"Four-legged Dacron graft was sewn into a patulous opening made in the aorta. The celiac, SMA, and bilateral renal artery origins were each ligated and transected off the aorta, and each attached to one of the limbs of the four-legged Dacron graft." I don't know if it matters, but the next day they are scheduled for EVAR. Would this be reported with code 35631 x 4?
Can you help with the CPT codes for this scenario? (This is professional billing.) Can I use 92928 two times here, one for the LAD and one for the LC? "1) Left main lesion: An 8Fr guide catheter was positioned at the ostium of the LM........A BMW wire was advanced across the LM lesion and positioned in the LAD. A 2.0x12mm balloon was used to pre-dilate the lesion. A 2.5x15mm Emerge balloon was then used to further predilate the lesion. Two 3.5x23 Alpine drug-eluting stents were then deployed as kissing stents from the left main into the LAD and LCx. Very sluggish flow was observed in the LCx after opening the LM. In the summary of the report, it says "Successful deployment of drug eluting stents to the LM and ostial LAD/LCx . . . ."
How would you code the transhepatic approach? The report includes: "Attention was first turned to gaining access into the hepatic venous system. Due to known complicated vascular anatomy, decision was made to perform direct stick hepatic vein venogram. Under ultrasound guidance, the middle hepatic vein was accessed using a Chiba 22 gauge,15 cm needle. Contrast was injected filling the right hepatic vein. A nitinol wire was inserted, and the Chiba needle was exchanged for the inner cannula of a 6 French AccuStick catheter. AccuStick catheter was advanced into the middle hepatic vein. Contrast was injected and a venogram was performed. This showed patent middle hepatic vein filling to the right atrium. Decision was made to perform rendezvous procedure through from right IJV access."
This patient had a brachiocephalic fistula. Excision of an aneurysm/aneurysmorrhaphy was performed on the "middle portion of the fistula". Stenting was performed for an 80% "outflow stenosis", specifically the axillary vein. The Dr. Z Vascular & Endovascular Surgery Coding Reference states that, if surgical revision is performed on a graft, we should not code angioplasty/stenting within the graft (anastomosis to anastomosis). How do we code when it's a fistula? In the case above, is it okay to code the stent as well as the revision, since the stenting was performed in the axillary vein and the revision was on the brachiocephalic fistula? Are we looking to see if different veins are worked on or for words like "outflow"? Or do you believe we should not code for both a revision and angioplasty/stenting for fistulae when done in the same zone?
Can you please tell me if there is a code for aortic paravalvular leak closure with Amplatzer vascular plugs? It's a bioprosthetic valve. I see the code for transcatheter mitral valve repair, but nothing for aortic. I'm assuming I need an unlisted code here?
"The left hepatic artery was catheterized, and diagnostic angiography was performed. One-third of the 5 mCi 99m-Tc-MAA dose was injected into the left hepatic artery. The SMA was then selected, and, using the Progreat microcatheter, the replaced right hepatic artery was selected and diagnostic angiography performed. The other two-thirds of the 5 mCi 99m-Tc-MAA dose was then injected." I reported codes 36247, 36248, and 36245-59, but the reviewer is insisting that code 37242 should also be reported. What do you think?
What code should I use for axillary conduit during endovascular procedure? Unlisted 37799 or 35266?
I was told by my trainer that if the physician states that "tachycardia cycle lengths" were measured, we could code 93609 mapping, since mapping measures cycle lengths. Can you clarify if this is accurate? I cannot find any documentation of this in my references.
Patient was here a week ago and had a LHC/RHC with angiography, and was found to have disease in his circ and is now back for stenting (no new symptoms). Physician did a LHC "to manage fluid status" before he placed the Xience stent. Would this be coded only with C9600-LC? Or would you also submit code 93452? There is a disagreement among our team. Also, does LHC follow the same rules as angiography for repeat serivces?
Please review and provide coding recommendations. "LC femoral artery cannulated using landmark technique. Bentson wire inserted into the aorta. Aortogram performed showing patent distal aorta, patent common iliac arteries bilaterally, patent external iliac arteries bilaterally, patent common femoral arteries bilaterally, no evidence of stenosis profunda femoris arteries. Right common iliac artery orifice selected. Angiogram performed of right lower extremity selectively showing an area of stenosis in distal SFA, chronic total occl of the popliteal artery w/ calcified plaque at that location & chronic total occl of the tibial/peroneal trunk with 90% stenosis of peroneal arteries. Peroneal artery was the dominant artery runoff to the foot with reconstitution distally of the posterior tibial artery. 6 French sheath, 55 cm placed in right common femoral arteries. These areas were traversed with a 0.018 wire under fluoroscopic guidance. These areas were balloon angioplastied from proximal to distal using drug-eluting balloon and Sterling non-drug-eluting balloons."
"Right arm prepped and draped in the usual sterile fashion. An elliptical incision was made at the base of this large venous aneurysm. Using electrocautery, the soft tissue around it was dissected free, and several small arterials were Bovied for closure. The base of the stalk was mostly fatty tissue with lymph and venous filling. These were controlled with electrocautery and Bovie as well. The aneurysm was excised and then sent to pathology. The wound deficit was extremely superficial and was closed with 2-0 Vicryl pops and 4-0 Moncryl for the skin and Dermabond." I am starting to get excisions of venous aneurysms from two of my doctors pretty often. When it's describe as being in an AVF/AVG, I usually lean toward the revision codes. But, what about this note where there is no mention of an AVF/AVG?
The surgeon did an embolization for a menigioma. He selectively catheterized the right CC, right ICA, right ECA, left CC, left ICA, left ECA, left MMA, left IMAX, and left accessory meningeal artery. He embolized the left MMA. Would you code the left MMA, left IMAX, and left accessory meningeal artery with 36228? Or are the IMAX and accessory meningeal artery bundled?
According to your cardiology reference book, you can report code 93623 for inducing or suppressing an arrhythmia using drugs isoproterenol, epinephrine, procainamide, dobutamine, and adenosine. A report that I reviewed this morning used aminophylline to induce the arrhythmia. Is that or other stimulants like caffeine acceptable when coding 93623?
If you pace the left side from the coronary sinus (CS) and not directly from the left atrium, can you still report code 93621? "A 7 French sheath and a 6 French sheath were placed the left femoral vein using the modified Seldinger technique. An 8 French sheath and two 6 French sheaths were placed in the right femoral vein using the modified Seldinger technique. Multipolar catheters were advanced to the high right atrium, His bundle recording position, the RV apex. A live-wire deflectable catheter was advanced into the CS. CS electrograms were recorded, and the catheter was subsequently used for left atrial recordings and evaluation. Programmed and incremental stimulation was performed in the atrium and ventricle at two times the diastolic threshold in the baseline state. Various diagnostic maneuvers were performed. AVNRT was diagnosed. An 8 French large curve 5 mm tip ablation catheter was advanced via the right femoral vein and positioned in the triangle of Koch posterior to the His at the level of the CS os."
We treat in patients with severe PDA. Lately a few cases the physician has had failed attempts for access. These patients have had a previous angiogram and were scheduled to come back to have an intervention performed on the lower leg. Unfortunately the physician was unable to gain access. The patients were given sedation. The only purpose for being in the procedure room was to have the intervention performed. The question is, do you code (charge) this as an attempted intervention (37224-74)? The current practice at this facility is to charge only for the supplies. I believe I have read that if the patient was brought into the lab for the intent to do the angioplasty and was given sedation the -74 modifier could be used. Can you clarify when to use modifier -74 (especially for this particular scenario)? Is there specific documentation to explain when it is appropriate to use in cath and IR procedures?
"PROCEDURE: The left axillary lymphatic malformation was examined with ultrasound and a suitable access site for needle placement was identified and the skin marked. The left axilla was prepared and draped in the usual sterile fashion. Using ultrasound guidance the first site (site #1) in the deep aspect of the axillary region was accessed with a trocar 6.3 French Dawson-Mueller pigtail drain. Next, using ultrasound guidance, the second, more superficial site (segment #2) was accessed with a trocar 6.3 French Dawson-Mueller pigtail drain. Finally, a superficial collection (site #3) was accessed with a 21-gauge micropuncture needle through which direct injection of 2 mL of doxycycline was performed. The predominant injection solution composed of a 4:1 dilution of doxycycline (10 mg/mL):Omnipaque 300 was injected under ultrasound and fluoroscopic guidance, according to the following outline: A total of 160 mg doxycycline in 16 mL saline was injected."
Recently our hospital has been having denials from commercial payers, Medicaid, and Medicare HMOs on ICD implants placed for cardiomyopathy where a -Q0 modifier was added. Our billing department has requested that we only add -Q0, when indicated, to straight up Medicare payments only. Could you please tell me if -Q0 modifiers should be added to commercial payers, Medicaid, and Medicare HMO payers as well when placed for cardiomyopathy? And, would a -Q0 modifier be necessary when Medicare is secondary insurance?
Radiologist injected sinus tract with contrast and then scanned the patient's abdomen in CT (74150). Would it be correct to charge the injection code (20501) along with the CT scan? Or would both codes 76080 and 20501 be appropriate? "Non-contrast abdominal CT scan performed prior to and following the injection of the patient's fistulous tract with contrast." The draining wound was cannulated with small Foley catheter to define the tract of the coloncutaneous fistula. Documentation includes location, size, length with detail.
"Incision was made between the basilic vein and the brachial artery. Dissection was carried down. Basilic vein was identified and mobilized proximally and distally. I then mobilized the brachial artery and anastomosed the basilic vein to the brachial artery in an end-to-side fashion." It says end-to-side, which is similar to 36819, but there are not two incisions, so it points me to code 36821, which is side-to-side. Which is correct? Does the side-to-side or end-to-side have to do with the code choice? What code would you use, and can you explain why you chose the code?
Are these billable using code 34812, or should I be using G0269? "1) An oblique femoral cutdown incision was made. A 6 French sheath was then placed and flushed, and this was replaced with a 10 French Prostar device, which was deployed and the sutures laid out in a radial orientation for later direct femoral arterial repair at the conclusion of the case. Attention was then turned to the right groin. Using ultrasound guidance, the right CFA was accessed, and a wire was advanced up into the aorta under fluoroscopic guidance. An oblique femoral cutdown incision was made, and a 6 French sheath was then placed and flushed. This was replaced with a 10 French Prostar device, which was deployed and the sutures laid out in a radial orientation for later direct femoral arterial repair at the conclusion of the case. 2) The right common femoral artery was cannulated using a 18 gauge needle. An oblique incision was made in the right groin and dissected bluntly down to the anterior wall of the CFA with a hemostat. Two Proglide sutures were then placed in the right CFA for direct repair."
What code should we use for trying to snare a catheter? "This is a 48 year old male with history of metastatic pancreatic cancer. A Portacath was placed in the right chest approximately three months ago. His Portacath is not working very well during chemotherapy infusions. Portacath study today showed retraction of catheter tip from SVC into right brachiocephalic vein and a full circle turn in the catheter. Contrast sudy of Portacath showed a fibrin sheath around the distal part of catheter, but otherwise no leakage or break in catheter was seen. Using right femoral approach the femoral vein was accessed and a snare was advanced into right brachiocephalic vein. However despite multiple attempts the tip of catheter could not be engaged with the snare. Portacath was left accessed for use the next day."
The MD is performing ERFA of the left lesser/greater saphenous vein. There were secondary varicosities involving the left calf and thigh that were treated with ultrasound-guided scleral therapy. Can we report these separately with codes 36475 and 36471?
"A patient has PVD with no pulse in the left leg and goes for a diagnostic angiogram with IVUS of the SFA, popliteal, and proximal tibial vessels. Physician finds extensive thrombus and performs a thrombectomy in the SFA and popliteal arteries, followed by placement of a stent in the popliteal artery, atherectomy and stent in the anterior tibial artery, and atherectomy and angioplasty in the posterior tibial artery." Can you clarify whether we'd use code 37184 or 37185? The reason for the visit was not of a known thrombus; however, once the angiogram/IVUS was performed the treatment was for the thrombectomy, with the other treatments for the additional stenosis in the anterior and posterior tibial arteries. Do you recommend reporting codes 37184, 37185, 37252, 37226, 37231, and 37233? Or do you recommend coding thrombectomy with 37186, 37252, 37226, 37231, and 37233?
A patient has stenosis of the proximal LD and is stented via the native LD, and a distal LD stenosis is stented via a saphenous vein bypass graft. Should you report both codes 92928-LD and 92937-LD?
For add-on codes 32668/32507, AMA's intent for these codes appears to be that they are reported when the intended procedure was therapeutic resection of the lung nodule/mass, but based on intra-op pathology a more extensive resection is needed and then performed, which causes the wedge resection to be "reclassified" as a diagnostic wedge resection (as per CPT Assistant, September 2012). That said, when I read the NCCI Policy Manual, Chapter 5, Section C.19, Medicare appears to be precluding payment for any diagnostic biopsy of the lung from a location that is removed in a more extensive procedure such as a lobectomy during the same encounter. However, CMS has assigned a fee to codes 32668 and 32507 on the MPFS, which seems odd if Medicare policy precludes payment for diagnostic wedge in the same area per NCCI and the only time you can report 32668/32507 is when they precede an anatomic resection in the same lobe/area. Do you know if the guideline in the NCCI Policy Manual is referencing codes 32668 and 32507, or are those exceptions to the rule based on the AMA definition?
Would it be appropriate to bill code 21825 when performing an open heart procedure? Due to bilateral sternal fractures and a significant amount of osteoporosis, each sternal table was repaired with vertical Robicsek weaves using # 7 wires. If reported, what do you look for to determine the reporting of this? If no, please explain why. All the information I have found points to not being able to report the 21825 with the open procedures due to if you created it you must fix it. Any guidance would be appreciated. We have a physician who routinely wants to report this code with bypass procedures.
For the following procedure, should I report codes 62305, 62284, and 72270? Or should I only submit code 62305? "Using fluoroscopic guidance, a 20 gauge needle was directed with a single puncture into the thecal sac until CSF was yielded. Subsequently, 10 cc of Omnipaque 300 contrast agent was instilled intrathecally. Afterwards, the tubing was removed and the stylet replaced. The needle was removed and pressure applied. No complications were evident. Maneuvers to facilitate distribution of intrathecal contrast were performed. The patient did not complain of any lower extremity symptoms. The patient was sent to CT for further scanning. Single fluoroscopic image demonstrated a needle directed towards the thecal sac from an interlaminar paraspinal approach at L4/L5 on the left."
"Patient was diagnosed with breast cancer, so she was referred to have her pacemaker moved to the upper abdominal area. No new generator was implanted, but the generator was explanted from the original location and relocated to a new pocket that was created in the upper abdominal area. A tunneling tool was used, and extenders were connected to the leads and brought to the new pocket, where the generator was connected and the upper abdominal pocket was closed." It seems to me that code 33222 is insufficient to cover this entire procedure. I believe it would it also be appropriate to code 33215 x 2 in this case. Do you agree?
I would appreciate some coding assistance. "Indication: Patient is a 61-year-old male with a successful kidney transplant who wants his AV fistula removed because of persistent pain. The area of the fistula was infiltrated with local anesthetic, and the skin was incised sharply. The dissection was carried down using electrocautery and sharp dissection until the level of the graft. The graft was dissected freely from the surrounding tissues from the level of the arterial anastomosis in the antecubital fossa to the level of the connection between the vein and the axillary vein at the level of the shoulder. The graft was then transected, and the proximal portion was tied with a silk suture. The distal portion was oversewn with a 5-0 prolene. It was removed and handed off the operation field. After hemostasis was achieved, the wounds were irrigated and then closed." How would you code this? I'm thinking it's got to be unlisted. The physician verified this was a large AV fistula that was excised, not a graft.
Could you please define what a surgical field is considered in the case where you have multiple aneurysms that are coiled in the intracranial arteries?
"Patient had bilateral stent grafts placed for a hemorrhage, after embolizations and stent were previously placed. Via right groin access, a 5 French marking pigtail catheter was advanced through the existing right common femoral artery stent graft into the abdominal aorta, and an aortogram was performed. The marking pigtail catheter was removed. A 13 mm x 10 cm Viabahn stent graft was advanced via the right groin access, and an 11 mm x 10 cm Viabahn stent graft was advanced via the left groin access. Both were positioned with the superior margins at the level of the mid L3 vertebral body and the distal extent above the iliac bifurcations. These stent grafts were subsequently simultaneously deployed and simultaneously molded with 9 mm x 80 mm Armada balloons. Successful deployment of kissing aorto-bi-iliac Viabahn stents (13 mm x 10 cm on the right, 11 mm x 10 cm on the left). No evidence of active extravasation before stent graft deployment." I was thinking code 37244 would be best to use since it was for the treatment of bleeding. Or should we use 37221, 37221-59 instead?
I'm having trouble finding the appropriate code for a bypass from anterior tibial to dorsalis pedis artery using a reverse greater saphenous vein? Would it be safe to use code 35570?
Physician performs a coronary artery evaluation (93454) and also does a cine evaluation of the valve. Is the cine of the valve separately reportable? 2016 NCCI narrative, chapter 11, section I, #17 states, “Fluoroscopy is not separately reportable with diagnostic coronary angiography or cardiac catheterization.” Would this directive also include cine?
A physician rotated an ICD device (only). Would you bill an unspecified code for this? Here is the report: "The patient was brought into the EP lab and was hooked up to an EKG monitor, pulse oximetry, and blood pressure monitor. He was sedated by anesthesia. His left shoulder was prepped and draped in the usual sterile fashion. Lidocaine was used to infiltrate the skin. Incision was made over the device using Bovie and blunt dissection, and the device pocket was entered. Device was removed and rotated more medially. The device was sutured in a very medial location away from the shoulder. The pocket was washed with triple antibiotic solution and closed."
What is the correct CPT code assignment for Cormatrix CanGaroo insertion? Documentation from Cormatrix seems to recommend coding 11043/11046 and 11042/11045 (depending on size); however, we get a medical necessity edit with these codes. Here is an excerpt from the operative report: "A new dual chamber pacemaker (Table 2) was connected to the leads and placed in the pocket. The device was sewn down with a silk tie to prevent migration of the generator. Cormatrix was placed in the pocket. The pocket was closed with multiple layers of Vicryl sutures. The final layer was closed with staples. Sterile dressing was placed with pressure dressing on top of the sterile dressing. Patient left the clinical electrophysiology laboratory in stable condition with the device functioning normally. Patient tolerated the procedure without any complications."
Can we bill code 93352 if the doctor states "intravenous contrast used" and doesn't state Definity, etc.? The doctors are stating that intravenous contrast was used, but not what was used. I just need some clarification.
My surgeon performed an open repair of a thoracoabdominal and left common iliac artery aneurysm with a bifurcated graft. Also, they performed a bypass to the left renal artery and common hepatic artery using another bifurcated graft. I think the bypass to the renal and hepatic are included in code 33877. My question is, since the bifurated thoracoabdominal graft treated the iliac aneurysm too, is the treatment of the iliac aneurysm also included in code 33877? Or should I bill a separate code for the iliac aneurysm?
I just would like some clarification on code 35650. Is this code for when a bypass is done from the right side to the left side? I have a case where he states, "Bilateral axillary arteries were exposed, a tunnel was created in a somewhat curvilinear fashion over the Manubrium, and a 6 mm ringed GORE-TEX was tunneled." It also states that the right-sided anastomosis was completed first, followed by the left side anastomosis. My concern is that the description of code 35650 does not state if left to right, etc. It states, "He then passes the graft around the blockage and sutures it to the other side." It's clear as mud to me. I just want to verify that this is NOT just for unilateral procedure.
Is there an additional code (or codes) that should be assigned if an AV fistulogram is performed by the radiologist (36147) and he decides to investigate the patient's hypotension and advances the catheter into the right atrium and transduces right atrial pressures? It was 0 mmHg. He then pulls the catheter back, and his venous pressures were between 0-1 mmHg.
Is there a CPT code for the exchange of a tunneled peritoneal catheter?
The doctor performed a left bronchial artery embolization (arterial access) and left pulmonary artery embolization (venous access). Although these are separate vascular systems and we can code the catheter placements and imaging as such, the question that has come up is whether we can code both of the embolizations or if this is considered one operative site and we should code for only one embolization?
Is it appropriate to use add-on code 50705 for non-permanent ureteral occlusion? "OP: Successful uncomplicated placement of a left modified 10.3 French nephroureteral stent with distal end, intentionally trimmed and occluded as described in detail above. The ureteral segment of this modified nephroureteral stent results in functional left ureteral occlusion by antegrade nephrostogram. The tube is in satisfactory position and placed to gravity drainage... Indication: Severe urethral erosion to the bladder neck with Resulting continuous urinary incontinence preventing the healing of chronic decubitus ulcers." I coded 50434 for conversion of a nephrostomy to a nephroureteral stent via the existing nephrostomy tube tract performed. Modification: utilizing methodology as published by Bush and Mayo in the Journal of Urology Volume 43, Number 5 (May 1994), a 10.3 French Boston Scientific nephroureteral stent was intentionally modified by..
"Right CFA was cannulated, and a 5 French sheath was advanced. Through this, a catheter was advanced to the distal abdominal aorta and angiography was performed, which showed a widely patent distal aorta and common external and internal iliac arteries, femoral arteries, and proximal SFA and profunda femoris arteries. Next an angled taper catheter was advanced to the left SFA after exchange over a wire, and left lower extremity runoff angiography was performed. This showed a relatively focal 95% stenosis of the distal SFA just above the adductor canal with patent popliteal artery and three-vessel runoff to the foot. After a series of catheter exchanges over a wire, a 6 French sheath was advanced to the left SFA and the patient was heparinized. The lesion was crossed with a wire, and the lesion was dilated with 5 and 6 mm balloons yielding dissection requiring stenting. Next a 7 x 80 mm self-expanding stent was deployed and post-dilated with a balloon with 0% residual stenosis and excellent result." Would you use codes 75630/75774 for imaging, or something else?
"LT brachiocephalic vein catheterization and venography via RT CFV access. Next, the LUE fistula was cannulated and a catheter was then advanced to the left axillary vein and venography performed from LUE access. Venograms demonstrated total occlusion of the left subclavian vein with large and tortuous draining collateral vein. A catheter and hydrophilic wire were then used thru the RT groin sheath in an attempt to negotiate thru the occluded left subclavian vein. A gooseneck snare was advanced thru the LUE catheter in attemtp to capture the wire from above, however this was unsuccessful despite multiple attempts. It was decided to perform radiofrequency wire recanalization. Appropriate grounding pads were placed on the patient's thighs and the radiofrequency wire was advanced thru a catheter from below and recanalization performed in the subclavian/axillary vein junction. The wire was snared with a gooseneck and removed thru the LUE. Balloon catheter was used to perform venoplasty of LT subclavian vein." Are codes 35476, 36147, 36012, 75820, and 75978 correct? Are there additional codes for radiofrequency wire recanalization?
"Patient with history of PVD and aortobifemoral bypass 35 years ago. He presents with a right leg pseudoaneurysm. After brachial cutdown, right limb of graft was accessed and injected, revealing a leak in the graft about 1 1/4 inches from the anastomosis to the common femoral artery. A 38 mm stent was deployed extending slightly into the common femoral. A second 38 mm stent was deployed to overlap the first and to cover the leak into the pseudoaneurysm." I reported codes 37236, 36246, and 75710-XU because the current indication is a leaky graft. However, the auditor says codes 37226 and 75710-XU are correct. Is she correct in using the revascularization code since the original indication for the graft 35 years prior was PVD?
If the physician did PVI for A-flutter, do we still charge PVI a-fib or SVT?
"Patient came to IR to have peritoneal dialysis catheter evaluated and manipulated, if needed. The radiologist injected the catheter and found the catheter in a small loculated cavity with no free spill and some adhesions. He used a wire to attempt to break up the adhesions and change the position of the catheter." Would it be appropriate to code this as 49400 and 74190 for the injection and 49999 and 76496 for the manipulation? A fibrinolytic was not used, so I am questioning if codes 49999 and 76496 should be reported for this procedure.
My physician has heard that, when doing spinal angiography, if he were to image the thyrocervical trunk and the costocervical trunk he could use code 75705 for the supervision and interpretation of these vessels. Would this be appropriate during spinal angiography?
Will you please advise on coding a Dobutamine stress test done during a cardiac cath procedure? MD states it was done to assess for transvalvular gradient and severity of aortic stenosis. Procedure is described as being done with a pigtail advanced across AV into the LV. Initially measured the baseling gradient and then up to 40 mcg of dobutamine was infused. The finding are as follows: "Good contractile reserve in response to dobutamine infusion with improvement in LVEF from 25% to 45% with increasing transaortic gradient from 25 to 49 mmHg at peak dobutamine infusion, suggestive of severe aortic valve stenosis."
Patient has SVT with an implanted loop recorder due to unsuccessful ablation and breakthrough SVT on medical treatment with atenolol. He presented for removal of loop recorder due to end of life of the battery with insertion of new loop recorder. Can we bill code 33282 with modifiers -52 and -59 appended, along with code 33284?
"The patient is brought to the operating suite for recanalization of an occluded left fem-pop bypass graft. A Destination sheath was placed at the left brachial artery and advanced to the distal aorta. The sheath was then directed into the left common iliac artery. Attempts to cross a severe stenosis at the common femoral artery in antegrade fashion were unsuccessful. Under US guidance, access was obtained via the dorsalis pedis artery, and a V18 wire was advanced in retrograde fashion all the way into the common femoral artery crossing the occluded fem-pop graft. The wire was snared and externalized at the left brachial artery, allowing advancement of a NaviCross catheter into the popliteal artery in antegrade fashion. A Pilot 200 wire was advanced into the peroneal artery. Multiple severe lesions at the common iliac, the entire fem-pop graft, and the common femoral artery were treated with balloon inflations." Can the access obtained via the dorsalis pedis be reported separately with code 36140-59? Or does this access also bundle with the intervention?
I am a little confused about when we can report code 93623. I know if they are just checking the efficacy of the ablation it cannot be coded, but I read somewhere that if they are looking for other arrhythmias then the code can be added. If the physician does an ablation and then administers isoprotenolol and notes that "no other inducible arrhythmias were found", would this be good enough documentation to support the separate reporting of code 93623 since they looked for additional arrhythmias?
Would you recommend using code 32553 for a 20 gauge hooked localization wire placed into a left lower lobe mass for planned surgical resection?
When billing for a TAVR case (i.e., CPT 33361 – TAVR with prosthetic valve; percu femoral artery approach), we have a cardiothoracic surgeon and two interventional cardiologists on the case. Would it be appropriate to report code 33361 with modifier -82 (assistant surgeon) appended if there is no qualified resident available, and there is a statement from the provider for medical necessity for the assistant surgeon for the second interventional cardiologist, in addition to 33361-62 for cardiothoracic surgeon and 33361-62 for the first interventional cardiologist?
Please help with the following scenerio: Patient had a diagnostic cath performed, and a thrombus formed as a consequence/complication of the cath in the RCA. Patient then had angioplasty for the acute total occlusion. Since an AngioJet wasn't performed, code 92973 wouldn't be appropriate, would it? Would we just code this to a plasty ? Or would we code it at all?
"The device was freed from the surrounding tissue and brought to the surface. A pocket was modified inferomedially using blunt dissection and electrocautery to accommodate for bigger device. The axillary vein was accessed two (2) times via the modified Byrd technique with the guidewires placed into the right heart. A 9.5 French sheath was placed in the axillary vein. However, the vein was dilated with serial dilators prior to this due to stenosis at the subclavian and brachiocephalic vein junction. The RV lead was advanced into the RA through the 9.5 French sheath with difficulty, as the sheath was kinked. I was not able to advance the RV lead into the RV due to difficulty in torquing the lead, likely due to stenosis in the SVC. At this point we had used almost 55 minutes of fluoroscopy. Hence the procedure was aborted on the right side. The old device and lead were placed into the pocket, and the wound was closed in layers. CONCLUSION: 1) Unsuccessful right-sided CRT-ICD upgrade. Plan for left-sided biventricular ICD upgrade." Codes 33212 and 33233 do not work. Do you have any suggestions?
When performing a full combined congenital right heart catheterization and transseptal left heart catheterization through intact septum (93532), my doctors feel that if the septum is then balloon dilated to allow for the sheath to pass through to get to the left atrium, we should also be able to bill for an atrial septostomy (92992). For example: “Transseptal needle puncture: The atrial septum was punctured with an adult transseptal needle through a 7 French long sheath. Injection of contrast confirmed placement in the left atrium, after which a 5 x 2 Maverick was inflated across the atrial septum, allowing advancement of the long sheath.” The doctor is billing codes 93532 and 92292. I believe the septum balloon dilation would be included in the transseptal puncture in this case, and that we should bill code 93532 only. I would greatly appreciate your input on this.
I am unsure whether the cath for the right side for the angiogram would be billable. There was intervention on both the right and left sides, but it was through the left access. "The decision to intervene was based on today's study, and there were no prior cath based studies to compare. Percutaneous 5 French RIGHT common femoral artery access. Cannulation of abdominal aorta. Pelvic arteriogram. Percutaneous 6 French LEFT common femoral artery access. 6 mm balloon angioplasty of the LEFT external iliac artery. Cannulation of RIGHT common iliac artery. Recanalization of chronically occluded RIGHT internal iliac artery. Primary balloon angioplasty to 4 mm of the origin of the RIGHT internal iliac artery."
If a patient has a soft tissue mass at a previous mastectomy site, and this soft tissue mass is biopsied, should I report code 20206, 76942, or 19083 for ultrasound-guided biopsy?
"A 10 mm x 2 cm Armada balloon was advanced into the biliary system for balloon sweep of both the segments 1 and 3 biliary ducts into the common bile duct." Can we use code 47542 for balloon sweep of biliary duct? Or not code it? This was done at the time of an internal/external biliary drain exchange (not really a dilation, but not 47544 either).
Selective coronary angiogram and IVUS of bilateral common iliac, external iliac, and common femoral arteries. One access in the right femoral artery. Physician performed coronary angiogram and then catheter from right common femoral artery into descending aorta. IVUS catheter from descending aorta into the common iliac, external iliac, and common femoral. Then crossed over into left common iliac, all the way to the SFA, and pullback from common femoral into the external and common iliacs. Physician gives IVUS interpretation of all vessels. Can we add codes 37252 and 37253 in addition to code 93454? Can we add cath placements as well?
"Patient with femoral pseudoaneurysm status post cardiac cath almost 2 months prior. Patient was taken to the cath lab, and manual pressure was applied to right groin area for 20 min." How would this be billed? There is no mention of US guidance. Is this even billable?
The patient underwent an implant of a dual chamber pacemaker (33208). The report next states that the patient was in atrial flutter at the time of the lead placement. The ventricular thresholds were measured and were adequate. The atrial sensing thresholds were tested, and the patient was rapidly atrial paced and was converted to sinus rhythm. Are we able to code anything for the rapid atrial pacing? If so, what is the appropriate code?
While placing a dual chamber pacemaker, the patient was found to have significant subclavian vein stenosis via venography. “There was a stenosis of the left subclavian with collateral veins. An incision was made in left deltopectoral groove. Left cephalic vein access with a cutdown technique. The micropuncture wire was unable to be advanced from the cephalic to the subclavian, and would enter different collateral channels. Contrast injection showed wire to be intraluminal. Terumo glidewire was maneuvered across the subclavian stenosis, and using serial dilation with 7, 8, 9, and 10 French dialators, the stenosis was traversed and dilated. Sequentially two 7 French safesheaths were advanced to allow delivery of the leads.” I realize that in this case the venography would likely be considered roadmapping and would not be separately billable. However, could we bill anything for the sequential dilation of the subclavian vein? The physician states that this is a preferable technique (vs. balloon venoplasty). Please advise on appropriate billing in this case.
My question is regarding removal of an intracoronary thrombectomy at time of a stent placement. Biller says it's bundled, I believe there has to be a separate code when it’s a STEMI acute MI. Study performed reads: "Left heart catheterization, left ventriculography, selective coronary angiography, complex percutaneous coronary intervention to right coronary artery involving balloon angioplasty, suction thrombectomy, and intracoronary stent placement." Keyed codes: 93458-XU and C9606-RC.
The attending physician performed the following three interventions: PCI of the m D2 using Synergy stent (C9601/92929) PCI of the p-m LAD using Synergy stent (C9600/92928) PCI of the S1 (LAD septal perforator) with balloon dilation Is the LAD septal perforator S1 considered a branch of the LAD? And, as such, can it be coded as an additional intervention?
When an echo reveals only trace or trivial valve regurgitation, do you apply an ICD-10 code for the regurgitation? Or would this be considered a normal echo? My physician indicates the regurgitation in the body of the echo report, but his impression states unremarkable echo.
I am unsure how to code this case of PTA of a bypass graft. What do you think of reporting codes 75710-XU, 36215-LT, 36222-LT, 75962, and 35475-LT? Or should I ignore the carotid since it was the bypass that was selected? "DESCRIPTION OF PROCEDURE: The patient was taken to the angiography suite. We accessed the left brachial artery. We did access the common carotid to the subclavian bypass. We did upper extremity arteriogram, a left carotid arteriogram, and then we did an angioplasty of the proximal anastomosis. FINDINGS: LEFT CAROTID ARTERIOGRAM: The previously placed left carotid stent at the origin is patent. The distal carotid stent is patent. There was a high-grade stenosis of the proximal anastomosis of the carotid subclavian bypass. LEFT UPPER EXTREMITY ARTERIOGRAM: The subclavian and brachial arteries were patent. ANGIOPLASTY OF PROXIMAL ANASTOMOSIS: An angioplasty was performed of the left carotid to subclavian bypass graft at the proximal anastomosis with a 6 x 4 balloon. Completion arteriogram revealed it was widely patent."
I was under the impression that, in order to bill 75625, the physician must document the findings from the renal arteries or visceral arteries on down to the aorto-iliac bifurcation. Now I am not seeing where I got that information. Can you please clarify what all must be visualized and documented in order to bill code 75625? Do the bilateral common femoral arteries need to be mentioned in order to bill code 75630?
Could you please clarify some confusing verbiage from your Diagnostic & Interventional Cardiovascular Coding Reference? Patient is having right and left heart cath (93460) and aortic root angiography for aortic stenosis (93567). Patient also has PVD with diffuse iliofemoral disease, renal artery stenosis, and disease of the distal aorta, so they did an abdominal aortogram and bilateral iliofemoral study from one catheter position in the aorta. Your guidelines state to use code 75630 if there is no catheter repositioning and if it is medical necessity for AAA. Your notes also state not to use 75630, but rather to use codes 75625 and G0278, if done during cath for "screening". Well this isn't a screening, and if it were just a screening with no medical necessity, we wouldn't code it anyway, correct?? So are we using code 75630 since there is medical necessity, even though it's not an AAA, or do we use codes 75625 and G0278?
How would I code for placement of bilateral internal iliac angioplasty non-inflated balloon catheters in preparation for C-section (possible focal placenta accreta), with possible inflation later by OB physician? Contrast and fluoroscopy were utilized.
I read somewhere that when a patient has CAD in a heart transplant that it is coded as I25.811. Others have told me that the ICD-10 code should be T86.20, which is a complication code. Can you tell me the difference between the two and what ICD 10 codes are valid for each of these?
Is this coded correctly? Can code 36246-XU be reported in this scenario? 75710 59, 37252, 37253 x 3, 37226, 37221, 37222. "1 U/S guide cannulation RT C Femoral A 2 Aortoiliac angiogram 3 LT LE angiogram 4 IVUS pre/post LT C ext. Iliac, c femoral, sfa, popliteal, tpt trunk arteries 5 angioplasty lt sfa 6 stent lt sfa and popliteal 7 stent lt c iliac 8 angioplasty lt external iliac PROC: RT C Femoral A cannulated, sheath placed, cath positioned in infrarenal aorta and aortoiliac angiogram done...stenosis in C Iliac A and bifurcation. Up and over technique, cath positioned in LT C femoral A. LT LE angiogram done. Occluded SFA and Popliteal w. fx stent in P SFA. 1 vessel runoff. Heparinized. Quick cross and wire traversed occluded stents and reenter TPT trunk. angiography. Emboshield. Balloon angioplasty SFA and popliteal. both IVUS. stenosis along SFA. Both Stented and angioplasty. IVUS C. Femoral A, stenosis. Stent and angioplasty to C. Iliac A. Balloon angioplasty entire external Iliac A. IVUS E Iliac A."
If during an ablation an arrhythmia is terminated, but later the same arrhythmia recurred in the same location and requires mapping and ablation, can code 93655 be billed? Or is this arrhythmia inclusive to the primary ablation?
Is this enough documentation to support coding 37243, 36247, 75726-26-XU, 75774-26-XU, and 96420 (facility only)? "Via left common femoral artery access, a selective celiac arteriogram to the portal venous phase demonstrated the hepatic artery origin from the celiac axis and absence of a replaced right hepatic artery and patent portal vein. Selective right hepatic arteriogram shows tumor blushes in the inferior right hepatic lobe and the hepatic dome, both originating from branches of the right hepatic artery. Chemoembolization utilizing mitomycin, pva, ethiodol, saline, and contrast was administered through the catheter into the right hepatic artery."
How do you code redo fem exposure of prior bypass (35656, +35700, or 35883)? "Skin incision of left limb of a previous aortobifemoral bypass graft was isolated. An incision was then made in left medial calf, exposing the b/k popliteal artery. A subsartorial tunnel created between the incisions, through which a Propaten PTFE graft was passed. Vas clamps applied to the left limb of the aortofemoral graft. A portion of the graft was excised. The fem-pop bypass graft cut on a bevel, and an end-to-side anastomosis was created using 5-0 Prolene. Upon venting the artery, the vascular graft was occluded, and flow was restored into the patient's native circulation. Attention was directed distally. Vas clamps were applied. An arteriotomy was made. The popliteal artery was partially calcified, extensively atherosclerotic, and smallish in caliber. The graft was cut on a bevel. An end-to-side anastomosis created. Prior to completion of the anastomosis, the graft was flushed and the artery was back bled."
Recently we started getting reports from our hospital-based cardiology group for "Vascular Femoral Artery Compression Screening". The hospital is billing code 93971 for this procedure, but I'm not sure if that is the correct code. We are billing for the cardiology reading only. Here is an example of the report: "The femoral vein was three times larger than the femoral artery, and it did not expand with cough. The meaning of these findings showed that the patient had borderline fluid overload with possibility of pulmonary hypertension." Is 93971-26 the correct code for this?
Which modifier is more appropriate (-78 or -79) during a 90-day global period for dialysis procedures? Example: During initial visit patient's graft is thrombosed, and there is also a venous stenosis (36870, 35476, 75978). Patient returns several weeks later, and there is a recurrent stenosis (35476, 75978). Would you use modifier -78 or -79 on code 35476?
"Abdominal aortogram with left lower extremity runoff. Cannulation of left radial artery using # 6 French slender sheath. Placement of a pigtail catheter in the abdominal aorta and performance of the left lower extremity runoff. Percutaneous transluminal angioplasty and intravascular stent placement in the left common iliac and external iliac artery. Selective left lower extremity angiography. Placement of a terumo band for closure of the left radial artery." What do you suggest we code?
I have a question in regards to the Sano shunt takedown. One of our providers, who is very much dedicated to coding and reimbursement, has instructed us to bill code 33924 for the Sano shunt takedown. I am confused because the description of CPT code 33924 is the takedown of a systemic-to-pulmonary artery shunt, and the Sano is a RV-to-PA shunt. Is this correct? If not, what code would you recommend for the Sano shunt takedown?
"Patient came in for a dual pacemaker to biventricular upgrade. After accessing the subclavian vein, a distal CTO was encountered and angioplasty was performed. The same thing happened in the superior vena cava. They were then able to successfully upgrade this patient's dual pacemaker to a biventricular pacemaker, using the patient's prior leads and inserting an LV lead and new generator." For the pacemaker portion we are charging codes 33229 and 33225. Can you charge anything for the angioplasty of the subclavian vein and superior vena cava CTO lesions?
Should the following congenital heart cath be coded 93533 and 93567? Or 93531 and 36221? Would we need more documentation of the specific vessels visualized to submit code 36221? "Patient has a history of a large VSD, a PDA, LAD coronary artery to RV fistula. A catheter was advanced to the right heart, and a pressure and saturation sweep was performed. The Wedge catheter was also advanced across the atrial septum to the left lower pulmonary vein where pressures and saturations were recorded. A careful pullback from the LV to the descending aorta was performed using a Pigtail catheter. The catheter was placed in the aorta, and two angiograms were performed in the aortic root. Aortic Root: Two angiograms via the Pigtail catheter demonstrate the aortic root and left arch with normal brachiocephalic branching pattern. Both angiograms demonstrate the coronary artery branching patterns, without specific evidence of coronary artery fistula."
An ICU patient needed a temporary Quinton placed for CVVHD and was too unstable to travel. The radiologist performed this procedure bedside, utilizing the cath lab staff, supplies, and ultrasound (properly documented). We feel that codes 36556 and 76937 are the appropriate charges for this procedure. However, our manager (who came from a different hospital system) is telling us that charging for this procedure is fraud because it is built into the ICU room charge. Can you help clarify what is appropriate to charge for these bedside procedures?
"One of our patients had a thrombosed HeRO graft of the left internal jugular. The procedure started with removal of the venous component by our vascular surgeon. It was replaced with 16 French peel-away sheath. The interventional radiologist then tunneled a hemodialysis catheter from the left anterior chest wall to the left neck incison. The tip was positioned in the superior vena cava under fluoroscopic guidance. Catheter was then flushed and secured to the skin." Is this a co-surgery, and what code should we use? Or are there two separate codes, one for the vascular surgeon's removal and one for the interventional radiologist's placement of a tunneled left internal jugular hemodialysis catheter? And what would those codes be?
We bill codes 93294 and 93296 for remote pacemaker interrogation along with codes 93295 and 93296 for remote ICD interrogation. Is there a tech charge that should be billed with 93293 for transtelephonic rhythm strip evaluation?
I'm not sure the codes the physician is advising us to use are correct. He advises codes 37220-50 and 37236 for aortic stent. Code 37220 seems okay, but I'm unsure of the stenting code he has chosen. Your opinion would be greatly appreciated. Here is the dictation: "With great difficulty, angiographic catheter was maneuvered from each groin through the high-grade at lower abdominal aortic stenoses. Kissing balloon dilation was performed, dilating the lower aorta and proximal common iliac arteries bilaterally. A 40 x 12 mm stent was then deployed spanning the lower abdominal aorta. Completion angiography was then performed. Angio-Seal closure of each groin was performed after fluoroscopy revealed normal appearance of the distal common femoral arteries bilaterally."
We need clarification for a MD, Slide 65 states, “Codes are per vessel imaged however only 1 code is reported for multiple contiguous vessel lesions (DVT eval from POP vein to IVC is reported as one IVUS)”. Slide 66, IVUS Case 71, states, “Venography shows DVT throughout the LE veins. Thrombectomy performed. IVUS of entire venous system on the LT from POP to IVC with findings described.” Coding indicated 37252 as the only IVUS code, no add-on code 37253. Our question: Is the IVUS only coded once IF a contiguous lesion is found crossing the vessels? Otherwise, if no lesion is identified, or separate lesions documented in the separate named vessels then each vessel is coded individually (initial vessel 37252 plus each additional vessel studied with 37253?) Ex: If the MD uses IVUS to view the TP tr, POP and SFA, documents findings in each vessel as separate lesions in each named vessel, would this be reported as 37252, 37253, 37253-59, although they are contiguous vessels? Since there is not a contiguous lesion documented can the IVUS be reported per vessel?
Do I report unlisted 53899 code for a ureteral stent placement via the ileal conduit?
I have used code 34834 for a brachial artery cutdown for AAA repair. Can you please advise on what CPT code should be reported for cutdown of brachial artery for repair of SFA aneurysm with a VIABAHN stent?
How would you code repositioning an implantable LVAD on a subsequent day? If unlisted, what do you feel is comparable (33393 for repositioning percutaneous VAD doesn't seem to reflect the complexity to me)? "I opened up her previous subxiphoid incision, exposed the actual outflow portion of the pump, and extended this to her inferior sternal and took out two sternal wires. I took out the previously placed external bolsters and repositioned the pump, and there was no change in her degree of pump malfunction. I did elect to cut the entirety of the bend relief around this pump site to relieve any potential kinking, and as soon as I did this and spread the xiphoid, her pump started functioning appropriately again. At this point, having repositioned this multiple times, I elected to make a small laparotomy to allow the pump to sit intraperitoneal, as well as the driveline, and at this point, I thought it best to also reapply the coupling device, which I did."
I am wanting to code the below example with just code 37242. Is that correct? "Ultrasound evaluation of the right periorbital cystic hygroma was performed, and a permanent recording of the ultrasound image was saved to the patient`s medical record. Using sterile technique and under ultrasound guidance, a 19 gauge butterfly needle was inserted within the cystic hygroma. 3 cc of 3% Sotradecol solution were injected within the cystic hygroma. The Sotradecol was allowed to sit for approximately 10 minutes and was then aspirated from the hygroma. 3 cc of a mixture of doxycycline and contrast were then instilled within the cystic hygroma. This mixture contained 100 mg of doxycycline. Butterfly needle was removed and hemostasis obtained with manual compression."
Recently I have come across two cases in which they accessed the deep circumflex iliac artery for an angiography: one case for a possible endo leak and the other was for a evaluation of the branch vessels directed towards the right paraspinous and retroperitoneal soft tissues. In both cases they were looking at the L4. For these types of cases what angio code would you recommend? 75705?
"Under fluoroscopic guidance, access was obtained to the patient's fistula tract. The catheter was then placed within the bowel, and contrast injection confirmed position of the catheter within the bowel. Following this, flossing of the fistula tract was carried out. Following this, a bio design enterocutaneous fistula plug was introduced into the colon at the site of the fistula with the distal end of the device deployed within bowel in the plug traversing the fistula tract." Are codes 20500 and 76080 appropriate?
I see CT-guided epidural injections all the time. In another question regarding fluoro-guided epidural injections, you quoted CMS in saying, “After considering comments received, we are finalizing CPT codes 62310, 62311, 62318, and 62319 as potentially misvalued, finalizing the proposed RVUs for these services, and prohibiting separate billing of image guidance in conjunction with these services.” I noticed it just says image guidance and does not specify what kind. Our pain management coder is telling me that only fluoro guidance is bundled, but that CT guidance is separately reportable. Is that true?
Can you please clarify the appropriate CPT codes for these procedures? 1) Selective catheter placement in third order with selective placement in the left brachial, axillary, subclavian, and aorta with DSA imaging via left radial artery access. 2) Selective separate catheter placement in additional second order via right radial artery access in the right brachiocephalic and subclavian artery and DSA imaging. 3) Successful PTA and 8.0 x 37 and overlapping 8.0 x 57 stent to the left subclavian artery. 4) Successful PTA and 5.0 x 40 mm stent of the left brachial into the axillary artery in second arterial territory. 5) Thoracic aortogram.
What code would you suggest for percutaneous balloon pericardiotomy?
Can I code for atherectomy/PTA of the medial plantar artery? I know the medial plantar artery is a continuation of the posterior tibial artery. Is it appropriate to assign it code 37229?
Would you just code the cholangiogram (47531) and/or repositioning of biliary drain (47999)? "Procedure: Initial cholangiogram demonstrates contrast opacification of the duodenum with no significant intrahepatic biliary tree opacification. It was therefore decided to reposition the biliary drain catheter proximally. The catheter was pulled back with the tip at the level just distal to the biliary stent. Contrast opacification of the nondilated intrahepatic biliary ducts noted. There is no evidence of contrast leak. Catheter was then sutured to skin. Impression: Cholangiogram performed via existing biliary drainage catheter with repositioning of the catheter as above."
If a physician performs a percutaneous liver biopsy on the left and right lobe of the liver under ultrasound guidance, can we bill for both biopsies (47000 x 2)? Or is it still considered one surgical site and only one biopsy is allowed during the procedure? If the reason for each biopsy in the left and right lobe is done for different diagnosis, could both biopsies be billed then?
We treat patients with great saphenous vein reflux on ultrasound with endovenous laser vein abalation. Lately a few cases the physician has had failed attempts for the wire after access to the vein. "With ultrasound guidance, attempts were made to cannulate the great saphenous vein below the knee and at the level of the knee and slightly above. Ultrasound indicated that the needle was in the vein, and the wire would not pass. The size of the vessel indicated that there is reflux, but unable to pass wire. After adequate amount of time trying, I elected to terminate the procedure." Patient declined any lidocaine for needle access, but the venous laser sterile procedure pack had been opened. Can we charge code 36478-74? If not, can we charge for the ultrasound (76937) and supplies( A4649)? Not sure if the HCPCS code is correct.