Knowledge Base

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Set Descending Direction

KX Modifier

What is going on with the delay on the use of the -KX modifier on pacemaker procedures? I know the ruling to use it was delayed in July 2014. Has there been any further development on whether or not it should be applied?

G-tube check using room air and fluoro

Is it correct to report code 76000 for an injection of room air into a gastrostomy tube under fluoroscopy to evaluate the tube? No contrast is used, so I don't think code 49465 would be appropriate.

Peripherals with Cath

"Common femoral artery was cannulated, and a sheath was placed. Because resistance was met, right iliofemoral arteriography was performed via the sheath. A glide wire was advanced beyond the common iliac artery, and the sheath was exchanged; the tip of sheath was in the distal abd aorta. Through this, abdominal aortography was performed. A catheter was advanced into the ascending aorta and aortic pressures recorded. Catheter was then used to engage the left main, and selective left coronary angio was performed. Catheter was then disengaged and exchanged, which was used to engage the right coronary artery and each of two aortocoronary bypass grafts. Selective right coronary and bypass angio performed. A catheter was then used to engage the innominate artery. Selective innominate angio was performed. Prior to this, limited aortic arch angiogram was performed via the catheter, which was placed immediately proximal to the innominate artery." I reported codes 93459, 75625, 75710, and 36222. Does this sound right? Sorry not enough room to put all specific but included the main points.

Device Pocket Revision

How would a pacemaker pocket revision be coded when the pocket is not relocated? Since code 33222 is now only for relocation of the pocket, I am not sure how this should be coded. "The patient had a pocket revision due to painful movement of the pacemaker within the pocket. The device was removed from the capsule, and the capsule was enlarged laterally and superiorly. A Parsonnet pouch was placed over the device and excess leads. The device within the pouch was placed back in the pocket and fixed at 5 points to the underlying pectoral muscle a few centimeters lateral and superior to the original position."

G0278 not with PCI

I know that the code for non-selective iliac angiography done at the same time as 93452-93461 is G0278. However I ran into a situation. A patient was admitted to an outside hospital for NSTEMI, had a left heart cath with coronary angiography, and was transferred to our hospital for intervention because the lesion was complex. My physician did a coronary angiography and placed three drug -luting stents in addition to performing a non-selective peripheral angiography of the iliacs. However, since the patient had a coronary angiography three days prior, the compliance department advised against billing the coronary angiography since we had the imaging from the procedure done at the outside hospital and were intervening on lesions identified during that procedure. How can I bill for the peripheral procedure if I am unable to bill code 93454? My understanding is that code G0278 has to be billed with 93452-93461. Please advise.

Additional Ablation

Documented AF and atrial flutter. Physician goes on to describe pulmonary vein isolation and then states: The RIPV could not be occluded with the balloon but was electrically isolated post ablation. There was no phrenic nerve injury demonstrated during the lesions. Block was demonstrated in each vein. Exit block was demonstrated. Using Carto 3D mapping a voltage map (0.3-1 mV) was performed in the LA. Using Carto, 3D mapping of the RA and the CTI was targeted for ablation. An Ablation line was performed with RF at 6 o'clock using the 3D map and Intracardiac Echo map. Block was obtained. There was a prominent Eustachian ridge and both the RA and RV leads were crossing the isthmus. IMPRESSIONS: Successful isolation of pulmonary veins CTI ablation RHC with pressure measurement of RV/PA 3D mapping Trans-septal cath Intracardiac Echo Mapping Normal AVN and HP function Would this be enough documentation to add CPT 93655 to 93656? Thank you!

Creation/Closure of New Generator Pocket

"Patient had a previous ICD that was infected and removed. Several days later we created a new pocket on opposite side. We attempted to access veins, and venogram with contrast was done, which showed everything to be occluded. Procedure was aborted and the new pocket was closed." Is there a code for just the creation/closure of the new pocket?

Y-90 with GDA Embolization

"Initial placement of the microcatheter (by IR) into the right hepatic artery resulted in decreased antegrade flow and reflux into the small, patent gastroduodenal artery. The decision was made to embolize the GDA prior to the Y-90 treatment by the AU." In this case, can the IR bill for the GDA embolization since the AU is billing the Y-90? If so, would that be reported with code 37242?

Catheter Placements

If an angio is done during an intervention that is NOT a diagnostic study, would you code and bill the catheter placement? For example, embolization of a liver tumor. "The physician selectively catheterizes the cystic artery, right hepatic artery, and branch of right hepatic artery. Findings: Location of cystic artery confirmed, both the main right hepatic artery and branch of right hepatic artery were confirmed to supply the tumor. Intervention: The catheter was advanced into the right hepatic branch, and embolization was done." The codes I am using are 37243 and 36247. Would you also report code 36248 for the cystic artery cath placement?

Placement of a Loop Recorder (33282) and Fluoroscopic Guidance (76000)

Can you bill fluoroscopic guidance with the placement of a loop recorder for hospital based billing? I can't find anything that states you can't bill it, but yet I can't find anything that states that you can bill it.

Sheath Removal

My patient had a splenic embolization done, and the sheath was left in place for possible use in the following splenectomy. The following day the patient was brought back into IR for subsequent removal of the sheath. "DESCRIPTION OF PROCEDURE: The right groin was cleaned and prepped in the usual sterile fashion. Local anesthesia was then injected into the skin and subcutaneous tissues. An angiogram of the right common femoral artery was performed through the existing 5 French sheath. The 5 French vascular sheath was seen within the midportion of the right common femoral artery. The sheath was then removed, and hemostasis was achieved using 6 French Angio-Seal device. The patient tolerated the procedure without difficulty or immediate complications. IMPRESSION: Successful Angio-Seal device deployment in the right common femoral artery." How would you code the pro fee for this, if at all? I was considering reporting code 75710. Is there anything else you would suggest?

Performing More Procedures Than Initially Intended

Our physician performed a redo open thrombectomy, right limb of aorto-bi-femoral bypass graft. Then a stent placement, right limb of proximal aorto-bi-femoral bypass graft, followed by another stent. Those were successful. There was then brisk flow through the right limb of the graft. Because of the patient's small, poor outflow, it was felt best to perform a fem-pop bypass with vein, as the SFA was occluded. The physician wants to bill all services performed. Can we bill everything or just the bypass?

34812 with 34803

When billing code 34803, would I also report code 34812 if that is done? In our Encoder pro software it says that code 34812 is included in code 34803. "34803 - INCLUDES: Balloon angioplasty/stent deployment within the target treatment zone; introduction, manipulation, placement, and deployment of the device; open exposure of femoral or iliac artery/subsequent closure (34812)." Not sure if I should be billing code 34812 with a -59 (-XS) modifier or just not using it at all.

Dialysis Access

Can you please explain the difference between codes 36818, 36819, 36820, 36821, and 36825? Perhaps with examples of each? I've been reading through my new book, Dr. Z's Vascular & Endovascular Surgery Coding Reference, but I am still as confused as ever.

Modifier for Same Day Stent and Cardioversion

My cardiologist did a cardioversion and a stent on the same day. Do I use modifier -59 on both the stent and cardioversion since they are in the same CPT code set?

Echo Documentation

I would appreciate your guidance on documentation. It has been proposed that the CPT guidelines before a section are technical requirements that need to be performed, but are not necessary to be documented in the professional report unless they are “clinically relevant”. For instance, for a complete echocardiogram (93306), the guidelines state the structures that need to be evaluated or the reason that they can’t be visualized needs to be stated. If, for instance, the right atrium was not referenced in the report because it was not deemed to be clinically relevant, could a complete echocardiogram be billed if all of the other elements were on the professional report? In your opinion, have we met the requirements for documenting a full echo (without including all the elements in the professional report) because we have the supporting tape to show that the service was rendered completely? Secondly, would a statement indicating that “the structures were visualized” suffice? In other words, must it be an interpretation of what is seen?

Temporary Device Interrogation/Programming

A critically ill neonate with coarctation of the aorta with multiple ventricular septal defects s/p CoA repair, patch closures of membranous and mid-muscular VSD, and PAB placement, who is in complete heart block with temporary pacemaker. A plan is in place by a cardiothoracic surgeon to place permanent pacemaker when patient stabilizes. In the meantime, our EP doctors do temporary device interrogations. Can we bill for temporary device interrogations? If so what codes can we use?

ICD-9 Coding, Sick Sinus Syndrome

We have been audited by an insurance carrier and told we can not use the diagnosis of sick sinus syndrome if the patient has had a pacemaker placed and it is working properly. They have instructed us to only use the dx code for status post pacemaker placement. Do you agree with the above information? If not can you please provide me with sources that I can use to back up that information?

Follow-Up Angiogram with Aneurysm Clipping and Diagnostic

Our physician recently attended a conference where he was told that you can now bill all of the following: 4-vessel diagnostic angio done (36226-50 & 36224-50), emergent crani done for aneurysm clipping (61697), and follow-up angio done in internal carotid (36224) to make sure the clipping was complete. This is done all in one operative session. MUEs previously had 36224 as one, so we have only been billing code 36224-50 in these cases. But I see the MUE table for April 1, 2015 now is showing three per day for code 36224. (Looking at the January 1, 2015 MUE table on your site the MUE for code 36224 is still at 1.) So with that in mind, is it acceptable after April 1, 2015 to then bill codes 36226-50, 36224-50, 61697, and an additional 36224?

Conversion of Inferior Vena Cava Filter to Stent

I was wondering if you have ever seen this before? And what you would code to? An IVC filter, stent? "Utilizing the gooseneck snare and sheath, the hook of the filter was engaged with the snare. Gentle traction was then placed on the gooseneck snare and sheath to allow the hook to be disengaged from the filter and removed in its entirety under fluoroscopy onto the table. A fluoroscopic image was taken, demonstrating that the struts of the inner portion of the filter did not fully deploy. A 5 French Sos catheter was advanced over the wire into the inferior vena cava under fluoroscopy. Several passes were made with the catheter in order to remove any fibrous bands. Repeat images demonstrated that several of the struts were not fully deployed. Further maneuvers were performed with a Rim and Cobra catheter. Despite these additional maneuvers with these catheters, there were two struts that were not fully deployed. At this time, a balloon was used to assist deployment of the struts fully. Following the use of a balloon, the structures were fully deployed."

Lower extremity catheter placement and angiogram

"Right common femoral artery was accessed, and a 5 French sheath was placed. Omni flush catheter was advanced to the abdominal aorta using the support of a Glidewire. A flush catheter was placed in the abdominal aorta, and angiogram was performed. Next, the Glidewire was advanced to the common femoral artery on the left. Next, Omni flush catheter was exchanged for straight flush, which was advanced to the proximal left common iliac artery. Next, run-off was performed. Next, the catheter was removed and right groin sheath was used to perform right lower extremity angiogram." I reported codes 36245-LT, 75625, and 75716. Are those the correct codes for this scenario? Glidewire was up to left common femoral artery, but catheter was placed at left common iliac artery.

Mitral Valve Prosthesis Repair

Would code 33418 be appropriate for repair of regurgitation of an existing mitral valve prosthesis? The physician used an Amplatzer device.

Ultrasound for Inguinal Hernia

What is the best CPT code to use for an ultrasound of the abdomen/lower extremity for ingunal hernia? 76705 or 78881/78882?

Atherectomy of Left Arm

Could you please clarify the uses of code 0234T. The CPT description states "transluminal peripheral atherectomy". Since there is a separate code for the brachiocephalic trunk and branches (0237T) on the right side of the body, does this mean that code 0234T may be used for atherectomies in the left arm, as well as renal atherectomies?

Venography and PICC Line

Please let me know if I can code venography and PICC line together on this type of case. "Clinical History: Needs improved central venous access, poor peripheral access. A small amount of contrast was injected, confirming chronic occlusion of the right upper extremity central venous system. Therefore, right internal jugular central venous catheter placement was pursued. Access to the right internal jugular vein was gained by sonographically-guided puncture. A permanent sonographic image was obtained. The vein was confirmed to be patent. Under fluoroscopic guidance, a dual lumen peripherally-introduced central venous catheter was placed with the tip at the junction of the superior vena cava and right atrium at completion. A permanent radiographic image was obtained. Fluoroscopy time was 3.1 minutes. Successful placement of right internal jugular central venous catheter." Please let me know if I can report codes 75820 (not sure), 77001, 76937, and 36556 for this case.

Mofidifer for 93287

When a patient with a biventricular defibrillator comes in for an EPS study (93620, 93621, 93623), and his/her defibrillator is turned off before the EPS procedure, then turned back on and reprogrammed after the procedure, we have been placing a -59 modifier on the second instance of 93287. Will that still be the most specific/appropriate modifier in this scenario, or will modifier -XU or -XS be more appropriate?

19083-50, no longer

I took a webinar for the CIRCC exam by Dr. Z, and I think Dr. Z mentioned that we no longer would apply modifier -50 if -LT and -RT breast lesions are biopsied. Instead we would use add-on code. Could you let me know where I can find the AMA article about it. I was just reviewing 3M Encoder Pro, and they still recommend using modifier -50 for a bilateral procedure. Could you clarify?

62311 with CT Guidance

I know fluoroscopic guidance is included with code 62311, but our IR people almost always use CT guidance for this procedure. Would you use code 77012 with this procedure, or are all types of guidance included?

Modifier 52 on Nuclear Medicine Study

I have a question on using a -52 modifier. Patient comes in for a nuclear medicine stress test (78542). The rest portion is performed with images, and for various reasons the stress portion is not completed. Should this be reported with code 78452-52 or 78451 for what was actually performed? The interpreting physician does not want the code to be changed, but to code what was originally ordered. Documentation is there to describe that the test was not completed. I have some advice that says to code the original order with a -52 modifiier, with the example that the patient could not cooperate for the complete study. My thought is if there is a code for what was performed that is what should be coded. Any help would be appreciated.

Aspiration Thrombectomy of Lower Extremity

Can aspiration thrombectomy of the lower extremity be considered a mechanical thrombectomy and reported with codes 37184-37186? Or does an AngioJet need to be used to report for these codes? The patient had tPA for 18 hours (second and final day) and was brought back for a re-look. Infusion catheter was removed. The thrombus was still present in the popliteal artery. Aspiration thrombectomy was performed, still not sufficiently removing the thrombus. The physician then performed balloon angioplasty. I am thinking of reporting code 37214 for the final day of tPA infusion, code 37184 for a primary thrombectomy of the popliteal, and code 37224 for the PTA of the popliteal. Am I reporting the correct codes?

Post-op EKG

The patient had an external cardioversion for atrial fibrillation. Case end was called and patient was transferred to "holding". An EKG was performed at this point. Is this EKG (93005) considered included/during the procedure and not separately chargeable? Or is this chargeable, as it was performed after procedure ended and patient was transferred to a different area?

Inflow, Outflow Procedures

I would like to know if the physician does a fem-pop bypass with reversed transposed gsv, iliofemoral thromboendarterectomy, and profundoplasty, can I bill codes 35556, 35572, and 35355?

Foreign Body Retrieval

We have physicians who have been given the direction, by company reps, to use code 37197 when snaring a wire advanced from an access site in the foot and exteriorizing it though a sheath placed in the common femoral artery. Is that an appropriate use of code 37197? I code for the facility and have never reported code 37197 in that scenario. I don't believe it is an appropriate use for code 37197, and I am being questioned by the physicians. If you could clear that up for me, I sure would appreciate it!

Attempt Upgrade Single ICD to Biventricular ICD

Patient has single ICD at end-of-life and RV lead. Plan is to upgrade generator to biventricular ICD and place LV lead. Multiple attempts made to place LV lead are unsuccessful, so in the end only a single ICD is replaced. How would you code this scenario?

Onyx 34 (1cc)

Is there a HCPCS code specifically for Onyx/embospheres for the hospital charge related to embolization procedure for nosebleed?

CTO with Dual Injections

At our facility we have started a new CTO program. These cases are, as expected, more complex. The technique that has been adapted here is bilateral access with dual injections of both the LMCA and RCA to assess the collateral flow for a potential retrograde approach. The physician who has been doing these procedures feels that we should be able to charge something in addition to code 92943 or C9607. I have been expressing my disagreement with him. I feel that the CTO charge already encompasses the additional access and greater procedure involvement. Please advise.

Prior Duplex Sonography of graft prior to angiogram and intervention. Performs limited angio of tibal artery. Do you code for angio even thought is a limited area of study with prior knowledge of stenosis based on Duplex Sonography?

Indications: Significant stenosis of posterior tibial artery (by duplex sonography) Procedure Report: The skin overlying the graft was infiltrated with 1% Lidocaine without epinephrine, and the graft punctured with a micropuncture needle. An .035 glide wire was inserted into the graft and the needle exchanged for a 4F sheath. Multiple AP and oblique views of the distal femoral to posterior tibial artery, and tibial artery were obtained. A diffuse stenosis was seen distal to the graft. In fact, approximately 15 cm of vessel was very narrowed. A 014 Choice PT wire was passed across the anastomosis followed by a 2x120 Fox SV balloon. The vessel was angioplastied, stent placed. This case is a sample of a phyisian that uses Duplex sonography on graft patients in office then brings them in for an angiogram of the portion of interest. This is not a full extremity angio. Can you still code a diagnostic angio. Prior to intervention. We are reluctant due to the limited area being studied and prior duplex sonography. In this case we coded Stent placement.

93352 Stress Echo Billing

Are there any physician supervision requirements (direct vs. general) for billing the contrast code 93352 with a stress echo? Code Correct indicates that the physician gives the patient the contrast, but our locations have general supervision, and the tech usually gives the contrast.

96450, 62270

How do I code diagnostic lumbar puncture and intrachecal CNS chemotherapy injection - CSF removed?

EKG Rhythm Strips

My physician states "rhythm ECG monitoring with interpretation performed" within his OP note. He also states that "because of patient's medical status, EKG monitoring was used during this procedure." Ive been told during an audit of our OP notes that I can code for the EKG monitoring if a monitoring strip is saved in the patient's chart, but I thought EKG monitoring is now bundled with code 36147. Can you please let me know what your thoughts are on coding both codes 36147 and 93040?

TEE during LAA Ablation

Physician performed percutaneous left atrial appendage exclusion using epicardial and femoral access via the Lariat Suture delivery device (33999). A different physician performed a transesophageal echocardiogram, which demonstrated no evidence of a left atrial appendage thrombus. This physician performed TTE throughout the entire procedure. Is this TEE separately billable, or is it included in code 33999?

Possible ASD Closure

"TEE for possible ASD. Scheduled for possible ASD closure, however, unable to cross the defect using the Coournand catheter. Then RHC performed to measure right sided pressures, and we were able to wedge the catheter and obtain wedge pressure. Then pulmonary angiogram was performed for possible AVMS. ICE catheter also used. Also perfomed SVC, which showed no persistent left SVC." We coded 93451/93568/75827 and 93799 for ICE. Please advise. Thanks Follow-Up Inquiry: If it is ASD closure/diagnosis, then only RHC performed, do you suggest coding 93530 or 93451? According to the CPT Codebook for PFO use non-congenital heart caths? Sometimes they find ASD but not able to cross the defect and RHC/pulmonary angiogram/ICE/SVC performed. In both cases we charge 93799 for ICE, but not sure of 93530 versus 93451? Please advise.

Multiple Intracranial Aneurysm Embolizations

I've got a case in which the patient has multiple intracranial aneurysms: aneurysm in the distal left vertebral artery, a separate aneurysm in the mid basilar artery, as well as a separate aneurysm in the distal basilar artery. This totals three separate aneurysms. The physician performs coiling of each of these aneurysms. Would it be permissable to report code 61624 for each of embolizations of the prior addressed aneurysms? In your 2014 Vascular & Endovascular Surgery Coding Reference on page 259, it's indicated that intracranial aneurysm are coded per surgical field. Three surgical fields: right and left cerebral hemishperes and cerebellum. It's instruced to code per surgical field. However, in the CPT Assistant November 2006, Volume 16, Issue 11, it states (when reference 61624): "This code can be reported more than once for additional aneurysm treated at the same setting." Basically, I'm wanting your thoughts on this situation and to query where the information on page 259 of the ZHealth Publishing Vascular & Endovascular Surgery Coding Reference was obtained.

TEE during TAVR

Can we code a TEE during TAVR? Your 2015 Diagnostic & Interventional Cardiovascular Coding Reference, page 146, #3, says do code for TEE if utilized during percutaneous valve replacement; however, your online member newsletter dated December 17, 2014 states under Chapter 5 that "TEE is also NOT separately reportable with TAVR". Which is correct?

Pulmonary Angiograms

Can you elaborate on what constitutes a "basic" exam of the pulmonary arteries? Can a basic exam be performed non-selectively at the main artery (75746) first, and then performed selectively? Would you still then report code 75746 (non-selective artery from the main pulmonary) if a selective placement of one or more of the other pulmonary arteries are selected? Or is the non-selective artery bundled once a selective arteriogram is done? For example, say a non-selective was done at the main, and then just one side is done selectively at the left pulmonary artery. Could you give some examples? I'm looking in your book, and I'm not quite understanding the scenario of what constitutes a basic exam. Your book says the basic exam is a "bilateral pulmonary angiogram", but the vessels can be viewed selectively and non-selectively, so I guess that's what is tripping me up.

Vascular Technician Question

If we do a right or left ax-bi-femoral bypass graft surveillance, which code is appropriate, 93931 or 93926? Or is it appropriate to use both?

Relocation of ICD gen, with RV, RA replacement and addition of LV lead

Patient had existing dual AICD on left side with erosion. Generator was moved to right side; RV and RA leads were replaced, and a new LV lead was inserted to existing generator. I'm coming up with codes 33244, 33217, 33223, and 33224, but I'm getting an edit on 33223. Is this the correct code assignment for this scenario? Should we not report code 33223?

Multiple Angiograms

Please help me code the following: "Reason - asymmetric arm blood pressures, abnormal stress test, leg pain, abnormal lower ext arterial Doppler. Performed: Left heart cath coronary angio selective right brachiocephalic angiogram selective left subclavian angiogram infrarenal and aortoiliac angiogram with runoff selective right external iliac angiogram selective left external iliac angiogram unsuccessful pci attempted of occluded left common iliac Accessed both left and right groins, due to left iliac total occlusion. Results: Patent subclavian and brachiocephalic Distal aortoiliac disease." Please help me code the above procedures and include what dx code could be used for the asymmetric arm blood pressures.

Fiducial Marker Placement in Liver

Prior to TIPS, a fiducial marker is placed into the liver. "Under real-time CT fluoroscopic guidance, a 3 cm x 3 mm coil was placed to mark the portal vein bifurcation. FINDINGS: Archived images demonstrate excellent positioning of the fiducial marker at the portal vein bifurcation. IMPRESSION: Successful marker placement." Following, TIPS was attempted. "Access the right internal jugular vein using US guidance. A multipurpose angiographic catheter was used to select right hepatic vein, accessory right hepatic vein, and left hepatic vein. Hepatic venography was performed in each vessel. I tried several times to pass a working sheath into the occluded left hepatic system, and was unsuccessful each time. Due to hepatic venoocclusive disease, no invasive pressure measurements were obtained. IMPRESSION: Hepatic venoocclusive disease." I am unsure of how to code the coil. It's not being used for radiation, so I don't believe code 49411 is correct. It is not an embolization either. Also, would the hepatic venography be reported with codes 75891 and 36011 x 2?

75625 vs. 75630

I have a question. My physician parks the catheter in the distal aorta and does an aortogram of the distal aorta and bilateral iliacs. He then moves the catheter to the contralateral limb and does another angiogram followed by an intervention. Can I bill code 75625 and the intervention?

S&I Billing with Surgical Level

If a surgical level is billed for angioplasty (35476), should the supervision and interpretation be billed separately (75978)?

CoolGuard Cooling Catheter

I'm not sure how to code this procedure. "The patient who suffered an out of hospital cardiac arrest came into the ER. Patient previously had a PFO closure and a history of LBBB. A left heart catheterization and coronary angiogram were performed and were completely normal. At the intensivist request, a Cool Guard Cooling catheter was placed via the right femoral vein." I am not really sure how I would bill for the cooling catheter. 37799 maybe? I was wondering if you could give me some input on which code should be used.

IVUS with Bundled Cath Codes

Caths are bundled into lower extremity revascularization codes, renal imaging, carotids, etc...and my physicians only document caths in the aorta during AAA endografts (so non-selective codes). Most of my insurance companies will not pay for IVUS because in the CPT Codebook, it states..."(For Catheterizations, see 36215-36248) and (For transcatheter therapies, see 37200, 37202, 37236-37239, 37241-37244, 61624, 61626)"... It does not list renals, carotids, AAA repairs, or lower extremity interventions. Is there any kind of documentation anywhere I can use to appeal these? They deny on the basis that no primary codes were on claim. When I speak to insurance companies they tell me they have to have one of the selective codes on the claim to be considered. The cath is bundled, so I can't bill for it.  Thoughts?

37242 and 93568

We are in disagreement with the pulmonary angiogram codes and the number of coil closures that can be billed for this case. The procedures were right and retro left heart cath for CHD, selective right and left pulmonary angiograms, and multiple subsegmental pulmonary angiograms. The embolizations performed were: 1) Inferior lateral basilar right lower pulmonary artery, 2) posterior segmental lateral basilar right lower pulmonary artery, 3) posterior-superior subsegmental accessory right upper pulmonary artery, 4) antero-inferior subsegmental accessory right upper pulmonary artery, 5) apical segmental right upper pulmonary artery, 6) medial and lateral subsegmental anterior right upper pulmonary arteries. Code suggestions have been: 93531, 93568, 37242 x 2 (right upper and right lower as two separate surgical fields) 93531, 93568 multiple times for the pulmonary and subsegmental angiograms, and 37242 x 6 93531, 93463, 93568, 36015/75741 multiple times for the subsegmental pulmonary angiograms, and 37242 x 6

Tetralogy of Fallot

A right and left heart cath with cors was done for this patient with an unrepaired tetralogy of Fallot along with left and right ventricular angiography. I'm not familiar with congenital cath coding. Would this be reported with codes 93531, 93563, 93565, and 93566?

75625 vs. 93567

Below is a portion of dictation from a cardiac catheterization; just the portion related to the aortogram is included; a full catheterization and coronary angiogram were performed. Can you please help settle a dispute between the cath lab and the coders? Would the correct code for the aortogram be 75625 or 93567? "PROCEDURE LIST: 1) Left heart catheterization. 2) Coronary angiogram. 3) Left ventriculogram. 4) Abdominal aortic angiogram with flow through angiogram of both renal arteries and right iliofemoral artery. TECHNIQUE OF PROCEDURE: The catheter was then pulled to the abdominal aorta. Abdominal aortic angiogram with flow through angiogram of the right iliofemoral artery and both renal arteries was performed. ANALYSIS OF DATA: 1) No abdominal aortic aneurysm is noted. 2) No renovascular stenosis is noted. 3) The right common iliac artery has no significant stenosis."

Peripheral Angiography

I would like some coding advice on coding the aortic root aortogram and peripheral angiography in the following example. "PROCEDURES: Coronary angiography, right heart cath, aortic root aortogram, peripheral angiography. PERIPHERAL ANGIOGRAPHY: Peripheral angiography of the renals was done. Abdominal aortogram: Technique - RBA access, DSA, with pigtail in abdominal aorta. Findings: Right and left renal arteries are patent; severe calcification of aortic bifurcation; right common iliac moderate focal stenosis; right external iliac moderate diffuse narrowing; right common and external iliac linear defect; right internal iliac is patent; left common iliac mild stenosis; left external iliac occlusion; left internal iliac is patent. AORTIC ROOT AORTOGRAM: A selective aortogram was performed. The size of the ascending aorta is in the upper limits of normal. Maximum aortic diameter: 3 cm. There is no aortic valve regurgitation."

36227 without 36222, 36223, or 36224

Our physician states he selectively catheterized the left subclavian artery and then advanced into the left vertebral artery where an angiogram was done. We want to report code 36227, but he did not state that an angiogram was done in a previous artery. In order to bill code 36227 you need to have either 36222, 36223, or 36224. What do we bill without angiograms being done in these areas?

Right Iliac Intervention

I have a question on coding the interventions for the following example. Would this all be captured with codes 37221 and 37223? "Right CFA accessed. Contrast injection revealed high-grade stenosis of the right common and external iliac arteries. The stenosis was secondary to eccentric 90% plaque. Decision was made to intervene with right-sided stent placements. The right iliac system was stented from just below the bifurcation down to the inquinal ligament. A series of Nitinol stents were placed. Upon placement of the last stent, patient began to bleed profusely. Pressure was applied. A second puncture was made in the lower right common femoral artery and a sheath placed. A Viabahn graft was placed to line the entire bare metal stents. Final angiogram showed excellent flow and palpable pulses in both feet."

Reocclusion to RCA Stent, Same Date of Service

Patient had drug-eluting stent to RCA and then was taken back to cath lab on same day because of re-occlusion to RCA stent. Patient had second procedure with more drug-eluting stent to RCA. Can we bill C9600 x2?

New CPT Code for TEE

Do you have any guidance for using new TEE code 93355 with the TAVR procedures? If I am understanding the code correctly it is for use with these procedures, but when I run through the coding edit it appears to bundle under NCCI.

Pharmacologic Challenge with Esophageal EP Procedure

At our children’s hospital we have a procedure where they did an esophageal recording/pacing (93616) along with a programmed stimulation and pacing after drug infusion (isoproterenol or epinephrine). Normally for EP procedures we charge for the drug stimulation/pacing (93623), but code 93616 is not a parent code to 93626. We do this to determine if they need a full invasive EP procedure or if continuation of antiarrhythmic medication is still needed until they are large enough (weight or age depending on the child’s size) to have the EP procedure. What would you suggest to code in addition to 93616? Is there an appropriate code to charge for the pharmacologic portion of these procedures?

76380 with TACE

My IR group wants to bill for the CT acquisition along with 3D reconstruction code 76377 when performing TACE or Y-90 procedures. I can't locate any documentation to state they can or cannot do this. The physicians are telling me permanent CT images are being obtained by this machine and stored in the patient's chart. If they can code for this in addition to the TACE or Y-90 procedures, what additional documentation should they include in their reports?

Non-Selective Codes for Diagnostic Angio and Embolization

If non-selective catheter placements (36200 and 36005) are done to perform diagnostic angiography, and then the decision is made to perform embolization, would the non-selective catheter placements be coded in that situation or not? I understand only selective catheter placements would be coded with the embolization typically, but I wasn't sure if needing diagnostic angio first would make a difference.

US Guided Venoplasty of Shunt

How would you code catheter placement in a dialysis fistula, when doing venous angioplasty, if the patient only had ultrasound-guided PTA, without injection of contrast? At your conference, I thought I heard you state that code 36147 requires contrast injection. Code 36005 is for venography, and code 36010 does not work (neither does 36011). Am I limited to unlisted code 37799?

Ascites Needle Confirmation with Injection for Nuclear Study

I have a dictation under the heading "Paracentesis with Imaging Guidance", and the hospital has billed for a paracentesis with imaging guidance. I am billing for the provider, and I am not so certain that this should be coded as a paracentesis. My concern is that report states this: "The most accessible fluid pocket in the right lower quadrant was localized under ultrasound guidance, and the overlying skin was marked. The patient was prepped and draped in the standard sterile fashion. Approximately 5 mL of 1% lidocaine was injected into the skin and subcutaneous tissue for local anesthesia. With the patient supine, a micropuncture needle was used to access the identified pocket of fluid. Approximately 2 mL of serous fluid was aspirated to confirm placement. 4 mCi of technetium-99m MMA was injected into the ascites fluid." Can you please give some input for this?

FFR without Pharmacologic Agent (IFR)

IFR is now being performed regularly in the cath lab. The difference between it and FFR is that there is no pharmacological agent being given (adenosine). As the CPT for FFR (93571) specifically states “including pharmacologically induced stress”, is there another code that can be used for IFR, or can it perhaps be modified? It is performed using the exact same wire and control module. Any suggestions?

Lower Extremity Dialysis Graft

For purposes of coding, can we retain both codes 36147 and 36148 when arterial anastomosis is angioplastied, or are we required to drop the catheter (either 36148 if two cannulations, or 36147 and gain 75791) since a lower extremity intervention is being performed?

Bypass to a Fistula

Left upper extremity bypass with reverse great saphenous vein from the radial artery to the proximal brachiocephalic arteriovenous fistula with ligation of arteriovenous fistula at the level of the arteriovenous anastomosis. What are all codes associated with this procedure?

AV Node Ablation After PVI and Others

We have a case wherein the doctor started with a PVI ablation (93656), did an additional (93657), and an SVT additional (93655). Along with these ablations, mapping (93613), LV pacing (93622), ICE (93662), and ICD reprogramming (93287) were performed. At the end the doctor did an AV node ablation (93650). Our question is what can be charged here? The AV node ablation edits to most everything.

61624 for AVM Treatment

"A surgeon performed an embolization to a large middle cerebral artery arteriovenous malformation by accessing the left internal carotid artery and infusing DMSO and ONYX 18 into the nidus feeder, which was coming off of the MCA branch. The surgeon then accessed the right internal jugular vein and placed 6 coils into the distal segment of the draining vein." Since the AVM was accessed by two separate points, one venous and one arterial, can we code for both? Or is it still considered one code because the AVM is consider one surgical field? Also, if one AVM is accessed and treated by two different arterial access points, would we be able to code for both? Or is this only one code based on the surgical treatment field?

CPT 93463

"Left heart catheterization with intraprocedural Nitroglycerin administration with hemodynamic monitoring. A 6 French JL4 catheter was advanced into the ascending aorta. Aortic blood pressure was measured. It was markedly elevated at 220/110. The patient was administered 0.4 mg sublingual Nitro. Hemodynamic monitoring was performed. Repeat blood pressure was obtained a few minutes after Nitro administration, and blood pressure had dropped to 160/100." Can code 93463 be billed for this part of the heart cath procedure? My physician needs clarification regarding the criteria for use of this CPT code.

Modifier -26 and -52

This is a two part question, but involving the same situation. Part 1: If two radiologists from the same practice each perform one element of an S&I code (Dr. A performs the supervision; later Dr. B performs the interpretation), would the modifier -52 rule apply? I interpret CMS Pub. 100-04 Chapter 13 Section 80 to indicate that the separation of the two components can be billed separately with modifier -52 when two practices/specialties are involved; not physicians from the same group. Is this correct? Part 2: In either case, is the -26 modifier appropriate? If the radiologist performs BOTH the supervision and the interpretation, is the -26 modifier necessary (i.e., cholangiogram performed in a hospital setting where the radiologists are employed by another entity, not the hospital)? Your guidance is much appreciated. I have searched all regulatory guidelines and reliable sources I can find, but have found no direct answer to my question thus far.

ICE Catheter

I am at a loss as to what code to use for the procedure listed below. It appears that an ICE procedure was performed, but code 93662 is an add-on code, and no other procedure was performed. "Procedure: Time-out was observed with full agreement of all participants. Thereafter, an intracardiac echocardiographic (ICE) catheter was placed from the right femoral vein to the right atrium. A full scope of the right heart chambers was visualized from where the leads entered the atrium from superior vena cava to their termini. No vegetations were observed on leads or adjacent structures. The ICE catheter was removed, and the sheath secured in place pending subsequent percutaneous pacing system extraction. Summary: Clean pacing leads without large vegetation; she is suitable for an attempt at percutaneous lead extraction."

Intravascular Fractional Reserve

Can you please tell me what the difference is between an iFR and an FFR done during a heart cath? And is the same code 93571 utilized when billing either procedure?

US Guidance to Avoid Liver During G-tube Placement

Our IR department is routinely charging a limited ultrasound (76705) to "identify the margins of the liver" when placing gastrostomy and GJ tubes. Is this appropriate, or do you think that would be considered part of the procedure?

CT Guided Breast Clip Placement.

We are reporting CT-guided breast clip placement with an unlisted code. Do you agree, and what is the reasoning behind not setting up a CT-guided code in the 19281-19288 code range? Was it lack of use? No one covers this in their references.

Micropuncture Technique

Can code 34812 be billed when micropuncture technique is used to access the common femoral artery?

Uterine Artery Embolization

If embolization was performed on the right and left uterine arteries, only one embolization can be billed, correct?

Abdominal Fluid Drainage

If my understanding is correct, for abdominal drainage, when a catheter is not placed for continuous drainage, we are to use code 10160 instead of 49406. My question is, if the previous sentence is correct, why can we not use code 49083 instead? Does it depend on what is being drained? Peritoneal abscess drainage would be reported with code 10160, but peritoneal fluid would be reported with code 49083 if catheter was not left in for continuous drainage? If so, if a patient has a fluid collection that requires continuous drainage, but the fluid is NOT specified to be an abscess, hematoma, seroma, lymphocele, or cyst, do we still use code 49406?

Coil Embolization of Leaking Biliary Tract

Would we report codes 20500 and 76080-26 for the following example? "Int/ext drain recently removed, patient continues to leak previous contents from the previous catheter exit site. RT flank prepped , 5 French kumpe cath is advanced along the tract and contrast is injected, delineating the tract and the peripheral biliary ducts, The cath is then associated to the central of the tract and 8, 5mm coils were deployed wthin the tract centrally. small amount of contrast is then injected again and continue to flow through the coil pack. Because of this, approx. 0.5 ml of onyx 34 was slowly injected into the tract, with careful monitoring to make sure it was retained within the coil pack. contrast injection at the conclusion of this failed to demonstrate any ongoing communication with the biliary system. skin site was approximated with dermabond."

IFR

What CPT code should we be using for iFR done in the coronaries versus FFR?

Left Brachial Artery Selection

I am about to take the CIRCC exam, and I hope you can clear up a discrepancy between your Interventional Radiology Coding Reference, 2015 edition, and the ZHealth anatomical charts. On page 142 of the reference book, #12 states "AMA appendix L considers the entire left brachial artery as second order selective (36216), with the ulnar, radial, and interosseus as third order vessels." This information conflicts with the upper extremity chart on page 671, and also with your 'exam ready' chart, that shows the left brachial as a third order artery (36217). So, I need to know if the left brachial should be coded as second or third order. Also, both charts show an unnamed short section of second order artery in the region of the subscapular and circumflex humeral arteries. If that short section is truly the only second order portion of the left arm, could you please tell me the name of it so that I can recognize it when coding from reports?

Discharge Summaries

I work for a group of cardiologists, and sometimes the doctors will perform a cath on patients and discharge them the next day. They bill for a discharge but do not dictate a note. They say that for such a short stay, there does not need to be a dictated note; the progress note serves as the discharge note. Usually, "discharge note" is written on the handwritten progress note somewhere. I was always under the assumption that there should be a dictated note for discharges regardless of the length of stay, and I can't find any information to confirm this. Can I bill a discharge and submit the handwritten progress note if requested by the carrier, or should I be changing these discharges to a subsequent visit unless there is a dictated discharge note? These patients are usually in outpatient observation or extended outpatient surgery.

Modifier 62 with 33249

Dr. A performed device pocket creation, tunneling of LV epicardial lead to surgical pocket, vascular access. Dr. B performed positioning of RA and RV leads and DFT. The operative note states that Dr. A secured both leads to deep muscular plane of the pocket. Dr. B wants to report codes 33249-62 and 93641-26. Dr. A wants to report code 33249-62 as well, along with 33225.  Please advise.

Modifier 25 and ECG

Is modifier 25 required to be appended to an E/M code in POS11 (office)? Code 93000 has an XXX global and is a diagnostic procedure, not therapeutic. Medicare requires that modifier 25 always be appended to the emergency department E&M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). Per NCCI: "With most “XXX” procedures, the physician may perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure is correct coding."

Using 75726 and 75774 for a Y90 or Sir Spheres

My physicians would like me to explain why they can't use 75726 and 75774 during a Y90 or Sir Sphere injection, when they have done the mapping the day before and the diagnostic angiogram was done then?

Fluoroscopy guidance with CPT 62311

I code cases for a hospital, and we are needing clarification regarding epidural steroid injections. Your 2015 Interventional Radiology Coding Reference, page 511, #1, states, "Per CMS, do not use code 77003 with codes 62310-62319." What is the specific CMS guideline/regulation stating not to report code 77003 with 62310-62311?

RVAD with Impella RP

Our cath lab is going to start placing RVADs with an Impella RPs. The vendor's description of the procedure matches the lay description for 33990 very closely; the main difference is right versus left. I want to validate with you that code 33990 would be appropriate, or if we should use unlisted code 33999 for these procedures. What are your thoughts?

Pacemaker Pocket Revision vs. Unlisted Cardiology Procedure

I'm unsure whether to report unlisted cardiology procedure code 33999, skin tissue procedure code 17999, or pocket revision (as the doc is calling it) code 33222. He did remove the generator, place an antibiotic sleeve on it, and place it back into the pocket. "Procedure: Patient came into the pacemaker clinic with some drainage from her previously placed ICD site. After local anesthesia, the pocket was opened. The pocket was lavaged. There was no active bleeding. There was no obvious purulence. Cultures have been obtained in the clinic and were not done during this setting. The pacemaker was placed into an antibiotic sleeve and placed back into the pocket which was closed in layers. Sterile dressing was applied. Conclusions: ICD pocket revision for draining hematoma."

Medial Compartment Fasciotomy

"Injury to popliteal artery post knee arthroplasty surgery. Patient returned to operating room for femoral-tibioperoneal trunk bypass (beyond the take-off of the anterior tibial). At completion of the bypass, through the medial incision, a fasciotomy was completed of the medial compartment down to the level of the ankle; wounds are closed in layers." I’m thinking of reporting code 35666 since below the take-off of the anterior tibial, as well as 27601 for the fasciotomy. I'm not finding anything specific to just medial compartment. Thoughts?

Transposition Fistula vs. Direct Fistula

Can you code a cephalic vein transposition if the documentation doesn't specifically state that a tunnel was created or that two incisions were created? Documentation states, "The cephalic vein was identified and mobilized with ligation of collateral vessels. It was then "swung over" to the brachial artery and anastomosed end to side." I am debating between codes 36818 and 36821 when the documentation does not specifically state that "tunneling was performed". If the vein is anatomically superficial and did not require a tunnel could this still be a transposition?

Patch Angioplasty of a Vein Fem-Pop Bypass

We performed a patch angioplasty of the proximal portion of the left fem-pop vein bypass graft with a Vascu-Guard patch. We wanted to use code 35883, which fits; however, that code is for a synthetic arterial bypass graft and we are revising the femoral anastomosis of a vein graft. What code would you use for this scenario?

Alcohol Ablation for VT

"Patient continues to have episodes of VT storm resulting in multiple ICD therapies, and he is therefore now being referred for selective septal coronary alcohol ablation during which EP testing and RV stimulation protocol along with 3D mapping and ICE are being utilized. Conclusion: Successful alcohol ablation of basal septal branch for the treatment of medically refractory and catheter ablation refractory septal VT."  (A heart catheterization was also done.) I don't think I can use code 93583, as the patient does not have HOCM. How do I code this? Unlisted? And are all the add-ons a loss?

Redo Valve

When using code 33530, should both approaches be sternotomies? Meaning, if the first CABG or valve procedure was performed via sternotomy approach and a year later the redo CABG or valve was performed via port access or thoracotomy, may I bill code 33530? I think code 33530 is for sternotomies only, but I need your advice.

Right Common Carotid to Right Axillary Artery Bypass with PTFE Graft

Please help with the following case: "Patient had right subclavian artery occlusion. Upon incision and exposure of the distal common carotid artery, it was found to be amenable for use as an inflow vessel for a bypass. Then the axillary artery was exposed and good for use as target vessel. A tunnel was created between the common carotid and infraclavicular incision to allow for passage of the bypass graft. A plane was created underneath the clavicle connecting the two incisions, and an 8 mm ring PTFE graft was selected for the conduit. The conduit was passed through the tunnel, and the PTFE graft was passed through the tunnel. Arteriotomy was created over the common carotid artery and anastomosis created in an end-to-side fashion. Flow was restored through the graft to the right carotid artery. Arteriotomy was then created over the axillary artery. The vascular graft was then cut for a wide spatulated anastomosis. The anastomosis was then created in an end-to-side fashion between the graft and the axillary artery. A strong brachial artery was noted upon completion of the bypass."

Repositioning of PPM/ICD Lead vs. ICD Lead Removal and PPM/ICD Lead Insertion

I have a physician who extracted both the atrial and ventricular leads of an ICD. The physician thinks he should report codes 33217 and 33244. I feel it should be reported with code 33215 x 2 (repositioning PPM/ICD lead). What are your thoughts? "Indication: Mechanical complication. The ICD was placed several weeks ago. He then accessed the axillary vein (x2) and used the same leads placing them in different positions, the right atrial appendage and right ventricular apical septum."

Pre-Procedure SIRTeX GDA Embolization with Angiograms

We routinely perform pre-procedure embolization and roadmapping prior to the SIRTeX procedure. The GDA is embolized using CPT 37242. Can we bill the pre-procedure roadmapping for the SIRTeX at the same time as the GDA embolization? From report: "IMPRESSION: Arterial mapping and coil embolization as described above for preprocedure SIRTeX SIR-Spheres selective internal radiation therapy (SIRT)."

Popliteal to Popliteal Bypass

"Right saphenous vein harvested for use in both legs. Right: The popliteal space was opened below the knee. I could see the area of obvious contusion at the proximal aspect of the popliteal below the knee. The thigh incision above the knee was then deepened into the popliteal space. Popliteal artery was identified. A tunnel was bluntly created between these two. Vein was brought onto the field reversed and marked oriented. It was spatulated and anastomosed end-to-end to the popliteal artery. Vein was then passed back into popliteal space. The vein was trimmed at the proper length and an end-to-side anastomosis was created. Left: The incision was made below the knee. I was able to identify the tibial/peroneal trunk. A longitudinal incision was made above the knee overlying the popliteal space. Vein was then anastomosed end-to-side to tibial/peroneal trunk and then run subcutaneous around knee to popliteal space. Anastomosed end-to-side to popliteal artery above knee." I'm not sure how to code: unlisted, fem-pop bypass, or popliteal-distal vessel bypass?

Joint Injections

It is our understanding that we can report code 77002 (all anatomic areas except spine) or 77003 (spinal anatomy) for fluoroscopic guidance with codes 20600, 20605, and 20610. Is this applicable to all insurance carriers, including Medicare? Or would Medicare be excluded from this guidance?

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