We are having trouble with how to code for a pocket revision when the pocket is not relocated. It is our understanding that the revision is bundled into the placement or replacement of the pacemaker/AICD. What do we code if all that is performed is a revision of the pocket?
"Patient initially presented for insertion of a dual-chamber pacemaker. Right ventricular lead is placed. However, physician could not get the right atrial lead to capture anywhere. After attempting pacing at five different positions, physician stopped attempts to place a right atrial lead. Instead, physician decided to place a left ventricular lead since patient was going to be paced 100% of the time. Left ventricular lead was implanted and advanced into the coronary sinus. Then an Evia HF-T generator was connected to the leads." Would codes 33207 and 33225 be used in this case since this is a CRT-P? There is an edit coming up that indicates because we are billing C1882 as a device code we would need different codes. Will you please comment on how to appropriately code this case? Should it be coded as though the atrial lead was placed and then add a -74 modifier on the code? This one has me stumped.
A documented pacemaker dependent patient was brought in for end-of-life pacemaker generator replacement. A temporary pacemaker single chamber was inserted, and the dual pacemaker was replaced. The patient was placed in observation where it was noticed that there was a sudden loss of ventricular capture due to the chronic ventricular lead being displaced. The patient was taken to the special radiology suite emergently and had a temporary pacemaker wire placed and then was taken to the cardiology suite where the chronic ventricular lead was replaced. This was originally billed as two sessions (33228 with 33210-59, and 33234 with 33216 and 33210-59). Code 33228 is not allowed with 33216 even with an appropriate modifier. Can we bill codes 33207, 33234, and 33210-59 x 2?
The patient has a pacing defibrillator with the tachycardia detections turned off for several years. The underlying rhythm is complete heart block, so he relies on the pacing function, and the device is at elective replacement indicator status. He comes in to get this replaced with a dual chamber pacemaker. Leads are atrial and ventricle, and only the generator was changed. Would you recommend coding it as a downgrade from AICD to pacemaker or as a pacemaker change?
My question concerns the coding of a temporary pacemaker during a pacemaker or ICD change out for patients who are pacemaker dependent. If during the change out the physician documents that the patient was "quickly connected to a pacing system analyzer", is this codeable in CPT? The PSA is used rather than the insertion of a temporary wire. I'm not clear as to when this would be used rather than an actual temporary pacemaker. Can you explain?
Patient with status post pancreatic and kidney transplant with dropping hemoglobin. A cobra catheter was used to select the pancreatic artery which came directly off the right common iliac (access was right femoral artery). An angiogram was performed. I coded 36245 and 75726. Is this correct?
I am aware of the rules surrounding multiple guidance; however, I had a case that caused me to pause. If a paracentesis or thoracentesis is performed along with a biopsy with guidance, will the guidance used with the biopsy not be coded since the guidance is bundled with the para/thora? My case was a para with ultrasound and a liver biopsy with CT guidance. Since CT is higher than the ultrasound, am I overthinking how this should look? Would it just be codes 49083 and 47000?
"An 18 gauge Caldwell needle was advanced into the peritoneum. Appropriate needle location was documented with cont. sonographic and a paracentesis was performed. The patient's skin was cleaned and dressed. The pt. tolerated the procedure well and was discharged in stable condition. At this time, the Denver Shunt along the left lateral chest wall was accessed with a Huber needle. Manual aspiration demonstrated free flow of ascities. 6 mg tPA was then infused through the upper port of the Denver shunt. Post tPA infusion with contrast under fluoroscopy demonstrated patency of the Denver shunt. The Huber needle was then removed." I planned to report codes 49427, 75809, and 37211, but wanted your opinion regarding my code selection.
We (facility) had a patient come in for a parotid biopsy. The procedure was cancelled after the neck was scanned with ultrasound and no mass was found. This is how the report reads: "By ultrasound exam and palpation, no pathologic discrete lesion was found, and therefore, no attempts were made to perform a biopsy at this time. The area that he pointed out to me appears to represent a strained muscle with no underlying lesion by ultrasound. A thorough exam of the full neck by ultrasound including the parotid area was also conducted." The department wants to charge guidance code 76942 with a -52 modifier. This seems incorrect to me. I think that either we report codes 76942 and 42400-52 or 76536. Can you please give us some guidance for this?
Please advise the propert way to get reimbursement from Medicare or private insurance when billing for insertion and removal of impella device VAD using and unlisted procedure code 33999 not getting any luck
I have a question regarding the use of the "branch" add-on codes for coronary interventions. If the patient has a stent placed into the RC and also has an angioplasty of the OM, would the OM be reported as a "branch", even though it is not a branch of the RC? Would this be reported with codes 92928-RC/92920 (OM), or would it be reported with codes 92928-RC/92921 (OM)? Thank you! You are our go-to guru!
Our physician did a diagnostic left heart catheterization with left ventriculography, coronary artery angios, and bypass graft angios. He then did an angioplasty at the anastomosis of the LIMA graft to the distal LAD. Following this, he placed a drug eluting stent in the circumflex artery and performed a kissing balloon angioplasty of the proximal circumflex and the proximal LAD. I am thinking of reporting codes C9600-LC, 92937-LD, and 93459-59. Could I also report code 92921-LD for the proximal LAD kissing balloon angioplasty since it was via the native arteries and not through the bypass graft?
Can we bill the PA angiogram (93568) if done as a follow-up to verify the occluder is in the appropriate position after a PDA closure? My concern is that this is a follow-up, and a PA angiogram is not done prior to device placement.
Dr. Z- Could you please direct us on a catheter placement code. The physician did a right pedal access and selected the right SFA. Thank you in advance for your help!
The radiology department has submitted code 49460 for the following case, which we are not sure is correct. Will you review and offer how this service should be reported? "History: G tube removal, unable to deflate balloon at bedside, no longer needed. Using sterile technique, the existing PEG tube was injected with contrast and multiple images were obtained catheter within the gastric lumen. A 035 Amplatz guidewire was then advanced through the catheter into the stomach lumen. Gentle pulling traction was applied to the catheter coupled with the Amplatz guidewire. The retention dome was then easily pulled through the gastrostomy site. The catheter was removed intact. A sterile dressing was applied."
Hello! I recently purchased the 2012 coding charge sheets from ZHealth (which, by the way, are wonderful!!)and had a question regarding the updated coding suggestion for an abscess drainage of the pelvis via transrectal approach (for males). It lists the code as 49021, shouldn't this be 49061 since it is labeled as a pelvic abscess;transrectal approach? I understand that a pelvic abscess could extend into different areas such as the peritoneal cavity, however wouldn't the code depend on what area the catheter ended up in? Example-anterior pelvis and/or peritoneal would be 49021 and 49061 for retroperioneal and/or transgluteal abscess.
Is there anything that can be coded for the physician in the following scenario? "Patient has a left femoral arterial line that is no longer needed for monitoring in the ICU. The patient is taken to the interventional suite, and angiography is performed for placement of an Angioseal plug. No other intervention is performed on this day. The patient had intracranial embolization five days earlier with Angioseal placement on the contralateral side (right side)." I don't see a way of coding anything, but I want to be sure I'm not missing anything.
There is a new category three code for a percutaneous laminotomy of 0275T which I am using as of July 1st however what code should I have been using prior to July 1st?
How would you code percutaneous placement of a drainage cathter into an anterior abdominal wall fluid collection? The fluid is located between the abdominal wall and the peritoneal lining. The CT scan prior to this procedure says the fluid collection is adjacent to the inner abdominal wall in the midline and extends inferiorly to the left into the pelvis. There was spontaneous drainage of brown, partially clear fluid from the tube when it was placed. Is it unlisted CPT 49999 and 75989?
If a patient has an appendiceal abscess and a drain is placed in the peri-appendiceal area, would this still be coded 44901 per indication? Or would it be 49021 since drain not placed in appendix?
Per the physician's dictation, aTEE was done, which demonstrated a jet of eccentric severe periprosthetic aortic valve insufficiency. The fistulous tract was crossed with a slip-tip catheter. Through this catheter an AGA patent ductus occluder was deployed through the fistulous tract. Upon release of the occlusion device significant reduction in the periprosthetic valve regurgitation was seen on the TEE and was confirmed by left aortography. The procedure was then concluded without complication. This is not a procedure that we have done in the past and therefore need your advice on how this should be coded/billed.
I have a report for an epicardial VT ablation. The physician advanced a Biosense-Webster NaviStar ThermoCool ablation catheter into the pericardial space and ablation was performed. The dictation states, "The pericardial space was periodically aspirated throughout the procedure and the fluid remained clear." The physician has checked off 33010 on the encounter form. I did a little research on the catheter and it sounds to me like the physician is aspirating fluid accumulated from the irrigation catheter. There was no mention of an effusion and, in fact, an echo earlier in the day stated that none was found. Should I bill code 33010? Or in this case is the aspiration just part of the ablation?
Please do NOT include any actual patient medical records with your question. When a pericardiocentesis is done (33010) and Ultrasonic Guidance (76930) is utilized, does 76930 get a modifier 59? Thank you, Maria (CCA)
In the following example, how would it change if only a fibrin sheath was demonstrated and the tPA was injected but the brush wire was not used. Everything else the same. 2011 case. 1) Patient with a poorly functioning peritoneal dialysis catheter presents for evaluation. In a sterile fashion, the tube is injected with contrast and evaluation of the peritoneal cavity is performed (49400, 74190), demonstrating fibrin sheath around the catheter and multiple adhesions in the abdominal cavity. 8 mg tPA is mixed with saline and injected through the catheter. After thirty minutes, the area is reevaluated, and a wire is placed through the catheter with subsequent disruption of the fibrin sheath (49999, 76496). A repeat injection demonstrates free spill of contrast throughout the peritoneal space.
Dr. Z, How would I code the following report? I'm not sure if 36596/75902 is correct. Historyâ€Ž: â€ŽRecent abdominal Pleurx drain placement, now no longer drainingâ€Ž. â€ŽPlease check tubeâ€Ž.â€Ž Techniqueâ€Ž/â€Žfindingsâ€Ž: â€ŽLimited ultrasound of the abdomen revealed the Pleurx catheter within anechoic fluid within the peritoneal â€Ž cavity of the patient's pannusâ€Ž. â€ŽLimited ultrasound of the remaining abdomen reveals no significant ascitesâ€Ž. â€ŽFluoroscopy of â€Ž the drain revealed no kinkâ€Ž. â€ŽAspiration of the Pleurx catheter yielded nothingâ€Ž. â€ŽContrast injection of â€Ž10 â€ŽmL of Isovue â€Ž200 â€Žwas â€Ž performed under fluoroscopic guidance into the Pleurx drain, confirming contrast extravasation out of the side ports into the â€Ž peritoneal cavityâ€Ž. â€ŽA stiff glide wire was inserted vigorously through the Pleurx catheter out multiple sideholes under â€Ž fluoroscopic guidanceâ€Ž. â€ŽAspiration of the Pleurx catheter still yielded nothingâ€Ž. â€ŽNext, TPA â€Ž4 â€Žmg was administered into the â€Ž Pleurx drain and the drain was cappedâ€Ž.â€Ž Impressionâ€Ž:â€Ž 1â€Ž. â€ŽPersistent occlusion of the abdominal Pleurx drainâ€Ž. â€ŽFollowing TPA infusion, repeat attempt at aspiration will be performed â€Ž in â€Ž2 â€Žhoursâ€Ž. â€ŽIf this attempts still yielded nothing, the abdominal Pleurx drain will likely not function and may be scheduled to â€Ž be removedâ€Ž.â€Ž Thank you... my email address is firstname.lastname@example.org
Recently our cardiologists have started prophylactically inserting a "permatemp pacemaker" at the end of all TAVR procedures as part of a new guideline (I'm not sure whether this is an internal policy or a new guideline for standard of care on all TAVR). If no significant heart block develops, they are removed later. I feel that we should not bill for prophylactic care and that code 33216, and then the subsequent 33234, should only be billed when the patient is documented as having heart block necessitating the continued pacing after the removal of the pacing wire/balloon used during the TAVR. What are your thoughts?
Hi Dr. Z, Could you please help me with this procedure? Our interventional radiologist reason is PermCath insertion for hemodialysis. In his impression he says it was a successful right subclavian dual port dialysis catheter insertion via skin tunneling on the right. It was a 14.5 French dialysis catheter. Thanks for your help!
In what circumstances would you use the following codes? ô€‚ƒ Level ll Codes G0219, G0235, or G0252 for Medicare non-covered indications. Thanks
Pt had RHC with pulmonary artery angiogram, bilat selective pulmonary vein angiogram and lt atrial angiogram. The next day had ASD repair. We billed 93451-26 and 93568 for cath and angio and for ASD billed 93580. We were told you could not bill congenital codes for PFO but according to your book if diagnostic cath is done prior to PFO closure device placement you can code w/congenital codes. It also states an isolated PFO is not considered congenital. What is an isolated PFO? Also, our physician states the ASD repair was much more involved than the PFO, it was a hole in the heart rather than a "flap" but the diagnosis code is the same (745.5) so don't see how you can get around it. Would appreciate any help you can give in clearing up the confusion.
Under what circumstances can I bill 93580 ASD closure with 93531 Right and left heart cath? I code/bill for hospital and I get NCCI edit 0020 when I put the two codes together, however the physicians office coder tells me that she has billed the two together without any problems. I would certainly like to code/bill the heart caths because they are definately done. Thanks
"Patient with recurrect CVAs. Hypercoagulable workup negative, TEE with postive bubble study, thought to have PFO. Presents for closure. PROCEDURE: 10 French venous sheath was placed in left femoral vein, and 8 French Lamp catheter was advanced with wire into SVC. Bolton catheter was used, and intra-atrial septum was interrogated with ICE catheter. We were unable to cross septum with multiple catheters. Lamp catheter was advanced and demonstrated tenting. Agitated bubble study x 3, 2x with Valsalva maneuver, and we saw no bubbles across septum. Detailed interrogation of septum showed no evidence of PFO. Agitated bubble study negative, and septum couldn't be crossed. Procedure was discontinued. Impression: No intra-atrial septal defect, no PFO identifed." Not sure how to code 93462-74 and 93662, but these are add-on codes with no base code. No pressures were taken. What are your suggestions on how to code?
Dr. Z: I have a question regarding CPT 76937. The radiologist documents the following: "A limited ultrasound examination was performed to confirm the existence and patency of the right internal jugular vein. An image was saved in the chart. The skin was anesthetized with 1% lidocaine. Under direct ultrasound guidance the vein was punctured with a 21-gauge micropuncture needle." Must the radiologist specifically state that permanent US recording was made of the needle access? Thank you for your assistance!
Can you give me your opinion on this type of situation? Our facility is starting to use the Sherlock ECG monitoring device with our PICC lines. Do you know the appropriate codes that we are supposed to use for the ECG? So far I have the PICC line code 36569, then they are doing an ultrasound with hard copy 76937... and what would we code for the ECG?? Would any of these be appropriate: 93000, 93005, or 93010? Or something else?
Hello, If i have a nurse inserts a PICC line can the hospital bill for that service. Thank you
Dr. Z I would greatly appreciate your guidance with the following situation. In our hospital facility we have PICC line Rns that place PICC lines with fluoro guidance (36569, 77001). The PICC team performs PICC placements in a special procedure room and has an agreement with the radiologists to use fluoro. Occasionally the PICC RN cannot successfully advance the line and a radiologist is called for assistance. The radiologist will go to procedure room and advance the PICC line under fluoro. Is it appropriate for the Radiologist to charge for a PICC reposition (36597, 76000) or for a PICC placement(36569-59, 77001-59)? Does the PICC Team need to modify any of their charges? I was told we could not bill for a reposition during an initial picc placement. Thank you for your assistance.
Can you take a look at this one for me? Do codes 77001 and 36584 fit this case? Anything else? "Superior venacavography and right upper extremity venography via the existing PICC site. Exchange of existing 6 French PowerPICC line for same. The existing catheter was cut over a wire, and a sheath was placed. A 5 French diagnostic catheter was placed to the level of the axillary vein, and venography was performed. The right internal jugular vein was catheterized as well, and venography was performed. This revealed a widely patent central venous circulation. A new 6 French PowerPICC line was placed over a wire with its tip residing at the cavoatrial junction. The line was sewn to the skin with 2-0 Ethilon, sterilely dressed, and flushed with sterile saline. Spot and digital subtraction angiography was sent to PACS archive. Total fluoroscopy was 7.4 minutes. Findings: Normal central venography. No evidence of hemodynamic significant stenosis or thrombus. The right internal jugular venin is patent. No evidence of thrombus in the right upper extremity venography."
Can a doctor image or see the aorta on an angio with the pigtail in the proximal iliac? Not very sure if being a pigtail makes a difference. Does the pigtail need to be within the aorta for the doctor to see the aorta? I have a doctor who doesn't explicitly state that the pigtail was in the aorta when he did an aortoiliac angio (he was treating an ilaic aneurysm). I have read here before that the aortogram could be done with the catheter (or even sheath) in the proximal iliac, but I am not sure if "pigtail cath" makes a difference.
What is the correct CPT code for the following? "Pigtail catheter was advanced into the left ventricle, and pressure measurements were done."
Can we charge for non-coronary IVUS when using the Pioneer catheter to re-enter a peripheral vessel during peripheral intervention? The Pioneer utilizes Volcano IVUS technology; however, no images are archived to WITT/PACS. Basically, the IVUS helps guide the physician to enter the true vessel when they are sub-intimal. I don't think so, based on the premise that ultrasound procedures generally must have images, but I wanted your take on this. Thanks!
Dear Dr. Z, Would the use of the "Pipeline Embolization Device" for treatment of carotid wide-mouth aneurysm be considered 61626 / 75894? No coils are placed so I'm wondering if it is still considered an embolization. Thank you. mlb
What code do you suggest for endovascular treatment of an aneurysm using the Pipeline reconstruction device?
Should treatment of an intracranial aneursym with a flow diverter be coded as an intracranial embolization or a stent placement (61624/75894 or 61630)? The device seems to be considered an methof of embolization in some the literature I have found online about them but the device is a stent, correct?
Hello! (again!) We have this scenario, the procedure was removal of ICD, revise the ICD pocket, added a new ICD, tested the defibrillator threshold, and added a subcutaneous anterior chest coil array was added to the vector after the new ICD and old leads werenâ€™t providing optimal results. This is what we coded â€“ 33249, 33241, and 93641 with device codes C1894, C1721, and C1896. Is there something else that you would suggest? Thanks for your continued advice!!! Melinda Neeley Nebraska Methodist Hospital
Dr. Z, In the outpatient setting, how would you report the replacement of an implanted cardiac event recorder at a single session due to its end of life? There is a CCI edit for mutually exclusive procedure between 33282 and 33284. Thank you!
Dr. Z, My question concerns placement of a carotid stent via an open approach. I do not think we can use 37215 because it states "percutaneous" in the code description. Here is his dictation: An oblique incision at the lower neck level, I dissected out the common carotid artery and isolated with a vessel loop towards the cranial end. I then placed a 7-French sheath over a wire and performed diagnostic imaging demonstrating the stenosis and then crossed it primarily stenting with a 7 x 22 iCAST covered stents. We then postdilated to 8 mm and then removed the sheath and balloon and opened the arteriotomy a little bit wider so that we can get good antegrade flushing of the artery. The performing physician did dictate an addendum (to document distal protection, he said): The common carotid artery had been clamped cephalad of the entry site for placement of the sheath. After deploying the stent, the artery was flushed aggressively in order to remove all debris prior to closing the arteriotomy and then restoring flow antegrade to the brain. I cannot find a CPT code for an open placement of a carotid stent. Am I missing it or should this be an unlisted procedure code? I have tried to contact his office coder to see how it was submitted from his office, but I haven't had any success to date. Thanks, Chris McCoy
If a patient is having a ureteral stent placed via an ileal conduit, is it still reported with codes 50393/74480 since the code states the catheter is inserted through the renal pelvis? Or would it be unlisted since it is via the ileal condiut? Report: Conversion of a left nephrostomy tube to a left nephroureteral stent through the patient's existing urostomy. Clinical Information: This patient is an 80-year-old gentleman has a history of left renal obstruction. He is pulled out his tube from the urostomy in and now presents for conversion of his existing left nephrostomy tube to nephroureteral stent. Procedure: After the procedure was explained and consent obtained from the wife, the patient was placed in a decubitus position on the fluoroscopy table. The patient had the urostomy site and nephrostomy tube exit site prepped and draped in the sterile fashion. The patient was numbed with 1% lidocaine solution around the nephrostomy tube exit site. The nephrostomy tube was removed over a 0.035 guidewire and a 5 French vertebral catheter was then placed within the renal collecting system. This in conjunction with a 0.035 hydrophilic guidewire was utilized to access the left ureter. This is also used to pass the anastomosis and enter the ileal conduit. After this was then, the catheter and guidewire combination were used with fluoroscopic guidance to traverse the conduit with the catheter and wire protruding through the ostomy site. Exchange was made for a 0.035 Amplatz guidewire. After this was done, the catheter was removed. The patient was then placed in the supine position on the fluoroscopy table. A 10 French drainage catheter was then placed over the guidewire using fluoroscopic guidance into the proximal loop is located within the renal pelvis. The guidewire was then removed. A contrast injection with gadolinium demonstrates the tip of the catheter to be located within the renal pelvis. The patient tolerated the procedure. The patient received Versed and fentanyl intravenously for conscious sedation. Impression: Conversion of the left nephrostomy tube to a left nephroureteral stent which extends in a retrograde fashion through the urostomy site.
Patient was brought to IR suite with an ishemic foot. A pelvic angiogram was performed and the catheter was advanced to the right external iliac and a lower extremity angiogram was performed. The catheter was advanced into the fem-pop graft an angiogram was performed showing thrombosis. Catheter advanced to the above knee jump graft to below knee angiogram showed a 90% stenosis. Angioplasty was performed at the jump graft anastomosis. Next an infusion catheter was placed in the fem-pop graft and an infusion wire was then advanced through the infusion catheter to the peroneal artery. Overnight thrombolysis was performed. I know catheter placements are bundled into angioplasty codes. Can we code 36247 for placing the infusion wire in the peroneal artery since it is past the location of the angioplasty?
Pertaining to a previous Question below. If the Physician places a sheath or a dilator to be used for CT would you use 36410/76937? Thanks Question: If a patient comes in for a CT scan and requires an IV access to be placed by IR due to "poor venous access", is the 36000 and 76937 seperately reportable? Typically the 36000 is bundled, but due to the poor access and the fact that they are taken to IR for the procedure, does that warrant the charges? The fact that is performed for the sole purpose of administering the contrast, regardless of the reason they have poor access, does that void charging the 36000/76937 seperately? Answer: I would not code additionally unless CVC catheter was placed. An IV, no matter how hard it is, is part of a CT scan. Dr.z
We are going to be doing a platelet rich plasma injection with ultrasound guidance. Code 0232T includes guidance, harvesting, and preparation. The harvesting and preparation are going to be done in a physician's office and then the patient will be sent to our outpatient radiology department for the injection with ultrasound guidance. Any suggestions on how to make sure we get paid for the guidance portion of this procedure?
Dr. Z, I can not find a CPT code for an exchange of a PleurX pleural catheter? Can I use 32552 for the removal, and 32550 for the re-insertion? Thanks in advance,
We are going to start doing PM/ICD progamming and interrogations. Do codes 93279-93289 require a physician interpretation/report?
I have a patient who developed breast cancer. The physician wanted to place a port, so the pacemaker was removed from one side and replaced on the other side. Old leads capped, new leads inserted. I wanted to report it with the removal code 33233 and the insertion with code 33208. I am now getting an edit to add a device "C" code. My concern is we did not add a new device; we used the existing pacemaker. How should I code this case?
"Patient was brought into the EP lab one week status post dual chamber pacemaker insertion with leads due to lead dislodgement. The generator was explanted, the leads were removed, and the wound was closed. A new incision was made superior to the previous one, and a new subcutaneous pocket was formed. Through a percutaneous stick, axillary vein access, an 8 French shealth peel-away sheath was inserted. The two previously explanted bipolar screw in leads were then positioned in the right ventricular septum and right atrium successfully. The generator was connected to the leads and then placed in the pocket with the leads positioned beneath it." The physician wants to call this a pocket revision with a lead repositioning. Since the leads were explanted from the body and reimplanted, does this qualify as a repositioning?
We had a plastic surgeon come to the Lab to perform a subfascial/submammary pocket. The ICD was explanted from one area and moved to this new pocket. I am thinking this is more than a pocket revision code...? 15734,but not sure. What do you think?
Z-Health Diagnostic and Interventional Cardiovascular Coding Reference book, page 406 number 9, states "Do not code pocket revision during generator change to accommodate a different shaped or larger sized generator. This is considered part of the replacement, just like a pocket creation is considered part of an initial insertion of a new device". Per the above, codes 33262,33263 and 33264 should not be billed with 33223 if done only to change the size of the pocket. What if the physician had to remove scar tissue or debride the pocket at the time of ICD replacement, could we then bill for 33223? Per the CCI edits I can bill 33223 with the replacement codes and add a 59 modifier to 33223. Please help clarify this because the physicians want us to bill the 33223. Thank you
Hi Dr. Z and Dr. Dunn,I have a combined procedure between surgeon and interventional radiologist for bilateral popliteal aneurysms with endartarectomy on one side. I'm unsure as to whether this is coded as open stent placements, popliteal aneurysm repair or exclusion of the aneurysm which leads me to an embolization code. The surgeon exposed the arteries via cutdown so I'm clear on this being an open procedure. The dictation describes the following: Access to the common femoral arteries was provided by the vascular surgeon, who performed bilateral cut-downs. Single-wall needles were utilized to access the common femoral arteries bilaterally directed in an antegrade fashion. Eventually vascular sheaths were advanced into the proximal superficial femoral arteries and bilateral selective angiography was performed, confirming large bilateral popliteal aneurysms (right greater than left). Additionally, there is severe stenotic disease noted in the left superficial femoral artery. Utilizing 0.035 Glidewires, 5-French catheters were advanced into the distal popliteal arteries and over 0.035 guidewires, overlapping Viabann stents were deployed at the site of the aneurysm and post-dilated using 7mm angioplasty balloons. Completion angiography demonstrated excellent exclusion of the aneurysms with preserved distal flow bilaterally. The vascular surgeon now picks up the dictation and continues: Upon completion of the endo-stenting angiograms sluggish flow to the right side was demonstrated. The superficial femoral artery on the righ had very weak pulsation. It was noticed to be due to a large plaque in the common femoral, which was partially lifted during the previous procedure. The arteriotomy was extended and a large plaque removed from the base of the common femoral and into the entrance of the profunda femoral. A patch was needed in order to establish a better flow in to the superficials and this was done with an Impra patch. The surgeon goes on to describe repair and closure of the groins. What I'm most concerned with is the IR portion of the stent placements. I initially coded as 37207/75960 and 37208/75960 X2 for the two popliteals, then saw the implant documentation indicated for all four stents as Right SFA, Left SFA, Right Popliteal and Left popliteal. I'm hesitant to code the SFA as additional vessels for stent placement since I don't have documentation of why the stents were extended into that vessel. The encoder software wants to code this as an exclusion of the aneurysm cpt 37204. I have never used the popliteal aneurysm 35151 code so not sure this is the right code either or if that requires excision of the aneurysm. I am not coding any angiography as he states this was only to confirm the aneurysm. Catheter placements from common fem to popliteal antegrade I believe would be 36246 on both sides. Any help is greatly appreciated.
Patient had a port-a-cath in left jugular. During chemotherapy, he complained of severe pain and so presented for catheter check. Fluoroscopy indicated that the catheter was dislodged from the port and was within the right atrium and ventricle. This was removed with the use of fluoroscopy and an ensnare. Then incision was made over the port, and it was removed. I am not sure how to code this, so I would appreciate your help.
A patient has a port-a-cath, and while in the hospital the catheter is noted to be in the subclavian artery instead of the internal jugular vein. The physician takes the patient to angio to remove the catheter. From the femoral artery he places a catheter in the subclavian and performs an angiogram of the extremity and removes the port-a-cath. The physician then inflates a balloon for hemostasis. A coder is telling us we can report codes 35475, 36215, 36590, 75710-2659, and 75962-26. I do not agree with the arterial angioplasty codes, as there was no stenosis. Nor do I agree with code 36590, as it was not in the venous system. I'm thinking this should be an unlisted code along with the diagnostic angio. Can you give me your thoughts?
Can you clarify what, if anything, would be appropriate to bill for the following circumstance? "The physician went into the right femoral artery performed a left heart catheterization and stent x 2 in the RCA (overlapping), and prior to getting the patient off the cath table to physician noted the patient had an ST-elevation. He proceeded on with cannulating the left groin to the RCA where the stents were placed and by a guided projection taken showed TIMI III through the RCA with thrombus formation in the nmiddle of the stent. He then placed a balloon, which he had to inflate x 3. After removal of balloon, the thrombus had resolved." What code(s) would the physician be able to bill for the post angioplasty for the thrombus formation? Can we bill anything?
Dear Dr. Z: Which intracranial vessels are included in the vertebrobasilar system for assignment of 75685 via selective catheter placement / injection of the vertebral artery? I know vertebral origin to basilar,posterior inferior cerebellar artery (PICA), anterior inferior cerebellar artery (AICA), and superior cerebellar artery (SCA). What about the posterior communicating artery? I assume any cerebral arteries are included in 75671. Thank you and have a good day. mlb
Presacral fluid drainage via transgluteal approach using a 18 gauge Yueh needle. Which code is appropriate - 10030 or 49406?
The CPT Manual specifically references a catheter-based study when discussing adding modifier -59 for billing a diagnostic study at the same time as an intervention. If a patient has a previous CT angio showing an LAD lesion, and a diagnostic cardiac cath is planned, which proceeds to intervention, is it appropriate to bill the diagnostic with the intervention? My docs say that, while it is probable they will do an intervention, they never really know until they do a diagnostic cath to know if PCI is appropriate.
What would be the correct way to enter charges for upper and lower extremity studies that are done on same day with same cpt. Medicare is dening claims if we enter both charges (upper ext study) (lower ext study) and add a 59 on 2nd charge. Should we enter charge one time and put a 2 in quanity and use modifier 59?
Patient was prepped and draped for a left and right heart cath. Pt consented, began conscious sedation time out completed. Pt decides she wants to be under general anesthesia and does not want to continue. Procedure aborted. What can be coded?
Dr. Z - This question is in regards to modifiers 78 and 79. The patient has an internal/external biiary drain, 47511, placed on 7/30. The drain was "pulled back by the patient" on 9/2 and the radiologist replaced it, 47525. Since this falls within the global period of the 7/30 procedure would the appropriate modifier be 78 or 79? Then 4 days later the drain "fell out" and the radiologist placed a new one int/ext, 47511 - 78 or 79? Thanks so much for any advice you can give on these modifiers!
Please do NOT include any actual patient medical records with your question. Dr. Z my Dr. placed the stent in left superficial femoral, profunda femoris,and external iliacs artery. I can bill 37226 for SFA 37221 for External iliac artery but my question is how I report the stent in profunda femoris? Please advise, Thanks, Renata
Thrombin injection was done into a pseudoaneurysm located at the site of a previous breast biopsy under ultrasound guidance. The CPT code 36002 is for extremity. What can I use for this? I have U/S code, but need the surgical CPT. Thank you.
Psoas muscle (abscess) aspiration - what is the CPT code for this procedure? Site muscle unlisted code 20999 or what? How does this related to the "findings" description? INDICATION: Left central and muscle fluid collection r/o abscess. PROCEDURE: Patient placed lateral decubitus on CT gantry couch. After induction of anesthesia, pre-procedure scan performed to select an appropriate entry site. Mark placed on the skin overlying left lower axilla, which was prepped in the usual fashion with wide barrier chlorhexidine preparation. Site then anesthetized with 1% lidocaine. Under fluoroscopic guidance, an 18 gauge trocar needle was inserted from 6 x 4 cm cystic fluid collection in the left psoas muscle. Approximately 52 mL of series fluid was aspirated. Needle withdrawn. Patient tolerated the procedure well without procedural complication. Multiple fluoroscopic spot images confirmed intra-articular location of contrast. FINDINGS: A well-circumscribed cystic fluid collection measuring 6 x 4 cm in the left upper pelvis/left lower quadrant of the abdomen. Impression: 1. Successful and uneventful CT-guided left psoas muscle aspiration. 2. 52 mL of serosanguinous fluid collected and sent for culture analysis and cell count.
Dr.Z, This is pedi case. During pulmonary valvuloplasty was performed and during the procedure the MD covered the valve as well as pulmonary artery stenosis and used the same balloon inflation to dilate areas of stenosis. Since a single balloon was used and covered both areas of stenosis (valvular and supravalvular) can we charge only 92990 or both 92990 and 92997? Please advice. Thanks
Dr. Zielski, Good afternoon it has been a while since I have sent you a question. I love the 2012 book by the way! I have a question that I would like to ask as it is a rare situation that occurred and now I am trying to figure out how to code it. A patient came to the ER hypoxic and not doing well, went to ICU and was there for several days. The patient was found to have a right pulmonary artery/pulmonary vein fistula and was shunting past the left atrium. The patient was not a surgical candidate and on high levels of oxygen. This case was a combined effort with the Interventional Radiologist and the Interventional Cardiologist (just like Amir Motarjeme once told me that it would be) where the Radiologist did the diagnostic and filming via low resolution CT and the Cardiologist managed the intervention (has does the ASD/PFO closures in the Cardiac Cath Lab and is very familiar with the device) The fistula was closed with an amplazter septal occluder (not vascular plug as there was no "tunnel/tube"). The patient's oxygen saturations immediately increased. The patient was returned to ICU and walked out of the hospital on room air a few days later. Now my fun begins. I was thinking of using the embolization codes of 37204/75894. The C code for the device is C1817. There are no "procedure to device edits" per the Jan. CMS list for procedure 37204. The patient was an inpatient but all of the charging of procedures are attached to CPT codes as per the chargemaster. Thank you for your time and consideration.
Are codes 93451, 37211-50, and 36014-50 correct for the following procedure? (Patient had diagnostic CT priot to this procedure.) "A balloon-tipped Swan-Ganz catheter was advanced serially through the right heart chambers (pressures were measured) and was then advanced up into the right main pulmonary artery into the wedge position where pulmonary wedge pressure was measured. Another wire was advanced through the catheter lumen and advanced into the mid lobe of the right pulmonary artery. Another wire was able to be selectively directed into the left main pulmonary artery and the left mid branch. It was used to perform selective angiogram of the main pulmonary artery. This catheter was removed. The 12 cm long EKOS catheters were then advanced along each of the two V-18 wires and positioned carefully with their proximal infusion edge being above the level of the pulmonic valve. Following positioning, the V-18 wires were removed and replaced with the inner core wires of the EKOS catheters to provide ultrasonic drug delivery. The catheters were then sutured in place and connected appropriately to the infusion devices. Thrombolytic infusion was initiated per protocol."
"Terumo guidewire was used to selectively catheterize the left subclavian vein. A venogram was performed demonstrating the takeoff of the external jugular vein. The external jugular vein was selectively catheterized. A run in the AP and lateral projection demonstrated multiple abnormal engorged venous pouches with venous outflow restriction. An SL 10 microcatheter and Precision Master microwire were used to selectively catheterize the distal pouch. At this juncture the entire distal bulb and pouch were obliterated with a series of Cashmere and Presidio coils. Control venogram revealed complete obliteration near the external auditory meatus and mastoid air cells. The patient woke up with complete cessation of pulsatile tinnitus." Would I use 61626, 75894, 75898, 36012, 36012, 75860, 75820?
How would pulse spray or injection ofâ€ thrombolytics into the cerebral vasculature" be coded? It would not meet the guidelines for 37201 since it is not really an infusion. Thank you!
When the physician documents ablation of PVC or PAC, would that be reported with code 93653 or 93654? In one instance, the physician documents non-inducible for VT, but PVCs were ablated.
Dr.Z, Pacemaker dependant patient with complete AV block comes in for upgrade to biventricular AICD. Patient was recently found to have severe nonischemic cardiomyopathy, progressive CHF, ejection fraction below 35%. Procedure: Cardiologist replaced dual chamber pacemaker with biventricular AICD device, inserted ventricular lead and left corornary sinus lead, re-used chronic atrial lead (old ventricular lead was capped), performed DFT testing. Codes = 33249-Q0, 33225, 33233. Is it appropriate to add the Q0 modifier in this case? The patient had a dual chamber pacemaker, no ICD device. The precipitating symptoms occurred recently. Thank you.
Dr. Z, Our cath lab wants to charge complete EP study when they place a spiral catheter in pulmonary veins and pacing and recording to isolate them. When asked for rationale – catheters are positioned in many veins and that’s they are charging complete EP study. But per CPT book and CPT assistant catheters must be in right heart (RA/RV/HIS) for pacing and recording at least two areas (or one area with ‘52’ ) and these cases they are only placing a catheter in CS and an ICE catheter in RA and a spiral catheter in one of the pulmonary veins to perform ablation for A-Fib. Not sure this constitutes a complete EP study. We would like to explain our cath for documentation requirements, please explain.
Patient had an abdominal aortogram, selective bilateral common iliac artery angiograms, and runoffs from a left radial artery access. We know these are reported with codes 36245-50, 7625, and 75716-59. Following this, catheter was withdrawn into the left brachial artery with angiography performed and left radial artery with angiography performed here too. As these are “pull-backs”, my first thought was that they would not be reported. Is this correct? If incorrect, how will they be reported?
I have had two situations with procedure (93458) where the MD has gotten radial access, advanced to the coronaries, and was unable to select them. The other case he was able to select the left, but not the right, coronary artery. Both changed their approach to femoral and were able to complete the procedure. Are these coded differently with the second access site? Since both times the catheter was advance beyond the access site?
With the new embolization code 37242 (arterial embolization) for radioembolization procedures, is it appropriate to also bill for a visceral angiogram (75726)? Should you report code 75726 when performing a mapping pre-procedure for radioembolization?
Would you use code 64640 for a radiofrequency ablation to a third occipital nerve (TON)?
Can we attach a modifier 52 to the study below to recoup some of the cost? Inpatient had blood drawn for a white blood cell study on Tues Dec 6th and the radioactive tracr was reinjected that same day. We were to obtain delayed images after a 24hr period, but on Wed the pt was tired and refused to come down to dept for scan. The pt was contacted on Thurs Dec 8th for 48hr delays to complete the study, but once again the pt refused the scan portion of test and was discharged. My question is "Should I cancel the study and eat the cost of the medication, or is pt responsiblee for dose charge?
Greetings, A patient has dehiscence of a amputation stump with infection. The pt is taken to the OR and 4 inches of femur were removed with the saw. Is this a reamputation or a debridment? Thanks,LW
New generator ICD, RA capped, new RV (actually recall, but that aside and let's talk pro fee). LV had to be tunneled from left to right. So would reposition of LV be reported with code 33249? Or, would it be code 33249-22, or perhaps 33249 and unlisted?
Any suggestions on coding the catheterization and imaging of the left subclavian artery if the vertebral artery has been anastomosed to the left common carotid artery and no longer arises from it? This angiogram was done due to post op TIA symptoms the same day as the vertebral reimplantation surgery. Can I bill codes 36225 and 36223 for the following? "Catheter advanced under hemodynamic and fluoroscopic control, positioned selectively into the left subclavian artery, single view cervical zone accomplished. No gradient at catheter tip. Catheter then selectively placed into the left common carotid artery multiple views cervical and intracerebral accomplished. Left vertebral artery anastomosis to the left common carotid artery defined in multiple projections. Complete and diagnostic angiograms were done of both the left subclavian and the left common carotid including extrancranial and intracranial circulation plus the vertebral." (I just did not have room to include the findings in the question.)
Greetings, I have a physician coding both 36832 and 35903 for the following procedure procedure. I do not think I can bill these two codes together in the same area. Here is what the physician surgically completes: He opens at the site of the graft and drains the sinus tract. He transects the graft on the venous side. Then he make add'l incision and places a new peice of graft tunneled well away from the infected area and anastomosed to the remenent of the venous side of the graft then he transects the arterial side of the original graft and attaches the new graft to the remenent of the old graft. At the end of this the physicuan goes back to the original incision and removed the piece of infected graft. My thought is I can only code this as a revision using code 36832. Am I correct, or is the physician correct?
Greetings, How would gou code the removal of a broken tunneled CVA with port? The physician had to perform a cutdown to remove part of the cath and he also removed the port from the pocket. The physician then repaired the jugular vein. Would you code 35201 and 36590? It seems like a repair would be bundled. I thought about 22 and also about a unlisted code and base the RVU on the cutdown code but I just don't know. Any ideas? Thanks, LW
We have a patient that came in for a gastrostomy tube removal and they used flouro. We know that with chest tubes, gastrostomies there isn't a code for removal and they normally just pull these out. What if they use flouro, are we able to charge for these? Either with a low E&M or the flouro time? Below is the report that we have. Thank you so much for looking at this. Thank you, HISTORY: Removal of a percutaneous gastrostomy tube as it is no longer required for feeding. PROCEDURE: Fluoroscopic guided removal of the gastrostomy tube. FLUORO TIME: 0.2 minutes. PROCEDURE DESCRIPTION: The retention balloon was deflated and the gastrostomy tube was removed. An image was obtained to document complete removal. IMPRESSION: Fluoroscopic guided removal of the indwelling gastrostomy tube.
I have a question for you - One of my resources allows codes 35903, 35286-59, but I am hesitatant to add the patch closure. How would you code the following procedure? Thanks for your help. BILATERAL GROIN INFECTIONS WITH INFECTED FEMORAL-FEMORAL BYPASS GRAFT. The bilateral groins were prepped with a Betadine solution and draped aseptically. I began by aggressive debridement of the obviously necrotic, foul-smelling fatty tissue in the right groin. This was carried down to allow identification of the right limb of the bypass graft. Proximal and distal control were achieved in the femoral artery. Five thousand units of intravenous heparin was administered. The graft was clearly not incorporated in the surrounding tissues. Thus, it was removed from the common femoral artery and the artery was closed in a patch fashion with bovine patch with 5-0 Prolene suture. The groin was then copiously irrigated with a pulse irrigator with 3 liters of normal saline. A layer was closed over the artery and the rest of the groin left open given the presence of the infection and packed with Dakin's soaked Kerlix. Next, attention was directed to the left groin where necrotic tissue was sharply debrided down to healthy granulation tissue. The groin was once again copiously pulse irrigated. Of note, the graft had been removed through the right groin. The pocket was copiously irrigated. The groin was then packed open with Dakin's soaked Kerlix. Sterile dressing was applied.
Cardiologist inserted tube for pericardial drainage during critical care episode. A few days later, one of his partners removes the tube. Is removing it billable? If so, what code and does the doctor need to make a report? (Right now we just have handwritten notes).
Can I get your advice on how to code for an upgrade from a dual chamber Defibrillator to a CRT-D - new LV lead, and change generator keep chronic R Atrial and R Ventricular leads. All we would be doing is changing out the generator and adding an LV lead. I realize there might not be a great answer for this procedure, but curious as to your recommendation.
Patient scheduled for a pocket revision, but the day of the procedure only two superficial skin lesions near the pacemaker incision were removed and placed in Formalin. What should the hospital code?
I hope is well! I need your assistance on the coding recommendation of a Renal Angiography, case example: RT Renal, superselective in to multi branches and LT Renal main renal , only. My thoughts are to code both unilateral codes to support the service provided 36253–Rt and 36251-Lt. Would this be correct?
I have a case where the patient has two renal arteries coming off the aorta on the right side and an angiography was done on each. Would I report code 36251 twice because you have to come back out to the aorta to select the second renal artery, or is it coded once because the description for code 36251 mentions accessory arteries also, but does that just mean arteries that branch off the main renal? And if it is coded twice with 36251 would the second have a -59 modifier?
This was a left heart cath and selective coronaries - 93458 with aortogram CPT codes charged by the cath lab: 75625, 36245, 75724 Dr Z. I beleive that the G0275 would be the more appropriate code instead of 75625. Then 36245 & 75722. The report only reflects the description of the renals and no other description of the aorta or other arteries/structures G0275, 36245 & 75722 for the right selective placement. Is this correct. Op report description: Aortogram was performed at the level of the renal arteries. She has had renal artery stenting for renovascular hypertension. The angiogram showed a patent left renal artery but there was overlap of the origin of the right renal from the inferior mesenteric artery. In light ofthis, a selective reight renal angiogram was performed. We find about 30% to 40% ostial narrowing within the stent but no significant obstruction.
Regarding renal artery interventions, i was informed when renals are treated with a balloon angioplasty and a stent, regardless of 'recoil' or lack of improvement of stenosis only the stent placement procedure code is allowed to be billed and not the angioplasty and is considered a predilation unless the patient has a congenital condition. is this accurate for renals?
Following informed consent and verification of the correct patient identity and planned procedure, the patient was placed in the prone position and the right flank was prepped and draped in the usual sterile fashion. Under ultrasound guidance, a 4Fr Micropuncture set was used to access the patient's calyceal diverticulum. Contrast was injected and spot film imaging was performed. Over an Extrastiff wire, an 8.5Fr Dawson Mueller Drain was placed. The pigtail was formed and locked. The catheter was sutured to the skin and placed to external drainage. Clear fluid was returned from the diverticulum. The rest of the collecting system was not seen in contrast injection. INTERPRETATION: 1. Successful percutaneous drainage of the right kidney calyceal diverticulum as described. Would you consider this a 74475/50392? Thanks!
Dr. Z, wtih the new codes, i have a question regarding renal intervention without diagnostic study, my thought process we may not code catheter placements separate (with the new code 36251 includes both catheter placement and S&I) however some consultants are advising us to use 36245 along with the intervention codes. Can you please clarify. Thanks
Dear Dr. Z: A CT guided needle biopsy of a renal mass was performed and then CT guided cryoablation of the same mass was performed (same patient encounter). Is it appropriate to code 50200, 77012-59 for the needle biopsy and 50593, 77013 for the cryoablation of the renal mass? Or should only 50593, 77013 be coded since it is the same mass? Thank you. mlb
I'd appreciate your insight on the more complex AAA coding scenarios (using CAT III codes 0078T, 0079T for fenestrated modular bifurcated prosthesis). However, for the aorto-uniiliac prosthesis (34805) with renal snorkel stents, should the conventional stent codes, 37205/06 be used (with cath codes 36245 and stent RS&I)? Op note attached. "PREOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm. Left internal iliac artery aneurysm. Bilateral common iliac artery aneurysm, complex anatomy. POSTOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm. Left internal iliac artery aneurysm. Bilateral common iliac artery aneurysm, complex anatomy. OPERATION PERFORMED: Complex endovascular aneurysm repair with an aorto UNI right iliac Medtronic Endurant device with coil embolization, left internal iliac artery aneurysm. Plug Medtronic occluder device, left common iliac artery, with additional coils placed. Right-to-left femoral-femoral bypass, bilateral renal artery covered stents in a "snorkel" technique and intravascular ultrasound."
Dr. Z. Pt had bilateral selective renal angiography (36252) Pt had 2 arteries on the left, both were stented. Can we bill for both stents placements (37205, 37206 and 75960 x2) or are we only allowed 1 per surgical site? Thanks!