Patient is pre-op for planned gastric bypass. 74241 was coded. The question is whether 74246 would be more appropriate. Coder is questioning with KUB. No diagnostic info regarding kidney/ureter/bladder is given, but in the coders desk reference KUB is referred to as a general abdominal exam. Is diagnostic info pertaining to kidney/ureter/bladder necessary to append code 74241? Clinical Notes: Pre-Op Gastric Bypass ESOPHAGRAM AND UPPER GI SERIES - 4/6/12: HISTORY: Obesity. FINDINGS: Preliminary film of the abdomen is unremarkable. The patient swallowed barium without any difficulty. There is no evidence of a hiatal hernia or gastroesophageal reflux. The esophagus is unremarkable. The stomach shows normal motility and distensibility. Mucosal folds of the stomach are unremarkable. Duodenal bulb and loop are well seen. There is no evidence of peptic ulcer disease. CONCLUSION: THERE IS NO EVIDENCE OF A HIATAL HERNIA OR GASTROESOPHAGEAL REFLUX. THERE IS NO EVIDENCE OF PEPTIC ULCER DISEASE. ROOM TIME IS 45 MINUTES. FLUOROSCOPY TIME IS 2 MINUTES 45 SECONDS.
Since the NCD for single and dual chamber pacemakers has been put on indefinite hold per MLN Matters CR8525, does this mean that we should not be appending the -KX modifier to pacemaker implants to indicate the patient has documented symptomatic bradycardia?
We discovered that the RVUs for code 22524 jumped from 16.61 in 2011 to 223.41 in 2012. Approximately $1463.00 to $22,109.00 in 2013. Is there a specific reason for this high increase? I would appreciate any information you have for us to pass on to our concerned patients and physicians.
Hello Dr. Z, Are there other products besides Kyphon, such as the Carefusion "AVAmax" system, that would meet the kyphoplasty cavity creation CPT code definition (22523, 22524)? Thanks so much!
I have a patient on whom the physician has used a DFINE Stabili kit to perform what I would consider a "kyphoplasty" procedure. The physician performed a cavity creation by using a curved osteotome and then placed cement in the vertebral body of the L1. I have had this procedure pulled for an audit, and the auditor counted this as a vertebroplasty because the physician did not use a balloon during the procedure. I was told if the DFINE Stabili kit meets the definition of a kyphoplasty then it would be appropriate to code it as one. Can you give me some insight on this?
For services of 2014, what is the suggested code for the Lariat suture of the atrial appendage, transcatheter?
One of our electrophysiology cardiologists performed left atrial appendage ligation using Lariat device. The reimbursement consultant from Sentreheart recommended using code 33999 or 93799 with a possible crosswalk to codes 92987 and 33203. The procedure was performed through epicardial access with left appendage contrast injection. A TEE was also perfomed by another cardiologist by the same practice. Please advise the best possible way to bill this service, what the RVU value should be, and probable allowed amount for this service. As of 9/9/13, the Medicare carrier for IL is NGS.
We are contemplating the use of the Lariat device for LAA closure. I see Dr. Dunn suggested using 33999 earlier this year for the device. I am wondering why you thought that 33999 was a better choice than 0281T? 0281T Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation If you look at the NUBC definition for implant, the Lariat device, meets the criteria. The reason I am being doubly cautious is that I noticed almost all payers will not reimburse 0281T due to the investigational nature of the devices previously used for this procedure (the Watchman and the Amplatzer). Thanks in advance!
During the conference in Las Vegas in December you mentioned Lariat can be reported with code 93799; however, we are getting info within our organization stating to use code 0281T... is this correct? I thought code 0281T was an older code and not payable as for investigational, whereas code 93799 is unlisted and is possibly reimburasble.
Would a laser thrombectomy qualify for a 92973 thrombectomy add-on code?
I have a question about cardiac cath stent placement. There was a DES in the RC - G0290RC. Another DES SV graft to OM - DES placed in the LC - G0291LC. The question is can we charge for G0291RC-59 for the saphenous vein graft stenting?
Hello Dr.Z, I have a question in regards to the 2011 Endovascular Revasculatiion Codes. Left percutaneous femoral access was done and angio demostated occulsion. A PTA was done in the Rt SFA, Rt Anterior Tibial and Rt Posterior Tibial would you code as; 37224, 37228,& 37232? Or should it be 37224, 37232 & 37232? Because there is no add on code for the Fem/Pop Territory I am not sure if it is correct to do the 37224 & 37228 together.. Also if the doctor selectively does Angiogram ie: multiple times do we Not bill for any of those? I would also like to verify that 36245-36248 is included in the PTA revasculariztion coding! Thanks for your time and prompt reply..It is greatly appreciate..:) Deb
The physician tried an Easytrak 2 lead (LV lead) and was unable to get satisfactory thresholds, so he exchanged with an Easytrak 3 lead. We obviously only ended up with one lead in the patient, but we used two and we were charged for both. Is there a modifier for this? What is the appropriate charge situation for the supplies used?
Please do NOT include any actual patient medical records with your question. Have cardiologist that wants to charge 33216(lead replacement,33233(PM removal), 33234(lead removal) and 33222(pocket revision) on patient that required replacement of chronic RA lead due none capture. Per patient's report generator removed, leads tested (noise defect reproduced with pressure on part of lead entering cephalic vein), Chronic RA lead removed, new lead placed, connected to generator, pocket washed with gentamycin saline and pocket closed. Per report no new generator placed and no revision of pocket. My understanding is that 33216 bundles the chronic PM removal and replacement. And documentation not adequate for charge of revision of pocket.Do you have avialable clear instructions on what is included in lead repair/replacement procedures. Thank you for your help. Rick
A physician is doing a dual chamber pacemaker exchange and finds the RA lead has fractured and the RV lead has dislodged. He removes the device, removes the RA lead, places a new RA lead, repositions the RV lead, and then replaces the device. We were told to report codes 33206, 33235, 33233, and 33215. I see that code 33215 is an NCCI edit to code 33206. Can they be charged together?
Should code 93640 be used for the testing of "leads only" at time of initial ICD implant or ICD generator change? For example the report reads, "Ventricular pacing and sensing thresholds were checked and were good. Final sensing and pacing thresholds were checked and were good." I have been instructed to use code 93640 with modifier -52 (reduced services) because sensing and pacing were checked, but no arrhythmia was induced for termination. Is this an appropriate use of code 93640? Or is the checking of leads for pacing and sensing thresholds considered part of the ICD implant procedure and not billed separately?
Please do NOT include any actual patient medical records with your question. Dr. Z. I have a question in referece to th recalled ICD Riata lead. One of our physicians dictates a sepatate report for fluoroscopy of the thorax on patients having an Icd gen change who have a riata lead. He states that the flouroscopy is medically necessary and mandated by the FDA. Should 76000 be charged in this situation? Thanks. D.
Rapid atrial pacing induced left A-flutter into A-fibrillation back into A-flutter into A-fibrillation. Ablation of the roof near the LSVP terminated the A Fib. Ablation contined down the posterior antrum of the L atrium which induced A-Flutter. We ablated around the entire L antrum, the tachycardia continued. We ablated the roof of the LA, from LSPV to RSPV as well as the posterior line from the L antrum to the R antrum and the left A-flutter terminated. The left flutter was posterior wall dependent. Multiple ablations were done in the mitral isthmus region and the corresponding contralateral CS region. After ablation was complete, EPS was done with no inducible atrial tachydysrhythmia. Adenosine bolus was given to induce pulmonary vein fascicles. None were induced. Post op dx are atrial fibrillation and two different left atrial flutter. Should this be coded to 93656, 93657 x 2 or 93653, 93656, 93657 x 1? In this case, would 93623 be billed for the adenosine?
I have a left heart catheterization with aortic root, along with a abd-aortic run-off. The physician describes the non-selective renals, then repositioning for the non-selective bilateral ilio-femoral run-off. The bilateral lower extremity angiographies are described in complete detail all the way down to the ankles. My initial thought was 93458, 93567, G0278, and G0275. But he gave such a full and complete seperate report of the lower extremities starting at the iliacs that I felt that maybe I need to drop the G0278 and replace it with 75716-59. What is your opinion?
One of our providers is wanting to bill for left heart catheterization (93452) with VT ablation (93654). It's my understanding that VT ablation includes a comprehensive diagnostic study of the right heart and left ventricle. I've noticed we can bypass the NCCI edit by adding modifier -59, but I am wondering when it would be appropriate to bill separately when performed with the VT ablation.
Please do NOT include any actual patient medical records with your question. Question about failed stents Chronic total occlusion of the left anterior decesending, which is unsuccessfully crossed percutaneoulsy due to the inability to see the origin of the occlusion. Successful deployment of StarClose device. Cardiac catherization reason for procedure: Continued angina despite maximal medical therapy. How do I code the cath and the failed stent? The cath is a LHC. Thank you Marchelle Cagle 205-327-7728
If just aortic pressures are taken (during a catheterization without mention of where the catheter ended up/placed), would that constitute charging/coding a left heart catheterization?
Dr. Z, Hi -- would appreciate your opinion. MD placed LEFT MAIN DES. He describes "high-grade disease in the proximal circumflex" and subsequently describes intervention (DES) "distal left main." Cath Lab reviewed the films and says, "Treated lesion(s) are continuous - the distal left main and into high proximal circ/OM branch were target lesions. MD ballooned multiple times at this site. THE STENT IS CLEARLY IN THE LEFT MAIN." MD has summarized: "LM = DES and PTCA; Left circumflex = PTCA" Would you charge/code: G0290-LC only or G0290-LD with 92984-LC? THANK YOU.
I have a new Dr who is asking about coding coronary interventions and wanted to be sure we were aware of when we could bill the left main as 2 interventions. I am not aware of this and do not think you can seperate and bill 2 intervention done in the Left Main. Please help!
Successful angioplasty opening of left SFA CTO in retrograde ipsilateral fashion (via left popliteal artery) followed by antegrade angioplasty and stenting of the left SFA in contralateral fashion (via right femoral artery) due to dissection and suboptimal results. Is it appropriate to report code 37226 with 37224-59 due to additional access sites?
Original Question: Can you help with this new (to me) device: EndoRE® Remote Endarterectomy Device. I have a doctor using this procedure from an endarterectomy with distal atherectomy. Is this still considered an endarterectomy, or should these be billed as a true atherectomy? PRODUCT Description: "The MollRing Cutter® Transection Device is a tool designed to transect and remove the plaque core at the designated endpoint or site of the reconstitution of the artery. MollRing Cutters provide the ability to cut the core of the wall of the artery without tearing. The rounded bottom edge of the cutter ring allows for a smooth advancement from the proximal arteriotomy to the designated endpoint." Follow-Up Question: Dr. Dunn answered a question for me last month. Is it possible to get a little more information? This group of doctors is doing an arteriotomy iliofemoral area. Doing an endarterectomy, then extending this "cutter" down and cutting the plaque in the popliteal and distally as far as the post tib. Should I be coding as endarterectomy iliofemoral and the popliteal etc.? Or when the cutting device is extended beyond the original vessels into seperately billable vessel, should I code these as atherectomy even though this isn't an approved device? These are all open procedures with an endarterectomy at the arteriotomy site, and then sometimes it is extended half way down the leg for a remote atherectomy.
Patient presents with history of coronary artery disease, peripheral vascular disease of the extremities, and carotid artery stenosis, status post PCI and PTA of subclavian artery. Recent stress test and Doppler ultrasound of great vessels had abnormal results. Procedures performed include left heart catheterization plus selective injections of coronary arteries, (native) right/left internal mammary arteries, right/left subclavian arteries, right/left vertebral arteries (from subclavian catheter placement), and right/left carotid arteries. Interpretations include coronary artery stenosis (414.01), subclavian artery stenosis (440.20), normal internal mammary arteries, normal vertebral arteries, and carotid artery stenosis (433.10). Are the following codes appropriate for the combination of coronary and peripheral vascular procedures performed in the same setting: 93459-TC, 36225-50, 36222-50, 36216-59RT, 36215-59LT, and 75716-59TC?
How would you code a ligation of the anterior branch of the greater saphenous vein?
What is the CPT code for ligation of accessory vein? ESRD with a poorly matured right arm fistula. Procedure: Balloon angioplasty of the cephalic arch and peripheral cephalic vein, ligation of the accessory vein to improve blood flow. Incision through the subcutaneous tissue to the accesory vein and was freed up from the surrounding tissue and ligated with 2-0 silk tie.
How would you bill for ligation of axillary vein and its tributaries to control bleeding from a gunshot wound? Procedure in detail: Patient's right anterolateral thoracotomy generously exposed the third portion of the axilla and the axillary artery and vein. Myriad tributaries and the axillary vein itself were lacerated, both by direct impact and cavitation. Serial Prolene 4-0 sutures over sewed, ligated the venous tributaries, as well as the anteromedial wall of the axillary vein itself. Copious irrigation was used. Hæmostasis was achieved, though the pectoral muscles (minor and major) were injured from the GSW blast. The axillary artery was palpated, and no overt injury was noted. Closure is under the ægis of Dr. X.
What is the difference between a limited Doppler (93321) and a complete Doppler (93320)?
I have a question relating to PICC line placement. If a nurse attempts to place a PICC line but cannot place the catheter centrally, how do you code for this? The catheter terminates in the arm, short of the axillary vein. I'm told they can last up to two weeks in this position. Thanks so much!
In regards to 93312 - is there a standard for bare minimum required findings? The only finding is "no clot found on TEE prior to ablation", would you add a modifier or not bill based on these limited findings. In regards to ablation, we do a follow-up TEE , usually to r/o pericardial effusion prior to discharge(usually next day). Many times the findings state "no effusion". Is this billable and what code would we use? Lastly, still in regards to ablations. How do we correctly bill 93462 transeptal puncture with ablations? *We have some payers reimbursing only $4-5,ooo when we use 93462 with 93651 and 93652. If we don't submit 93462 on the bill, we have the same payers reimbursing $45,000+. Many thanks for your time and assistance! Lori Sprenger
This is a Protocol. Patient has a kidney or liver biopsy. Radiologist has technologist perform a limited ultrasound two hours post biopsy to check for possible complications. Would you consider this part of the biopsy procedure? My feeling is yes, if there were no signs/symptoms of a problem, just routine follow-up. But if there are signs/symptoms, then charge the limited ultrasound. Your comments are appreciated.
Physician performed a percutaneous needle core biopsy of the liver using ultrasound guidance (47000 and 76942). At the end of his dictation for the biopsy he said, "An introducing needle was then placed into the lesion. An 8 x 4 tornado coil was placed through the introducing needle." Can I code for this coil placement? If so, what code(s) would I use?
Can catheter selectivity be determined in the hepatic arteries when only liver segments are mentioned (i.e., report states, "selective catheterization of segment II hepatic artery... selective catheterization of segment V-VIII hepatic artery... selective catheterization of segment IV hepatic artery")? If so, what are the rules for that?
If an intervention is performed from the left main into the circumflex or left anterior descending (on a single bridging lesion), do you add -LM as the modifier, or LC/LD?
I have never seen gold seeds used for localization of a lesion before surgery. There was increased activity in the paraspinous tissue L1 area on a PET/CT scan.. The patient's mid back is prepped and draped in a sterile manner. Under CT guidance a 18 gauge needle was advanced into the area of interest to the left of the L1 vertebral body. Two gold seeds were placed 0.8 mm x 5mm. The seeds were placed lateral to the left fusion rod and medial to the left 12th rib in the area of increased activity. The patient will have a PET CT scan to identify the relationship of the gold seeds to the area of increased activity. "Impression: Status post CT-guided placement of localization gold seeds." I was thinking of using code 77012 for the guidance and an unlisted code for the gold seeds... not sure of the correct unlisted code 20999 (musculoskeletal) or 22899 (spine). What would you suggest?
Physician used a Lombard AorFix device to repair a common iliac aneurysm that extended into the internal iliac artery. Internal iliac was embolized, and the device was placed just below the renal arteries, seated at the aortoiliac bifurcation, with one docking limb extending down the common/external iliac and covering the internal iliac. Reason for device was due to torturous aorta in a patient with multiple surgeries for colitis with a colostomy and a chronic abdominal fistula.
I code for both the primary and assistant surgeons. The primary surgeon from the first procedure was the assistant for the second and visa versa. How do you code one procedure that turns into two, that stretches from 7:45 am to after 4:30 pm on a patient that exceeded 400 lb? They did a bilateral femoral artery cutdown, with attempted deployment of aortobiiliac unibody graft. They added a micropuncture to the left brachial artery for additional access. In addition to the patient’s size he also had severe tortuosity of both iliac arteries with at least two 90 degree bends. They had difficulty unsheathing the right limb, and after many attempts to unsheathe the limb and a broken wire, they decided to move to the OR where they performed an open AA aneurysmorrhaphy with aortobiiliac bypass. After thoughtful research I feel that the following is correct, but I would like a second opinion. Surgery 1: 34812-50, 36200-RT, 36200-59LT, 34804-53, 75952-26. Surgery 2: 35102-2278. One of my concerns is that code 35102 will be bundled into code 34804 due to NCCI edits.
I have a request for a misc charge 33999 to capture reposition of loop recorder. I'm not sure this would be a valid charge. Everything I find indicates that repositioning should be included at the time of the loop recorder insertion with code 93620. Please advise.
Within the PVL, a written physician order is documented within the patient chart that requests: • Deep Vein studies/ lower extremity • Bilateral Carotid Duplex • Bilateral Lower extremity vein mapping When these orders are entered from the unit and received within the Radiology order billing system; CPT 93970 is reported for both (venous mapping and Bilateral Lower Extremity Duplex) orders selected (93880, 93970, 93970). Although a distinct service modifier would pass edits, I feel that when performed during the same encounter, the venous mapping is inclusive with the bilateral duplex scan of extremity veins and should not be reported separately. I submit that both technical and professional charges for this encounter should only be reported as 93880 and 93970. I would respect your opinion on this to support my position for what I feel could be a duplication of procedural charges. Dictated report for all procedures are provided below: PROCEDURE: BILATERAL SAPHENOUS VEIN MAPPING COMPARISON: None. INDICATION: Pre open heart surgery. TECHNIQUE: Gray-scale imaging was performed on the bilateral greater saphenous veins with caliber measurements. FINDINGS: RIGHT GSV: Thigh proximal: 2.9 mm Thigh mid: 3.0 mm Thigh distal: 2.7 mm Knee: 2.4 mm Calf proximal: 1.9 mm Calf mid: 1.7 mm Calf distal: 2.2 mm LEFT GSV: Thigh proximal: 3.8 mm Thigh mid: 2.8 mm Thigh distal: 2.0 mm Knee: 2.2 mm Calf proximal: 2.0 mm Calf mid: 1.5 mm Calf distal: 1.4 mm CONCLUSION: The bilateral greater saphenous veins were imaged and measured as described above. PROCEDURE: BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND FOR DVT WITH DOPPLER COMPARISON: None. INDICATION: Previous DVT. TECHNIQUE: Gray-scale and color Doppler imaging were performed on the bilateral lower extremities. FINDINGS: RIGHT LOWER EXTREMITY: CFV: Normal. SFV: Reduced. PFV: Normal. POP-V: Reduced. PTV: Normal. PER: Normal. ATV: Normal. GSV: Normal. LEFT LOWER EXTREMITY: CFV: Normal. SFV: Normal. PFV: Normal. POP-V: Normal. PTV: Normal. PER: Normal. ATV: Normal. GSV: Normal. Normal findings indicate good phasicity, spontaneity, compressibility, augmentation response, and competence. CONCLUSION: Chronic DVT seen in the right SFV and popliteal vein with recanalization. Remaining deep vessels show no evidence of acute or chronic DVT. No evidence of superficial thrombophlebitis. PROCEDURE: BILATERAL CAROTID DUPLEX ULTRASOUND COMPARISON: None. INDICATION: Preop screening. HISTORY: CAD. TECHNIQUE: Gray-scale and color Doppler imaging were performed on the bilateral carotid arteries. FINDINGS: RIGHT: COMMON CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar PEAK SYSTOLIC VELOCITY: 80 cm/s END-DIASTOLIC VELOCITY: 17 cm/s PROXIMAL INTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. Calcified. SURFACE CHARACTERISTICS: Irregular. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 207 cm/s END-DIASTOLIC VELOCITY: 62 cm/s DISTAL INTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 188 cm/s END-DIASTOLIC VELOCITY: 37 cm/s EXTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 137 cm/s END-DIASTOLIC VELOCITY: 21 cm/s VERTEBRAL ARTERY: Antegrade. ICA:CCA SYSTOLIC RATIO: 2.6 LEFT: COMMON CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 87 cm/s END-DIASTOLIC VELOCITY: 21 cm/s PROXIMAL INTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. Calcified. SURFACE CHARACTERISTICS: Irregular. FLOW CHARACTERISTICS: Turbulent. PEAK SYSTOLIC VELOCITY: 184 cm/s END-DIASTOLIC VELOCITY: 54 cm/s DISTAL INTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 162 cm/s END-DIASTOLIC VELOCITY: 47 cm/s EXTERNAL CAROTID ARTERY: PLAQUE MORPHOLOGY: Heterogenous. SURFACE CHARACTERISTICS: Smooth. FLOW CHARACTERISTICS: Laminar. PEAK SYSTOLIC VELOCITY: 157 cm/s END-DIASTOLIC VELOCITY: 27 cm/s VERTEBRAL ARTERY: Antegrade. ICA:CCA SYSTOLIC RATIO: 2.1 CONCLUSION: Bilateral 60-79% ICA stenosis with irregular plaque characteristics and turbulent flow. The vertebral arteries appear patent with antegrade flow bilaterally.
I'm thinking I would code this 36147, 37221, 37223. Ultrasound was used to obtain access into the graft. Contrast injected showing severe stenosis involving the external iliac and common iliac veins. This was angioplastied with residual stenosis. Patient has had multiple angioplasties, so I decided to stent lesion. Stent deployed in the common iliac vein into the proximal external iliac vein. Contrast shows residual stenosis involving the distal external iliac vein so I decided to deploy another stent, which extended the stent down to the level of the distal external iliac vein. Attention then directed toward pseudoaneurysm, which was in the venous limb of graft. Stent deployed across pseudoaneurysm to cover it and was pulse dilated. Since the external iliac is part of the peripheral zone, and the common iliac is part of the central zone I think I can code the stenting of both. I'm fairly new to vascular coding and appreciate your input!
Good Morning, When a stent and or angioplasty of the lower extremities are performed on the venous side do we use the new lower extremity intervention codes (37220 -37239). I would say not. Please advis.
I am reading in your example #2 under the AV shunt interventions chapter. It reads "2) Patient with clotted left leg dialysis graft undergoes cross catheter technique (36147, 36148) with shuntogram (included) and declot utilizing a thrombectomy catheter (36870). An arterial inflow stenosis in the native iliac artery 8 cm proximal to the arterial anastomosis is ballooned (36245, 37220) as is a common iliac vein stenosis (35476, 75978)." my question is concerning the 36245 coded with 37220. Wouldn't 36245 bundled with 37220? I would think that you would only be able to capture 37220 and not the cath placement code. What is your reasoning for add both 36245 and 37220? I have a similar situation AV shunt in lower leg venous outflow stenoses treated with stent deployment. I thought I should code with 36147, 37221.
With regards to Question ID #5330, we have a similar case with balloon inflation throughout the graft across the anastomosis to the right external iliac vein, with stent placement across the venous anastomosis into the venous limb. In #5330, you agreed with codes 36147, 37221, which is an arterial stent placement. I keep coming to code 37238, but it excludes lower extremity. What code will be used for iliac venous anastomosis stent placement?
I have a patient who had a lung bx at 13:05. At the time of the bx, he had a large pleural effusion. Following the bx, he developed a hydropneumothorax which resulted in the low oxygen saturation. The patient was brought back to the angiography suite for placement of chest tube. Because of his effusion as well as pneumothorax, a decision was made to place two cathers, one for drainage of the effusion (right lower pleural cavity) and one for the drainage of the pneumothorax (upper pleural cavity) at 17:53. DOS - 08/11/11 Coded as: 32405 - lung bx 77012 - CT guidance 32551 - thoracostomy tube 75989-26 - imaging guidance for tube 32551-59 - 2nd thoracostomy tube 75989-26-59 - 2nd imaging guidance for tube What would be the proper modifiers in this scenario?
I found a Q&A dated 6/3/11 that partially relates to a procedure I am trying to code, but still need clarification. This is regarding a Bi-v ICD and coronary sinus angioplasty. In my case, the dr made quite a few attempts to place the LV lead. There was stenosis encountered and a separate cardiologist was brought in to help angioplasty this area. Angioplasty was able to be done, but the LV lead was still not able to be advanced and was not placed. Is there any code I can use for the CS angioplasty work that was done? Sure seems to me that since there was a separate reason for this being done that I could pick up something. Or is all this extra work just part of the ICD placement(dual chamber was done)? Thank you for your time.
Dr Z, if the pt is having existing crt-d replaced and existing RV pacing and RA leads are reattached to the new generator with a new left Bi-ventricular lead placed, would we code that to 33249, or 33240,33241 and 33225?~thanks!
Please tell me which codes you recommend for this procedure that was performed in 2013. "PROCEDURE:Ultrasound and fluoroscopically-guided sclerosis of a venolymphatic malformation in the subcutaneous tissues of the right buttock. CLINICAL HISTORY: Female with painful subcutaneous venolymphatic malformation in the subcutaneous tissues of the right buttock. TECHNICAL DESCRIPTION: The patient was brought to interventional radiology and positioned prone on the fluoroscopy table. The right buttock was sterilely prepped and draped. Under ultrasound guidance, the venolymphatic malformation was accessed with a 25 gauge needle. Contrast was injected through the needle to verify positioning within the malformation. Approximately 3 mL of Sotradecol foam (four parts 3% Sotradecol, four parts air, one part lipiodol) was injected into the malformation under intermittent fluoroscopic visualization. This was repeated at two additional sites of the malformation. Needles were removed from the patient. Hemostasis was achieved with manual compression."
Please assist with coding of the following scenario. There is debate between codes 19083 + 19084 OR 19083 + 38505 (with 76942). "Patient taken to ultrasound suite for biopsy with history of large mass lateral right breast. Right axillary adenopathy. Using direct ultrasound visualization, vacuum-assisted automated core needle samples were obtained from the large mass in the lateral breast using a Celero biopsy device. A marker clip was deployed at the biopsy site under ultrasound guidance. Next, the right axilla was cleansed in a sterile fashion. 1% lidocaine was used for local anesthesia. Using direct ultrasound visualization, vacuum-assisted automated core needle samples were obtained from one of the abnormal axillary lymph nodes using a Celero biopsy device. Pathology report for the axillary tissue shows complete replacement by ductal carcinoma…lymphoid tissue not seen…shows staining with CK7 and GATA, in keeping with breast primary."
Hello, I have a case that i have not come across before and would like your help and/or feedback if possible. I am coming up with 37799, 76496 and maybe 36299 for the contrast injection. Thank you for all your help.... PROCEDURES 1. Ultrasound guidance 2. Flouroscopic confirmation 3. Left neck/ upper extremity LYMPHATIC MALFORMATION access, drainage and doxycycline direct injection venogram and sclerotherapy RESULTS: 15-20 cc of yellow drainage from multilocular/multiseptated LYMPHATIC MALFORMATION. Placed 4 F system and instilled doxycycline sclerotherapy of 180 mg/18cc with 4 cc contrast. No complications. Dressed. Will return in 1-2 weeks for follow up and perhaps more sessions.
Code 38999 (unlisted CPT due to direct approach) vs. 2014 transcather codes... Code 37244 does not seem to fit lymphatic malformation direct approach embolizations. "Ultrasound-guided needle placement: Ultrasound evaluation showed numerous predominantly microcystic changes in a thicken soft tissues in the submandibular and right facial region and in the tongue base. A few macrocystic changes are present. Under ultrasound guidance, 18 gauge catheters were carefully inserted into multiple areas of the macro and microcystic areas. Percutaneous embolization: 6 ml of 3% sodium tetradecyl sulphate mixed with 10 ml of room air and a foamed emulsion was made. The sclerosant was slowly injected with ultrasound guidance at 6 lymphatic micro and macrocystic malformation sites. Firm manual compression was applied after needle withdrawal for 3 minutes. A small amount of fluid was aspirated prior to the cyst injections."
In your book it says to use code 10160 for inguinal lymphocele drainage catheter placement. Is the tx perirenal lymphocele considered inguinal? What else would you charge for it? Its not really an abcess. Thanks,
Can you bill twice for a bilateral lymphoscintography (78195)? And if you can, would you use modifier -50 or bill twice with a modifier -59?
We have been reporting code 79445 for the MAA injection for Y-90 planning and code 77778 for the actual Y-90 injection, according to an SIR article written by Dr. Siskin back in 2007. For the CY 2014, the CPT Codebook suggests that code 79445 now be reported for the Y-90 injection. What code would you suggest for the MAA injection performed weeks prior to the Y-90 injection? We are also reporting for the planning, handling, and dosimetry, when applicable.
Dr. Zielski, I hope this e-mail find you well. We have a meeting tomorrow to discuss the MAC issue with our physicians. My understanding from your in-service was that the hospital and physician charges should match, otherwise neither the hospital nor the physicians would get paid. My co-worker heard a different thing. She heard that if the bills do not match, the bill from whoever charged more (hospital or MD) would be rejected. Could you please clarify? Thanks in advance, Lucy Seoane BCVI
For codes 37211-37214 (infusion therapy), if they are using a Mustang balloon to macerate the clot during infusion therapy, is this included in the codes above? Is there anything we can bill for the maceration procedure?
Good Morning, We are having some difficulty with medical necessity for an ICD. Our facility has created a form based on the Medicare NCD to ensure patients are meeting the criteria for implant. We have a patient that is falling out based on class I heart failure. The physician has stated the patient still meets medical necessity because they are meeting the MADIT II criteria. The patient has ischemic cardiomyopathy, h/o MI, and EF of 25% and class I heart failure. Can you please help us determine if patients that are meeting MADIT II criteria automatically meet the Medicare medical necessisty criteria for implant? Thank you for your assistance!
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.
What specifically would be considered mechanical removal for coding? For example, what types of procedures would need to be performed for reporting code 49460?
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?
I appreciate your feedback on the following question regarding billing of two MitraClips. "PROCEDURAL DETAILS: 1) 7 French sheath was placed in the right femoral vein. 2) A Baim-Turi catheter was used to perform right heart catheterization. 3) Using TEE guidance, transseptal access was performed using lamp 45 catheter and BRK1 needle. 4) The lamp catheter was used to position an Amplatz Super Stiff wire in left upper pulmonary vein. The dermotomy was enlarged with a 16 French sheath. A 24 French clip delivery sheath was inserted into left atrium. 5) MitraClip was advanced into left ventricle. After several attempted grasps, A2 and P2 were successfully approximated slightly medial to midline of the line of coaptation. This resulted in reduction of MR from 4+ to 3+ with no change in transmitral gradient. The clip was deployed. A second clip was positioned just lateral to the first clip and grasped A2-P2 relatively easily. MR reduced to 1+ with no change in transmitral gradient. The second clip was deployed."
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
We are trying to come up with a guideline for this. What is your opinion? If the physician doesn't give a reason for doing less than a comprehensive diagnostic study before an ablation, I believe that modifier -74 should be appended by the hospital rather than the -52 modifier, since the time, staff, and equipment remains pretty much the same. If I remember correctly, modifier -74 is also appropriate to indicate that a planned surgical or diagnostic procedure was partially reduced at the physician's discretion.