Knowledge Base

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TEE during LAA Ablation

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

Possible ASD Closure

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

Multiple Intracranial Aneurysm Embolizations

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

TEE during TAVR

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

Pulmonary Angiograms

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

Vascular Technician Question

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

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

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

Multiple Angiograms

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

Fiducial Marker Placement in Liver

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

75625 vs. 75630

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

S&I Billing with Surgical Level

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

CoolGuard Cooling Catheter

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

IVUS with Bundled Cath Codes

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

37242 and 93568

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

Tetralogy of Fallot

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

75625 vs. 93567

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

Peripheral Angiography

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

36227 without 36222, 36223, or 36224

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

Right Iliac Intervention

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

Reocclusion to RCA Stent, Same Date of Service

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

New CPT Code for TEE

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

Pharmacologic Challenge with Esophageal EP Procedure

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

76380 with TACE

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

Non-Selective Codes for Diagnostic Angio and Embolization

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

US Guided Venoplasty of Shunt

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

Ascites Needle Confirmation with Injection for Nuclear Study

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

FFR without Pharmacologic Agent (IFR)

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

Lower Extremity Dialysis Graft

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

Bypass to a Fistula

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

AV Node Ablation After PVI and Others

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

61624 for AVM Treatment

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

CPT 93463

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

Modifier -26 and -52

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

ICE Catheter

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

Intravascular Fractional Reserve

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

US Guidance to Avoid Liver During G-tube Placement

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

CT Guided Breast Clip Placement.

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

Micropuncture Technique

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

Uterine Artery Embolization

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

Abdominal Fluid Drainage

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

Coil Embolization of Leaking Biliary Tract

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

IFR

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

Left Brachial Artery Selection

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

Discharge Summaries

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

Modifier 62 with 33249

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

Modifier 25 and ECG

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

Using 75726 and 75774 for a Y90 or Sir Spheres

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

Fluoroscopy guidance with CPT 62311

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

RVAD with Impella RP

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

Pacemaker Pocket Revision vs. Unlisted Cardiology Procedure

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

Medial Compartment Fasciotomy

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

Transposition Fistula vs. Direct Fistula

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

Patch Angioplasty of a Vein Fem-Pop Bypass

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

Alcohol Ablation for VT

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

Redo Valve

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

Right Common Carotid to Right Axillary Artery Bypass with PTFE Graft

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

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

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

Pre-Procedure SIRTeX GDA Embolization with Angiograms

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

Popliteal to Popliteal Bypass

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

Joint Injections

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

Steroid Injection and Contrast for Monitoring

For the following, would you code both an arthrogram and an injection? "The left hip was prepped and draped in the usual sterile fashion. Fluoroscopic guidance used to mark a site overlying the left femoral neck. Local anesthesia was applied to the skin and subcutaneous tissues. 25 gauge needle was then placed in the left hip joint, and 3 cc Optiray was injected to confirm position. This was followed by injection of 7 cc 1% lidocaine and 40 mg of Kenalog. The needle was removed and patient transferred to the holding area. Impression: Fluoroscopic-guided left hip lidocaine and steroid injection."

75726 vs. 75887

Should the following be coded as 75726 or 75887? "A Simmons I catheter was formed in the aortic arch, and the superior mesenteric artery was selectively catheterized. A conventional angiogram was obtained and carried into the portal venous phase. Findings: Superior mesenteric artery is patent. This was carried out in the main portal vein, and the main portal vein and its branches appeared patent."

EVAR and Cosurgeons

I code for a vascular surgeon who co-surgeons with an interventional radiologist from another practice performing AAA repairs. These are performed at the local hospital. My question is, what codes can I bill for the vascular surgeon as a co-surgeon? The vascular surgeon performs the exposure for AAA cases for the interventional radiologist. He is present throughout the entire procedure and both doctors note that both physicians were present for the entire duration of the procedure and performed all critical portions of the procedure together. The vascular surgeon confers after the takedown (34812), as the IR wants his opinion throughout. Can I code for the prosthesis (i.e., 34802-348083) as well as 34825 and 34826, if done, with a -62 modifier appended to each? The vascular surgeon concedes that he does the takedown only, but is present throughout the procedure to offer advice. If any complications arise at the time of surgery or postoperatively, the patient is still the vascular surgeon’s.

Numerous Endarterectomies and Thrombectomies

I’m not sure if I can bill the numerous endarterectomies and thrombectomies since there is only one large incision. What are your thoughts? "Incision was made in the right groin. Right proximal CFA exposed and dissected. The SFA was dissected sharply and mobilized to about 10 cm along with the profunda artery. All vessels encircled with vesseloop. No pulse in the right SFA and the distal CFA. SFA entered. This was extended all the way to the mid CFA. Large burden of plaque including the proximal SFA and distal CFA. Extensive endarterectomies done at the SFA to at least the proximal 6 cm of the SFA and distal 2 cm of the CFA. All tissue was cleaned and debrided; the distal flap in the SFA was tacked. Bovine patch used to close. Of note before this step I forgot to mention I used balloon to thrombectomize the right SFA, popliteal, and tibial arteries because there was sluggish backflow from the SFA. First pass there was a very long fresh clot, about 30 plus cm in length. Second pass was about 20 cm long, fresh thrombus. But after three passes the entire length of 80 cm had no more thrombus."

Cancelled MRI

"Patient was scheduled for MRI elbow arthrogram with contrast. Radiologist injected contrast in elbow with fluoroscopic guidance. A single radiograph in the lateral projection with the elbow flexed was obtained. Patient went to MRI." Procedure was canceled per nursing note: "Attempted, Unsuccessful, Claustrophobic." I appended codes for the contrast injection portion of the procedure (24220/77002), but I get an incidental services edit. Should I also code the MRI with a -52 modifier? Please let me know what you think.

Perfusion Studies 0042T

We are planning to use IschemaView software in our stroke protocol for cerebral perfusion studies. Code 0042T is status indicator N and not covered by Medicare/Noridian. Is code 0042T appropriate? What are the appropriate codes for CT cerebral perfusion study?

Axillary Artery Exposure with Conduit Creation for TEVAR

"Open exposure of the right axillary and later left femoral artery. A glide wire and catheter were used through the axillary artery and a pigtail placed in the mid aortic arch for aortogram. The wire was advanced down the true lumen of the dissection and followed carefully with IVUS to make sure we remained in the true lumen. The air into the true lumen was essentially completely obliterated. We followed the contrast into the infrarenal aorta and confirmed location with angiography and IVUS, then continued down into the left femoral artery, where we cutdown and grabbed the artery. We passed a long sheath retrograde back up into the non-dissected portion of the arch and a wire, which was opened pressed up against the aortic valve, and used a 22 dry seal sheath from the left groin. The TEVAR device was delivered. Completion images confirmed landing zone; guidewires and catheters were removed." I was thinking of reporting codes 33881, 75957, 34812, 36200x2, 37250, and 75945. Any coding advice on axillary exposure and conduit is appreciated.

76377

How many times can you use code 76377 in a cerebral case? For the following example, would we submit codes 76377 and 76377-59? "There are multiple large aneurysms of the distal basilar artery. The exact characterization of these aneurysms is not possible on standard projection AP lateral imaging and would require a 3D angio, which was performed from the right vertebral artery. 3D performed on right vertebral, then right internal carotid artery injection shows multiple aneurysm of the infraclinoid and supraclinoid ICA. The exact measurements of these aneurysms are not clear on standard projection AP lateral imaging. 3D rotational angiogram was indicated."

Popliteal-Plantar Artery Bypass, Insitu

Would you use code 35587 (in-situ vein bypass, popliteal-tibial, peroneal) or an unlisted code (37799) for popliteal-plantar artery bypass?

Aspiration Thrombectomy

Laser catheter SFA, popliteal, tibioperoneal trunk. Angioplasty of the left popliteal artery. Aspiration thrombectomy of the left popliteal and left peronal/left tibioperoneal trunk arteries was then performed using a Pronto LP aspiration catheter. Is it okay to code the thrombectomy with atherectomy?

Embolization of Vein Branches off FP/SVBPG

For the following example, which is the correct code to report? 37241 or 37242? "Patient has in place a right common femoral artery to below-knee tibioperoneal trunk insitu great saphenous vein bypass, which appears patent. Several areas of enlarged tributary veins emerge from within the proximal, mid, and distal thigh, providing rapid flow of contrast into the venous system. These appear to be filling antegrade from the bypass. The anterior tibial artery, beyond the anastamosis, was in need of revascularization; however, it could not be accessed. A prograde catheter was advanced down into the bypass and selective access into a tributary vein branch off the insitu conduit was obtained. Coil embolization x three coils was performed using 2 x 20, 2 x 40, and 2 x 40 coils into different vein branches. These coils are under arterial pressure and were accessed through the arterial system, but as an insitu vein, it is connected to the venous system."

Cone CT

Can code 76380 be added to the interventional coding for the following? "IVCgram with complex retrieval of IVC filter requiring dissection. Post retrieval cavagram and cone CT without contrast demonstrate a single fractured filter leg as seen on cone CT and with fluoroscopy."

Cerebral Angiogram with Embolization

"Cavernous carotid artery aneurysm was found on CTA. Therefore, selective catheter was placed on right internal carotid artery, and cerebral angiogram was confirmed aneurysm. Catheter was then navigated into the right middle cerebral artery, and Pipeline embolization device was placed across the neck of the aneurysm. Angiogram showed endoleak. So the second pipeline embolization device was placed." Can I report code 36224 along with 61624, 36217, and 75894? Or, should I use codes 36224 and 61624 only?

Epicardial Lead Removal Only

"In 2012, patient had left mini-thoracotomy and placement of epicardial pacing system; however, the place where these leads were attached to the pacemaker generator was infected. In view of this, in October 2014, the leads were truncated at the point where they were entering the pericardial space, removing the remaining part of the leads towards the pacemaker generator as well as the generator itself. This admission, patient was temporized with a transvenous pacemaker system from the neck and was sent to Cardiothoracic Surgery for placement of epicardial leads. Upon performing median sternotomy, we noted significant adhesions inside of the pericardial space from the previous opening of the pericardium. These adhesions were carefully taken down to the point where I was able to identify 3 epicardial leads that were placed before and were truncated at the level of the entry into the pericardial space. These were carefully released and removed and sent to the pathology." The only code I am coming up with is 33999 (in addition to 33202/33221-51, implant report not attached).

75625 vs. 75630

"Patient with aortic stent graft in to evaluate for endoleak. From right CFA, catheter was advanced over a wire into proximal abdominal aorta cephalad to patient’s graft. Carbon dioxide aortogram performed. Catheter was withdrawn into the graft and aortograms performed in different projections. Selective right internal iliac arteriogram was then performed. Left CFA was accessed and catheter advanced into the left internal iliac artery for selective arteriogram. These demonstrated small endoleak at base of aneurysm below the graft bifurcation." Codes 36245-50, 75736, 75736-XS, and 75625 were assigned. As patient already has a known aneurysm treated with stent graft, would the aortogram be reported with code 75625 or 75630?

Defibrillator RV lead replacement due to defect with repair of the RA lead

"Patient admitted due to multiple shock from defibrillator and deterioration of the insulation and exposed part of the RV conduction wire. After testing, the decision was made to implant a new RV lead and repair the old lead with silicone. A new RV lead was advanced to the right atrium transvenous and then positioned under fluoroscopic guidance with the tip in the mid right ventricular septum. Attention was then turned to repairing the exposed portion of the right ventricular lead. First all 3 pins were capped with silicone caps, which were tied in place. The exposed part of the lead was then covered with a silicone tube, the medical adhesive silicone was placed inside the tube, and the tube was closed with 2-0 silk ties at approximately 3 cm intervals. The right atrial lead was repaired in a similar fashion. The old atrial lead and the new RV lead were reattached to the old defibrillator. The leads were then checked through the device. The device with the capped RV lead was placed in the pocket and the wound was closed." Would you report codes 33216 and 33218?

V45.82

I am finding little reference for the use of this code. Would you use V45.82 if the provider documents history of stent or PCI? Can it only be reported if the exact word "angioplasty" is dictated and at no other time?

Vertebral Body Biopsy at Two Levels

The patient had breast cancer with multiple vertebral lesions. The physician biopsied the L1 and L2 vertebral bodies using two different access sites. Would you report code 20225 twice? One of the coders is saying that we should only code one biopsy since it is a contiguous site and it was probably done just to ensure a proper specimen. We would like your opinion.

LHC Documentation

If aortic pressure is documented, but not the ventricular pressure, can you still bill code 93458? We need to understand exactly what documentation is required to bill left heart catheterization code 93458.

Lead Fracture

We have a patient who presented with an existing dual chamber ICD for an upgrade to a biventricular ICD. The LV lead was inserted, but after the insertion this lead was accidentally damaged with the slitter catheter. This new LV lead was then removed, and a new LV lead was inserted. Do we code for a lead removal in this case or just stick with the code for the addition of the LV lead (33225) since it was all the same operative episode?

Cystoscopy with insertion of an occlusion balloon catheter for PCNL

I'm not sure what code would be appropriate for cystoscopy with insertion of an occlusion balloon catheter(52005 vs. 53899). "The urologist performs this prior to the patient going to IR for percutaneous nephrostomy tract dilation. The interventionalist manipulates the ureteral balloon cath, positioning it near the UPF, and the balloon is inflated. Contrast and air are injected, and the collecting system is opacified and distended. Tract is dilated (50395-59), and case goes back to urologist where he does the percutaneous endoscopic nephrolithotripsy and nephrolithotomy (50080, 50081). Then the interventionalist places a double-J ureteral stent and a nephrostomy tube (50393-59, 50392-59). The following day a percutaneous nephrostogram is done to evaluate integrity of right collecting system and ureteral stent function. No obstruction was noted, so removal of the neph tube was done (50394??, 50389)." The 70000 codes are picked up by the chargemaster.

Brachiocephalic Artery

I have a case in which the catheter was placed in the right brachiocephalic artery and documented as below. "Right brachiocephalic artery: Cervical view: The catheter was advanced into the right brachiocephalic artery, and angiography was performed over the cervical region. The cervical view of the right brachiocephalic artery shows tortuous origin of the right common carotid artery and tortuous origin of the right subclavian artery. The origin of the right vertebral artery is not well visualized. There is no significant steno-occlusive disease noted." If the left subclavian was also selected and the left vertebral was viewed and documented, would I only report code 36225 (unilateral)? Or would I also be able to report code 36221 for the right side? 

Contrast Echo

How would we bill for Definity administered as contrast during a non-stress echo? Code 93352 is defined as used during a stress echo, but they did not perform the stress portion and they used Definity instead of doing a bubble study. Would 93352 still be the correct code in addition to 93306?

Angiography with Laser, ICD-10

I came across ICD-10 code B210110, Fluoroscopy of single coronary artery using low osmolar contrast, laser, intraoperative. In which scenario is laser used for angiogram? If it is for atherectomy or thrombectomy, I would think it should be an additional code instead of angiogram with laser.

Branches of the LAD

In the left anterior descending (LAD), is the left posterior descending artery (LPDA) considered an additional branch in coding? Or are only the diagonals of the LAD considered additional branches?

Coding Both Bone Marrow Aspiration and Bone Marrow Core Biopsy

According to the CPT Assistant March 2015, when both bone marrow aspiration and bone marrow biopsy of the same site are performed we can report both codes 38221 and 38220. Since there is an NCCI edit, can we use a -59 modifier to override this? Please clarify.

Biventricular Pacemaker Gen C/Out

Our physician performed a biventricular pacemaker generator change. He also inserted a new right ventricular lead and capped the old one. I reported codes 33229 and 33216; however, code 33216 is being denied. Maybe I am not seeing what is a simple answer. Could you please assist?

Removal of Previously Placed Occluded Graft

We could use help on coding for the removal of the previous placed occluded graft. "Procedure: The common femoral, the superficial femoral, and profunda femoris arteries were dissected first on the right and then on the left. The femoral-femoral crossover bypass was dissected. The bypass was found occluded. The patient had an excellent pulse on the right side, but no palpable pulse on the left side. We cross-clamped first on the right side the distal external iliac artery, the profunda femoris, and the superficial femoral artery. We transected the femoral-femoral bypass that was occluded, and excised as much graft tissue as possible so that we had a good inflow through a wide opening in the right common femoral artery. On the left side, an identical procedure was performed of the occluded superficial femoral and profunda femoris artery. We transected the femoral-femoral crossover bypass. We almost completely excised the old graft that was well incorporated. It had no evidence of infection."

Midline Catheters

We are confused on what CPT and ICD-9 codes should be used for placement of a midline catheter. We were using code 36000, but our auditor recommends code 36569-74 (local anesthesia is used) based on CPT Assistant September 2014. The intent is to place a midline, not a PICC, so there is some confusion as to why code 36000 isn't appropriate. Also, wouldn't we change 38.97 to 38.99 as well, since these are not in the central circulation? Here is an example of our dictations: "An appropriate arm vein for line access in the upper arm was widely patent, and a hardcopy ultrasound image was recorded. 1% lidocaine was used for local anesthesia. Using ultrasound guidance, real-time visualization of midline needle entry was used to gain access to the patent right basilic vein above the antecubital fossa. The midline was deployed and was flushed with saline and fixed to the skin. Tip of the midline catheter lies in the peripheral venous circulation distal to the axillary vein. IMPRESSION: Successful right 18-gauge midline placement with use of real-time ultrasound."

Midline Catheter Placement

What is the appropriate CPT code for a midline catheter placement?

Stent for Dialysis

What is the appropriate code for non-coronary stent replacement performed on a dialysis patient?

Pericardial Window

What is the appropriate code for the creation of pericardial window with biopsy?

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?

Pecutaneous Gallbladder Aspiration

I have read the guidance for use of code 10160 when there is not site a specific code for aspiration of abscess, but with our Medicare carrier (NGS) they do not allow for coverage for the dx's that I usually receive for percutaneous aspiration of the gallbladder. I have therefore been using the unlisted biliary tract CPT code. What would you recommend for this scenario? Usually the dx is acute cholecystitis and the providers usually state that no catheter was to be placed.

92970 vs. 33990

I am very confused about the Impella devices used during heart catheterization. I was comfortable using code 92970 since it was explained that code 33990 is for heart transplant patients and a long-term situation versus 92970 short-term (6-8 hours). However, the hospital is stating they are using code 33990. What is one key fact I can look at that would positively identify the proper code one way or the other?

Re-Open Pocket While Patient Still in the Room

Is this additional work codeable? If so, what codes? "Implantation of dual chamber pacemaker was performed. The wound was then closed. During the closure, postoperative check revealed that there was increased impedance in the atrial channel. The wound was then reopened without the patient leaving the room. The lead was then removed from the header and reinserted with resolution of normal function. This may be secondary to air in the header. Set screw was in place. After this adjustment, the device is functioning normally. The patient was taken out of the room in satisfactory condition. The pocket was also irrigated with bacitracin solution for a second time."

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.

77002 vs. 77003

A radiology tech and I are having a disagreement on which fluoroscopy code is correct for a vertebral body bone biopsy. He says it should be 77003, but I think it should be 77002. I think code 77003 is for injections/aspirations, while code 77002 is for biopsies. Can you help settle this for us?

Arterial and Venous Stent

For patient with dialysis access, the following findings are noted and treated: "An 80% stenosis was observed in the arterial anastomosis. A 70% stenosis was observed in the axillary vein. A 70% stenosis was observed in the subclavian vein. The arterial anastomosis stenosis was treated with angioplasty using a standard balloon, size 8 x 4. The post intervention stenosis was 50%. The residual stenosis was treated with a nitinol stent, size 8 x 40. The subclavian vein stenosis was treated with angioplasty using a standard balloon, size 10 x 4. The post intervention stenosis was 40%. The residual stenosis was treated with a stent using a nitinol, size 12 x 40." We reported code 37236 for AA stent and 37239 for subclavian stent, but since 37239 is an add-on to 37238 the claim was denied for not having identifying code. Are we to submit code 37236 for arterial stent and 37238 for the venous stent since both are billable?

Duplex

When a duplex scan (93976) is performed on the patient, as well as color flow Doppler and spectral Doppler, is there anything additional to report? My understanding is that if something separate and distinct is happening, a modifier may be applicable. However, in this case, all patients seen in the facility for the duplex are also undergoing a pelvic ultrasound (non-OB), so none of the cases seen are encountering anything separate and distinct, as it has been adopted as a policy it seems. Just looking for clarification, as this is the feedback we received from some auditors: "Color flow Doppler done without spectral Doppler has always been a non-billable charge, as color Doppler alone is inclusive to the US procedure. However if a true duplex evaluation, including both color and spectral Doppler, is performed, there is most definitely an additional service to report (93975/93976)."

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