Knowledge Base

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Set Descending Direction

Removal of an Occluded Lower Extremity Bypass Graft

One of our physicians removed an occluded lower extremity bypass graft. Would code 35903 be correct to use? If not, what would be the correct code? There was no revision performed or a new graft.

Arteriogram of Lower Extremity

"Physician does an ultrasound-guided access of right common femoral. Complete abdominal aortogram, pelvic arteriogram, selective cath of left common femoral artery with select left lower extremity arteriogram, and selective right lower extremity arteriogram with interpretation. An Ansel catheter is used to select out the right external iliac artery as well as right common iliac artery. Ominiflush catheter was placed into the infrarenal abdominal aorta at L1-L2 interspace, and a complete abdominal aortagram was taken. The catheter was then brought down to the iliac bifurcation, and a pelvic arteriogram was taken. The catheter was then brought up and over the bifurcation, and then selective cath of the left common iliac, left external iliac, and left common femoral artery was taken. The catheter was then pulled back to the bifurcation down to the right external iliac artery and right common femoral artery, and a selective right lower extremity arteriogram was taken." I want to make sure my codes are correct: 36246 x 2, 75625, 75716, 75774, 75774-26-76-59, and 76937.

IVUS at Two Sessions

A patient came in for a diagnostic IVC-gram and bilateral lower extremity venograms. IVUS was used at that time. As we did not have large enough stents to treat the stenosis, the patient was scheduled to return for intervention. IVUS was used again at that time. I know I cannot recode the diagnostic venograms, but does IVUS follow the same rules? Is it non-billable roadmapping if it is used for precise placement of the stents, or is it a billable service at both encounters? 

37211 and 37212 in AV fistula

"Patient with thrombosed AV fistula was taken to Interventional Radiology. Ultrasound revealed a 5 cm segment of thrombus extending centrally from the arterial anastomosis. Venous limb of fistula is patent. Access was obtained directed towards arterial anastomosis, and infusion catheter was advanced to arterial anastomosis. tPA was pulsed into fistula under fluoro guidance, and tPA drip was started. Patient to return in one day for follow-up fistulogram. Impression: Successful initiation of thrombolysis therapy left upper extremity dialysis fistula." The department charged codes 37211 and 37212. Should this actually be reported with code 37211 only? In other cases by this radiologist he uses two infusion catheters in opposite directions, but in this case he uses only one. In an AV fistula, is it even appropriate to charge both codes 37211 and 37212 if two infusion catheters are used, one directed to the vein side and one to the arterial side?

Lynph Node FNA with Clip Placement, US Guidance

Patient comes in for US guided breast biopsy (19083) and FNA of the axillary lymph node (10022-59) under US guidance (76942). At the location of the FNA in the lymph node, a localization clip is placed (10035-59). Is it appropriate to charge the US guidance for the FNA (76942) separately when it is already bundled with the clip localization?

Device Codes

We are a physician office (place of service 11) that places PICCs, ports, etc. Can we charge separately for catheters and other supplies?

27096 and G0260

We are instructed to report code 27096 for commercial payers and G0260 for Medicare. Your book indicates that code 27096 can be reported with a -50 modifier when performed bilaterally. Can code G0260 be reported with a -50 modifier as well?

Rescue Thrombectomies

A Terotola thrombectomy of an AV fistula was attempted but resulted in the clot embolizing downstream in the radial and ulnar arteries. Rescue thrombectomies of the radial and ulnar arteries were then performed. Is this considered a "complication" and therefore only code 36870 should be reported? Or should codes 36870 + 37188 (or 37184 + 37185) be reported?

MUE for Cervicocerebral Imaging

I was wondering if there has been any discussion regarding an MUE of 1 for cervicocerebral imaging. Does this only reflect physicians as stated, or does this also apply to the facility setting? Does the "1" denote one line (with a -50 modifier), or just one period?

ZIO Patches

For code 0296T, who would be the billing provider? Example is we have a nurse in the cardiology department who will connect the ZIO Patch to the patient even though it was ordered by a different specialty provider. Do we bill under them or the cardiologist?

Bilateral Venous Studies for Upper and Lower Extremities

Our providers order venous studies of bilateral upper and bilateral lower extremities. We are billing them with codes 93970-26 and 93970-26XS. We place a box 19 comment on the claims to say what the exam was for, either bilateral upper or bilateral lower extremity studied. Insurance is denying them both. We appeal with notes and they are still denying, stating they are following MUEs. Do you have any suggestions for us? Should we use a different modifier?

Ascending Aortic Endoleak Repair

A patient has a type 1A endoleak with expanding thoracic aortic aneurysm. Thoracic dissection was previously repaired with Cook endograft as well as embolization of left subclavian by coverage of the left subclavian artery. "Current procedure: The physician placed aptus screws into the lesser curvature of the thoracic stent graft at the level of the fabric. There was improvement, but endoleak still there. There was approximately 5 mm between the leading edge of fabric to the left common carotid artery. Wire was placed within the ascending thoracic aorta, and stent graft was deployed under fluoroscopic guidance to ensure that the top of the fabric was at the level of the right common carotid artery." Should this be reported with code 33881? Or code 33886 perhaps? Was this performed in the ascending aorta or thoracic aorta? If ascending aorta repaired, do we still use descending codes? The previous procedure performed at another hospital. Also, is the screw placement included in repair, or do we report code 37799?

Nephrostomy Tube Placement with Double J Stent

Would you report both codes 50432 and 50433 for the following case? "The patient was placed prone. The skin was anesthetized with lidocaine, and a small needle was advanced into the inferior pole collection. Contrast injection confirmed location within the left kidney. Under fluoro, a guidewire was passed into right ureter. The tract was dilated and a sheath placed. A 22 x 8 French internal double J stent was then deployed with its distal tip in the urinary bladder and the proximal end in the left renal pelvis. Next, an 8 French nephrostomy tube was placed into the left renal pelvis. A locking mechanism was deployed. The line was sutured in place at the skin exit site. Successful placement of a nephrostomy tube and left-sided double J stent."

Placement of Fiducial Marker in Iliac Bone

I'm looking for the appropriate CPT code. No biopsy was performed, just marker placement in bone. "The patient was placed prone on the CT table. A preliminary, limited CT examination of the pelvis was obtained, localizing the left iliac bone. A suitable skin entry site was marked. The patient's left buttock was sterilely prepped and draped in usual fashion. 2% lidocaine was infiltrated into the subcutaneous tissues for local anesthesia. A small dermatotomy was created. Under direct CT guidance, an 11G bone marrow biopsy needle was advanced into the left iliac bone. Two fiducial markers were deployed at the inferior aspect of the iliac bone lesion. The 16G bone marrow biopsy needle was subsequently advanced into the superior aspect of the iliac bone lesion, and an additional fiducial marker was deployed at this site. The needle was removed. The site was sterile bandaged. No significant bleeding was noted. The patient tolerated the procedure well. IMPRESSION: Successful CT-guided percutaneous fiducial marker placement in the left iliac bone."

Diagnostic Imaging

In regards to coding diagnostic imaging at the same time as intervention, your vascular/endovascular book states to code separately if prior catheter-based angiography was not "recently" done. The CPT Codebook just states "no prior" catheter-based angiography. Is there a time frame attached to the "no prior" or "recently" performed CTA/MRA of the area of interest? I have seen no reference to this in your question database.

CPT 36200 for Co-surgeon

My thoracic surgeons did co-surgeon for AAA repair. Dr. A accessed from the left side and Dr. B accessed from right side. How should we bill for catheter placement? Should I report code 36200-LT for Dr. A and code 36200-59RT for Dr. B? And also for S&I code 75952 (34804) and ultrasound access code 76937, should I bill for each of the surgeons or just one of them? 


We have a physician who was told that when he does a AAA procedure that the Perclose of the groins does count as a cutdown (34812), even though it is not a full cutdown. It is more like a partial, but suture is still used to close the artery. What are your thoughts on this, and what is the correct code? 

HCPCS Code for Turbo-Elite Atherectomy Catheter

Is a separately reportable HCPCS Level II code allowed when using an Excimer Laser System catheter when treating peripheral and coronary arterial disease?


We are having a debate on billing code 34812. There are some that say code 34812 is just exposing the femoral artery, and vessel access can be done by a "puncture" or arteriotomy. Based on AMA Vignette and AMA KB 1585, both reference that exposure is done of the femoral artery, but the access must be done by arteriotomy. What are your thoughts?


The physician selected bilateral inguinal lymph nodes, then accessed the thoracic duct and embolized it because of a leak. Would he still get credit for both of the inguinal lymph nodes? If you have any additional info on this type of procedure it would be greatly appreciated.

36228 without contrast injection

"Patient had diagnostic cerebral angiogram on a right internal carotid artery and coil embolization on a ruptured right middle cerebral artery aneurysm. Catheter was placed on the right internal carotid artery, and contrast was injected. Cerebral angiogram was then performed in AP. 3D reconstructions were done on a separate workstation. Microcatheter was navigated in the right middle cerebral artery for coil embolization. Contrast injection was not used. Intermittent angiogram and post embolization angiogram were done." Can I report code 36228 along with codes 61624, 36224, 75894, 75898, and 76377?

Ureteral Stent Injecton and Nephrostomy Catheter Exchange

For the following, would the correct codes be 50431 and 50435-59? "The patient's indwelling Seidmon catheter was injected with contrast. It was noted to be within the mid ureter, and most of the side holes were outside the patient. This catheter was then removed, as it could not be cannulated with a guidewire due to calculus material within it. This was followed by injecting a ureteral catheter previously placed by the urologist, which demonstrated distal ureteral near complete obstruction secondary to two large calculi. The patient's nephrostomy tube was then attempted to be cannulated with a guidewire, which was unsuccessful, as the nephrostomy tube was obstructed secondary to calculus material. Next to the nephrostomy tube a Kumpe catheter with a glidewire was placed so that the renal pelvis was entered. Several attempts at entering the urinary bladder with glidewire were unsuccessful. It was elected to replace the nephrostomy tube at this time and no longer attempt to place a ureteral stent."

Nephrostomy Catheter and Seidmon Catheter Placed on Same Side

For the following, would the correct coding be: 50432, 50395-59, and 74485? "An upper pole calyx was punctured percutaneously and a antegrade pyelogram was done showing moderate hydronephrosis as well as a distal stricture in the left ureter. Within the left renal collecting system opacified with contrast, a Hinck needle was used to percutaneously puncture a lower pole calyx. Through the exisiting lower pole needle access, a 0.018 wire was placed and advanced into the renal pelvis. Over this, a Accustick catheter was placed. Through this, a glidewire was advanced down to the left ureter to the level of the distal stricture. The stricture was crossed with the glidewire, which was then advanced into the neobladder. The Berenstein catheter was removed, and a Seidmon cath was advanced over the wire with its distal end pigtailed within the neobladder. The external portion of the Seidmon was capped. A J-wire was advanced through the sheath into the proximal left ureter. Sheath was removed, and dilation and exchange were done resulting in a placement of a 10 French nephrostomy within the renal pelvis." 

Arm Pain

Would I report codes 36222, 36225, 36218, and 75774 for the following case? "A 5 French sheath was started in the right common femoral artery. A pigtail catheter was advanced to the thoracic aorta. Thoracic aortography was obtained. The catheter was exchanged and engaged the left common carotid artery. Angiography was obtained. Catheter engaged left subclavian with angiography. No thrombus was seen, and catheter was advanced to left axillary. Left arm upper extremity angiography was obtained. Findings: Type 1 aortic arch, patent left common carotid and left internal carotid. Left subclavian widely patent. Left vertebral artery widely patent. Left innominate without significant stenosis. Left radial and ulnar arteries patent." 

Left common carotid angiography and left middle cerebral cannulation only

If the physician performed left common carotid (with intracranial imaging) and also cannulation of left middle cerebral artery without imaging, would I use code 36217 for the cannulation of the left middle cerebral artery as well as 36223 for the cath placement and imaging of the left common carotid? He imaged the common carotid and found stenosis of the middle cerebral. At this point the plan was to perform intervention. He cannulated to the insular branches but could not pass guidewire through the occluded middle division, so the intervention was not performed. So my question is, do I only bill code 36223 for the carotid imaging? Or can I bill code 36217-59 as well for the cannulation of the middle cerebral artery?

Neuro Intervention

"Patient has a six-vessel cerebral angio and is found to have an aneurysm on the right internal artery. The next day, the patient has a repeat bilateral internal carotid and bilateral vertebral arteriogram, then has a stent-assisted aneurysm coiling where an aneurysm angio was performed. The patient has a complication of non-occlusive thrombus in the right middle cerebral, which was treated with thrombolysis." Do I code for the repeat angiogram before the embolization? And do I use code 37211 for the thrombolytic injection?

Lymph Node Resection

When using code 32674 or 38746, mediastinal and regional lymphadenectomy, what is the minimum number of lymph nodes resected? Is it allowed if only one or two nodes are taken, or does it need to be more than that?

Umbilical Node Biopsy

Would a core biopsy of an umbilical node be reported with code 38505 or 49180?

Contralateral cerebral imaging after ipsilateral cerebral imaging after a CTA obtained.

The patient presents for thrombectomy for known left MCA occlusion. Then, after left thrombectomy, the attending moves the catheter to the right internal carotid and performs imaging, documents findings (no stenosis seen), and ends the procedure. Would you report codes 61645 and 36217-59? It seems like 61645 and 36224-59 would not be appropriate since the condition was known and the contralateral imaging was after the therapy. The attending documented that no prior diagnostic angiogram was available and the decision to treat was based on this angiogram, but the patient presented for mechanical thrombectomy. Could the right-sided imaging still be diagnostic, or would it be considered follow-up imaging?

Primary AV Fistulogram Left Upper Arm

"An 18 gauge angiocatheter was used to cannulate the AV access. Contrast was injected to perform diagnostic fistulogram of outflow tract... The more proximal stenosis was addressed by 'redirecting' the guidewire and sheath into the fistula in the opposite direction under fluoroscopic guidance. The stenosis was angioplastied." I know that I can code 36147 for the catheter placement in the AV fistula. Can I code 36148 (second cannulation of dialysis access) for the ‘redirecting’ or ‘redirection’ of the guidewire/sheath to perform a PTA?

59 vs. 76 Modifier

I just started working for a client that used your company to do audits. They do internal audits, and they dinged me for using a -59 modifier on code 37211 for a bilateral pulmonary (they didn't have it set up for -50 in the system). They told me I should use a -76 modifier on the additional 37211. I explained that goes against any coding guidelines I have been taught. They stated your company does their auditing and has agreed with the use of -76 on all Carriers because it's based on Carrier policy. Can you please confirm that this correct?

PTCA with Drug-Eluting Stent

If a PTCA with drug-eluting stent to the LC is performed and extended slightly into the OM-2, is it reported with 92928-LC? Or 92929 also?

Right-Side Tandem Heart

"TTE demonstrated collapse of left atrium and dilalted right ventricle with patient on left-sided Tandem Heart Support. Therefore HTS requested right-sided mechanical circulatory support. A 6 French x 35 cm sheath was inserted into the right jugular vein. A 6 French x 110 cm wedge cath was inserted into the SVC. The 6 French x 110 cm wedge cath was repositioned into the right ventricle. A Tandem Set Up Kit was inserted into the right atrium. Counterpulsation was initiated. The Tandem Set Up Kit was sutured in. Right-sided Tandem Heart was initiated with Proteck Duo cannula inserted via right IJV." Would you report code 33991-52 (33991-74 for facility), or is there another code that is more appropriate for this procedure?

Chest Port Catheter Malfunction due to Fibrin Sheath

How would you code this procedure? "Left chest port catheter was accessed in a sterile fashion using a Huber needle. 2 mg of tPA was infused into the chest port catheter for a 3-hour span, followed by easy aspiration from the port catheter, which was then locked with Hep-Lock. The port is ready for use."

Removal of Aneurysmal Angioaccess Arteriovenous Fistula

Please advise if code 36832 is appropriate for the following scenario: "The patient has a functioning brachiocephalic fistula and presents for excision of a severely aneurysmal radiocephalic fistula. The radial artery proximal and distal to the anastomosis was dissected out and controlled with vessel loop. The radial artery proximal to the fistula was noted to be severely dilated. The excision was extended along the length of the fistula to the antecubital fossa, and the aneurysmal radiocephalic fistula was exposed. The fistula was then dissected out to free up its adhesions to the overlying subcutaneous tissue. There were multiple branches that were hypertrophied and were suture ligated. The cephalic vein was amputated at the antecubital fossa and oversewn proximally. The aneurysmal fistula was then freed up from underlying adhesions all the way to the wrist. There were multiple crossing veins, which were hypertrophied and required ligation. The aneurysmal anastomosis was taken down, and the radial artery was ligated."

Stent graft repair

1. Stent graft repair of lt common iliac artery aneurysm to preserve lt hypogastric artery utilizing an Endurant bifurcated graft with snorkeling of the lt hypogastric artery and stenting of the lt hypogastric artery using iCAST stents. 2. Ballon angioplasty of lt external iliac artery for residual stenosis. Endurant graft inserted from lt fem and positioned in the lt limb of the previously deployed endograft. Graft deployed so contralateral gate landed 1.5 cm above takeoff of lt hypogastric. The ipsilateral limb of graft was deployed in the lt external iliac artery. Proceeded to snorkeling of the lt hypogastric. Advanced an iCAST stent into contralateral limb of graft, directing it into lt hypogastric. The initial stent was deployed in the contralateral gate and extending into the origin of lt hypogastric. We advanced a 2nd iCAST stent into lt hypogastric. Allowed for 2 cm of overlap with the initially deployed iCAST stent. 2nd stent extended into lt hypogastric and landed prior to the takeoff of the 1st order sub branches of lt hypogastric.

93657 After PVI in Persistent Afib

I was explaining to a physician that he needs to clearly say that Afib remains after PVI ablation rather than/or in addition to speaking about potentials that remain. He wanted me to inquire about the following: Patient has persistent Afib but arrives in NSR. Post PVI ablation, the 4 veins are isolated and he measures potentials, and he finds it is necessary to do a posterior wall. After posterior wall, no potentials remain. Because of NSR, we can't say Afib remains after PVI but additional is done because of measured potentials. Can he use code 93657 anyway?

Resection of Mediastinal Tumor

Is code 39220 appropriate to report for the following case? "Procedure: Transternal resection of apical posterior mediastinal neurogenic tumor. Indication: Patient with large posterior mediastinal tumor in the apex of the left chest. Tumor entering spinal canal. Neurosurgery performed a laminectomy earlier and released the tumor from the canal. Patient was brought to the OR, and a C-shaped incision was made over the left sternocleidomastoid, down at the mid-sternum and around to the third interspace. The mass was evident towards the left side and was entirely extrapleural. The pleura at the reflection of the mass was incised with harmonic scalpel, and the mass was gently dissected of the chest. The area of the laminectomy was easily seen now, appeared undisturbed, and hemostasis was adequate. A chest tube was placed on the left pleural space. The sternum was closed." 

AV Fistula/Graft

Where is the "inflow" segment of the AV fistula? When treated with PTA, is it venous or arterial? Also, where is the "access" segment of AV fistula?

Popliteal Aneurysm

We are looking for a code for popliteal aneurysm (37236 perhaps?). This is what one of our physicians said: "Code 34900 is an aneurysm procedure code, and although it specifies iliac it is far more reflective of the procedure type and work, including large sheath placement that is involved with popliteal aneurysm repair. In fact, the two procedures are almost identical, except one is done at a more distal location." What code do you suggest we use for popliteal aneurysm and why?

PCI on Two Sub-branches of an Obtuse Marginal

"Patient had 80% stenosis of a main superior sub-branch of OM3 and also had 60% ostial stenosis of an inferior sub-branch of OM3. The 80% superior was treated with a drug-eluting stent across the lesion, jailing the inferior sub-branch. Angiogram then revealed a 90% inferior side branch stenosis, not improving after nitroglycerin administration. Plain balloon angioplasty then was performed at ostium of inferior branch. Then kissing balloon inflations were done in the superior sub-branch and ostium of inferior sub-branch, resulting in 0% residual in the main superior and 5-10% residual in the inferior sub-branches." Would it be appropriate to report codes 92928 and 92921? Or should I only report code 92928 since these were both sub-branches of the OM3?

Iatrogenic Procedures

If we are doing a procedure and cause a dissection that needs to be treated with a stent, can stent device and/or pro fee for placement be charged? Is there a CMS or ACR directive on billing an iatrogenic procedure caused during a procedure?

Transvenous Lead Extraction

We have started doing lead extractions, which are new to me. If we extract an ICD right ventricular lead (33244) and insert a new right ventricular lead, can we bill for both removal and insertion? Or is it all included in the insertion code?

Epicardial Lead and Generator

Procedures: 1) Epicardial lead implant x 1, 2) VVI pacemaker implant in LUQ, 3) Dual chamber pacemaker explant, 4) Pacing lead extraction x 2 with laser, 5) Right femoral a-line placement, 6) Exploratory left thoracotomy. Our coding tool bundles code 33212 (insertion) with 33233 (removal) with no modifier allowed; however, these were two different areas. Do you have any suggestions? (We reported codes 33202, 33212, 33233, and 33235.) 

Internal Carotid Embolic Filter

Patient has bilateral stenting and now there is evidence of narrowing in the left stent. The physician performed selective views of right and left cervical and cerebral (36223-RT), selective view of internal carotid (36224-LT), selective view of vertebral left and right (36226-50). He is also placing embolic filter device into the internal carotid. What code would I use for the filter? I only come across codes 37215-37218, but these include the stent.

Subclavian Vein Stenosis Treatment During AV Fistula Evaluation (36147)

If the subclavian vein is selected during an AV fistula exam evaluation of a brachial artery to axillary vein PTFE graft), and severe stenosis is found and treated with angioplasty, can you add selective code 36011 in addition to codes 36147, 35476, and 75978?

Code Edits with 76937

We use coding software that's showing OCE edit when reporting 76937 with any procedure outside of the 34001-37799 range. The edit is as follows: "76937 is an add-on code and must be reported in conjunction with 34001-37799." The CPT Codebook does not indicate what base code(s) would be acceptable to use with 76937. Do you have any current guidelines on the appropriate use of code 76937?

Thrombectomy of Graft and Native Artery

Would the following example be reported with codes 34201 and 35875? "11 blade was used to make a longitudinal graftotomy, which was extended with Potts scissors. A 4 French Fogarty balloon was used to perform a right graft limb thrombectomy with extensive clot burden retrieved. Next a 3 French Fogarty was used for SFA and PFA thrombectomy with excellent back bleeding, particularly from the PFA. After obtaining robust forward bleeding and excellent back bleeding, the graftotomy was repaired with 5-0 prolene sutures." 

Bridging Lesion LM-LC and Additional Lesion Prox to Mid First OM

Procedures: 1) Percutaneous coronary intervention of bridging lesion distal left main artery into proximal left circumflex artery with one drug-eluting stent, 2) Proximal to mid first obtuse marginal artery with two drug-eluting stents. For professional coding, would this be reported with codes 92928-LM and 92928-LC? 


I am having a big debate over CPT code C2623. How is this code reported for the hospital and physician coding/billing?

Biventricular Upgrade of an Existing VVI Defibrillator

"The patient was prepped. The pocket was opened with sharp dissection followed by blunt dissection. The existing ventricular lead was dissected from the pocket, and the existing defibrillator was removed from the pocket and detached from the lead. Left subclavian vein access was obtained at two separate puncture sites, and peel-away sheaths were advanced over guide wires. The coronary sinus was cannulated, and a left ventricular sinus lead was easily advanced into a posterolateral vein. Difficulty was encountered in advancing the right atrial lead into the right heart, and venogram was performed through peripheral IV, which revealed a persistent right-sided superior vena cava connecting into the left superior vena cava with a markedly tortuous route. Subsequently the wire lead was advanced across into the left superior vena cava and down into the heart, and the atrial lead was then placed without difficulty. The sheaths were then peeled away, and the leads were sutured in the pocket." Will I charge for generator change out and two lead insertions?

92941 Clarification

Does the following documentation/example support the use of code 92941? Indications listed in the procedure note include known history of CAD, status post prior stenting of LC, typical chest pain, EKG suggestive of inferior wall ischemia, and cardiac enzymes that became positive. Because of her increase in enzymes and her acute EKG change, she was taken emergently to cardiac catheterization laboratory. Findings consist of 70% hazy lesion of the LC as the culprit lesion and is type A or low risk. Procedure performed was angioplasty of the circumflex artery. 

Diagnostic Cerebral Angiogram Pre and Post Hematoma Evacuation

A diagnostic angiogram was done prior to planned hematoma evacuation. The catheter was removed, and the sheath was left in place for performance of a completion angiogram after the evacuation of the hematoma. Can the angiogram be billed twice (pre and post)?

FB Retrieval of Fractured Neph Cath

"Neph tube is fractured. MD retracted tube for removal of the fractured fragment remains left in the renal pelvis. Using the strings which are attached to the fragment and blunt dissection and a hemostat the retained fragment was successfully retrieved. Under fluoro guidance a new neph tube was placed." Can anything be coded for the retrieval for the fractured cath, or is it considered part of the tube exchange code (50435)?

Percutaneous Paravalvular Leak S/P TAVR

We are having a discussion about which code to use for percutaneous paravalvular leak status post TAVR. According to a previous question posted on January 28, 2016, the code to use is 33399. Is this still correct, or have they created any codes for the closure of the leak for 2016?

Angioplasty in the Venous Outflow with Revision

Can you clarify the definition of "within the graft" as it relates to open surgical revision of an AV fistula/graft with balloon angioplasty in the venous outflow? Is the entire peripheral segment considered "within the graft" or just the anastomoses, graft material between the anastomoses, and the immediately adjacent areas? For example, a physician creates a surgical incision over the venous anastomosis of an AV graft. He opens the graft and retrieves thrombus using a Fogarty and places a patch angioplasty at the venous anastomosis to treat an area of stenosis there. He then performs a balloon angioplasty of an area of stenosis in the venous outflow in the cephalic vein through the same surgical incision (the stenosis is proximal to the venous anastomosis and not immediately contiguous with the anastomosis). Would you agree with 36833, 35460, and 75978 here? Or can I only report the angioplasty and radiology S&I (either 35460/75978 or 35476/75978) if these additional procedures are performed in the central segment?

Bone Biopsy, Deep vs. Superficial

Do you have a chart or document that identifies which bones would be considered superficial versus deep? The CPT book gives examples, but I’m looking for a bit more.

US in Emergency Department

Recently one of our facility has requested to implement ultrasound in the ED performed by the ED physician. This has been endorsed by ACEP, and the only argument I can defend is that revenue code 320 or 402 would not define the area where the service was provided. How medicine is practiced is evolving, so if a report is produced and images are stored in PAC system, would attaching revenue code 320 or 402 be appropriate in the ED? 

AVF Thrombectomy/Revision with PTA/Stent of the newly created anastomosis

I have a question regarding a thrombectomy/revision of a brachiocephalic AVF followed by PTA/stenting of the newly created anastomosis. "The surgeon performed a fistulogram, revealing occlusion/thrombus of the cephalic vein. He then removes the thrombus. Further occlusion was found near the shoulder. Incision was extended to dissect out more of the cephalic vein. A second incision was made in the axilla, and the basilic vein was dissected out. The basilic vein was then anastomosed to the cephalic vein. Another fistulogram was performed, revealing stenosis in the area of the end-to-end anastomosis. The surgeon then angioplastied and stented this." Would the correct coding for this be 36833 (thrombectomy/revision) and 36147 (fistulogram) only? I do not believe that I should code for the stenting (37238) due to it being done at the anastomosis just created. I was looking at it as an inflow/outflow type issue. Am I correct in my thinking?


One of our vascular surgeons routinely orders 93971 for "swelling". The established protocol is to image both the upper and lower extremity on the same side (charging 93971 x 2). I have been adding the -59 or -XS modifier since it is a different extremity and it is not bilateral. Is this appropriate?

38792, Modifier Usage

We are coding for breast procedures where the surgeon is injecting the isotope and placing wires in a stereotactic suite. After the appropriate time frame the patient is then brought to the OR, where a lymphatic mapping injection is performed along with excision of sentinel nodes. We are currently applying the -XE modifier to CPT code 38792 for an edit with code 38900. We are being advised by our facility that this is not truly a separate encounter and therefore an -XU modifier should be used instead. We currently code for both facility and professional charges. Is there a difference in modifier guidelines? Can you please advise on which is the correct modifier usage?


If I'm billing codes 93225 and 93227, do they need to be billed on separate days? Or together on the same day the Holter is put in?


When is it appropriate to use CPT code 76140 as opposed to billing the specific procedure code with modifiers -26, -77 for a re-read of imaging? Scenarios: A) Patient is referred from a different healthcare provider for another opinion, requesting re-read of radiology services. B) Patient presents from an outside provider with images but no interpretation. Our provider needs to re-interpret the original images since no report is available. C) Other?

Left common carotid and innominate artery stenting.

Operative report indicates aortic arch, selective innominate artery, left common carotid, and selective left subclavian angiography. In addition, balloon angioplasty and stenting of the ostium of the innominate and ostium of the left common carotid. Greater than 80% stenosis in innominate and left common carotid verified by CT angiography sometime prior to procedure. Procedure included access from right radial and right femoral. It appears that code 37216 has an MUE of 1, and it is not appropriate based on Medicare Fee Schedule to use modifiers -RT/-LT. Should code 37216 be reported separately for the right common carotid and the innominate? Would modifier -59 be appropriate? Is everything else performed bundled?

I&D Removal/Drainage of Superficial Thrombosis

I am not very familiar with this procedure and would love your assistance with CPT codes. Here is the report: "Pre-procedure diagnosis: 1) leg pain/tenderness, 2) superficial thrombophlebitis, 3) varicosities/reticular veins. The patient was taken into the procedure room for pre-op procedure limited ultrasound on the segment to be treated. The treatment areas were prepped and cleaned with isopropyl alcohol or chloroprep. Lidocaine without EPI was injected under the skin overlying the superficial thrombosis. Access was then gained with an 18 gauge 3/4 needle under ultrasound and visual guidance. The thrombosed area was then aspirated or expulsed with mild pressure, removing the superficial clot. Post treatment: The treated areas were cleaned and compressed with Cast Padding and Coban and a thigh high, 20-30 mmHg graduated compression stocking was placed on the patient's lower extremity."

Heartflow FFR-CT

Our facility is going to begin utilizing the recently approved Heartflow CTA-based FFR calculations. Is there a separate code for this? My initial thoughts were that it was just another piece of post-processing.

Extracorporeal Venous Circulation

What are the appropriate codes for extracorporeal venous circulation? "Patient was placed in prone position, and right popliteal venous access was obtained under ultrasound guidance. After that, a venogram was done, showing a total occlusion of the right femoral vein with extensive clotting throughout the vessel. A venogram from the left popliteal vein showed clotting of the femoral vein all the way up to the IVC. After that, a wire was advanced from the right popliteal access to the IVC. The wire was able to cross the area of total occlusion, and exchange catheter was put in place. Patient was turned into supine position and bilateral venous access through right and left IJ was done under sonographic guidance. An 18 French sheath was placed via the right IJ. A 26 French sheath was placed via the left IJ. Angiovac aspiration catheter was advanced to the IVC, and extracorporeal veno-venous bypass circulation was started. Using left popliteal venous access, wire was advanced to IVC and treatment was started from IVC to popliteal venous access. After flow improvement, PTA of IVC, left Iliac, and femoral vein was done. After adequate results on the left side, we concluded. Successful EV treatment for extensive clotting."

93613 and 93615

When the documentation supports it, is there any reason that we should not bill both the 3D mapping (93613) and esophageal recording (93615) with 93620, 93653, or 93656?

Removal of Stent Fragment

If a fragment of a vascular stent is protruding from the patient's skin, would code 10120 be more applicable than 20670? "The fragment of stent was then grabbed with a Kelly clamp and pulled from the skin. The fragment was cut with a heavy scissor at the base of the skin. This essentially removed the protruding fragment."

Drainage of Groin Lymphocele

I work for a hospital. I would appreciate help in coding the following lymphocele drainage procedure: "Under sonographic guidance, a 5 French Yueh centesis catheter needle was advanced into the fluid collection, and over wire (Amplatz) exchange was made for an 8 French Dawson Mueller drainage catheter. A total of 50 cc of clear yellow fluid was manually aspirated. A sterile dressing was applied."

Humulin Insulin

When the patient has a procedure performed, there are drugs that the physician can bill on the claim. My question is, when the physician gives the patient Humulin Regular Insulin during the operative session in the office setting, what HCPCS code would be billed? And, is it reimbursable under the physician fee schedule, or is this a drug that would only be billed under DME guidelines? We do not have a DME contract, so I am interested in your opinion.

A-fib Ablation Without PVI

Would code 93656 be appropriate for persistent a-fib ablation without PVI? Or does code 93656 require that PVI be done?

In Situ Bypass Graft with Endarterectomy

Physician did a left fem-pop in situ bypass, left profunda femoral endarterectomy, silver profundoplasty with SFA endarterectomy and vein patch, and common femoral artery endarterectomy. How would this be coded?


We currently bill A9500 (Tc-99 sestamibi) to Medicare for our nuclear stress test. A company has approached us about converting to Tc-99 non-highly enriched uranium (Q9969). They are telling us we can use Q9969 non-highly as a substitute drug, but continue billing code A9500. Currently Medicare hasn’t approved Q9969 as a billable code. Would that be acceptable Medicare billing? I have concerns, so I want to see if you have already had other questions about the newer drugs coming out. I didn’t find anything in the topic search.


In our hyperbaric wound clinic, we have started performing ultrasound duplex scans of a unilateral leg along with TCPO2 or TCOM measurements. Would you submit codes 93926 and 93998 if both are done at the same setting?

Spinal Angiogram 75705 MUE

Patient presents for spinal angiogram from T3 to L3 bilaterally, with a couple of common trunks. The total units for this case of 75705 was 23, but the Medicare MUE is 13. How are you supposed to bill these cases with an MUE that low? The bilateral surgery indicator for code 75705 is 0. Are you supposed to appeal these with report every time, or is there a different way to code them?


How would you code for a digital 3D fractional flow reserve model (super-computer; analytically derived) of the arteries derived from a standard CT scan? Would you consider this a component of a coronary CTA (75574), or is this separately codable?

Modifiers -SC and -KX for Pacemakers

In regards to the ZHealth Online Member Newsletter from March 31, 2016, I have a few questions regarding the -SC and -KX modifiers. When we have one of the following codes (33227, 33228, 32229, and 33233) should we be adding both the -SC and -KX modifiers to both the CPT and pacemaker C-code?

Nephroureteral stent versus nephroureteral catheter

What is the difference between a nephroureteral stent versus a nephroureteral catheter? They seem like the same thing. Is the stent purely internal and the catheter has tubing that also drains to the outside? So when would I use CPT code 50433 versus codes 50693-50695?

Port-a-cath Repair vs. Revision

"Patient had a port-a-cath inserted last week. It was not functioning properly. On flouroscopic exam they notice a kink in tubing. They took her back to the OR and to release two adhesive bands. Then the port sat well." Do I code the release of the bands? Surgeon is saying 36576, but we didn't repair the port-a-cath. What are your thoughts?

Multiple Units 75898

Is it possible to bill multiple units of 75898? I see the MUE is 2, but are there circumstances that would allow this code to be billed upwards of 13 times? These are cerebral embolization cases.


With the new code 61645, is all of this inclusive? "Mechanical/aspiration thrombectomy: A coaxial Reperfusion catheter, microcatheter, and microwire were taken to the lacerum portion of the left internal carotid artery. Then, the microcatheter and the microwire were advanced to the left M1 segment of the MCA. A Solitaire device was advanced in the M1 trunk of the left middle cerebral artery, using roadmap and fluoroscopic guidance. Control angiography was performed. The Solitaire device was then deployed within the M1 segment and was left in place for about 5 minutes. Then, under continuous suction the Solitaire device was removed from the system. This process was repeated for the thrombus within the inferior M2 division of the left MCA. Intra-arterial infusion of thrombolytic: Small thrombi remained in the distal left inferior M2 and left ACA, which were treated with 10 mg of intra-arterial tPA from the left ICA. The total duration of infusion was less than 10 minutes. Vessels catheterized and angiogrammed: Left CCA, left ICA, left MCA M2 segment, right common femoral artery.

Thrombosis in saphenous vein graft in earlier CABG

Patient underwent CABG, and later in the ICU it was noticed the saphenous vein graft was thrombosed. 1) Re-exploration of mediastinum. 2) Initiation of cardiopulmonary bypass. 3) Takedown of prior saphenous vein graft to right posterior descending artery. 4) New saphenous vein graft to acute marginal. 5) Temporary closure with open sternum. Would this be reported with code 33510?

Removal of Left arterial A-line in Femoral Graft Under Fluoroscopic Guidance

What is the best code to report this procedure? "The patient underwent prior lytic treatment. Because of the elevated ACTs, we elected to remove her left groin arterial access catheter in the operating room for definitive closure. In the operating room, following induction of anesthesia, the patient's left groin line was prepped and draped in the usual sterile fashion. First using fluoroscopy, we demonstrated that there was a good arterial flow through the left external iliac to profunda femoral bypass graft, which there was. We then used a closure device to assist with closure. A 5 French sheath Exoseal device was advanced through the catheter and drawn back and then used to assist closure of the 5 French sheath. Manual compression was held until adequate hemostasis was achieved. The patient otherwise tolerated the procedure well, and a sterile dressing was applied. She was returned to the recovery area in good condition."

IABP in Different Sites

A patient came into the cath lab with an existing IABP via the left CFA. The existing IABP is removed from the left CFA, and a new IABP is inserted via the left axillary artery. Can we bill codes 33967 and 33968 for the removal of the left CFA IABP and the insertion of the left axillary IABP? This was the same session, but different sites.

Aortogram with Bilateral Lower Extremity Run-off

I have coded aortogram with bilateral lower extremity run-off as 36200, 75625-26, and 75716-26. Lately our Medicaid Carrier has been denying code 36200 for procedure and modifier restriction. Am I missing something? 

Angioplasty and Stent of the Left Subclavian Artery Origin

"We then accessed the anterior wall of the artery with a micropuncture needle and wire, then up-sized it to a 5 French sheath using modified Seldinger technique. We then used a Glidewire and Quick-Cross catheter to cross the critical lesion at the origin of the subclavian artery and made our way into the ascending arch of the aorta. We then pre-dilated this area with a 5 mm angioplasty balloon so that we could deliver the pigtail catheter and later the stent. We angioplastied the area of critical stenosis with a 5 x 20 mm balloon with the inflation taken up to 8 atmospheres and left up for 1 minute. We then advanced the pigtail catheter over the wire and positioned it in the proximal ascending aorta and hooked it up for power injection angiography. We then advanced a 6 x 45 cm destination sheath across the lesion into the arch of the aorta, and then delivered a 6 x 22 mm iCAST stent through the sheath and then un-sheathed the stent. We then expanded the stent in the location of of the critical stenosis." Are codes 37236, 36215, and 75710 appropriate?

36217 with 75710

"INDICATION FOR PROCEDURE: Right upper extremity pain and pulselessness with evidence of occlusion of the right axillary artery on Doppler. PROCEDURES PERFORMED: 1) Right femoral arterial access. 2) Right axillary artery angiogram. PROCEDURE TECHNIQUE AND ANGIOGRAPHIC FINDINGS: After informed consent, the patient was brought to the cardiac cath lab and was placed in a supine position. The right femoral artery was accessed, and a 6 French sheath was advanced. A 6 French multipurpose catheter was then advanced into the brachiocephalic trunk and then selectively into the right subclavian artery and then pushed into the right axillary artery. Right axillary angiogram was done after that. The angiogram showed total occlusion of the right axillary artery with a large amount of thrombus and a very faint collateral circulation with very slow flow distal to the occlusion." The fee sheet says 36217 with 75710. Is this correct?

Thrombosed AV Access in Lower Extremity

Patient had thrombosed AV graft for dialysis in lower extremity. She underwent thrombectomy of AV graft, fistulogram, angioplasty of arterial anastomosis of the femoral artery with 6 x 4 Conquest, angioplasty of femoral vein with 8 x 8 balloon, and bilateral upper extremity venogram to assess veins for future AV graft placement. I would report codes 36870, 36147, and 36148. Should I code arterial or venous angioplasty? Also, what codes would I use for bilateral upper extremity venogram?

Pulmonary Valvuloplasty and Angioplasty

I am in disagreement with the physician on this one. I am thinking either code 92990 or 92997, but not both. He is thinking both. What would you code? "4 French Glide catheter was exchanged for an 8 mm x 3 cm Tyshak-II balloon dilation catheter, which was advanced and positioned across the pulmonary valve, supravalvar narrowing, and proximal right pulmonary artery, where it was inflated on one occasion with a trivial residual waist at the supravalvar main pulmonary artery narrowing and persistence of a waist at the proximal right pulmonary artery."

LE Intervention, CPT and PCS

Do we have the same guidelines with CPT? Need help on CPT and PCS. "Ischemic right foot ulceration with arterial occlusive disease. History of prior left left revascularization, gangrene, and foot salvage. Procedures performed: Abdominal aortoiliac angiogram and right left runoff via left common femoral artery approach. Selective right common femoral artery angiography and right leg doralis pedis artery angiography. Percutaneous right leg superficial femoral artery and above-knee popliteal artery atherectomy (SXC Turbohawk). Percutaneous right leg superficial femoral artery and above-knee popliteal artery cutting balloon angioplasty (4 mm x 6 cm VascuTrak Bard balloon. Percutaneous right leg anterior tibial artery and dorsalis pedis artery atherectomy (EXL SilverHawk and SXC TurboHawk). Percutaneous right leg anterior tibial artery and dorsalis pedis artery cutting balloon angioplasty (2.5 mm x 10 cm VascuTrak Bard balloon). Left femoral retrograde, angiography with interpretation and supervision of direct fluoroscopy, radiography, and intervention. Total contrast volume used: 60 mL of diluted Visipaque."

Biopsy in the Office with Patient Observation by Physician and Nurse

When we perform a liver biopsy in the office (POS 11), can we charge separately for the 4+ hours that the patient is being monitored by the physician and RN? If so, what CPT code?

Cutting Balloon: Angioplasty vs. Atherectomy

The patient has an indwelling subclavian and axillary vein stent with thrombosis. The physician ballooned the area with a cutting balloon. Would this be considered angioplasty or atherectomy?

Angioplasty of the Iliac with the Sheath

Can we bill code 37220 for an angioplasty of the iliac artery with the sheath? I don't think so, but I just wanted to double-check because the CPT description does not use the word "balloon".

UGI Contrast Injected

If during a UGI the contrast is injected through the PEG tube and there is no visualization of the esophagus, is there a reduced charge? Or can we report code 74241? Reason for exam was gastric distention. "240 cc of Gastrografin water-soluble contrast was injected through the patient's gastrostomy tube. Impression: Unremarkable upper GI series. The stomach is normal in morphology. No gastric outlet obstruction or leak."

Subclavian Artery Conduit for Endo AAA

Is there a code for creation of a subclavian artery conduit when performed for endo AAA repair? My physicians usually access bilateral CFAs, but will sometimes create a subclavian conduit for access. Is there a separate code when this is performed?

Drug-Coated Ballons

When doing an angioplasty with drug-coated balloons, do you bill the procedure as an angioplasty or as an atherectomy?

Procainamide Challenge Testing

Our physicians have been submitting add-on code 93623 when using a drug called Procainamide for the following situations: 1) to assess if someone has Brugada pattern ECG, 2) to assess for conduction system disease, which is pretty rare nowadays. There are two ways to perform Procainamide challenge for diagnosing Brugada disease: 1) in the lab after doing an EP study with catheters, 2) in the lab as a stand-alone procedure where patient is infused with the drug and serial ECGs are done for about 20 minutes (in that case, no catheters are inserted; it is simply an IV drug infusion with blood pressure monitoring and continuous ECG monitoring). Is code 93623 appropriate? I've found information that advises that if these tests are IV infusion and when performed in the hospital the infusion is not separately billable and we could only bill for the ECG interp and report separately. Is this correct?

Duplex Doppler Studies 93975/93976

Can you please explain the documentation requirements for codes 93975/93976 as it pertains to gray scale imaging, spectral analysis, and color flow? Most ultrasounds are 2D imaging. Is it required that the radiologists dictate all three?

ER Thoracotomy with Aortic Clamp

Patient had multiple gunshot wounds to the abdomen. He received emergency thoracotomy in the ER where they clamped the aorta. He was then taken to the OR and had experimental lap. Is there a code to bill for the emergency thoracotomy and clamp in ER? We found 32110, but in the details it says it is for actual repair of bleed not just control to.

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