Knowledge Base

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Set Descending Direction

Explanation of Dual Chamber Pacemaker and Implant of Single Chamber Pacemaker with Issues

"An incision was made paralleling the old scar, and the pacemaker was isolated. The pacemaker was explanted, and multiple attempts with multiple screwdrivers were made to detach the atrial and ventricular leads. The screws were stripped, and the patient is pacemaker-dependent. Attempts were made to access the left subclavian vein, but the lead would not pass at the junction of the subclavian vein and superior vena cava due to an occluded vein. The pacemaker was placed back in the pocket temporarily. A new pacemaker pocket was created on the right side. The pacemaker was implanted, and the ventricular lead was advanced to the level of the right ventricular and sutured in place. The atrial port was plugged. Attention was turned back to the left side. The leads were removed by pulling the leads apart from the headers, and the leads were capped. The pacemaker was explanted, and the pocket was irrigated." Would I bill code 33228 or 33227 since the final result was a single lead system as well as code 33222 for a pocket revision?

Exploration of vessel

Hi Dr. Zielske and Dr. Dunn, I need some assistance with coding a femoral vein venotomy and foreign body removal. This is a condensed portion of the procedure: During an IVUS procedure of the IVC and lower extremity veins stenosis was found in the left common iliac vein. Angioplasty was done on this vein. Balloon ruptured and upon removal the balloon remained in the left common femoral vein and became detached from the catheter. An incision was made over the left groin and a left femoral vein exploration was carried out. The femoral vein was identified and a venotomy performed. The ruptured balloon was then extracted under direct vision from the left femoral vein and the venotomy was repaired with 4-0 Prolene until hemostasis was achieved. I have searched my CPT book and have come up with 35226 for repair of a blood vessel or 37799 for an unlisted vascular procedure. Is there a better way to code this? As always, thanks for your assistance. Pam Johnson

Exposed Opthalmic Catheterization

I need advice with the following case please. "Intra-op direct exposure of superior opthalmic vein with angiocath access was secured. Patient then brought to IR department for embolization of carotid-cavernous fistula. In IR, angiocath sticking out of opthalmic vein accessed with microcath and moved to cavernous sinus with coil placement. After embolization, patient went back to operating room for decannulation and ligation of opthalmic vein."  Would you do anything for the catheterization into cavernous sinus from superior opthalmic (36211)? Unlisted (36299)? Or just stick with embolization codes and follow-up angio from RCCA? There is no mention of imaging findings through opthalmic vein, just advancement of microcath and coil embolization into cavernous sinus.

Expression of blood post plebectomy

If a patient comes in to have a varicose vein procedure (phlebectomy 37766/endovenous ablation 36478) and they’re within the global period of having the same procedure done on the opposite leg, and during this visit the physician nicks and expresses old blood from the previous wounds, would 10140-79 be appropriate for that?  I put a -58 on the 37766/36478.  Or wouldn’t the 10140 be billable? Thanks!

Extension vs. Stent placement

If a physican places a stent at the time of an AAA graft, but he specifically states it is for stenosis, do you use code 37221 or 34825? It is placed inside the distal portion of the graft down to the external iliac stent that was placed at a previous session.

Extensions, 34825

I have another question for you this morning...if extension pieces are placed after an endograft and two pieces are placed in the same vessel...one overlapping the other to make it longer, would you consider that one 34825? I didn't think 34826 would be appropriate since it was within the same vessel...It was mentioned that 34825 x2?? your thoughts? thanks!

External Biliary Drain Replacement

Patient presented to the ER after biliary drain fell out. Initially the tract was recanalized with a Kumpe catheter and a Benston wire. Following a diagnostic study, the tract was dilated, and a new 8.5 Dawson Mueller external biliary drain was replaced. Can we report this with codes 47500/74320 and 47510/75980?  Or report this as a replacement with code 47525? If we code this as a replacement, how do we capture the diagnostic study?

External Iliac Angioplasty Performed to Stop Bleeding, NOT for Stenosis

One of our cardiologists was assisting another surgeon, and our cardiologist performed an angioplasty in the external iliac to stop bleeding below the iliac so the surgeon could perform repairs. Since the angioplasty was done for bleeding and not disease, I don't think code 37220 would apply. I'm thinking of using code 37799 (unlisted procedure, vascular surgery), but I would appreciate your opinion on this one.

External Marking Scans Pre-Biopsy Procedure

In your Diagnostic Radiology Coding Reference book, page 212, item 10, it states it is appropriate to report code 76645 when ultrasound is used to externally mark the breast for subsequent biopsy or aspiration. Does this concept apply to all biopsy/aspiration procedures (e.g., thyroid biopsy)? If yes, do we need to append a -52 modifier to the limited scan CPT since it is not a complete scan?

Externalization of Generator

We have a patient with an infected pocket. The doctor removed the generator, taped it to the patient's body, and cleaned out the pocket. The patient returns to the EP lab five days later for new leads and a new generator. When the doctor removed and externalized the generator, can we bill code 33241?

Externalized Pacemaker Insertion

We had a patient who needed a pacemaker in place for anticipated surgery, but could not have a permanent pacemaker due to infection. So a permanent lead was placed in the right ventricle through the jugular vein and attached to a new single chamber permanent pacemaker externalized. What can I charge in this case?

Extremity angiograms

A patient comes in on day one and has an aortogram and right lower extremity angiogram. Doctor starts TPA infusion in SFA, then later in the day does a follow-up. Day two, he does a follow-up and left lower extremity angiogram. My codes are 37201, 75896-59, 36247-RT, 75625, 75710-RT and 75898 for day one. Day two 75898 and 75710-LT. Should I code for two separate lower extremity angiograms or combine them using 75716 since it was a continuing procedure. Thanks, Cynthia Boyer

Extremity angiography before transfemoral heart valve implant (TAVR)

This may be the second time I'm sending this, I can't tell if the first one went through.... Hello Dr. Z and Associates, Our physicians have started performing peripheral angios and IVUS to evaluate lower extremity peripheral arteries for possible transfemoral heart valve implant (0256T). This is normally done a few days before scheduled valve implant. Would this meet medical necessity requirements for 75716 and/or 75945/75946? Thank you!

Extremity Bypass Graft

I have never coded a procedure like this, so I would love your assistance. The surgeon did a right fem bypass graft to the left iliac artery. He then attached the iliac artery on the left to the previous fem/pop bypass graft on the left. Then from the pop bypass graft he did a graft to the tibial artery. Would you use code 35665 ileofemoral and then 35671 popliteal-tibial? The right femoral to left iliac has got me stumped.

Extremity Distal Bypass Graft

Is it okay to use code 35571 for distal bypass graft to dorsalis pedis artery using cryopreserved saphenous vein? Or should we use code 35671?

Facet and Nerve Root Injection at Same Time

Our physicians state they are performing a facet joint injection and a nerve root block. If both of these procedures were performed at the same session, are we allowed to report both codes 64483 and 64493-50? "Utilizing sterile technique, fluoroscopic guidance, and local anesthetic, 22 gauge spinal needles were advanced into the bilateralL4-L5 facet joints. After injection of dilute contrast into the joints, confirming the needle position, 1 ml mixture of 0.25% bupivacaine and 20 mg of Kenalog were injected into each joint space. Utilizing sterile technique, fluoroscopic guidance, and local anesthesia, a 22 gauge spinal needle was advanced into the perineural space of the left L4 nerve root. After injection of dilute contrast into the perineural space, confirming needle position, 1 ml mixture of 0.25 bupivacaine and 20 mg of Kenalog was injected."

Facet Cyst

The radiologist injected bivicaine into the L4-5 & L5-S1 facet joints bilaterally. He also aspirated synovial fluid from the right L5-S1 facet joint. How would you code the aspiration?

Facet Injections, Determining Number of Facets Injected

Can you clarify something for me? This relates to question 5222 where you said if injections were done of the L2, L3, and L3 facets that you would only code two injections (L2-3 and L3-4). If my physician dictates that he did facet injections of the L2-3, L3-4, and L4-5, would you then code three injections because he is giving the levels?

Facial sclerotherapy

Hello Dr. Z A percutaneous neuro sclerotherapy was done on facial venolyphatic malformations. The ethanolamine was injected through a direct puncture 22 gauge butterfly needle of the mandible lesion with live fluoro Should the 37799 or 36470 code be uses along with the 77002 for needle placement guidence?

Failed Attempt for LHC

Would you report the following example with code 36140? "Access from the right groin with multiple attempts and radiological guidance was unsuccessful, and the left side was also unsuccessful. The patient is extremely corpulent, and access was not possible. The patient had the radial artery used during surgery, so we are going to need to go from the left arm brachial or radial in order to access her arteries, and this will be rescheduled."

Failed Attempts for Central Venous Cath

Can you charge all attempts for a central venous cath? There were multiple sites tried and all failed. I know I can only charge guidance once, but I am not 100% on charging all attempts.

Failed Lumbar Puncture

If we went through the whole process of performing a lumbar puncture after anesthetizing the area and could not obtain any fluid, do I have to modify the procedure as attempted but failed?

Failed/Unsuccessful CTO Crossing Lower Leg

How does one properly code for a failed/unsuccessful procedure to recanalize (cross a CTO) an obstructed peripheral artery (e.g., lower leg)?

FB Modifier Pertains to 2013

If a warranty credit is received in 2014 for a procedure that took place prior to January 1, 2014, do we still use the -FB/-FC modifiers? Following is an extract from MLN Matters® Number: "MM8572 No Cost/Full Credit and Partial Credit Devices Effective January 1, 2014, CMS will no longer recognize in the OPPS the FB or FC modifiers to identify a device that is furnished without cost or with a full or partial credit. Also effective January 1, 2014, for claims with APCs that require implantable devices and have significant device offsets (greater than 40%), the amount of the device credit will be specified in the amount portion for value code “FD” (Credit Received from the Manufacturer for a Replaced Medical Device) and will be deducted from the APC payment for the applicable procedure."

Fem-Pop Bypass with Angioplaty of External Iliac Artery

My physician completed a right fem-pop bypass using saphenous vein. As the right external iliac was not clampable for an endarterectomy, he instead balloon angioplastied the stenotic segment and placed a stent through a micropuncture needle in the common femoral artery. I would only code for the bypass, as I would consider this part of localized inflow and outflow. My provider disagrees and thinks this should be billed in addition to the bypass. Can you please provide your thoughts?

Fem/Pop Bypass Graft AV Fistula

"Patient had a CTA with run-off showing AV fistula at the fem-pop bypass graft and came to IR. Bilateral run-off was done, catheter was placed in the graft, and embolization occurred with many coils. PTA was done in the popliteal artery at the anastomosis." I believe I should report code 37242 for the embolization and code 37224 for the PTA of the popliteal. The vascular surgeon wants to code the bilateral run-off plus catheter placements. Would you verify for me please?

Femoral Acetabular Impingement (FAI) exam

What is the correct coding for a femoral acetabular impingement (FAI) exam? In our protocol, we perform a CT through the bony pelvis and proximal femurs, 3D reconstructions are created of both hips. In addition we obtain axial CT imaging through the knees to evaluate for femoral anteversion. Since this exam is primarily focused on the hips it seems most appropriate to code this as a Bilateral CT Lower Extremities (which covers the hips and knees) and include a 3D post processing component (76377). We also considered billing it as a CT Pelvis with 3D post processing component however that seems to ignore the added imaging through the knees?

Femoral arteriovenous fistula for a pedicle free flap to lumbosacral area

Greetings, I have a physician completing a femoral arteriovenous fistula for a pedicle free flap to the lumbosacral area. They tried a iliac artry exposure first but due to scar tissue they had to expose the femoral vessels. The physician harvested the entire greater saphenous vein,then anastomosted the vessel to the common femoral artery. This was then tunneled to the lumbosacral area. While tunneling the illiac vein was injured. How would I code this? A fistula tranposition code with a 36818- 22. The unlisted code 37799. Do you have any advice? Thanks, LW

Femoral to Femoral Bypass Same Leg

How do I code for a common femoral to profunda bypass using a Dacron graft same leg?

Femoroperoneal Bypass Graft with Graft Revision

I am hoping you can help with the following case. I don't believe that code 35879 should be billed at the same time as code 35566, but I am considering the use of a -22 modifier. "Once femoroperoneal bypass was completed, ultrasound Doppler was used to evaluate graft, and the graft was found to have relatively low velocities of 15cm/sec in the thigh. There was a significant flow difference noted with velocities of 80 cm/sec in comparison to adjacent velocities of 15cm/sec. Incision was made over the graft, graft was mobilized, and it was decided to proceed with patch angioplasty since abnormality was likely a frozen valve. A segment of residual GSV was harvested and opened longitudinally for patch purposes. Arteriotomy was made through the valve and fibrotic tissue debrided away from the wall. Standard onlay vein patch angioplasty was then performed. Repair was complete, flow restored, and duplex showed no abnormalities with significantly improved velocities. Total procedure time was 7 hours."

Fenestrated Codes for 2014

My question is regarding the new codes for fenestrated grafts for repair of the visceral aorta. Am I assuming these codes apply to grafts from the manufacturer and ones that are custom made by the surgeon in the OR suite?

Fenestrated EVAR

Our practice just performed their first fenestrated EVAR. They used a fenestrated aortic cuff with a bifurcated stent graft. They also stented both renal arteries with iCAST stents and used an extension on the right iliac and used an iCAST stent on the left iliac. From what I have researched, I believe the codes would be 0078T, 0079T, 0080T, 0081T for the fenestrated cuff with bifurcated EVAR graft, and codes and 34825, 75953-26 for the extension on the right iliac. Are the renal stents included in the fenestrated graft codes, or can they be coded additionally? And can the iCAST stent for the left iliac be coded with 37221? A stent was done because 'there was only 4-5 mm of available iliac artery to extend the graft and there was noted to be poor apposition of the stent wall due to tortuosity of the proximal iliac artery'.

Fenestrated Repair of Aortic Dissection

We've just done our first fenestrated repair of an aortic dissection, and we are needing help with coding it. Can you help us? Here is what was done: 1) Successful balloon-assisted juxtarenal and infrarenal aortic fenestration. 2) Unchanged SMA occlusion. Patent celiac axis, IMA, and bilateral renal arteries. 3) Occlusion of right common iliac artery successfully treated with bare metal stent.

Fenestration Closures 93580 and 93568

Is it okay to report code 93580 (fenestration closure) and 93568 (pulmonary angiography) when the angiography is done after the fenestration closure when documentation states that "angiography revealed complete occlusion of fenestration in right atrium"? It is my understanding that codes 93580 and 93568 are bundled and should not be billed separately.

Fetal Cardiac Interventions

One of our doctors will soon begin doing fetal cardiac interventions (aortic valvuloplasty, pulmonary valvuloplasty, ASD creation, pacing) in conjunction with doctor from Maternal Fetal Medicine for the access to the fetus. Any idea how both doctors would bill for these procedures? Please help.

Fetal Echos

Pediatric cardiologists bill codes 76825, 76827, and 93325 for fetal echos. They also look at the umbilical artery. They want to bill code 76820 in addition to the three above codes. Looks like there is a bundling issue with codes 76820 and 93325, but 76820 pays more. I can't seem to find anything about billing these codes together. I'm assuming code 76820 cannot be billed in addition to these codes, but I would like to confirm.

FEVAR

The doctor did a FEVAR (with the graft covering the entire abdominal aorta) with placement of stents into bilateral renals and bilateral femoral exposure. One side was inserted through the "scallop" and the other through the fenestration. Is this reported with code 34846? Or with codes 34845 and 37236?

FEVAR

When choosing the code for repair of an AAA with a fenestrated device, is the code determined by the number of fenestrations or the number of stents placed in visceral arteries? The CPT code description says "including 1, 2, 3, or 4 visceral artery endoprostheses", which leads me to think the code is determined by the stents... but then how would I code a graft with four fenestrations and zero stents? My physician has done several cases where there are four fenestrations, and he only places stents in one, two, or three arteries.

FEVAR

Can I bill surgical cutdown codes 34812 and 34834 along with fenestrated aortic stent graft with three visceral artery endoprostheses?

FFR 93571 and Drug-Euting Stent C9600

We are hitting an edit whenever we code an FFR 93571 with a drug-eluting stent procedure. We are told that we need a primary procedure code with 93571 and that C9600 is not acceptable. (Note, this is a hospital.) The acceptable codes for 93571 are the heart catheterization codes and the bare metal stent codes. I would appreciate you help.

FFR and IVUS

Dr Z ~ Now that we can charge for individual vessels for PCI (LAD, diagonal) can we also charge separately for Radi wire diagnostic, per vessel (93571 and 93572)?

FFR in Non-Coronary Vessels

Would there be anything separately reportable on FFR performed on a renal artery, or would that be part and parcel of "including pressure gradient measurements when performed" in the description of CPT procedure codes 36251-36254?

FFR in renals

Hi Dr Z, One of our physicians recently performed a bilateral renal angiography, and placed a FFR wire in the left renal artery. It is my understanding that the FFR is not separately billable with a non coronary angiography. Thank you

FFR Repeat Coronary Angiography

The patient first had a left heart catheterization with angiography at his doctor's office owned by our hospital (93458). The patient then was sent over to the hospital for FFR of the LAD and RCA. Our hospital cath lab charged code 93454 for the coronary angiography and codes 93571, 93572 for the FFR. When computing, we are getting an edit stating that code 93454 is a component of 93458 (because the charges for the two facilities are being combined). Is it acceptable for the hospital cath lab to charge for the coronary angiography once again (with the -59 modifier) since it was already performed by the physician office during the heart cath the same day? Or should the hospital cath lab only charge for the FFR? Current charges are: 93458, 93454, 93571, 93572.

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?

Fibrin sheath disruption with a balloon

Distruption of fibrin sheath with angioplasty balloon 2011 Z Health Vascular & Endovascular Coding Reference lists 36595-52 & 75901-52. Distruption of fibrin sheath with angioplasty balloon 2012 Z Health Cardiovascular Coding Reference lists 36595-52 & 75901 without the 52 modifier. Why the difference in 2011 & 2012?

Fibrin Sheath Disruption with CVC Exchange

Do you have guidance when it comes to disruption of a fibrin sheath with a CVC diaylsis catheter exchange (not a Tessio catheter)? If a fibrin sheath was disrupted in the SVC and another fibrin sheath in the innominate vein, would codes 36595-52/75901 be assigned twice (once for each vessel) or just once (similar to guidelines of coding only one central PTA)?

Fibrin Sheath PTA for Hospital (Same Access)

Can you please explain why when fibrin sheath PTA is done via the same access in a hospital facility modifier -52 is not utilized only on the physician side? This modifier is used in other outpatient hospital coding and is approved per the CPT Manual (where modifiers are listed). I know this is in your literature but not the explanation behind it.

Fibrin Sheath vs. PTA

Is the following coded as a fibrin sheath (36595-52), a PTA (35476), or both?  "A pull-back SVC venogram was then performed, revealing a fibrin sheath and stenosis at the superior cava/right atrial junction. The existing catheter was exchanged for an 11 French vascular sheath. Balloon angioplasty was performed using a 12 mm balloon, followed by a 14 mm balloon for fibrin sheath disruption and stenosis dilation. Follow-up venogram demonstrated satisfactory results with disruption of the fibrin sheath and slight improvement in the SVC stenosis."

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?

Fiducial Markers

Is a biopsy performed at the same time as a fiducial/vesicoil placement inclusive? So, if the physician performed a vesicoil placement in the chest under CT guidance and performed a biopsy at the same encounter, I would report codes 32553 and 77012 only, correct?

Fiducial Markers and Biopsies

I had previously submitted the question, if a biopsy and a fiducial placement were performed at the same encounter, could they both be billed. You answered that they COULD both be billed. My compliance department wants to make certain they can both be billed if the biopsy and fiducial marker placement are performed from the same access point with the same needle.

Filter Removal

We have multiple opinions flying around on this one, so I wanted to run it by you. Patient has/had DVT of the lower extremities and had a filter placed. She is seen now to have a lower extremity venous ultrasound done prior to removing the filter to check the status of the DVT. On the left it looks to have resolved, but on the right it's undeterminable if it has completely resolved. Would you use the DVT diagnosis (453.41/453.42), a follow-up (V58.81/V58.89), or a pre-op (V72.83) diagnosis code? I'm leaning towards the DVT, but a few do not agree, so I was hoping to get your opinion on it.

Filter retrieval from the pulmonary artery, 37193

Dear Dr. Z: IVC filter migrated into the right lower lobe pulmonary artery requiring removal. Would 37203, 75961, 36014 be reported or would we report the standard filter retrieval 37193? Thank you. mlb

Filter wire

I apologize for my last question: It should have read what is the coding difference between a flow wire/pressure wire (93571-26) and a filter wire. I do not have a code for the filter wire.

FIRM and PVI Catheter Ablation

Can we report both codes 93655 and 93656 for FIRM (focal impulse & rotor modulation) and pulmonary vein isolation catheter ablation to treat atrial fibrillation? Usually these rotor ablations are done in both the right and left atrium prior to PVI. If reportable, should we assign code 93655 twice for left and right no matter how many rotors/lesions were ablated? Or do we code based on the number of lesions ablated? Here's an example: "The 60 mm basket catheter was deployed in the left atrium and Epoch 3 created, which appeared to show rotors on the mitral annulus just anteroinferior and posteroinferior to the left lower vein. These rotors were ablated and ablation lesions connected. Epoch 4 showed a posterior wall rotor, which was over the esophagus and was difficult to ablate extensively due to heating. Epoch 5 and epoch 6 were created after adjusting the basket to better contact the posterior wall. These revealed rotors in similar areas as the prior rotors. Ablation lesions were delivered extending the prior lesions along the mitral isthmus and on the posterior wall. During ablation, atrial fibrillation terminated."

Fistula Anastomosis

Is the fistula anastomosis considered an arterial anastomosis or a vein anastomosis? I have been coding a stenosis in the fistula anastomosis (like a brachiocephalic fistula) with codes 35475/75962.

Fistula Revision

Will code 36833 cover the following procedure? Or are codes 36147 and 36148 also needed? Please advise. "Patient with aneurysmal left brachiocephalic AV fistula with aneurysmal stick site, skin ulceration over upper stick zone. Micropuncture needle was inserted into proximal portion of fistula with wire advanced under fluoroscopy into upper fistula beyond aneurysmal stick zones. Sheath inserted up into subclavian vein and parked there with fistulogram done. Long segment of high grade stenosis (80%) began just beyond aneurysmal upper stick zone. Stenoses were balloon-dilated with good result and puncture site sutured. Attention turned to aneurysmal site in upper stick zone. Ulcer was excised with elliptical incision back to healthy skin on both sides, down to fistula. Inflow portion of fistula into stick zone was dissected and clamped. Patient was heparinized. Part of aneuyrsmal fistula was excised, revealing ulcer had penetrated into fistula with layer of thrombus between scabbed area and fistula. This was excised including excessive thrombus. Opening was oversewn in two layers, clamps were released, and suture line was hemostatic. Subcu and skin sutured."

Fistulogram and intervention in two settings

Dr Z, we had an interesting case in which a patient with a brachio-cephalic AVF was complaining of severe arm swelling. Fistulogram was performed revealing the fistula to be widely patent, so an upper extremtiy arteriogram was performed revealing an occluded brachial (just distal to the anastomosis) and ulnar artery, as well as occlusion of a previouslly placed stent in the left subclavian. At this point the sheath is pulled and hemostatis is achieved. Vascular surgery consult is obtained. Later the same day, they re-access the AVF, but this time a diagnostic exam is not performed, just thrombectomy and restenting. How do you recommend we code the re-accessing of the AVF on the same day, should we use 36148 even though it is a separate session? Thank you

Fistulogram of Abdominal Wall

"Operative report: The catheter was placed in the fistula located in the left abdomen near the lap band adjustment port. Next, contrast was administered during fluoroscopy observation. Contrast is administered, which demonstrates a fistulous track between the skin and the implantable port. There was a contrast leakage along the catheter to the skin surface. No intraperitoneal extravasation or fistulous connection is seen." Code 76080 has been billed for this procedure, but shouldn't a surgical code such as 10030 or 20501 also be reported in this case?

Fistulogram with Thrombolysis and PTA Coding Assistance

The following case was coded with 35476, 36870, 75978, 36147. We were asked to add codes 37212 and 75791 by our HIMS dept. Not sure if this would be appropriate. "The graft was accessed with a micropuncture needle in an antegrade fashion. A fistulogram was then performed from the right atrium to the level of the fistula. Two improve visualization of the central stenosis a Kumpe catheter was advanced to the subclavian vein and subsequent venography performed. Fistulogram demonstrated a large thrombus within the fistula distal to the venous anastomosis. Thrombolysis was performed and this thrombus was laced with 6 mg of TPA. After a short waiting period a catheter and wire were advanced beyond the thrombus. Another 6 mg of TPA were used to lace the venous outflow thrombus. Mechanical thrombectomy was performed through the outflow vein and the fistula thrombus. The above described conduit and venous outflow stenosis was negotiated with a glide wire. Subsequent balloon angioplasty was carried out without significant residual. Brisk flow was acheived."

Flair and Fluency stent grafts

Hello. My question is regarding C1874 stent coated/covered with delivery system. Is the flair stent inserted in this example a drug eluting stent? Does the HCPCS code C1874 necessarily equal a drug eluting stent? thanks for your help! Utilizing 2% lidocaine as local anesthesia a 21-gauge needle was corrected into the arterial limb of the AV dialysis graft directed towards the venous anastomosis. Subsequently, a AV shuntogram was performed demonstrating a high-grade focal stenosis involving the venous anastomosis. A 6 French sheath was placed and the anastomosis crossed. This was then dilated to 7 mm which appeared to improve flow, however, residual intimal regularity remains. As a result, a 7 mm x 5 cm fluency stent was deployed across the venous anastomosis. This was then dilated to 7 mm. The graft also demonstrates mild diffuse intergraft stenosis. This was also dilated to 7 mm. A post procedure shuntogram demonstrates no significant residual stenosis, however, the thrill was suboptimal following this procedure. As a result, the arterial anastomosis was evaluated. This demonstrates a high-grade arterial anastomotic stenosis. A 21-gauge needle was then directed into the venous limb of the graft directed towards the arterial anastomosis. A 5 mm x 2 cm balloon was then inflated across the anastomosis. A post procedure fistulogram was then performed demonstrating no significant residual stenosis. A nice palpable thrill was achieved within the graft. As a result, the access guidewires, vascular sheath, and balloon catheter were removed.

Flecainide challenge

Dear Dr. Z, Thank you for taking the time to consider my question. Our facility treated a patient who they suspected as having Brugaga Syndrome so a flecainide challenge was done. The patient had a base EKG done then was given 400mg of oral flecainide. EKG’s were then done after one half hour, one hour, two hours, three hours and four hours. My question is what CPT code (if any) would be appropriate for this procedure? I have reviewed the Noninvasive Physiologic Studies and Procedure section of the CPT book and 93799 – unlisted cardiovascular service or procedure is the only one I feel can be used. The other option I have considered is to only code the EKG’s and not apply a code for “flecainide challenge”. Thank you in advance for your input. Debra Patterson, RHIT

Flolan 93463

Can we use 93463 for the evaluation of pulmonary hyperetnsion reversibility using intravenous Flolan (epoprostenol)during a right and left heart cath?

Flouroguided Epidural Steroid injection

The instruction under code 77003 says, "Injection of contrast during fluoroscopic guidance and localization [77003] is included in 22526,...., 62310-62319." And yet there is no NCCI edit. We have not been coding for the guidance since discovering this note. Does this note mean that we can charge code 77003 if it is for localization but not if contrast is injected? How should this note be interpreted?

Flow Diversion into A1 and M1

I am coding a case of a dissecting aneurysm of the supraclinoid left internal carotid. The physician used a Y-stenting technique without the use of coils to divert flow and "occlude" the aneurysm. One stent was placed in the supraclinoid ICA and A1 segment. The M1 segment was selected through an open cell of the previously deployed stent, and a second stent was deployed in the supraclinoid ICA and M1 segment, bridging the aneurysm. This created aneurysm occlusion through flow diversion. Would this be coded as an intracranial embolization with code 61624, or should I use an unlisted code? I have read that this is a new technique used for wide-necked aneurysms, aneurysms where the emanating branches are incorporated in the sac, or it's a giant aneurysm causing mass effect.

Fluoro code/charge with Spinal Surgeries done in OR

Our hospital/neurosurgeons use fluoro in all their spinal cases. What is the instruction for charging/billing for fluoro done in the OR for these cases? It seems that cpt codes for open procedures 63001 and on, do not include fluoro. The minimally invasive/percutaneous procedures 0274T and 0275T seem like they do include the fluoro charge. If we do charge for the fluoro, would we use 77003 or 76000. Thank you very much.

Fluoro Guidance during Operating Room Procedure

Can we charge for fluoroscopy guidance (77003) when the fluoroscopy is provided by a radiology tech and the procedure is performed by a surgeon? The surgeon dictates fluoroscopy guidance was used in the operating room procedure. An example is code 62311, epidural injection (myelogram, epidurogram, and arthrogram are not performed in the OR procedure).

Fluoro guidance for epidural and facet injections

Dr. Z, If a patient recieved an epidural injection along with a facet injection, can I add a modifier 59 to 77003 (fluoro guidance for the epidural)? Patient has right lower back pain radiating to the right lateral thigh. Impingment of right L3 and L4 nerve roots seen on recent MRI. Patient also has moderate central canal stenosis and facet arthrosis per the CT done 9 days earlier. Thanks for any help you can give me. Michelle

Fluoro Guidance with Port Removal

One of our IR docs is taking a spot image after removal of a port and cath, and we are trying to determine if it is appropriate to bill code 77001-26 in this circumstance (pro fee side).  What are your thoughts?

Fluoro Guided Transvenous FB Retrieval

I love your site! thanks for all your help. Could you help me code this case. Fluoroscopically Guided Transvenous FB retrieval Using US guidance we acessed the rt common femoral vein. I advanced the guidewire to the level of the inf vena cava and then inserted a 6 fr sheath. The sheath was flushed. I advanced the guidewire to the level of the SVC over a guidewire I inserted a 6 fr long sheath the guidewire was removed through the sheath and under fluoro I advanced a multiloop snare with maxium transverse diameter of 1.5 cm LOOP snare was positioned adjacent to the venous catheter fragment in the right atrium. Multiple attempts were made with the snare that were unsuccessful. I then exchanged for a separate multiloop snare with max transverse diameter of 3cm. Again attempts made were unsuccessful. the catheter fragment is felt to be lodged against the wall of the rt atrium. I then removed the long sheath and inserted a 5 french pigtail in the rt atrium. I then placed a Ampltz guidewire through the pigtail catheter to open the catheter loop. The loop was then gently placed across the waist of the catheter fragment. Counterclockwise traction was applied to the catheter and guidewire which allowed the catheter to entangle the waist of the catheter. Under Fluo I gently pulled the catheter away from the right atrium and into the vena cava. The catheter was then pulled lower to the level of the rt common iliac vein. I removed the catheter and guidewire and replaced the loop snare. The loop snare was then used to grasp the end of the catheter fragment. I then removed the intact catheter fragment, loop snare and sheath from the right common femoral vein. The fractured catheter fragment measures 11 cm in length. During the procedure the patient had a prolonged episode of atrial tach which did not resolve the following repositioning of the cath Cardiology was asked to evaluate the patient. The patients heartrate did return to baseline and no cardioversion or addl cardiac intervention were required. Successful Fluoroscopically guided retrieval of Venous catheter fragment from the rt atrium. Thanks for your help

Fluoro of the diaphragm with heart cath and biopsy

Here is a brief synopsis: the patient is having prolonged post-transplant hospital course with persistent pericardial effusion and persistent mild respiratory distress. The patient presents to cath lab for fluorscopic evaluation of the diaphragm as well as her routine post-transplant RHC and biopsy. The eval of the diaphragm is a fluoroscopically saved image which demonstrated that the left hemidiagphragm is paretic with evidence of paradoxial motion of the diaphragm. The existing pericardial drain and 350 ml of straw-colored fluid was removed. Oximetries & hemodynamics of the RH were done pre and post pericardial drainage. Endomyocardial biopies were done X5. I wanted to bill 93451-26-59, 93505-26, 33010, and 76000-26. However,76000-26 hits an edit with 93505 as bundled and no modifier is allowed. Is there another code I should be using or is the evuluation of the diaphragm non-billable? Thanks so much for your help with this scenario!!!

Fluoroscopially-guided Balloon Dilation of Esophagus

Could you please tell me if unlisted code 43499 should be used in this scenario, or can code 43453 be used? I am thinking of the unlisted but need help. "A 5 French Berenstein catheter, in combination with a 0.035 inch Amplatz guidewire, was advanced through the oropharynx and cervical esophagus across the anastomosis and into the thoracic stomach. A 14 mm Atlas balloon was advanced over the guidewire and into appropriate position. The balloon was inflated. The waist resolved with inflation to 20 atmospheres. The balloon was left inflated for 1.5 minutes. The balloon was then deflated and removed. Repeat dilation was performed using a 16 mm balloon and inflated to 20 atm for 1.5 minutes. A repeat esophagram was performed. This demonstrated improvement in luminal caliber. There was no extravasation demonstrated."

Fluoroscopic Guided Injection for CT Myelogram

Patient goes to X-ray department for fluoro-guided injection for myelogram, then to CT for spinal exam. Code 62284 bundles 77003 per hospital NCCI edits. Should X-ray only report code 62284 and not 77003?

Fluoroscopic insertion of spinal fiducial marker

What are the appropriate facility codes for the fluoroscopic insertion of spinal fiducial markers for a spinal tumor? If the patient is a medicare outpatient, would HCPCS C9728 and 77002 be the correct codes for this type of case?

Fluoroscopy and G0260

Dr.Z, Since code 27096 now includes fluoro, does G0260 follow the same rules and include Fluoro? Thanks so much Henri

Fluoroscopy and room time

Dr. Z, a facility wants to charge 76001 for a tech and a fluoro machine being in the OR for more than an hour even though the documented time for use of the fluoro is less than an hour. There is a physician in the room for more than an hour but the fluoro machine is not being used for the whole time. What is the correct way for the facility to code for the fluoro when the OR procedure does not involve an S&I code and the documented time is less than time in the room. Thank you.

Fluoroscopy Documentation

Is it enough to dictate that 6 minutes of fluoroscopy was used to support the use of the code 77001 or 49440? If not, what would be the appropriate documentation? For example, if the dictation stated that the wire was advanced under fluoroscopic guidance, is that enough? Or should the use of the fluoroscopic guidance be matched up with the final placement of the catheter?

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?

Fluoroscopy to check a valve or a lead

Hi Dr. Z We were discussing the fluorscopy code (76000) vs the cineradiography code (76120). If the doctor uses fluoroscopy to check on a valve or a lead, takes some images and that is all....which code is appropriate or can both be used? Thanks for your help!

Fluoroscopy with Tunneled Catheter Removal

Original Question: Will you please address the issue of tunneled catheter removal since it now has its own code (32552)? Is it appropriate to code a fluoro guidance code, 76000 or 77002? I don't get an edit, but the your IR book states S&I is N/A. In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter. The catheter could have been compromised because of infection. Why is this?  Thank you! Additional Information: In this particular case, fluoro was utilized to make sure there were no retained fragments of catheter.  The catheter could have been compromised because of infection.  

Fluoroscopy/CT Myelography and NCCI Edits

In light of the July 2014 NCCI edit update, we (hospital staff) have been debating whether or not it is appropriate to append a -59 modifier to existing myelography codes when a CT scan of the same area is performed on the same date of service. We routinely perform a full and complete conventional myelogram with a separate report amd then send the patient to CT. Bottom line - can we bill separately for the conventional myelogram, or is it now considered bundled with the CT study performed in the same patient encounter?

FNA Thyroid

We have a question regarding FNA of thyroid nodules. We have a physician who mentions in his report that he is doing a capillary and suction technique, but never mentions FNA. When we say we need documentation for FNA versus core, his reply is "capillary and suction technique" is FNA. Can we assume and code these as FNA? Please advise.

FNA vs. Core Biopsies

I have a radiologist who has told me whenever he does a biopsy of the thyroid it is always core; however, he never dictates "core" in his reports... he always just says "tissue". Pathology from the hospital always says FNA. So my question is, do I report code 60100 because that's how he instructed me to code, or do I go with the pathology and report code 10022?

FNA vs. Core Biopsy

I need to know when I can code both a fine needle aspiration and a core biopsy. Sometimes our physicians do not say why they go on to obtain a core after an FNA has been done. If a reason is not documented, should I just code for the core biopsy? Following is an example: "Ultrasound of the neck revealed 2.5 cm of right cervical lymph node/mass. A 25 gauge needle was advanced into the mass with ultrasound guidance, and an FNA was obtained and given to pathology. The needle was removed, and a total of six core biopsies were also obtained. Post ultrasound demonstrated no hematoma or complication."

Foley Balloon Placement in Pleural Space

We have a patient who had an IR px for insertion of a Foley balloon into the pleural space with injection of calcium channel blocker to stop a massive hemothorax.  Once bleeding was controlled, it was determined that the intercostal artery was punctured from a previous chest tube placement. Do you have a suggested CPT code and ICD9 px code?

Foley catheter placement in the cath lab or EP

Can we code/charge for foley catheter placement in Cath lab or EP lab? It's done prior to long procedures in EP. It's done in the Cath lab if the bladder is too full or patient will have difficulty using bed pan after procedure. As always, we appreciate your assistance! Thank you!

Follow up CT MRI during 90 day global

Dr. Z, Our radiologist does Discectomies, vertebroplasties, and kyphoplasites quite a bit. He always has a follow up CT/MRI in 2 weeks to 1 month. These procedures have a 90 day global, can I charge for the follow-up CT/MRI? Thanks

Follow Up to Question ID #5966, FFR/IVUS performed by separate physician

Follow Up to Question ID #5966, it states: ‘A caveat would be if two physicians are in same group and use same billing number then code as usual, as add-on code 93571 would be okay with the heart cath.’ Can you further clarify what is meant by ‘code as usual’? Do you mean first physician can code and bill add-on code since second physician is in the same group even though first physician didn’t perform add-on procedure? CPT manual, p. xiv outlines: “The add-on code concept in CPT 2014 applies only to add-on procedures or services performed by the same physician. Add-on codes describe additional intra-service work associated with the primary procedure…Add-on codes are always performed in addition to the primary procedure and must never be reported as stand-alone code.” CMS 1/1/14 policy outlines the same principal. Also, if FFR/IVUS is performed on same day as heart cath but by two physicians in different groups then do you recommend each physician code their part with second physician utilizing unlisted code 93799 to capture the stand alone px of FFR/IVUS.

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?

Follow-up angiography

For follow-ups post infusion/embo (75898), I know it's to be done once (other than for intracranial procedures), but my physician asked about doing multiple AVM's (right and left lung), if they embo there, is that still just one follow up? or would it be two, one for each lobe? Same for multiple hepatic tumors? one follow up even if they embo multiple tumors through different cath. placements? thanks!

Follow-up angiography following cerebral aneurysm embolization

Please do NOT include any actual patient medical records with your question. DR Z I have a general question about Follow-Up (75898 ) charges. We coiled a cerebral aneurysm. Nine coils were placed into the aneurysm but only the last 2 were deployed.The other seven were removed because the DR did not like their placement. After each placement a follow-up angio was performed. Do you charge 9 follow-up's or only 2 for the 2 coils that were leftin for the embolization? I say you only charge Follow-up for the coils that actually embolized not the ones that were removed. TY

Follow-Up Diagnostic Mammography with CAD

A question came up as to whether or not it is appropriate to charge for CAD when performing "spot compressions" on a follow-up diagnostic mammogram. Is there a requirement for the type/number of images on a diagnostic mammogram in order to charge CAD?

Follow-up Gallbladder Drainage

According to your reference and previously asked questions, codes 47805 and 74305 are reported for a cholecystostomy tube check. I'm coding for a "follow-up of post gallbladder drainage" in which "scans are obtained through upper abdomen without contrast and after injection of the drainage catheter. After injection there is filling of the gallbladder." The impression was "after injection of contrast through the drain there is a small amount of leakage into the pericholecystic region." So I am told by the IR coder that in this case code 74150 should be used. However, could code 47505 also be used for the injection into the catheter? Or is code 47505 only to be used for a specific check of the tube functioning?

Follow-up on Carotid Cavernous Embolization

"Patient had right-sided carotid cavernous fistula and upon imaging before embolizing the right they discovered that a left carotid cavernous fistula was present, so they came back two days later to embolize the left. They performed a bilateral cerebral angiography from the common carotids prior to the embolization, which was performed from the left cavernous sinus via femoral vein access. After embolizing, the physician came back and performed cerebral angiography as a follow-up from the bilateral internal carotids, the bilateral external carotids, and the left vertebral." So my question is, can I code the extrernal carotids as angiography?  Or do I have to consider those a follow-up? Also since the catheter went further and since we code to the highest catheter placement, I am unsure if I should code the highest order and use the internal carotid code 36224 instead of the common carotid code 36223... or should it be 75898?

Follow-up to Cone Beam CT coding (Question 2143)

Does a separate report need to be created to support the filing of both codes 76380 and 76377 when a cone beam CT hepatic artery injection and 3D reconstruction are performed in conjunction with diagnostic hepatic arteriography in Y-90 planning? Alternatively, in reporting codes 76380 and 76377, is it sufficient to only note that the cone beam CT was completed during the angiographic procedure? Findings are reported as a single discussion without specifically noting what modality (angio or CT) was used, both having been completed. Reference is made to the angio and CT in the conclusion. How much documentation is required to support these codes?

Fontan Fenestration dilation

Dr Z, What is the appropriate code for balloon angioplasty of a Fontan fenstration? " we then turned out attention to the Fontan fenestration. We crossed the Fontan fenestration with a coronary wire and glide catheter. We then exchanged the Glide catheter for an Apex RX 4.5 mm x 20 mm balloon. We advanced the balloon over the wire, across the Fontan fenestration and made a total of 3 inflationsfor a total of 6 seconds each. We then repeated the IVC angiogram and this revealed much improved shunting throught the Fontan fenestration and a slight drop in arterial saturations." Cath lab is using 92992, however I don't think that's correct. Is this an unlisted 93799 or would it code to a valvuloplasty code? Thanks!

Foreign Body Removal - Open

I’m not sure what to do with this one. Patient came to cath lab to have an angioplasty of his AVF. While ballooning the subclavian and innominate vein, the balloon ruptured. Due to aspiration of blood from the inflation port of the balloon, the surgeon decides to take the patient to the OR for emergent surgery. In the OR he opens the arm, creates a venotomy in the fistula, and removes the balloon. It is noticed that there is some thrombus, so he removes the small amount of clot present and closes the venotomy. I don’t like code 37197 since this is open instead of percutaneous. I was thinking of reporting the exploration with code 35761 (which includes foreign body removal) (or possibly 35860 since there was bleeding) with modifier -XU or -59, as well as the open thrombectomy with code 36831 since they shouldn’t have had to do a thrombectomy as well. My other thought was unlisted code 37799. What are your thoughts?

Foreign Body Removal of Occluder Device

After a PFO closure procedure (93580) the occluder device was seen to be floating in the left ventricle. During a second procedure, on the same day, the same doctor retrieved the device. To capture the device he actually pulled it back into the ascending aorta and there successfully pulled it into the sheath. Can I use code 37197 for this procedure or go to an unlisted procedure code?

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!

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