During a stereotactic breast biopsy there was considerable bleeding at the puncture site. The physician administered D-stat through the biopsy need to stop the bleeding. I am not comfortable charging for this injection, as it was done during the procedure for a procedure-related problem. The techs would like to charge code 96372 for a therapeutic injection. What are your thoughts on this?
Patient has right internal jugular vein occlusion and innominate vein occlusion with massive symptomatology head edema, saphenouse vein was harvested, median sternotomy was performed and innominate vein to right atrium bypass was performed with spiral vein conduit. Right atrial appendage was free of any lesion and was a good location for distal bypass, innominate vein was dissected, and found to be hard and filled with throbus. Innominate vein was transected , stump leading to superior vena cava was over sewn with 2 layer suture. innominate vein leading to the axillary and subclavian and jugular was explored, thrombus was evacuated. Next using the consturcted spiral vein conduit with a running polene suture, end to end anastomosis of the vein to the innominate stump was performed. Would you stil use 34502? Thanks for your help Dr. D
Please clarify the coding (catheter placement and S&I) associated with selective innominate venography in conjunction with a congenital cardiac catheterization procedure (93530-93533) from both an ipsilateral and contralateral internal jugular vein approach, as well as an ipsilateral and contralateral femoral vein approach.
Hello Dr. Z, can you please advise on how you would code the following? Pt came in with left brachiocephalic fistula with a hx of cephalic arch stenosis with a stent and central innominate stenosis where previous innominate PTA was required from a femoral approach because the wire would not pass from the AVF. RFV was cannulated. Angio of SVC and RA were normal and L innominate vein was not seen due to complete occlusion. The L innominate vein was selectively catheterized from the SVC. Angio of the central veins revealed a 90-100% stenosis of the innominate vein. Central venous angioplasty was carried out with <10% residual. An attempt was then made to pass a wire into the cephalic arch from the subclavian which was unsuccessful due to the presence of occlusion at the junction of the stent in the cephalic arch with the subclavian vein. Therefore, decision was made to cannulate the AVF. Left upper brachiocephalic fistula was cannulated and an angiogram was performed that showed 90% stenosis in the stent in the cephalic arch vein extending into the subclavian. Venous angioplasty was carried out showing 10% residual stenosis. Would the following codes be correct since there are 2 separate accesses? 36011, 75827-59, 35476, 75978 36147, 35476-59, 75978-59 ...or would the 36147 need to be changed to 75791? Thanks - a little confused.
What are the inpatient billing guidelines for Revenue Code 636 on commercial (non-Medicare) facility claims? Our facility would like clarification regarding when it is appropriate to bill pharmacy items under Revenue Code 636 on commercial (non-Medicare) inpatient facility claims, as some of our commercial contracts have inpatient reimbursement clauses outlined for Revenue Code 636. We know that for Medicare claims, Revenue Code 636 is used for: 1) Inpatient – exclusively billing hemophilia clotting factors. 2) Outpatient – billing for "Drugs that require detail coding" (i.e., pharmacy with HCPCS). Are commercial (non-Medicare) claims required to adhere to Medicare inpatient billing guidelines for Revenue Code 636, or can "drugs that require detail coding" (i.e., pharmacy with HCPCS) be billed under Revenue Code 636? If possible, please provide references so that we may support our decision.
"Patient comes in and has an embolization of an ACA aneurysm, and a follow-up angiogram shows nonopacification of the majority of the A2 segment of the ACA. Subsequent angio demonstrates thrombosis of the portion of the A1 segment of the ACA and ciling was halted. An internal carotid angio was performed, and the occlusion of the distal aspect of the A1 segment was identified. 7.5 mg of Integrelin was infused into the A1 segment of the ACA. After 10 minutes a repeat angiogram was performed . The A1 segment remained occluded. It was decided not to further pursue thrombolytic therapy and clot retrieval at the current time." Is this a true infusion? Can we report code 37211 for the Integrilin that was given, or is this documentation not enough to support an infusion?
When doing intercostal angios for the purpose of a retroperitoneal hemorrhage, do you use code 75705 or 75726?
Patient with jaundice presents for biliary evaluation. Physician performed: percutaneous transhepatic cholangiography (47500-59, 74320-59), cholangioplasty with stent placement (47556, 74363), and internal/external drainage catheter placement at the initial presentation. Would you please give us your insight on why the drainage catheter (47511, 75982) is not coded in addition to ductal dilation with or without stenting when the procedure was not staged?
How would you code an internal cardioversion through an existing ICD? I understand code 92961 is an open procedure and would not apply, and code 92960 would not be correct either. Can you help?
With the new cardiac catheterization we were wondering how you would code the injection and imaging of the IMA--this is not a graft, but was done to determine the patency of the IMA for possible CABG. Thank you
Please do NOT include any actual patient medical records with your question.FLUORO NON RAD DOCTOR OVER 1 HR: Order Number: 90005 Date of Exam: Aug 13 2012 10:54AM EXAMINATION: FLUORO-NON RAD DR OVER 1 HR CLINICAL HISTORY: Cervical fusion. COMPARISON: None. TECHNIQUE: Frontal and lateral views of the cervical spine. RESULTS: There is anterior fixation of C3, C4, C5 and C6 with prosthetic disc material in the intervening disc spaces. Surgical drain in the prevertebral soft tissues. There is anatomic alignment without evidence of hardware failure. IMPRESSION: ACDF C3, C4, C5 and C6. I do the billing for the Radiologist portion and our hospital bills for the tech component and I wanted to know if I can bill for a 2 view cervial x-ray for the above (72040).
My physician is an Interventional Radiologist. He is the only one on call for one of the area hospitals. He will get called in at all hours of the night for a "consult", which I bill a 99222. During that consult he will usually find that a procedure needs to be done of some sort. The procedure is scheduled for the next day. Medicare will pay my procedure but deny the 99222 as "pre-op or post-op care". Not only is my physician being woken up in the middle of the night, I can't even get him paid for his services. Is there a way around this? Is there a modifier I can use that would help? Thank You, Shannon Dr. Stephen K Liu
If intervention is done on a fem-pop graft and the MD states where in the graft it corresponds to the native artery location, can I code it the same as the native or because it is a graft I only get to code intervention once? In other words he talks about stenting graft corresponding to SFA and to POP. I have tried to find documentation of how to code but can find nothing.
Do I need a modifier on code 93458 for the initial diagnostic exam with the C-codes for the PTCA?
I have a physician who wants to bill infusion code 37202 for cerebral intra-arterial injections of verapamil when the combined carotid injections equal 30 minutes. What do you think of this?
Dear Dr. Z: Is it appropriate to bill intra-operative views with findings which appear to be only confirmatory of the procedure which was performed? Imaging is often included in the surgical codes now (i.e., spine injections) or in the radiological S&I code billed with the surgical component. If the view is for QA purposes, confirmatory only, or not diagnostic shouldn't it be a no charge? Thank you. mlb
My physician is a vascular physician who inserts an IABP by transaxillary vein cuff approach. Is this reported with code 33973, even though he is not directly approaching the aorta? Or would it be an unlisted procedure? Also, four days later the IABP has migrated retrograde into the aorta and out into the subclavian artery, so the physician takes the patient back into surgery and reopens the previous incision and repositions the IABP further into the aorta and resutures. Is there coding for this, as I don't see a repositioning code for IAB's, only VADs?
I have a radiology physician who does pre-Y90 mapping and MAA shunt evaluation when he infuses the intra-arterial administration of 6.5 mCi Technetium 99m labeled MAA for the shunt evaluation. Is there a way we can capture this charge? I am only coming up with a HCPC code C1204 for this, and I'm wondering if there is an additional CPT code we can use to capture this.
Patient has a history of ELG with a type 2 endoleak (not global). During an open embolization of the aortic sac and ligation of IMA, the physician inserted a sheath into the aortic sac and obtained intra-arterial pressures. Is that a separate billable service? If yes, what code(s) would I be able to use? We currently have code 37244 for the embolization and code 35221 for the ligation of the IMA.
Patient was being treated for a GBM. After completion of cerebral angiogram, a guide catheter and a Terumo guidewire were used to selectively catheterize the distal LICA. A roadmap technique demonstrated best view of the feeding pedicle. Once this was achieved, a microcatheter and Precision Microwire were used to selectively catheterize the distal M2 segment. Superselective angiogram revealed a discrete tumor blush. Once this was achieved, 35 mg of mannitol, after being filtered, was slowly injected. This was followed by a total dose of 400 mg dosing selectively injected into the distal MCA. He does say that this is an off-label non-FDA approved and compassionate use procedure. The only codes I can see to use are either 37202 or 37211, but neither seems to fit. And would I assign code 36228 for the superselective angio of the M2 segment even though done by roadmap technique?
I need some clarification on intra-operative billings…vasc. surgeons sometimes do arteriograms in the OR and then a radiologist or CVIR phys. will also interpret the findings. Here are some questions from one of my cvir physicians…I just want to make sure I'm telling them the correct thing. should cvir/rad be billing a technical chrg. only for interpreting their findings since the vasc. surgeon did the supervision and interpretation? Since I don't normally see the radiology part but I do see and bill the vasc. surgeon, we're afraid of duplicate billing. thanks! So, here are my questions: 1. If we provide an appropriate dictation for the images, what would we be billing for? We may be providing an interpretation, but what about the "supervision" part? 2. If we provide an appopriate dication for the images, would we be double billing (ie we and the vascular surgeon?). In reality, I doubt that can happen. 3. If we are providing a dictation to bill for the "techincal" aspects of having radiology techs go up there, is it sufficient to say, "Please see findings reported on operative report." 4. Is it the norm for radiology techs to provide this service in the OR? I know the CVIR techs used to go up there, but don't any more.
I have a question regarding a heart cath and billing intracoronary nitroglycerin give for spasms. Is this separately billable with a basic heart cath? 93458 92980-LC 92975???? Billable? thank you for any guidance you can give me.
Physician performed: 1) Left carotid endarterectomy with patch repair - 35301. 2) Intraoperative carotid arteriogram (no cath placement documented). 3) Intracranial parenchymogram on the left side. I cannot find any information on what a parenchymogram is other than it has something to do with the capillaries. As it stands I can only see reporting code 35301.
Am I suppposed to use code 37211 (arterial thrombolysis, initial day) for the following scenario? "Penumbra cath advanced to the left MCA. Two mg of tPA IA injected in this branch, over three minutes. Follow-up angiography done, and due to persistent thrombus, additional 2 mg tPA was given over three to four minutes. Follow-up angiography done, and Perclose placed." LCDs are not updated for new codes yet.
Can code 93641 be billed for intraoperative ICD testing, or is this only for defibrillation threshold testing?
Is there a code for measuring the blood flow rate using an intravascular heat exchange catheter?
Dr. Z, what would you suggest for intravascular imaging of coronary vessel by optical coherence tomrgraphy (OCT), not sure if we can use 93799? Thanks
Is there an IR procedure for treating liver tumors using brachytherapy, Ytrrium 90? It is a form of radiation that is injected into the tumor bed? Is there a dosimetry charge that can be billed? If so, is there any specific FDA-approved treatment planning or wordage that is necessary? Also, what about the use of SPECT/CT or PET/CT being reimbursed afterwards?
When the interventional radiologist assists the surgeon in the OR, should we report S&I codes if documentation supports coding? The cardiovascular center wants to charge code 76000 as a way of tracking the number of procedures the interventional radiologists assist in the OR. What is protocol for this scenario?
I haven't run across this before and I'm not sure how to code it on both FAC and PRO side. Pt was brought in for possible DC cardioversion for possible atrial flutter. Anesthesia was provided by anesthesia colleagues. In order to evaluate whether or not the patient had underlying atrial flutter the patient was given IV Adenosine 6mg at 10:04 and 12mg at 10:06 (by the cardiologist). With ensuing bradycardia no underlying atrial futter was noted. Response consistant with sinus rhythm. In summary, pre-op and post-op diagnosis were normal sinus rhythm with cardioversion being cancelled. Do I code 92960-74 or 96374 (IV push) for the FAC side and just 96374 on the PRO side? Thanks for you assistance.
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?
Dr. Z, I am requesting coding advice about the following scenario in the hospital outpatient setting R neck prepped and draped. U/S used to interrogate the neck. Could only see collateral veins. Tried to cannulate one of the larger collaterals but was unsuccessful. Converted to L neck which was prepped, draped, U/S interrogated. Micropuncture used to cannulate the vein under U/S guidance. Wire placed. Needle placed over catheter. Wire down to IVC under Fluoro. Dilator/sheath to distal IVC. IVC-grams performed. Renal veins level was marked. Filter placed. Completion IVC-grams. Wire placed and triple lumen catheter was placed. I understand that for 2012, the IVC filter placement would be coded as 37191 which bundles catheter placements, imaging and ultrasound guidance. However, I am unsure whether to report anything additional for the attempted catheter access to the R neck. I am also unsure whether the fluoro, which was used in addition to ultrasound, should be reported. Lastly, how would the central catheter placement be coded. It is not a replacement catheter, but it is being placed through the same catheter access as the IVC filter placement and so might not merit reporting of the insertion. Thank you very much!
Are diagnostic IVCgrams (75825) and US guidance for vascular access (76937) still ok to bill in conjunction with 37191 through 37193? Is 36010 now included? Also, if an SVC filter is placed, is that unlisted (37799) thanks!
I’m sorry I was not able to make it the Las Vegas conference this year but I do plan to attend your 2012-Tennessee conference. As always, I always come to you guy with the tough questions. What is your coding recommendation for coding a IVC filter Placement and Removal during the same session and same access? First time I’ve have ever seen this. Patient has extensive IVC and bilateral iliacs thrombus and is on day 3 for thrombolysis. F/U angiogram via bilateral extremity, Filter placed via rt internal jugular, Venoplasty via rt fem vein access, Thrombectomy and Stent placement of IVC via rt inj access and rt com femoral vn, bilateral venoplasty of iliac veins and then IVC filter was removed at the end. Your feedback is greatly appreciated. Thank you,
Hi Dr. Z, The physician performed a right and left heart cath with left Vgram and coronary angiography and aortic arch angiography. Because the patient had a history of IVC ligation, the physician performed a hand injection through the venous sheath in her right groin in an effort to identify her venous anatomy to faciliate the right heart cath. This revealed a narrow venous structure region with continuous flow present into a more normal appearing inferior vena cava adjacent to the entrance of the right atrium. He suspected that this is a well developed collateral that has developed as a result of ligation. He was able to navigate the right heart catheter through this vessel into the heart. My codes are as follows - 93460, 93567, but I question if I should use 75825-59. I decided against 36010 first because there is an edit, and I didn't feel that was distinct from the catheter placement used for the cardiac cath portion. I'm thinking the 75825-59 is in fact appropriate but would greatly appreciate your fine wisdom!! Thanks!
Dr. Z. Pt had a LHC whcihc showed 90% stenosis in LCX. 2 weeks later pt was brought to the cath lab for staged intervention. Physician did and IVUS which showed less than 50% stenosis and therefore did not procedure with the intervention but rather ended the procedure. Can we bill anything for the IVUS? Can we bill for the intended stent placement procedure with a modifier -74? Thanks!
Bilateral kissing iliac stents IVUS bilateral common iliac arteries Can I bill for the IVUS With 37221; 37221-59 or is IVUS included in 37221? 37221,37221-59, 37250, 75945, 37251, 75946 Thanks for help,
Dr Z, During a thoracic endovascular aortic aneurysm repair with left subclavain artery coverage 33880 75956/26 the physician places an intravascular ultrasound catheter and performes an intravascular ultrasound of the thoracic aorta from the arch all the way down to the celiac axis in the abdominal aorta. This was done to confirm diameter measurements proximally and distally. Is the IVUS 37250 75945/26 a billable service with the placement of the thoracic graft in this case? Thank you, LaVonn
Dr Z, If IVUS is performed in the Aortic arch, Thoracic and Abdominal aorta do you code as 3 procedures? Thanks
Procedure: femoral AV fistula, fistulogram, stents outside fistula, upper extremity venogram, and IVUS (several vessels including fistula). Can IVUS inside the fistula be billed?
I am writing about a scenario that we sometimes see in the cath lab. The first physician performs a diagnostic heart catheterization, and then physician #2 comes in and performs the IVUS/FFR (one or the other). Most of the time, the patient leaves the lab and is held in the holding area and is then brought back to the lab for physician #2 to perform the additional procedure. Occasionally, there is no further intervention. So, how does physician #2 bill for his services since he only performed the IVUS/FFR, which are both add-on codes (either 92978 or 93571)? We were specifically wondering if it was appropriate for an unlisted code (93799)?
Dr. Z, When the physician documents IVUS and then inserts a drug eluting stent we get an edit stating that 92978 needs to be billed with another CPT code. It is not recognizing the C9600- C9607 codes. You do not mention the use of these the C codes with 92978 in your chapter on IVUS. Is this not acceptable? Please advise. Thanks!! JD
Is IVUS 37250 and 37251 reimbursed on top of endovascular revascularization 37220-37235?
We have a vascular surgeon who performs IVUS imaging on patients with venous congestion syndrome or venous hypertension. He routinely images the IVC, bilateral common iliacs, external iliacs, and common femoral veins. Venography is not done during these procedures. When no intervention is done, how should I be coding for the IVUS? What I have been doing is coding for the bilateral catheters placements in the IVC (36010, 36010-59) and for the S&I portion of the IVUS (75945, 75946 x 6). Is this appropriate coding?
I just found out that codes J0152/G0275 were deleted 12/31/2013. What are the replacement codes?
Hi Dr. Z, Since the Jetstream device is approved for both thrombectomy and atherectomy, if BOTH procedures are performed during the same session, can BOTH procedures be coded along with BOTH C-codes? Thanks in advance!
I am encountering an issue with the use of the Jetstream atherectomy device. As you know, this device is indicated for both atherectomy and thrombectomy from the same catheter. The physician dictated that he performed an atherectomy/thrombectomy within a lower extremity vessel. There is no mention of the presence of thrombus within the vessel during the procedure. Is it appropriate to charge/code for atherectomy and thrombectomy for this procedure, as the physician only mentioned a calcified lesion in the vessel?
Hi Dr. Z, Since the Jetstream device is approved for both thrombectomy and atherectomy, if BOTH procedures are performed during the same session, can BOTH procedures be coded along with BOTH C-codes? Thanks in advance!
I have a question on coding an AP view of the bilateral hands and an AP view of the bilateral feet ordered by a rheumatologist. Is it correct to bill code 77077 x 2 for these exams?
While dilating the origin of the left iliac artery stent, a 7 mm balloon was simultaneously insufflated in the proximal right iliac system with both balloons extending into the aorta in a kissing fashion to protect the right iliac origin and dilated distal aorta. Since this is done to protect the artery, can I report code 37220-59 for one side along with the stent placement on the opposite side?
Patient is pre-op for planned gastric bypass. 74241 was coded. The question is whether 74246 would be more appropriate. Coder is questioning with KUB. No diagnostic info regarding kidney/ureter/bladder is given, but in the coders desk reference KUB is referred to as a general abdominal exam. Is diagnostic info pertaining to kidney/ureter/bladder necessary to append code 74241? Clinical Notes: Pre-Op Gastric Bypass ESOPHAGRAM AND UPPER GI SERIES - 4/6/12: HISTORY: Obesity. FINDINGS: Preliminary film of the abdomen is unremarkable. The patient swallowed barium without any difficulty. There is no evidence of a hiatal hernia or gastroesophageal reflux. The esophagus is unremarkable. The stomach shows normal motility and distensibility. Mucosal folds of the stomach are unremarkable. Duodenal bulb and loop are well seen. There is no evidence of peptic ulcer disease. CONCLUSION: THERE IS NO EVIDENCE OF A HIATAL HERNIA OR GASTROESOPHAGEAL REFLUX. THERE IS NO EVIDENCE OF PEPTIC ULCER DISEASE. ROOM TIME IS 45 MINUTES. FLUOROSCOPY TIME IS 2 MINUTES 45 SECONDS.
Since the NCD for single and dual chamber pacemakers has been put on indefinite hold per MLN Matters CR8525, does this mean that we should not be appending the -KX modifier to pacemaker implants to indicate the patient has documented symptomatic bradycardia?
We discovered that the RVUs for code 22524 jumped from 16.61 in 2011 to 223.41 in 2012. Approximately $1463.00 to $22,109.00 in 2013. Is there a specific reason for this high increase? I would appreciate any information you have for us to pass on to our concerned patients and physicians.
Hello Dr. Z, Are there other products besides Kyphon, such as the Carefusion "AVAmax" system, that would meet the kyphoplasty cavity creation CPT code definition (22523, 22524)? Thanks so much!
I have a patient on whom the physician has used a DFINE Stabili kit to perform what I would consider a "kyphoplasty" procedure. The physician performed a cavity creation by using a curved osteotome and then placed cement in the vertebral body of the L1. I have had this procedure pulled for an audit, and the auditor counted this as a vertebroplasty because the physician did not use a balloon during the procedure. I was told if the DFINE Stabili kit meets the definition of a kyphoplasty then it would be appropriate to code it as one. Can you give me some insight on this?
For services of 2014, what is the suggested code for the Lariat suture of the atrial appendage, transcatheter?
One of our electrophysiology cardiologists performed left atrial appendage ligation using Lariat device. The reimbursement consultant from Sentreheart recommended using code 33999 or 93799 with a possible crosswalk to codes 92987 and 33203. The procedure was performed through epicardial access with left appendage contrast injection. A TEE was also perfomed by another cardiologist by the same practice. Please advise the best possible way to bill this service, what the RVU value should be, and probable allowed amount for this service. As of 9/9/13, the Medicare carrier for IL is NGS.
We are contemplating the use of the Lariat device for LAA closure. I see Dr. Dunn suggested using 33999 earlier this year for the device. I am wondering why you thought that 33999 was a better choice than 0281T? 0281T Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation If you look at the NUBC definition for implant, the Lariat device, meets the criteria. The reason I am being doubly cautious is that I noticed almost all payers will not reimburse 0281T due to the investigational nature of the devices previously used for this procedure (the Watchman and the Amplatzer). Thanks in advance!
During the conference in Las Vegas in December you mentioned Lariat can be reported with code 93799; however, we are getting info within our organization stating to use code 0281T... is this correct? I thought code 0281T was an older code and not payable as for investigational, whereas code 93799 is unlisted and is possibly reimburasble.
Would a laser thrombectomy qualify for a 92973 thrombectomy add-on code?
I have a question about cardiac cath stent placement. There was a DES in the RC - G0290RC. Another DES SV graft to OM - DES placed in the LC - G0291LC. The question is can we charge for G0291RC-59 for the saphenous vein graft stenting?
Would you report codes 92928-LD and 92928-59LD for the following case? "Right femoral access: Stent to the LD with subsequent angio showing excellent results. Removed wires and started to close groin when patient went into cardiac arrest. Angio showed thrombosis of LD. Could not access left femoral for IABP. Had to pull wires from right to insert IABP. With chest compression and IABP support we were finally able to access left common femoral and place a stent across LD thrombosis."
Hello Dr.Z, I have a question in regards to the 2011 Endovascular Revasculatiion Codes. Left percutaneous femoral access was done and angio demostated occulsion. A PTA was done in the Rt SFA, Rt Anterior Tibial and Rt Posterior Tibial would you code as; 37224, 37228,& 37232? Or should it be 37224, 37232 & 37232? Because there is no add on code for the Fem/Pop Territory I am not sure if it is correct to do the 37224 & 37228 together.. Also if the doctor selectively does Angiogram ie: multiple times do we Not bill for any of those? I would also like to verify that 36245-36248 is included in the PTA revasculariztion coding! Thanks for your time and prompt reply..It is greatly appreciate..:) Deb
The physician tried an Easytrak 2 lead (LV lead) and was unable to get satisfactory thresholds, so he exchanged with an Easytrak 3 lead. We obviously only ended up with one lead in the patient, but we used two and we were charged for both. Is there a modifier for this? What is the appropriate charge situation for the supplies used?
Please do NOT include any actual patient medical records with your question. Have cardiologist that wants to charge 33216(lead replacement,33233(PM removal), 33234(lead removal) and 33222(pocket revision) on patient that required replacement of chronic RA lead due none capture. Per patient's report generator removed, leads tested (noise defect reproduced with pressure on part of lead entering cephalic vein), Chronic RA lead removed, new lead placed, connected to generator, pocket washed with gentamycin saline and pocket closed. Per report no new generator placed and no revision of pocket. My understanding is that 33216 bundles the chronic PM removal and replacement. And documentation not adequate for charge of revision of pocket.Do you have avialable clear instructions on what is included in lead repair/replacement procedures. Thank you for your help. Rick
A physician is doing a dual chamber pacemaker exchange and finds the RA lead has fractured and the RV lead has dislodged. He removes the device, removes the RA lead, places a new RA lead, repositions the RV lead, and then replaces the device. We were told to report codes 33206, 33235, 33233, and 33215. I see that code 33215 is an NCCI edit to code 33206. Can they be charged together?
Should code 93640 be used for the testing of "leads only" at time of initial ICD implant or ICD generator change? For example the report reads, "Ventricular pacing and sensing thresholds were checked and were good. Final sensing and pacing thresholds were checked and were good." I have been instructed to use code 93640 with modifier -52 (reduced services) because sensing and pacing were checked, but no arrhythmia was induced for termination. Is this an appropriate use of code 93640? Or is the checking of leads for pacing and sensing thresholds considered part of the ICD implant procedure and not billed separately?
Please do NOT include any actual patient medical records with your question. Dr. Z. I have a question in referece to th recalled ICD Riata lead. One of our physicians dictates a sepatate report for fluoroscopy of the thorax on patients having an Icd gen change who have a riata lead. He states that the flouroscopy is medically necessary and mandated by the FDA. Should 76000 be charged in this situation? Thanks. D.
Rapid atrial pacing induced left A-flutter into A-fibrillation back into A-flutter into A-fibrillation. Ablation of the roof near the LSVP terminated the A Fib. Ablation contined down the posterior antrum of the L atrium which induced A-Flutter. We ablated around the entire L antrum, the tachycardia continued. We ablated the roof of the LA, from LSPV to RSPV as well as the posterior line from the L antrum to the R antrum and the left A-flutter terminated. The left flutter was posterior wall dependent. Multiple ablations were done in the mitral isthmus region and the corresponding contralateral CS region. After ablation was complete, EPS was done with no inducible atrial tachydysrhythmia. Adenosine bolus was given to induce pulmonary vein fascicles. None were induced. Post op dx are atrial fibrillation and two different left atrial flutter. Should this be coded to 93656, 93657 x 2 or 93653, 93656, 93657 x 1? In this case, would 93623 be billed for the adenosine?
I have a left heart catheterization with aortic root, along with a abd-aortic run-off. The physician describes the non-selective renals, then repositioning for the non-selective bilateral ilio-femoral run-off. The bilateral lower extremity angiographies are described in complete detail all the way down to the ankles. My initial thought was 93458, 93567, G0278, and G0275. But he gave such a full and complete seperate report of the lower extremities starting at the iliacs that I felt that maybe I need to drop the G0278 and replace it with 75716-59. What is your opinion?
One of our providers is wanting to bill for left heart catheterization (93452) with VT ablation (93654). It's my understanding that VT ablation includes a comprehensive diagnostic study of the right heart and left ventricle. I've noticed we can bypass the NCCI edit by adding modifier -59, but I am wondering when it would be appropriate to bill separately when performed with the VT ablation.
When a patient has a left heart catheterization, followed by percutaneous intervention, both are considered necessary and can be billed. I'm not sure how to bill services provided when the patient emergently arrives to the hospital and requires this sequence: coronary angiography, percutaneous intervention, and left heart catheterization last. Is the catheterization still billable even though it was done second since there wasn't time to do it prior to the intervention? Or is it not supposed to be billed since it was not done to determine if the intervention should be put in? If not, can I bill for the coronary angiography since that was done prior to the intervention?
Please do NOT include any actual patient medical records with your question. Question about failed stents Chronic total occlusion of the left anterior decesending, which is unsuccessfully crossed percutaneoulsy due to the inability to see the origin of the occlusion. Successful deployment of StarClose device. Cardiac catherization reason for procedure: Continued angina despite maximal medical therapy. How do I code the cath and the failed stent? The cath is a LHC. Thank you Marchelle Cagle 205-327-7728
I'm new to cardiology coding. If a physician performs a left heart catheterization and bilateral coronary angiography, is it acceptable to report codes 93458 and 93454? I know the left coronary angiography is inclusive with code 93458, but can we report code 93454 for the right coronary angiography?
If just aortic pressures are taken (during a catheterization without mention of where the catheter ended up/placed), would that constitute charging/coding a left heart catheterization?
Dr. Z, Hi -- would appreciate your opinion. MD placed LEFT MAIN DES. He describes "high-grade disease in the proximal circumflex" and subsequently describes intervention (DES) "distal left main." Cath Lab reviewed the films and says, "Treated lesion(s) are continuous - the distal left main and into high proximal circ/OM branch were target lesions. MD ballooned multiple times at this site. THE STENT IS CLEARLY IN THE LEFT MAIN." MD has summarized: "LM = DES and PTCA; Left circumflex = PTCA" Would you charge/code: G0290-LC only or G0290-LD with 92984-LC? THANK YOU.
I have a new Dr who is asking about coding coronary interventions and wanted to be sure we were aware of when we could bill the left main as 2 interventions. I am not aware of this and do not think you can seperate and bill 2 intervention done in the Left Main. Please help!
Successful angioplasty opening of left SFA CTO in retrograde ipsilateral fashion (via left popliteal artery) followed by antegrade angioplasty and stenting of the left SFA in contralateral fashion (via right femoral artery) due to dissection and suboptimal results. Is it appropriate to report code 37226 with 37224-59 due to additional access sites?
Original Question: Can you help with this new (to me) device: EndoRE® Remote Endarterectomy Device. I have a doctor using this procedure from an endarterectomy with distal atherectomy. Is this still considered an endarterectomy, or should these be billed as a true atherectomy? PRODUCT Description: "The MollRing Cutter® Transection Device is a tool designed to transect and remove the plaque core at the designated endpoint or site of the reconstitution of the artery. MollRing Cutters provide the ability to cut the core of the wall of the artery without tearing. The rounded bottom edge of the cutter ring allows for a smooth advancement from the proximal arteriotomy to the designated endpoint." Follow-Up Question: Dr. Dunn answered a question for me last month. Is it possible to get a little more information? This group of doctors is doing an arteriotomy iliofemoral area. Doing an endarterectomy, then extending this "cutter" down and cutting the plaque in the popliteal and distally as far as the post tib. Should I be coding as endarterectomy iliofemoral and the popliteal etc.? Or when the cutting device is extended beyond the original vessels into seperately billable vessel, should I code these as atherectomy even though this isn't an approved device? These are all open procedures with an endarterectomy at the arteriotomy site, and then sometimes it is extended half way down the leg for a remote atherectomy.
Patient presents with history of coronary artery disease, peripheral vascular disease of the extremities, and carotid artery stenosis, status post PCI and PTA of subclavian artery. Recent stress test and Doppler ultrasound of great vessels had abnormal results. Procedures performed include left heart catheterization plus selective injections of coronary arteries, (native) right/left internal mammary arteries, right/left subclavian arteries, right/left vertebral arteries (from subclavian catheter placement), and right/left carotid arteries. Interpretations include coronary artery stenosis (414.01), subclavian artery stenosis (440.20), normal internal mammary arteries, normal vertebral arteries, and carotid artery stenosis (433.10). Are the following codes appropriate for the combination of coronary and peripheral vascular procedures performed in the same setting: 93459-TC, 36225-50, 36222-50, 36216-59RT, 36215-59LT, and 75716-59TC?
How would you code a ligation of the anterior branch of the greater saphenous vein?
What is the CPT code for ligation of accessory vein? ESRD with a poorly matured right arm fistula. Procedure: Balloon angioplasty of the cephalic arch and peripheral cephalic vein, ligation of the accessory vein to improve blood flow. Incision through the subcutaneous tissue to the accesory vein and was freed up from the surrounding tissue and ligated with 2-0 silk tie.
How would you bill for ligation of axillary vein and its tributaries to control bleeding from a gunshot wound? Procedure in detail: Patient's right anterolateral thoracotomy generously exposed the third portion of the axilla and the axillary artery and vein. Myriad tributaries and the axillary vein itself were lacerated, both by direct impact and cavitation. Serial Prolene 4-0 sutures over sewed, ligated the venous tributaries, as well as the anteromedial wall of the axillary vein itself. Copious irrigation was used. Hæmostasis was achieved, though the pectoral muscles (minor and major) were injured from the GSW blast. The axillary artery was palpated, and no overt injury was noted. Closure is under the ægis of Dr. X.
What is the difference between a limited Doppler (93321) and a complete Doppler (93320)?
I have a question relating to PICC line placement. If a nurse attempts to place a PICC line but cannot place the catheter centrally, how do you code for this? The catheter terminates in the arm, short of the axillary vein. I'm told they can last up to two weeks in this position. Thanks so much!
In regards to 93312 - is there a standard for bare minimum required findings? The only finding is "no clot found on TEE prior to ablation", would you add a modifier or not bill based on these limited findings. In regards to ablation, we do a follow-up TEE , usually to r/o pericardial effusion prior to discharge(usually next day). Many times the findings state "no effusion". Is this billable and what code would we use? Lastly, still in regards to ablations. How do we correctly bill 93462 transeptal puncture with ablations? *We have some payers reimbursing only $4-5,ooo when we use 93462 with 93651 and 93652. If we don't submit 93462 on the bill, we have the same payers reimbursing $45,000+. Many thanks for your time and assistance! Lori Sprenger
This is a Protocol. Patient has a kidney or liver biopsy. Radiologist has technologist perform a limited ultrasound two hours post biopsy to check for possible complications. Would you consider this part of the biopsy procedure? My feeling is yes, if there were no signs/symptoms of a problem, just routine follow-up. But if there are signs/symptoms, then charge the limited ultrasound. Your comments are appreciated.
Physician performed a percutaneous needle core biopsy of the liver using ultrasound guidance (47000 and 76942). At the end of his dictation for the biopsy he said, "An introducing needle was then placed into the lesion. An 8 x 4 tornado coil was placed through the introducing needle." Can I code for this coil placement? If so, what code(s) would I use?
Can catheter selectivity be determined in the hepatic arteries when only liver segments are mentioned (i.e., report states, "selective catheterization of segment II hepatic artery... selective catheterization of segment V-VIII hepatic artery... selective catheterization of segment IV hepatic artery")? If so, what are the rules for that?
If an intervention is performed from the left main into the circumflex or left anterior descending (on a single bridging lesion), do you add -LM as the modifier, or LC/LD?
I have never seen gold seeds used for localization of a lesion before surgery. There was increased activity in the paraspinous tissue L1 area on a PET/CT scan.. The patient's mid back is prepped and draped in a sterile manner. Under CT guidance a 18 gauge needle was advanced into the area of interest to the left of the L1 vertebral body. Two gold seeds were placed 0.8 mm x 5mm. The seeds were placed lateral to the left fusion rod and medial to the left 12th rib in the area of increased activity. The patient will have a PET CT scan to identify the relationship of the gold seeds to the area of increased activity. "Impression: Status post CT-guided placement of localization gold seeds." I was thinking of using code 77012 for the guidance and an unlisted code for the gold seeds... not sure of the correct unlisted code 20999 (musculoskeletal) or 22899 (spine). What would you suggest?
Physician used a Lombard AorFix device to repair a common iliac aneurysm that extended into the internal iliac artery. Internal iliac was embolized, and the device was placed just below the renal arteries, seated at the aortoiliac bifurcation, with one docking limb extending down the common/external iliac and covering the internal iliac. Reason for device was due to torturous aorta in a patient with multiple surgeries for colitis with a colostomy and a chronic abdominal fistula.
I code for both the primary and assistant surgeons. The primary surgeon from the first procedure was the assistant for the second and visa versa. How do you code one procedure that turns into two, that stretches from 7:45 am to after 4:30 pm on a patient that exceeded 400 lb? They did a bilateral femoral artery cutdown, with attempted deployment of aortobiiliac unibody graft. They added a micropuncture to the left brachial artery for additional access. In addition to the patient’s size he also had severe tortuosity of both iliac arteries with at least two 90 degree bends. They had difficulty unsheathing the right limb, and after many attempts to unsheathe the limb and a broken wire, they decided to move to the OR where they performed an open AA aneurysmorrhaphy with aortobiiliac bypass. After thoughtful research I feel that the following is correct, but I would like a second opinion. Surgery 1: 34812-50, 36200-RT, 36200-59LT, 34804-53, 75952-26. Surgery 2: 35102-2278. One of my concerns is that code 35102 will be bundled into code 34804 due to NCCI edits.
I have a request for a misc charge 33999 to capture reposition of loop recorder. I'm not sure this would be a valid charge. Everything I find indicates that repositioning should be included at the time of the loop recorder insertion with code 93620. Please advise.
Within the PVL, a written physician order is documented within the patient chart that requests: • Deep Vein studies/ lower extremity • Bilateral Carotid Duplex • Bilateral Lower extremity vein mapping When these orders are entered from the unit and received within the Radiology order billing system; CPT 93970 is reported for both (venous mapping and Bilateral Lower Extremity Duplex) orders selected (93880, 93970, 93970). Although a distinct service modifier would pass edits, I feel that when performed during the same encounter, the venous mapping is inclusive with the bilateral duplex scan of extremity veins and should not be reported separately. I submit that both technical and professional charges for this encounter should only be reported as 93880 and 93970. I would respect your opinion on this to support my position for what I feel could be a duplication of procedural charges. Dictated report for all procedures are provided below: PROCEDURE: BILATERAL SAPHENOUS VEIN MAPPING COMPARISON: None. INDICATION: Pre open heart surgery. TECHNIQUE: Gray-scale imaging was performed on the bilateral greater saphenous veins with caliber measurements. FINDINGS: RIGHT GSV: Thigh proximal: 2.9 mm Thigh mid: 3.0 mm Thigh distal: 2.7 mm Knee: 2.4 mm Calf proximal: 1.9 mm Calf mid: 1.7 mm Calf distal: 2.2 mm LEFT GSV: Thigh proximal: 3.8 mm Thigh mid: 2.8 mm Thigh distal: 2.0 mm Knee: 2.2 mm Calf proximal: 2.0 mm Calf mid: 1.5 mm Calf distal: 1.4 mm CONCLUSION: The bilateral greater saphenous veins were imaged and measured as described above. PROCEDURE: BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND FOR DVT WITH DOPPLER COMPARISON: None. INDICATION: Previous DVT. TECHNIQUE: Gray-scale and color Doppler imaging were performed on the bilateral lower extremities. FINDINGS: RIGHT LOWER EXTREMITY: CFV: Normal. SFV: Reduced. PFV: Normal. POP-V: Reduced. PTV: Normal. PER: Normal. ATV: Normal. GSV: Normal. LEFT LOWER EXTREMITY: CFV: Normal. SFV: Normal. PFV: Normal. POP-V: Normal. PTV: Normal. PER: Normal. ATV: Normal. GSV: Normal. Normal findings indicate good phasicity, spontaneity, compressibility, augmentation response, and competence. CONCLUSION: Chronic DVT seen in the right SFV and popliteal vein with recanalization. Remaining deep vessels show no evidence of acute or chronic DVT. No evidence of superficial thrombophlebitis. PROCEDURE: BILATERAL CAROTID DUPLEX ULTRASOUND COMPARISON: None. INDICATION: Preop screening. HISTORY: CAD. TECHNIQUE: Gray-scale and color Doppler imaging were performed on the bilateral carotid arteries. FINDINGS: RIGHT: COMMON CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar PEAK SYSTOLIC VELOCITY: 80 cm/s END-DIASTOLIC VELOCITY: 17 cm/s PROXIMAL INTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. Calcified. SURFACE CHARACTERISTICS: Irregular. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 207 cm/s END-DIASTOLIC VELOCITY: 62 cm/s DISTAL INTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 188 cm/s END-DIASTOLIC VELOCITY: 37 cm/s EXTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 137 cm/s END-DIASTOLIC VELOCITY: 21 cm/s VERTEBRAL ARTERY: Antegrade. ICA:CCA SYSTOLIC RATIO: 2.6 LEFT: COMMON CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 87 cm/s END-DIASTOLIC VELOCITY: 21 cm/s PROXIMAL INTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. Calcified. SURFACE CHARACTERISTICS: Irregular. FLOW CHARACTERISTICS: Turbulent. PEAK SYSTOLIC VELOCITY: 184 cm/s END-DIASTOLIC VELOCITY: 54 cm/s DISTAL INTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 162 cm/s END-DIASTOLIC VELOCITY: 47 cm/s EXTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 157 cm/s END-DIASTOLIC VELOCITY: 27 cm/s VERTEBRAL ARTERY: Antegrade. ICA:CCA SYSTOLIC RATIO: 2.1 CONCLUSION: Bilateral 60-79% ICA stenosis with irregular plaque characteristics and turbulent flow. The vertebral arteries appear patent with antegrade flow bilaterally.
I'm thinking I would code this 36147, 37221, 37223. Ultrasound was used to obtain access into the graft. Contrast injected showing severe stenosis involving the external iliac and common iliac veins. This was angioplastied with residual stenosis. Patient has had multiple angioplasties, so I decided to stent lesion. Stent deployed in the common iliac vein into the proximal external iliac vein. Contrast shows residual stenosis involving the distal external iliac vein so I decided to deploy another stent, which extended the stent down to the level of the distal external iliac vein. Attention then directed toward pseudoaneurysm, which was in the venous limb of graft. Stent deployed across pseudoaneurysm to cover it and was pulse dilated. Since the external iliac is part of the peripheral zone, and the common iliac is part of the central zone I think I can code the stenting of both. I'm fairly new to vascular coding and appreciate your input!
Good Morning, When a stent and or angioplasty of the lower extremities are performed on the venous side do we use the new lower extremity intervention codes (37220 -37239). I would say not. Please advis.
I am reading in your example #2 under the AV shunt interventions chapter. It reads "2) Patient with clotted left leg dialysis graft undergoes cross catheter technique (36147, 36148) with shuntogram (included) and declot utilizing a thrombectomy catheter (36870). An arterial inflow stenosis in the native iliac artery 8 cm proximal to the arterial anastomosis is ballooned (36245, 37220) as is a common iliac vein stenosis (35476, 75978)." my question is concerning the 36245 coded with 37220. Wouldn't 36245 bundled with 37220? I would think that you would only be able to capture 37220 and not the cath placement code. What is your reasoning for add both 36245 and 37220? I have a similar situation AV shunt in lower leg venous outflow stenoses treated with stent deployment. I thought I should code with 36147, 37221.
With regards to Question ID #5330, we have a similar case with balloon inflation throughout the graft across the anastomosis to the right external iliac vein, with stent placement across the venous anastomosis into the venous limb. In #5330, you agreed with codes 36147, 37221, which is an arterial stent placement. I keep coming to code 37238, but it excludes lower extremity. What code will be used for iliac venous anastomosis stent placement?
I have a patient who had a lung bx at 13:05. At the time of the bx, he had a large pleural effusion. Following the bx, he developed a hydropneumothorax which resulted in the low oxygen saturation. The patient was brought back to the angiography suite for placement of chest tube. Because of his effusion as well as pneumothorax, a decision was made to place two cathers, one for drainage of the effusion (right lower pleural cavity) and one for the drainage of the pneumothorax (upper pleural cavity) at 17:53. DOS - 08/11/11 Coded as: 32405 - lung bx 77012 - CT guidance 32551 - thoracostomy tube 75989-26 - imaging guidance for tube 32551-59 - 2nd thoracostomy tube 75989-26-59 - 2nd imaging guidance for tube What would be the proper modifiers in this scenario?