If the anesthesiologist actually places the TEE probe, can the cardiologist still charge the intra-op TEE code (93355) during procedures such as mitral valve repair, TAVR, etc.?
We have a patient with an injury to the spleen; the radiologist is doing a diagnostic angio and embolization. I'm not sure how to code these additional catheter placements and angiograms. Can you please assist me? He did a selective celiac and angio (75726-26), selective splenic and angio (36246, 75726-26), and then three additional superselective 4th order splenic artery branch vessels with angiograms (36248 x 3, 75774-26 x 3??). He then performed an embolization for the bleeding (37244). Ultrasound guidance was used for femoral puncture with image stored (76937-26).
I have a two-fold question: 1) What CPT codes would you recommend for a diagnostic percutaneous nephrostogram, nephroureterostomy placement, and nephrostomy placement in one kidney in preparation for a nephrolithotomy the next day by a urologist? Would you use 50393, 50392, and 50390? The notes do not mention dilation. 2) If yes, would the -XU modifier be used instead of -59 in 2015?
If a surgeon performs a stereotactic (or mammographic) guided breast biopsy, and the radiologist then does a post-procedure mammogram, can the radiologist bill for the post-procedure mammogram? What if the surgeon performs an ultrasound-guided breast biopsy, and the radiologist then does a post-procedure mammogram; can the radiologist bill for the post-procedure mammogram?
Could you please review this example and help with the coding of 92928 and 92921 or just 92928? "A wire was advanced into the distal portion of the left anterior descending. A wire was advanced into the distal portion of a medial branch of the first diagonal branch. The diagonal was dilated at its ostium and mid portion with a 2.0 x 15 mm Mini TREK balloon. The ostium was then dilated using a 2.25 x 8 mm NC TREK. Subsequently, a 2.25 x 8 mm Xience Alpine drug-eluting stent was deployed at the ostium of the diagonal. Post-dilation was performed using a 2.5 x 6 mm NC TREK balloon at the ostium of the diagonal and a 3.25 x 12 mm NC TREK balloon within the left anterior descending. Successful stenting of ostial diagonal lesion using drug-eluting stent. The initial stenosis of 90% was reduced to final residual stenosis of 0% with an excellent angiographic result. Successful balloon angioplasty of lesion in a medial branch of the diagonal branch of the left anterior descending."
"A 22 gauge spinal needle was inserted into spinal canal using fluoroscopy. Omnipaque was injected into the thecal sac. Multiple radiographs were performed. Subsequently, because a 'block' to the cephalad flow of contrast material was encountered from the lumbar region at the T12 level, a C1-C2 puncture was accomplished under fluoroscopy. Clear, colorless cerebral spinal fluid was obtained. Approximately 8 cc of Isovue-M 300 was injected into the cervical subarachnoid space. Because the procedure was performed in Special Procedures, the dynamics of the table would not allow sufficient elevation of the head for the contrast material to flow caudally to the thoracic spine. Afterwards the patient underwent a CT, which will be dictated separately." Would it be correct to report code 62305, or should we use code 61055?
Patient had an implantation of patient-activated cardiac event recorder on Sept. 12, 2014 (33282, 90 day global-period). In November 17, 2014, patient returned to the OR for the removal of the implantable event recorder and permanent dual pacemaker implantation (33208, 90-day global as well). Since the patient is on the 90-day global period I was considering appending a -78 modifier to the pacemaker code (33208). This claim was denied by the insurance carrier already because of the 90-day global period. Is it possible to use a -78 modifier and resubmit this claim or not?
We have a patient coming to us after having a biventricular ICD implanted at another facility. The left ventricular lead was not attached, nor was the screw tightened. What would you code for opening the pocket and tightening the set screw?
"The patient had stenosis of a previous fem-pop bypass. Access with cutdown due to previous placed kissing iliac stents. Angiography was performed, which showed the stenosis at the proximal anastomosis, which was angioplastied. A stent was deployed from the anastomosis down into the proximal graft. Sheath was removed and suture placed to close access site." What's the appropriate code here?
In addition to performing a left heart cath and coronary angiography, the report reads: "A gradient assessment across the aortic valve was performed using manual pullback technique. Due to the patient's ongoing chest discomfort we elected to perform an aortogram in the LAO position using 15 cc/second for a total of 30 cc of contrast. Findings: Aortography- Ascending, transverse, and descending thoracic aorta appear to be normal." The provider selected code 93567 for supravalvular aortography; however, the AMA CPT Codebook notes in parentheses: "For non-supravalvular thoracic aortography or abdominal aortography performed at the time of cardiac catheterization, use the appropriate radiological S&I codes (36221,75600-75630)." In the above scenario, is code 93567 appropriate, or would 75600 (without serialography) or 75605 (by serialography)/aortography, thoracic radiological S&I be appropriate? Also how do you determine if aortography is performed with or without serialography? In addition a 12 lead EKG was performed. Is this billable or bundled in 93458?
"BRTO was performed with coil embolization of varices. Balloon left inflated overnight. Patient was brought back to IR department the following day for evaluation." What, if anything, can be charged for the release and removal of the occlusion balloon and subsequent imaging?
Patient had a temporary catheter that was converted to a permcath, and using the same entry site a triple lumen central venous line was placed. Would these both be coded as replacements, or what would you suggest?
"The 8 French sheath was exchanged for a 9 French curved Flexor sheath over the Amplatz wire. The 2.5 mm Turbo-Elite laser was advanced coaxially (calibrated per protocol) and activity to perform laser thrombectomy within the iliac stents. A Lunderquist wire was advanced through the laser catheter until tip to tip. This was then shaped within the laser catheter to allow for better torque-ability, control, and improved thrombectomy." The above info is for a common/external iliac veins. There were two distict catheters involved, one from the RIJ the other from the LFV, for the tip to tip. In the 2015 book, code 37187 can be reported twice if two vascular distributions are involved with two separate treatment caths. Would the above scenario constitute coding 37187 twice?
Recently our practice started placing MidLine catheters using US guidance for antibiotic use. The catheter lengths range between 14cm and 22cm. Can I code these as a CVC with a -52 modifier as it does not reach the central system?
A patient had thrombin mixed with gel foam slurry injected into subcutaneous tunnel tract site from left chest wall permacath to control tract bleeding. The tunneled permacath was removed the day prior and patient later developed unconrollable bleeding. What would you code for the thrombin injection in this case? Here is script from report: "The left chest wall was prepped and draped at the site of permacath exit. 100 international units of thrombin was mixed with gel foam slurry and injected through the micropuncture sheath which was introduced into the tract. Pressure was then held over the site."
In the facility setting, can we capture code 76937 for the ultrasound guidance used when a nurse places a PICC (stored paper image)? I was under the impression "no" because of the patency documentation (which requires a report), and they can't generate ultrasound reports.
I'm still pretty new in coding cath and want to make sure I'm on the right path. One of my providers performed a coronary artery fistula closure with a congenital cath plus coronary angiogram and supravavular aortography. This is what I'm coming up with so far: 37242, 93531, 93567, and 93563.
The doctor would like to bill codes 36217, 37218, and 75710-26 for the following: "Right femoral artery cannulated in retrograde fashion. Catheter into origin of the innominate. Then catheter passed selectively into the origin of the common carotid artery. Then catheter passed selectively out into the subclavian and selective angiography performed, confirming subclavian to be widely patent. Balloon dilation was performed and did not get a good result. Stent placed over ostial and proximal portion of innominate artery." Any help on this is greatly appreciated.
What documentation is required to submit code 71555? Would you feel comfortable reporting code 71555 according to the documentation that follows? "Technique: TWIST MRA and contrast-enhanced MRA of aorta performed after administration of a total of 16 mL Gadavist contrast. Delayed gadolinium enhancement imaging was obtained. MRA: The size of the right ventricular outflow tract, main pulmonary artery, and main branch left and right pulmonary arteries are normal without any evidence of stenosis or aneurysm. Thoracic aorta appears normal in size without any evidence of coarctation or aneurysm. LATE GADOLINIUM ENHANCEMENT: There is no definitive evidence of focal abnormal late gadolinium enhancement to suggest fibrous changes/scarring in the left ventricle. IMPRESSION: 1. Normal LV and RV size and function. LVEF=75%. RVEF=60%. 2. No evidence of pulmonic stenosis, including subvalvular or supravalvular stenosis. Normal caliber right ventricular outflow tract, main pulmonary artery, and branch pulmonary artery vessels."
How do we code for cardiomens insertion with right heart cath? Do we report codes 93451 and 93568? Or do we only report code C9741?
The patient had supraventricular tachycardia. Electrophysiology was done, as well as ablations. At the end of the procedure, additional final venogram was done, which showed the coronary anatomy to be the same as when the procedure was started. Do you code separately for a venogram of the coronary sinus anatomy after EP and ablation?
If my IR physicians are not doing the injecting, we cannot charge for code 38792, correct? The surgeon is doing the injecting, not my imaging physicians.
Could you please clarify CPT code 93463? In question #2610 you state that it cannot be coded for intra-coronary injection of nitroglycerin. In the CPT Codebook it states to use code 93463 in conjunction with codes 93451-93453, 93456-93461, 93563, 93564, 93580, and 93581. This code range includes diagnostic heart cath procedures. The CPT Codebook and the Coders' Desk Reference do not explicitly state that it cannot be used for intra-arterial coronary injection. In the scenario I am questioning, the performing physicians are hand-injecting intra-coronary nitroglycerin to evaluate a stenosis in a vessel and then re-imaging that vessel after injection during a diagnostic heart cath without intervention. Is it appropriate to report code 93463 in this scenario?
For physician billing, is 37215 the only billable code to use for the following procedure? "Pigtail was brought to the aortic arch, and an aortic arch angiogram was performed. This revealed a type I aortic arch. There is also some calcification observed in the ostium of the right common carotid. The pigtail was removed, and a Simmons 2 catheter was used to selectively engage the right common carotid. Angiograms were taken. Intracerebral angiograms were taken. Given the type I arch and 95% occlusion, with adequate landing zone for an embolic protection device, we felt it was reasonable to proceed with carotid stenting. Stenting of the right internal carotid artery with distal embolic protection was done. The patient had prior to this procedure, a CTA of the neck."
Should the following be reported with code 35102 only? Or with codes 35081 and 35131? "Diagnosis: AAA. Right common iliac aneurysm. OP: AAA repair (Hemashield 24 mm straight graft). RCIA aneurysm repair (Hemashield 12 mm graft from aorta to RCIA)...There is a large pulsatile infrarenal AAA...There is a large saccular aneurysm arising from the RCIA...The infrarenal aorta was clamped…Aneurysm sac opened...Aneurysm tapered at the level of the renals. A 24 x 12 bifurcated graft was transected above the bifurcation to create a straight graft and anastomosed to the aorta at renal level...Distally anastomosed to the aorta at bifurcation...Aneurysm originating off the RCIA was excised and couldn't be repaired primarily/inflow not good through the RCI orifice. We placed second graft using 12 mm limb of the bifurcation graft and anastomosed this to CFA at aneurysm level, end-to-side. The proximal end of the graft was then anastomosed to the previously placed Hemashield graft in end-to-side fashion."
How would I code this open procedure to remove foreign body? "A median sternotomy incision was made, and she was placed on cardiopulmonary bypass. Cardio plegia given into the aortic root until good diastolic arrest was achieved. I placed tapes around the superior and inferior vena cava. Once these were shared I opened the right atrium. I could see with retraction the stent adherent to the tricuspid valve chart. We also did a transesophageal echocardiogram at the beginning of procedure. She was found to have moderate tricuspid insufficiency on TEE preoperatively. I removed the stent; it came out very easily. The tricuspid valve did appear to be intact but not in great shape. I felt there would be some leakage; however, at her age I did not want to replace her tricuspid valve if at all possible. I removed the foreign body and closed the atrium with 2 layer with running 4-0 prolene suture. The aortic cross-clamp was removed, and the patient rewarmed and weaned from cardiopulmonary bypass. Stable back to ICU. TEE performed."
"Incision made in anastomosis; hyperplasia found with plaque. Extended incision down into vessel and removed stenosis then patch placed." I have always coded this with 36832 as an outpatient procedure due to being a minor, approximately 30-minute procedure. If documented that it is extensive, or incision taken further than basic, I then would code it as an endarterectomy. The physician states he would not consider this as extensive of what he would call a normal endarterectomy. What are your thoughts?
Could you please assist me with this scenario? Physician has placed drug-eluting stents in the posterior descending artery as well as the left ventricular branch. For coding purposes, is the left ventricular branch considered an additional branch off the right coronary artery? If so, are we allowed to code for stent placement in this vessel?
Which CPT code would we use to bill for the Allen test?
Can you tell me if code 51600 is charged when you perform a cystogram through an indwelling Foley catheter? I thought you would only report code 74430 if the catheter was already in place.
Bilateral carotid (36222-50) with abdominal aortogram (75625) was charged. The billing department informed us that a surgical code should be added to charges (in this case 36200). They said to add with modifier -59. As code 36200 is non-selective, and 36222 is selective, why is 36200 needed? The billing department stated they are receiving an edit and cannot bill. I was under the impression that code 36222 includes 36221, and that code 36200 is bundled into 36221. Are we not billing 36200 twice in this scenario? I am in disagreement with coding. Please clarify.
When performing these tests and they are deemed normal findings, and the reason for testing was "leg pain when walking", what would you use for diagnosis 729.5 or 440.21? I say 729.5, but could you possibly use 443.9 if dictation states "leg pain when walking"?
I am hoping you can lend your expertise on whether or not you consider this to be an adverse event/surgical complication/misadventure. The account is being audited, and third party believes it should have been coded with complication code 996.1 and manufacturer notified of defective coil. "While the coil was being introduced into the aneurysm, a snap was felt. At this point the coil was attempted to be removed, but it was clear it was broken and detached. At this point a 2 mm snare was brought up over the microcatheter after the microcatheter was cut, and the distal hub was removed. The coil was then ensnared and removed along with the microcatheter. There was a total of 4 coils placed into the aneurysm, and post coil emobolization after final coil demonstrated good position of the coiling with no herniation into the parent vessel and no associated thrombus or embolus. There's a small neck remnant remaining in close proximity to the PCOM measuring 1.1x1.1 mm, but the PCOM filled appropriately and control angio showed no filling of aneurysm neck."
What is the difference between 35556 fem-pop bypass, which includes procurement of the SVG, and 35583 in-situ vein bypass, fem-pop?
Would you use unlisted code 19499 for tomosynthesis-guided breast biopsy?
We need some advice on whether we can use a modifier to bill both 93975 and 76770 for this procedure: "Grayscale and color Doppler of the kidneys and bladder. Duplex doppler US exam was performed of the renal arteries. No aortic aneurysm seen. Renal artery duplex: Pole to pole measurements given for both kidneys as well as peak velocities. Resistive indices and renal veins are patent. There is no hydronephrosis or shadowing stone in either kidney. Bladder is partially contracted." In short, there is disagreement as to whether this dictation supports both codes. We would appreciate any help.
For the following, do you agree with codes G0269, 36217, 36218, 75726, 75774, 37242, and 37244? "Right CFA was accessed using a micropuncture needle. The right bronchial artery was catheterized, and angiogram was obtained. Subselective cath of a bronchial artery branch was then performed, and angiogram was obtained. The decision was made to perform embolization. The right bronchial artery was embolized until hemostasis was achieved. Post embolization angiogram right bronchial artery showed satisfactory hemostasis. Next right intercostal artery was catheterized, and angiogram was obtained. Subselective catheterization of a right intercostal artery branch was performed, and angiogram was obtained. The decision was made to perform embolization. The right intercostal artery was embolized. Post embolization angiogram of the right intercostal artery showed satisfactory hemostasis. The brachiocephalic artery was catheterized, and angiogram was performed. The angiogram demonstrated normal opacification of the brachiocephalic, right subclavian, and right common carotid arteries. Hemostasis was achieved with an Angioseal closure device."
For the following, are both codes 37241 and 37238 appropriate? "Fistulogram performed. Multiple enlarged escape veins arising from the proximal venous outflow as well as stenosis and pseudoaneurysm formation of the perianastomotic venous outflow. The remaining portions of the venous outflow and central veins are patent. The arterial anastomosis is patent. To treat the perianastomotic stenosis, pseudoaneurysm, and enlarged escape vein, the fistula was accessed in a retrograde fashion under direct sonographic guidance. Brachial artery was then catheterized. Arteriogram was performed, confirming findings. A 6 x 5 cm Viabahn stent was then positioned across the pseudoaneurysm and stenosis and was successfully deployed. The stent was posted with a 6 mm balloon. The escape vein was then selectively catheterized. An 8 mm Amplatzer plug was then positioned and deployed. Delayed 10-minute venogram shows persistent filling of the escape vein despite adequate sizing of the Amplatzer plug. Therefore the stent was extended. Follow-up venogram demonstrates successful exclusion of the escape vein."
In the following example, can the position of the sheath in the radial artery be considered for the catheter selectivity? "A timeout was performed, and then a 4 French vascular access needle was used to puncture the right brachial artery at the mid to lower right humerus under ultrasound guidance. A 0.018 in. Nitrex wire was then advanced through the needle into the distal brachial and then into the radial artery under fluoroscopic guidance. The needle was then exchanged for a 4 French transitional dilator, and the wire and inner stiffener were then removed. A 0.035 in. wire was inserted through the 4 French outer dilator, and the dilator was exchanged for a 4 French x 11 cm sheath. Initial right upper extremity angiogram demonstrated diffuse spasm of the brachial and radial arteries. Occlusion of the ulnar artery at its origin was again noted. 200 mcg of intra-arterial nitroglycerin was then administered. Then a tPA infusion at 1 mg per hour was started through the right brachial sheath. The sheath was secured to the skin using 2-0 nylon suture."
Can we (or, should we) report code 61626 with 37216 if they put an Amplatzer plug in the external carotid to embolize the external carotid because when they stent the common carotid aneurysm (37216, no filter) they are going to cover the external carotid origin? Code 61626 documents “. . . . (eg: for tumor destruction, to achieve hemostasis, to occlude a vascular malformation)”. There is not a bundling edit.
With the new myelogram codes it states that you are still supposed to use the old CPT codes when two different physicians are performing the services. How does this affect the hospital billing? Should we follow suit and bill separately to be in line with the physician billing, or should we bill the new code by itself?
Our interventionist cardiologist has requested to clarify if he consults a patient in the hospital and does a procedure (i.e., cath/stent/PCI) in the same day can he bill for both?
A CT-guided RF ablation of a kidney was performed, along with a CT-guided core renal biopsy. May both codes 77013 (RF ablation) and 77012 (biopsy) bill billed together with -59 or -XS modifier?
I am needing some clarification of how to charge IVUS or FFR as a stand-alone procedure. I have read the newletter from November 2014 about this and have since then adapted what I believed to be the correct interpretation of charging these procedures. Please correct me if I am wrong in my thinking... I understood this as: 93799 used as the base code and still charge 92978 or 93571. Like earlier stated I have been using this method for a while now and have never had any issues until recently. Please clarify for me exactly how I am supposed to bill these add-on procedure codes without a base code. Is it supposed to be as I believed: 93799 and 92978/93571? Or should I bill only the cardiac unlisted code (93799)?
When an IAPB is replaced with a new IAPB, do we code for the removal of the existing balloon pump as well as code for the insertion of the new one as well?
For the following, what code should I use for the bypass? "Moving back to the left-sided aortic exposure, an aortoaortic bypass was created. The supraceliac aorta was occluded between atraumatic vascular clamps. A longitudinal aortotomy was made using 11 blade and potts scissors. The aorta was somewhat thickened in this location, consistent with her diagnosis of Takayasu's arteritis, but there was no evidence of acute inflammation. A 12 mm diameter Dacron graft that had been soaked in rifampin was attached end-to side to the supraceliac aorta using 4-0 prolene suture."
If two venous stents were placed through different access sites to two different veins (e.g., one from jugular vein access site to common iliac vein, one from femoral vein access site to external iliac vein), how we code these stent placements? Should we code two initial venous stent placements (37238, 37238-59), or should we report one 37238 and one 37239?
My physician did a selective cath of the bilateral common and internal carotids, subclavian, and left vertebral arteries. I was taught that when you go into one family you will code to the highest level, and for other arteries in that family second order or higher we will use the add-on code. Thoughts?
If we place a tunneled PICC, does the catheter have to be cuffed to be considered a tunneled placement (36557)?
What is the rationale for the edit between 33263 (generator replacement) with 33218 (lead repair)? I don't see how the generator replacement is really a component of the lead repair, and I want to modify this, but I want to understand the rationale behind the edit. Any clues?
I am very confused with this procedure. "The patient has a 1 year old radiocephalic AV fistula (left arm). Suspected steal syndrome versus compounding PVD. Under ultrasound guidance (no documentation of image storage), access was gained into the left brachial artery in the antecubital fossa. The sheath was then advanced over a microwire into the ulnar artery, and an ulnar arteriogram was performed of the forearm and hand. Next, an antegrade fistulogram was performed after contrast was injected in the ulnar artery. The sheath was retracted into the brachial artery, and a left brachial arteriogram was done. Then the sheath was directed into the left radial artery, and a radial arteriogram was done." Do I report a fistulogram and extremity angio? And what about catheter placements?
"A 6 French EBU 3.5 guiding catheter was used to cannulate the LMCA without difficulty. UFH was used for anticoagulation and ACT was verified to be therapeutic. Target lesion for iFR is the proximal LAD. Before the pressure wire was guided into the distal LAD, air embolism was noted in the LAD system. Oxygen was set at 100% immediately and a BMW wire was delivered to the distal LAD immediately. Multiple runs of aspiration were done. Patient remained bradycardic and ST elevation was noted. Repeat aspiration runs were done. Dopamine was started and atropine was given. Epinephrine was also given ×1. A balloon pump was placed via right common femoral artery access. CPR was done for 30 seconds. He never completely lost consciousness. He did not require intubation. Flow was then restored, and hemodynamically he improved. We then proceeded with a pressure wire measurements, which didn't show a hemodynamically significant lesion in the proximal LAD." The above was done in addition to a left heart catheterization. What CPT codes would be appropriate to bill?
"The right hepatic artery was selected. A single branch of the right hepatic artery was feeding the mass. The branch was totally embolized. The catheter was pulled back with the other branches of the right hepatic artery evaluated and none appeared to feed the mass. The catheter and sheath were removed from the celiac axis. A Simmons catheter over a glidewire; the SMA was selected. Contrast was injected with no evidence for feeding artery from the SMA to the hepatic mass. The catheter and sheath were removed." I was using 37243, 37247, and 75726. Should code 75726 be removed from this case? I was using it since the SMA was selected and imaged after the chemoembolization.
Please help me code the following: 1) Coronary angiogram. 2) Angioplasty of distal RCA in-stent restenosis. 3) Angioplasty and stenting of mid RCA. 4) Angioplasty of proximal RCA. Report states this was a complex intervention due to multiple stents in place and a moderate tortuosity of the mid RCA, where the stent had been previously placed. Can modifier -22 be used when the MD has documented the difficulty of the case, such as complex intervention, challenging case with multiple attempts?
How would you code diagnostic pulmonary vein angiography and catheter placement for following pulmonary vein procedures if no heart cath was performed? 1. Left lingula pulmonary vein dilation (35476/75978). 2. Left upper pulmonary vein dilation and stent placement (37238). 3. Right upper pulmonary vein dilation (35476/75978).
The cardiologist performed a LHC, and an interventional cardiologist performed stent in the LD and RD. In the recovery the patient developed chest pain, which brought him to the cath lab. The interventional cardiologist performed a coronary angiogram and found the RC stent to be patent, but found thrombus on the newly placed LAD stent, which was successfully treated with PTCA. Can we charge for the repeat coronary angiogram for the different physician for change in medical necessity as new chest pain?
"Aortogram performed (75625) and LLE angiography performed (75710). Patient has iliofemoral venous bypass graft. Stenosis found at distal margin of venous bypass at junction of superficial femoral artery. This was angioplastied. Thrombus was found at blind ending portion at the anastomosis between the iliac limb and bypass vein graft and was treated with AngioJet." How would you code the angioplasty and thrombectomy? Would this be considered arterial or venous?
"A patient has a left internal jugular vein to left common carotid artery fistula. A stent was placed in the left jugular vein, spanning the insertion of the fistula into the vein (via a left common femoral vein access). Coil embolization was placed in the distal aspect of the fistula at the jugular communication via the left common carotid artery (by right common femoral access)." Will I be able to report codes 61624 (36223, 75894, and 75898) and 37238 (36011) for the above procedure?
We have recently started a CTO program. Here's the scenario: Heart cath performed by Physician 1. Physician 1 comes to the conclusion that the lesion present is a CTO. Physician 1 consults Physican 2 about the CTO case. Viability study done. Heart muscle viable. Physician 2 looks at films from recent (within the allowed period of time) heart cath. (Patient has not had a change in status.) Finds that the images don't show the collateral circulation well enough. Physician 2 decides to bring the patient back to re-study the coronary anatomy to fully assess the collateral circulation as staging for future CTO case. What can/do I charge for this encounter?
Physician states he performed left heart catheterization with coronary angio with grafts, FFR, and aortogram to see left subclavian stent stenosis. Do I use code 93567 since catheter is placed in aortic root, or do I use code 36221 since he is looking at the subclavian stent restenosis? His findings were well documented.
You advised to use 64999 to describe ganglion impar sympathetic block. I've been looking at using 64520 for this procedure. If the needle is passed through the sacrococcygeal ligament and placed along the anterior coccyx, or just inside the coccyx with injection outlining the inner aspect of the coccyx, wouldn't 64520 be more appropriate?
I've coded the removal of the catheter with 36590, but the MD also reported they punctured the common femoral vein and advanced a 7 French sheath into the IVC and used a snare to remove the broken fragments. Can this be separately coded? If so, what code?
I'm a radiology coder at a large hospital. Can we bill a low level E&M code for the removal of a GI feeding tube that has no CPT code? We will receive orders to remove a feeding tube that was placed by my facility or an outside facility. This is the only procedure that the patient is having done.
Can I add code 93571 for the following example? "While the patient has left heart catheter, FFR on mid circumflex was done. Adenosine (90 mg/90 ml NS) 140 mcg/kg/min IV was started. Then FFR 185 cm Pressure Wire Prestige Straight was assessed at mid circumflex. Adenosine was discontinued. FFR: 0.92 was documented."
I have a patient with an aorto-bi-femoral graft with bilateral stenosis at the distal anastomoses. Angioplasty of the right and left limb was done. Would you code for one (37224) or two (37224-50) angioplasties of this graft?
My physician performed AAA. Can he also code an aortic endarterectomy at the same time? If so, do you use an unlisted code?
I am confused about coding for intracranial embolization. If the patient has an aneurysm of the anterior communicating artery AND aneurysm of the right internal carotid artery (both treated with coil embolization), do I code 61624, 75894-26 twice? I have instructions that say, "Assign one procedure code regardless of the number of studies per operative field or site. However, multiple pathologies qualify as multiple sites." I know the "head" is one operative field, but I guess my confusion is since it is two separate aneurysms; does this qualify as "multiple pathologies-multiple sites?"
"Patient had a removal of an AV graft that was painful by taking the graft off the brachial artery just above elbow and suturing it. Incision was then made over the graft in loop-like fashion up the axillary vein, with graft removed from subcutaneous tissue. A large stent was removed as well, which was across the venous anastomosis, then the vein was sutured. Arm was then sutured." I thought 36815 included a revision or a closure, but it has a device-dependent edit. With removal there was no device placed. Is this code correct? If it is correct, how do we get this paid with the device-dependent edit? If not, what would be correct?
I need a little guidance. Patient underwent fistulogram a week ago, and the MD recanalized and angioplastied the cephalic vein. Vein was not matured, and patient returns for repeat fistulogram and balloon maturation of fistula. "Procedure: Left renal cephalic fistula accessed, and micropuncture needle placed into fistula. Fistulogram was performed (36147). Cephalic vein measured 5 mm. It was patent and much improved from previous procedure. The physician angioplastied antecubital fossa to wrist to 7 mm (35476, 75978-26)." Is this correct, and does catheter placement always get coded with the venoplasty?
We recently performed a pediatric magnet procedure (for children who have esophageal atresia). There is no CPT code yet for this procedure. We charged fluoro room time. Do you have any suggestion as to what CPT code to use for this? Or are you aware that a CPT code exists?
Could you please help code the following non-coronary IVUS and coronary IVUS performed 2 days prior to TAVR? "Procedures performed: 1) IVUS assessment of ostial RCA lesion. 2) Peripheral angiography. 3) Peripheral IVUS. Prior coronary angiography was completed and revealed a 70% ostial RCA lesion. Access RFA. After angio, a steelcore wire was placed in the descending aorta, and IVUS measurements of the right-sided iliac and femoral vasculature were obtained. A 5 French RIM catheter was used to redirect the steelcore wire into the left iliac artery, and the wire was advanced into the left common femoral artery. IVUS of the left femoral and iliac. Angiographic diameters and IVUS diameters were recorded for the CIA, EIA, and CFA bilaterally." Non-coronary codes: 37250/75945, 37251/75946, 36245, 75630. Coronary IVUS: 93799. Should the peripheral IVUS codes be reported for each vessel on each side (total of 6), or just once on each side? Do you feel first order catheter selection is supported?
Pt was scanned in LT decubitus position & a LT parasacral skin entry site was sterilely prepped, draped,local anesthesia infiltrated. Using intermittent CT fluoro guidance, an 18-gauge needle was advanced into rectovesical fluid collection. Was only able to aspirate a small, 2 mL amount of cloudy, old sanguinous material which was submitted for culture purposes. No further material could be aspirated,needle was removed. This catheter is not of sufficient size for drainage catheter placement. A skin entry site medial to RT iliac crest was then sterilely prepped, draped local anesthesia by infiltration additional 7 mL 1% lidocaine. Using intermittent CT fluoro guidance, a 22-gauge needle was advanced into the RT pelvic sidewall cystic area, FNA was performed yielding scant material. Using CT fluoro guidance a 20-gauge needle was advanced into this area & was then able to aspirate 2 mL of clear, amber fluid. All material aspirated from RT pelvic sidewall was submitted for cytology. Please advise as to correct reporting of these services & rationale for same.
What code is used for injection of varithena into the greater saphenous vein for venous insufficiency? Would code 36470 or 37799 be used?
We placed an AFX Endovascular AAA System in a patient with distal abdominal AO stenosis and separate (non-bridging) lesions in the right and left common iliacs. Our question is, would we just code the AO stent placement with 37236, or would we also code 37221-50? The nature of this stenting system is that the main body, as well as the ipsilateral limb and the contralateral limb, are housed together in the same delivery system, but each limb is pulled down and deployed separately. The contralateral limb is on its own wire and crimped to the side of the mainbody delivery system. The wire from the contralateral limb is snared and pulled through and out the other groin access sheath and is pulled down and placed using that wire. We are not sure if this would be considered one stent covering multiple lesions or separate stents covering separate and distinct lesions. The device was placed into the abdominal aorta via the left groin and an Omniplush catheter from the right for catheter placements of 36200, 36200-59 only if we code it just as a 37236 correct?
From the right approach a temporary pacemaker wire and intraaortic balloon are placed. From a left approach a limited coronary angiography is performed. Can catheter placement on the right side be billed for this event?
When a cerebral angiogram (36224) is done, and a 3D reconstruction is done on an independent workstation (76377), as well as a cone CT to check for a bleed, can the CT scan be billed? if yes, would billing it as a limited (76380) or (70450) be correct ? If a limited CT is done for a non-invasive spinal procedure, would the CT be bundled into the S&I code?
A 6-week-old girl with HLHS, interrupted aortic arch type B, and moderate VSD who is status post Norwood, modified BT shunt and DKS presents with concerns for RV dysfunction with moderate tricuspid regurgitation and LPA stenosis on last echo. She presents for diagnostic cath to rull out causes of RV dysfunction and/or possible intervention. A right and left heart cath via existing atrial septal opening (93533-26) was done. Contrast injection of the innominate artery shows a right-sided BT, which is widely patent. The RPA appears to be of good caliber. There is severe long segment stenosis of the LPA with severe hypoplasia distally with normal pulmonary venous return of the left atrium." Is the statement 'rule out causes of RV dysfunction' sufficient documentation to support medical necessity for billing the S&I for the BT shunt (75710-26)? Also, can we bill for the catheter placement in the innominate artery (36215), or would that be bundled in the pulmonary angiography code 93568?
"We have a patient who presented to IR for an attempted transvenous esophageal varices sclerotherapy. The portal vein, splenic vein, and superior mesenteric veins are known to be occluded. The access site was the right femoral vein. A draining vein for a splenorenal shunt was selected without success in accessing the varices. Catheter was moved superiorly into the inferior phrenic vein (36012) and venogram performed with no access. Catheter withdrawn to find second vein from the femoral vein without success. Venocavogram was then performed at the level of the kidneys and catheters removed." We have findings for the selective vessels, vena cava, and kidneys. What would we use for our imaging codes? I don't think medical necessity was met for the vena cava imaging, but I also cannot find a code for the visceral venous imaging.
Does code 36147 include selective venography of a collateral vein to assess for surgical turndown option? Or should I use codes 75791, 36011? "Patient has left upper brachial artery to cephalic vein fistula. Lower fistula is punctured and contrast injected, demonstrating decent flow through the fistula which is well-dilated peripherally. There is one focal area of mild narrowing in the mid fistula which is not felt to be flow limiting. There is diffuse stenosis of the cephalic arch with collateral vessels draining to the axillosubclavian veins. Left-sided central veins are widely patent, as is SVC. Next a glidewire is advanced centrally and a sheath placed. A glide catheter was used to selectively catheterize the left arm basilic vein. Diagnostic venogram was performed at the same time that the fistula imaging was performed to assess the feasibility of surgical turndown option. This showed the basilic vein to be a large caliber vessel comparable in diameter to the fistula. It was widely patent through its transition to the axillosubclavian vein."
For the following case, are the angioplasties performed in the iliofemoral billable, or would they be considered bundled into the carotid stent with filter procedure (37215)? "The patient has extensive lower extremity vascular disease. The right femoral artery cannot be accessed percutaneously, and left side is therefore accessed. Severe occlusive disease is present in the iliofemoral segment. Angioplasty was required with a 6 mm balloon of the external iliac and common femoral on the left, allowing placement of 6 French sheath. A 6 mm balloon was dilated to 12 atmosphere pressure of the left external iliac and proximal-mid common femoral. Stenting was not performed. The physician went on to selectively catheterize bilateral common carotids, and left subclavian retrograde for grams, and eventually placed a right carotid artery stent with filter."
If a central line is placed (including a central venogram because of concerns that the left brachiocephalic might be occluded) and able to be placed "with its tip located in the mid superior vena cava even when the catheter was fully inserted. This high location and visualization of a kink in the neck suggested that this access would be problematic. It was felt that another puncture into the left internal jugular vein could be performed from a slightly lower location and using a different angle that would likely be less prone to create a kink in a catheter." So another access in the left jugular was used to replace the central line. Can the first access and venogram be placed in this situation in this situation in addition to the CVL placement or not?
I could use your input on the following scenario: The patient has a non-functional AV bovine graft in the left forearm, which our physician ligated and removed to prevent steal phenomenon in a new upper arm fistula, which he created in this same operative session. Normally, I would code for the ligation of the AV graft (37607) and the creation of the new upper arm direct type fistula (36821). Is there another code that could be used for the ligation and removal of the old forearm graft, which was not infected? The ligation was successful, but our physician was concerned that once he created the new AV upper arm fistula the patient would develop a steal phenomenon without removing the old forearm graft.
A 4-vessel cerebral arteriogram was performed on a patient with two aneurysms on two different vessels. 3D spin with reconstruction was performed on each vessel with the aneurysms. Can we bill 76377 for each spin that was done?
POSTOPERATIVE DX: Enlarging symptomatic thoracoabdominal aneurysm. PROCEDURE: 1. Left iliac artery to superior mesenteric artery bypass. 2. Left iliac artery to hepatic artery bypass. 3. Endovascular repair of thoracoabdominal aneurysm using Medtronic Valiant thoracic stents x2. IMPLANTS: 1. 12 x 6 bifurcated knitted Dacron graft. 2. Thoracic stent Valiant Medtronic 44 x 44 x 150, proximal main. 3. Valiant thoracic stent 46 x 46 x 100, distal main.
We are having difficulty determining whether we should code both C9604-LD for the drug-eluting stent and 92928-LD for the bare metal stent. Can you help? Report follows: "Saphenous vein graft to diagonal was selectively engaged with the left coronary artery bypass graft catheter. A 0.014 filter wire was advanced through mid body lesion of the graft. There is a 90% lesion with what almost looks like a dual tract. After crossing the lesion, a 3 x 12 mm stent was advanced and deployed at high pressure. There is an 80% to 90% lesion in the diagonal below the graft as well. At this point, filter wire was retrieved, and a 0.014 All Star wire was used to cross the diagonal lesions. A 2 x 23 mm Vision mini stent was deployed with no residual stenosis. The patient tolerated the procedure well, and there were no immediate complications. IMPRESSION: Successful drug-eluting stent deployment to mid body of saphenous vein graft and also a bare-metal stent deployment to diagonal downstream."
We are receiving denials for bilateral tPA codes 37213 and 37214. We spoke to a customer service rep at Medicare (First Coast Service Options) and were informed that a -50 modifier is appropriate for the initiation of (venous in this particular case) tPA (37212). However, codes 37213 and 37214 may NOT be filed with a -50 modifier, as the second will be denied for MUEs. My question is, if Medicare allows bilateral initiation of tPA, why are the subsequent and final day tPA codes not allowed with a -50 modifier? FCSO also does not allow anatomical modifiers (-RT/-LT). This appears to be a contradiction. To your knowledge, is someone working on this MUE/NCCI edit? We appreciate any insight you have with this issue.
It's our understanding that if/when a CT angiogram is performed prior to a Y-90 pre-treatment selective catheter study, then the diagnostic angiogram is not separately billable. (That is, unless there is a qualifying reason why another diagnostic study was necessary.) Having said that, when there is no documented reason for another "diagnostic" study and no need for protective embolization during the pre-treatment study, what codes should be reported? The selective catheter placements and MAA injection only?
I am new to thoracic coding and could use some help. "A small left anterior thoracotomy incision was made, and the chest was entered through the 3rd intercostal space. Pericardium was tented and opened. An area on the lateral side of the left ventricle was identified, and an epicardial pacemaker lead was affixed to the left lateral ventricular surface. Parameters were excellent. The lead was then connected to a VVI permanent pacemaker, and it was placed in a left upper quadrant pacemaker pocket."
Could you please help with the case below? We have a disagreement regarding which code is appropriate to report (32551 or 32557) and why. I want to assign 32557 since 32551 states it is an open procedure. "After local anesthesia was administered with lidocaine 1%, a 18 gauge coaxial needle was advanced into the air pocket in the left posterior chest wall using CT guidance. A stiff 035 Amplatz wire was advanced into the air collection through the coaxial needle. After the tract was dilated, a 12 French locking pigtail catheter was advanced into the collection. A completion non-contrast CT was performed to evaluate catheter positioning. The catheter was secured to the skin using 2-0 Prolene suture and attached to a Pleur-evac at 20 cm suction. A sterile dressing was applied."
Is that description automatically a TMVR? Can't this procedure be done on other valves as well?
Patient has a device (e.g., dual chamber pacemaker) placed on day 1. The next day (before hospital discharge) a device check or reprogramming occurs. Is this device check/reprogramming billable? We have differing opinions on this. Opinion 1: No, it is part of the device implantation and is not separately billable. Opinion 2: Yes, because the CPT Codebook states that you cannot bill device evaluations, etc. “in conjunction with” the device or “at the time of implant”. Because it is the next day, it is neither “in conjunction with” or “at the time of implant” and therefore is billable. Please advise with definitive documentation (if possible) to support, as this both sides feel confident in their positions. I have done searches at HRS and coding websites with no definitive answers.
This case has really gotten me stumped. My provider used a covered Viabahn stent graft to exclude an aneurysm in a saphenous vein bypass graft from the femoral to the popliteal artery. "A micropuncture wire was advanced into the bypass graft and sheath advanced over the wire. Dilator was removed and an Amplatz superstiff wire placed distally. A 6 French Pinnacle sheath was placed over the wire. Angiographic images confirmed aneurysmal dilation. A 5 x 8 cm balloon was placed and low-inflation dilation performed. We then placed a 5 x 15 cm self-expanding Viabahn covered stent graft. A 5 x 12 cm balloon was then used for light post stent angioplasty. Angiography revealed no further residual aneurysm." I don't think this code would be from the 37221-37235 group because it is not to treat occlusive disease. It was not an open procedure, so I don't think codes 35141-35152 apply either. Should I use an unlisted code?
After a cath, it was determined that the patient needed a CABG and repair of aortic root dissection. The surgeon used BioGlue to glue the root back together, then fully transected the aorta and performed an end-to-end anastomosis to prevent it from propagating any further. I'm considering using modifier -22 on the CABG CPT code, but I'm not sure. The only other code for aortic repair is 33320, but I'm not sure about that either. Please share your thoughts.
Can you use code 92973 if a mechanical thrombectomy is attempted but clot could not be removed? Would a modifier suffice?
How would I code a bypass from the saphenous vein bypass graft (fem-pop bypass) to the bovine carotid artery graft (iliofemoral bypass)?
Can you use code 76937 with arterial access? This is why I am asking... CPT Assistant, December 2004, page 13, states: "This imaging includes preaccess assessment of venous patency and actual real-time visualization of needle passage to the venous lumen. The descriptor for code 76937 includes all phases of actual guidance, documentation, and reporting required to perform this procedure. Use of code 76937 requires a permanent recorded image(s) of the vascular access site to be included in the patient record, as well as a documented description of the process either separately or within the procedure report. Therefore, for those instances when ultrasound is utilized only to identify a vein, mark a skin entry point, and proceed with nonguided puncture, it would not be appropriate to report code 76937 for ultrasound guidance."
Can code 49083 be reported for aspiration of ascitic fluid when performed with fluoroscopy and the peritoneal port is what was accessed for the aspiration?
One of our physicians had a complication during a venous intervention, and I'm just wondering if it can be billed and, if so, what the correct codes would be. "The patient had stents placed in the bilateral common femoral veins, external iliac, common iliac vein, and a double-barrel stenting of the IVC. The complication occurred during the ballooning of the last stent in the left common femoral vein. The balloon ruptured and would not deflate fully; it appeared to get stuck on the stent and pull it in a more caudal position. After multiple attempts to remove the balloon it was decided he would have to do a cutdown. The physician opened the femoral vein, removed the balloon and stent, explored the vessel, and closed." He is billing 35860 and 37197, and I'm pretty sure they are not correct. Can this complication be additionally coded, or is this included in the primary codes? If it can be coded, what would the correct codes be?
Cerebral carotid angiogram was done and determined that aneurysm clipping would be done by craniectomy (not done same day). An intraop angiogram was done (36224) after surgery and within the report it states, "See separate dictated operative notes for details." Would this be billable? I am thinking not (done more for a check of the aneurysm), but I was thinking if angiogram is not billable would I be able to bill for the catheterization (36217)?
I have always billed G0278 to Medicare patients for non-selective injection of the iliofemoral system. Recently, I have seen a lot of denials for medical necessity, insufficient documentation, CAD, SOB, etc.... none of these are deemed medically necessary. Should I not bill code G0278, or should I appeal with notes? I have not had a problem with denials before, but now that there are more my billing system has created an edit to stop these from being billed and I'm not sure what is the proper way to proceed.