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ICD and pacemaker

Dr. Z,               I attended the course in Nashville as well as the one in Vegas the year before. We are having issues with the CPT code 33224 LV lead placement. In the past, we have charged for the generator removal (pacemaker usually) 33233, place the LV lead and put in the new ICD (usually) generator. So, we would have had 33233, 33224 and 33249 (because they would put in an ICD lead also), as well as fluoro. We didn’t realize that 33224 last year included the removal and replacement of the generator, which was always a new generator because the old generator couldn’t hold all three leads. My problem is that we were charging for the old generator to be removed and a new one placed and didn’t realize it was included in the code 33224. So our cost was much more than what it should have been, we are now realizing. One thing that might have kept us not getting any edits or have any other type of issue, is that the coders probably didn’t code that for payment(generator removal.) Our finance department can’t understand why the cost for an ICD placement is higher than a pacemaker placement. We are trying to stay budget neutral until this budget year is over. Ours runs from June 1 to May 31. Is it normal for the ICD implant cost to be higher? I don’t have anything to do with setting cost, but need to try and help make this correct from here on out. Again, we didn’t have any issues with the bills or payments, so I feel that the coders were correcting the bill before it dropped for billing. Any insight would be very much appreciated. Hope to attend the Nashville seminar again this year. Thanks,

ICD diagnosis coding

Hi Dr. Z, I am having a problem with coding an ICD case. The paient had a single chamber ICD put in for primary protection in 2003. He is back for replacement of his depleted generator, and also an upgrade to a Bi-v ICD due to his worsening CHF (class 111), EF of 29% conduction delay on ekg, with QRS duration of greater than 120. He is an out patient. He received a Bi-v ICD generator, atrial lead and a bi-v lead. I coded 33249, 33241, and 33255. I did not use the Q0 modifier because of the existing ICD and I thought the Q0 was only for new ICD inserts. MR coded 428.22 as the diagnosis code. 33249 hit an edit for a modifier, or addd't diagnosis code. " 33249 requires a modifier, or a diagnosis (per CR3604) must be present if the AICD is for secondary prevention of sudden cardiac arrest. I was told that V53.32 could not be used because of the upgrade. Should I use Q0 to bypass the edit? Thanks, Dr. Z Diane

ICD Downgrade to Pacemaker

A patient had a biventricular AICD with a right atrial lead. They brought the patient to the EP lab and did an AV node ablation. Then they added a His bundle lead and capped the right atrial lead. They replaced the generator with a biventricular pacemaker generator. I am unsure of how to code this. I was thinking of reporting codes 93650, 33207, and 33241. What are your thoughts?

ICD downgrade to pacer 33229

Patient received a "down grade" in a device. Patient had a BIV ICD and we replaced it with a BIV PPM. We coded 33229, removal and replacement of a BIV PPM, is this correct?

ICD generator exchange with lead movement subcutaneously (33263)

Good morning DrZ...I was wondering if you could help with this case. Procedure Performed: 1)Explant of a BiV ICD, 2)Tunneling of the right ventricular ICD and a left ventricular paciong lead from the left subclavian to right subclavian 3)Placement of a new biventricular cardioverter defibrillator. I coded it, 33241, 33215, 33226, 33240. However, 33226 includes removal and insertion and moving the pacer to the right was more work then just repositioning LV lead. Can you help me? Thanks, Melissa

ICD Implants

Dr. Z, I am being told that when coding ICD implant (33249)and DFT testing (93641) to use a diagnosis code of 427.41 for 33249, because during DFT test the patient was induced into V-fib. My understanding of NCD 20.4 number 1, is that v-fib is used when the patient has a documented episode of cardiac arrest due to V-fib not due to a transient or reversible cause.No where in the medical record can I find where the patient has had cardiac arrest due to V-fib and there fore I have been using what the report says and assigning 414.8 with QO mod and assigning 427.41 for the DFT test (93641). Is it appropriate to assign 427.41 to 33249 because the patient was induced into v-fib for the DFt test? Thankyou

ICD Lead

A patient has an existing biventricular ICD that was previously repositioned into the abdominal area from its original location in the pectoral region. The old ICD lead was capped and left in the pectoral pocket. Now the patient presents with the abandoned lead ”externalized” (a small portion of the lead having made its way outside of the body). The patient was taken to the OR and placed under sedation by anesthesia. The surgeon made an incision parallel to the externalized (old abandoned) lead. Then the surgeon dissected the lead out to where the yoke of the old trifurcated defibrillator lead rested. The ”externalized” lead was cut down as far as possible and then also capped. The pocket was freed up of extensive scar tissue, but no sign of infection was present in the pocket or tunneled areas. At that point, the surgeon placed as much of the leads as possible back in the pectoral pocket in an antibiotic sleeve and the pocket was closed. What would be the appropriate CPT code(s) to report?

ICD Lead for Support

A new single chamber pacemaker was implanted in attempting to screw the lead to the right ventricular, which would not hold. They also implanted an ICD lead for additional support, but leads implanted same location with both leads being attached to the system. Lead placement is right ventricle. How should this be coded?


What are the appropriate codes for a NIPS study (EP study performed through a patient's exisiting device) and termination of an arrhythmia through a patient's pre-exisiting device? Is it code 93724 (pacer) and code 93642 (ICD)?

ICD Replacement

I would appreciate some help with this AICD scenario. The patients come in for a replacement atrial or ventricular lead due to malfunction of the lead (not a recall). The physician replaces the lead and also the generator. It is not dictated that the generator is at end-of-life. I believe the replacement is so that the patient does not have to have another surgery anytime soon when the generator is actually at end-of-life. I used CPT code 33249. Can codes 996.04 and V53.32 be used for secondary prevention in this scenario, even though the generator may not be at end-of-life? Or, can the lead issue be ignored and the -Q0 modifier used? These patients were originally primary prevention.

ICD to Pacemaker

"Patient has multi-lead ICD. Generator was explanted and replaced with pacemaker generator. Atrial lead was capped, then existing right ventricular and left ventricular leads were attached to new pacemaker generator." How would this be coded? Would it be reported with codes 33213 and 33241?

ICD upgrade 33263 vs 33249

Hello Dr Z. Question on new 2012 Rhythm Device Coding. The patient has a ICD (single lead) and presents for a Upgrade to BiV ICD (dual lead)Would it be coded as: Removal of ICD generator (33241) Insert ICD generator, multi(33231) Insert BiV lead (33225) Insert New lead (atrial) (33216) Thanks for your help Melissa


Will your 2014 live seminars discuss ICD-10-CM and/or ICD-10-PCS coding? If so, in how much detail?

ICD-9 code for endocarditis of the aortic, mitral and tricuspid valves

Please do NOT include any actual patient medical records with your question. We use ICD9 Code 424.0 for Mitral Valve disorder, 424.1 for Aortic Valve disorders and 424.2 Tricuspid Valve disorder., But our doctors want Endorcaditis of the Aortic, the Mitral and Tricuspid.Is theres such a ICD9 code for Endocarditis of the Aortic Valve, Endocarditis of the Mitral Valve and Endocarditis of the Tricuspid. Please Help. Thank You!

ICD-9 for follow-up angiogram post placement of coils

DR. Z or Dr. Dunn: I have a follow-up arteriogram post placement of coils. Diagnosticly speaking would we use the V58.73 and the current disease process that necessitated the placement of coils for this follow-up exam? Such as V58.73 and V12.59 or V58.73 and 437.3 Thanks for your in put.

ICD-9-CM for postoperative compliction

I have question that maybe Ruth can help with concerning ICD 9 post op codes. I am not sure how long we can code for 997.1 post op complication. I see our physcians dictate post op afib after many procedures/ For Example: Pt has surgery by a "another" surgeon.. different practice. Develops post op Afib. Seen at hospital for post op Afib by one of our MDs. Placed on anti arrhythmic meds. Pt is seen a couple times over a couple month period while pt is on these new meds. 8-9 months after the initial hospital visit, the patient is seen back in office. MD has been trying to wean patient off the anti arrhythmic. Are we still using post op Afib at that 8-9 month visit?

ICM Remote Interrogation

If remote ICD and ICM interrogation is performed, can the next remote ICM interrogation be performed on day 31? Are the service periods separate for ICD and ICM?

ICY Catheter

Is there a specific code for placement of ICY catheter for patients who have had cardiac arrest and are being treated per the hyperthermia protocol?

IFR Assessment

I was wondering if you had come across anyone who has had a physician using the Volcano IFR. Code 93571 cannot be used since adenosine is not injected, but I was wondering if you had any ideas if this can be charge captured or not?

Ileostomy Injection and Imaging

How would we code for contrast injection into the ileostomy with imaging? Is code 49465 appropriate, or would codes 20501 and 76080 be reported? Brief Report: "Fluoroscopic evaluation of abdominal ostomy after cannulation of bowel ileostomy openings and administration of water-soluble iodinated contrast. Left ostomy opening demonstrates opacification of distal ileum, which extends to the ileocecal valve and inferior cecum. Mild blush of contrast outside small bowel surrounding small segment prior to the ileocecal valve is seen. Right sided ostomy demonstrates slight more proximal segment of small bowel opacification overlying the left mid pelvis."

Iliac Aneurysm Treatment with EVAR and Two Extensions

Our surgeon treated an iliac aneurysm using a unibody bifurcated endograft that was deployed on the aortic bifurcation and two Iliac extension grafts (same side). Can code 34804 be used in this type of situation, even though the patient does not have an aortic aneurysm? Code 34900 is only for tube endografts. But can we use it anyway, because of the extensions? Or should we use an unlisted code? If yes, what code should we use for the extensions?

Iliac angioplasty and atherectomy

Dr. Z, I am having difficulty understanding the bundling and reporting for code 0238T. 1. In the case of an atherectomy in conjunction with a PTA in the iliac artery territory, would you add code 0238T to the primary code 37220? 2. In the case of an atherectomy in conjunction with a stent in the iliac artery territory, would you add code 0238T to the primary code 37221? Thank you for your time!

Iliac angioplsty with EVAR placement

Dear docs-I was hoping you could help with when can you charge ballooning the iliac for an EVAR placement (and anything else I might be missing)Can I charge 37220 for stenosis when I am not sure that this isn't just for the clearing the way for deployment? And is there really an extension being placed? (including preop discussion, hopefully that helps) In the office in the preoperative area, we had a discussion with the patient regarding the difficult nature of the aneurysm including poor iliac access, high-grade stenosis of the iliac and the need for fem-fem bypass graft. We explained the creation or placement of an aortomonoiliac bypass graft with a fem-fem crossover. Bilateral groins were opened in a vertical fashion. We dissected down to the common femoral, profunda femoris, superficial femoral artery junction. 34812-50 I cannulated the right common femoral artery without complications or difficulty and inserted a wire into the aorta. This was followed by a sheath, flush catheter and then the wire was switched out for stiff wire. Catheter and wires were removed as needed to perform angiography. Please recall that the left common iliac artery is completely occluded. 36200-59RT We performed balloon dilatation of the external iliac artery prior to deployment of the stent graft. 37220-LT The patient was heparinized prior to any ballooning and we planned for the placement of a distal extension and this was carried out by placing a 1610 limb with 124 length in the aneurysm sac and out into the common iliac artery through preexisting stents. 34825/75953-26 A 20 20, 82 limb was then placed with sufficient overlap with the 10 16, 124 graft and finally an Endurant cuff, which was a 32 32 x 49 was placed in an infrarenal location. 34802-75952-26? Completion angiography demonstrated patent renal arteries bilaterally, no evidence of endoleak and widely patent aorto-mono-iliac bypass graft. Having this in mind, we removed the wires, catheters and sheaths and tunneled a piece of 8 mm ringed Gore-Tex from one incision to the other, created arteriotomies on the common femoral arteries and performed anastomosis of the end of the 8 mm bypass graft to the side of the common femoral artery with 6-0 Prolene suture. 34813 thank you so much for your expert opinion!!

IlIac bone biopsy

Dr. Z, Patient came in with bony lesion iliac for bone biopsy. After administering anesthesia bone biopsy needle was advaced into the iliac bone. Satisfactory position was confirmed with CT. Approximately 3cc of bloody fluid was aspirated too. Multiple core biopsies were performed thorugh the 13-gauge cannula. Samples sent for both culture and cytology. Not sure what else we can charge for the aspiration along with bone biopsy? Please advice. Thanks

Iliac Stents at Time of TEVAR

"Patient presented for TEVAR for thoracic aortic ulcer. Bilateral femoral cutdowns were done (34812-50). On the right, pigtail was passed for diagnostic angio (36200). Device sheath could not be advanced due to iliac disease. Common and external iliac stents were placed (37221/37223). Still could not advance device sheath. Right side was abandoned. Device sheath couldn't advance on the left either, so an iliac conduit was placed (34833). Catheter was advanced into arch through conduit (36200-50). TEVAR not covering subclavian was placed (33881/75957). Conduit was then converted to a ilio-common femoral bypass (35665)." Since the right side was abandoned and the stents were placed to facilitate passage of device, can I still code the stents? Can I code the conversion of the conduit as a bypass and as a conduit? Can I report code 36200-50 since the catheter was for the TEVAR, not the stents? Your expertise is greatly appreciated.


How do you code for an ilioplasty (bone).  Would you think this is unlisted or do the T codes apply?

IMA injection for graft

I just want to clarify what I read in this Q/A in the Jan 2011 newsletter please: Q: In 2010 I would code 93539 to check IMA for suitability for CABG. What would be used in 2011? A: Codes 93455, 93457, 93459, and 93461 describe coronary angiography(the blockages you found)and arterial/venous grafts (even if for evaluation of subsequent use as a graft, such as the IMA before it is a graft) by itself, with RHC, LHC,and RHC w/ LHC. So, it will just be part of the larger code. If this were a congenital case, then consider code 93564 for the IMA evaluation. In this answer, if a LHC is done + imaging the IMA for patency before CABG but the patient has no grafts at all. You would code the ungrafted IMA as if it were already grafted? CPT 93459 Thank you

Imaging guidance and EP

Dr Z, Is guidance bundled in with an EP study? we have heard several different things. Also, If our doc. uses ultrasound guiance and flouroscopy during an icd or PPM placement can we bill 71090-26 and 76998-26? Thank you for your help Traci

Imaging of the Lower Extremity, 73592

Would you consider the following a reference to determine the age of an “infant”? CPT 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year). If hip and lower extremity can be imaged on one film and the patient is 15 months old, would you code CPTs for hip and LE for tech component opps?

Imaging with stent placement coronary

When can you code 92980 and 93508, and 93556 together?


Good morning! Our cath lab is going to be using the Impella Device in a case today and we were woundering how to go about coding it. We have seen a lot of different ways to go about coding it but are not sure what to go with. We saw where the website said to use 33999, 93799, 92970 but the actual package for the device says to use 33975 or 33975-52. Also is there HCPCS code that goes with it? Any help would be greatly appreciated! Thanks!

Impella (2.5) Inserted during PTCA/Stent

Our physicians are wanting to schedule patients who may need an Impella 2.5 to assist during cardiac stent procedures as outpatients. Code 33990 is an inpatient-only procedure. 3M Encoder and CPT Assistant still lead to code 33999 for this type of intervention. Will there be updates to CPT Assistant or the 3M Encoder to relay the new 2013 codes, as we are in May 2013 now and still no updates? Does code 33990 cover any situation that an Impella 2.5 would be used including during a coronary stent procedure and removed at the conclusion of the procedure?

Impella 33990

Is there more information on the coding of the Impella Heart Assist Device, if we should use 33990 vs. 33999? The Encoder still specifically directs the use of 33999 with the keyword Impella even with a 2013 date of service. Your advice in 2012 was 33999, but you mentioned code 33990 would be available (which it is in 2013 CPT now). I'm hesitant to change the code without verification and contradicting the encoding system. Thanks for your help!!

Impella Use for Procedures

There are many different scenarios in which we have used the impella lately and would like clarification as to when we can charge the removal on the same day as insertion.  (Also trying to clarify definition of separate distinct session.)  For instance: Impella inserted in cath lab for procedure that would be done in different department later in the day.  At the end of the procedure in the other department, the Impella is removed. Impella inserted in cath lab for procedure in cath lab, but patient goes back to his room, and a few hours later when the MD is available, it is removed.  Impella inserted in EP procedure room by cardiologist for a left heart catheterization by cath lab staff, followed by an EP procedure by EP staff.  Hours later after the ablation, the Impella is removed by the cardiologist while still in the EP lab.  The IABP is a different class of assist device but curious as to when it's appropriate to bill removal on the same day as well.  We understand if put in for a procedure and removed at the end of a procedure, the removal is not billable.  However, when put in for a procedure but left in for continued support (for a few hours) and then removed, can the removal be charged?

Independent Interpretation of a Cardiac Cath

We've got a physician who just started with us who states that he has been able to bill for independent interpretations of cardiac caths that were previously done on a patient. Is that possible? What code would we use?

Inferior vena cavagram with heart catheterization

Dr. Z,  Lets say that a physician performs a full right & left heart cath on a congenital patient followed obtaining pressure, sats, and a picture of either the SVC(75827) or IVC(75828) can these codes be applied? For example, 93531, 75827 (so in this case I would not apply the 36010) I think so but you know the physician want me to double check.

Infusion of tPA in AV Fistula

Using the glide catheter to deliver 4 mg of tPA, the entire AV fistula outflow tract was laced with tPA, and we subsequently introduced a 6 x 20 cm angioplasty balloon and macerated the thrombus in the AV fistula, performing a balloon dialtion of the entire AV fistula outflow tract. The question is, what code should I use to report the tPA? Code 37212 (venous) or 37211 (arterial)?

Infusions and Pushes Performed During a Cardiac Cath/Coronary Intervention

I received the following statement from a cath lab director: "What I saw about injections integral to a procedure is that for cardiac cath, the only injections integral to the procedure are the basic sedations, which we don’t charge for. Anything else such as NTG given intracoronary, metopralol IV, Integrillin bolus, and then infusion are not integral to every case. Those are very specific instances and in my mind it seems we should be able to charge for them." My feeling is that separate billing for the administration of these drugs with code 96374 or 96365 would not be appropriate when administered during the course of a cardiac cath or a coronary intervention due to well established NCCI bundling edits. The reason why I say that is that the cardiac cath/coronary intervention would not be considered complete or performed properly on a patient without the performance of these infusions, therefore integral to the main procedure. Is this take more conservative than it should be? Do you agree with it, or is there another code that should be considered?

Injecting radiopharmaceutical with no imaging

Please do NOT include any actual patient medical records with your question.RADIOPHARM INJ W/O IMG: Order Number: 90003 Date of Exam: Jan 31 2012 7:40AM EXAMINATION: RADIOPHARM IV INJECT W/O IMAGING CLINICAL HISTORY: Hyperparathyroidism. PROCEDURE: Radiopharmaceutical Injection Without Imaging RESULTS: PROCEDURE: 10.5 mCi Tc 99m Sestamibi was injected intravenously and no imaging in the Nuclear Medicine Department was performed. The patient was sent to Surgery for intraoperative localization of possible parathyroid tumor. IMPRESSION: 1. Please see above. what if anything can the Radiologist charge on the above for the professional portion?

Injection of adenosine during cardiac catheterization

Hello~ I am asking for clarification of your answer below. Q uestion: Does the new code 93463 include adenosine? Answer: Yes, if given and a repeat heart Cath is done. Code 93463 is for repeating the heart cath after infusion of a drug, not just giving a drug. Dr.z So if adenosine is given as part of the FFR, which includes pharma stressing, and the report reads: resting FFR across lesion is .9x following maximal adenosine infusion this jumps to .8x, showing no evidence of hemodynamically significant stenosis". We would not code 93463 additionally, but can you provide a situation that adenosine is used that we could? Thanks, Eileen

Injection of contrast pain pump

Hi, I'm not for certain how this would be coded? Would you suggest the unlisted spine code(22899) for this procedure? Thanks! PROCEDURE: Fluoroscopic guidance provided for baclofen pump access INDICATIONS: lower extremity spasticity CONSENT: The procedure was explained, risks/benefits/alternatives explained, questions answered and informed consent obtained from the patient. TIME-OUT:A pre-procedure time-out was performed to confirm patient identity and procedure. GUIDANCE: Fluoroscopic guidance TECHNIQUE: The patient was placed in supine position on the fluoroscopy table. The patient's right lower quadrant over the region of the baclofen pump implant was prepped and draped in standard sterile technique. A 25-gauge needle was used to access the baclofen pump implant, with the assistance of fluoroscopic guidance. No cerebral spinal fluid could be aspirated from the baclofen pump, suggestive of catheter dysfunction. Needle was removed and hemostasis obtained with manual compression. The patient returned to the recovery area in stable condition, and was subsequently discharged. FLUOROSCOPY TIME: 0.2 min IMPRESSION: Fluoroscopic guidance provided for baclofen pump access.

Injection of isuprel with 93616

From the NCCI Manual: 3. A number of diagnostic and therapeutic cardiovascular procedures (e.g., CPT codes 92950-92998, 93501-93545, 93600-93624, 93640-93652) routinely utilize intravenous or intra-arterial vascular access, routinely require electrocardiographic monitoring, and frequently require agents administered by injection or infusion techniques. Since these services are integral components of the more comprehensive procedures, codes for routine vascular access, ECG monitoring, and injection/infusion services are not separately reportable. Fluoroscopic guidance is integral to diagnostic and therapeutic intravascular procedures and is not separately reportable. HCPCS/CPT codes describing radiologic supervision and interpretation for specific interventional vascular procedures may be separately reportable. Our recommendation is NO as it appears that you would absolutely be trying to get around correct coding per NCCI, CCI edits, and everything else that CMS has put into place to prevent you from coding that.  

Injection of pain pump catheter with intrathecal imaging

Dr. Z, In reference to an earlier coding question that you answered on July 6, 2011 we have a similiar coding question but need clarification if we should also use the CPT code 61070 and 77003. Our exam reads: (possible baclofen pump malfunction) The catheter access of the pump was punctured with a 24 G needle and aspiration retrieved 3 cc of clear fluid. Under flouroscopic control a total of 5 cc of contrast was injected into the pump catheter. Intrathecal subarachnoid spread of contrast was noted at the tip of the catheter in the thoracic spine. Spot films to document the course of the pump catheter were taken and there was no evidence of rupture. IMP: baclofen pump catheter contrast study and myelogram w/o complications. Aspiration of CSF was successful. They have been previously coded as myleograms?? Thanks

Injection of peritoneal catheter

Hello Dr. Z Could you please help us?! The procedure that was done is a contrast injection of the peritoneal dialysis catheter under fluroscopy. The catheter was not functioning properly, the doctor wanted to see where the problem was. Would 36598 be appropriate, or should we go to an unlisted code? Thanks!!! Mindi Neeley Team Leader Coding

Injection of Yttrium-90

Dr. Z. Which is the appropriate code to use for the injection of Yttrium-90, 77778 or 79445 during a Theraspheres embolization? The doc from Nuc Med comes up and injects the Theraspheres. The confusion stems from 77778 being a Rad Oncology code. Thanks, Judy A.

Injection to Control Bleeding during a Breast Biopsy

During a stereotactic breast biopsy there was considerable bleeding at the puncture site. The physician administered D-stat through the biopsy need to stop the bleeding. I am not comfortable charging for this injection, as it was done during the procedure for a procedure-related problem. The techs would like to charge code 96372 for a therapeutic injection. What are your thoughts on this?

Innominate vein to right atrium bypass with spiral vein conduit

Patient has right internal jugular vein occlusion and innominate vein occlusion with massive symptomatology head edema, saphenouse vein was harvested, median sternotomy was performed and innominate vein to right atrium bypass was performed with spiral vein conduit. Right atrial appendage was free of any lesion and was a good location for distal bypass, innominate vein was dissected, and found to be hard and filled with throbus. Innominate vein was transected , stump leading to superior vena cava was over sewn with 2 layer suture. innominate vein leading to the axillary and subclavian and jugular was explored, thrombus was evacuated. Next using the consturcted spiral vein conduit with a running polene suture, end to end anastomosis of the vein to the innominate stump was performed. Would you stil use 34502? Thanks for your help Dr. D

Innominate Vein Venography in Conjunction with Congenital Heart Cath

Please clarify the coding (catheter placement and S&I) associated with selective innominate venography in conjunction with a congenital cardiac catheterization procedure (93530-93533) from both an ipsilateral and contralateral internal jugular vein approach, as well as an ipsilateral and contralateral femoral vein approach.

Innominate venoplasty

Hello Dr. Z, can you please advise on how you would code the following? Pt came in with left brachiocephalic fistula with a hx of cephalic arch stenosis with a stent and central innominate stenosis where previous innominate PTA was required from a femoral approach because the wire would not pass from the AVF. RFV was cannulated. Angio of SVC and RA were normal and L innominate vein was not seen due to complete occlusion. The L innominate vein was selectively catheterized from the SVC. Angio of the central veins revealed a 90-100% stenosis of the innominate vein. Central venous angioplasty was carried out with <10% residual. An attempt was then made to pass a wire into the cephalic arch from the subclavian which was unsuccessful due to the presence of occlusion at the junction of the stent in the cephalic arch with the subclavian vein. Therefore, decision was made to cannulate the AVF. Left upper brachiocephalic fistula was cannulated and an angiogram was performed that showed 90% stenosis in the stent in the cephalic arch vein extending into the subclavian. Venous angioplasty was carried out showing 10% residual stenosis. Would the following codes be correct since there are 2 separate accesses? 36011, 75827-59, 35476, 75978 36147, 35476-59, 75978-59 ...or would the 36147 need to be changed to 75791? Thanks - a little confused.

Inpatient Billing Guidelines for Revenue Code 636

What are the inpatient billing guidelines for Revenue Code 636 on commercial (non-Medicare) facility claims? Our facility would like clarification regarding when it is appropriate to bill pharmacy items under Revenue Code 636 on commercial (non-Medicare) inpatient facility claims, as some of our commercial contracts have inpatient reimbursement clauses outlined for Revenue Code 636. We know that for Medicare claims, Revenue Code 636 is used for: 1) Inpatient – exclusively billing hemophilia clotting factors. 2) Outpatient – billing for "Drugs that require detail coding" (i.e., pharmacy with HCPCS). Are commercial (non-Medicare) claims required to adhere to Medicare inpatient billing guidelines for Revenue Code 636, or can "drugs that require detail coding" (i.e., pharmacy with HCPCS) be billed under Revenue Code 636? If possible, please provide references so that we may support our decision.

Integrilin Infusion

"Patient comes in and has an embolization of an ACA aneurysm, and a follow-up angiogram shows nonopacification of the majority of the A2 segment of the ACA. Subsequent angio demonstrates thrombosis of the portion of the A1 segment of the ACA and ciling was halted. An internal carotid angio was performed, and the occlusion of the distal aspect of the A1 segment was identified. 7.5 mg of Integrelin was infused into the A1 segment of the ACA. After 10 minutes a repeat angiogram was performed . The A1 segment remained occluded. It was decided not to further pursue thrombolytic therapy and clot retrieval at the current time." Is this a true infusion? Can we report code 37211 for the Integrilin that was given, or is this documentation not enough to support an infusion?

Intercostal Angio

 When doing intercostal angios for the purpose of a retroperitoneal hemorrhage, do you use code 75705 or 75726?

Internal Biliary Stent and Internal/External Biliary Drainage Catheter

Patient with jaundice presents for biliary evaluation. Physician performed: percutaneous transhepatic cholangiography (47500-59, 74320-59), cholangioplasty with stent placement (47556, 74363), and internal/external drainage catheter placement at the initial presentation. Would you please give us your insight on why the drainage catheter (47511, 75982) is not coded in addition to ductal dilation with or without stenting when the procedure was not staged?

Internal Cardioversion through Existing ICD

How would you code an internal cardioversion through an existing ICD? I understand code 92961 is an open procedure and would not apply, and code 92960 would not be correct either. Can you help?

Internal mammary artery imaging

With the new cardiac catheterization we were wondering how you would code the injection and imaging of the IMA--this is not a graft, but was done to determine the patency of the IMA for possible CABG. Thank you

Interpretation of spot films

Please do NOT include any actual patient medical records with your question.FLUORO NON RAD DOCTOR OVER 1 HR: Order Number: 90005 Date of Exam: Aug 13 2012 10:54AM EXAMINATION: FLUORO-NON RAD DR OVER 1 HR CLINICAL HISTORY: Cervical fusion. COMPARISON: None. TECHNIQUE: Frontal and lateral views of the cervical spine. RESULTS: There is anterior fixation of C3, C4, C5 and C6 with prosthetic disc material in the intervening disc spaces. Surgical drain in the prevertebral soft tissues. There is anatomic alignment without evidence of hardware failure. IMPRESSION: ACDF C3, C4, C5 and C6. I do the billing for the Radiologist portion and our hospital bills for the tech component and I wanted to know if I can bill for a 2 view cervial x-ray for the above (72040).

Interventional radiologist consults

My physician is an Interventional Radiologist. He is the only one on call for one of the area hospitals. He will get called in at all hours of the night for a "consult", which I bill a 99222. During that consult he will usually find that a procedure needs to be done of some sort. The procedure is scheduled for the next day. Medicare will pay my procedure but deny the 99222 as "pre-op or post-op care". Not only is my physician being woken up in the middle of the night, I can't even get him paid for his services. Is there a way around this? Is there a modifier I can use that would help? Thank You, Shannon Dr. Stephen K Liu

Interventions in a fem-pop graft

If intervention is done on a fem-pop graft and the MD states where in the graft it corresponds to the native artery location, can I code it the same as the native or because it is a graft I only get to code intervention once? In other words he talks about stenting graft corresponding to SFA and to POP. I have tried to find documentation of how to code but can find nothing.

Intial Diagnostic Angiogram and Cardiac Cath with PTCA/c

Do I need a modifier on code 93458 for the initial diagnostic exam with the C-codes for the PTCA?

Intra Arterial Injections of Verapamil for Vasospasm

I have a physician who wants to bill infusion code 37202 for cerebral intra-arterial injections of verapamil when the combined carotid injections equal 30 minutes. What do you think of this?

Intra operative imaging

Dear Dr. Z: Is it appropriate to bill intra-operative views with findings which appear to be only confirmatory of the procedure which was performed? Imaging is often included in the surgical codes now (i.e., spine injections) or in the radiological S&I code billed with the surgical component. If the view is for QA purposes, confirmatory only, or not diagnostic shouldn't it be a no charge? Thank you. mlb

Intra-Aortic Balloon Pump via Axillary

My physician is a vascular physician who inserts an IABP by transaxillary vein cuff approach. Is this reported with code 33973, even though he is not directly approaching the aorta? Or would it be an unlisted procedure? Also, four days later the IABP has migrated retrograde into the aorta and out into the subclavian artery, so the physician takes the patient back into surgery and reopens the previous incision and repositions the IABP further into the aorta and resutures. Is there coding for this, as I don't see a repositioning code for IAB's, only VADs?

Intra-Arterial Administration of 6.5 mCi Technetium 99m Labeled MAA

I have a radiology physician who does pre-Y90 mapping and MAA shunt evaluation when he infuses the intra-arterial administration of 6.5 mCi Technetium 99m labeled MAA for the shunt evaluation. Is there a way we can capture this charge? I am only coming up with a HCPC code C1204 for this, and I'm wondering if there is an additional CPT code we can use to capture this.

Intra-Arterial Aortic Sac Pressure

Patient has a history of ELG with a type 2 endoleak (not global). During an open embolization of the aortic sac and ligation of IMA, the physician inserted a sheath into the aortic sac and obtained intra-arterial pressures. Is that a separate billable service? If yes, what code(s) would I be able to use? We currently have code 37244 for the embolization and code 35221 for the ligation of the IMA.

Intra-Arterial Mannitol

Patient was being treated for a GBM.  After completion of cerebral angiogram, a guide catheter and a Terumo guidewire were used to selectively catheterize the distal LICA.  A roadmap technique demonstrated best view of the feeding pedicle.  Once this was achieved, a microcatheter and Precision Microwire were used to selectively catheterize the distal M2 segment.  Superselective angiogram revealed a discrete tumor blush. Once this was achieved, 35 mg of mannitol, after being filtered, was slowly injected.  This was followed by a total dose of 400 mg dosing selectively injected into the distal MCA.  He does say that this is an off-label non-FDA approved and compassionate use procedure.  The only codes I can see to use are either 37202 or 37211, but neither seems to fit.  And would I assign code 36228 for the superselective angio of the M2 segment even though done by roadmap technique?

Intra-operative billing for interventional radiology procedures

I need some clarification on intra-operative billings…vasc. surgeons sometimes do arteriograms in the OR and then a radiologist or CVIR phys. will also interpret the findings.  Here are some questions from one of my cvir physicians…I just want to make sure I'm telling them the correct thing.  should cvir/rad be billing a technical chrg. only for interpreting their findings since the vasc. surgeon did the supervision and interpretation?  Since I don't normally see the radiology part but I do see and bill the vasc. surgeon, we're afraid of duplicate billing. thanks! So, here are my questions: 1.  If we provide an appropriate dictation for the images, what would we be billing for?  We may be providing an interpretation, but what about the "supervision" part? 2.  If we provide an appopriate dication for the images, would we be double billing (ie we and the vascular surgeon?).  In reality, I doubt that can happen. 3.  If we are providing a dictation to bill for the "techincal" aspects of having radiology techs go up there, is it sufficient to say, "Please see  findings reported on operative report." 4.  Is it the norm for radiology techs to provide this service in the OR?  I know the CVIR techs used to go up there, but don't any more.

Intracoronary nitroglyscerin infusion during cardiac catheterization

I have a question regarding a heart cath and billing intracoronary nitroglycerin give for spasms. Is this separately billable with a basic heart cath? 93458 92980-LC 92975???? Billable? thank you for any guidance you can give me.  

Intracranial Parenchymogram

Physician performed: 1) Left carotid endarterectomy with patch repair - 35301.  2) Intraoperative carotid arteriogram (no cath placement documented).  3) Intracranial parenchymogram on the left side.  I cannot find any information on what a parenchymogram is other than it has something to do with the capillaries. As it stands I can only see reporting code 35301.

Intracranial Thrombolysis

Am I suppposed to use code 37211 (arterial thrombolysis, initial day) for the following scenario? "Penumbra cath advanced to the left MCA.  Two mg of tPA IA injected in this branch, over three minutes. Follow-up angiography done, and due to persistent thrombus, additional 2 mg tPA was given over three to four minutes. Follow-up angiography done, and Perclose placed."  LCDs are not updated for new codes yet.

Intraoperative ICD Testing

Can code 93641 be billed for intraoperative ICD testing, or is this only for defibrillation threshold testing?

Intravascular Heat Exchange

Is there a code for measuring the blood flow rate using an intravascular heat exchange catheter?

Intravascular imaging of coronary vessel by optical coherence tomography (O

Dr. Z, what would you suggest for intravascular imaging of coronary vessel by optical coherence tomrgraphy (OCT), not sure if we can use 93799? Thanks

IR Procedure for Liver Tumors Treated with Brachytherapy

Is there an IR procedure for treating liver tumors using brachytherapy, Ytrrium 90? It is a form of radiation that is injected into the tumor bed? Is there a dosimetry charge that can be billed? If so, is there any specific FDA-approved treatment planning or wordage that is necessary? Also, what about the use of SPECT/CT or PET/CT being reimbursed afterwards?

IR/OR Hybrid Procedure

When the interventional radiologist assists the surgeon in the OR, should we report S&I codes if documentation supports coding? The cardiovascular center wants to charge code 76000 as a way of tracking the number of procedures the interventional radiologists assist in the OR. What is protocol for this scenario?

IV adenosine administration to check for atrial flutter pre EP

I haven't run across this before and I'm not sure how to code it on both FAC and PRO side. Pt was brought in for possible DC cardioversion for possible atrial flutter. Anesthesia was provided by anesthesia colleagues. In order to evaluate whether or not the patient had underlying atrial flutter the patient was given IV Adenosine 6mg at 10:04 and 12mg at 10:06 (by the cardiologist). With ensuing bradycardia no underlying atrial futter was noted. Response consistant with sinus rhythm. In summary, pre-op and post-op diagnosis were normal sinus rhythm with cardioversion being cancelled. Do I code 92960-74 or 96374 (IV push) for the FAC side and just 96374 on the PRO side? Thanks for you assistance.

IV placed in IR for CT scan with contrast

If a patient comes in for a CT scan and requires an IV access to be placed by IR due to "poor venous access", is the 36000 and 76937 seperately reportable? Typically the 36000 is bundled, but due to the poor access and the fact that they are taken to IR for the procedure, does that warrant the charges? The fact that is performed for the sole purpose of administering the contrast, regardless of the reason they have poor access, does that void charging the 36000/76937 seperately?


Dr. Z, I am requesting coding advice about the following scenario in the hospital outpatient setting R neck prepped and draped. U/S used to interrogate the neck. Could only see collateral veins. Tried to cannulate one of the larger collaterals but was unsuccessful. Converted to L neck which was prepped, draped, U/S interrogated. Micropuncture used to cannulate the vein under U/S guidance. Wire placed. Needle placed over catheter. Wire down to IVC under Fluoro. Dilator/sheath to distal IVC. IVC-grams performed. Renal veins level was marked. Filter placed. Completion IVC-grams. Wire placed and triple lumen catheter was placed. I understand that for 2012, the IVC filter placement would be coded as 37191 which bundles catheter placements, imaging and ultrasound guidance. However, I am unsure whether to report anything additional for the attempted catheter access to the R neck. I am also unsure whether the fluoro, which was used in addition to ultrasound, should be reported. Lastly, how would the central catheter placement be coded. It is not a replacement catheter, but it is being placed through the same catheter access as the IVC filter placement and so might not merit reporting of the insertion. Thank you very much!

IVC and SVC filters

Are diagnostic IVCgrams (75825) and US guidance for vascular access (76937) still ok to bill in conjunction with 37191 through 37193? Is 36010 now included? Also, if an SVC filter is placed, is that unlisted (37799) thanks!

IVC Filter Placement and Removal during same session

I’m sorry I was not able to make it the Las Vegas conference this year but I do plan to attend your 2012-Tennessee conference.  As always, I always come to you guy with the tough questions. What is your coding recommendation for coding a IVC filter Placement and Removal during the same session and same access?  First time I’ve have ever seen this.  Patient has extensive IVC and bilateral iliacs thrombus and is on day 3 for thrombolysis.  F/U angiogram via bilateral extremity, Filter placed via rt internal jugular, Venoplasty via rt fem vein access, Thrombectomy and Stent placement of IVC via rt inj access and rt com femoral vn, bilateral venoplasty of iliac veins and then IVC filter was removed at the end. Your feedback is greatly appreciated. Thank you,

IVC with heart catheterization

Hi Dr. Z, The physician performed a right and left heart cath with left Vgram and coronary angiography and aortic arch angiography. Because the patient had a history of IVC ligation, the physician performed a hand injection through the venous sheath in her right groin in an effort to identify her venous anatomy to faciliate the right heart cath. This revealed a narrow venous structure region with continuous flow present into a more normal appearing inferior vena cava adjacent to the entrance of the right atrium. He suspected that this is a well developed collateral that has developed as a result of ligation. He was able to navigate the right heart catheter through this vessel into the heart. My codes are as follows - 93460, 93567, but I question if I should use 75825-59. I decided against 36010 first because there is an edit, and I didn't feel that was distinct from the catheter placement used for the cardiac cath portion. I'm thinking the 75825-59 is in fact appropriate but would greatly appreciate your fine wisdom!! Thanks!


Dr. Z. Pt had a LHC whcihc showed 90% stenosis in LCX. 2 weeks later pt was brought to the cath lab for staged intervention. Physician did and IVUS which showed less than 50% stenosis and therefore did not procedure with the intervention but rather ended the procedure. Can we bill anything for the IVUS? Can we bill for the intended stent placement procedure with a modifier -74? Thanks!

IVUS and lower extremity revascularization

Bilateral kissing iliac stents IVUS bilateral common iliac arteries Can I bill for the IVUS With 37221; 37221-59 or is IVUS included in 37221? 37221,37221-59, 37250, 75945, 37251, 75946 Thanks for help,

IVUS and stent grafting 37250

Dr Z, During a thoracic endovascular aortic aneurysm repair with left subclavain artery coverage 33880 75956/26 the physician places an intravascular ultrasound catheter and performes an intravascular ultrasound of the thoracic aorta from the arch all the way down to the celiac axis in the abdominal aorta. This was done to confirm diameter measurements proximally and distally. Is the IVUS 37250 75945/26 a billable service with the placement of the thoracic graft in this case? Thank you, LaVonn

IVUS aorta

Dr Z, If IVUS is performed in the Aortic arch, Thoracic and Abdominal aorta do you code as 3 procedures? Thanks

IVUS in AV Shunt

Procedure: femoral AV fistula, fistulogram, stents outside fistula, upper extremity venogram, and IVUS (several vessels including fistula). Can IVUS inside the fistula be billed?

IVUS or FFR Without Heart Catheterization

I am writing about a scenario that we sometimes see in the cath lab. The first physician performs a diagnostic heart catheterization, and then physician #2 comes in and performs the IVUS/FFR (one or the other). Most of the time, the patient leaves the lab and is held in the holding area and is then brought back to the lab for physician #2 to perform the additional procedure. Occasionally, there is no further intervention. So, how does physician #2 bill for his services since he only performed the IVUS/FFR, which are both add-on codes (either 92978 or 93571)? We were specifically wondering if it was appropriate for an unlisted code (93799)?


Dr. Z, When the physician documents IVUS and then inserts a drug eluting stent we get an edit stating that 92978 needs to be billed with another CPT code. It is not recognizing the C9600- C9607 codes. You do not mention the use of these the C codes with 92978 in your chapter on IVUS. Is this not acceptable? Please advise. Thanks!! JD

IVUS with lower extremity revascularization

Is IVUS 37250 and 37251 reimbursed on top of endovascular revascularization 37220-37235?

IVUS without Intervention or Angiography

We have a vascular surgeon who performs IVUS imaging on patients with venous congestion syndrome or venous hypertension. He routinely images the IVC, bilateral common iliacs, external iliacs, and common femoral veins. Venography is not done during these procedures. When no intervention is done, how should I be coding for the IVUS? What I have been doing is coding for the bilateral catheters placements in the IVC (36010, 36010-59) and for the S&I portion of the IVUS (75945, 75946 x 6). Is this appropriate coding?


I just found out that codes J0152/G0275 were deleted 12/31/2013.  What are the replacement codes?

Jet stream G2 atherectomy, thrombectomy

Hi Dr. Z, Since the Jetstream device is approved for both thrombectomy and atherectomy, if BOTH procedures are performed during the same session, can BOTH procedures be coded along with BOTH C-codes? Thanks in advance!


I am encountering an issue with the use of the Jetstream atherectomy device. As you know, this device is indicated for both atherectomy and thrombectomy from the same catheter. The physician dictated that he performed an atherectomy/thrombectomy within a lower extremity vessel. There is no mention of the presence of thrombus within the vessel during the procedure. Is it appropriate to charge/code for atherectomy and thrombectomy for this procedure, as the physician only mentioned a calcified lesion in the vessel?

Jetstream G2 atherectomy, thrombectomy

Hi Dr. Z, Since the Jetstream device is approved for both thrombectomy and atherectomy, if BOTH procedures are performed during the same session, can BOTH procedures be coded along with BOTH C-codes? Thanks in advance!

Joint Surveys Code 77077

I have a question on coding an AP view of the bilateral hands and an AP view of the bilateral feet ordered by a rheumatologist. Is it correct to bill code 77077 x 2 for these exams?

Kissing Balloon to Protect Iliac Origin

While dilating the origin of the left iliac artery stent, a 7 mm balloon was simultaneously insufflated in the proximal right iliac system with both balloons extending into the aorta in a kissing fashion to protect the right iliac origin and dilated distal aorta. Since this is done to protect the artery, can I report code 37220-59 for one side along with the stent placement on the opposite side?


Patient is pre-op for planned gastric bypass. 74241 was coded. The question is whether 74246 would be more appropriate. Coder is questioning with KUB. No diagnostic info regarding kidney/ureter/bladder is given, but in the coders desk reference KUB is referred to as a general abdominal exam. Is diagnostic info pertaining to kidney/ureter/bladder necessary to append code 74241? Clinical Notes: Pre-Op Gastric Bypass ESOPHAGRAM AND UPPER GI SERIES - 4/6/12: HISTORY: Obesity. FINDINGS: Preliminary film of the abdomen is unremarkable. The patient swallowed barium without any difficulty. There is no evidence of a hiatal hernia or gastroesophageal reflux. The esophagus is unremarkable. The stomach shows normal motility and distensibility. Mucosal folds of the stomach are unremarkable. Duodenal bulb and loop are well seen. There is no evidence of peptic ulcer disease. CONCLUSION: THERE IS NO EVIDENCE OF A HIATAL HERNIA OR GASTROESOPHAGEAL REFLUX. THERE IS NO EVIDENCE OF PEPTIC ULCER DISEASE. ROOM TIME IS 45 MINUTES. FLUOROSCOPY TIME IS 2 MINUTES 45 SECONDS.

KX Modifier

Since the NCD for single and dual chamber pacemakers has been put on indefinite hold per MLN Matters CR8525, does this mean that we should not be appending the -KX modifier to pacemaker implants to indicate the patient has documented symptomatic bradycardia?

Kyphoplasty 22524

We discovered that the RVUs for code 22524 jumped from 16.61 in 2011 to 223.41 in 2012. Approximately $1463.00 to $22,109.00 in 2013. Is there a specific reason for this high increase? I would appreciate any information you have for us to pass on to our concerned patients and physicians.

Kyphoplasty cavity creation

Hello Dr. Z, Are there other products besides Kyphon, such as the Carefusion "AVAmax" system, that would meet the kyphoplasty cavity creation CPT code definition (22523, 22524)? Thanks so much!

Kyphoplasty with DFINE Osteotome Device

I have a patient on whom the physician has used a DFINE Stabili kit to perform what I would consider a "kyphoplasty" procedure. The physician performed a cavity creation by using a curved osteotome and then placed cement in the vertebral body of the L1. I have had this procedure pulled for an audit, and the auditor counted this as a vertebroplasty because the physician did not use a balloon during the procedure. I was told if the DFINE Stabili kit meets the definition of a kyphoplasty then it would be appropriate to code it as one. Can you give me some insight on this?

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