I just completed your 2016 updates webinar, and I understand that there are new nephrostogram and pyelogram codes that bundle diagnostic imaging. However, I noticed that in the 2016 codebook, under code 50390, it still directs the coder to add code 74425 (urography) to the 50390 injection code. I assume this is not for a diagnostic study. Under what circumstances or in what scenario in 2016 would you use code 50390 with 74425?
"The physician performs a diagnostic angiography of the left lower extremity (75710-59) and then decides to place stents in the mid, distal, and proximal SFA (37226-LT). After this he performs a confirmatory angio and determines there is thrombus material in the posterior tibial and peroneal arteries. He then performs a suction thrombectomy, which removes the thrombus." I am unsure how to code the thrombectomy, as it was not mechanical and it is in a different vessel territory than the SFA stents. Is unlisted code 37799 my only option here, or is this not even billable?
If an electrophysiologist performs an ICD removal from the left side, moves it to the right side, and then tunnels the lead from left to right and reattaches the lead to the right-sided defibrillator, is there a reportable code the physician can use for the work involved in the tunneling?
Patient was admitted and 1 gm IV procainamide was given in an outpatient setting. My doctor dropped the charge of 93623 (the add-on code) and nothing else. This was done alone and not part of an EP study. What code should I use to bill for this?
The use of MAC is being done more frequently within hospitals during EP studies as well as other diagnostic services. Both G-codes currently available are G-codes assigned status indicator M. Per AMA, this should only be done when medically necessary or potential for adverse reactions to the procedure. Our OR currently charges this a regular anesthesia for all EP studies, but I'm not sure this is appropriate. Code G9654 will be new for 2016 (also status indicator M). Any advice?
This Q& A below was in the ZHealth coding newsletter of December 2011. Does this still apply, or has there been changes to billing angioplasty with stent placement based on intent? Original Question: "Can you bill angioplasty code 35476 and stent placement code 37205 in the same venous (SVC-IVC) or pulmonary artery (92997, 37205) when angioplasty is not just for inflating a stent that is placed?" Original Answer: "Depends. There needs to be an intent to only perform balloon angioplasty, with a suboptimal outcome requiring stent placement to code for both. If this is not documented, I would only code the stent placement."
The intended procedure was to place a coronary stent, but, after much time and many attempts with various caths, the lesion was not crossed. How should this be billed?
I'm getting denials for codes 75716 and 75625 billed with 37221/37224 or intervention codes billed on same encounter. The CPT Codebook indicates that for lower extremities the radiological S&I directly related to intervention is included. In the past we have billed these S&I codes with a -59 modifier. Are they still eligible to code?
I have an attempted port placement: "Right internal jugular vein was accessed with a needle under ultrasound guidance with angiography of the right internal jugular vein. Catheter was removed. Left internal jugular vein was accessed with needle under ultrasound guidance. Needle was advanced to the brachiocephalic and imaged obtained of the left jugular and brachiocephalic veins." Since the SVC could not be accessed via either of the jugular veins due to central occlusion, the port catheter placement was aborted. Are codes 36000, 36000-76, 75860, and 75860-76 appropriate?
Can I bill for both codes 36010 and 93531 for the following, since it comes up as bundled in the NCCI edits and needs a modifier? "Catheter Course: The right femoral vein and right femoral arteries were percutaneously entered under ultrasound guidance, and a 4 French sheath was placed in each vessel utilizing the modified Seldinger technique. The right femoral vein was pre-closed with three (3) Perclose devices. The 4 French sheath in the right femoral vein was eventually upsized to a 16 French Gore DrySeal sheath. A 4 French pigtail catheter was inserted into the 4 French right arterial sheath and subsequently advanced retrograde to the ascending aorta and into the morphologic right ventricle (systemic ventricle). A 7 French GL catheter was inserted in the right femoral sheath and advanced in the usual fashion to the IVC, inferior and superior baffles, and SVC. Pressures and saturations were taken, and an angiogram was performed of the IVC."
In your endovascular surgery book it states that venous code 37187 is used once per day per vascular territory. Is the venous vascular territory the same as arterial iliac, fem-pop, and tibial-peroneal territories? If a physician is doing a thrombectomy in the iliacs (common, external) and femoral (common, SFA, and popliteal) would code 37187 be reported twice or just once? I just want clarification on the initial day.
Is the following documentation enough to support charging code 76937? If not, can we down-code it to 76942? Physician is placing a bedside non-tunneled CVC. He uses US guidance. Here is a copy from the note: "Preparation: Sterile preparation of site (in usual fashion, with 2% chlorhexidine gluconate, with full drapes, gown, gloves and mask). Vessel was identified with ultrasound guidance. Technique: Seldinger technique used, location (left, femoral vein, 1 attempt), anterior approach used, catheter type 4 lumen catheter, location confirmed via flashback, catheter flushed with saline, dressing applied (catheter secured, semi-permeable transparent dressing applied), monitoring during procedure (blood pressure, cardiac, continuous pulse oximetry). Procedure tolerated: well."
I am coding for the hospital cath lab services. We have a large percentage of patients who are admitted with an acute MI, and the intervention is performed the next day. My understanding is that code C9606 is appropriate if the patient goes to the cath lab within 90 minutes [e.g., patient presents with NSTEMI and 24 hours later goes to the cath lab for a left heart cath with V-gram, coronary and graft angiography, and two drug-eluting stents in the LCx (95%)].
What would we report when only a right heart catheterization was performed in addition to an LV injection?
I'm not sure if I can bill separately for the Sitz marker placement. I'm thinking unlisted, but what are your thoughts on this case? "The lower abdomen and current cecostomy site were prepped and draped in the usual sterile fashion. Initial fluoroscopic image identified the pigtails of the current Chait tube to be within the region of the cecum. A stiff Glidewire was introduced through the Chait tube and advanced into the ascending colon. The current Chait tube was removed in its entirety. A 12 French vascular sheath was inserted over the Glidewire with tip positioned within the ascending colon. A C-wire was placed through the 12 French vascular sheath with tip positioned in the ascending colon. The 12 French catheter sheath was then removed and replaced over the Glidewire. The Glidewire and inner dilator of the vascular sheath were removed. The external portion of the gastric sheath was cut. Under fluoroscopic guidance, 72 Sitz markers were placed through the vascular sheath and into the cecum. The sheath was then removed. A new 28 Chait tube was replaced."
"Femoral access gained. Cath to infrarenal aorta, aortogram performed showing high grade stenosis in right main renal artery and on left 3 renal arteries. Left renal cannulated and angiogram performed, confirming 3 renal arteries and no significant stenosis. No intervention on left. On the right catheter placed at the level of the right renal ostium and crossed this with a wire. Obtained an angiogram to confirm placement and then placed a stent across the lesion. Post treatment angio showed widely patient right renal artery." Would you report codes 36251, 37236, and 36245?
I know in past years renal vein transposition was unlisted, and it is what I have always used. I have a physician asking if we can use code 34502, but I am not sure I agree with that code, as the only IVC repair/reconstruction completed is where the renal vein is taken down. I am just wondering if there is something I am missing somewhere of any new codes that can be used, or if it truly is just unlisted.
We did a Mitraclip with TEE (93355) guidance. I noticed that medical records coded this as "B244ZZ4 - ULTRASONOGRAPHY OF RIGHT HEART, TRANSESOPHAGEAL". When I asked about it, I was told the following: "The cardiologist needs to state 'right and left TEE' in the procedures performed or description of findings. The coders cannot assume.” However, the report has the supporting findings of right/left chambers, all valves and measurements, pressures, etc. Before I speak with the cardiologists on this request, what is the appropriate documentation for ICD-10 coding on inpatients? HELP!!
The way things are in the book is confusing. When looking in the index, both "insufficiency, aortic" and "insufficiency, mitral" go to the I3x codes (nonrheumatic), but the "insufficiency, tricuspid" leads you right to code I07 (unspecified). If you are coding aortic stenosis (with or without insufficiency), you are brought to the I35 codes (nonrheumatic), yet mitral stenosis (with or without insufficiency) brings you to I08 (rheumatic) codes. ICD-9 was clear, as the codes were specific to either being rheumatic or NOS. With ICD-10, the description in the tabular section of the book for the rheumatic codes includes conditions whether specified as rheumatic or not. How would you diagnosis code a patient with aortic, mitral, and tricuspid insufficiency?
Our office has been experiencing a new problem when billing HAP insurance. We had a patient who had MRI of the thoracic spine and an MRI of the right shoulder on the same encounter, which was billed using CPT codes 72146 and 73221-RT. HAP paid only on the MRI of the shoulder and not the MRI of the thoracic spine. HAP informed us that the MRI of the thoracic spine was denied based on CMS cutbacks. The same happened with another instance when a patient came in for an MRI of the thoracic, cervical, and right shoulder on the same encounter; HAP only paid for the MRI of the right shoulder and denied the thoracic and cervical due to CMS cutbacks. Am I missing an additional modifier that needs to be appended, or is it that the MRI of the spines should be done on a different day than the MRI of the extremities??
During a CT biopsy of the lung, the patient had a pneumothorax. The doctor performed "autologous intrathoracic administration of blood product for treatment of pneumothorax". Is there a code we can bill for this?
Now that there is an edit in place between C2616 and any of the liver/spleen NM scans, should we no longer report the NM scan following a Y90 embolization procedure?
"Intractable idiopathic epistaxis. Selectively cathed the right and left CCA to view neck and face vessels, selectively cathed the right ECA, and selectively cathed the right and left internal maxillary arteries confirming no undesired collaterals. Embolized the right and left internal maxillary artery with PVA and gelfoam. Post angio was done to confirm no residual nasal mucosal stain. Then a right facial artery was selected, and angio proved no significant supply to the nose from this artery." Please let me know if you would code this differently and why. I'm looking at codes 36222-50, 36227-50, 61626-RT, 61626-59LT, 75894-RT, 75894-59LT, and 75898. Is there another code for catherization of another branch off the ECA?
I'm not sure how to code this. Patient was in our facility as an IP from 11/20-11/29. We do charge our cath codes on IP, but they don't "go out the door on the bill"... we use them for revenue tracking in the facility. Patient had diagnostic cath with angios on 11/20 and was then brought back on 11/25 to evaluate the LIMA for potential graft as a stand-alone procedure. Then, on 11/27, they decided to do high risk PCI because patient was not a candidate for CABG due to lung issues. So, since the LIMA was evaluated on a different day and not in correlation with a cardiac cath procedure, should I use code 75756? I don't think it's appropriate to code/charge the LIMA evaluation as a coronary angio on 11/25, and for the 11/20 DOS I don't think it's appropriate to change that to a bypass angio because only native arteries were looked at. What are your thoughts?
Can we report 35476/75978 (x3) with a -52 modifier for ATTEMPTED recanalizations if no angioplasty is performed? "Procedures performed: Right and left heart catheterization. Attempted recanalization of LUPV, RMPV, and RUPV using radiofrequency (Nykanen RF wire). Several rounds of RF were placed at the pulmonary vein sites, but were unable to gain access to a vein. At this point, we did not feel that there was a feasible transcatheter approach to recanalize the stenotic/atretic pulmonary veins. This was the end of the interventional portion of the case."
I’m having a bit of an issue with our physicians documenting crossing the septum (when performed) during some of our congenital heart caths (93532 and 93533). I’ve encouraged them to document whether or not the septum was crossed and also to document if it was through an existing opening or transseptal puncture. In some cases they have documented “patient underwent a prograde right and left heart catheterization” or “the atrial septum was crossed” and then charged 93533. Is that sufficient? If the patient has an ASD, VSD, or PFO, can I assume if they say they crossed the septum if it was through one of those openings? In hopes of clearing this issue up, can you share your recommendation of what the documentation should reflect in order to properly charge CPT codes 93533 and 93532? I've been taught never to assume anything.
"Right common femoral artery was accessed utilizing micropuncture technique. A Bentson wire was advanced into the abdominal aorta, over which a 5-French vascular sheath was placed. A 5-French Contra 2 catheter was then used to select the right renal artery and digital subtraction angiography was performed in the PA and RAO projections. The catheter was repositioned into the left renal artery and digital subtraction angiography was performed in the PA and LAO projections. Decision to intervene was made based of these images. The vascular sheath was exchanged for a new 6-French sheath. A 6-French guiding catheter was then advanced into the proximal renal artery. A 0.018 inch McNamara wire was advanced into the upper pole artery of the kidney, and a 0.016 inch fathom wire was advanced into the lower pole. Angioplasty of the proximal aspect of the upper pole renal artery was then performed utilizing a 5 mm x 2 cm balloon. The balloon was deflated and post angiography angiogram was obtained." Unilateral or bilateral renal angiogram? Which is correct: 36254 OR 36251-RT, 36253-LT with 35471/75966?
"INDICATION: 36 year old female with a family history of ruptured intracranial aneurysms, who underwent clipping of an unruptured right anterior choroidal aneurysm in 2003, was recently found to have growth of a right posterior communicating artery aneurysm over the past several years. Embolization of this aneurysm with a biplane embolization device was therefore recommended. COMPARISON: Cerebral angiogram dated 11/18/15 LVA catheterization and angio RCC and RICA catheterization and angio 3D angio transferrred and processed on separate workstation. Embolization of right PCA anuerysm using pipeline embolization device. Post-embolization right ICA, RCCA, left vertebral." Is this reported with codes 61624, 75894, 75898 x 3, 36217, and 76377?
"Patient with stable angina and abnormal nuclear stress test has a left heart catheterization with LV pressures measured and coronary angiograms. Then proceeded to PCI of RCA chronic total occlusion. Tried wires using an over-the-wire balloon, but never could cross due to bridging collaterals and inadequate support from radial access in addition to poor visualization due to obesity." Will chronic total occlusion require coding C9607-74RC/92943-74RC even though there was no combo of the three (3) revascularization techniques attempted? If only angioplasty were used rather than a combo of angioplasty, stent, and atherectomy techniques, would codes C9607-74RC/92943-74RC still be reported? Or would angioplasty 92920-RC be reported instead?
"Patient has a known MCA aneurysm associated with a left occipital AVM (previously coiled M1 segment of aneurysm now with a neck remnant). Angiography is done with catheter in the left ICA in order to obtain optimal working projection for treatment of the known aneurysm. They deployed a stent across the aneurysm neck and proceeded with coil embolization of the aneurysm sac. Post embolization angio was performed and demonstrated near complete obliteration of the aneurysm sac." These are the codes I am considering: 36217, 61624, 75894, and 75898. I would appreciate your thoughts on coding the cath placement of the MCA. And, is the stent placement just part of embolization code 61624?
Multiplanar T1 & T2 images were obtained with pre & post contrast. Images were obtained sequentially after the intracutaneous inj. Of 4ml of Multihance mixed w/lidocaine & sodium bicarb. 19 ml of contrast was injected IV w/o complication. Sagittal, axial, and MIP images are provided. Precontrast T2 weighted images show a mild amount of edema along the plantar & radial forearm. Max thickness of adipose tissue in forearm is 1.4 cm Max thickness upper arm is 6.6cm. Multiple enhancing channels are seen on sequential images performed after intracutaneous inj. Majority of these are smooth w/ increase in size on the MR venogram single channel on the dorsum of forearm extends from level of radial styloid proximally 3 cm. terminates at level of dermal backflow etc. MR lymphangiogram and venogram show probable lymphatic channel along the dorsal distal forearm. Is the lymphangiogram an unlisted 76498 & MR venogram extremity 73225.
I think these back injections are based on substance injected and location of injection. When would we choose codes 62311 and 64483? I think the office used codes 62282 and 62311, but code 62282 is injection of a neurolytic substance, and the examples given in CPT for the medications don't seem to line up with the medications used in these injections.
A 19 year old male was recently evaluated for Brugada syndrome. The procedure was done while he was an inpatient. The physician generated the following report: "Resting EKG normal. 17 mg/kg procainamide given over 30 minutes. No significant ST changes, RV delay patterns w/ T V1-V2 ; ST normal. Evidence does not suggest Brugada or other await genetic testing, no specific intervention at this time." I apologize for the gaps, this was a hand-written report, and I am unable to copy. I am having difficulty finding the proper code for this procedure. While this procedure is not performed often, there is the chance it may be done again. Would it be appropriate to code an infusion code versus 93017 for hospital tracing of an EKG, the miscellaneous cardiology code 93799, or would it simply be part of E/M services for that day?
"A metal port was placed, and a 10 mm 30 degree scope was introduced. The pleura showed many areas of white plaque and some areas of asbestosis. The white plaque was biopsied. A 3 cm incision was then made overlying the 4th interspace starting at the anterior axillary line and extending posterior. The soft tissue was dissected with cautery, and the pleural space was entered under direct vision and dissected. A small Alexis wound retractor was placed into wound and tightened. Using ring forceps, the lung was pushed off the diaphragm. On the medial posterior portion, we found a 2 cm cyst coming off the diaphragm. There were no masses visible or palpated in the LLL. The cyst was grasped and resected with cautery taking the entire cyst with rim of diaphragm. There was a second smaller cyst just anterior to the first. It was grasped and resected with portion of diaphragm. These were sent for frozen section. Preliminary path shows benign mesothelial cells. There were two small 0.5 cm holes in the diaphragm from the resected cysts right next to each other. These were closed with suture." What code(s) would you recommend for this?
"The left ventricular apex was then exposed utilizing a small anterior thoracotomy, French delivery mechanism was placed into the left ventricular apex and into the central orifice of the mitral valve, just above the closure plane of the valve. A 20 mm Tendyne transcatheter mitral valve was then successfully deployed in a supra-annular position utilizing transesophageal echocardiographic guidance. Once proper position of the valve was confirmed and lack of left ventricular outflow obstruction also verified, the valve was released and apical pad was secured to the apex of the heart." What would be the correct codes: 33999 only or 33418 and 93462?
When is it appropriate to bill codes 35302, 35371, and 35372 together on the same side? If the physician states an eversion or deep in the profunda, can it be billed with modifier -59?
How should we code the following? We have reported code 33363-62 and nothing else. Is that appropriate? "DX: Significant left ventricular failure with a need for transarterial aortic valve. Procedure: Placement of Dacron shunt to anterior surface of the left subclavian artery to facilitate placement of a transarterial aortic value. Procedure Note: Traverse incision in the left infraclavicular. Longitudinal arteriotomy was made in the vessel with a 15 blade and extended with Potts scissors. 10 mm Dacron graft was then anastomosed end of graft to side of the subclavian artery. Clamps were removed from the vessel, and two leaks in the suture line were controlled with interrupted 6-0 Prolene simple suture. Procedure was then done to implant a trans Dacron graft aortic valve."
I am coding a case for insertion of a CentriMag bivad device "with ECMO support". The provider places a cannula in the left atrium and then an additional cannula in the right atrium via femoral vein insertion. He then places a 10 mm Hemashield graft in the pulmonary artery and one in the ascending aorta. After tunneling all grafts out to the chest wall, he states, "The patient was then converted to biventricular support with inflow for the RVAD from the right femoral venous cannula and outflow to the pulmonary artery cannula, and to the LVAD with inflow from the left atrial cannula and outflow to the ascending aortic cannula with ECMO support." This note reads exactly like a standard bivad insertion with the placement of the cannulas. I know ECMO circuits are sometimes used as temporary VADs, but the CentriMag does appear to be a VAD device per the manufacturer's website. Given the mention of ECMO support here, though, I wanted to ensure the coding should still be 33978 for implantation of an extracorporeal BIVAD.
I was needing some information on how my physicians should dictate certain x-ray reports. Is it appropriate for them to only dictate 6 views of the spine, or should they include bending or flexion views in their documentation? The same with reporting codes 73510 and 72170... If they give me two separate reports, can I bill for both or only for one?
We work in a hospital where MRI enterography is performed. We code these studies with 74183 and 72197. What terminology needs to be included to support the use of code 72197? Our radiologist feels that stating "no significant retroperitoneal lymphadenopathy seen" would suffice. Please advise.
I have a physician who did a left nephrostogram, ureteral stent insertion, and a nephrostomy tube exchange at the same setting. With the new 2016 codes there is no scenario with a pre-existing nephrostomy tract tube exchange and a placement of ureteral stent. I am getting an NCCI edit for code 50435 saying it shouldn't be billed with code 50693. Am I missing something or misinterpreting something? Would you bill codes 50693 and 50435-XU? The payer is Medicare.
Can codes 36245-36247 be billed when performing diagnostic angiography for a lower extremity exam on the same day of intervention if no previous imaging exists (or if condition has changed since previous imaging)?
In 2016, what are the appropriate CPT codes for the following? "Patient was placed prone on the table. Contrast was injected via left nephrostomy tube and nephrostogram performed. This revealed complete obstruction of distal left ureter at the UVJ. Nephrostomy tube was removed and cath was placed at the UVJ. After multiple attempts, sheath was placed at distal left ureter and dilated with a 6 mm balloon. Next, internal left stent was placed. 10 French safety nephrostomy tube was placed and capped. Impression: 1) Complete obstruction of the distal left UVJ. 2) With difficulty, obstruction was crossed and dilated. An 8 French left ureteral stent was placed. 3) A 10 French safety nephrostomy tube was placed and capped."
What is the appropriate coding for coil embolization of the GDA? Are the caths included? Procedure performed: 1) Selective SMA, hepatic angiography. 2) Coil embolization GDA. 3) Tc-MAA infusion right hepatic artery and left hepatic artery.
I know that, in the past, paravalvular leaks that were repaired with Amplatzer plugs have been coded with unlisted codes. I was wondering, since TAVR procedures are becoming more frequently done, are the percutaneous repairs of paravalvular leaks of repairs still reported with the unlisted codes? Since the TAVR procedure has more defining charge codes I was hoping that these repairs would have been given codes for 2016. Also, do these codes include the heart cath procedures and TEE monitoring done during this repair?
"Patient presented with a Hunt and Hess II, Fisher grade III subarachnoid hemorrhage concentrated in the 4th ventricle with hydrocephalus. Eleven coils were deployed in the vertebral artery to the V4 segment to remove a right pica aneurysm." How do I code this?
"The right groin was anesthetized using 1% Lidocaine. Intravascular access was established via the right common femoral artery under ultrasound guidance. A 6 French sheath was placed. Similarly venous access was established under ultrasound guidance. A 4 French sheath was placed. Venous access was established due to the underlying malfunctioning left antecubital IV. A 5 French JR4 diagnostic catheter was used to cross aortic valve. Left ventriculography was not performed. Next, the same catheter was used to engage the native right coronary artery. Next, JL4 diagnostic catheter was used to engage the left main. Arterial and venous access was established under ultrasound guidance via the right common femoral artery and vein with direct visualization of the needle entering the right common femoral artery as well as the right common femoral vein. Images of the arterial access established with the ultrasound guidance were acquired and recorded in the permanent document." Should I code separate access?
Can we report code 77001 (fluoro guidance) for attempted access prior to the start of heart catheterization? "Venous access was obtained in the left femoral vein with ultrasound, and a permanent record was stored with a 4 French sheath. It should be noted that we used ultrasound for the LFV, but could not enter the vessel initially despite blood return. We then advanced a JR catheter and angled glide wire from the RFV sheath and retrograde down to the LFV. This was used as a target for LFV access under fluoroscopy with success."
What information and/or situation can be documented by the physician to code angina? Does the physician have to specify angina to code angina or WITH angina? What if the patient also has chest pain? Does the physician have to specify ischemic chest pain?
We are looking for an industry standard (based on CPT rules) for how to correctly code critical care (99291 and 99292) for more than one provider. Per rules in the CPT Codebook (on page 25), what should be coded if MD1 spends 30 mins with the patient and MD2 spends 40 minutes?
"A supraumbilical transverse incision was created with a #10 blade. The muscle layers were divided with a bovie cautery. The Omni tract retractor was placed in position. The small bowel was eviscerated to the right side. The aorta, vena cava, left renal vein, and superior mesenteric artery were dissected. All lymphatic tissue encountered was ligated with hemoclips and divided. It was noted that the juncture of the left renal vein and vena cava was unusually high, at or slightly above the level of the SMA, such that the renal vein was as a sling around the base of the SMA contributing to its compression. The vena cava was clamped encompassing the left renal vein juncture, and the left renal vein transected at that level. The vena cava was closed in 2 layers using 5-0 prolene. The closure was hemostatic. The vena cava was then clamped further down from this point (approximately 4 cm) and then incised. The left renal vein was mobilized and anastomosed to the vena cava." My physician wants to charge code 35450 for this procedure. Is there another code to best describe this?
For Permcath placement, should I be billing for failed access site as well as the procedure36558, 36000? "The right internal jugular vein was noted to have a prominent valve. There was hematoma present between the jugular and carotid. The right internal jugular vein was accessed using an 18 gauge needle with one stick using ultrasound guidance. A wire was not able to traverse the right innominate vein. The wire was exchanged for a Glidewire and Berenstein catheter; however, this combination could not successfully traverse the occlusion. The access was removed, and manual pressure was held. Hemostasis was achieved without complications. Attention was then turned to the left neck. The left internal jugular vein was accessed with one needlestick using ultrasound guidance."
We have a new EP doctor coming to our facility. Recently he did an SVT ablation (93653) that was right- and left-sided, pre/post isuprel, 3D mapping, placed a catheter in the CS, utilized ECHO, and performed a transseptal puncture. He is stating that he does not need LA pressures to prove he was in the atrium so that we can charge for code 93462. I disagree. I feel like he should have established proof for charging and record purposes. Also he is charging and reporting that he did both LA and LV recordings via the CS. So to recap, 93653, 93662, 93462, 93621, 93622, 93623, and 93613. Is he correct?
I am having a hard time coding this one. I am having trouble finding an appropriate code for SVG angio. I'm assuming that the other codes are 93458, 93567... "CAD Presentation: Angina cath. Post Procedure Diagnosis: Single Vessel Coronary, 70% Ostial RPDA. Occluded SVG to RPDA. Mechanical Aortic Valve. Severely Dilated Aortic Root. Procedure Performed: Coronary Angiography, LHC, Aortic Root Angiogram and SVG Angiogram. Findings: L-Main-OK LAD-OK LCX-OK RCA-70% Ostial RPDA. SVG to RPDA. Aortic Root-Severely Dilated SVG to RPDA."
"1. IVC gram 2. New filter deployment in the suprarenal position 3. PTA of the infrarenal IVC within the area of stenosis in the occluded IVC filter 4. retrieval of the infrarenal IVC filter 5. stent IVC in the infrarenal portion 6. retrieval of the suprarenal IVC filter and redeployment of this filter in the infrarenal position above the stent. Patient has CTO IVC. She underwent thrombolysis and now has a tight stenosis of the IVC in the area of the IVC filter. Plan is to remove this filter, stent it, and then redeploy a filter higher. Because the filter could have clots, the plan was also to put a filter in the suprarenal position temporarily to make sure she did not embolize. Venogram of the IVC performed. PTA the IVC within the filter to allow smoother passage. Deployed new filter in the suprarenal position. I then retrieved the old filter. Residual stenosis that had grown within the filter, so I stented it and then put a 12mm balloon within this stent. I then retrieved the suprarenal filter and re-deployed it in the infrarenal position above the stent." What would the appropriate codes be?
Can you please help clarify when to code diagnostic angiography? Since we know that patient has cancer, and arteriography and embolization were planned, would these codes be correct: 37242, 36245, 36247, 36248 x4, 72726 x2 (59), 75774 x3 (59)? "CLINICAL HISTORY: Female with hepatocellular carcinoma and hypersplenism presents today for planned arteriography and embolization in preparation for planned radioembolization. PROCEDURE PERFORMED: 1) Selective superior mesenteric artery angiogram. 2) Selective celiac artery angiogram. 3) Selective proper hepatic, right hepatic, left hepatic, and middle hepatic artery angiograms. 4) Infusion of Technicium-MAA into the right hepatic artery. 5) Selective splenic artery angiography with embolization."
Patient underwent endo AAA Endurant II. Provider said two docking limbs with no extensions. We coded 34803, 75952, 36200-50, and 34812-50. After all performed, they discovered a problem in femoral artery, placque removed, and required femoral artery endarterectomy. I'm a little confused as to when we can bill for problems such as this. Do you consider the femoral endarterectomy billable as well? AAA aneurysm and PVD diagnoses given.
"Patient is post-op ventral hernia repair with aspiration of multiloculated fluid collection. After as much fluid as possible was removed, 8 cc of fibrin glue was instilled." Is this separately reportable? If so, what code would be reported?
"PROCEDURE: IV drug infusion Clinical Summary: This is a 40 year old male with idioventricular rhythm, VT and PVCs all coming from the same source. These are gith bundloid with an interesting transition. There are negative in I and aVL; positive in the inferior leads. DESCRIPTION OF PROCEDURE: I brought him in. He was not having any PVCs and that was despite stopping flecainide and beta-blockers, so we put him IV drug. We put him on Isuprel and got his sinus rate up to 150 beats per minute or there abouts, and he had no PVCs. We let it wash out. There were no PVCs. He was never sedated. He then received an IV infusion of caffeine 500 mg IV, and he had a total of 2 PVCs, and that was only when we gave Isuprel combined with the caffeine. FINAL IMPRESSION: This patient has scant ventricular ectopy despite prolonged IV drug infusion of multiple agents." My question is, would you bill this with codes 37202 with 75896? Someone stated that only the meds used can be billed. I am new to cardio, so I am in need of your advice.
73540: Radiologic examination, pelvis and hips, infant or child, minimum of 2 views In 2016, CPT parenthetical notes state "73530, 73540 have been deleted. To report see 73501, 73502, 73503). Note that the previous bilateral code stating hips (plural), which in 2015 had a bilateral status indicator “0” (Indicator "0" in the Bilat Surg Column on the MPFSRVU means that the bilateral concept does not apply for this code), is now “cross referenced” to unilateral replacement code sets (73501, 73502, 73503). I am not able to find a reference that explains this conversion to my satisfaction, as I feel we should instead use the appropriate 2016 bilateral hip code sets 73521, 73522, 73523 dependent on the number of views. I would appreciate your insight on correct reporting in 2016 for imaging a child bilateral AP hips & pelvis on the first view along with a frog lateral bilateral hips & pelvis on the second view.
"After single attempt of manual aspiration thrombectomy, there was extravasation noted of the right middle cerebral artery. The vessel was successfully embolized with Onyx liquid agent with resolution of the extravasation. Can you bill for both the thrombectomy and the embolization? I thought that if in the process of one procedure the physician accidentally punctures a vessel that you cannot bill the patient for fixing that error. Or is that a known risk of thrombectomy that can be billed?
The PA sees a patient in the ER department and performs an initial visit and determines that surgery is necessary. He documents his service while the supervising provider is in a case. When the surgeon is available he has a face to face visit with the ER patient on the same day. The surgeon performs a physical exam agrees that surgery is necessary and documents his portion of the E&M service appropriately. Can the E&M shared between surgeon and PA from the same group practice be billed to Medicare under the physicians number? Does it matter that the PA has made the decision for surgery and orders have been started since this is a shared visit?
Is the following reported with codes 35876 and 35304? "Thrombectomy of the fem-pop bypass was performed with vein patch angioplasty, and flow was successfully restored through the vein graft; however, it reclotted within minutes of restoring flow. After multiple attempts to restore flow, it was felt that there may be an issue with the vein graft, so the graft was removed from the proximal and distal anastomoses. The popliteal artery arteriotomy was closed with a vein patch. A 6 mm thin-walled, ringed gore PTFE graft was tunneled through the previously created tunnels. The ends were spatulated and anastomosed in end-to-side fashion with 6-0 gore suture. Flow was then restored. Doppler interrogation demonstrated excellent flow-through graft. The distal outflow sounded somewhat high resistant. This point dissection was carried down the distal popliteal artery to the tibial/peroneal trunk. There was significant calcification noted at the origin of the tibial/peroneal trunk and anterior tibial artery. A longitudinal arteriotomy was made, and a limited endarterectomy was performed."
I could use some help in this interesting situation. "History: Patient had a dual AICD implanted on the left side. Patient's treatment plan included radiation on the left. The left dual AICD was removed and the leads capped with a single AICD implanted on the right. Treatment was discontinued." Also need help with this procedure: "The single AICD on the right is removed along with the leads (33241 & 33244). A dual AICD was implanted on the left, and the existing leads that were previously capped were uncapped and attached to the dual generator (33230)." I reported codes 33241, 33244, and 33230, but there is a hard edit with 33241 and 33230. CPT indicates code 33263 should be used, but the same type of system was not used (single removed and dual implanted); therefore, I don't think 33263 is correct. Is it correct to code this procedure with 33230 and 33244? I thought the implantation was more important to code than the removal.
"Six vessel diagnostic cerebral exam was performed. Decision was made to treat vasospasm of RICA and LICA." Discussion is whether or not the catheter selections for the bilateral ECA vessel selections are still chargeable since the catheter selections of the RICA and LICA are bundled into code 61650. I don't feel they are since, they are add-on codes to 36224 bilateral in this case.
"Patient underwent a DICD implant. Patient had an existing vagal nerve stimulator where the physician wanted to implant the DICD. The physician removed the VNS and capped the lead. Pocket was then revised to accommodate a DICD and atrial and ventricle leads. The VNS was not re-implanted and was discarded." In this scenario can you code only the DICD implant (33249), or can you also code the VNS removal (61888)?
Is there an ICD-10 procedure code available for coronary brachytherapy?
"Bilateral lower extremity arterial duplex scans were performed with evaluation of the infrarenal abdominal aorta. The infrarenal abdominal aorta measures 2.3 cm proximally, 2.1 cm in its mid portion, and 2.1 cm in its distal portion. The waveform is biphasic, and the peak systolic flow velocity is 74cm/sec. Ankle-brachial indices were measured in both LE. They are 0.96 or greater bilaterally. Waveforms are biphasic in both lower extremities down to the level of the dorsalis pedis artery. Peak systolic flow velocities are within normal range. Conclusions: 1) Resting ankle-brachial indices and pedal Doppler waveform suggesting no evidence of significant arterial insufficiency of either lower extremity. 2) Continuous wave Doppler waveforms of both lower extremities are within normal range. 3) No evidence of infrarenal abdominal aortic aneurysm." We reported codes 93925, 93978, and 93923. Is this correct?
"Patient with AAA aneurysm and critical vascular occlusive disease with claudication presents for endovascular repair. Vascular and IR co-surgeons: the vascular surgeon performs bilateral cutdowns, RCI to femoral bypass (used as access for delivery of Endologix main body device and to bypass critical occlusive disease on the right), and right femoral endarterterectomy." I'm thinking that the bypass could be coded separately and that it would include the cutdown on that side and the endarterterectomy as inflow-outflow...34804-62, 36556, 34812-XS for the vascular surgeon? Please advise.
Is 62360 the correct code for a Baclofen pump insertion?
If ultrasound and fluoroscopic guidance are used for a liver biopsy, should we report code 76942 or 77002? Or both?
We just noticed that guidance codes 76942, 77001, 77012, and 77021 were added as column 2 codes for CPT 50200 effective 1/1/16. There has been no change to the CPT description or to the notes following the CPT code regarding radiological S&I. Are you aware of the CMS rationale for implementing these edits? Any insight you could provide would be appreciated.
How many times may CPT code 76377 be used in a single encounter? Bilateral internal carotid arteries and the left vertebral artery were imaged.
Hi Dr Z, Coding Open and Catheter use procedure? Senario: Discected upper ext. graft and performed graftotomy. Thrombectomized venous end graft which inadvertently thrombectomized arterial limb. Arterial limb clamped. Patient heparinized with 3000 units. After thrombectomy performed, then contrast inj, show residual thrombus at venous outflow of graft. Using clot catheter removed residual thrombus. Inj. contrast. Balloon angioplasty 7mm Armada balloon, then deployed 7x50 mm Viaben stent graft. Resulting arteriography demonstrated wide patency, no residual stenosis and nice luminal surface. We then utilized balloon to perform contrast inj centrally which demonstrated in-stent stenosis of innominate vein stent. Therefore use a 12mm x 60mm Armada balloon angioplastied innominate vein stent. Removed catheter, wire and sheath, locally heparanized and performed contrast inj. through arterial limb of graft, demonstrating wide patency. Closed graft with running 6-0 Prolene suture. Verified homstasis, irrigated wound and close wound with deep layer closer.
I have an interesting case, and I'm wondering if you may have some insight. The patient was to undergo brachiocephalic arteriovenous fistula creation for dialysis access and required a brachial endarterectomy with a bovine patch angioplasty, to which the cephalic vein was then attached to create the fistula. I know in lower extremity bypass procedures the inflow/outflow would be inclusive, but this is not technically a bypass procedure. It has no NCCI edit per Craneware. However, since code 36821 has a "separate procedure" designation, I hesitate to bill these together, as they are in the same anatomic site at same session. If only one code is determined to be billable, could I bill the endarterectomy since this is more extensive (higher RVUs) than the fistula creation (36821), even though the intent of the operative session was for creation of the fistula?
"In order to excise the infected abdominal graft at a later date, patient was scheduled for axillary bi-femoral bypass. However, he developed hemorrhagic shock with hemoptysis and was emergently taken to the operating room 10 days ago to endovascularly cover the pseudoaneurysm with placement of two 28 x 28 x 49 extension prosthesis and Amplatzer plug. He then underwent axillo-bi-femoral bypass 7 days ago and came back to the OR to remove the infected aorta bi-femoral bypass graft (35907-58). Surgeon also removed the endografts and the Amplatzer plug that were placed 10 days ago emergently, which he encountered while removing the aorta bi-femoral graft." Do we separately code for removal of endografts and the Amplatzer plug? If so, do we bill an unlisted CPT code with a -58 modifier?
If sedation is bundled into the procedure code(s), can the physician-owned facility still invoice for the narcotics used?
I am billing for the radiologist who is interpreting images from an intraoperative retrograde urogram. The report is as follows: "Images from an intraoperative retrograde urogram demonstrate opacification of the ureters and collecting systems. No filling defects on these images. A left nephroureteral double-J stent is identified. Please refer to the operative report for further details." Can I report code 74420-26? Many of these types of reports give less detail and only mention seeing a stent in place, such as: "Two fluoroscopic spot images were submitted for review and demonstrate wire and stent placement within the ureter. For complete findings see the procedural report."
Would the following be coded as a 54230-74445 and 54231, or 54235? "23 gauge butterfly needles were inserted into the right and left corpora caverosa just behind the glans penis. Small contrast injection with fluoroscopy confirmed secure intracavernosal location of both needles. While occluding cavernosal outflow with umbilical tape placed around the base of the penis, papaverine 60 mg followed by phentolamine 1 mg was injected into the right needle. The drugs were distributed between the two corpora with massage. Ten minutes later, infusion of half strength contrast material was done through the right cavernosal needle at 1 mL/second for over one minute while pressure was continuously recorded from the left cavernosal needle. Radiographs were saved. Because of markedly abnormal response, redosing was done with papaverine 60 mg and phentolamine 1 mg with one minute of cavernosal occlusion and manual drug distribution. Five minutes later, infusion cavernosometry and cavernosography were repeated. Needles removed."
"Nephrostogram and nephrostomy. Catheter was removed. Using snare, existing antegrade ureteral stent was removed. Glidewire was advanced and a 10 French nephroureteral stent was placed." Should this be reported with codes 50384 and 50433?
"Patient underwent left first rib resection and scalenectomy for thoracic outlet syndrome. Following this, due to significant tightness at the inferior level and to give complete relief, excision of left subclavius muscle and left pectoralis minor muscle was performed." My thought is to use codes 21615 and 21700 for the excision of the first rib and scalenectomy, but I am not sure how to code for the excision of the subclavius and pectoralis muscles, and I would appreciate any direction you could give.
"Patient has a right subclavian pacemaker and is going for radiation to that area and has to have the device relocated. Decision was made to move the device to a subcostal location. Previous device was removed, subcostal abdominal pocket was created, and leads were tunneled to the abdominal pocket and connected to a new generator." Is this just a change out (33228) with the relocation included in code 33228, or is this an instance when we can report the relocation with code 33222?
"Patient had her atrial lead protruding up and tenting the skin. We were afraid it would rupture through. The lead was pulled out as best as it could. We cut it and then pulled the inner core and put an O suture around the end and sutured it to a deeper layer of the epidermis." CPT Assistant, October 1996, page 9 states that code 33218 "includes services like splicing a fracture and/or modifying a terminal pin". Would you consider coding this "repair" with 33218?
Is there a CPT code for the division of the median arcuate ligament? Also, can you bill for this separately with the bypass?
I need clarification on blebectomy/bullous disease. "26 year old male with spontaneous pneumothorax due to small bleb. Physician does VATS wedge resection of small bleb and pleurodesis." Is it okay to use codes 32666 and 32650 for blebectomy vs. 32655? Is it ever okay to use code 32666 for VATS wedge resections of bullae, even small ones, including another pleural procedure? The physician feels he should be able to use code 32666 and pleural procedure like 32650, as he is doing the same work as 32655 but getting less RVUs for 32655.
A patient had an intervention on the right coronary artery. The distal RCA had a chronic total occlusion, and only an angioplasty was performed there (93943). The proximal RCA had an 80% lesion, and a drug-eluting stent was placed there (C9600). I have two questions: 1) Would you suggest coding 93943 or C9600? 2) If only the proximal lesion had been intervened on, would we have to code C9600 since that part of the vessel did not have the CTO, or could we code C9607? (This is for a hospital.)
Can you bill more than one CPT code for embolectomies done on the brachial, radial, and ulnar arteries via the same incision? I understand that, if they are contiguous, you can only bill one CPT code, but what if there are more than two vessels?
Right Popliteal, Tibial/Peroneal,and Posterior Tibial Artery Exploration with Unsuccessful Thrombectomy
"Due to adherent veins it took physician two hours to expose the tibial/peroneal trunk. Both arteries were very calcified. Both were opened longitudinally. Fogarty cath was attempted, but neither artery would allow passage. Incision was extended with exposure down the leg to isolate the posteriort ibial, and arteriotomy was made. Lumen of the artery would not allow any thrombus to be removed. Slight backbleeding from posterior tibial was not enough to proceed with bypass." The physician reported codes 34201 and 34203. I added a -22 modifier to 34203 and a -53 modifier to 34201. Can you please give me directive on this procedure? I felt as though both needed a -53 modifier, but I felt the -22 modifier would not pay, and since it took him so long to isolate that artery I did not feel it appropriate for his sake not to append the -22 modifier. I also wondered if there should just be exploration billed with a -22 modifier. Many questions are running through my head on this one.
Provider performs a fem-pop bypass due to popliteal aneurysm and also ligates the popliteal aneurysm. Can you bill code 37618 with 35583?
"Patient with a prior MI 20 years ago with a scarred calcified anterior wall. He had a worsening EF down to 20% with increasing SOB and, therefore, had a heart cath with Physician A one month ago. He was found to have LVEDP of 13 at that time, as well as 70% left main lesion. The LAD was diffusely diseased. The circumflex had no obstructive disease, and there was some disease in the calcified ramus. Physician B reviewed the films, and he was concerned that the left main may be hemodynamically significant and that ischemia may be causing the patient's fall in EF. Patient was requested to come back in for an FFR of the left main. During the FFR they also performed a LHC." My question is, since the patient had a previous heart cath a month earlier, can we report the LHC with the FFR? If not, then how do we code the FFR, as it is an add-on code?
Related to pelvic, abdominal, and retroperitoneal ultrasounds, we understand that code 93975 or 93976 should not be reported in addition to the base ultrasound code when used for a quick assessment of blood flow or to simply identify a structure. Could you help us clarify for our physicians what elements should be seen in the report in order to substantiate these codes? This is an example of what we often see: "Technique: Transabdominal and transvaginal imaging, 2D gray scale, color Doppler, spectral waveform analysis. Findings: Uterus measures XX, uterine fundus circumscribed hypoechoic structure measuring XX. Another located in the posterior fundus measures XX. Endometrial measures XX. No endometrial fluid seen. Overlying bowel gas structures obscures right ovary. Left ovary measures XX. It demonstrates normal color flow Doppler and spectral waveform analysis. No free fluid seen." Could you please review and clarify if there is sufficient documentation to report codes 93975/93976 in addition to pelvic and transvaginal ultrasound codes?
Can code 37186 be reported twice when performed on bilateral lower extremities at time of angioplasty also performed bilaterally, since these are different vascular families?
Can angiogram and angiography CPT codes be reported if CO2 is being used rather than contrast media due to the patient having CKD?
I have a facility that needs to do a brachial artery cutdown for a splenic artery embolization with coils (37242). The codes for embolization/occlusion do not specify open or percutaneous. Would you charge unlisted code 37799 for the cutdown procedure? Or is it included as part of the overall catheterization access?
Exchange of 1 internal/external biliary catheter in the right posterior inferior intrahepatic biliary duct and exchange of 3 internal/external biliary catheters in the right intrahepatic biliary duct. Can we code 47536 x 4 or just 2?
What code(s) are appropriate when an initial pacemaker system is being implanted and the lead is broken or damaged and has to be replaced?
Is there a code for embolization of a cholecystostomy tract with coils when removing the tube?
Patient underwent AFRO with Viabahn stenting of a right popliteal aneurysm via left common femoral percutaneous access. I am unsure how to code this since popliteal artery aneurysm is not a valid diagnosis for 37226 per LCD. Is there another code you might suggest for this scenario?
Can we bill for an iliac endarterectomy along with the fem-fem bypass here? "CFA was exposed through left groin incision. The femoral artery was not pulsatile, and the incision was extended proximally splitting the inguinal ligament until the ileal femoral segment was exposed. The artery was calcified but pulsatile, and a spot was identified for clamp placement. The artery was dissected and side branches were controlled with loops. Loops were placed around the inflow artery as well as the superficial and deep femoral arteries on the left side. A second vertical incision was made in the right groin, and the fem bifurcation was exposed. At this point there was some lateral plaque but the vessel was generally soft. A suprapubic tunnel was created from the left groin to the right groin. Arteriotomy made in the left CFA and extended up the circumflex iliac artery. An endarterectomy of the vessel was then done with a clean break achieved in the deep femoral artery. Proximally the endarterectomy was blindly extended into the EIA to the point of clamp placement. The graft was anastomosed end-to-side to the endarterectomy. Graft passed into the right groin and anastomosed to CFA."
Years ago I went to a seminar (unfortunately not yours), and I remember the consultant mentioning that it is not good for a doctor to add the actual CPT and ICD-10 (was ICD-9 at the time) codes into the dictation of an operative note. I currently see a doctor who is doing this, and I'm wondering if it is appropriate. Can you tell me if this was just an opinion brought forth from a Medicare auditor or if there is a general rule or guideline on this? For the most part the coding is correct, but some of it is not, and I fear there may be a compliance issue. When I try to find documentation on the subject, I cannot locate much of anything, so I would like to know how you feel about this. Is there is any kind of guideline that states a doctor should or shouldn't? If you feel that dictating the codes into the operative report is a good idea can you explain why?