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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.

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 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 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 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!

Four Coronary Artery Stents

"1st lesion intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the 1st obtuse marginal 2nd intervention: A successful stent with balloon angioplasty was performed on the 99% lesion in the 2nd obtuse marginal 3rd intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the right posterior descending artery. 4th intervention: A successful stent with balloon angioplasty was performed on the 90% lesion in the mid RCA." I am reporting codes 92928-RC, 92929-RC (right posterior descending), and 92929-LC (1st obtuse). Can you code for the 2nd obtuse (92929-LC)? Per CPT: Additional PCI in a third branch of the same major coronary artery is not separately reportable. Since there are two PCI in one branch and one PCI in another, could you use code 92929 three times? I understand that Medicare considers the add-on code bundled into the base code.

FRED Device

Would placement of the FRED (Flow Re-Direction Endoluminal Device) be coded as an embolization or a stent? It looks like a stent, but it is used to occlude an aneurysm.

G tube check without fluoroscopy

In the main radiology department, the tech will inject the gtube with contrast but then not use fluoro. they use regular xray instead. would we still charge a 49465 or something else?

G-J Tube via Nasal Approach

Initial percutaneous placement of G-tube into the jejunum or duodenum is reported with codes 49440 and 49446. Using that same logic, would it be incorrect to report codes 43752 and 43761 for G-tube placement into the duodenum via nasal approach for enteral nutrition? The description of code 44500 in the Coder’s Desk Reference does not seem to describe what was actually done. Example: "Under fluoroscopic guidance, a 10 French nasoduodenal/jejunal feeding tube was advanced using real-time fluoroscopic guidance as well as a 0.035 stiff Terumo Glidewire and positioned in the proximal jejunum."

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.

G-Tube Unclog

How would you code a clogged G-tube clearance using soda water with follow-up contrast injection to confirm patency?

G0269

Please do NOT include any actual patient medical records with your question. For 2011, would the G0269 code still be coded with heart catheterizations for hospital side coding? The CPT coding notes say that closure device placement is inherent to the catheterization and not separately reportable, but we were not sure if that applied to this code. Also, if the patient came back and just had stent or angioplasty(no heart cath)would the G0269 code be used then? Thank you.

G0269

Dr.Z: I'm confused to when we can code for 75710 when doing diagnostic angiograms? Example:Right Common femoral artery was selected.AP views showed to have normal caliber and branching. The puncture site was appropriate for Angio Seal device deployment. They then continue with the diagnostic angiogram. thank-you for your help.

G0269

Is use of a closure device included if only a cardiac intervention is performed & not a diagnostic cath? Thanks

G0269 and procedures CPT says it is bundled into

Dr. Z, At a resent conference, the speaker said that CMS wants us to charge for the closure device procedure, G0269, even if it is bundled in the procedure. The speaker said they want to know when the closure device is used for statistical reasons. Do you know of this being true with CMS? Thanks!

G0269 Vascular Plug Placement and Transcatheter Embolization

Is code G0269 bundled with the 2014 new embolization codes? It's not showing that it is on NCCI CodeManager. When would this code be applicable for billing with embolization?

G0269 with 36251-36254

Hello Dr Z! I was wondering regarding the renal codes for 2012, 36251, 36252, 36253 and 36254, all thou it does not say it in it's description, but is the closure device to be included in the charge as they were for the cardiac cath /endovascular revascularization codes for 2011?

G0269 with 92980

Hi there-- In the facility setting as of 2011, I know that we are no longer supposed to bill G0269 in conjunction with diagnositc cardiac catheterization procedures. But is it still ok to bill G0269 if the only procedure performed is a PCI Procedure? (ie. a stent, PTCA, or atherectomy)?

G0269/93799 Occlusive Device Placement

I am trying to put together a list for my IR department that contains information regarding occlusive device placement charges. Do you have a list of the procedures that bundle the charges for the placement, as well as a list of procedures where the charge is allowed to be added? The devices have C-codes, so I want to have the appropriate charge on the accounts.

G0275 in 2014

Our end coder, Code Correct, is advising that code G0275 has been deleted for 2014, but that G0278 is still active. Is it true? And if so, is MCR accepting any other code? I could only find a vague reference to it on MCR under Part A.

G0275 vs 75625

Dr. Z; I am torn on this report with the proper code assignment. In all honesty I am not sure that code G0275 is correct on this account and the Cath lab assigned 75625. I am in total disagreement with assignement of 75625 also I am not sure that G0275 is supported by this limited documentation. I am only giving infomration related to the abdominal aortography section of the report. Procedures Preformed: Left heart cath with ventriculography, selective imaging of the coronaries. Abominal aortography. Indications: Angia/MI: stable angina. Coronary artery diesase: suspected and abnormal stress test. Cardiac: arrhythmia. History: The patient has hypertension and medication-treated dyslipidemia. Coronary Bypass abdominal Aortography: A catheter was placed and contrast was injected. Aorta: There was medium-sizwed, localized(saccular) aneurysm formation. Infrarenal location. The root exhibited normal size. Thanks in advance for your help.

G0278

You have written much about G0278 amd G0275. I understand how to code for these and when to use it. However, I have an MD that codes for this but the indication for Cath does not address PVD. Wouldn't you have to mention this in the indication for Cath?

G0278

Please do NOT include any actual patient medical records with your question. Can selective catheter placement be reported when documentation states: A4Fr JR 4.0 catheter was advanced to the aorta and positioned at the vessel origin(common iliac) under fluoroscopic guidance. Right and left side. Cardiologist documents R/L heart cath with cors in addition to bilateral iliac angiography for arteriosclerosis. Department reported 93460. Look forward to your response.

G0278 for iliac imaging during heart cath

Please do NOT include any actual patient medical records with your question. My physician have started doing abdominal arteriogram (75625) on patients who come in for LHC and RHC for possible TVAR procedures.Here is the preop diag. and the finding below. preoperative diag: The pt has moderate to severe aortic stenosis by suface echo and present for evaluation of his coronary arteries and aortic valve for consideration of possible percutaneous aortic valve replacement vs tranditional repair. Findings: Abdominal Aortography: The patient was found to have calcified iliac vessels..diameter 1.6cm lt and rt iliac. My question is should I code G0278 or 75625 or can you code for this procedure when there is only a possible of a TVAR?

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.

G0278 with Heart Catheterization

I need help coding this report. The procedures were left heart catheterization, selective cornonary, saphenous vein and IM angiography, ventriculography, RAO view, aortography, AP view, right iliac angiogram, and primary stenting of vein graft to RCA with use of spider. Closure of access site using Mynx grip. Here is the part of the note that I don't know how to code: "Aortography was performed in the AP view, as patient was complaining of discomfort in his right leg. This shows significant stenosis of 60-70% in the right common iliac, which with the placement of the catheter was obstructing flow. Following this, selective right iliac angiogram was performed, and this iliac appeared to be diffusely diseased with 60-70% narrowing, but I felt I could get the procedure done and bring him back for elective intervention of his iliac vessel." I am new to cardiac coding, so I'm feeling very lost. The patient has Medicare.

G0290, DES

The CPT code book lists one CPT code for coronary stent initial and one CPT code for additional - no reference to type of stent used. There are G codes for CMS patients and those state drug eluting stents. My question: do we charge differently based on bare metal stent placement or drug eluting stent placement? We have been told to have charge codes for bare metal stent placement at one price, and another charge code for drug eluting stent placement at a different price for non-CMS patients. Is this correct?

G0365

DR. Z, The patient came in for AV fistula creation and in the same setting it states 'using ultrasound, the upper extremity was mapped. Based on the findings from the ultrasound decision was made to proceed with a left basilic vein transposition.' Not sure if this is good enough to code 'G0365'along with the creation of AV fistula? Is this ultrasound mapping included in the AV fistula performed in the same setting? Sometimes we see an order stating vein mapping or pre op for AV fistula creation and the procedure is bilateral venogram, please clarify when and what kind of documentation suports 'G0365'? Thanks

Gastrostomy Tube Explant

"Deflation of the balloon was unsuccessful with slip-tip syringe. Using a 25 gauge lidocaine needle, the gastrostomy balloon was ruptured for complete decompression. Gastrostomy tube was then pulled with traction. A sterile dressing was applied."  Is there a CPT code for gastrostomy tube explant?

Generator Change with Lead Placement

Indication for procedure was need for ICD generator replacement. Also, fluoroscopy was performed of the right ventricular lead because of its recall status. Fluoroscopy revealed externalization of the right ventricular cable. For this reason, a left arm venogram was performed that demonstrated patency of the left arm veins. Through the axillary vein, a wire and sheath were advanced. Right ventricular lead was advanced through the right ventricular septum and fixed in place. Old right ventricular lead was capped and a new generator placed after recreating the pocket in a better position. Codes 33263 and 33216 as well as 36005 were charged by the Cath Lab. I agreed initially with codes 33263 and 33216 until I saw a similar Q&A from last year that advised different codes but appear to need more clarification. Please advise. Also, would code 36005 be allowed separately with a -59 modifier?

GONADAL VENOGRAPHY

I have an exam that the physician selects the left renal vein for a venography and then advances the cath to the left gonadal vein. I know the selection will be a 36012, but what code whould I use for the interpretation of the gonadal vein?

Graft Angiography, 93459

How do I code left heart catheterization, left ventriculogram with LVEDP measurement, selective coronary angiography, and non-selective LIMA angiography?

Graft interventin 37225

Dr Z: My surgeon performed an atherectomy of the distal right popliteal artery. At the same session, he performed an atherectomy of the proximal portion of a right femoral-tibial bypass vein graft near its origin from the common femoral artery. Do we only bill 37225 once since we are in the femoral/popliteal area on both the vein graft and native artery and on the same side or can we bill 37225 and 37225-59 with the vein graft being considered a separate vessel? Thanks for your help.

Graft Thrombecomy with revision

Hello, I need help :) The surgeon did a Graft Thrombecomy with revision (36833). He then did a fistula gram (36147) and because of stenosis in the venous outflow did an PTA (35476 & 75978-26). And a segmental incisiion of graft & overlying skin with primary closure??? Separate incision and closure.. Diag: End-stage renal disease, thrombosed graft fistula with recurrent bleeding from the false aneurysm of arterial limb of the graft with skin erosion. After revison/thrombecomy proc; The inflow was then tapered due to the incision..sheath removal of the graft was clamped proxiamally and distally, sheath withdrawn and sheath hole closed with sutures. Clamps released and palpable thrill was present along the graft, hemostasis was obtained. Counts ere correct x2. The wounds were closed in layers with Vicryl & Monocryl for teh skin Dermabond waa applied to seal wounds. This is what I am not sure about: Incision was then made to excise the sutured skin at the site of graft bleeding. The skin was excised as well as the underlying graft. No evidence of infection. The wound was reapproximated with nylon suture. Because this was a separate incision and it was done after the revision was completed, he feels he should get credit for the work. Since the graft was no infected, I am thinking this is still a part of the revision but not 100% sure. Your advice would be so appreciated! Thanks you!

Gray zone 37204

Dr. Z: Would following be consider one operative field or two separate operative fields?: Following removal of an existing nephrostomy tube and placement of a new tube through a separate access site, active bleeding was noted from the lower pole of the left kidney to the posterior abdominal wall from the old nephrostomy tract. Embolization was performed on a segmental branch of the left kidney. Followup angiograms confirmed adequate occlusion of the vessel. A small focus of contrast extravastion was seen in the hematoma in the left posterior abdominal wall, fed by the left T12 intercostal artery. The T12 artery was embolized. Thank you for your assistance!

GTube exchange w/angioplasty of tract for stenosis

This is my first ever case where the physician is doing an angioplasty of the tract of a gastrostomy because of stenosis.  Wouldn’t I code for the angioplasty?  If so is this considered an open angioplasty or an unlisted code? Your feedback is greatly is appreciated.

Hard copy documentation for ultrasound

Hello, I recently heard a rumor that the Radiologist has to state within the report that hard copy sonographic images were obtain for us to be able to bill out 76942. Is this correct? Your feedback is greatly appreciated.. Thanks so much for all your help....

HCPCS 2014

Do you have any information on what code will be replacing deleted HCPCS code G0275?

Heart Cath Question

We are in discussion with the hospital about billing for intervention on a branch of a major artery. We have a situation where the physician intervened on the LAD (92928, not during an MI), and there was some plaque shift into the diagonal branch of the LAD. Physician then did angioplasty (92921) on the diagonal branch. Can we show that this was performed? (I know we, as physicians, don’t get paid, but we need to show it was performed.) The hospital says no because the physician caused the shift of the plaque.

Heart Cath with Intent to Place Closure Device

For example, 93458 done, and femoral angio performed with the intent of placing a closure device. Decision made not to place the device. How should this scenario be coded? Also, same scenario and closure device was placed how should that be coded? Within our cath lab we have debated this round and round and I would like the clearest guideline. 

Heart catheterization and 36010

Dr. Z, Question#4. If the physician perform a congenital or a non-congenital heart cath can the code 36010 be assigned along with 75827 or 75825 if the documentation supports? I think thing this can be used with a -59 but then again if the physician already has the catheter within the parameter of the heart/headed towards the SVC or IVC to take a picture then it seems that it can be an inclusive code.??

Heart catheterization documentation

Hi Dr. Z and Dr. Dunn, I have a couple of questions regarding required documentation. If a report lists hemo measurements, including systolic and end diastolic LV pressures, does the note also have to have specific verbiage stating 'the catheter crossed the aortic valve' or 'the catheter was pulled back (out of the valve)'? Wouldn't the documentation of those measurements be sufficient enough to bill for a left heart cath? On a similar note, does the report have to specifically state 'the coronary arteries were selectively injected' if the purpose of the exam is to evaluate CAD and the coronary vessels and any disease is described? CPT states that 'catheter palcement(s) in coronary arteriy(ies) involves selective engagement of the origins of the native coronary artery(ies)for the purpose of coronary angiography.' I would interpret this as catheter placement in the coronary artery itself or in the aorta at the origins of the left and right arteries. Your thoughts? Thank you so much.

Heli-FX for Endoleak Repair

I have a follow-up to question #5129. My surgeon is treating an endoleak for an AAA. The original surgery was done at an outside hospital, and now my surgeon is placing the Heli-FX to resolve the Type 1A endoleak. Any suggestions on what code should be used for this?

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