Dr. Z, I need some advice on coding this case. The physician dictated 2 angioplasties in the left renal artery. One was for intimal hyperplasia within a previously placed stent of an ostial lesion. The second angioplasty was for FMD of a subsegmental branch. I think that this should be 75966, 75968, 35471, 35471-59 and 36247. However, as I searched your database, you had recommended that 2 angioplasties should be charged only in instances where you could report 2 separate catheter placements. Am I trying to overcode this? Thanks for your help? Chris McCoy
Is it appropriate to report a diagnostic CAD and diagnostic mammogram for spot magnification and/or compression views for patients returning following a screening mammogram with CAD?
What are the proper codes and modifiers to use for follow-up mammogram for males with history of breast cancer?
A patient presents to radiology for a localization wire placement in the breast. The patient has had a biopsy and clip placement on a preivous date of service. On today's visit the localization wire is placed in the breast under ultrasound guidance. The patient then has a mammogram after the wire is placed to confirm wire location. These films are sent with the patient to surgery for a lumpectomy. Should any codes be awarded in this scenarios for the post wire placement mammogram?
I noticed in your radiology and IR reference books that effective for 2013 mammography following image-guided wire or clip placement is not reported separately. Does this also include when the breast biopsy was done with ultrasound guidance?
Can you bill for two separate diagnostic mammograms when they are done before and after a ultrasound guided breast biopsy?
Can a diagnostic unilateral mammogram be charged after a breast cyst aspiration was done with ultrasound guidance? The mammogram was done to assure that the cyst was completely evacuated. Thank you.
I am wondering if you are able to provide a point of clarification regarding the information that was contained in the May 20, 2013 ZHealth Online Newsletter (pasted below) that relates to charging for mammography post clip placement. Specifically, I am wondering if this new ruling applies to the technical component and the professional component, or just one or the other. And if it is just one, which one is it? May 20, 2013 ZHealth Online Newsletter: Mammography Post Breast Clip Placement We have had questions raised recently about the current rules regarding billing a diagnostic mammogram for mammography performed to verify clip placement after a breast intervention. This practice is no longer allowed. The mammogram is included in the intervention regardless of what imaging modality was used to perform the intervention. History When breast biopsies are performed, it is common practice to place a metallic clip in the place from which the biopsy specimen was removed for future identification of the biopsy site. After the clip is implanted, mammography is performed, usually two views, to verify the clip placement. For a long time, it was a grey area as to whether the clip verification imaging could be reported as a diagnostic mammogram. It was not really a diagnostic study, but it did not seem to be part of the biopsy, either. In the Fall 2010 issue of the American College of Radiology’s (ACR’s) Clinical Examples in Radiology, the ACR seemed to clear it up by saying the mammogram could be reported separately if performed on a separate piece of equipment from the intervention: “When performed on separate pieces of equipment, a unilateral diagnostic mammogram (usually two views) performed to verify the metallic clip position is appropriately reported with CPT code 77055, Mammography; unilateral, or HCPCS code G0206.” This was the rule everyone was following, or should have been, after the article was published. When the National Correct Coding Initiative (NCCI) Manual for Medicare Services was updated for 2013, CMS disagreed with the ACR. The following new paragraph was added to the manual: “11. If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with radiologic guidance (e.g., 76942, 77012, 77021, 77031, 77032), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging required to perform the procedure.” CMS does not agree that it is equipment-specific. It is included in the intervention performed regardless of the imaging modality. Today Since CMS guidelines supersede guidelines from any of the medical societies, a mammogram may not be reported separately when performed to verify clip placement. It is bundled.
We need your assistance! Can we bill mapping with an AV node ablation. EncoderPro.com no longer shows a CCI conflict. As always, thanks for your help.
I’m a bit confused with correct coding for this one: sclerotherapy “infusion” (embolization?) of microcystic spaces/lesions. I’ve never seen an “Angiocath needle was advanced into the mid-inferior aspect of the tongue bilaterally” – also the floor of the mouth bilaterally. Obviously non-CNS, but is it codes 61624/75894? No idea on “catheter” placement either. Please advise.
I am hoping you would be able to help me. I am trying to get clarification on MCOT codes 93229 and 93228. The practice bought the MCOTs from Cardionet. They also pay Cardionet a fee (not sure if it is monthly or per monitor usage). Cardionet is telling the doctors to report both codes 93229 and 93228. Also, would it make a difference if they bought them or rented them?
An IR doctor has asked me if we can bill for measuring interstitial pressure with a device. They will be doing a biopsy of a tumor, and the plan is to place a needle to measure pressures in a tumor. A component of the tumor pressure is transmitted arterial pressures. The plan is to simultaneously measure the pressures when the biopsy is done. What code(s) can be billed for this (in addition to the biopsy/guidance for biopsy)? I would appreciate any recommendations you may have for billing this additional procedure.
Is code 92973 reserved for AngioJet only? Patient with MI had thrombus burden (100% occlusion) in the RCA, where PCI was done with a DES. This led to thrombus embolization into the posterolateral branch(es), which was treated with adenosine and nicardipine. "The mechanical curettage was also performed with guidewire manipulation and passing the previously inflated stent balloon down into the proximal portions of the branches of the posterolateral branch." We were wondering if the intervention here to the posterolateral branches would be considered a mechancial thrombectomy.
Can I use 37184 per Date of Service. Lets say that a the radiologist does a mechanical thrombectomy on the same patient multiple days (same leg) while the patient is going through thrombolisis infusion. Thanks,
For a Medi-Port insertion (36561), does the name of the device alone (right IJ 8 French power injectable AngioDynamics Smart port) suffice to support the reporting of code 36561, or is it necessary to document the pocket creation? Dictation documents the ultrasound used- with permanent image kept, the fluroscopic guidance for final placement, tunnel creation, just not the actual port pocket.
Our pain management physicians are doing facet joint injections, medial branch blocks, and RF ablation of the facet joints. We are having them dictate the joint levels for the RF ablations, as I get that they need to inject multiple levels for one joint, but I’m confused on how we should be coding the facet joint injections and the medial branch blocks. I thought these would still be per injected level. This is what we have been doing for the three areas… what do you think?? L2, L3, and L4 would be three facet injections (64493, 64494, 64495). L2, L3, and L4 would be three medial branch blocks (64493, 64494, 64495). L2, L3, and L4 would be two RF ablations for two facet joints (64635, 64636).
Dr Z How would you code angioplasty of the posterior tibia and the medial plantar artery? How would you code atherectomy of the anterior tibia, the dorsal pedal and the peroneal? Thank you
How would you code for a core needle biopsy of a mediastinal lymph node? The report stated the biopsy was challenging because the lymph node was close to the heart and pulmonary artery, so it definitely was not superficial. We didn't think code 38505 really applied here, but it is not abdominal or retroperitoneal, so we didn't know if we could use code 49180 here. Would it be appropriate to report code 32405 for a mediastinal lymph node or not?
Dr. Z, Sorry if this has been covered already. I checked your IR reference and SIR's reference, MedLearn's reference, etc. ad nauseum. Forgive me if I'm reading too much into this, but I was wondering if a physician indicates symptoms only in one leg does that mean that there is only medical necessity for a unilateral extremity angiogram (75710). Or is it common practice and acceptable to perform and charge bilateral extremity angiogram (75716) even if there are no documented signs and symptoms in the contralateral leg? We have many interventionalists who perform bilateral angiograms but have only indicated signs/symptoms in one of the legs in their report. I am grappling with whether medical necessity supports bilateral imaging when only one leg is indicated. Is there some unspoken rule that a bilateral extremity angiogram is standard and acceptable for documented PVD in only one leg? Your help would be greatly appreciated!
A medically necessary question! Patient had a bilary stent placed with external drain left in on January 11th. Patient came back on February 13th to evaluate and check patency of the stent. There was no output from catheter for a week. Choli was normal and external biliary tube was capped. Radiologist dictated in report to have patient return in a few days for a check and to see if the patient's biliary tube can be removed. Patient comes back on February 15th, and cholangiogram is done again and biliary cath pulled. Since there is a big crack down on doing procedures that are not medically necessary, I just wanted to make sure I can charge for the second cholangiogram. Was it really needed after one just performed two days ago (no new problems or pain reported)? Is this normal practice accepted as medically necessary? If I shouldn't charge the choli code, what can I charge, or what modifiers can I use with the choli charge to bill it?
We are trying to determine if sacroplasties are covered by Medicare with the diagnosis of compression fracture (w or w/o osteoporosis/osetopenia). We have had claims denied in the past for medical necessity but we cannot find a LCD or NCD for Michigan indicating what is considered medically necessary. Do you have any information on this?
We are having a debate in between a couple of us and would like your opinion on this case. Patient comes in with hemochromatosis and hepatocellular carcinoma. MRI shows persistent nodular enhancement with in the right lobe medially. Right CFA approach. Cannulates the celiac, pic. Advances into two right hepatic branches, pic. Both are embolized. Moves to left hep, pic. Moves to right inferior phrenic artery off celiac, pic. Embloizes phrenic artery. The physician cannulates the accessory right hepatic off SMA, pic. We have codes 36246, 36248 x 3, 75726 x 2, 75774 x 5, and 37204/75894. The debate is... are we missing a 36247? And can we not bill code 75898 for follow-up from the embolization?
I have something different to code that I have not come across before - a Methylergonovine injection into the RCA during a heart catheterization. Is this separately coded? And, if so, what would the code be? I have looked everywhere for this and the only thing that I found was that you should not report code 37202 or 93463 for injection of drugs into the coronary arteries. Note states: "Methergonovine challenge to the right coronary artery in view of the patient's persistent symptoms and unchanged anatomy decided to continue with a metahemoglobin challenge to the right coronary artery. Methergonovine was given in three-minute intervals, initially at 0.05 mg up to 0.15 mg with presence of angina, as well as diffuse coronary spasm of about 70% to 80% stenosis, especially distally in the posterior descending artery and posterior left ventricular branches."
I have a question for you from the webcast on Tuesday regarding the Acute MI code. There is much confusion on whether or not a non-STEMI is an acute MI. Are we to assume that a non-STEMI is an Acute MI? If so, what clinical indications (documentation) would need to be present?
I work for an acute care hospital facility. Patient arrives in process of having an STEMI. The physician describes multiple "culprit" lesions and doesn't identify only one as the cause of the MI. Is it correct to code more than one intervention utilizing the acute MI codes such as C9604, C9606, and 92941 if the physician decribes several culprit lesions?
Would you code this as an unlisted 37799? I wasn't sure if microphlebectomy was the same as 37766? thanks MICROPHLEBOTOMY OF VARICOSE VEINS BOTH LOWER EXTREMITIES History: 60-year-old female with previously injected symptomatic large varicose veins of the both lower extremities. She has painful areas of entrapped blood. Indications: Symptomatic previously treated bilateral varicose veins. Medications: None Contrast: None Complications: None Technique: Confirmation of patient identification and the planned procedure were obtained. The courses of the large thrombosed varicosities along the anterior and posterior aspects of both legs were noted. The patient was then placed prone on the stretcher. Both legs were cleansed with alcohol from the buttock to the ankles. Microphlebotomy was performed as described below. Dressings were applied and she was turned supine. After additional alcohol cleansing, a total of more than 40 (including those on the back) small (2 mm) incisions were made in the various marked areas of each leg. Old blood was manually expressed from the various sites. Manual pressure was held. Gauze pads were placed over each incision. She tolerated the procedure well. Findings: The multiple large varicosities with entrapped blood from previous sclerotherapy in both legs were treated with microphlebotomy as described above with a very good early result. She tolerated the procedure well. Impression: Successful microphlebotomy of entrapped blood from previous sclerotherapy in both legs.
Dr. Z Physician performed gonadal vien embolization for vacicocele. While doing the procedure the final coil migrated to left renal vein. Physician made several attempts to remove the coil using several catheters and snare but unsucessful. He even considered using different access however after viewing the images decided the the diameter and high flow of the renal vein make future clinically significant events related to this short protruding segment of coil very unlikely.He left the migrated coil and successful embolization of gonadal vein. We are charging embolization of gondal vein however not sure if we can charge 37203-74 75961-74 since multiple attempts, time and effort to retract the migrated coil and also we have different opinions what to code for the diagnosis of the migrated coil? Please advice. Thanks
We have an unusual case and I am hoping you can advise what is the best way to bill for the procedure. Thank you. Patient had a previously placed subclavian stent. It was found on CTA that the stent migrated to the bifurcation of the aorta and lt common iliac. The physician went in and snared the stent and repositioned it in the left common iliac artery. He has also dictated a complete lower extremity angiogram. Since he did not remove the stent would you use an unlisted code? I don't think there is medical necessity to bill for the angiogram even though it shows Lt SFA stenosis needing angioplasty at a later date. Thank you.
Patient was sent to the cath lab with a central line removal and possible surgical intervention. The central line catheter was placed from subclavian vein and ended in the innominate artery. We imaged this to confirm placement. We changed out the central line catheter to a 4 French sheath and used an AngioSeal to close. We then accessed the groin to do an aortic arch to be sure that there was no extravasation. I have reported code 36221. Can we code for the injection through the central line?
Our cardiovascular group has begun using transcatheter mitral valve-in-valve implantation for treating mitral paravalvular leaks in patients with failing bioprosthetic valves. Would it be correct to use 0256T for this procedure? Thanks
If our physician is performing a heart cath at the hospital, do we put a 26 modifier on the new heart cath codes eg 93458-26
Please do NOT include any actual patient medical records with your question. Does procedure 93459 need a modifier 26 added if my physician goes to the hospital and performs this procedure
We had a STEMI come through the ER. The patient recieved a left heart cath, and a drug eluting stent was placed in the OM2. The procedure ended and the patient was taken off the table and moved to his room. About two hours later, the performing physician was reviewing the study and realized he had unknownly recanalized a lesion in OM1 that he now felt was the true culprit lesion. This vessel did not have good flow, so the patient was at risk for another cardiac event. So, the patient was brought back into the lab and a drug eluting stent placed in this vessel. As both of these interventions were done in the left circumflex distribution, will we be able to charge for the second stent placement with a -76 modifier? Or can we only charge for the initial procedure?
When is it appropriate to add a 25 modifier to an E&M cpt code the same day as a stress test?
I am confused about the 2013 cervicocerebral coding. The more I look, the more confused I get. For hospital billing, when bilateral ICA arteriograms are done, do we use the -50 modifier, or do we charge code 33224 twice? The 2013 CPT Code Book and ZHealth Publishing books say to use the -50 modifier when performed bilaterally. The back side of the anatomical chart from ZHealth says to report the codes twice. When I looked online, the latest question answered about this subject only said, "For hospital billing, these codes are assigned status indicator Q2, so only one is reimbursed by Medicare when multiple cervicocerebral codes are submitted." But, that doesn't really tell me which way I should be coding this. Please help me with this very confusing subject!
We have a case where a PTCA occurred in the RCA, and an attempt was made to stent the mid lesion (there were three lesions in the RCA), but "due to profound calcification and tortuosity, unable to cross the lesion site. There was TIMI-3 flow with good results and the procedure was aborted". Does this description qualify as the procedure being terminated at "the provider's discretion", as relates to the stenting? In other words, would you code the attempted stenting (92928) with modifier -52, or would you just report code 92920 for the PTCA? We are an OP hospital, in case I didn't mention it. The type of stent was not mentioned in the dictation.
For a limited (unilateral) noninvasive physiologic study of an upper or lower extremity (93922), you’re to add a -52 on the professional charge. Does a -74 go on the technical portion then?
Dr, Question for pressure wire during coronary intervention. After diagnostic angiogram which 70% stenosis noted in LAD and proceeded to evaluate the LD and a pressure wire was advance through teh guidewire into the left main but could not be manipulated or advanced into the left LD due to tortuosity below, as well as the sharp angle of the LD. After several attempts, it was decided to go ahead with PTCA and a DES was placed. Can we code 93571-74 here they used the supply and several attempts made even though the procedure unsuccessful? Thanks
A patient has a successful elective cardioversion for atrial fibrillation in the morning, and later in the day converts back to afib and is cardioverted again. Would the procedures be reported 92960, 92960-59? Thanks
If one cardiologist does the diagnostic catheterization, and his partner does the intervention, do they have to apply a modifier? If so, which one (same day, same encounter with the patient)? I'm not sure if modifier -62 applies. I'm seeing more and more of this with physician groups. One reason is cheaper malpractice insurance.
I note in the CPT book the description of the new angioplasty/stent codes (37220-37235)state unilateral. Should the modifiers LT or RT be appended to these codes? For example if a left SFA angioplasty and stent were done, should this be coded as 37226LT? or just 37226.
Hi Dr. Z: Is it appropriate to (for HOPPS)attach a -73 or -74 modifier to certain radiology 70,000 codes? I was told by one of our coders that it is only applicable to the surgical range. I did see a couple of responses where you did use it on a 70,000 code. My example is: A CT guided lung biopsy was to be performed, however, upon completion of the initial scan, the mass was no longer present, so I was going to put a modifier -73 on the 77012 code, but I was told that is incorrect. I would have also put the -73 on 32405. Also, can you give me any tips to tell me what the radiologist needs to cover in his report for an exam that is terminated due to extenuating circumstances? Thank you very much.
Dr. Z, I bill for a hospital. Is modifier 76 and 77 based on whether the same or different radiologist reads the film? Example: Two hip x-rays done on the same ED visit for dislocated hip. The first one shows the dislocation and the 2nd one confirms that it was reduced. Some of the coders thought the modifier is based by the ED doctor and not the reading radiologist. Thanks for you guidance. Michelle,
This is an "appeal to common sense" question. We've reached out to our Carrier, and now I'm inquiring on your thoughts. The new 2014 stent codes (37238/37236) reflect on the CMS RVU table that there is a 000 global period; therefore, a global modifier would be necessary if performed within the global period of another service. Submitting with a global modifier of -78 (related, unplanned procedure) denies the charge for "inconsistent"; however, modifier -79 (unrelated/unplanned) is acceptable. I am using modifier -78 in the context of dialysis graft that declotted patient returns due to a subsequent declot and stent is additionally placed due to persistent recoil. Can you make the case the stent is "unrelated", as the recoil is due to current visit, or related since it is all being performed in dialysis graft?
Please do NOT include any actual patient medical records with your question. Hi Dr. Z: We are trying to determine if modifier -59 is required on CPT 93458 - LHC, when it is reported with G0290-RC & G0291-LC. This is for OPPS billing. I cannot find any documentation that it is required or should be appended to 93458, when reported togather w/G0290. There are no NCCI edits or OCE edits. Thanks for your help!!
What is the correct coding for MR enterography? We are getting pushback from a major payer, and I was wondering if there is any guidance out there. "Report includes GI tract, abdomen, and pelvis. "Technique: Axial, coronal, and sagittal T2 HASTE; axial T2 fat-sat; coronal pre and post-contrast VIBE; axial post-contrast VIBE."
What is the appropriate code for MRA of the heart?
Is there a difference in an MRI venogram and an MRA?
If a patient has a brain MRI in the morning and an fMRI later in the evening, can we bill for both?
Dr Z the radiology managers asked me if they need to create two accession #'s when the physicians are asked to dictate separate reports for MRI/MRA same anatomical site. The Radiologists say there must be two accession #'s and I agree but the managers have asked me to verify this. The business office has been bundling MRI/MRA together instead of reporting each with modifier 59 on second code for a composite APC, thus potentially losing the hospital money. The Radiologists have been billing both procedures with 59 and mostly get paid, particurlarly by Medicare. CMS indicatd these can be submitted if two separate dictated reports are created. Thanks J
We routinely do MRI/MRAof the head together as part of our stroke protocol. How do you bill for MRI/MRA head done on same-day? Should we report this service with 70551(MRI head) and 70544-59(MRA head) to receive payment on both MRI and MRA head according to the CCI Edits? Is this appropriate?
Dr.Z I did read your 2009 reply regarding brain mri in addition to iac mri, but wonder if there are new edits prohibiting appending 70553/70553-59? is the following dictation sufficient to attach both codes? thank you. MRI Head and IAC w/wo IV Contrast FINAL REPORT Clinical Notes: WORSENING DIZZINESS MRI HEAD: HISTORY: Headache. Worsening dizziness. TECHNIQUE: MRI of the brain with and without IV contrast. Multihance administered by the technologist per PIH protocol. DESCRIPTION: MRI of the brain with and without IV contrast on the 3 Tesla unit was performed demonstrating normal flow voids within the carotid siphons and basilar arteries. No evidence of retrobulbar mass. Suprasellar cistern is intact. Meckel's cave and CP angles are symmetric. Optic chiasm is intact. No evidence of abnormal intracerebral enhancement. Cisternal portions of the fifth nerves are symmetric. Extraocular muscles are symmetric. No acute infarct, mass, or hemorrhage. IMPRESSION: MRI OF THE BRAIN WITH AND WITHOUT CONTRAST IS UNREMARKABLE OTHER THAN PARANASAL SINUS DISEASE INVOLVING THE SPHENOID SINUS. NO CP ANGLE MASS. MRI IAC: TECHNIQUE: MRI of the IAC with and without IV contrast. HISTORY: Dizziness, progressively worsening. DESCRIPTION: The fifth nerves are symmetric. Meckel's cave and CP angles are symmetric. No evidence of acoustic neuroma or vestibular schwannoma. Mucoperiosteal thickening in the sphenoid sinus. No evidence of enhancing masses of the eighth nerve. IMPRESSION: NO EVIDENCE OF ACOUSTIC NEUROMA or vestibular schwannoma. No evidence of intracerebral mass. CP angles and Meckel's cave are symmetric. IMPRESSION: MRI OF THE INTERNAL AUDITORY CANALS IS UNREMARKABLE.
Hi Dr. Z, Could you take a look at this for me? Im not sure that i agree with what our department coded. Procedure: MRI is performed both prior to and following intravenous administration of 20 cc multi-Hance. Lateral breast mass is not as well defined as on the prior MRI. An ovoid area od enhancement is selected to be biopised as this is the most closelt approximates the mass seen on prior MRI. The skin is terilized. Local anesthesia is obtained using 2% lidocaine subcutaneously as well as a 1% lidocaine and epinephrine solution to the deeper tissues. Using CAD stream grid localization, the mass in the lateral half of the breast is targeted. Incision is made in the skin and through this incision an 8G vacuum assisted core biopsy not needle is placed and confirmed with MRI. Incision was approximated using a Steri-Strip and a Band-Aid. Patient tolerated the procedure well and was given instructions for post biopsy care. Specimen was submitted to pathology. This is what the department coded: 19103RT 77021 C8908 0159T A9577
We are having a debate at my facility... When the breast MRIs state CAD with 3-D for Non-Medicare, wouldn't this be reported with codes 77059 and 0159T for example, and an MC would have the C-code and 0159T? "INDICATION: Bilateral breast MRI new on-set microcalcifications patient history of breast CA. TECHNIQUE: The patient was positioned in the dedicated bilateral breast coil. Pre-Gadolinium sequences: Axial T2 TIRM, axial T2 turbo spin echo and axial T1 3D gradient echo. Post Gadolinium sequences: Following bolus intravenous administration of 10 ml of Gadavist, a dynamic series of T1 weighted 3D gradient echo sequences was obtained at one minute intervals out to 5 minutes. A high resolution sagittal T1 weighted series was also obtained. The images are submitted to the CAD stream dedicated breast MRI work station. The data from the dynamic series was used to construct angiogenesis maps displaying the enhancement characteristics. In addition coronal reformatted images were produced along with thin MIP, axial, sagittal and coronal images derived from the subtraction images as well as whole breast bilateral MIP reconstructions."
We had an MRI order from the referring physician stating an MRI of the left trapezius muscle. The MRI report reads MRI of the left shoulder and trapezius muscle. Should we only bill using 73221? Or, should we bill using non-joint code 73218 since the trapezius muscle is a non-joint? Please provide us with the correct coding.
1. (Medicare account) Would it be appropriate to bill for an MRI of the pelvis when imaging of the prostate is done with or without contrast if no other organ structures are imaged or reported. Would it be appropriate to append a modifier -52 if the only findings are related to the prostate since complete imaging of the pelvis was not performed. 2. (Medicare account) Would it be appropriate to bill for an MRI of the abdomen if the procedure performed was an MRCP without 3D rendering. The findings are only related to the bile ducts and gallbladder, the other organ structures are not mentioned. Would it be appropriate to append a modifier -52 if the only findings are related to the gallbladder and bile ducts since complete imaging of the abdomen was not performed.
Should the MRA codes be used for MRVs?
I have recently been receiving rejections from Medicare when I bill bilateral code 34812. After trying 34812/34812-59, then 34812-RT/34812-LT, 34812-50 and 34812 x 2, I filed a redetermination. I was told it was denied because I billed with quantity of "two". Upon looking up the MUE, I found it now states one unit. Is this a new edit?
Can you please explain the rationale behind code 50393 with an MUE of 1, and its coding pair 74480 with an MUE of 2? I find this contradictory if bilateral stents are inserted. Thank you.
I thought if the physician stented both the LC and LD in the same procedure, the codes reported would be 92928-LC and 92928-LD. But, there is an MUE of one for code 92928. Would this be billed with just 92928-LC?
Dr. Dunn, I am getting conflicting information. I have been told that on one of your webinars that you say the new gen replacement codes such as 33264 can not be used with any new leads. In all the Zhealth products I have purchased I do not see that. Maybe this is new infromation I missed??...So even though it has been asked before: how do you code for multi lead gen replacement (33264) attached to exsisting RA and RV leads with a new LV lead inserted, DFT testing. I thought it was 33264, 33225 and 93641. Has this information changed? From what I have read from the Zhealth and other sites is that the new gen replacement codes cannot be coded with new RA and RV lead insertion because combined codes exist but the LV lead is different because there is not a seprate code that combines them so they are coded seperatly. Let me know if I missed something or maybe I am not understanding....Thank you for your help and hopefully I will understand it this time!
Dr Z can you help with this case?? The Doctors notes a type 3 aortic arch. He punctures the right common femoral artery in a retrograde direction, he goes up and does an arch angiogram. He then selectively catheterizes the left sublclavian artery. Additional images of the left subclavian artery are obtained. He then selectively caths the left subclavian artery distally and was able to advance a sheath over a stiff wire into the left subclavian artery. The shuttle sheath was advanced distal to the left vertebral artery and a atrium stent was deployed in the distal subclavian lesion. This was post dialated with a balloon to a more acceptable caliber across the lesion. He then places a genesis stent within the sheath and pulls the sheath back to the origin of the left subclavian artery where another stent was deployed across the origin of the artery. He then removes the catheters and wires from the left subclavian position and pulled down to the abdominal aorta. Additional images of the right iliac system where obtained and this demonstrated a very significant external iliac artery lesion of approx. 70% and a common iliac artery multifocal calcified lesion. He then does an angioplasy of the external and common iliac arteries with significant recoil. A Smart stent was deployed across the lesion and this stent was postdilated with a balloon. He then goes on to deploy a closure device. Can you help me code this?? Thanks
Hi Dr. Z. I need your help. Scenario 1 A 50 year old patient presented for placement of PICC line, the right basilic vein was accessed, this access site was abandoned due to an occlusion of the vein, the PICC line was then successfully placed via the left basilic vein. Is it safe to say only the successful PICC placement should be reported 36569? Scenario 2 50 year old patient presented for placement of a PICC line, right basilic vein access was occluded the physician performed a formal extremity venography to evaluate the abnormality with documentation of the clinical findings, the PICC line was successfully placed via the left basilic vein. I coded the successful PICC line 36569 Would it be appropriate to additionally report the extremity venography (75820) and the vein access (36005)?
Need some help please. We have a patient that came in ER in cardiac arrest, brought back and then taken to the cath lab. Cardiologist #1 did coronary angio only and then Cardiologist #2 attempted PCI of ostial RCA (which was subtotal occlusion) but was unsuccessful. The patient arrested during cath and had to be cardioverted along with CPR several times. Once patient was back in sinus rhythm a ballon pump was placed and the patient was transferred. The Cardiologist documents 2 hrs of critical care spent with this patient. My question is should we use 92982-74 for the unsuccessful PCI along with 33967 and 93508? I know we can't charge for the cardioversions. Appreciate any help you can give. Thanks.
Will the hospital be reimbursed if an EP physician performs multiple diagnostic testing such as a Tilt table study (93660), an EP study (93620), and an Ablation (93651) before deciding to do an implant (33208)? Should the implant be done on a different day of service? Thanks,
We have a case where they placed three needles for localization in the breast, each dictated in a separate report. They were placed at 12 o'clock posterior depth, 12 o'clock anterior depth, and 12 o'clock middle depth. In each impression it reads needle localization for the marker clip in the left breast at 12 o'clock middle depth, 12 o'clock anterior depth, and 12 o'clock posterior depth was successful. We asked the tech at the hospital if these were three separate lesions, and she said no they were three separate areas of the breast, not really a lesion. The patient did have three biopsies of these areas with the clip placement. Would we report this with codes 19290 and 19291 x 2? Or just code 19290?
For the new revascularization codes, are there any multiple procedure payment reductions we should be aware of? Like if they do stent in 2 places or even a primary and 2 add on’s in the iliac or tib/peron territory, would the 2nd add-on payment be reduced or would they get full reimbursement? Docs are asking and I really am not sure where to find this info!
Dr Z, I have been searching through your database online. I couldnt find it on here and online theres a lot of conflicting information. When billing 33240, 33241, and 93641-26 our new system is appending a 51 to the 33241 and the 93641-26. It is also appending a 51 if we do a diagnostic heart cath and an intervention. Can you please advise on what we should be doing? Thanks Traci Alwell
Dr. Z -- Thanks for all your past assistance. This question is about ablations and whether or not, in this unique situation, would be appropriate to charge TWO 93651's (one appended with modifier -59). Physician dictation states, "She had complex ablation because there were TWO arrhythmias treated with different techniques. Two SVT's: AV node reentry with cryo and atrial flutter with externally irrigated RF." Cryoablation was performed in the posteroseptal region. RF performed in the right atrial isthmus. That, to me, says two separate sites were ablated. For the RF says, "The line was completed with the RF catheter documenting complete line of block..." This statement does not equal "complete heart block" (in which case 93650 would be charged), but rather an ablation for which 93651 would be charged...right?? I hope the last part of this question makes sense and that you agree with my recommendation to the department to charge two 93651's. THANKS VERY MUCH!
Dr.Z, We see lot of myelograms where they use fluoroscopy to injection contrast and then sent patient to the CT myelogram for lumbar, cervical and thoracic. For myelogram we only code 62284 and 77003-59 and then CT cervical, Lumbar and thoracic separate. Lately our physicians documenting a small paragraph describing the myelogram images “digital images were obtained of the lumbar and thoracic spine to document the flow of contrast. There was prompt flow of intrathecal contrast surrounding the cauda equine nerve roots, conus and cord without evidence of myelographic block” then transferred the patient to CT myelogram for lumbar and thoracic regions where very clear documentation for both CTs separate. My question is can we charge complete myelogram 62284 72270 based on the myelogram images documentation besides charging separate CTs? Please advice. Thanks
CT myelogram was performed with contrast was injected via an already existing lumbar drainage. Would we code this by using code 62284 with a -52 modifier? "Using the patient's existing lumbar drain, the side port was accessed. 15 cc of Omnipaque 180 mg contrast was administered intrathecally through the spinal needle. There was no fluoroscopically noted extravasation during the contrast injection, and the needle was removed. Multiple fluoroscopic radiographic images were obtained, after the table was tilted with the patient's head moving up and the feet down, to keep the contrast in the lumbar spine and define the inferior margin of the thecal sac."
In 2010 I would code 93539 to check IMA for suitability for CABG. What would be used in 2011? Thank you. Becky
I need clarification Column 1/Column 2 edits. With the Column 1 being the major component if a Column 2 code (71010 is perform after the Column 1 code)is performed, the column 2 code should not be coded/charged. Coding both codes would be unbundling. The column 2 code should only be charged if there is a new symptom post prodecure documented as reason for exam. Fluoro is not used. In the below it says "When billed together, 75625 (the Column 2 code) should not be paid." but they should not have been coded on the bill together at all. I want to make sure I understand it. Thanks Column 1/Column 2 edits, previously called Comprehensive and Component, are to detect when a procedure is billed separately that should be included in another procedure billed. When used together on a claim, these procedure codes are considered unbundled. The Column 1 code represents the major procedure. It requires greater effort and time as compared to a Column 2 code. The Column 2 code represents the lesser procedure or service, is Considered part of the Column 1 procedure, and is often represented by a lower payment. An example of this is code 75724, bilateral renal arteriogram, and 75625, abdominal aortogram. Code 75724 is the Column 1 code and is considered to include the work that is described by 75625. When billed together, 75625 (the Column 2 code) should not be paid.
Do you know if there is any place in one of Dr. Zielske's books where it says certain edits do not apply to children with congenital heart defects? I'm specifically wondering about angiography prior to an intervention. CPT says the intervention includes all angiography for roadmapping and hemodynamic data, but the physician says this edit doesn't apply if it's a child with a congenital heart defect. I'm trying to find a place in one of his books to support the fact that 93531 is included in 92997 unless the angiography a true diagnostic procedure as defined by CPT. CPT says: Diagnostic angiography performed at the time of an interventional procedure is separately reportable if: 1. No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR 2. A prior study is available, but as documented in the medical record: a. The patient's condition with respect to the clinical indication has changed since the prior study, OR b. There is inadequate visualization of the anatomy and/or pathology, OR c. There is a clinical change during the procedure that requires new evaluation outside the target area of intervention. Thanks for your help! Jane
Are there CCI edits with any of the new heart cath codes and 93505 for the Hospital? Those I have seen seem to be for Physician only. Thank you.
When we are coding for biventricular pacemakers, we are having a conflict with the NCD for Single and Dual Chamber Pacemakers. The claims are being held if they do not have diagnosis acceptable for this NCD. Is there a separate NCD for biventricular pacemakers? We can only find NCD for biventricular defibrillators. This seems to be a recent development.
"Transverse, longitudinal, and oblique ultrasonic sections of both neck were performed. Color Doppler evaluation also was performed. Entire study was real-time with no images. Right lower neck and left lower neck level VI lymph nodes are localized on the overlying skin. Right neck level III and level II jugular chain of lymph nodes are identified and localized on the skin. Findings were demonstrated and discussed with physician on real-time images. FINDINGS: Bilateral lower neck level VI and right level II and level III nodes were identified and localized on the skin for surgical planning." I'm not sure what the appropriate CPT code to use would be. I'm thinking of maybe unlisted code 38999 for lymphatic system. Any suggestions?
Procedure coded as 36299, 76499, 37204, 75894, not sure if this is correct. Physician not clear as to where in the neck the patient was accessed. Thanks! Indication: Right neck venous malformation Procedure: Right neck venous malformation embolization Findings: After obtaining informed consent, the right neck was prepped and draped in normal sterile fashion. Sedation was provided by the anesthesiology service in the form of general endotracheal anesthetic. Sonographic guidance was used to direct needle access to a vascular structure within the malformation. Contrast material was injected for malformation venography. There is a complex vascular structure with what appears to be irregular venous as well as lymphatic component. Via this access, a total of 4 cc of 3% STS was foamed and administered in 3 separate sessions with interval dwell time for the purpose of malformation venous scleroablation. Needle access was removed. A compressive dressing was placed. The patient tolerated this should well and left the department in stable condition. Impression: 1. Right neck vascular malformation venography demonstrates a complex venolymphatic lesion 2. Technically successful scleroablation of the lesion utilizing foamed STS with excellent result
What CPT code should we use to report the new Nellix Endovascular Aneurysm Sealing System (EVAS)?
We placed a nephrostomy tube last week and then received an order to place a nephroureturostomy tube this week. We inserted a wire into the nephrostomy tube down into the bladder. We removed the nephrostomy tube. We then placed an internal/external nephrouretuostomy tube over the wire and injected contrast to verify placement. Since we basically already had access from the previously placed nephrostomy tube, do we use a modifier on code 50393?
I have two questions: Patient came for nephrostomy tube and the following day scheduled for nephrolithotomy. Nephrostomy tube was placed by IR physician accessing the renal pelvis and nephrostogram performed and there are findings for the collecting system. Then inserted a nephrostomy tube. Coded 50390-59, 74425, 50392, 74475, however, since scheduled for nephrolithotomy we can only code 50395, 74485? How do you suggest coding when nephroureteral stent was placed for PCNL. Patient came and the IR physician performed nephrostogram and nephroureteral stent was inserted. Same as nephrostomy tube?
Would it be appropriate to report code 50387 for a patient who, in IR, has a nephroureteral catheter removed OTW and two wires and a sheath left in place to provide access for a nephrolithotomy to be done in OR later in the day? Since the work of creating the access was done in a separate session, code 50395 doesn't seem appropriate.
Please explain the differences between codes 50393, 50398, and 50688. Often patients with prior cystectomy with ileal pouch come in for what is termed "exchange or replacement of nephroureteral stent". "Nephroureteral" seems to imply this was of both kidney and ureter, but that combo is not a choice in CPT Index. "Procedure note: Indwelling nephroureteral stent was accessed in sterile manner. Glide wire was placed through the nephroureteral stent. Retention suture within tube was released and tube removed intact. A new 10.2 French nephroureteral stent was then advanced over the wire. Tip was coiled in the retention suture locked. Nephrostogram was obtained through the tube." Please advise how to code this, and please comment on when it is appropriate to use the three codes above.
How would you code a nephrourteral stent replacement when the stent fell out at home? The tract is already in place, so a new stent would be overcoding, wouldn't it? Please see below. INDICATION: Nephroureteral stent accidental dislodgment and removal. PROCEDURES: 1. Percutaneous nephroureteral stent placement using fluoroscopic guidance. 2. Nephrostogram. Patient's existing skin defect at previous nephroureteral stent slight was probed with a KMP catheter and Glidewire. Tract was identified and Glidewire and came P. were advanced into the renal pelvis and down into the bladder. Wire was changed for a Amplatz wire. A 10 French nephroureteral stent was placed. This is confirmed by contrast injection which showed moderate hydroureteronephrosis. Catheter was secured to the skin with stitches Catheter was secured to skin with suture. The patient tolerated the procedure without complication.
Hello from KC,MO--Have a situation that has both IR & HIM stumped. Briefly patient had cystectomy secondary to bladder CA. Approximately one month post-op the stent placed at that time migrated causing spasm VS ureteral stricture. IR was requested to place a left flank nephrostomy. Patient seen several times for check & exchange of nephroeueteral stent. Patien now returns for nephrotomy check & possible removal of nephroureteral stent. The neproureteral stent is removed & the nephrotomy capped. Our questions are: is the nephrostogram billable separately & is 50389 correct for the nephroureteral removal? Appreciate you help.
With the changes in the rules for coding nephroureteral stents earlier this year, I’m a bit confused though. In light of the recommended changes, I believe that I would code ( report below) the left side with CPT 50393 and 74480 even though it involves an ileal conduit. Correct? The right side is where I’m a bit confused. This side also involves an ileal conduit. Is this now correctly coded with CPT 50398 and 75984? TIA for a timely response! Reason For Exam bilat convert perc neph convert to NU STENT PLMNT Report PROCEDURE: Bilateral nephroureteral stent placement CLINICAL HISTORY: 61-year-old male with a history of bladder cancer with ileal conduit reconstruction. Hydronephrosis was subsequently diagnosed and bilateral nephrostomy tubes were placed. He now returns for internalization. FLUOROSCOPY TIME: 14.7 minutes TECHNICAL DESCRIPTION: The patient was placed in the prone position. The indwelling nephrostomy tube areas were prepped and draped in a sterile fashion. Initially, dilute contrast material was injected through each of the nephrostomy tubes. The left-sided nephrostomy tube was removed over a guidewire. After advancing a guidewire through a hydrophilic catheter into the ileal conduit, an 8-French internal/external drainage catheter was advanced over the guidewire until the pigtail portion lay within the ileal conduit with proximal sideholes along the ureter. Contrast was injected to confirm position. Attention was turned to the right-sided nephrostomy tube. Again, following infiltration of the soft tissues with 1% lidocaine, the nephrostomy tube was removed over a guidewire. Guidewire and catheter technique were used to traverse the anastomosis into the ileal conduit. However, the internal/external drainage catheter could not be advanced across the stenotic anastomosis. As a result, a 5-French pigtail catheter was advanced over the guidewire across the anastomosis and left with its pigtail portion within the ileal conduit. Over a separate guidewire, an 8-French nephrostomy tube was advanced and left with its pigtail portion in the dilated right renal pelvis. Contrast was injected to confirm position. The catheters were flushed, fixed to the skin, and left attached to gravity drainage. The patient tolerated the procedure well and there were no immediate complications. He was later transported back to his ward in stable condition. DIAGNOSIS: 1. Successful internalization of the left percutaneous nephrostomy tube for an 8-French internal/external nephroureteral stent. 2. Although an internal/external stent could not be placed on the right side, a 5-French pigtail catheter was left across the right-sided anastomosis to the ileal conduit. In addition, an 8-French nephrostomy tube was left in the right renal pelvis. 3. A tight residual stenosis is noted at the right ureteral implantation anastomosis. 4. No definite stones were seen on this examination. PLAN: The above findings were discussed with the referring team for operative planning
Ethanol nerve block was performed, but my colleague and I are debating whether or not code 64680 or 64530 should be reported. See report that follows: "Under CT guidance, a 22 gauge Chiba needle was advanced to the celiac ganglion bilaterally from a left and right paraspinal approach, respectively. With the target celiac ganglion at the tip of the Chiba needle, the stylet was removed and monitored for any blood draw back to assure the needle tip was not within a vascular structure. Very dilute contrast was injected to evaluate placement of the needle tip and to again assure the needle tip was not within a vascular structure. Approximately 15 mL of 95% ethanol mixed with approximately 5 mL of 0.5% bupivacaine and 3 mL of Isovue 370 was hand injected to the celiac ganglion bilaterally at a rate of approximately 0.5 mL per second while under intermittent fluoroscopic CT guidance." Would this be coded as a nerve block or nerve destruction?
I have a question regarding catheter placements during neuro interventions. Often times, a diagnostic study is performed with catheter placed in a lower vessel (e.g., the internal carotid) along with the corresponding imaging. This would be reported with code 36224. There are findings related to intracranial (e.g., middle cerebral artery) blockages, which can be treated with thrombectomy, embolization, etc. I know the catheter must be placed within these intracranial vessels in order to perform the intervention; however, since there is not a diagnostic study to go along with the catheter placement, you cannot report code 36228. What, if anything, can be reported for the catheter placement within an intracranial branch artery during a neuro intervention when a diagnostic study was not performed in that branch?
Would you please clarify your statement regarding diagnostic angiography prior to intervention of carotid artery? On page 324 #11 it states "do code" for this IF not recently performed, if there is a change in clinical status or vascular distribution distant from site of intervention. On page 325 #26 it states diagnostic imaging is bundled into intracranial, carotid an vertebral stenting (specifically in our case we are looking at 37215 for carotid stenting w/diagnostic angiography during same session prior to procedure with no previous diagnostic angiogrpaphy). Under what scenario would you be able to bill for the diagnostic angiography at time of intervention? It doesn't seem to make sense. Thank you for your help in clarifying.
Can you please help and tell me if I’m on the right path of thinking with these new cardiac intervention codes? For the following case, I coded: C9606-RC, C9601-RC, 92920-LC, 92921-LC, 93458. PROCEDURE: Left heart catheterization, coronary arteriography, left ventriculography, placement of drug-eluting stent and percutaneous transluminal coronary angioplasty. INDICATIONS: Acute ST-elevation MI. HISTORY: The patient is a 60-year-old gentleman with no significant past history who presented with chest pain for several hours duration and presented with an acute inferior ST-elevation MI. DESCRIPTION OF PROCEDURE: 1) PREMEDICATION: Versed and fentanyl IV in the cath lab. 2) CATHETERS USED: 6 French sheath, 6 French 4 curve, right and left Judkins, 6 French pigtail. For PTCA, FL 3.0 guide, Runthrough wire, BMW wire, 2.25 x 12 NC Trek, 2.25 x 12 NC Trek, 2.25 x 12 Xience stent, 2.25 x 12 Xience stent. 3) MEDICATION DURING THE PROCEDURE: Versed and fentanyl for anxiety. Heparin, Integrilin, and IC nitroglycerin. 4) COMPLICATIONS: None. 5) COMMENTS: Right femoral artery was used without complications. Perclose was used for hemostasis. ANGIOPLASTY PROCEDURE: Initial arteriography revealed an occluded distal circumflex. It was hard to tell if that was the culprit vessel. In any case, we did put a JL 3.0 guide. A VL guide would not fit; hence, only a JL was used. A Runthrough wire was advanced and initially tried to do a Pronto catheter extraction but Pronto would not advance to the distal circumflex. Then we abandoned that and put a 2.25 x 12 NC Trek and dilated. Subsequently, the same wire was removed from the distal circumflex and into the OM3. That was also angioplastied using the same balloon. Actually, initially we used a 2.5 balloon with low pressure and then realized that the size of the vessel was very small. Then we used a 2.25 x 12 NC Trek. End result was adequate. The vessel was quite small distally and decided not to stent it. Attention was then directed to the right system. I not 100% sure which vessel was responsible for the ST elevation. A 6 French JR4 guide was placed. Runthrough wire was advanced into the PDA and BMW into the PLV. A 2.25 x 12 NC Trek was used to predilate both. Then we used kissing PTCA for both. There does appear to be a dissection or rupture in the PDA side of the lesion so decided to stent it. A 2.25 x 12 Xience stent was advanced to both, but we could not get it beyond the guide. At that time, we removed the whole equipment and changed it to a 7 French system. Once the 7 French system was in place, it was very easy to put both the stents. A 2.25 x 12 was placed into the PLB and another 2.25 x 12 into the PDA. Both were simultaneously inflated up to 14 atmospheres. End result was excellent. Case was terminated. He was sent to the floor in a stable condition. FINDINGS: LEFT VENTRICULOGRAM: Left ventriculography was performed in the RAO projection. Left ventricle is normal in size with distal inferoposterior hypokinesis, ejection fraction 55%. No mitral regurgitation. HEMODYNAMICS: Elevated left ventricular end-diastolic pressure at 22. CORONARIES: Right dominant system. A) Left main: Left main is free of disease. B) LAD: LAD has a 60-70% mid stenosis with extensive luminal irregularities as well as calcification. C) Circumflex: Circumflex is nondominant and is occluded distally which after PTCA is less than 30%. D) Right coronary artery: The right coronary artery is dominant and has a 90% PLV and a 90% PDA which after kissing stents both were 0%. CONCLUSION: 1) Severe two-vessel coronary artery disease involving the distal circumflex and distal right coronary artery with successful percutaneous transluminal coronary angioplasty to the distal circumflex/obtuse marginal 3 and kissing stents to posterior left ventricular and posterior descending artery. 2) Borderline stenosis in the mid left anterior descending. 3) Normal left ventricular size and function with distal inferoposterior hypokinesis, ejection fraction 55%.
I am in the process of getting ready for training with our techs on the new 2014 drainage procedure codes. It appears that the changes will simplify things for the techs that are ordering these procedures. I was confused that code 10140 is not changing. It seems that the new codes 10030, 49405, and 49406 mean almost the same thing as code 10140. Can you please explain the difference and tell me when we will be using code 10140 instead of the new codes in the future?
When the physician selects the right hepatic artery for a tumor embolization we would no longer report code 36247, correct? Because new embolization code 37243 includes the selection codes now?
I am setting up new orders for our hospital. I see the new embolization codes bundle the imaging guidance. For 2013 we use codes 75894 and 37204. I see code 37204 is being deleted, but not 75894. When would you use 75894 if all of the new embolization codes have the guidance bundled?
Is a mammogram done after a breast biopsy (19081-19086) or breast localization (19281-19288) separately reportable? Or is it included in the new codes?
When would I use new code 10030? Would I ever use it for the breast?
With the new drain codes I am confused on why and when would we use code 75989 or 77012 with 10022 versus 10030, 49405-49407?
To use the new drainage codes (e.g., 10030), does the catheter need to be left in? I am trying to understand when code 10160 would be appropriate to use. I have been told that code 10160 is only used when the catheter is removed after the procedure and not left in.
Thank you for sending out your recent communication about the new embolization codes. I understand that these new codes package the S&I 75894 and roadmapping and imaging 75898. Am I correct in my thinking that the diagnostic angiogram 75726 and additional selective 75774 would also NOT be billed by the facility and the physician?
2012 Codes - Patient comes to EP Lab for ICD upgrade to BiV ICD. Box upgrade and LV lead addition. What are the appropriate codes?
I saw the question and answer below. My question is if the NG tube is placed by the radiologist and left in place to feed the patient until they start using the G-tube would you then code the 43752? Question: Hi Dr. Z When we place a G-Tube(49440) we put a NG tube down so we can inflate the stomach. We have been charging 43752, but a person at another hospital said your not to charge that because its part of the procedure. We do pull out the NG when the case is finished. Thank you for your time Answer: 43752 should not be used for a G-tube placement. Code 49440 for G-tube placement includes fluoroscopy, NG tube placement, all guidance and imaging to perform the procedure. Dr.z Revised 02-18-10