If a pregnant woman has a bilateral uterine artery embolization immediately prior to a C-section/hysterectomy due to placenta accreta or placenta percreta and high risk for hemorrhage during surgery, would this be coded with 37244 or 37242?
"Patient has thrombosis of aortofemoral bypass graft. Physician performed excision of PTFE femoral-femoral bypass graft with vein patch angioplasty and repair of right common femoral artery. Then he redid right to left femoral bypass graft using cryopreserved femoral vein. The patient does have some persistent drainage from the resent surgical wound in her right thigh, therefore a decision has been made to use cryopreserved femoral vein." Can I bill code 35903 for removal of infected graft with code 35661? Please advise.
In a lower extremity endovascular revascularization of a chronic total occlusion, does a device like the Crosser™ Catheter fulfill the requirements as an atherectomy device? Also, in a procedure where a Crosser™ Catheter was utilized and the occlusion could not be crossed, does the physician report the procedure with code 37225 with a -52 modifier appended, or should it be reported with code 37224?
Can you report codes 35721 and 27364 together? Another coder thinks that because the description of code 35721 says if you do a more comprehensive procedure through the same incision site to code the more comprehensive procedure that this means the original surgical incision site. I think this means the same incision site of the femoral artery. To me, if it was the surgical incision, all codes would bundle with it and only vascular codes bundle with. Plus everything I have read says you can code them together and CPT guidelines are for more comprehensive VASCULAR procedures, not any procedure.
My doctor did a selective catheter placement on the left for T4-T7 and L4. He then did a selective catheter placement on the right for T8-T12 and L1-L3. How should I code this?
The RCA, OM1, and OM2 were all stented. Would it be appropriate (because the CIRC was not treated) to report code C9600 x 3? The descriptor states "main vessel OR branch of".
Please advise on the CPT codes applicable to this procedure. "Operation: Patient has had problems with dialyzing on the right groin graft and is undergoing AV fistulogram. Procedure performed is right groin fistulogram, PTA, stenosis of arterial and venous anastomoses. Patient heparinized. A 6 mm x 4 cm balloon was used to dilate arterial anastomosis. Second sheath in venous limb and performed angioplasty of venous anastamosis with 6 mm balloon and then with 7 mm ballooon. After completing, fistula appeared widely patent. Sheaths were removed and direct pressure applied."
Our surgeon assisted on a CABG, and primary surgeon coded CABG (3+1) 33533 and LIMA 33519. Our surgeon thought it would be CABG (x4) 33536 and Lima 33522. "Procedure: Coronary artery bypass grafting x 4 with LIMA to LAD, vein graft to the diagonal artery, vein graft to the second obtuse marginal artery and vein graft to the LV branch of the right coronary artery. Saphenous vein graft harvested in L leg. Simultaneously, sternotomy was performed..Bypass was initiated. Target vessels identified and marked. Aorta was cross-clamped...The LV branch was nice target over 1.5mm in diameter. Vein graft was anastomosed end-to-end; R coronary artery and posterior descending aorta was severely and diffusely calcified. The vein graft to LV branch of R coronary artery anastomosed to aorta..Marginal vessel was exposed. Vein graft was anastomosed to this vessel which on small side, 1.5cm. Vein graft was then anastomosed over diagonal vessel, also small, 1.5cm LIMA was anastomosed to LAD beyond its midportion. LAD was again quite small, 1.5 cm...anastomosis sewn, etc..."
Physican performs infrarenal aortic resection with aortic reconstruction with homograft (end-to-end anastomosis) and IMA reimplantation for indication of infrarenal aortitis due to Clostridium septicum infection. Since the indication is infection, rather than aneurysm, pseudoaneurysm, or other occlusive disease, I'm thinking of using code 33330 for the reconstruction (insertion of graft), along with add-on code 35697 for the IMA reimplantation, but I'm having trouble locating a code for the resection. Procedure: "Aorta was clamped just below the renal arteries and at the common iliac vessels. Aorta was divided 3 cm from the left renal artery and 2 cm from the aortic bifurcation distally. The homograft was cut to length just below the renals and an end-to-end anastomosis created. Distally the left and right iliac anastomoses were completed. 4 mm punch used to create an opening in the ant wall of the aorta. 6-0 Prolene used to create an anastomosis between the IMA and the side of the aortic homograft."
Two interventionists performed separate interventions during the same case; one did 92941-RC and the other 92928-LD. Each performed IVUS on the artery they intervened on. Can each bill for an initial vessel IVUS for professional billing?
Would codes 21899 (unlisted procedure, neck or thorax) and 76942 be correct to bill for a wire localization of a neck mass? The payer (UHC) has denied twice, even with the operative notes were sent, for reason "CPT code inconsistent with provider". They paid on code 76942, but not 21899. Do you know if there is instruction somewhere saying these are the appropriate codes that could be sent to insurance company that might get them to consider paying on code 21899?
When looking at reimbursement for 2016 codes we are finding that code 61645 (intracranial thrombectomy/thrombolysis) is showing no reimbursement for outpatient. This code is not listed on the inpatient-only list (that we could find). Is there a different CPT code we should be using for this procedure, or are we missing something?
"CVT SURGERY OP note Dx ASHD Angina pectoris, CAD, NSTEMI Diabetes Hypertension Hyperlipidemia Morbid Obesity Sleep apnea OP CABG x 5 Vein graft to diagonal to OM to PDA IMA to diagonal to IMA Endoscopic vein harvest right thigh Findings Good LV, vein and IMA Morbidly obese Aorta OK Moderate distal disease thin walled vessels Tolerated well Off bypass easily No inotropes very bloody counts correct. This is all my surgeon has documented can i code based on this documentation." How can I explain to my manager that I need more documentation to correctly code? Where can I find the minimum documentation requirements for procedures in CMS? Your expertise will be a great help in this.
How do you code stent repair of distal artery to pulmonary artery conduit (5 mm x 15 mm Genesis bare metal stent)?
I'm not sure if this is reported with codes 36147, 35475, and 75962, or if there is more to code for the radial artery cath and imaging. What are your thoughts? "Percutaneous retrograde puncture of the left forearm arteriovenous fistula was then performed at the level of the upper forearm with a single wall arterial entry needle. A fistulogram was then obtained. There was a focal stenosis at the arteriovenous anastomosis. This was crossed with a Glidewire. A Bernstein catheter was advanced selectively into the radial artery, and a selective radial artery angiogram was obtained. A 3 x 30 mm eV3 EverCross balloon was advanced over the wire and positioned across the arteriovenous anastomosis. The balloon was inflated to its nominal pressure, and the inflation was maintained for 2 minutes and repeated twice. Completion angiogram showed an excellent result with a widely patent arteriovenous anastomosis."
Our physicians use a variety of wording when it comes to the permanent recording and reporting of code 76937. Evaluating the access site, documenting patency, and real-time needle entry is usually not an issue; however, they will document things like "a permanent still image of wire position was archived", "ultrasound documented wire position", or "I advanced wire and documented wire position". Wire placement/position?? "Documented" doesn't necessarily mean saved and stored in my opinion. Are these acceptable examples of permanent recording and reporting?
We have been told by the pacemaker rep that, if we see the patient in the office and provide a pacemaker or AICD check and make changes, we can still bill the remote check every 91 days. However, we are receiving denials for one of the checks for frequency issues. Can you clarify if we can bill the mix of device checks in person with remote device checks, or will each check bump out a new time frame that the next check can be done?
I have some physicians who insist on billing code 33224 along with codes 36005, 75820, and 75860. My understanding is that you have to use venography to see the proper placement, so it would be inappropriate to code additionally. I have also explained that code 75860 is not intended for the "coronary sinus", but I still hear arguments. Can you clarify please?
Please advise if codes 37242, 34900, 75954, and 36200-50 are appropriate for the following: "Sheath was inserted into the right SFA and left SFA. Pre-operative imaging demonstrated two primary outflow branches from the right hypogastric aneurysm. We were able to advance a wire from the ipsilateral groin into the right hypogastric artery aneurysm, and, fortunately, this wire passed easily into the primary outflow branch. Nine 8 mm x 4 cm Tornado coils were deployed into the branch. Completion angiogram showed small type II endoleak. Left hypogastric aneurysm was stented into primary outflow branch. There was another small endoleak, so we chose a Gore Excluder limb stent from right common iliac to the external iliac, past the origin of hypogastric artery. Second stent was placed slightly above aortic bifurcation to complete perfect seal."
I have a physician who is wanting to know how to report His bundle lead in CRT-D therapy cases. He is placing three leads: 1) RA in RA port, 2) RV in RV port, and 3) His Bundle lead in the LV port. Codes 33225 and 33224 both describe insertion of pacing leads for left ventricular pacing, but these codes do not seem to fit our physician's situation, as he is inserting leads into the His bundle. What are your thoughts?
If the physician places a stent in a 50% external iliac artery narrowing because the narrowing is causing difficulty passing the AAA endograft, can the stent placement in the external iliac be reported?
We've noticed that on the 2016 APC file, new code 61645 for intracranial mechanical thrombectomy/infusion for thrombolysis is assigned status indicator E (non-covered for Medicare). It is on the 2016 physician fee schedule, so it seems like an error on the APC file. Also, would 03CG3ZZ be the correct ICD-10-PCS code for intracranial thrombectomy?
How do you report the new codes for a nitroglycerin spasmolytic procedure? The description is for prolonged service and does not fit what we are doing.
What can you tell us about code 93050?
Is there a separate code for billing an MRI lymphangiogram? The radiologist performed an MRI with and without contrast, along with MIPS. Exam is being performed for pre-surgical planning (patient has left leg lymphedema).
I'm having a hard time locating an exact CPT code for this procedure, and I am wondering if I should use unlisted code 37799. "The patient's venous aneurysm was marked in the erect position. The skin overlying the venous aneurysm was infiltrated with 1% lidocaine with epinephrine. It was incised with a #15 blade. The aneurysm was dissected from the surrounding soft tissue. The branch of the basilica vein, from which the aneurysm emenated, was ligated with 2-0 silk ties proximal and distal to the aneurysm. The skin was closed with 3-0 vicryl suture in a subcuticular fashion. The incision was reinforced with steri strips, and the wound was dressed." If the unlisted code should be used, what procedure is it comparable to? For pricing purposes?
Consultation was requested regarding patient with prolonged bleeding from AV fistula after dialysis. Patient was seen in the ED – persistent bleeding from fistula’s single puncture site. There was no ulceration or infection. Physician placed a single purse-string suture to control bleeding. Is there enough here to code a simple wound repair, or would you code an E&M visit?
What codes would l use for a right lower extremity angiogram and a third order catheterization right SFA? Patient also had an angioplasty of right lower extremity vascular graft with a follow-up angiography.
Please advise on the proper codes for this procedure. "Operation performed: Open exploration, left common femoral vein, femoral profunda, femoris vein with endovenectomy of femoral vein. Construction of arteriovenous fistula between the left SFA and femoral vein with reversed anterior accessory saphenous vein. Bilateral lower extremity venogram and inferior vena cavogram. Open angioplasty of the left common femoral vein, external and common iliac veins, and inferior vena cava. Double-barrel stent placement of the para renal inferior vena cava with Palmaz open stent placement from the left and percutaneous stent placement from the right." So far I'm thinking I will need to use an unlisted code for the endovenectomy. I'm not sure about the AVF since there was no bypass performed. Any advise and help would be greatly appreciated.
Will you please review the documentation below and advise on appropriate coding? "Patient is positioned in Selenia Dimensions Affirm stereotactic biopsy system (this is an attachment that goes on our Selenia Dimensions Tomosynthesis Mammography system). A tomosynthesis image is taken and target confirmed. Biopsy needle put into position in the patient’s breast. Stereotactic 2D pre-fire images acquired. Biopsy device is advanced further into the breast (fired). Stereotactic post-fire images acquired to confirm position of biopsy needle. Tissue specimen was obtained. Specimen imaging was performed (as indicated) on separate mammography unit. Biopsy clip was deployed. Post biopsy image was taken to confirm clip has deployed. This is done either 2D or 3D. Two-view tomosynthesis combo (2D + 3D) mammogram (full field image) performed to confirm clip placement, and area of target was biopsied."
We have a patient who had an ulcerated left AVF. We ligated the fistula, and she had further issues with the wound healing after the ligation surgery. She came in for her new access in the right arm and had foul smelling drainage from the open wound in the left arm. Decision was made to debride the wound and excise the portion of the AVF that contained the infected hematoma and to create the new AVF in the right arm. We did the AVF creation in the right upper extremity. My concern is how to code the excision/debridement. This was an AVF, not graft, so I don’t feel as though code 35903 would be accurate. I also don’t feel as though a debridement code or 10180 would cover the amount of work actually done. I don’t think I like a revision code either, because they don’t intend on using the AVF. I would appreciate your input!
Can I bill a femoral cutdown , aortogram w/ bilateral iliofemoral arteriogram with the placement of stent femoral artery?
I believe I can only bill code 37226 with 75630 if decision to perform intervention after iliofemoral arteriogram. No other codes. Is this correct?
I just completed your 2016 updates webinar, and I understand that there are new nephrostogram and pyelogram codes that bundle diagnostic imaging. However, I noticed that in the 2016 codebook, under code 50390, it still directs the coder to add code 74425 (urography) to the 50390 injection code. I assume this is not for a diagnostic study. Under what circumstances or in what scenario in 2016 would you use code 50390 with 74425?
"The physician performs a diagnostic angiography of the left lower extremity (75710-59) and then decides to place stents in the mid, distal, and proximal SFA (37226-LT). After this he performs a confirmatory angio and determines there is thrombus material in the posterior tibial and peroneal arteries. He then performs a suction thrombectomy, which removes the thrombus." I am unsure how to code the thrombectomy, as it was not mechanical and it is in a different vessel territory than the SFA stents. Is unlisted code 37799 my only option here, or is this not even billable?
If an electrophysiologist performs an ICD removal from the left side, moves it to the right side, and then tunnels the lead from left to right and reattaches the lead to the right-sided defibrillator, is there a reportable code the physician can use for the work involved in the tunneling?
Patient was admitted and 1 gm IV procainamide was given in an outpatient setting. My doctor dropped the charge of 93623 (the add-on code) and nothing else. This was done alone and not part of an EP study. What code should I use to bill for this?
The use of MAC is being done more frequently within hospitals during EP studies as well as other diagnostic services. Both G-codes currently available are G-codes assigned status indicator M. Per AMA, this should only be done when medically necessary or potential for adverse reactions to the procedure. Our OR currently charges this a regular anesthesia for all EP studies, but I'm not sure this is appropriate. Code G9654 will be new for 2016 (also status indicator M). Any advice?
This Q& A below was in the ZHealth coding newsletter of December 2011. Does this still apply, or has there been changes to billing angioplasty with stent placement based on intent? Original Question: "Can you bill angioplasty code 35476 and stent placement code 37205 in the same venous (SVC-IVC) or pulmonary artery (92997, 37205) when angioplasty is not just for inflating a stent that is placed?" Original Answer: "Depends. There needs to be an intent to only perform balloon angioplasty, with a suboptimal outcome requiring stent placement to code for both. If this is not documented, I would only code the stent placement."
The intended procedure was to place a coronary stent, but, after much time and many attempts with various caths, the lesion was not crossed. How should this be billed?
I'm getting denials for codes 75716 and 75625 billed with 37221/37224 or intervention codes billed on same encounter. The CPT Codebook indicates that for lower extremities the radiological S&I directly related to intervention is included. In the past we have billed these S&I codes with a -59 modifier. Are they still eligible to code?
I have an attempted port placement: "Right internal jugular vein was accessed with a needle under ultrasound guidance with angiography of the right internal jugular vein. Catheter was removed. Left internal jugular vein was accessed with needle under ultrasound guidance. Needle was advanced to the brachiocephalic and imaged obtained of the left jugular and brachiocephalic veins." Since the SVC could not be accessed via either of the jugular veins due to central occlusion, the port catheter placement was aborted. Are codes 36000, 36000-76, 75860, and 75860-76 appropriate?
Can I bill for both codes 36010 and 93531 for the following, since it comes up as bundled in the NCCI edits and needs a modifier? "Catheter Course: The right femoral vein and right femoral arteries were percutaneously entered under ultrasound guidance, and a 4 French sheath was placed in each vessel utilizing the modified Seldinger technique. The right femoral vein was pre-closed with three (3) Perclose devices. The 4 French sheath in the right femoral vein was eventually upsized to a 16 French Gore DrySeal sheath. A 4 French pigtail catheter was inserted into the 4 French right arterial sheath and subsequently advanced retrograde to the ascending aorta and into the morphologic right ventricle (systemic ventricle). A 7 French GL catheter was inserted in the right femoral sheath and advanced in the usual fashion to the IVC, inferior and superior baffles, and SVC. Pressures and saturations were taken, and an angiogram was performed of the IVC."
In your endovascular surgery book it states that venous code 37187 is used once per day per vascular territory. Is the venous vascular territory the same as arterial iliac, fem-pop, and tibial-peroneal territories? If a physician is doing a thrombectomy in the iliacs (common, external) and femoral (common, SFA, and popliteal) would code 37187 be reported twice or just once? I just want clarification on the initial day.
Is the following documentation enough to support charging code 76937? If not, can we down-code it to 76942? Physician is placing a bedside non-tunneled CVC. He uses US guidance. Here is a copy from the note: "Preparation: Sterile preparation of site (in usual fashion, with 2% chlorhexidine gluconate, with full drapes, gown, gloves and mask). Vessel was identified with ultrasound guidance. Technique: Seldinger technique used, location (left, femoral vein, 1 attempt), anterior approach used, catheter type 4 lumen catheter, location confirmed via flashback, catheter flushed with saline, dressing applied (catheter secured, semi-permeable transparent dressing applied), monitoring during procedure (blood pressure, cardiac, continuous pulse oximetry). Procedure tolerated: well."
I am coding for the hospital cath lab services. We have a large percentage of patients who are admitted with an acute MI, and the intervention is performed the next day. My understanding is that code C9606 is appropriate if the patient goes to the cath lab within 90 minutes [e.g., patient presents with NSTEMI and 24 hours later goes to the cath lab for a left heart cath with V-gram, coronary and graft angiography, and two drug-eluting stents in the LCx (95%)].
What would we report when only a right heart catheterization was performed in addition to an LV injection?
I'm not sure if I can bill separately for the Sitz marker placement. I'm thinking unlisted, but what are your thoughts on this case? "The lower abdomen and current cecostomy site were prepped and draped in the usual sterile fashion. Initial fluoroscopic image identified the pigtails of the current Chait tube to be within the region of the cecum. A stiff Glidewire was introduced through the Chait tube and advanced into the ascending colon. The current Chait tube was removed in its entirety. A 12 French vascular sheath was inserted over the Glidewire with tip positioned within the ascending colon. A C-wire was placed through the 12 French vascular sheath with tip positioned in the ascending colon. The 12 French catheter sheath was then removed and replaced over the Glidewire. The Glidewire and inner dilator of the vascular sheath were removed. The external portion of the gastric sheath was cut. Under fluoroscopic guidance, 72 Sitz markers were placed through the vascular sheath and into the cecum. The sheath was then removed. A new 28 Chait tube was replaced."
"Femoral access gained. Cath to infrarenal aorta, aortogram performed showing high grade stenosis in right main renal artery and on left 3 renal arteries. Left renal cannulated and angiogram performed, confirming 3 renal arteries and no significant stenosis. No intervention on left. On the right catheter placed at the level of the right renal ostium and crossed this with a wire. Obtained an angiogram to confirm placement and then placed a stent across the lesion. Post treatment angio showed widely patient right renal artery." Would you report codes 36251, 37236, and 36245?
I know in past years renal vein transposition was unlisted, and it is what I have always used. I have a physician asking if we can use code 34502, but I am not sure I agree with that code, as the only IVC repair/reconstruction completed is where the renal vein is taken down. I am just wondering if there is something I am missing somewhere of any new codes that can be used, or if it truly is just unlisted.
We did a Mitraclip with TEE (93355) guidance. I noticed that medical records coded this as "B244ZZ4 - ULTRASONOGRAPHY OF RIGHT HEART, TRANSESOPHAGEAL". When I asked about it, I was told the following: "The cardiologist needs to state 'right and left TEE' in the procedures performed or description of findings. The coders cannot assume.” However, the report has the supporting findings of right/left chambers, all valves and measurements, pressures, etc. Before I speak with the cardiologists on this request, what is the appropriate documentation for ICD-10 coding on inpatients? HELP!!
The way things are in the book is confusing. When looking in the index, both "insufficiency, aortic" and "insufficiency, mitral" go to the I3x codes (nonrheumatic), but the "insufficiency, tricuspid" leads you right to code I07 (unspecified). If you are coding aortic stenosis (with or without insufficiency), you are brought to the I35 codes (nonrheumatic), yet mitral stenosis (with or without insufficiency) brings you to I08 (rheumatic) codes. ICD-9 was clear, as the codes were specific to either being rheumatic or NOS. With ICD-10, the description in the tabular section of the book for the rheumatic codes includes conditions whether specified as rheumatic or not. How would you diagnosis code a patient with aortic, mitral, and tricuspid insufficiency?
Our office has been experiencing a new problem when billing HAP insurance. We had a patient who had MRI of the thoracic spine and an MRI of the right shoulder on the same encounter, which was billed using CPT codes 72146 and 73221-RT. HAP paid only on the MRI of the shoulder and not the MRI of the thoracic spine. HAP informed us that the MRI of the thoracic spine was denied based on CMS cutbacks. The same happened with another instance when a patient came in for an MRI of the thoracic, cervical, and right shoulder on the same encounter; HAP only paid for the MRI of the right shoulder and denied the thoracic and cervical due to CMS cutbacks. Am I missing an additional modifier that needs to be appended, or is it that the MRI of the spines should be done on a different day than the MRI of the extremities??
During a CT biopsy of the lung, the patient had a pneumothorax. The doctor performed "autologous intrathoracic administration of blood product for treatment of pneumothorax". Is there a code we can bill for this?
Now that there is an edit in place between C2616 and any of the liver/spleen NM scans, should we no longer report the NM scan following a Y90 embolization procedure?
"Intractable idiopathic epistaxis. Selectively cathed the right and left CCA to view neck and face vessels, selectively cathed the right ECA, and selectively cathed the right and left internal maxillary arteries confirming no undesired collaterals. Embolized the right and left internal maxillary artery with PVA and gelfoam. Post angio was done to confirm no residual nasal mucosal stain. Then a right facial artery was selected, and angio proved no significant supply to the nose from this artery." Please let me know if you would code this differently and why. I'm looking at codes 36222-50, 36227-50, 61626-RT, 61626-59LT, 75894-RT, 75894-59LT, and 75898. Is there another code for catherization of another branch off the ECA?
I'm not sure how to code this. Patient was in our facility as an IP from 11/20-11/29. We do charge our cath codes on IP, but they don't "go out the door on the bill"... we use them for revenue tracking in the facility. Patient had diagnostic cath with angios on 11/20 and was then brought back on 11/25 to evaluate the LIMA for potential graft as a stand-alone procedure. Then, on 11/27, they decided to do high risk PCI because patient was not a candidate for CABG due to lung issues. So, since the LIMA was evaluated on a different day and not in correlation with a cardiac cath procedure, should I use code 75756? I don't think it's appropriate to code/charge the LIMA evaluation as a coronary angio on 11/25, and for the 11/20 DOS I don't think it's appropriate to change that to a bypass angio because only native arteries were looked at. What are your thoughts?
Can we report 35476/75978 (x3) with a -52 modifier for ATTEMPTED recanalizations if no angioplasty is performed? "Procedures performed: Right and left heart catheterization. Attempted recanalization of LUPV, RMPV, and RUPV using radiofrequency (Nykanen RF wire). Several rounds of RF were placed at the pulmonary vein sites, but were unable to gain access to a vein. At this point, we did not feel that there was a feasible transcatheter approach to recanalize the stenotic/atretic pulmonary veins. This was the end of the interventional portion of the case."
I’m having a bit of an issue with our physicians documenting crossing the septum (when performed) during some of our congenital heart caths (93532 and 93533). I’ve encouraged them to document whether or not the septum was crossed and also to document if it was through an existing opening or transseptal puncture. In some cases they have documented “patient underwent a prograde right and left heart catheterization” or “the atrial septum was crossed” and then charged 93533. Is that sufficient? If the patient has an ASD, VSD, or PFO, can I assume if they say they crossed the septum if it was through one of those openings? In hopes of clearing this issue up, can you share your recommendation of what the documentation should reflect in order to properly charge CPT codes 93533 and 93532? I've been taught never to assume anything.
"Right common femoral artery was accessed utilizing micropuncture technique. A Bentson wire was advanced into the abdominal aorta, over which a 5-French vascular sheath was placed. A 5-French Contra 2 catheter was then used to select the right renal artery and digital subtraction angiography was performed in the PA and RAO projections. The catheter was repositioned into the left renal artery and digital subtraction angiography was performed in the PA and LAO projections. Decision to intervene was made based of these images. The vascular sheath was exchanged for a new 6-French sheath. A 6-French guiding catheter was then advanced into the proximal renal artery. A 0.018 inch McNamara wire was advanced into the upper pole artery of the kidney, and a 0.016 inch fathom wire was advanced into the lower pole. Angioplasty of the proximal aspect of the upper pole renal artery was then performed utilizing a 5 mm x 2 cm balloon. The balloon was deflated and post angiography angiogram was obtained." Unilateral or bilateral renal angiogram? Which is correct: 36254 OR 36251-RT, 36253-LT with 35471/75966?
"INDICATION: 36 year old female with a family history of ruptured intracranial aneurysms, who underwent clipping of an unruptured right anterior choroidal aneurysm in 2003, was recently found to have growth of a right posterior communicating artery aneurysm over the past several years. Embolization of this aneurysm with a biplane embolization device was therefore recommended. COMPARISON: Cerebral angiogram dated 11/18/15 LVA catheterization and angio RCC and RICA catheterization and angio 3D angio transferrred and processed on separate workstation. Embolization of right PCA anuerysm using pipeline embolization device. Post-embolization right ICA, RCCA, left vertebral." Is this reported with codes 61624, 75894, 75898 x 3, 36217, and 76377?
"Patient with stable angina and abnormal nuclear stress test has a left heart catheterization with LV pressures measured and coronary angiograms. Then proceeded to PCI of RCA chronic total occlusion. Tried wires using an over-the-wire balloon, but never could cross due to bridging collaterals and inadequate support from radial access in addition to poor visualization due to obesity." Will chronic total occlusion require coding C9607-74RC/92943-74RC even though there was no combo of the three (3) revascularization techniques attempted? If only angioplasty were used rather than a combo of angioplasty, stent, and atherectomy techniques, would codes C9607-74RC/92943-74RC still be reported? Or would angioplasty 92920-RC be reported instead?
"Patient has a known MCA aneurysm associated with a left occipital AVM (previously coiled M1 segment of aneurysm now with a neck remnant). Angiography is done with catheter in the left ICA in order to obtain optimal working projection for treatment of the known aneurysm. They deployed a stent across the aneurysm neck and proceeded with coil embolization of the aneurysm sac. Post embolization angio was performed and demonstrated near complete obliteration of the aneurysm sac." These are the codes I am considering: 36217, 61624, 75894, and 75898. I would appreciate your thoughts on coding the cath placement of the MCA. And, is the stent placement just part of embolization code 61624?
Multiplanar T1 & T2 images were obtained with pre & post contrast. Images were obtained sequentially after the intracutaneous inj. Of 4ml of Multihance mixed w/lidocaine & sodium bicarb. 19 ml of contrast was injected IV w/o complication. Sagittal, axial, and MIP images are provided. Precontrast T2 weighted images show a mild amount of edema along the plantar & radial forearm. Max thickness of adipose tissue in forearm is 1.4 cm Max thickness upper arm is 6.6cm. Multiple enhancing channels are seen on sequential images performed after intracutaneous inj. Majority of these are smooth w/ increase in size on the MR venogram single channel on the dorsum of forearm extends from level of radial styloid proximally 3 cm. terminates at level of dermal backflow etc. MR lymphangiogram and venogram show probable lymphatic channel along the dorsal distal forearm. Is the lymphangiogram an unlisted 76498 & MR venogram extremity 73225.
I think these back injections are based on substance injected and location of injection. When would we choose codes 62311 and 64483? I think the office used codes 62282 and 62311, but code 62282 is injection of a neurolytic substance, and the examples given in CPT for the medications don't seem to line up with the medications used in these injections.
A 19 year old male was recently evaluated for Brugada syndrome. The procedure was done while he was an inpatient. The physician generated the following report: "Resting EKG normal. 17 mg/kg procainamide given over 30 minutes. No significant ST changes, RV delay patterns w/ T V1-V2 ; ST normal. Evidence does not suggest Brugada or other await genetic testing, no specific intervention at this time." I apologize for the gaps, this was a hand-written report, and I am unable to copy. I am having difficulty finding the proper code for this procedure. While this procedure is not performed often, there is the chance it may be done again. Would it be appropriate to code an infusion code versus 93017 for hospital tracing of an EKG, the miscellaneous cardiology code 93799, or would it simply be part of E/M services for that day?
"A metal port was placed, and a 10 mm 30 degree scope was introduced. The pleura showed many areas of white plaque and some areas of asbestosis. The white plaque was biopsied. A 3 cm incision was then made overlying the 4th interspace starting at the anterior axillary line and extending posterior. The soft tissue was dissected with cautery, and the pleural space was entered under direct vision and dissected. A small Alexis wound retractor was placed into wound and tightened. Using ring forceps, the lung was pushed off the diaphragm. On the medial posterior portion, we found a 2 cm cyst coming off the diaphragm. There were no masses visible or palpated in the LLL. The cyst was grasped and resected with cautery taking the entire cyst with rim of diaphragm. There was a second smaller cyst just anterior to the first. It was grasped and resected with portion of diaphragm. These were sent for frozen section. Preliminary path shows benign mesothelial cells. There were two small 0.5 cm holes in the diaphragm from the resected cysts right next to each other. These were closed with suture." What code(s) would you recommend for this?
"The left ventricular apex was then exposed utilizing a small anterior thoracotomy, French delivery mechanism was placed into the left ventricular apex and into the central orifice of the mitral valve, just above the closure plane of the valve. A 20 mm Tendyne transcatheter mitral valve was then successfully deployed in a supra-annular position utilizing transesophageal echocardiographic guidance. Once proper position of the valve was confirmed and lack of left ventricular outflow obstruction also verified, the valve was released and apical pad was secured to the apex of the heart." What would be the correct codes: 33999 only or 33418 and 93462?
When is it appropriate to bill codes 35302, 35371, and 35372 together on the same side? If the physician states an eversion or deep in the profunda, can it be billed with modifier -59?
How should we code the following? We have reported code 33363-62 and nothing else. Is that appropriate? "DX: Significant left ventricular failure with a need for transarterial aortic valve. Procedure: Placement of Dacron shunt to anterior surface of the left subclavian artery to facilitate placement of a transarterial aortic value. Procedure Note: Traverse incision in the left infraclavicular. Longitudinal arteriotomy was made in the vessel with a 15 blade and extended with Potts scissors. 10 mm Dacron graft was then anastomosed end of graft to side of the subclavian artery. Clamps were removed from the vessel, and two leaks in the suture line were controlled with interrupted 6-0 Prolene simple suture. Procedure was then done to implant a trans Dacron graft aortic valve."
I am coding a case for insertion of a CentriMag bivad device "with ECMO support". The provider places a cannula in the left atrium and then an additional cannula in the right atrium via femoral vein insertion. He then places a 10 mm Hemashield graft in the pulmonary artery and one in the ascending aorta. After tunneling all grafts out to the chest wall, he states, "The patient was then converted to biventricular support with inflow for the RVAD from the right femoral venous cannula and outflow to the pulmonary artery cannula, and to the LVAD with inflow from the left atrial cannula and outflow to the ascending aortic cannula with ECMO support." This note reads exactly like a standard bivad insertion with the placement of the cannulas. I know ECMO circuits are sometimes used as temporary VADs, but the CentriMag does appear to be a VAD device per the manufacturer's website. Given the mention of ECMO support here, though, I wanted to ensure the coding should still be 33978 for implantation of an extracorporeal BIVAD.
I was needing some information on how my physicians should dictate certain x-ray reports. Is it appropriate for them to only dictate 6 views of the spine, or should they include bending or flexion views in their documentation? The same with reporting codes 73510 and 72170... If they give me two separate reports, can I bill for both or only for one?
We work in a hospital where MRI enterography is performed. We code these studies with 74183 and 72197. What terminology needs to be included to support the use of code 72197? Our radiologist feels that stating "no significant retroperitoneal lymphadenopathy seen" would suffice. Please advise.
I have a physician who did a left nephrostogram, ureteral stent insertion, and a nephrostomy tube exchange at the same setting. With the new 2016 codes there is no scenario with a pre-existing nephrostomy tract tube exchange and a placement of ureteral stent. I am getting an NCCI edit for code 50435 saying it shouldn't be billed with code 50693. Am I missing something or misinterpreting something? Would you bill codes 50693 and 50435-XU? The payer is Medicare.
Can codes 36245-36247 be billed when performing diagnostic angiography for a lower extremity exam on the same day of intervention if no previous imaging exists (or if condition has changed since previous imaging)?
In 2016, what are the appropriate CPT codes for the following? "Patient was placed prone on the table. Contrast was injected via left nephrostomy tube and nephrostogram performed. This revealed complete obstruction of distal left ureter at the UVJ. Nephrostomy tube was removed and cath was placed at the UVJ. After multiple attempts, sheath was placed at distal left ureter and dilated with a 6 mm balloon. Next, internal left stent was placed. 10 French safety nephrostomy tube was placed and capped. Impression: 1) Complete obstruction of the distal left UVJ. 2) With difficulty, obstruction was crossed and dilated. An 8 French left ureteral stent was placed. 3) A 10 French safety nephrostomy tube was placed and capped."
What is the appropriate coding for coil embolization of the GDA? Are the caths included? Procedure performed: 1) Selective SMA, hepatic angiography. 2) Coil embolization GDA. 3) Tc-MAA infusion right hepatic artery and left hepatic artery.
I know that, in the past, paravalvular leaks that were repaired with Amplatzer plugs have been coded with unlisted codes. I was wondering, since TAVR procedures are becoming more frequently done, are the percutaneous repairs of paravalvular leaks of repairs still reported with the unlisted codes? Since the TAVR procedure has more defining charge codes I was hoping that these repairs would have been given codes for 2016. Also, do these codes include the heart cath procedures and TEE monitoring done during this repair?
"Patient presented with a Hunt and Hess II, Fisher grade III subarachnoid hemorrhage concentrated in the 4th ventricle with hydrocephalus. Eleven coils were deployed in the vertebral artery to the V4 segment to remove a right pica aneurysm." How do I code this?
"The right groin was anesthetized using 1% Lidocaine. Intravascular access was established via the right common femoral artery under ultrasound guidance. A 6 French sheath was placed. Similarly venous access was established under ultrasound guidance. A 4 French sheath was placed. Venous access was established due to the underlying malfunctioning left antecubital IV. A 5 French JR4 diagnostic catheter was used to cross aortic valve. Left ventriculography was not performed. Next, the same catheter was used to engage the native right coronary artery. Next, JL4 diagnostic catheter was used to engage the left main. Arterial and venous access was established under ultrasound guidance via the right common femoral artery and vein with direct visualization of the needle entering the right common femoral artery as well as the right common femoral vein. Images of the arterial access established with the ultrasound guidance were acquired and recorded in the permanent document." Should I code separate access?
Can we report code 77001 (fluoro guidance) for attempted access prior to the start of heart catheterization? "Venous access was obtained in the left femoral vein with ultrasound, and a permanent record was stored with a 4 French sheath. It should be noted that we used ultrasound for the LFV, but could not enter the vessel initially despite blood return. We then advanced a JR catheter and angled glide wire from the RFV sheath and retrograde down to the LFV. This was used as a target for LFV access under fluoroscopy with success."
What information and/or situation can be documented by the physician to code angina? Does the physician have to specify angina to code angina or WITH angina? What if the patient also has chest pain? Does the physician have to specify ischemic chest pain?
We are looking for an industry standard (based on CPT rules) for how to correctly code critical care (99291 and 99292) for more than one provider. Per rules in the CPT Codebook (on page 25), what should be coded if MD1 spends 30 mins with the patient and MD2 spends 40 minutes?
"A supraumbilical transverse incision was created with a #10 blade. The muscle layers were divided with a bovie cautery. The Omni tract retractor was placed in position. The small bowel was eviscerated to the right side. The aorta, vena cava, left renal vein, and superior mesenteric artery were dissected. All lymphatic tissue encountered was ligated with hemoclips and divided. It was noted that the juncture of the left renal vein and vena cava was unusually high, at or slightly above the level of the SMA, such that the renal vein was as a sling around the base of the SMA contributing to its compression. The vena cava was clamped encompassing the left renal vein juncture, and the left renal vein transected at that level. The vena cava was closed in 2 layers using 5-0 prolene. The closure was hemostatic. The vena cava was then clamped further down from this point (approximately 4 cm) and then incised. The left renal vein was mobilized and anastomosed to the vena cava." My physician wants to charge code 35450 for this procedure. Is there another code to best describe this?
For Permcath placement, should I be billing for failed access site as well as the procedure36558, 36000? "The right internal jugular vein was noted to have a prominent valve. There was hematoma present between the jugular and carotid. The right internal jugular vein was accessed using an 18 gauge needle with one stick using ultrasound guidance. A wire was not able to traverse the right innominate vein. The wire was exchanged for a Glidewire and Berenstein catheter; however, this combination could not successfully traverse the occlusion. The access was removed, and manual pressure was held. Hemostasis was achieved without complications. Attention was then turned to the left neck. The left internal jugular vein was accessed with one needlestick using ultrasound guidance."
We have a new EP doctor coming to our facility. Recently he did an SVT ablation (93653) that was right- and left-sided, pre/post isuprel, 3D mapping, placed a catheter in the CS, utilized ECHO, and performed a transseptal puncture. He is stating that he does not need LA pressures to prove he was in the atrium so that we can charge for code 93462. I disagree. I feel like he should have established proof for charging and record purposes. Also he is charging and reporting that he did both LA and LV recordings via the CS. So to recap, 93653, 93662, 93462, 93621, 93622, 93623, and 93613. Is he correct?
I am having a hard time coding this one. I am having trouble finding an appropriate code for SVG angio. I'm assuming that the other codes are 93458, 93567... "CAD Presentation: Angina cath. Post Procedure Diagnosis: Single Vessel Coronary, 70% Ostial RPDA. Occluded SVG to RPDA. Mechanical Aortic Valve. Severely Dilated Aortic Root. Procedure Performed: Coronary Angiography, LHC, Aortic Root Angiogram and SVG Angiogram. Findings: L-Main-OK LAD-OK LCX-OK RCA-70% Ostial RPDA. SVG to RPDA. Aortic Root-Severely Dilated SVG to RPDA."
"1. IVC gram 2. New filter deployment in the suprarenal position 3. PTA of the infrarenal IVC within the area of stenosis in the occluded IVC filter 4. retrieval of the infrarenal IVC filter 5. stent IVC in the infrarenal portion 6. retrieval of the suprarenal IVC filter and redeployment of this filter in the infrarenal position above the stent. Patient has CTO IVC. She underwent thrombolysis and now has a tight stenosis of the IVC in the area of the IVC filter. Plan is to remove this filter, stent it, and then redeploy a filter higher. Because the filter could have clots, the plan was also to put a filter in the suprarenal position temporarily to make sure she did not embolize. Venogram of the IVC performed. PTA the IVC within the filter to allow smoother passage. Deployed new filter in the suprarenal position. I then retrieved the old filter. Residual stenosis that had grown within the filter, so I stented it and then put a 12mm balloon within this stent. I then retrieved the suprarenal filter and re-deployed it in the infrarenal position above the stent." What would the appropriate codes be?
Can you please help clarify when to code diagnostic angiography? Since we know that patient has cancer, and arteriography and embolization were planned, would these codes be correct: 37242, 36245, 36247, 36248 x4, 72726 x2 (59), 75774 x3 (59)? "CLINICAL HISTORY: Female with hepatocellular carcinoma and hypersplenism presents today for planned arteriography and embolization in preparation for planned radioembolization. PROCEDURE PERFORMED: 1) Selective superior mesenteric artery angiogram. 2) Selective celiac artery angiogram. 3) Selective proper hepatic, right hepatic, left hepatic, and middle hepatic artery angiograms. 4) Infusion of Technicium-MAA into the right hepatic artery. 5) Selective splenic artery angiography with embolization."
Patient underwent endo AAA Endurant II. Provider said two docking limbs with no extensions. We coded 34803, 75952, 36200-50, and 34812-50. After all performed, they discovered a problem in femoral artery, placque removed, and required femoral artery endarterectomy. I'm a little confused as to when we can bill for problems such as this. Do you consider the femoral endarterectomy billable as well? AAA aneurysm and PVD diagnoses given.
"Patient is post-op ventral hernia repair with aspiration of multiloculated fluid collection. After as much fluid as possible was removed, 8 cc of fibrin glue was instilled." Is this separately reportable? If so, what code would be reported?
"PROCEDURE: IV drug infusion Clinical Summary: This is a 40 year old male with idioventricular rhythm, VT and PVCs all coming from the same source. These are gith bundloid with an interesting transition. There are negative in I and aVL; positive in the inferior leads. DESCRIPTION OF PROCEDURE: I brought him in. He was not having any PVCs and that was despite stopping flecainide and beta-blockers, so we put him IV drug. We put him on Isuprel and got his sinus rate up to 150 beats per minute or there abouts, and he had no PVCs. We let it wash out. There were no PVCs. He was never sedated. He then received an IV infusion of caffeine 500 mg IV, and he had a total of 2 PVCs, and that was only when we gave Isuprel combined with the caffeine. FINAL IMPRESSION: This patient has scant ventricular ectopy despite prolonged IV drug infusion of multiple agents." My question is, would you bill this with codes 37202 with 75896? Someone stated that only the meds used can be billed. I am new to cardio, so I am in need of your advice.
73540: Radiologic examination, pelvis and hips, infant or child, minimum of 2 views In 2016, CPT parenthetical notes state "73530, 73540 have been deleted. To report see 73501, 73502, 73503). Note that the previous bilateral code stating hips (plural), which in 2015 had a bilateral status indicator “0” (Indicator "0" in the Bilat Surg Column on the MPFSRVU means that the bilateral concept does not apply for this code), is now “cross referenced” to unilateral replacement code sets (73501, 73502, 73503). I am not able to find a reference that explains this conversion to my satisfaction, as I feel we should instead use the appropriate 2016 bilateral hip code sets 73521, 73522, 73523 dependent on the number of views. I would appreciate your insight on correct reporting in 2016 for imaging a child bilateral AP hips & pelvis on the first view along with a frog lateral bilateral hips & pelvis on the second view.
"After single attempt of manual aspiration thrombectomy, there was extravasation noted of the right middle cerebral artery. The vessel was successfully embolized with Onyx liquid agent with resolution of the extravasation. Can you bill for both the thrombectomy and the embolization? I thought that if in the process of one procedure the physician accidentally punctures a vessel that you cannot bill the patient for fixing that error. Or is that a known risk of thrombectomy that can be billed?
The PA sees a patient in the ER department and performs an initial visit and determines that surgery is necessary. He documents his service while the supervising provider is in a case. When the surgeon is available he has a face to face visit with the ER patient on the same day. The surgeon performs a physical exam agrees that surgery is necessary and documents his portion of the E&M service appropriately. Can the E&M shared between surgeon and PA from the same group practice be billed to Medicare under the physicians number? Does it matter that the PA has made the decision for surgery and orders have been started since this is a shared visit?
Is the following reported with codes 35876 and 35304? "Thrombectomy of the fem-pop bypass was performed with vein patch angioplasty, and flow was successfully restored through the vein graft; however, it reclotted within minutes of restoring flow. After multiple attempts to restore flow, it was felt that there may be an issue with the vein graft, so the graft was removed from the proximal and distal anastomoses. The popliteal artery arteriotomy was closed with a vein patch. A 6 mm thin-walled, ringed gore PTFE graft was tunneled through the previously created tunnels. The ends were spatulated and anastomosed in end-to-side fashion with 6-0 gore suture. Flow was then restored. Doppler interrogation demonstrated excellent flow-through graft. The distal outflow sounded somewhat high resistant. This point dissection was carried down the distal popliteal artery to the tibial/peroneal trunk. There was significant calcification noted at the origin of the tibial/peroneal trunk and anterior tibial artery. A longitudinal arteriotomy was made, and a limited endarterectomy was performed."
I could use some help in this interesting situation. "History: Patient had a dual AICD implanted on the left side. Patient's treatment plan included radiation on the left. The left dual AICD was removed and the leads capped with a single AICD implanted on the right. Treatment was discontinued." Also need help with this procedure: "The single AICD on the right is removed along with the leads (33241 & 33244). A dual AICD was implanted on the left, and the existing leads that were previously capped were uncapped and attached to the dual generator (33230)." I reported codes 33241, 33244, and 33230, but there is a hard edit with 33241 and 33230. CPT indicates code 33263 should be used, but the same type of system was not used (single removed and dual implanted); therefore, I don't think 33263 is correct. Is it correct to code this procedure with 33230 and 33244? I thought the implantation was more important to code than the removal.
"Six vessel diagnostic cerebral exam was performed. Decision was made to treat vasospasm of RICA and LICA." Discussion is whether or not the catheter selections for the bilateral ECA vessel selections are still chargeable since the catheter selections of the RICA and LICA are bundled into code 61650. I don't feel they are since, they are add-on codes to 36224 bilateral in this case.
"Patient underwent a DICD implant. Patient had an existing vagal nerve stimulator where the physician wanted to implant the DICD. The physician removed the VNS and capped the lead. Pocket was then revised to accommodate a DICD and atrial and ventricle leads. The VNS was not re-implanted and was discarded." In this scenario can you code only the DICD implant (33249), or can you also code the VNS removal (61888)?
Is there an ICD-10 procedure code available for coronary brachytherapy?
"Bilateral lower extremity arterial duplex scans were performed with evaluation of the infrarenal abdominal aorta. The infrarenal abdominal aorta measures 2.3 cm proximally, 2.1 cm in its mid portion, and 2.1 cm in its distal portion. The waveform is biphasic, and the peak systolic flow velocity is 74cm/sec. Ankle-brachial indices were measured in both LE. They are 0.96 or greater bilaterally. Waveforms are biphasic in both lower extremities down to the level of the dorsalis pedis artery. Peak systolic flow velocities are within normal range. Conclusions: 1) Resting ankle-brachial indices and pedal Doppler waveform suggesting no evidence of significant arterial insufficiency of either lower extremity. 2) Continuous wave Doppler waveforms of both lower extremities are within normal range. 3) No evidence of infrarenal abdominal aortic aneurysm." We reported codes 93925, 93978, and 93923. Is this correct?