Knowledge Base

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Endovascular Aneurysm Repair with Aortic Cuffs

"Patient has history of end-to-side aorto-bi-femoral bypass and has developed a large AAA anastomotic aneurysm at proximal aorto-bi-fem bypass anastomosis. Aorto-bi-fem limbs are patent. After right fem incision, sheath was advanced up right iliac system. Surgeon placed aortic cuffs starting distally from old aorto-bi-fem bypass and building proximally up to infrarenal aorta utilizing 5 aortic cuffs overlapping. Proximal, distal, and junctions were ballooned. Angiogram revealed junctional leak. Reballooned. Persistent junctional leak. Two more cuffs were placed overlapping in midportion of previously placed cuffs and then ballooned. Leak improved, but was still faintly present. Patient not candidate for open repair. Surgeon feels that with heparin reversal and time this faint leak will seal." Is aneurysm repair with tube prosthesis 34800 and one cuff 34825? Or is the initial code 34825 since he used cuffs and it is for aneursym repair? I see the cuff code descriptions are for inital vessel and each additional vessel. This was all done in the aorta, so only one vessel had intervention. Seven aortic cuffs in all.

Endovascular Reconstruction for Occlusive Disease (not AAA)

What codes would you recommend for endovascular reconstruction of the aorto-bi-iliac vessels for occlusive disease? Exact same technique as an AAA repair, but not for aneurysm. Bilateral cutdowns. Bifurcated endoprosthesis deployed in aorta and bilateral iliacs, and iliac extender. Would you recommend unlisted? Or code it with the new stent codes (37236/37237)? According to the CPT Codebook, 348XX codes are exclusive to aneurysm repair.

Endovascular Repair of Popliteal Aneurysm

What code should I use for a Medicare patient with popliteal aneurysm when the physician plans to repair with percutaneous placement of a covered stent graft?

Endovascular Thoracic Aorta Stent Graft Procedure

I've got a couple of questions regarding the below patient. Is femoral cutdown (34812) always performed with these procedures? Our provider didn't document an open cutdown, only that 5 french sheath was placed into the common femoral arteries. "Following deployment of the endograft with intentional partial left subclavian coverage (33880-62) he attempted to close the left femoral arteriotomy using the Perclose Prostar sutures; however, they prematurely knotted in the subcutaneous tissue because of vessel depth in this obese patient. In order to control bleeding without vascular control of the artery established, he used a balloon in the iliac artery so he could surically repair the left common femoral artery with placement of a bovine pericardial patch." I'm thinking I should code this part of the procedure as 37204, 75894, and 35286, but I wanted your expert opinion. Here are the codes I came up with: 36200-50, 33880-62, 75956-26, 37204, 75894-26, 35226.

Endovascular Thoracoabdominal Aneurysm Repair

Patient with a stent graft in the proximal to mid descending thoracic aorta who is 8 months out s/p. Now with enlargement of not stented area (thoracoabdominal aneurysm repair). Physician performed the repair with stenting thoracic and abdominal aorta with total of four stents starting from abdominal aorta bifurcation and last one overlaps the previous stent in thoracic aorta. Is this correct to code aneurysm repair in the thoracic aorta (36200, 33881, 75957) with proximal extension (33883, 75958) and abdominal aorta aneurysm repair (34800, 75952) separately? Does the way the physician builds the grafts in thoracic aorta (proximally or telescopic way) affect coding (e.g. in this case the main body first in distal thoracic with one extension proximally to overlap with previous stent)?

Endovenectomy with Patch Angioplasty

"Procedures performed: Bilateral groin cutdown with common femoral vein exposure. Extensive left  common femoral vein endovenectomy followed by patch angioplasty. Focal right common femoral vein endovenectomy with primary closure. Kissing stents from IVC into the iliac system... Left groin venotomy was made and extended. An extensive amount of scarring was saline(?) as typical of chronic thromboses with recanalization and anatomy was seen. Extensive endarterectomy of the common femoral into the profunda and also the femoral vein and distal external iliac vein was performed. A bovine pericardial patch angioplasty with 6-0 prolene running suture was performed." We were unsure if open thrombectomy code 34421 would be appropriate in this case without findings or removal of thrombus. Is the reference to the scarring typical of chronic thromboses sufficient? We were unable to locate a venous equivalent to an endarterectomy. Your guidance is greatly appreciated.

EP

Our EP physicians would like to begin using AIGISRx anti-bacterial envelope when inserting PMs and ICDs. I am responsible for the facility billing. AIGISRx is an anti-bacterial envelope made from knitted polypropylene mesh substrate, coated with a polyarylate bioresorbable polymer containing two antimicrobial antibiotics, minocycline and rifampin. AIGISRx is a dual component (resorbable and non-resorbable), sterile prosthesis designed to reduce infection and to stabilize the implantable PM or ICD when implanted in the body. I have been notified by the manufacturer that they have "confirmed that using the CMS A4649-surgical supplies & devices-other implants, will allow for full reimbursement of the AIGIS anti-bacterial envelope ... this is a great first step toward CMS issuing a CPT code specifically for this type of device ... now we can say that this will not increase the cost of the procedure." 1. Do you agree, per OPPS 2009 Final Rule, there are no devices eligible for pass-through payment for 2009, and therefore, there would be no additional reimbursement, and the device would be unconditionally packaged into the reimbursement of the Insertion of the PM or ICD, whichever is performed. 2. Do you agree using this device will increase the cost of the procedure. 3. Would A4649 be the most appropriate HCPCS code to use with Revenue Code 0278? Thank you.

EP Ablation Components

I know this has been addressed many times, but I'm still not totally clear on the requirements of the new ablation codes. The errata says to document the reason any components might not be performed in order to use code 93656, which doesn't seem logical to me since the new descriptor states "when possible". I would think the reason for not performing would be needed on 93653 and 93654 instead. Do you recommend including the reason for not performing on all three ablation codes? I realize that would seem to be the easiest fix; however. I'm still struggling to get my physicians on the bandwagon and don't want to ask for more than I need.

EP Ablation Procedures

Is it appropriate to assign EP codes 93620, 93653, and 93656 when it is not necessary to induce an arrhythmia? In some cases, the patient presents for the procedure with an arrhythmia, such as atrial flutter, already present.

EP and echocardiogram

Dr Z I would really appreciate your assistance in the EP case below. The intended procedure was EP ABL w/ 3D mapping for A-fib. However all that was done was 93662 intracardiac echocardiogram which is an add on code with 93651 which did not take place. I have searched your database extensively and the only example I can come up with is for a PFO in which you suggested to use a 74 modifier for the intended procedure along with the add on code. Based on this would I charge 93651-74 and 93662. Or charge for possibly TEE 93318 as a completed procedure? Thank you for your expertise, Terri DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the electrophysiological laboratory in a fasting state. The patient's oropharynx was anesthetized using aerosolized lidocaine spray. Once sedation was achieved, I manually advanced the echo probe passed the oropharynx into the lower esophagus. Limited echocardiographic images were obtained in multiple views. FINDINGS: Left ventricle size is grossly normal. There appears to be left ventricular hypertrophy. Global left ventricular systolic function is normal. Ejection fraction is visually estimated to be 60-65%. There are no regional wall motion abnormalities. Right ventricular size and systolic function within normal limits. The mitral valve is morphologically normal. The tricuspid valve is grossly normal. The left and right atria both appeared mildly dilated, both measuring approximately 4.5 cm. The intraatrial septum is intact to 2-D imaging. There is a mass in the tip of the left atrial appendage thrombus highly suggestive of thrombus. Doppler velocities in the left atrial appendage are less than 0.4 meters per second. CONCLUSIONS: 1. Normal left ventricular size and systolic function. 2. Biatrial enlargement. 3. Left atrial appendage thrombus. PLAN: Based on this study, we will defer on left atrial ablation. His anticoagulation will be restarted and we can consider restoring sinus rhythm in approximately 1 month.

EP codes

Dr. Z, I have a couple of questions on 2013 codes. For 93656 I have heard that HRS is trying to get clarification or re-wording on the code so it does not read like all components must be done and if this is not accomplished a 52 modifier will be needed for professional billing. What are your views on this? And have you heard if there is to be any clarification of the code? Second question, there is no reimbursement on the SICD T codes is there? Thank you, Debbie Grant Follow-up Question: Dr. Z,   Thank you for your answers.  I know that you are recommending not charging for 93623 now and was wondering about 93621.  It is still an add on code to 93620 and causing an edit with 93653 and 93654 due to no primary procedure code.  What are your recommendations for this?   Thank you,   Debbie  

EP Possible Parent Coding 93653 and 93654

Below is a report from one of our physicians. Both coders disagree on the coding, and I would like your input, as it involves parent codes 93653 with 93654. Coder #1 reported codes 93654 and 93623. Coder #2 reported codes 93653 and 93621. PREPROCEDURE DIAGNOSIS Supraventricular tachycardia. POSTPROCEDURE DIAGNOSIS Typical atrioventricular nodal reentrant tachycardia. PROCEDURES PERFORMED 1. Comprehensive electrophysiology study with coronary sinus pacing and recording. 2. Arrhythmia indJction. 3. Drug infusion with isoprotereno~ 4. ~electroanatomic mapping. 5. Radiofrequency ablation of typical AV nodal reentrant ta~rdia with modification of the AV nodal slow pathway. HISTORY OF PRESENT ILLNESS This is a 61-year-old female ~.~tmedical history significant for recurrent frequent episodes o~dpalpitations. The patient had a recent visit to the hospital at Flagler where she was noted to have heart rate of approximately 200 beats per minute, which terminated with adenosine. The patient now presents to electrophysiology laboratory for further evaluation and management. DESCRIPTION OF PROCEDURE The patient was brought to electrophysiology laboratory and appropriately identified on the table. Twelve-lead ECG electrodes were placed in the patient and vital signs were recorded at baseline. A conscious sedation was administered by the nursing staff with intravenous fentanyl and Versed. The patient was prepped and draped in standard sterile fashion. Sheaths were inserted using modified Seldinger technique as indicated below. Catheters were then subsequently advanced to the sheath and placed in the heart under a cardiac fluoroscopy. Baseline intracardiac recordings were obtained followed by standard EP study. During the entire procedure, the patient's vital signs were continuously monitored, remained stable. Details of the EP study and subsequent ablation were outlined below. The patient remained hemodynamically stable and com£ortable throughout the en~ire procedure. At the conclusion of the procedure, all catheters were removed from the heart and woa~d sites were then dressed and the patient wls transferred to t~e Recovery Room '£~ea in stable condition. The postoperative orders were wfitten at that t~e. ; SUPPLIES < Diagnostic catheters were placed at the level of the high right atrium, His, right ventricular apex. A diagnostic catheter was also placed in the main body of the coronary sinus. A 4-mm radiofrequency ablation bidirectional catheter was used for right atrial mapping and ablation. BASIC EP STUDY FINDINGS 1. The AH interval was 101 msec, the HV interval was 39 msec. 2. The VA Wenckebach cycle length was 360 msec at baseline. The right ventricular effective refractory period while pacing from the right ventricular apical catheter was 220 msec at a pacing cycle length of 600 msec. 3. The AV Wenckebach cycle length was 400 msec while pacing from the high right atrial catheter. 4. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec. ARRHYTELl\,fIA AND ABLATION The patient presents to the electrophysiology laboratory in normal sinus rhythm. Following administration of conscious sedation, we proceeded with a basic EP study. The patient had normal EP study findings at baseline. Upon insertion of the catheter, she immediately went into a spontaneous supraventricular tachycardia. The tachycardia was typical AV nodal reentry for the following reasons. 1. The septal VA t~~e during SVT was approximately 0 msec, making typical AV nodal reentry the likely diagnosis. 2. The SVT tachycardia cycle length was 410-420 msec. 3. During a right ventricular apical pacing, the atrial activation sequence in the coronary sinus catheter was concentric, making left lateral pathway and AVRT unlikely. 4 .. During SVT, entrainment from the right ventricular catheter revealed a VAHV response to pacing, making atrial tachycardia unlikely. 5. During supraventricular tachycardia, right ventricular entrainment revealed a post-pacing interval minus tachycardia cycle length of 145 msec, making AV nodal reentrant tachycardia the likely diagnosis. 6. His-synchronized ventricular premature depolarizations during SVT did not reveal the presence of a septal bypass tract and was not able to the atrium. The patient had easilY sustained episodes of supraventricular tachycardia, which were spontaneous and also reproducible with both ventricular and atrial extrastimuli from the high right atrial, coronary sinus, and right ventricular catheters. We observed both echo beats and sustained tachycardia. At this t~~e, we proceeded with modification of the AV nodal slow pathway. The ablation catheter was positioned across the posterior septum just posterior t{ i the coronary sinus ostia. 3D electroanatomic mapping prior to this was used to identify the dehisced as well as the coronary sinus ostia. Ablation catheter was positioned across the tricuspid valve annulus with an A-V ratio of approximately 1-4. Using power controlled settings of 50 watts and 55 degrees under temperature, serial ablation was performed in this area. We monitored the AH and HV intervals during this time and a junctional ectopy was observed throughout the duration of these lesions. At final conclusion of my ablation, I rechecked the patient for dual AV nodal physiology. No sustained tachycardia was observed. Isoproterenol w~started up to 2 mcg per minute and no evidence of inducible SVT was no~ecr. With frequent atrial and ventricular extrastimulus pacing, the patient did have 1 echo beat with atrial extrastimuli; however, with continued decremental pacing on our extrastimulus beat, the patient would block on the subsequent beat. At this time, this was considered an acceptable endpOint as the patient previous to my ablation had easily inducible SVT. After waiting period, we attempted arrhythmia induction again and SVT was no longer observed. At this time, the procedure was terminated. AH and HV intervals remained stable and comparable to baseline. The postablation AH and HV intervals were 85 and 42 ITsec respectively. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec at this time. The catheters and the sheaths were then removed from the heart and body. Hemostasis was achieved. The patient made a complete neurologic and hemodynawic recovery. CONCLUSIONS 1. Normal EP study findings. 2. Typical AV nodal reentrant tachycardia. 3. Successful ablation of typical AV nodal reentrant tachycardia with modification of the AV nodal slow pathway.

EP repeat study

Hello Dr. Z, In your book you mention that a repeat EP study should not be coded â?oon a subsequent date unless there is documentation of a new arrhythmiaâ?. What types of circumstances would this include? VT vs. SVT? Same type of arrhythmia in a new location? Examples of when it would be appropriate to code an EP Study on a subsequent date due to a new arrhythmia would be especially helpful. I would appreciate any input you can provide. Thank you for your time. Jill Paul CPC-San Diego

Epicardial Ablation

I have never coded for the epicardial access for EP ablation and have not been able to find information. Would you give your insight on what the following procedure coding would look like? The patient was brought to the EP lab. The ICD was reprogrammed and interrogated. Both groins were prepped in the usual fashion. Local anesthetic was applied to the skin. Following a modified Seldinger technique, one 8 French sheath and one 11 French sheath were placed in the left femoral vein. A 4 French sheath was placed in the right femoral artery. Via the subxiphoid approach, epicardial access was obtained with an epidural needle and an 8 French flexible steel Arrow sheath. Mapping and ablation catheters were placed in the 9 French sheath and 9 French Arrow sheath. A 3D map of the epicardium was created. The 4 French arterial sheath was exchanged for an 8 French Arrow sheath due to the torturous nature of the aorta. During epicardial mapping an IBI HIS catheter was placed in the right and left ventricles for pacing. There was a patent foramen ovale present. The mapping and ablation catheter was advanced through the aorta to the left ventricle via the retrograde approach. Left ventricular pacing and recording were performed, a 3D map of the endocardium was created. Ventricular stimulation was performed and programmed ventricular stimulation was performed. Several different VT morphologies were induced by ventricular pacing. All of the VTs were mapped to an area posterior to the mitral valve. RF energy was delivered with termination of the VTs from within the left ventricle, epicardially, and from the anterior cardiac vein. Aspiration of the pericardial space was performed throughout the case. At the end of the procedure, protamine was given, Solumedrol 125mg was given via the epicardial sheath, the sheaths and catheters were removed, and good hemostasis was achieved with direct manual pressure.

Epicardial Ablation

I have a couple of ablation cases that are confusing to me and wonder if these should be considered unlisted codes or if they are like the other ablations and are diagnosis-driven. I have one case that is left atrial and right atrial ablation for numerous atrial macroreentrant atrial flutters, vein of Marshall alcohol ablation for mitral isthmus-dependent flutter, antral pulmonary vein isolation, and CAFE ablation for atrial fibrillation. The other case is an epicardial ablation with a subxyphoid access for VT. My question is, do we use unlisted codes for the alcohol ablation and the epicardial ablation to capture the extra work ? Or should I consider using a -22 modifier?

Epicardial Lead Removal Only

"In 2012, patient had left mini-thoracotomy and placement of epicardial pacing system; however, the place where these leads were attached to the pacemaker generator was infected. In view of this, in October 2014, the leads were truncated at the point where they were entering the pericardial space, removing the remaining part of the leads towards the pacemaker generator as well as the generator itself. This admission, patient was temporized with a transvenous pacemaker system from the neck and was sent to Cardiothoracic Surgery for placement of epicardial leads. Upon performing median sternotomy, we noted significant adhesions inside of the pericardial space from the previous opening of the pericardium. These adhesions were carefully taken down to the point where I was able to identify 3 epicardial leads that were placed before and were truncated at the level of the entry into the pericardial space. These were carefully released and removed and sent to the pathology." The only code I am coming up with is 33999 (in addition to 33202/33221-51, implant report not attached).

Epidural and transfemoral injections in same encounter

What are the correct CPT codes if radiologist performs L5 epidural injection followed by L5 transforaminal injection, followed by S1 transforaminal injection, uncomplicated procedure. The only diagnosis is radiculopathy. CCI edits state that the transforaminal injection is a component of the epidural injection, but isn't the transforaminal a more selective injection? I see a prior answer that states only 1 injection procedure should be coded, but which injection? 62311/77003 or 64483? thank you.

Epidural Blood Patch

I'm coding a fluoroscopically-guided lumbar puncture and epidural blood patch. I understand the CPT codes for the epidural blood patch are 62273/77003, but I'm a bit confused as to whether I need to also report codes 62270/77003 for the lumbar puncture. "TECHNIQUE: Under fluoroscopy the L2-L3 interlaminar space was identified, and a 22 gauge spinal needle was advanced into the thecal sac. A total of 8 ml of clear fluid was obtained in four tubes and sent to the lab. At the L4-L5 level a 20 gauge spinal needle was advanced into the epidural space under fluoroscopy. Subsequently, 9 ml of autologous blood was injected into the epidural space w/o complication. The needle was then removed." Please advise regarding the correct codes to use for this procedure.

Epidural Fibrin Glue Injections

I need to confirm how to code for selective transforaminal approach epidural fibrin glue injections for treatment of CSF leak. Levels were bi-lat L1-2, L2-3, and T9-10 with contrast and fluoroscopic guided needle verification. Is it correct to code to blood patch injections because the fibrin glue is a blood products, and it used for CSF leak repair? 62273-50, 62273-50-59, 62273-50,59, and 77003? Or, 62310, 62311, and 77003? Or 64999, 77003?

Epidural Plasma Rich Protein Patch

For the following example, is it appropriate to report codes 62273 and 0232T? "Patient with suspected CSF leak. L1-2 level was localized with fluoroscopy. Needle was then placed in the posterior epidural space under fluoroscopic guidance. Contrast was injected to confirm epidural position. 60 mL of peripheral blood was withdrawn from the IV catheter, which was then centrifuged to obtain 7 mL of platelet rich plasma that was slowly injected into the spinal needle. The patient maintained normal motor function in both feet and denied significant radicular symptoms throughout the injection."

Epidural steroid injection post discectomy

Dr. Z, Our radiologist did a discectomy 62287 and a week later the patient came back in because the pain was not gone. He did an ESI and transforaminal injections. My question is there is a 90 day global for the discectomy. Do I not bill for the ESI and transforaminal injections? Thanks

Epigastric Vein Embolization

How would I code the following case? "Inferior epigastric vein catheterization from a right femoral vein approach with injection and imaging. Subsequently, the anterior abdominal wall in the distribution of the right lower quadrant parastomal region was interrogated. Just along the caudal margin of the stoma there was a small vein that appeared to emanate to the surface. This was slightly ectatic. With ultrasound and dressing maneuvering, brisk bleeding was initiated. This was immediately treated with compression. Subsequently the bleeding site was intubated with a 4 French dilator. 3 mL of 3 percent sodium tetradecyl sulphate was instilled. 5000 units thrombin were placed at the superficial surface of the bleeding site. Compression was performed. Subsequently the site was further treated with three 2-0 Vicryl sutures. Sterile dressing was applied. Osteoma stoma reapplied. Bleeding cessation was encountered."

Epinephrine challenge

One of our EP doctors did a provocative testing drug study on a patient with recurrent syncope using Epinephrine and Procainamide. I have no idea what the code would be for this! When I checked my CPT book, it led me to 95078 which appears to have been deleted. Would I use the unlisted code 95199 instead?

EPS Study with Cardioversion

For the following report, can the cardioversion be coded along with the EPS study and injection of Isuprel? Patient was brought to the EP Lab in the fasting state, sedated by the Anesthesia Team. The right and left groins were prepped, and the right neck was prepped. A catheter was advanced. Patient had atrial fibrillation that was seen with catheter manipulation. This had to be cardioverted back to sinus rhythm. Patient had an EP study done and had no inducible SVT, no evidence for dual AV node physiology, and no evidence for an accessory pathway. VA conduction was not present. We started Isuprel, and the patient went into A-fib again, so we had to discontinue the Isuprel, and the patient received another cardioversion once the Isuprel was discontinued and went back to sinus, but then degenerated back into A-fib again. The patient also had an episode of atrial flutter that appeared to be typical flutter. Procainamide was ordered and was about to be hung, but the patient went back into sinus rhythm just as we were about to start the Procainamide. The patient was awake at this time with a baseline heart rate about 100. The EP study was repeated and again no VA conduction was seen during the awake state. The patient did have occasional episodes of a very short three to ten beat runs of nonsustained SVT that may have been an atrial tachycardia earliest in the high atrium, and it is possible that this may be the patient's clinical diagnosis. All catheters were removed. No ablation was performed. IMPRESSION: EP study significant for inducible atrial flutter, which was typical, atrial fibrillation and also a short atrial tachycardia that was nonsustained. Hard to know what is her clinical tachycardia. It may be the nonsustained atrial tach. The patient felt better on the Digoxin. We are going to resume Digoxin.

Ergonovie and acetylcholine challenge

Will you please clarify which of these instructions is the current one to go by in regard to this question posted 9/1/11: Is 93024 the appropriate code for a coronary artery spasm test using acetylcholine (acetylcholine challenge) during a heart catheterization procedure? Answer was no additional codes are reported for acetylcholine challenge tests. In AHA Coding Clinic for HCPCS Third Quarter 2009 the following coding instruction for hospital billing was given: • Do not report additional codes for performance of an acetylcholine (Ach) challenge test performed during cardiac catheterization. It is included in the cardiac catheterization procedure. Per page 505 in the Cardiac ebook: The ergonovine test - otherwise known as a "provocation test" - is not done often, but can be performed if angina is thought to be caused by coronary artery spasm. The procedure is conducted during coronary angiography.  "The artery-narrowing drug ergonovine (or, alternatively, acetylcholine) is injected to provoke coronary artery spasm.  The person's response to the ergonovine is then documented."  If the individual experiences severe arterial spasm in response to ergonovine, he or she probably has variant angina due to coronary arterial spasm. Coding Instructions: 1. Do code ergonovine provocation in addition to cardiac catheterization if documented. 2. Do not code separately for the injection of the pharmacologic agent, as it is considered part of the test and is not separately reimbursable. Thank you

Esophageal Atresia with Magnet Treatment

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?

Esophagram

I hope you can help with this unique request. The patient’s condition warranted a bedside esophagram. Fluoroscopy was NOT used. Instead, the tech used a digital portable x-ray machine with cassette placed behind and on the side of the patient to take 11 or so images in the AP and lateral projections in the chest area. This was done before, during, and after ingestion of contrast material, which was injected via GI tube at the level of mid esophagus by the patient’s physician (not the radiologist). What is the appropriate way to code this? Scout film demonstrates evidence of pneumomediastinum and soft tissue emphysema in the neck and supraclavicular regions. No pneumothorax is evident. Extensive bilateral pulmonary parenchymal disease is noted with diffuse infiltrates. Administration of contrast opacifies the mid to distal esophagus, which demonstrates no evidence of obstruction or extravasation of contrast. We are concerned if we need to report this as a chest x-ray or as an esophagram.

Ethiodol

If Ethiodol is injected during a visceral angiogram on a patient with a hepatic mass, is it correct to charge for an embolization?

Evaluate/Drain Tunneled Pleural Catheter

We have a patient who was brought to the IR department and had an ultrasound scan performed of the left chest to evaluate pleural effusion. The patient was then positioned in right decubitus and had the drain attached to suction to remove fluid. Would you recommend billing for a limited ultrasound, unlisted procedure, or a clinic visit for this service? The order was for a pleural drain evaluation, possible removal versus tPA of loculated collection.

Evaluation of AV Fistula/Graft

Access left radial artery with micropuncture, left arm AV fistulogram with interpretation. This is a radiocephalic fistula. Can code 36120 be used for direct radial artery puncture for evaluation of the fistula, or is that code only for the brachial artery (36120, 75791)? When a doctor uses the word "micropuncture", does this always mean percutaneous? First example: "Dissected out the fistula and then accessed the aneurysm with a micropuncture 6 French sheath." Second example: "We then accessed the graft with a micropuncture sheath near the arterial limb towards the venous outflow."

Evaluation of Drains in 2014

It is my understanding that billing for contrast injection/evaluation of drains is discouraged in 2014. There are instances in which our doctors evaluate these because of rising bilirubin (biliary), obstruction (urinary, biliary), etc. We are a cancer center; therefore, there is quite often obstruction. In what instances are we allowed to bill for these? This is an example: "Bilateral biliary catheters were removed over a wire and bilateral cholangiograms performed from the skin surface, demonstrating poor opacification of biliary tree, worse on the right than left. Plans were discussed with patient for possible need for a third biliary catheter in future. New bilateral 10 French internal/external biliary catheters were placed over the wires and sutured to the skin." In this example would you bill for these bilateral evaluations? Am I correct in billing codes 47505/74305 twice for these (injection was performed "from the skin surface")? There are also times when a cholangiogram is done in order to determine whether internal/external drain can be internalized. Would this also justify?

EVAR and Billing

I am not able to get a straightforward answer on billing EVAR with modifier -62. Everything in print states that two surgeons are allowed to use this modifier. If an interventional radiologist and vascular surgeon are performing this procedure, but the radiologist does not make any incisions, then how can he or she be classified as a surgeon?

EVAR and Co-Surgeon

Our general surgeons perform the exposure of endovascular AAA surgical cases for the interventional radiology group. The general surgeon performs a bilateral exposure (34812) and inserts the sheath. He leaves the OR at this point, and the interventional radiologist then presents to the OR and performs her portion of the AAA. The general surgeon then returns to the OR, removes the sheath, and closes the surgical site. The general surgeon dictates for the exposure and closure of the wound. Both the interventional radiologist and the general surgeon dictate as “co-surgeon” their individual portion of the case. Can we, as the general surgeon's office, bill for both the exposure (34812) and the repair of the AAA? The general surgeon is not in the OR during the time the interventional radiologist is doing her portion of the case. According to the interventional radiologist they suggest the general surgeon bills code 34802-62, as they say the general surgeon is there for the “critical” portion of the case. What are your recommendations on coding this?

EVAR and Cosurgeons

I code for a vascular surgeon who co-surgeons with an interventional radiologist from another practice performing AAA repairs. These are performed at the local hospital. My question is, what codes can I bill for the vascular surgeon as a co-surgeon? The vascular surgeon performs the exposure for AAA cases for the interventional radiologist. He is present throughout the entire procedure and both doctors note that both physicians were present for the entire duration of the procedure and performed all critical portions of the procedure together. The vascular surgeon confers after the takedown (34812), as the IR wants his opinion throughout. Can I code for the prosthesis (i.e., 34802-348083) as well as 34825 and 34826, if done, with a -62 modifier appended to each? The vascular surgeon concedes that he does the takedown only, but is present throughout the procedure to offer advice. If any complications arise at the time of surgery or postoperatively, the patient is still the vascular surgeon’s.

Event Recorder in September 2014, and Pacemaker implant in November 2014

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?

Exceeding MUEs, Change of Nephrostomy Tubes

Patient with duplicated right kidney has a bilateral nephrostogram and nephrostomy tube change in addition to a nephrostogram and nephrostomy tube change on the right duplicated kidney (two on right, one on left) because of poor drainage from the catheters. Initially we reported codes 50394-50, 50394-59RT, 50398-50, 50398-59RT, 75984-50, and 74425, but we got an MUE of 1 on 50394-59RT, 50398-59RT. What's the correct way to code this?

Exchange of Abdominal Catheter

Just curious what you come up with...thanks! PROCEDURE(S): Peritoneal Dialysis Catheter Repositioning HISTORY: End Stage Renal Disease INDICATION: Catheter Malfunction MEDICATIONS: Fentanyl 200mcg; Midazolam 4mg CONTRAST: Omnipaque 350, 3510 ml COMPLICATIONS: None. TECHNICAL: Following informed consent, and verification of the appropriate patient identification and procedure to be performed, the abdomen, including the indwelling peritoneal dialysis catheter were sterilely cleaned, prepped, and draped. Contrast was injected via the peritoneal dialysis catheter. A stiff Terumo wire was advanced through the catheter until the tip of the peritoneal dialysis catheter was redirected into a different portion of the peritoneal cavity. Post repositioning contrast injection confirmed free flow into the peritoneal cavity. The catheter was flushed with saline and sterilely dressed. FINDINGS: The existing peritoneal dialysis catheter was in a small contained space. Contrast flowed back along the distal 10 cm of the catheter until instilled into the open peritoneal space. The peritoneal dialysis catheter was repositioned from the contained space into the open peritoneal cavity. IMPRESSION: Peritoneal dialysis catheter repositioning as described.

Exchange of Biliary Draing

I have a patient that we are exchanging an external biliary tube with an internal external biliary tube. Would I just code for the placement of the new internal external tube?

Exchange of femoral CVC with bilat upper extremity selection via same acces

We did an exchange of existing right femoral CVC with the selectively of both the RT and LT upper extremity veins and  a bilateral venogram was done.  I’m thinking that we can not bill for the selection of the bilateral upper extremity nor the venogram because it is done via the CVC exchange access site and it is encompassed into the exchange code. The physician also accessed the lt ext jugular vein and angioplastied the Lt Brachiocephalic vein (occlusion) and placed tunneled CVC. Your thoughts,

Exchange of Rt femoral CVC with bilat upper extremity selection same access

We did an exchange of existing right femoral CVC with the selectively of both the RT and LT upper extremity veins and a bilateral venogram was done. I’m thinking that we can not bill for the selection of the bilateral upper extremity nor the venogram because it is done via the CVC exchange access site and it is encompassed into the exchange code. The physician also accessed the lt ext jugular vein and angioplastied the Lt Brachiocephalic vein (occlusion) and placed tunneled CVC. Your thoughts,

Exchange of Tunnelled Pleurx Chest Catheter

There is no CPT code for the exchange of a Tunnelled Pleurx Chest Catheter. What is your coding recommendation for the case example below: a) unlisted CPT code or b) 49424/76080?? "Chest and abdomen were prepped and draped in usual sterile fashion. The right-sided chest tube was removed over a stiff Glidewire, which allowed for placement of an 11 French peel-away sheath. After successful creation of a subcutaneous tunnel, the 11 French Pleurx catheter was advanced through the tunnel and through the peel-away sheath into the right-sided thoracic cavity. The incision was closed with 4-0 Prolene. Catheter was secured to the skin at the exit site from the tunnel with 2-0 Monosoft suture."

Excision of Infected Stent Graft Under the Clavicle

Could you please assist with coding the following? Indications and findings: ESRD patient noted swelling in the region of his LT chest/shoulder. MRI suggested a subcu mass superficial to the mid clavicle, suspicious for a complex loculated fluid collection, with angulation of the stent. The patient's stent graft in the axillary vein was known to be thrombosed.  I&D of abscess was performed; however, after one month, the wound has not completely closed. Today, the patient was found to have a chronic draining sinus, which extended down below the clavicle. There was an infected stent graft within the axillary vein identified at this level. The vein wall appears to have necrosed, and purulence was identified associated with the graft. After establishing proximal and distal control, the stent graft was removed. (From body of note:) ...I then made a curvilinear incision around the base of the previous LT shoulder wound....this was deepened and extended toward the clavicle....we also began exploring the base of the wound...the center of the wound...could be probed down and there appeared to be a sinus tract going below the level of the clavicle. We continued our excision of the surrounding tissue in an elliptical fashion along this sinus tract. At the base of the wound, we identified an FB...we identified a stent graft, going along with the history of previous LT axillary stent graft placement...we extended our incision medially and laterally along the course of the clavicle. This gave us better exposure along the segment of the axillary vein. This procedure does not fit codes 35903 nor 35905 [site is shoulder/chest, instead of extremity or thorax (within pleural space)]. Do we need to go with an unlisted procedure code?

Excision of Seroma Capsule

I have asked other coders and no one really can give me a clear answer on this... A patient develops a seroma, and an incision is made and it's drained, then the decision is made to excise the capsule. Since it is connected to the artery normally, it is more complex than just an incision and drainage. So what would you code the excision as?

Expiring Code HCPCS G0275

Any suggestions for a replacement code for G0275?

Explanation of Dual Chamber Pacemaker and Implant of Single Chamber Pacemaker with Issues

"An incision was made paralleling the old scar, and the pacemaker was isolated. The pacemaker was explanted, and multiple attempts with multiple screwdrivers were made to detach the atrial and ventricular leads. The screws were stripped, and the patient is pacemaker-dependent. Attempts were made to access the left subclavian vein, but the lead would not pass at the junction of the subclavian vein and superior vena cava due to an occluded vein. The pacemaker was placed back in the pocket temporarily. A new pacemaker pocket was created on the right side. The pacemaker was implanted, and the ventricular lead was advanced to the level of the right ventricular and sutured in place. The atrial port was plugged. Attention was turned back to the left side. The leads were removed by pulling the leads apart from the headers, and the leads were capped. The pacemaker was explanted, and the pocket was irrigated." Would I bill code 33228 or 33227 since the final result was a single lead system as well as code 33222 for a pocket revision?

Exploration of vessel

Hi Dr. Zielske and Dr. Dunn, I need some assistance with coding a femoral vein venotomy and foreign body removal. This is a condensed portion of the procedure: During an IVUS procedure of the IVC and lower extremity veins stenosis was found in the left common iliac vein. Angioplasty was done on this vein. Balloon ruptured and upon removal the balloon remained in the left common femoral vein and became detached from the catheter. An incision was made over the left groin and a left femoral vein exploration was carried out. The femoral vein was identified and a venotomy performed. The ruptured balloon was then extracted under direct vision from the left femoral vein and the venotomy was repaired with 4-0 Prolene until hemostasis was achieved. I have searched my CPT book and have come up with 35226 for repair of a blood vessel or 37799 for an unlisted vascular procedure. Is there a better way to code this? As always, thanks for your assistance. Pam Johnson

Exposed Opthalmic Catheterization

I need advice with the following case please. "Intra-op direct exposure of superior opthalmic vein with angiocath access was secured. Patient then brought to IR department for embolization of carotid-cavernous fistula. In IR, angiocath sticking out of opthalmic vein accessed with microcath and moved to cavernous sinus with coil placement. After embolization, patient went back to operating room for decannulation and ligation of opthalmic vein."  Would you do anything for the catheterization into cavernous sinus from superior opthalmic (36211)? Unlisted (36299)? Or just stick with embolization codes and follow-up angio from RCCA? There is no mention of imaging findings through opthalmic vein, just advancement of microcath and coil embolization into cavernous sinus.

Expression of blood post plebectomy

If a patient comes in to have a varicose vein procedure (phlebectomy 37766/endovenous ablation 36478) and they’re within the global period of having the same procedure done on the opposite leg, and during this visit the physician nicks and expresses old blood from the previous wounds, would 10140-79 be appropriate for that?  I put a -58 on the 37766/36478.  Or wouldn’t the 10140 be billable? Thanks!

Extension vs. Stent placement

If a physican places a stent at the time of an AAA graft, but he specifically states it is for stenosis, do you use code 37221 or 34825? It is placed inside the distal portion of the graft down to the external iliac stent that was placed at a previous session.

Extensions, 34825

I have another question for you this morning...if extension pieces are placed after an endograft and two pieces are placed in the same vessel...one overlapping the other to make it longer, would you consider that one 34825? I didn't think 34826 would be appropriate since it was within the same vessel...It was mentioned that 34825 x2?? your thoughts? thanks!

External Biliary Drain Replacement

Patient presented to the ER after biliary drain fell out. Initially the tract was recanalized with a Kumpe catheter and a Benston wire. Following a diagnostic study, the tract was dilated, and a new 8.5 Dawson Mueller external biliary drain was replaced. Can we report this with codes 47500/74320 and 47510/75980?  Or report this as a replacement with code 47525? If we code this as a replacement, how do we capture the diagnostic study?

External Iliac Angioplasty Performed to Stop Bleeding, NOT for Stenosis

One of our cardiologists was assisting another surgeon, and our cardiologist performed an angioplasty in the external iliac to stop bleeding below the iliac so the surgeon could perform repairs. Since the angioplasty was done for bleeding and not disease, I don't think code 37220 would apply. I'm thinking of using code 37799 (unlisted procedure, vascular surgery), but I would appreciate your opinion on this one.

External Marking Scans Pre-Biopsy Procedure

In your Diagnostic Radiology Coding Reference book, page 212, item 10, it states it is appropriate to report code 76645 when ultrasound is used to externally mark the breast for subsequent biopsy or aspiration. Does this concept apply to all biopsy/aspiration procedures (e.g., thyroid biopsy)? If yes, do we need to append a -52 modifier to the limited scan CPT since it is not a complete scan?

Externalization of Generator

We have a patient with an infected pocket. The doctor removed the generator, taped it to the patient's body, and cleaned out the pocket. The patient returns to the EP lab five days later for new leads and a new generator. When the doctor removed and externalized the generator, can we bill code 33241?

Externalized Pacemaker Insertion

We had a patient who needed a pacemaker in place for anticipated surgery, but could not have a permanent pacemaker due to infection. So a permanent lead was placed in the right ventricle through the jugular vein and attached to a new single chamber permanent pacemaker externalized. What can I charge in this case?

Extremity angiograms

A patient comes in on day one and has an aortogram and right lower extremity angiogram. Doctor starts TPA infusion in SFA, then later in the day does a follow-up. Day two, he does a follow-up and left lower extremity angiogram. My codes are 37201, 75896-59, 36247-RT, 75625, 75710-RT and 75898 for day one. Day two 75898 and 75710-LT. Should I code for two separate lower extremity angiograms or combine them using 75716 since it was a continuing procedure. Thanks, Cynthia Boyer

Extremity angiography before transfemoral heart valve implant (TAVR)

This may be the second time I'm sending this, I can't tell if the first one went through.... Hello Dr. Z and Associates, Our physicians have started performing peripheral angios and IVUS to evaluate lower extremity peripheral arteries for possible transfemoral heart valve implant (0256T). This is normally done a few days before scheduled valve implant. Would this meet medical necessity requirements for 75716 and/or 75945/75946? Thank you!

Extremity Bypass Graft

I have never coded a procedure like this, so I would love your assistance. The surgeon did a right fem bypass graft to the left iliac artery. He then attached the iliac artery on the left to the previous fem/pop bypass graft on the left. Then from the pop bypass graft he did a graft to the tibial artery. Would you use code 35665 ileofemoral and then 35671 popliteal-tibial? The right femoral to left iliac has got me stumped.

Extremity Distal Bypass Graft

Is it okay to use code 35571 for distal bypass graft to dorsalis pedis artery using cryopreserved saphenous vein? Or should we use code 35671?

Facet and Nerve Root Injection at Same Time

Our physicians state they are performing a facet joint injection and a nerve root block. If both of these procedures were performed at the same session, are we allowed to report both codes 64483 and 64493-50? "Utilizing sterile technique, fluoroscopic guidance, and local anesthetic, 22 gauge spinal needles were advanced into the bilateralL4-L5 facet joints. After injection of dilute contrast into the joints, confirming the needle position, 1 ml mixture of 0.25% bupivacaine and 20 mg of Kenalog were injected into each joint space. Utilizing sterile technique, fluoroscopic guidance, and local anesthesia, a 22 gauge spinal needle was advanced into the perineural space of the left L4 nerve root. After injection of dilute contrast into the perineural space, confirming needle position, 1 ml mixture of 0.25 bupivacaine and 20 mg of Kenalog was injected."

Facet Cyst

The radiologist injected bivicaine into the L4-5 & L5-S1 facet joints bilaterally. He also aspirated synovial fluid from the right L5-S1 facet joint. How would you code the aspiration?

Facet Injections, Determining Number of Facets Injected

Can you clarify something for me? This relates to question 5222 where you said if injections were done of the L2, L3, and L3 facets that you would only code two injections (L2-3 and L3-4). If my physician dictates that he did facet injections of the L2-3, L3-4, and L4-5, would you then code three injections because he is giving the levels?

Facial sclerotherapy

Hello Dr. Z A percutaneous neuro sclerotherapy was done on facial venolyphatic malformations. The ethanolamine was injected through a direct puncture 22 gauge butterfly needle of the mandible lesion with live fluoro Should the 37799 or 36470 code be uses along with the 77002 for needle placement guidence?

Failed Attempt for LHC

Would you report the following example with code 36140? "Access from the right groin with multiple attempts and radiological guidance was unsuccessful, and the left side was also unsuccessful. The patient is extremely corpulent, and access was not possible. The patient had the radial artery used during surgery, so we are going to need to go from the left arm brachial or radial in order to access her arteries, and this will be rescheduled."

Failed Attempts for Central Venous Cath

Can you charge all attempts for a central venous cath? There were multiple sites tried and all failed. I know I can only charge guidance once, but I am not 100% on charging all attempts.

Failed Lumbar Puncture

If we went through the whole process of performing a lumbar puncture after anesthetizing the area and could not obtain any fluid, do I have to modify the procedure as attempted but failed?

Failed/Unsuccessful CTO Crossing Lower Leg

How does one properly code for a failed/unsuccessful procedure to recanalize (cross a CTO) an obstructed peripheral artery (e.g., lower leg)?

FB Modifier Pertains to 2013

If a warranty credit is received in 2014 for a procedure that took place prior to January 1, 2014, do we still use the -FB/-FC modifiers? Following is an extract from MLN Matters® Number: "MM8572 No Cost/Full Credit and Partial Credit Devices Effective January 1, 2014, CMS will no longer recognize in the OPPS the FB or FC modifiers to identify a device that is furnished without cost or with a full or partial credit. Also effective January 1, 2014, for claims with APCs that require implantable devices and have significant device offsets (greater than 40%), the amount of the device credit will be specified in the amount portion for value code “FD” (Credit Received from the Manufacturer for a Replaced Medical Device) and will be deducted from the APC payment for the applicable procedure."

Fem-Pop Bypass with Angioplaty of External Iliac Artery

My physician completed a right fem-pop bypass using saphenous vein. As the right external iliac was not clampable for an endarterectomy, he instead balloon angioplastied the stenotic segment and placed a stent through a micropuncture needle in the common femoral artery. I would only code for the bypass, as I would consider this part of localized inflow and outflow. My provider disagrees and thinks this should be billed in addition to the bypass. Can you please provide your thoughts?

Fem/Pop Bypass Graft AV Fistula

"Patient had a CTA with run-off showing AV fistula at the fem-pop bypass graft and came to IR. Bilateral run-off was done, catheter was placed in the graft, and embolization occurred with many coils. PTA was done in the popliteal artery at the anastomosis." I believe I should report code 37242 for the embolization and code 37224 for the PTA of the popliteal. The vascular surgeon wants to code the bilateral run-off plus catheter placements. Would you verify for me please?

Femoral Acetabular Impingement (FAI) exam

What is the correct coding for a femoral acetabular impingement (FAI) exam? In our protocol, we perform a CT through the bony pelvis and proximal femurs, 3D reconstructions are created of both hips. In addition we obtain axial CT imaging through the knees to evaluate for femoral anteversion. Since this exam is primarily focused on the hips it seems most appropriate to code this as a Bilateral CT Lower Extremities (which covers the hips and knees) and include a 3D post processing component (76377). We also considered billing it as a CT Pelvis with 3D post processing component however that seems to ignore the added imaging through the knees?

Femoral arteriovenous fistula for a pedicle free flap to lumbosacral area

Greetings, I have a physician completing a femoral arteriovenous fistula for a pedicle free flap to the lumbosacral area. They tried a iliac artry exposure first but due to scar tissue they had to expose the femoral vessels. The physician harvested the entire greater saphenous vein,then anastomosted the vessel to the common femoral artery. This was then tunneled to the lumbosacral area. While tunneling the illiac vein was injured. How would I code this? A fistula tranposition code with a 36818- 22. The unlisted code 37799. Do you have any advice? Thanks, LW

Femoral to Femoral Bypass Same Leg

How do I code for a common femoral to profunda bypass using a Dacron graft same leg?

Femoroperoneal Bypass Graft with Graft Revision

I am hoping you can help with the following case. I don't believe that code 35879 should be billed at the same time as code 35566, but I am considering the use of a -22 modifier. "Once femoroperoneal bypass was completed, ultrasound Doppler was used to evaluate graft, and the graft was found to have relatively low velocities of 15cm/sec in the thigh. There was a significant flow difference noted with velocities of 80 cm/sec in comparison to adjacent velocities of 15cm/sec. Incision was made over the graft, graft was mobilized, and it was decided to proceed with patch angioplasty since abnormality was likely a frozen valve. A segment of residual GSV was harvested and opened longitudinally for patch purposes. Arteriotomy was made through the valve and fibrotic tissue debrided away from the wall. Standard onlay vein patch angioplasty was then performed. Repair was complete, flow restored, and duplex showed no abnormalities with significantly improved velocities. Total procedure time was 7 hours."

Fenestrated Codes for 2014

My question is regarding the new codes for fenestrated grafts for repair of the visceral aorta. Am I assuming these codes apply to grafts from the manufacturer and ones that are custom made by the surgeon in the OR suite?

Fenestrated EVAR

Our practice just performed their first fenestrated EVAR. They used a fenestrated aortic cuff with a bifurcated stent graft. They also stented both renal arteries with iCAST stents and used an extension on the right iliac and used an iCAST stent on the left iliac. From what I have researched, I believe the codes would be 0078T, 0079T, 0080T, 0081T for the fenestrated cuff with bifurcated EVAR graft, and codes and 34825, 75953-26 for the extension on the right iliac. Are the renal stents included in the fenestrated graft codes, or can they be coded additionally? And can the iCAST stent for the left iliac be coded with 37221? A stent was done because 'there was only 4-5 mm of available iliac artery to extend the graft and there was noted to be poor apposition of the stent wall due to tortuosity of the proximal iliac artery'.

Fenestrated Repair of Aortic Dissection

We've just done our first fenestrated repair of an aortic dissection, and we are needing help with coding it. Can you help us? Here is what was done: 1) Successful balloon-assisted juxtarenal and infrarenal aortic fenestration. 2) Unchanged SMA occlusion. Patent celiac axis, IMA, and bilateral renal arteries. 3) Occlusion of right common iliac artery successfully treated with bare metal stent.

Fenestration Closures 93580 and 93568

Is it okay to report code 93580 (fenestration closure) and 93568 (pulmonary angiography) when the angiography is done after the fenestration closure when documentation states that "angiography revealed complete occlusion of fenestration in right atrium"? It is my understanding that codes 93580 and 93568 are bundled and should not be billed separately.

Fetal Cardiac Interventions

One of our doctors will soon begin doing fetal cardiac interventions (aortic valvuloplasty, pulmonary valvuloplasty, ASD creation, pacing) in conjunction with doctor from Maternal Fetal Medicine for the access to the fetus. Any idea how both doctors would bill for these procedures? Please help.

Fetal Echos

Pediatric cardiologists bill codes 76825, 76827, and 93325 for fetal echos. They also look at the umbilical artery. They want to bill code 76820 in addition to the three above codes. Looks like there is a bundling issue with codes 76820 and 93325, but 76820 pays more. I can't seem to find anything about billing these codes together. I'm assuming code 76820 cannot be billed in addition to these codes, but I would like to confirm.

FEVAR

The doctor did a FEVAR (with the graft covering the entire abdominal aorta) with placement of stents into bilateral renals and bilateral femoral exposure. One side was inserted through the "scallop" and the other through the fenestration. Is this reported with code 34846? Or with codes 34845 and 37236?

FEVAR

When choosing the code for repair of an AAA with a fenestrated device, is the code determined by the number of fenestrations or the number of stents placed in visceral arteries? The CPT code description says "including 1, 2, 3, or 4 visceral artery endoprostheses", which leads me to think the code is determined by the stents... but then how would I code a graft with four fenestrations and zero stents? My physician has done several cases where there are four fenestrations, and he only places stents in one, two, or three arteries.

FEVAR

Can I bill surgical cutdown codes 34812 and 34834 along with fenestrated aortic stent graft with three visceral artery endoprostheses?

FFR 93571 and Drug-Euting Stent C9600

We are hitting an edit whenever we code an FFR 93571 with a drug-eluting stent procedure. We are told that we need a primary procedure code with 93571 and that C9600 is not acceptable. (Note, this is a hospital.) The acceptable codes for 93571 are the heart catheterization codes and the bare metal stent codes. I would appreciate you help.

FFR and IVUS

Dr Z ~ Now that we can charge for individual vessels for PCI (LAD, diagonal) can we also charge separately for Radi wire diagnostic, per vessel (93571 and 93572)?

FFR in Non-Coronary Vessels

Would there be anything separately reportable on FFR performed on a renal artery, or would that be part and parcel of "including pressure gradient measurements when performed" in the description of CPT procedure codes 36251-36254?

FFR in renals

Hi Dr Z, One of our physicians recently performed a bilateral renal angiography, and placed a FFR wire in the left renal artery. It is my understanding that the FFR is not separately billable with a non coronary angiography. Thank you

FFR Repeat Coronary Angiography

The patient first had a left heart catheterization with angiography at his doctor's office owned by our hospital (93458). The patient then was sent over to the hospital for FFR of the LAD and RCA. Our hospital cath lab charged code 93454 for the coronary angiography and codes 93571, 93572 for the FFR. When computing, we are getting an edit stating that code 93454 is a component of 93458 (because the charges for the two facilities are being combined). Is it acceptable for the hospital cath lab to charge for the coronary angiography once again (with the -59 modifier) since it was already performed by the physician office during the heart cath the same day? Or should the hospital cath lab only charge for the FFR? Current charges are: 93458, 93454, 93571, 93572.

FFR without Pharmacologic Agent (IFR)

IFR is now being performed regularly in the cath lab. The difference between it and FFR is that there is no pharmacological agent being given (adenosine). As the CPT for FFR (93571) specifically states “including pharmacologically induced stress”, is there another code that can be used for IFR, or can it perhaps be modified? It is performed using the exact same wire and control module. Any suggestions?

Fibrin sheath disruption with a balloon

Distruption of fibrin sheath with angioplasty balloon 2011 Z Health Vascular & Endovascular Coding Reference lists 36595-52 & 75901-52. Distruption of fibrin sheath with angioplasty balloon 2012 Z Health Cardiovascular Coding Reference lists 36595-52 & 75901 without the 52 modifier. Why the difference in 2011 & 2012?

Fibrin Sheath Disruption with CVC Exchange

Do you have guidance when it comes to disruption of a fibrin sheath with a CVC diaylsis catheter exchange (not a Tessio catheter)? If a fibrin sheath was disrupted in the SVC and another fibrin sheath in the innominate vein, would codes 36595-52/75901 be assigned twice (once for each vessel) or just once (similar to guidelines of coding only one central PTA)?

Fibrin Sheath PTA for Hospital (Same Access)

Can you please explain why when fibrin sheath PTA is done via the same access in a hospital facility modifier -52 is not utilized only on the physician side? This modifier is used in other outpatient hospital coding and is approved per the CPT Manual (where modifiers are listed). I know this is in your literature but not the explanation behind it.

Fibrin Sheath vs. PTA

Is the following coded as a fibrin sheath (36595-52), a PTA (35476), or both?  "A pull-back SVC venogram was then performed, revealing a fibrin sheath and stenosis at the superior cava/right atrial junction. The existing catheter was exchanged for an 11 French vascular sheath. Balloon angioplasty was performed using a 12 mm balloon, followed by a 14 mm balloon for fibrin sheath disruption and stenosis dilation. Follow-up venogram demonstrated satisfactory results with disruption of the fibrin sheath and slight improvement in the SVC stenosis."

Fiducial Marker Placement in Liver

Prior to TIPS, a fiducial marker is placed into the liver. "Under real-time CT fluoroscopic guidance, a 3 cm x 3 mm coil was placed to mark the portal vein bifurcation. FINDINGS: Archived images demonstrate excellent positioning of the fiducial marker at the portal vein bifurcation. IMPRESSION: Successful marker placement." Following, TIPS was attempted. "Access the right internal jugular vein using US guidance. A multipurpose angiographic catheter was used to select right hepatic vein, accessory right hepatic vein, and left hepatic vein. Hepatic venography was performed in each vessel. I tried several times to pass a working sheath into the occluded left hepatic system, and was unsuccessful each time. Due to hepatic venoocclusive disease, no invasive pressure measurements were obtained. IMPRESSION: Hepatic venoocclusive disease." I am unsure of how to code the coil. It's not being used for radiation, so I don't believe code 49411 is correct. It is not an embolization either. Also, would the hepatic venography be reported with codes 75891 and 36011 x 2?

Fiducial Markers

Is a biopsy performed at the same time as a fiducial/vesicoil placement inclusive? So, if the physician performed a vesicoil placement in the chest under CT guidance and performed a biopsy at the same encounter, I would report codes 32553 and 77012 only, correct?

Fiducial Markers and Biopsies

I had previously submitted the question, if a biopsy and a fiducial placement were performed at the same encounter, could they both be billed. You answered that they COULD both be billed. My compliance department wants to make certain they can both be billed if the biopsy and fiducial marker placement are performed from the same access point with the same needle.

Filter Removal

We have multiple opinions flying around on this one, so I wanted to run it by you. Patient has/had DVT of the lower extremities and had a filter placed. She is seen now to have a lower extremity venous ultrasound done prior to removing the filter to check the status of the DVT. On the left it looks to have resolved, but on the right it's undeterminable if it has completely resolved. Would you use the DVT diagnosis (453.41/453.42), a follow-up (V58.81/V58.89), or a pre-op (V72.83) diagnosis code? I'm leaning towards the DVT, but a few do not agree, so I was hoping to get your opinion on it.

Filter retrieval from the pulmonary artery, 37193

Dear Dr. Z: IVC filter migrated into the right lower lobe pulmonary artery requiring removal. Would 37203, 75961, 36014 be reported or would we report the standard filter retrieval 37193? Thank you. mlb

Filter wire

I apologize for my last question: It should have read what is the coding difference between a flow wire/pressure wire (93571-26) and a filter wire. I do not have a code for the filter wire.

FIRM and PVI Catheter Ablation

Can we report both codes 93655 and 93656 for FIRM (focal impulse & rotor modulation) and pulmonary vein isolation catheter ablation to treat atrial fibrillation? Usually these rotor ablations are done in both the right and left atrium prior to PVI. If reportable, should we assign code 93655 twice for left and right no matter how many rotors/lesions were ablated? Or do we code based on the number of lesions ablated? Here's an example: "The 60 mm basket catheter was deployed in the left atrium and Epoch 3 created, which appeared to show rotors on the mitral annulus just anteroinferior and posteroinferior to the left lower vein. These rotors were ablated and ablation lesions connected. Epoch 4 showed a posterior wall rotor, which was over the esophagus and was difficult to ablate extensively due to heating. Epoch 5 and epoch 6 were created after adjusting the basket to better contact the posterior wall. These revealed rotors in similar areas as the prior rotors. Ablation lesions were delivered extending the prior lesions along the mitral isthmus and on the posterior wall. During ablation, atrial fibrillation terminated."

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