliac and then the superficial femoral. There is residual stenosis, and iliac and popliteal stents are placed. They were unable to clean out the SFA, so the decision is made to do a PTFE fem-pop." If inflow and outflow are included by whatever means necessary, the endarterectomies are dropped, but do I still report codes 37221 and 37226? I have been having more and more hybrid cases and have been charging the stents. But when you read the "all inflow and outflow by whatever procedures necessary", I am questioning the correct coding. I would really appreciate your expertise.
Would aspiration of hydrocele be reported with code 55000? I noticed this is not listed in the ZHealth IR book and just want to be sure this is the code you would recommend. "Title of Procedure: Ultrasound-guided aspiration of hydrocele. Under sonographic guidance one step needle advanced into the left scrotum and a total of 470 mL of straw/amber fluid was removed. Catheter was removed at the termination of the procedure. A 22 gauge needle was advanced into the right scrotum where a total of 80 mL of straw-amber fluid was removed."
What code(s) would you suggest for the following procedure? An adult barium enema tip connected to large bore tube was gently inserted into the rectum. The first attempt at reduction with Gastrografin/warm water demonstrated a tight complete volvulus of the redundant sigmoid colon without contrast proximal to the torsed segment. The second attempt at hydrostatic reduction was also unsuccessful. However, at third attempt at reduction, the volvulus completely reduced. Approximately 2.5 L of stool and fluid were evacuated. Contrast was subsequently identified refluxing retrograde to the level of the distal transverse colon. IMPRESSION: Successful hydrostatic reduction of sigmoid volvulus with water-soluble contrast.
Hypoplastic left heart syndrome consists of several defects - mitral and aortic valve, aorta, and left ventricle. The question came up about whether other related conditions should be separately coded out with ICD-9 codes (mitral stenosis/atresia, aortic valve stenosis, coarctation of the aorta/aortic arch) or if all of these conditions associated with hypoplasty left heart syndrome would fall under the one ICD-9 code.
Dr. Z, How do we charge intercool insertion, an invasive catheter that stays in the body for hypothermia done in cath lab? Since it is CVC can we charge 36556 77001? Thanks
Hello, Please clarify cpt coding for iodine 131 administered through the gastric feeding tube for papillary thyroid cancer (thyroid surgically removed). Is it unlisted? Thank you