Knowledge Base

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Set Descending Direction

CVC Guidelines, Failed Access Site

For Permcath placement, should I be billing for failed access site as well as the procedure36558, 36000? "The right internal jugular vein was noted to have a prominent valve. There was hematoma present between the jugular and carotid. The right internal jugular vein was accessed using an 18 gauge needle with one stick using ultrasound guidance. A wire was not able to traverse the right innominate vein. The wire was exchanged for a Glidewire and Berenstein catheter; however, this combination could not successfully traverse the occlusion. The access was removed, and manual pressure was held. Hemostasis was achieved without complications. Attention was then turned to the left neck. The left internal jugular vein was accessed with one needlestick using ultrasound guidance."

EP Ablation with Transseptal Puncture

We have a new EP doctor coming to our facility. Recently he did an SVT ablation (93653) that was right- and left-sided, pre/post isuprel, 3D mapping, placed a catheter in the CS, utilized ECHO, and performed a transseptal puncture. He is stating that he does not need LA pressures to prove he was in the atrium so that we can charge for code 93462. I disagree. I feel like he should have established proof for charging and record purposes. Also he is charging and reporting that he did both LA and LV recordings via the CS. So to recap, 93653, 93662, 93462, 93621, 93622, 93623, and 93613. Is he correct?

LHC vs. Coronaries with Grafts

I am having a hard time coding this one. I am having trouble finding an appropriate code for SVG angio. I'm assuming that the other codes are 93458, 93567... "CAD Presentation: Angina cath. Post Procedure Diagnosis: Single Vessel Coronary, 70% Ostial RPDA. Occluded SVG to RPDA. Mechanical Aortic Valve. Severely Dilated Aortic Root. Procedure Performed: Coronary Angiography, LHC, Aortic Root Angiogram and SVG Angiogram. Findings: L-Main-OK LAD-OK LCX-OK RCA-70% Ostial RPDA. SVG to RPDA. Aortic Root-Severely Dilated SVG to RPDA." 

Stent with IVC Filter Removal and Placement

"1. IVC gram 2. New filter deployment in the suprarenal position 3. PTA of the infrarenal IVC within the area of stenosis in the occluded IVC filter 4. retrieval of the infrarenal IVC filter 5. stent IVC in the infrarenal portion 6. retrieval of the suprarenal IVC filter and redeployment of this filter in the infrarenal position above the stent. Patient has CTO IVC. She underwent thrombolysis and now has a tight stenosis of the IVC in the area of the IVC filter. Plan is to remove this filter, stent it, and then redeploy a filter higher. Because the filter could have clots, the plan was also to put a filter in the suprarenal position temporarily to make sure she did not embolize. Venogram of the IVC performed. PTA the IVC within the filter to allow smoother passage. Deployed new filter in the suprarenal position. I then retrieved the old filter. Residual stenosis that had grown within the filter, so I stented it and then put a 12mm balloon within this stent. I then retrieved the suprarenal filter and re-deployed it in the infrarenal position above the stent." What would the appropriate codes be?

Angiography and Embolization

Can you please help clarify when to code diagnostic angiography? Since we know that patient has cancer, and arteriography and embolization were planned, would these codes be correct: 37242, 36245, 36247, 36248 x4, 72726 x2 (59), 75774 x3 (59)? "CLINICAL HISTORY: Female with hepatocellular carcinoma and hypersplenism presents today for planned arteriography and embolization in preparation for planned radioembolization. PROCEDURE PERFORMED: 1) Selective superior mesenteric artery angiogram. 2) Selective celiac artery angiogram. 3) Selective proper hepatic, right hepatic, left hepatic, and middle hepatic artery angiograms. 4) Infusion of Technicium-MAA into the right hepatic artery. 5) Selective splenic artery angiography with embolization."

Endo AAA with Femoral Endarterectomy

Patient underwent endo AAA Endurant II. Provider said two docking limbs with no extensions. We coded 34803, 75952, 36200-50, and 34812-50. After all performed, they discovered a problem in femoral artery, placque removed, and required femoral artery endarterectomy. I'm a little confused as to when we can bill for problems such as this. Do you consider the femoral endarterectomy billable as well? AAA aneurysm and PVD diagnoses given.

Seroma Aspiration and Fibrin Glue Instillation

"Patient is post-op ventral hernia repair with aspiration of multiloculated fluid collection. After as much fluid as possible was removed, 8 cc of fibrin glue was instilled." Is this separately reportable? If so, what code would be reported?

Cardiac IV Drug Infusion

"PROCEDURE: IV drug infusion Clinical Summary: This is a 40 year old male with idioventricular rhythm, VT and PVCs all coming from the same source. These are gith bundloid with an interesting transition. There are negative in I and aVL; positive in the inferior leads. DESCRIPTION OF PROCEDURE: I brought him in. He was not having any PVCs and that was despite stopping flecainide and beta-blockers, so we put him IV drug. We put him on Isuprel and got his sinus rate up to 150 beats per minute or there abouts, and he had no PVCs. We let it wash out. There were no PVCs. He was never sedated. He then received an IV infusion of caffeine 500 mg IV, and he had a total of 2 PVCs, and that was only when we gave Isuprel combined with the caffeine. FINAL IMPRESSION: This patient has scant ventricular ectopy despite prolonged IV drug infusion of multiple agents." My question is, would you bill this with codes 37202 with 75896? Someone stated that only the meds used can be billed. I am new to cardio, so I am in need of your advice. 

73540: Radiologic examination, pelvis and hips, infant or child, minimum of 2 views

73540: Radiologic examination, pelvis and hips, infant or child, minimum of 2 views In 2016, CPT parenthetical notes state "73530, 73540 have been deleted. To report see 73501, 73502, 73503). Note that the previous bilateral code stating hips (plural), which in 2015 had a bilateral status indicator “0” (Indicator "0" in the Bilat Surg Column on the MPFSRVU means that the bilateral concept does not apply for this code), is now “cross referenced” to unilateral replacement code sets (73501, 73502, 73503). I am not able to find a reference that explains this conversion to my satisfaction, as I feel we should instead use the appropriate 2016 bilateral hip code sets 73521, 73522, 73523 dependent on the number of views. I would appreciate your insight on correct reporting in 2016 for imaging a child bilateral AP hips & pelvis on the first view along with a frog lateral bilateral hips & pelvis on the second view.

Accidental "Lacerations"

"After single attempt of manual aspiration thrombectomy, there was extravasation noted of the right middle cerebral artery. The vessel was successfully embolized with Onyx liquid agent with resolution of the extravasation. Can you bill for both the thrombectomy and the embolization? I thought that if in the process of one procedure the physician accidentally punctures a vessel that you cannot bill the patient for fixing that error. Or is that a known risk of thrombectomy that can be billed? 

Split/Shared visits for Medicare

The PA sees a patient in the ER department and performs an initial visit and determines that surgery is necessary. He documents his service while the supervising provider is in a case. When the surgeon is available he has a face to face visit with the ER patient on the same day. The surgeon performs a physical exam agrees that surgery is necessary and documents his portion of the E&M service appropriately. Can the E&M shared between surgeon and PA from the same group practice be billed to Medicare under the physicians number? Does it matter that the PA has made the decision for surgery and orders have been started since this is a shared visit?

Thrombectomy and revision of femoral-popliteal bypass

Is the following reported with codes 35876 and 35304? "Thrombectomy of the fem-pop bypass was performed with vein patch angioplasty, and flow was successfully restored through the vein graft; however, it reclotted within minutes of restoring flow. After multiple attempts to restore flow, it was felt that there may be an issue with the vein graft, so the graft was removed from the proximal and distal anastomoses. The popliteal artery arteriotomy was closed with a vein patch. A 6 mm thin-walled, ringed gore PTFE graft was tunneled through the previously created tunnels. The ends were spatulated and anastomosed in end-to-side fashion with 6-0 gore suture. Flow was then restored. Doppler interrogation demonstrated excellent flow-through graft. The distal outflow sounded somewhat high resistant. This point dissection was carried down the distal popliteal artery to the tibial/peroneal trunk. There was significant calcification noted at the origin of the tibial/peroneal trunk and anterior tibial artery. A longitudinal arteriotomy was made, and a limited endarterectomy was performed." 

AICD Removal and Implantation at a Different Site

I could use some help in this interesting situation. "History: Patient had a dual AICD implanted on the left side. Patient's treatment plan included radiation on the left. The left dual AICD was removed and the leads capped with a single AICD implanted on the right. Treatment was discontinued." Also need help with this procedure: "The single AICD on the right is removed along with the leads (33241 & 33244). A dual AICD was implanted on the left, and the existing leads that were previously capped were uncapped and attached to the dual generator (33230)." I reported codes 33241, 33244, and 33230, but there is a hard edit with 33241 and 33230. CPT indicates code 33263 should be used, but the same type of system was not used (single removed and dual implanted); therefore, I don't think 33263 is correct. Is it correct to code this procedure with 33230 and 33244? I thought the implantation was more important to code than the removal.

Vasospasm

"Six vessel diagnostic cerebral exam was performed. Decision was made to treat vasospasm of RICA and LICA." Discussion is whether or not the catheter selections for the bilateral ECA vessel selections are still chargeable since the catheter selections of the RICA and LICA are bundled into code 61650. I don't feel they are since, they are add-on codes to 36224 bilateral in this case. 

Vagal Nerve Stimular Removal with DICD Implant

"Patient underwent a DICD implant. Patient had an existing vagal nerve stimulator where the physician wanted to implant the DICD. The physician removed the VNS and capped the lead. Pocket was then revised to accommodate a DICD and atrial and ventricle leads. The VNS was not re-implanted and was discarded." In this scenario can you code only the DICD implant (33249), or can you also code the VNS removal (61888)?

Brachytherapy ICD-10

Is there an ICD-10 procedure code available for coronary brachytherapy?

Lower Extremity ABI/PVR Complete

"Bilateral lower extremity arterial duplex scans were performed with evaluation of the infrarenal abdominal aorta. The infrarenal abdominal aorta measures 2.3 cm proximally, 2.1 cm in its mid portion, and 2.1 cm in its distal portion. The waveform is biphasic, and the peak systolic flow velocity is 74cm/sec. Ankle-brachial indices were measured in both LE. They are 0.96 or greater bilaterally. Waveforms are biphasic in both lower extremities down to the level of the dorsalis pedis artery. Peak systolic flow velocities are within normal range. Conclusions: 1) Resting ankle-brachial indices and pedal Doppler waveform suggesting no evidence of significant arterial insufficiency of either lower extremity. 2) Continuous wave Doppler waveforms of both lower extremities are within normal range. 3) No evidence of infrarenal abdominal aortic aneurysm." We reported codes 93925, 93978, and 93923. Is this correct?

Iliofemoral Bypass Graft at Time of EVAR

"Patient with AAA aneurysm and critical vascular occlusive disease with claudication presents for endovascular repair. Vascular and IR co-surgeons: the vascular surgeon performs bilateral cutdowns, RCI to femoral bypass (used as access for delivery of Endologix main body device and to bypass critical occlusive disease on the right), and right femoral endarterterectomy." I'm thinking that the bypass could be coded separately and that it would include the cutdown on that side and the endarterterectomy as inflow-outflow...34804-62, 36556, 34812-XS for the vascular surgeon? Please advise.

Baclofen Pump Insertion

Is 62360 the correct code for a Baclofen pump insertion?

Guidance for a Liver Biopsy

If ultrasound and fluoroscopic guidance are used for a liver biopsy, should we report code 76942 or 77002? Or both?

NCCI Edits - Guidance for CPT 50200 - Renal Biopsy

We just noticed that guidance codes 76942, 77001, 77012, and 77021 were added as column 2 codes for CPT 50200 effective 1/1/16. There has been no change to the CPT description or to the notes following the CPT code regarding radiological S&I. Are you aware of the CMS rationale for implementing these edits? Any insight you could provide would be appreciated. 

76377

How many times may CPT code 76377 be used in a single encounter? Bilateral internal carotid arteries and the left vertebral artery were imaged. 

THROMBECTOMY/ANGIOPLASTY AV FISTULA

Hi Dr Z, Coding Open and Catheter use procedure? Senario: Discected upper ext. graft and performed graftotomy. Thrombectomized venous end graft which inadvertently thrombectomized arterial limb. Arterial limb clamped. Patient heparinized with 3000 units. After thrombectomy performed, then contrast inj, show residual thrombus at venous outflow of graft. Using clot catheter removed residual thrombus. Inj. contrast. Balloon angioplasty 7mm Armada balloon, then deployed 7x50 mm Viaben stent graft. Resulting arteriography demonstrated wide patency, no residual stenosis and nice luminal surface. We then utilized balloon to perform contrast inj centrally which demonstrated in-stent stenosis of innominate vein stent. Therefore use a 12mm x 60mm Armada balloon angioplastied innominate vein stent. Removed catheter, wire and sheath, locally heparanized and performed contrast inj. through arterial limb of graft, demonstrating wide patency. Closed graft with running 6-0 Prolene suture. Verified homstasis, irrigated wound and close wound with deep layer closer.

Endarterectomy w/fistula

I have an interesting case, and I'm wondering if you may have some insight. The patient was to undergo brachiocephalic arteriovenous fistula creation for dialysis access and required a brachial endarterectomy with a bovine patch angioplasty, to which the cephalic vein was then attached to create the fistula. I know in lower extremity bypass procedures the inflow/outflow would be inclusive, but this is not technically a bypass procedure. It has no NCCI edit per Craneware. However, since code 36821 has a "separate procedure" designation, I hesitate to bill these together, as they are in the same anatomic site at same session. If only one code is determined to be billable, could I bill the endarterectomy since this is more extensive (higher RVUs) than the fistula creation (36821), even though the intent of the operative session was for creation of the fistula?

35907

"In order to excise the infected abdominal graft at a later date, patient was scheduled for axillary bi-femoral bypass. However, he developed hemorrhagic shock with hemoptysis and was emergently taken to the operating room 10 days ago to endovascularly cover the pseudoaneurysm with placement of two 28 x 28 x 49 extension prosthesis and Amplatzer plug. He then underwent axillo-bi-femoral bypass 7 days ago and came back to the OR to remove the infected aorta bi-femoral bypass graft (35907-58). Surgeon also removed the endografts and the Amplatzer plug that were placed 10 days ago emergently, which he encountered while removing the aorta bi-femoral graft." Do we separately code for removal of endografts and the Amplatzer plug? If so, do we bill an unlisted CPT code with a -58 modifier? 

Bundled Sedation Narcotic Billing

If sedation is bundled into the procedure code(s), can the physician-owned facility still invoice for the narcotics used?

Retrograde Urogram

I am billing for the radiologist who is interpreting images from an intraoperative retrograde urogram. The report is as follows: "Images from an intraoperative retrograde urogram demonstrate opacification of the ureters and collecting systems. No filling defects on these images. A left nephroureteral double-J stent is identified. Please refer to the operative report for further details." Can I report code 74420-26? Many of these types of reports give less detail and only mention seeing a stent in place, such as: "Two fluoroscopic spot images were submitted for review and demonstrate wire and stent placement within the ureter. For complete findings see the procedural report."

Dynamic infusion cavernosometry and cavernosography

Would the following be coded as a 54230-74445 and 54231, or 54235? "23 gauge butterfly needles were inserted into the right and left corpora caverosa just behind the glans penis. Small contrast injection with fluoroscopy confirmed secure intracavernosal location of both needles. While occluding cavernosal outflow with umbilical tape placed around the base of the penis, papaverine 60 mg followed by phentolamine 1 mg was injected into the right needle. The drugs were distributed between the two corpora with massage. Ten minutes later, infusion of half strength contrast material was done through the right cavernosal needle at 1 mL/second for over one minute while pressure was continuously recorded from the left cavernosal needle. Radiographs were saved. Because of markedly abnormal response, redosing was done with papaverine 60 mg and phentolamine 1 mg with one minute of cavernosal occlusion and manual drug distribution. Five minutes later, infusion cavernosometry and cavernosography were repeated. Needles removed."

Conversion of Antegrade Ureteral Stent to Nephroureteral Stent

"Nephrostogram and nephrostomy. Catheter was removed. Using snare, existing antegrade ureteral stent was removed. Glidewire was advanced and a 10 French nephroureteral stent was placed." Should this be reported with codes 50384 and 50433?

Thoracic Outlet Procedures

"Patient underwent left first rib resection and scalenectomy for thoracic outlet syndrome. Following this, due to significant tightness at the inferior level and to give complete relief, excision of left subclavius muscle and left pectoralis minor muscle was performed." My thought is to use codes 21615 and 21700 for the excision of the first rib and scalenectomy, but I am not sure how to code for the excision of the subclavius and pectoralis muscles, and I would appreciate any direction you could give.

Pacemaker Relocation

"Patient has a right subclavian pacemaker and is going for radiation to that area and has to have the device relocated. Decision was made to move the device to a subcostal location. Previous device was removed, subcostal abdominal pocket was created, and leads were tunneled to the abdominal pocket and connected to a new generator." Is this just a change out (33228) with the relocation included in code 33228, or is this an instance when we can report the relocation with code 33222?

Repair of Atrial Lead

"Patient had her atrial lead protruding up and tenting the skin. We were afraid it would rupture through. The lead was pulled out as best as it could. We cut it and then pulled the inner core and put an O suture around the end and sutured it to a deeper layer of the epidermis." CPT Assistant, October 1996, page 9 states that code 33218 "includes services like splicing a fracture and/or modifying a terminal pin". Would you consider coding this "repair" with 33218?

Median Arcuate Release

Is there a CPT code for the division of the median arcuate ligament? Also, can you bill for this separately with the bypass?

Blebectomy

I need clarification on blebectomy/bullous disease. "26 year old male with spontaneous pneumothorax due to small bleb. Physician does VATS wedge resection of small bleb and pleurodesis." Is it okay to use codes 32666 and 32650 for blebectomy vs. 32655? Is it ever okay to use code 32666 for VATS wedge resections of bullae, even small ones, including another pleural procedure? The physician feels he should be able to use code 32666 and pleural procedure like 32650, as he is doing the same work as 32655 but getting less RVUs for 32655. 

Chronic Total Occlusion

A patient had an intervention on the right coronary artery. The distal RCA had a chronic total occlusion, and only an angioplasty was performed there (93943). The proximal RCA had an 80% lesion, and a drug-eluting stent was placed there (C9600). I have two questions: 1) Would you suggest coding 93943 or C9600? 2) If only the proximal lesion had been intervened on, would we have to code C9600 since that part of the vessel did not have the CTO, or could we code C9607? (This is for a hospital.) 

Multiple Embolectomies in the Upper Extremity

Can you bill more than one CPT code for embolectomies done on the brachial, radial, and ulnar arteries via the same incision? I understand that, if they are contiguous, you can only bill one CPT code, but what if there are more than two vessels?

Right Popliteal, Tibial/Peroneal,and Posterior Tibial Artery Exploration with Unsuccessful Thrombectomy

"Due to adherent veins it took physician two hours to expose the tibial/peroneal trunk. Both arteries were very calcified. Both were opened longitudinally. Fogarty cath was attempted, but neither artery would allow passage. Incision was extended with exposure down the leg to isolate the posteriort ibial, and arteriotomy was made. Lumen of the artery would not allow any thrombus to be removed. Slight backbleeding from posterior tibial was not enough to proceed with bypass." The physician reported codes 34201 and 34203. I added a -22 modifier to 34203 and a -53 modifier to 34201. Can you please give me directive on this procedure? I felt as though both needed a -53 modifier, but I felt the -22 modifier would not pay, and since it took him so long to isolate that artery I did not feel it appropriate for his sake not to append the -22 modifier. I also wondered if there should just be exploration billed with a -22 modifier. Many questions are running through my head on this one.

Ligation of Popliteal Aneurysm and Bypass

Provider performs a fem-pop bypass due to popliteal aneurysm and also ligates the popliteal aneurysm. Can you bill code 37618 with 35583?

LHC and FFR

"Patient with a prior MI 20 years ago with a scarred calcified anterior wall. He had a worsening EF down to 20% with increasing SOB and, therefore, had a heart cath with Physician A one month ago. He was found to have LVEDP of 13 at that time, as well as 70% left main lesion. The LAD was diffusely diseased. The circumflex had no obstructive disease, and there was some disease in the calcified ramus. Physician B reviewed the films, and he was concerned that the left main may be hemodynamically significant and that ischemia may be causing the patient's fall in EF. Patient was requested to come back in for an FFR of the left main. During the FFR they also performed a LHC." My question is, since the patient had a previous heart cath a month earlier, can we report the LHC with the FFR? If not, then how do we code the FFR, as it is an add-on code? 

93975 and 96976 Documentation

Related to pelvic, abdominal, and retroperitoneal ultrasounds, we understand that code 93975 or 93976 should not be reported in addition to the base ultrasound code when used for a quick assessment of blood flow or to simply identify a structure. Could you help us clarify for our physicians what elements should be seen in the report in order to substantiate these codes? This is an example of what we often see: "Technique: Transabdominal and transvaginal imaging, 2D gray scale, color Doppler, spectral waveform analysis. Findings: Uterus measures XX, uterine fundus circumscribed hypoechoic structure measuring XX. Another located in the posterior fundus measures XX. Endometrial measures XX. No endometrial fluid seen. Overlying bowel gas structures obscures right ovary. Left ovary measures XX. It demonstrates normal color flow Doppler and spectral waveform analysis. No free fluid seen." Could you please review and clarify if there is sufficient documentation to report codes 93975/93976 in addition to pelvic and transvaginal ultrasound codes?

Thrombectomy

Can code 37186 be reported twice when performed on bilateral lower extremities at time of angioplasty also performed bilaterally, since these are different vascular families?

Use of CO2 rather than contrast media

Can angiogram and angiography CPT codes be reported if CO2 is being used rather than contrast media due to the patient having CKD?

Brachial Cutdown with Embolization

I have a facility that needs to do a brachial artery cutdown for a splenic artery embolization with coils (37242). The codes for embolization/occlusion do not specify open or percutaneous. Would you charge unlisted code 37799 for the cutdown procedure? Or is it included as part of the overall catheterization access?

Four Biliary Catheter Exchanges

Exchange of 1 internal/external biliary catheter in the right posterior inferior intrahepatic biliary duct and exchange of 3 internal/external biliary catheters in the right intrahepatic biliary duct. Can we code 47536 x 4 or just 2?

Pacemaker System Implanted, Followed by Lead Being Broken During Procedure

What code(s) are appropriate when an initial pacemaker system is being implanted and the lead is broken or damaged and has to be replaced?

Embolization Cholecystostomy Tract

Is there a code for embolization of a cholecystostomy tract with coils when removing the tube?

Viabahn Stenting of Right Popliteal Aneurysm

Patient underwent AFRO with Viabahn stenting of a right popliteal aneurysm via left common femoral percutaneous access. I am unsure how to code this since popliteal artery aneurysm is not a valid diagnosis for 37226 per LCD. Is there another code you might suggest for this scenario?

Iliac Endarterectomy and Fem-Fem Bypass

Can we bill for an iliac endarterectomy along with the fem-fem bypass here? "CFA was exposed through left groin incision. The femoral artery was not pulsatile, and the incision was extended proximally splitting the inguinal ligament until the ileal femoral segment was exposed. The artery was calcified but pulsatile, and a spot was identified for clamp placement. The artery was dissected and side branches were controlled with loops. Loops were placed around the inflow artery as well as the superficial and deep femoral arteries on the left side. A second vertical incision was made in the right groin, and the fem bifurcation was exposed. At this point there was some lateral plaque but the vessel was generally soft. A suprapubic tunnel was created from the left groin to the right groin. Arteriotomy made in the left CFA and extended up the circumflex iliac artery. An endarterectomy of the vessel was then done with a clean break achieved in the deep femoral artery. Proximally the endarterectomy was blindly extended into the EIA to the point of clamp placement. The graft was anastomosed end-to-side to the endarterectomy. Graft passed into the right groin and anastomosed to CFA."

Dictating CPT Codes

Years ago I went to a seminar (unfortunately not yours), and I remember the consultant mentioning that it is not good for a doctor to add the actual CPT and ICD-10 (was ICD-9 at the time) codes into the dictation of an operative note. I currently see a doctor who is doing this, and I'm wondering if it is appropriate. Can you tell me if this was just an opinion brought forth from a Medicare auditor or if there is a general rule or guideline on this? For the most part the coding is correct, but some of it is not, and I fear there may be a compliance issue. When I try to find documentation on the subject, I cannot locate much of anything, so I would like to know how you feel about this. Is there is any kind of guideline that states a doctor should or shouldn't? If you feel that dictating the codes into the operative report is a good idea can you explain why? 

Pressures Taken in Ascending Aorta

My surgeon billed for a right retrograde left heart catheterization, but pressures were only taken in the right atrium and in the ascending aorta. Can we bill for that? Or is it just 93530?

Penumbra Device for DVT in the Legs and IVC

Our reps are pushing the Penumbra device to be used in the legs for DVT. If this device is like a thrombectomy device, wouldn't I use venous thrombectomy code 37187 even if we don'tt use tPA? According to what Penumbra is saying we don't need to use tPA with this device like we do with AngioJet or EKOS. That is their selling point. Can you please help?

RV Lead and Tricuspid Valve Replacement

"A patient has a tricuspid valve replacement and develops a complete heart block. A dual chamber pacemaker is placed with an atrial lead, and the RV lead is placed in the coronary sinus to avoid damaging the replaced valve." Would this be reported with 33206, 33225, or 33208?

AAA with Chronic Occulsion of Iliacs

I have been looking for a code for AAA and iliac repair. The device is "TriVascular Ovation Prime Bifurcated Device". I have read some info, but I can't figure out what code to use... or is this an unlisted one? What is different is there is Polymer injected and has a cure time (i.e., 20 min) on this patient. I have never seen this before. Any advice would be greatly appreciated.

Neph Stent Placement with Nephrostomy Tube Change

How do you code a ureteral stent placement using an existing nephrostomy tube tract and nephrostomy tube change? Are codes 50393 and 50435-XS appropriate?

Selective Coding

If the right subclavian artery is selected and the right vertebral artery is selected, would the coding be 36225 and 36226? Or just 36226?

Visceral/Renal Angioplasty

If the documentation states the doctor performed a selective renal unilateral or bilateral (36251 or 36252) diagnostic angiogram and catheter placement, can this be billed with code 35471 (angioplasty)?

Bundled Guidance Codes, 76942

If an ultrasound-guided needle biopsy is done on a superficial lymph node (38505, 76942), and a clip is placed at the same site (10035), should we be reporting ultrasound code 76942? There is an NCCI edit for codes 10035/76942. Are there specific guidelines I can reference for this situation?

Closure Device

We have a professional billing client that performed "angiogram through existing left groin sheath and removal of femoral arterial sheath with deployment of closure device". What, if anything, could we bill for this? This patient had a complex IR procedure embolizing multiple bleeding arteries 7 days prior, which I presume is why they did not place a closure device at that time.

61645 and 36224

Could you please confirm if we to bill 61645 and 36224 for the procedure performed below: "1. Diagnostic cerebral angiogram demonstrates acute vessel occlusion at the right M1 segment. TICI 2B revascularization was achieved with 1 deployment of the Solitaire stent retriever device. 3. Successful endovascular stroke therapy for treatment of right M1 occlusion with a TICI 2B revascularization." Please let me know if you need additional information.

Percutaneous Transluminal Balloon Angioplasty and Stenting of the Left ICA

My provider submitted codes 37215, 35475, 75898, and 75962 for percutaneous transluminal balloon angioplasty and stenting of the left ICA. This does not seem correct to me, as they bundle, and also the description of code 35475 says "brachiocephalic or branches" (and this is the left ICA). Can you help me with this scenario please?

Iliac Aneurysm Treatment with Bifurcated Aortic Stent Graft

"Unibody AAA Endologix placed at bifurcation to treat right iliac aneurysm. Extension placed in right common and external iliac. Left common iliac stent in left limb of graft to treat kinking of the left limb. The patient has a left iliofemoral bypass graft as well. Impression: Successful treatment of the right common iliac aneurysm with placement of an Endologix body endograft into the distal abdominal aorta and then placement of the stent graft into the right external iliac artery followed by placement of right iliac bridging prosthesis. A suprarenal aortic extension could not be placed due to lack of sufficient length between the lowest renal artery and the aortic bifurcation." Should we code the graft as unlisted? Or use code 34804 or 34900 plus extensions? 

End-to-end venous anastomosis

"During a Whipple procedure part of the portal vein is resected. Vascular service comes in and performs an end-to-end anastomosis between the portal vein and superior mesenteric vein." I believe this should be reported with unlisted code 37799, but I'm not sure what code to compare it to.

Second Stage Vein Transposition

It is my understanding that if, after the creation of an AV fistula, a vein transposition is performed at a later surgical session on the same fistula, that this should be reported with code 36832 (revision of AV fistula) instead of codes 36818-36820 for vein transpositions. My physicians disagree, stating that performing the vein transposition requires significantly more work than other, more simple revision procedures, and they believe the work RVU is more consistent with codes 36818-36820. They don't agree that the description in the CPT Codebook correlates to a one- or two-stage procedure and think they should use it in either scenario. I am hoping you can shed some more light from a clinical perspective that can assist me in explaining to them why this procedure should be coded this way.

OCT in Periphery

Is OCT separately billable when performed in conjunction with peripheral interventions? If so, is it reported with an unlisted code?

G-Tube Replacement, Multiple Aspects

I have an ED physician who performed dilation of old tract with cervical dilators and inserted a 4 cm Mickey G-tube. He sent patient off to Radiology Dept to complete the Gastrograffin injection and abdominal x-ray for tube confirmation. Code 49440 includes ALL of the above. Because this is a facility coding/charging issue, HOW do I report when multiple physicians and multiple departments performed different aspects of the procedure? Because, of course, they all want their revenue. 

93640

Could you please clarify the use of code 93640? "Patient here for biventricular generator change due to ERI. Patient was brought to the lab; all of the leads worked well. The old device was removed. The leads were inspected, and they all worked well. They were attached to the new device and placed into the pocket. Three layers were used to close the wound. High voltage resistance was checked. Patient left in stable condition. Patient was in complete AV block. No shocks on previous device." We are told the physicians test the leads when they place/change/upgrade an ICD and we should therefore report code 93640. We report code 93641 when they test the generator and the patient is induced into an arrhythmia and joules back into sinus rhythm. Can you clarify on implantation/change/upgrade regarding what the report has to indicate to report code 93640? Or is code 93640 considered inherent to the procedure and not coded if the report doesn't document an arrhythmia being induced? Does the report have to indicate that an arrhythmia was induced, or can it be assumed? We (hospital) reported the above with codes 33264 and 93640.

Balloon Maceration of Clot Induced by Catheter in Coronary

"Patient has right and left heart cath with coronary angio to dx reason for SOB. Minimal CAD is found, but not hemodynamically significant, as in impression he refers patient to pulmonary (has history of exposure to asbestos). During the coronary angiogram, an acute thrombus was angioplastied (likely source dx catheter)." Since there was no hemodynamically significant stenosis, can we code/charge for the angioplasty since it looks like it was caused by the catheter? 

Occluded EVAR graft

"Access via left CFA. Glidewire was negotiated into left external and common iliac artery stent occlusion. AngioJet percutaneous thrombectomy catheter was serially advanced through the long iliac occlusion rmoving 180 mL defibrinated thrombus. Retrograde angio revealed severe in-stent stenosis. Angioplasty of left CIA and EIA was performed; there were residual stenoses, so a 17 French AFX Endologix sheath was advanced into the AAA Afx graft. An Afx iliac ext cuff endograft was deployed at the flow divider of the previous placed Afx bifurcated endograft. Baloon angioplasty post-stenting noted resolution of proximal CIA stenosis, but residual mid-ext iliac artery stenosis remained. A second iliac balloon-expandable Omni link stent was deployed. Next a left fem arteriotomy was created and critically stenosed profunda was endarterectomized." Would this be reported with codes 37184, 37221, 37223, and 35372? Or are we to look toward an endograft extension limb even though the stent was placed for graft occlusion (rather than an endoleak)? AAA repair was 4 months earlier. 

75630

I was reviewing the Case of the Month from August 2015, and I noticed that you used code 75630 to report the aorto-iliac imaging. Per the 2015 Interventional Radiology Coding Reference, the use of code 75630 "requires imaging of the abdominal aorta, not just the distal most aspect of the aorta". This is confusing because in this case the imaging was performed below the level of the renals. While I understand that this is higher than being at the bifurcation, the instructions from the reference would suggest that this would not be coded as such. Is the rationale that 75630 would be used since we had some portion of the aorta and then the runoff into the single leg from that one catheter position in the aorta, despite only imaging a portion of the aorta?

2016 Vertebroplasty

Vertebroplasty of T12, L3, and L5... By the old codes these would have been reported with 22520 (T12), 22521 (L3), and 22522 (L5), correct? So by the new 2016 codes, wouldn't these reported with codes 22510 (T12), 22511 (L3), and 22512 (L5)? But NCCI is showing that code 22511 is bundled with 22510 with no modifier allowed. I'm not understanding, because code 22510 is only for cervicothoracic. Wouldn't/shouldn't code 22511 be the primary procedure code for L3?

Right renal artery and right venous TPA thrombolysis discontinuation

"A patient has right renal arterial and right renal venous TPA thrombolysis done with two separate catheters. Follow-up with discontinuation of the right common femoral arterial sheath was then removed and hemostasis obtained with a star close vascular clip. Right common femoral venous sheath removed and hemostasis obtained with manual compression." Can I bill 37214 twice with a modifier -59 because both arterial and venous TPA thrombolysis were discontinued? I guess I want to know if I can code per type of vessel? Or do I treat this like one surgical field because anatomically it's all of the right kidney: right renal artery and right renal vein? I'm conflicted because of it being an artery and then a vein, because we have separate codes for arterial 37211 and venous 37212 thrombolysis... so should I code them as two separate surgical fields? I feel like I can only code this once because CPT 37214 applies to both arterial and venous thrombolytic infusions. Please advise.

Angioplasty or Primary Thrombectomy with No Stenosis Documented

Patient on subsequent day EKOS lower extremity. Re-visualized still heavy clot burden seen. Physician ballooned anterior tib, posterior tib, and peroneal artery plus aspiration catheter each vessel post balloon due to loose clot seen with in same vessel. There is no documentation of stenosis in these vessels. Restarted EKOS patient brought back next day for angiojet to PTA and peroneal and thrombolytic spray through AngioJet for 20 min to post tib plus stent placement to post tib due to dissection. Day two was coded by staff as 37213, 37228, 37232. Based on my understanding of what I read in your book it should be coded as 37213, 37184 (post tib), 37185 (anterior tib), 37185 (peroneal), 36247. Day three should be 37214, 37184, 37185, 37230. Is this correct? There is disagreement and confusion on what is an angioplasty and what is thrombectomy in cases like these.

Cancellation of Planned MitraCLip Procedure

The patient was brought into OR suite for a planned MitraClip insertion. Patient was prepped, equipment opened for "Clips", and patient was placed under anesthesia. Case began by TEE probe attempted passing several times but due to small/stricture of esophagus, but unable to pass probe and procedure was cancelled. What am I able to charge for this since she was an inpatient (-74 modifier not applicable??). She was made an inpatient per CPT guidelines .

Stress Echos

I am trying to determine whether or not to use code 93350 or 93351 for stress echos in our clinic. It seems to me that in order to bill 93351 the physician has to be in the room monitoring the test and performing the echocardiogram. We have a tech/nursing staff member in the room with the patient, and then the physician provides an interpretation and report. Which code is appropriate in this case?

Transforaminal Epidural Injection with a Ganglion Impar Injection

My provider performed an S2 transforaminal epidural steroid injection and clearly states he then "turned his attention to the cauda area and performed a ganglion impar injection". Would I be correct in billing code 64483 in addition to 64999? Even though it is an unlisted code that shouldn't make it an issue with bundling, right? Do you agree?

Open Thrombectomy and Percutaneous Thrombectomy of a Fem-Pop Bypass Graft

If open thrombectomy is performed on the proximal aspect of a fem-pop bypass graft and a percutaneous thrombectomy is performed on the distal aspect of the same fem-pop graft, can both codes 37184 and 35875 be reported (same DOS/encounter)? The physician then places two stents; one is fully inside the graft and the other is 1/2 outside the graft. Can either stent be coded?

Stereotactic Post Biopsy Mammogram

It is my understanding that, if the proper guidelines/dictation are met, a post biopsy mammogram to verify clip placement may be charged after a stereotactic guided breast biopsy. Is this correct?

Re-Implantation of AICD

Broken RV lead was removed and replaced. Existing generator was re-implanted. Are codes 33240, 33241, and 33244 correct for this scenario? "The pocket housing the existing pulse generator was entered and the device removed. The ICD lead was disconnected from the pulse generator. The lead was completely removed with gentle traction without difficulty. The cut end of Fidelis lead did not have a cap present, and this was replaced… The right ventricular lead was placed via this sheath into the right ventricular apical location. The lead was positioned superior to the abandoned Sprint Fidelis… previously implanted generator re-implanted. Generator connected to leads and generator implanted in pocket. Existing right ventricle lead was removed intact. Durata lead was removed. Additional RV lead remains."

PVI for PVCs

I am needing a second opinion on this case. "Patient had a previous PVI a few months prior. Brought back in for PVCs and was in a right to left flutter on the CS. Ablation: Biosense Webster catheter was used for the ablative procedure. The PentaRay catheter was used to assess the veins. Both inferior veins had reconnected. During PentaRay manipulation, the tachycardia terminated when the splines were around the left posterior carina. This was inferior to where the previous line was placed. Ablation was guided by the prior left atrial CT scan, geometry performed with Carto 3D mapping, electograms, fluoro, and continuous ICE with targeted areas those of high voltage within the previous lines. Ablation in this area immediately terminated the signals in the LIVP. A line was made in this region joining ablated areas of the superior vein to electrically silent areas in the inferior vein. Leions were placed on the ridge where there was activity. The PentaRay was placed into the RIVP and the vein isolated at areas of reconnection. All four pulmonary veins were isolated."

TEVAR through Open Sternotomy

I have an unusual case that I would appreciate your assistance with coding. The provider documented opening the chest through a median sternotomy, but he then accesses the ascending aorta, introduces a catheter, and then passes the catheter to the descending thoracic aorta. The rest of the case proceeds through an endovascular approach after that initial sternotomy (the provider deploys a thoracic endograft with a proximal extension that does not cover the subclavian origin). I have settled on codes 33881 and 33883 with radiology S&I codes 75957 and 75958 with modifier -26. For the approach and the catheter insertion directly into the aorta, I do not see established codes to report this part of the procedure. Would you agree with unlisted code 37799 in addition to the graft/S&I codes listed?

Dislodged Nephrostomy Tube

I work for a hospital. I have an account in which the patient had a dislodged left nephrostomy catheter. The procedure involved reinsertion of the nephrostomy catheter via an existing sinus tract. Should this be coded as a new placement (50432) or as an exchange (50435)? Since the reinsertion is via an existing sinus tract, how does this affect coding?

Removal of an Occluded Lower Extremity Bypass Graft

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

Arteriogram of Lower Extremity

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

IVUS at Two Sessions

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

37211 and 37212 in AV fistula

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

Lynph Node FNA with Clip Placement, US Guidance

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

Device Codes

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

27096 and G0260

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

Rescue Thrombectomies

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

MUE for Cervicocerebral Imaging

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

ZIO Patches

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

Bilateral Venous Studies for Upper and Lower Extremities

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

Ascending Aortic Endoleak Repair

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

Nephrostomy Tube Placement with Double J Stent

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

Placement of Fiducial Marker in Iliac Bone

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

Diagnostic Imaging

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

CPT 36200 for Co-surgeon

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

34812

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

HCPCS Code for Turbo-Elite Atherectomy Catheter

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

34812

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

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