Knowledge Base

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Set Descending Direction

Transcatether Mitral Valve Replacement via Transapical Approach

What would be the proper coding for the following procedure? "The patient was then prepped and draped for transapical transcatheter mitral valve replacement. The physician will dictate all surgical aspects of the left ventricular transapical approach and closure. With the sheaths in place, we moved forward with the transcatheter mitral valve replacement via a transapical approach. The physician gained access to the left ventricular cavity with a Cook needle. A Rosen wire was then extended into the left atrium across the bioprosthetic mitral valve. We then advanced a long 7 French sheath into the left atrium. We exchanged an extra stiff Amplatz J-wire to the left atrium. An Edwards Sapien 29 mm XT bioprosthesis was malleted onto its transapical delivery system and advanced over the stiff wire. Under coaxial fluoroscopic guidance, we placed the XT transcatheter valve within the previously placed mitral valve prosthesis. Under rapid right ventricular pacing, we deployed the XT valve inside of the previously placed mitral valve prosthesis."

Abdominal Aortogram

I need some clarification on medical necessity for abdominal aortograms. Is peripheral vascular disease enough to justify an aortogram? I have been looking for aneurysm, pseudoaneurysm, abdominal bruit, aortic stenosis, and such. Please clarify what is sufficient.

Lower Extremity tPA with Thrombectomy

"Venogram was performed, demonstrating segmental thrombus throughout the right SFV, as well as popliteal vein. This was followed by placement of 4 mg of tPA infused with a mechanical device within the right lower extremity venous structures from the proximal SFV to the popliteal vein. Angiogram was performed, confirming some segmental thrombus in the right SFV and popliteal vein. This was followed by placement of a thrombectomy extraction 6 French catheter. Thrombectomy was performed within the right lower extremity from the SFV to the popliteal vein." Based on this documentation, can code 37212-59 be reported with thrombectomy code 37187? Via phone discussion, the physician states that after tPA the patient is sent to post-op for an hour and then brought back for the thrombectomy. Does the "mechanical device" used for the tPA support reporting the infusion service?

L subclavian angiogram during cardiac cath

Patient presents for cardiac cath and subclavian angiogram. Indications are positive stress test, angina, vertigo, memory issues, carotid US with suspicion of subclavian stenosis. Procedure performed via right radial artery access. Catheter placed in right subclavian artery and contrast injected, revealing diffuse atherosclerotic stenosis in proximal left subclavian artery. (Cardiac cath and intervention performed without issue.) How would the left subclavian angiogram be coded? Would this be reported with code 75710-LT?

Stent placed in Lower Exteremity Vein Graft to tibal artery

A patient with a LE vein graft to tibial artery was seen in office by surgeon. US revealed an impending stenosis. Patient brought to cath lab for angiogram and possible intervention. OP report states a 99% stenosis was seen proximal to a stent in the distal vein graft. More proximal vein graft lesions and the proximal posterior tibial artery were treated with a 5 x 40 and a 5 x 20 mm balloon respectively. Pre-occlusive stenosis in the distal tibial vein graft which was successfully stented. The proximal posterior tibial artery was also angioplastied1. Procedure was coded as 75710 37230. However, WPS Indiana has denied this due to non-covered diagnosis code T82.858A stenosis of prosthetic graft entered by coding. If believe dx code is incorrect since this is not a prosthetic graft. Is it appropriate to use 37230 for stent placed within vein graft? Or should a different CPT code be used. Recommendation of dx code. HP does not mentioned claudication.

Fractional Flow Reserve Without Catheterization

The physician performs a left heart catheterization at NCP cath lab and then transfers the patient to cath lab at hospital to do 93571. Since this is an add-on code and can't be billed alone, would you bill this with unlisted code 93799? The physician thinks that 93571-26-XE will get us paid for Medicare, and for commerical insurance to bill CORS only with 93571 to get paid. What are your thoughts?

Codes for Spinal Angio

I have findings for all the selective cath's. I'm really confused on the thyrocervical, T5's, and the LT supreme intercoastal. I find myself confused with the families when they are done with other 3622x codes. 

Cavo-tricuspid isthmus ablation

Can I report code 93655 with 93656 for cavo-tricuspid isthmus ablation? "Conclusions: 1) Apparently successful wide area circumferential ablation of the left atrium and pulmonary vein isolation. 2) Successful cavo-tricuspid isthmus ablation. Next attention was directed to the left antral region with wide area circumferential ablation, following which repeat voltage mapping again demonstrated elimination of all electrical activity. The Penta Ray catheter was then exchanged out for a Lasso catheter, and DC cardioversion was required to restore sinus rhythm. Entrance and exit block was demonstrated in each of the four pulmonary veins. Following completion of the WACA and PVI, adenosine was administered to evaluate for recurrent PV potentials and none were appreciated. Small electrograms appreciated on the posterior superior aspect of the right superior pulmonary vein were determined to be far field from the SVC. A complete EP study was performed, and no inducible tachycardia was appreciated. Given a previous history of isthmus ablation, trans-isthmus conduction time was measured and found to be over 190 ms in both directions."

Failed or billable access

I really need your help. Patient with iliac stenosis. Doctor states access is gained on the right side, and catheter is crossed over bifurcation and into the common iliac, but occlusion prevents access into the external iliac. So the doctor opens access from the left side (34812) and places a stent. Can we code the failed attempt catheter (36245) with the successful stent (37221)? I would normally code this contralateral access if diagnostic test was performed also, but in this case no angiography was documented. Could you please advise?

Upper Extremity Venous Angioplasty 35476

I have a case where they accessed the AV fistula via two access sites, completed a fistulogram, then performed angioplasty on the subclavian vein as well as the basolic vein. Would you report codes 35476/75978, 35476/75978 (for the 2nd intervention), 36147, and 36148? 

2017 Moderate Sedation Calculation with TEE and Cardioversion

My physicians are trying to determine how to calculate intraservice time when performing TEE followed by external cardioversion. I notice that internal cardioversion is on the list of codes to bill moderate sedation with, but not external cardioversion. Any guidance on how to determine start and stop time for moderate sedation for TEE and cardioversion?

Pacemaker insertion, transvenous and epicardial

The patient has one transvenous atrial lead and two epicardial right ventricle (open subxiphoid approach) leads placed with pacemaker insertion in the same initial placement session. How would this be coded?

Popliteal Aneurysm and Revascularization

Patient has large popliteal aneurysm treated with stent graft, but also has other disease treated with atherectomy and angioplasty in the fem/pop territory. If it was just popliteal aneurysm, I would follow advice to use code 37236. However, in the setting of other interventions, how would you approach? Do you suggest reporting codes 37236 and 37225? Or would you combine all of it into code 37227?

93979 vs. 93926

I was given direction many years ago to bill code 93979 for groin duplex for pain after angiogram being veins and arteries are addressed, and it's been brought to my attention that code 93926 would be more appropriate. I attached an example of a report. "Interpretation Summary: This is a normal groin arterial duplex of the right lower extremity. Right Leg Findings CFA: 79 cm/s, triphasic. CFV: Normal exam duplex groin right. Right Leg Findings DFA: 85 cm/s, triphasic Rt. DFV: Normal SFA Prox: 139 cm/s, triphasic SFV: Normal."

Arterial Injury With Shunt and Vein Graft Repair

Patient had a gunshot wound to the thigh. Through and through injury to the femoral artery. The patient was in shock, so we only did a shunt temporarily until the patient was hemodynamically stable. Later that day we returned to the OR and did a saphenous vein harvest and interposition graft repair. I’m thinking that the initial shunt is going to be bundled with the second surgery. Due to it being an injury, I was thinking of reporting code 35256 for the second surgery. How would we decide to code from the repair of blood vessel section (35256) vs. using a bypass graft code (in this case 35556)?

Celiac Block and Neurolysis

If a celiac block (64530) is performed and the patient is observed for a period of time, then the physician proceeds with celiac neurolysis (64680), would we only bill code 64680? If the procedures occurred on two separate dates for whatever reason, would they both be billable?

33263 vs. 33264 -- CPT book and Ask Dr. Z clarification

Page 195 of the 2016 Professional Edition CPT Codebook (page 197 in 2017 book) contains a grid listing some common ICD procedures and how to code them. The last scenario listed is the conversion of an existing ICD system to a biventricular system. The codes recommended are 33225+33263 or 33264. It is my understanding that a biventricular device is always considered a multi-lead device, even if only two leads are present. This was stated in Ask Dr. Z. question #8202 of July 29th. Under what circumstances would we report code 33225 with 33263 (instead of 33264) for a biventricular upgrade per the CPT book guidance?

Correct Modifiers for 61645 and 75710

Our patient had a cerebral arteriogram and thrombectomy of the left internal artery and middle cerebral artery. We coded as follows: 61645-LT, 36224-59RT, 36225-59LT, and 75710-26/59/76. Codes 61645 and 75710 were denied because the modifiers were inconsistent or missing. Please help us understand what we are missing.

JP Blake Drain

Which code do we use for the insertion of the drain, and which code for the removal?

Biventricular ICD Removal

What codes would you bill for a complete biventricular ICD removal? Patient was having complications, so the physician removed the generator, RV ICD lead, RA ICD lead, and LV ICD lead without replacement of anything. Is the LV lead removal billable? If so, what code would you suggest?

CT Guided Percutaneous Gastrostomy Tube Placement

While code 49440 is for fluoroscopically-guided G-tube placement, how would we code this if only CT guidance is used?

Reporting Pro & Tech

If a service is performed on one day, but the physician reads it on the following day, do we need to bill the pro and tech portions with different dates of service?

Coding Use of Bone Marrow Aspirate to Aid Wound Healing

I need help coding the injection of bone marrow aspirate into a non-healing wound. I've searched the Knowledge Base and couldn't find the answer. Here is an excerpt from the operative report. "Through two punctures in the anterior superior iliac spine area, harvest needles were applied to the bone marrow, and 120 mL of aspirate was removed from each iliac crest. This was spun down to clotted autograft material. After the autograft was formulated in syringes, we implanted the autograft proximal to the wound about the right heel into healthy tissue to effect late closure or delayed primary closure by secondary intention of the wound. In addition, we injected several areas along the anterior tibial and posterior tibial artery at 1 inch depth, 1 mL each injection to stimulate neovascularization in a patient with severe peripheral arterial occlusive disease." What would be the appropriate code for this?

93015

For our doctors' office, if one physician is supervising and another does the report, are we to split up the codes? Where one will charge supervision, one for the tracing and one for the interpretation? Or since they are from the same practice, can we bill code 93015?

Stab Phlebectomy

My physician did a stab phlebectomy, bilateral, with 5 incisions on the right and 6 on the left. I know it would be coded with 37799 since it is less than 10. But, it is appropriate to use modifier -50 since there were 5 on one side and 6 on the other? Or should I use -LT and -RT modifiers?

Additional Imaging in Visceral Arteries

I know in many of the examples from your publications that after the initial basic celiac (or other visceral artery) exam the suggested coding reflects 75774 for each new more selective vessel, but what is included in that initial basic exam? In other areas of imaging (i.e., extremity), staging the imaging by shooting small sections at a time likely wouldn't be coded with 75774, so I was just wondering what makes the visceral vasculature different. Here's a hypothetical report: "Celiac axis was catheterized, followed by selective arteriogram. Next the catheter was advanced to the common hepatic, proper hepatic, left hepatic, right hepatic, and right hepatic superior segment arteries for selective arteriograms."

2017 Conscious Sedation

The CPT Codebook contains a chart to assist with coding physician time. For example, 68-82 minutes you would code 99152 + 99153 x 4 (for 5 years or older), then 83 minutes or longer it states, "Add 99153." The "or longer" sounds like the timing ended. Does this mean you can only charge each additional 15 minutes 5 times maximum?

Renal Alcohol Ablation

Patient has metastatic transitional renal cell carcinoma. Can code 49185 be used for main renal alcohol ablation?

33210 versus 33216

Recently our physicians have started placing a C1898 lead as a temporary pacing lead, attached to an external single-chamber pacemaker. Can you advise us which code is more accurate? Code 33210 or 33216? Also, in what circumstance specifically would you use code 33216 instead of 33210?

Sacral Catheter Placement

I have a question on the new code for 2017. In-house patient needed to have infusion, so the interventional radiologist placed a catheter in the sacral epidural space with fluoroscopy guidance. Catheter was left for future infusion, but radiologist did not give drug. Local anesthesia was given by needle injection to the same space prior to the catheter placement. Can I report code 62327?

AV Fistula of Leg

When the physician has no other option to place a fistula in the arms, and he decides to do a direct in the leg from the common femoral vein to common femoral artery, should an unlisted code be used? If so, should we have the code mirrored to 36821?

35476

Can a venous angioplasty be coded when the report only indicates that the patient has thrombus or occlusion of the extremity vein(s)? I am seeing a lot of reports where they are doing extremity venous angioplasties, but they are not dictating that the patient has a stenosis. Should I return the reports to the doctor to clarify? My understanding is that angioplasty can only be billed when done for stenosis.

Deep Femoral Endarterectomy

My surgeon performed an endarterectomy of TWO branches of the deep femoral artery. An incision was made on a lateral deep femoral branch and extended onto the common femoral. A second incision was made on a medial deep femoral branch. Would you code this twice with 35372 x 2?

76881 once per extremity

With code 76881, can you bill this code per each joint on each extremity (more than once per extremity)? A Physician is insisting that you can bill code 76881 once for the shoulder and then again for the elbow at the same encounter. The LCD states, "More than one complete ultrasound per joint, per extremity, in a 12-month period will be considered not medically necessary." The physician is interpreting this to mean that they can bill per joint rather than per extremity (i.e., more than one 76881 on the same extremity). Can you please help clear this up and provide an official source other than this LCD that I can refer to. I could not find an NCCI policy on this. 

IVC Filter Removal

I have always coded an encounter for removal of an IVC filter with Z46.89. Now my auditor is telling me that I should be using Z45.89. I code a lot of these, and I would really appreciate an answer. Who is right?

Fem-pop In-situ Bypass with Iliac Angioplasties

Patient has in-situ bypass (fem-pop). Patient also has angioplasty of the ipsilateral common, internal, and external iliacs. The common femoral was exposed, and dissection was carried down to the inguinal ligament. The LCFA was then dissected and controlled, then the physician exposed the distal popliteal and prepared for bypass. The physician then dissects the in-situ vein. He prepared the in-situ vein for bypass, then turned his attention to performing the endovascular part of the case. Through the exposed common femoral artery, a micropuncture needle is inserted…” and he performs angioplasty of the LCIA, LIIA, LEIA. He clamps the LCFA distally with clamp and proximally with clamp, then turns his attention back to the actually in-situ bypass. Can I bill out the in-situ bypass with the iliac angioplasties? I am saying NO, they can’t be billed. I need someone else’s opinion.

Embolization of LV Pseudoaneurysm

Patient with prior cardiac trauma has developed a left ventricular pseudoaneurysm, which is treated by coil embolization. Would this be reported with code 33999 or 37242?

Billing for Fluoroscopic Guidance by Surgeon

There seems to be some confusion in our practice for billing code 77001-26 for port-a-cath insertion. If the surgeon uses fluoroscopic guidance stated in his note, can he bill for it without dictating a report? Our radiologist also bills for fluoroscopic guidance with a report. Can they both bill for it?

ClariVein vs. VenaSeal

What code do you use for a VenaSeal procedure? I have used unlisted code 37799 in the past for this. However, with the introduction of the new mechanochemical ablation codes in 2017, I believe that we could use code 36473-52 instead of the unlisted code. VenaSeal is similar to ClariVein with the exception of the mechanical component, therefore a reduced service would make sense, but I have not found any recommendations as of yet.

Pacemaker Laser Lead Removal

Our hospital recently started performing laser lead removal in the cath lab. With the use of laser, I understand there are no additional codes required, correct? We also use surgery standby and perfusion standby. Are additional charges allowed for those? Also, does code 33249 cover all of the following procedures? 1) Laser lead extraction of right ventricular pacemaker lead. 2) Laser lead extraction of right atrial pacemaker lead. 3) Pacemaker generator removal. 4) New right atrial pacemaker lead placement. 5) New right ventricular ICD lead placement. 6) New biventricular ICD generator to existing CS lead. 

Reduction Atrioplasty

Can we get coding assistance with the following? "During the time of reperfusion, a large swath of right atrium was then resected on the posterior aspect of the incision keeping this short of the crista terminalis. The right atrium was closed with a running double-layer 4-0 Prolene suture. We rewarmed to normothermia and then came off bypass."

76377

ER patient had CT head, CT cervical, CT chest, and CT abdomen and pelvis. Code 76377 was used for lumbar and thoracic findings, so there are 2 charges for 76377. If we can only report one 76377,  what can be billed for both the lumbar and thoracic regions documented findings? The radiologists feel the scanners are very good to detect the needed information on the CT of chest and abdomen, for the lumbar and thoracic region. What are your thoughts? We reported codes 76377 x 2, 71260, 72125, 74177, and 70450.

Clarification on 33210 vs. 33216

I need clarification on a previously answered question regarding 33210 vs. 33216. "Patient presents to ER with CHB and ventricular escape 25 beats a min. He’s temporized on IV dopamine, which was started emergently. A permanent screw-in pacemaker lead was placed temporarily in a patient who did not have a previous implanted device (no infection). The lead was temporarily attached to an external device, after which the lead was removed 4 days later, and a brand new device and leads were implanted (same setting)." Coding suggestions? I was thinking of coding 33216 for permanent screw in PM lead for first procedure and then 33249 and 33234 for second procedure. Is code 33216 only appropriate to report when a patient already has a device placed and the sole purpose for the lead placement was for infection?

Verbal Orders

Could we accept verbal orders while following CMS guidelines? For example, we have an order for a CT of the abdomen from the ordering physician. CT is performed, and now our physician says we need to do a MRI of the abdomen, so we call the ordering physician and get a verbal order. Is that acceptable? What is the protocol for verbal orders?

Multilevel Blood Patch

"Successful multilevel high volume autologous epidural blood patching. Using fluoroscopic guidance, three 20 gauge x 3.5 inch Touhy needles were localized to the dorsal epidural space at the L2/3, T9/10, and T3/4 levels. Positioning of the needles was documented radiographically and with injection of contrast material. Subsequently, a total of 22 cc of autologous blood obtained. A sterile fashion was injected into the dorsal epidural space. 6 cc at the T3/4 level, 6 cc at the T9/10 level and 10 cc at the L2/3 level. At each level, injection of blood was stopped when the patient felt discomfort. The needles were removed, and hemostasis was achieved with manual compression." Should code 62273 be reported x 3 or only once? 

G0463

What are the requirements for billing code G0463 in a facility setting?

2017 Moderate Sedation

If a procedure is being done with anesthesia, the moderate sedation codes would not also be used, would they?

ICD-10 AV Node Ablation

I have a case in which an AV node ablation was performed along with a pacemaker placement, and the pre-op and post-op diagnosis were dictated the same to reflect permanent a-fib. During the AV node ablation, the doctor dictated as achieving a complete heart block during the procedure. Is it okay to use the complete heart block as a diagnosis code since a complete heart block was created?

Aortogram with Heart Cath 75625

Our physician did an abdominal aortogram with a heart cath for an indication of "difficulty mounting catheter". Would this be considered a guiding shot? Or is this an indication justifying a separate code for a diagnostic aortogram?

BATO of Gastric Varices

Would the following be reported with codes 37241, 36011, and 36012? "Right portal vein punctured with ultrasound. Wire and catheter were passed into superior mesenteric vein. Contrast injection demonstrated a dilated left gastric vein feeding fundal varicosities and a gastrorenal shunt. Catheter was placed into gastric vein. Contrast was reinjected, confirming the presence of gastric varices. The right common femoral was punctured. A catheter was placed into the left renal vein. A directional catheter was placed at the origin of the gastrorenal shunt. Multiple attempts at placing an occlusion balloon into the origin were unsuccessful. A directional catheter was placed deep within the gastric vein. A balloon occlusion catheter was placed through directional catheter into the gastro vein. Onyx18 was injected, filling the varices in the fundus of the stomach. The Onyx was injected until a small amount was seen to opacify the large varices near the distal end of the gastrorenal shunt. The balloon was removed and contrast reinjected through directional catheter, confirming occlusion of gastric vein."

TAVR Percutaneous vs. Open

Patient had a TAVR procedure, and the valve was delivered percutaneously (33361). The large bore sheath was removed at the end of the case, and there was leaking around the femoral artery. Therefore, a femoral cutdown was done and the vessel repaired with suture. Should this be billed as open (33362)? Or should codes 33361, 34812, and 35226 be reported?

Subclavian Embolization

Would the following be reported with code 37242? "Patient has Kommerell diverticulum and is being prepped for thoracic endograft. Status post carotid subclavian bypass for treatment of dysphagia lusorm with aberrant subclavian artery. Here now for plug occlusion of the right subclavian. The pigtail catheter was exchanged for a vertebral catheter, which was used to selectively cannulate the aberrant right subclavian artery in its midportion. This catheter was exchanged for a 6 French flexor sheath, which was positioned in the mid right subclavian artery proximally to the vertebral artery. We then placed an 8 x 7 mm and 10 x 7 mm Amplatzer plug occluders in the proximal subclavian artery proximal to the vertebral artery."

Intracardiac Echocardiography - w/out a primary procedure

A patient who previously had a Zenker procedure and Watchman implant is now scheduled for an intracardiac echocardiography (93662). I do not have a primary procedure, so would 93662 be the correct code? The physician is indicating he cannot do a TEE, and he therefore wants to bill code 93662.

Physician reuses an ICD generator

My physician explanted the RV lead and implanted a new one. He reused the RA and LV leads. The old generator was removed and reimplanted. I only coded the new lead (33216) and removal of a lead (33244), but he wants to code the removal of the generator (33241). Is the removal of the generator billable?

49185

"Patient has a pelvic lymphocele status post pigtail drainage. Patient came to IR suite. 30 ml of fluid was aspirated from cyst through the catheter. Contrast was instilled to visualize cavity. Contrast was aspirated out. 50 ml dehydrated ethanol was instilled. Patient was advised to turn every 15 min for 2 hours. The catheter was then put to gravity bag." Can I report codes 49185 (sclerotherapy of cyst) and 10160 for aspiration? Or just 49185?

32551 vs. 32557

"IR chest tube placement indication: Large symptomatic right pneumothorax status post CT-guided lung biopsy. Technique: The patient was placed supine on the fluoroscopy table. The right hemothorax was prepped and draped in a sterile fashion. The fifth and sixth rib interspace was localized with fluoroscopy, and 1% lidocaine was utilized for local anesthesia. A Cook pneumothorax 9 French drainage catheter was placed into the right pleural space using a trocar under direct fluoroscopic surveillance. The drain was then connected to a Heimlich valve, and good re-expansion of the right lung was achieved after the patient coughed. Postprocedural images demonstrate a small residual right apical pneumothorax with the drainage catheter overlying the anterior midlung zone. Impression: Successful placement of 9 French chest tube with satisfactory re-expansion of the right lung." Is code 32557 or 32551 appropriate?

External Iliac Vein Stent with Venogram

Would the following be coded with 37238 and 76937? "Both groins were prepped and draped in the usual sterile fashion. The skin overlying the left femoral vein was infiltrated with 1% Lidocaine without epinephrine. The common femoral vein was punctured with a 19 gauge needle. A .035 glide wire was inserted into the aorta and the needle exchanged for a 4 French sheath. Hand injection was used to do an iliac venogram. Stenosis of the proximal external iliac vein was seen, which was therefore treated with a 14 x 40 mm Wall stent and angioplastied with a 12 x 40 mm balloon. The completion angiogram showed the distal common iliac vein to be narrowed in relation to the stent, so this vessel was angioplastied using the size balloon. Completion angiogram revealed wide patency of the iliac veins. Impression: Proximal left external iliac vein stenosis, which was successfully stented." 

Thoracoabdominal Aortic Aneursym

"Operation: Endovascular repair of thoracoabdominal aneurysm with fenestrated stent graft (4 branches) of visceral arteries and distal bifurcated aortoiliac stent graft. Repair of right common iliac artery aneurysm with iliac branch device. Percutaneous coil embolization of right internal iliac anterior branch. Left axillary artery conduit for delivery of stent graft components." Can I report selective catheterization of the patient's native right internal iliac anterior division (36247) and posterior division (36248)?

New ICD Generator with Left Ventricular Lead Replacement

Can you assist with the CPT codes for a new biventricular generator when only the left ventricular lead has been replaced? Would it be reported with codes 33264 and 33244? Or would the left ventricular lead replacement be unlisted? The other two remaining leads remained.

Removal Hero Graft (non-infected)

"A patient with a recently placed Hero graft has developed a thrombosis from the graft through to the central venous catheter portion. Despite thrombectomy the surgeon determines that the patient is in a hypercoagulable state, and, because of variant anatomy of the right atrium, the graft (as well as the central venous portion) is removed in its entirety. The separate temporary dialysis line in the patient’s femoral vein is replaced OTW with a tunneled dialysis catheter." Since the graft is not removed due to infection, would this be reported with code 37799 rather than 35903?

2017 Moderate Sedation

Procedure was performed in OP hospital setting. Can the provider performing the procedure bill for moderation sedation administration?

Modifier RT or LT on lower extremity

I have a question about modifiers -RT and -LT on the lower extremity procedures (37220-37235 and 36245-36248). When the intervention is done on the unilateral leg only, should we append modifier -RT or -LT? How about diagnostic angiogram? For example, when the stent was done on the right femoral artery, should we append modifier -RT to 37226? In the other case, patient had right lower extremity angiogram (access site: left common femoral artery, catheter site: right common femoral artery). Do we append modifier -RT or -LT modifier to code 36247 beside 75710-RT?

PN Modifier

I just need some clarification. We have an interventional radiology hospital-based clinic. Am I reading the information correctly that we need to add the -PN modifier to these claims? Does this apply to both the professional and technical billing? We have differing interpretations and need to make sure we are doing this correctly.

Endovascular Abdominal Aorta Stent Graft Placement for Abdominal Aorta Stenosis

Our physician places an endovascular abdominal aortic stent graft (Endologix AFX2) with deployment of extension stent in the iliac artery for the purpose of revascularization in a patient with abdominal aorta stenosis. Can we still use the codes for endovascular aorta repair (34804, 75952, 34825, 34826)? How should we code it?

CCI edit with new sedation codes

I just tried reporting code 36902 with codes 99152 and 99153. When I checked for edits it said the sedation codes were a component of 36902 on the facility side and could not be coded at all on the professional side. I wasn't expecting that based on what I had heard. Are there still some codes that include sedation? They are N-status codes on the hospital side anyway, but I have been telling physicians that they would be able to code it.

C-arm

If a tech is in the operating room using a C-arm for ankle case and is asked to save two images (from the C-arm), can both the C-arm (76001) and a two-view ankle (73600) be charged?

36907 vs. 37248

2017 CPT book, P247, “Codes 36907 and 36908 describe procedures performed through puncture(s) in the dialysis circuit. Similar procedures performed from a different access (e.g., common femoral vein) may be reported using 37248, 37249 or 37238, 37239.” 2017 CPT book, P255, continues to say “37248 and 37249 describe transluminal balloon angioplasty in a vein excluding the dialysis circuit (36902, 36905, 36907) when approached through the ipsilateral dialysis access.” I am confused about these two instructions. Can I understand in this way, for example, in a patient with dialysis circuit, if central dialysis segment angioplasty (e.g., external iliac vein) is performed through puncture in the common femoral vein, shouldn’t the procedure be coded with 36907 instead of 37248? Because the procedure is performed through dialysis circuit. (common femoral vein is part of the peripheral dialysis segment, which is part of the dialysis circuit). Only when the procedure is done in veins other than in the dialysis circuit, should the code 37248 be used?

Stent Jail

Would you code angioplasty of the ostium of a coronary branch for stent jail? No particular branch lesion is described.

Popliteal-Popliteal Bypass for Atherosclerosis

"Surgeon dissected the popliteal artery and excised a portion due to atherosclerotic total occlusion and replaces with PTFE graft. A prior endovascular revascularization was attempted but unable to cross the occlusion. Lower extremity angiogram was performed, finding 40% stenosis of the distal anastomosis and diffuse narrowing of the distal popliteal. A stent was placed from the distal popliteal just proximal to the takeoff in the anterior tibial with the proximal landing zone within the PTFE graft overlapping the distal anastomosis." Would code 35286 be appropriate with 37226 and 75710? Or would an unspecified code be a better choice for this graft, as it does not qualify for 35656 or 35671?

Sedation

the physician performs moderate sedation during the procedure can these codes 99152 etc be billed with the new codes 36901 - 36908 specifically. I am getting conflicting info

New 2017 Dialysis Fistula Codes

"Patient has a DVT in the right AV fistula cephalic vein and subclavian/innominate areas. Two accesses were done with US guidance and image saved to PACS. Angioplasty of the partially occluded cephalic vein was successful, and subclavian vein was plastied with stent placement but clot still present. A lysis catheter was placed for overnight with the tip in the subcutaneous vein. The next morning a venogram was performed and a moderate amount of clot was still present in subcutaneous vein, so thrombectomy was performed with a second stent placement from the subclavian vein into the innominate vein. Lysis was ended, and the fistula is now ready for use." Would you report code 76937, or is that bundled? Should I report codes 36902 and 36908 for day 1? And code 36906 for day 2?

Cryoablation

What would be the correct code for cryoablation for cryoneurolysis of the left T7, T8, and T9 intercostal nerves for control of post thoracotomy pain syndrome?

2017 Moderate Sedation

Here at our facility we are wanting to be sure of the best and correct practice of charging for moderate sedation, as well as with which procedures we are allowed to charge for it. To the best of my understanding we are allowed to charge moderate sedation with all of the procedures performed (heart caths, peripherals, fistulae/dialysis caths, pacemakers and EPS's) that get sedation in the Cath/EP Lab that do not utilize the assistance of anesthesia. There is question of whether or not this is the case, or if we can only charge moderate sedation on pacemaker implants where the RN is providing conscious sedation (higher level/doses) for the patient under the physician's instruction. For the majority of our other cases the RN is in the room administering lower doses of sedation under direct order from the physician, is monitoring vitals, and is attending to the patient as needed/requested. We feel that the intent of the majority of our sedation cases is to allay anxiety versus to truly provide conscious/moderate sedation. What would be our best practice of when we are allowed to charge for 99152/99153 in our department?

Angioplasty of a Pre-existing ASD

Is there a CPT code for static balloon dilation of an atrial septal defect? I did not do a Rashkind dynamic septostomy, just used an angioplasty balloon to dilate a pre-existing ASD. What is the CPT code for this?

INTRAOPERATIVE TRANSTHORACIC ECHO/TTE BEFORE AND AFTER TAVR

This question is regarding facility billing. When a transaortic valve replacement (TAVR) is performed under general anesthesia, a TEE is done “on the table” before and after the valve replacement (per TAVR protocol), and we report code 93355 once. When the TAVR is done under MAC, an intra-operative transthoracic echo complete is ordered and done “on the table” before and after the valve replacement. The department is charging two complete TTEs (93306). Is it appropriate to charge for the TTE twice on the same setting?

Deep Sedation

The ZHealth Online member newsletter from November 30, 2016 ("Billing for Moderate Sedation in 2017") states that codes 99151-99157 should not be used to report administration of medications for pain control, minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care. Is there a code for deep sedation administered by the same physician performing the diagnostic or therapeutic service?

93355 with Watchman Procedure

Dr. A performed the Watchman procedure, and Dr. B performed the TEE. The documentation for Dr. B's TEE is in Dr. A's operative report. Is this sufficient to bill code 93355 for Dr. B? Here are excerpts from the report: "Left atrial appendage occluder device placement in the form of a Watchman placed into the left atrial appendage under fluoroscopic guidance by Dr. A, as well as transesophageal guidance provided by Dr. B. Then the entire assembly, including the Daig SL1 sheath, the dilator, and the Brockenbrough needle, was pulled down as a unit into the fossa ovalis by Dr. A. This was confirmed with intracardiac echocardiography as well as transesophageal echocardiography performed by Dr. B. The patient underwent detailed transesophageal echocardiogram that was done by Dr. B during the procedure."

Brugada 93799 Procainamide Challenge

A patient with a history of palpitations and syncope several years ago. He has an abnormal EKG consistent with Brugada's syndrome. Physician brought him into the EP lab and gave him IV Procainamide to see if this would bring out the Brugada pattern more. If the Procainamide did bring out more of a Brugada pattern, the patient will then need an EP study and possible ICD implantation. It turns out the Procainamide challenge was negative, and he did not need an EP study. He did have a loop recorder implanted. Can I bill for Procainamide administration and checking of surface EKGs, without wires being put in for an electrophysiology study per se?

Peripheral CTO

Is there a separate CPT code for peripheral CTO like there is for coronary CTO?

Leadless Pacemakers

Have new CPT codes been assigned for leadless pacemaker insertion (category III 0387T)?

Single to Dual Pacemaker Upgrade

The procedure performed was an upgrade from a single chamber to a dual chamber pacemaker, by adding a right atrial lead and a new dual generator. How should this be charged: 33233 and 33206, or only 33214? What is the appropriate use of 33214?

Pacemaker upgrade vs. removal and replacement

In this case, the plan was to upgrade a single lead pacemaker to a dual lead pacemaker. However, the original single lead was malfunctioning and had to be extracted, along with the one-lead pacemaker generator. Then a dual lead pacemaker (generator and leads) was implanted. Should I code this as an upgrade still, with insertion of a (second) single lead? Or should I code for the removal of generator, removal of lead, and insertion of new dual lead pacemaker with dual leads (33233, 33234, 33208)? I believe it would be the latter, but I would like your take on this.

36246, 75630, 75716

"The LCF was accessed and guidewire placed in the AA. Abdominal aortogram was obtained, and catheter was advanced to right iliac system and then to distal common femoral where a right lower extremity arteriogram was obtained. Omni Flush catheter was switched out for a Rubicon catheter. This was passed over the bifurcation and into the common femoral artery. An attempt was made to cross the stenosis of the right superficial femoral artery total occlusion. The procedure was stopped at this point. An arteriogram of the left lower extremity was obtained through the side port." Would you agree to code this 36246, 75630, and 75716-59?

Selective Renal 36251 36253

"Right femoral arterial access was achieved. A 5 French catheter was advanced into the upper abdominal aorta, and abdominal aortography was performed. Catheter was exchanged for a 5 French JR4 catheter, and selective left renal artery angiography was performed in different views. The same catheter was used to selectively cannulate the right superior renal artery, and selective superior renal artery angiography was performed. The catheter was pulled down into the right inferior renal artery, and selective right inferior artery angiography was performed. The catheter was then advanced into the superior mesenteric artery, and mesenteric artery angiography was performed. The catheter was pulled into the lower abdominal aorta, and abdominal aortography with bilateral iliofemoral angiography and right femoral angiography was performed." Findings of each artery are provided. I’m coming up with codes 75716, 75726, 36245, 36251-LT for left renal, and 36253-RT for superior/inferior renal. Is this correct? I wasn’t sure if superior/inferior renals = superselective or not. 

93454 and 93451 performed on same DOS by same physician at separate times

"Patient was seen in the morning and had a coronary angiography performed for an NSTEMI (93454). LAD lesion was not amenable for PCI, and patient was referred for CABG evaluation. As the day went on, the patient 's troponins trended up, and the patient returned to the cath lab for a right heart catheterization and an IABP placement for hemodynamic support. This procedure documents right heart pressures, hemodynamic profiles, and oximetry.... Elevated left-sided filling pressures. Normal cardiac output. Balloon pump inserted for refractory angina." We want to bill codes 93451 and 33967 for the second procedure. However it was performed by the same physician, and NCCI edits will not allow us to bill both on the same DOS by the same provider, even with a modifier. What is the appropriate way to capture billing for this? Can we use combo code 93456 even though these procedures were performed at separate encounters? Please advise.

Endoleak Repair type 1

"Stiff guidewire was advanced successfully into the left limb to the endograft into the suprarenal abdominal aorta. Balloon was inflated to tamponade on the rupture; this did not improve. Medtronic aortic cuff endograft was placed to repair endoleak. Persistent leak was confirmed, so a Palmaz stent was premounted and deployed over the proximal aspect of the stent graft overlapping renal arteries. Endoleak persisted, endoanchors were placed, and additional balloon inflation was performed. Aortogram demonstrated serial of the endoleak, and no further bleeding was identified." I'm not sure how to code this. Endograft placement is 34825; however, the Palmaz stent was placed due to persistent leak, so do we then replace 34825 with 37236? What about the anchors 37799 with 37236?

MID-LINE CATHETER

"The left brachial vein is punctured, and a midline catheter is placed with its tip in the left brachial vein." Is this reported with code 36569-52 for a midline catheter, or should code 36410 be reported? Patient has end-stage renal disease with poor IV access. I thought that a midline catheter had to be placed past the access site, but not into the subclavian vein or further centrally. Please explain how this would be coded and why. 

Cryoablation of Adrenal Mass

I work for a hospital. I would like to know the appropriate CPT coding for CT-guided cryoablation of an adrenal mass. 

Dialysis Circuit Coding

Can you provide coding assistance for this case? "Procedure(s): 1) Ultrasound-guided access antegrade and retrograde left femoral AV graft. 2) Fistulogram with central venography. 3) Arteriography with iliofemoral runoff. 4) Angioplasty AV graft, arterial and venous anastomoses with 6x40 mm non-compliant balloon. Intraop Report: Using local anesthesia, ultrasound guidance, and a micropuncture system, the left femoral AV graft was accessed antegrade and retrograde. The transitional sheaths were immediately upsized to short 7 French sheaths. Contrast was injected to perform fistulogram with DSA runs visualizing the fistula in its entirety as well as the central veins in multiple views. This revealed venous outflow occlusion. Injection from catheter placed into the left iliac artery revealed focal stenosis at the arterial-graft anastomosis. These areas were angioplastied per above for 3-minute inflations."

Unsuccessful PCI

If a provider attempts to perform PCI of the RCA, but is unable to pass the stent, would you code the stent (e.g., 92928-52) or code to an angioplasty (92920)?

Popliteal Aneurysm

How can I code this? "Right lower extremity angiogram confirms diffuse calcific disease of the right superficial femoral artery (SFA) and popliteal artery. There is a very obvious 6 cm aneurysm at the distal aspect of the right superficial femoral artery/proximal popliteal artery. There is 2-vessel runoff via a diseased anterior tibial artery and a healthy peroneal artery. The posterior tibial artery occludes several centimeters beyond its origin. Right superficial femoral artery/popliteal artery aneurysm treated with placement of an 8 x 10 Viabahn covered stent placed distally and a 9 x 10 Viabahn covered stent placed proximally with 3 cm overlap. There is an excellent result with complete exclusion of the aneurysm and no evidence of delayed (type 2) endoleak. ProGlide hemostasis with excellent result."

93655 with 93653

Can the department add code 93655 with 93653? "Procedure List: 1) Comprehensive electrophysiologic study with coronary sinus recording and pacing. 2) 3D mapping with ESI NavX mapping system. 3) Radiofrequency ablation for SVT. 4) Radiofrequency ablation for SVT focus. Description: An 8 French St. Jude Tacti-cath RFA catheter was passed via a right femoral Agilis sheath. RF energy was placed in a linear line from the IVC to the lower end of the scar/crista region. The flutter terminated when the line was connected to the lower crista/scar. Further lesions were placed superiorly along the crista/scar to anchor the ablation line. Due to her history of sustained atrial flutter and possibility of typical as well as atypical atrial flutter, RF energy was then placed in a linear line from 6 o'clock on the tricuspid annulus to the IVC. Bidirectional block was demonstrated with pacing from the proximal CS and low right atrium."

Diprivan as moderate sedation

Can diprivan or ketamine be captured as moderate sedation with the new 2017 sedation codes?

New AV coding

If the doctor access the fistula, does a fistulogram, and sees occlusion only in the innominate vein, should we use code 36902 for an angioplasty of the vein?

Ultrasound Guidance - multiple access attempts (pediatric)

We have complex heart cath cases where multiple vessels are attempted for vascular access under ultrasound guidance with recorded imaging. I've recently been instructed that it's not appropriate to bill more than one 76937 per patient encounter. The MUE for code 76937 is 2, and I've been reporting the initial 2 on one line, with additional on a separate line. Can you please confirm if reporting one 76937 is correct, or can I continue reporting multiple?

99024

Are there documentation requirements to bill code 99024 during a global period?

ICY Catheter

In 2008, you recommended that CPT code 37799 be used for placement of ICY catheter for patients who have had cardiac arrest and are being treated per the hyperthermia protocol. Is there a recent update, or does this recommendation still hold true?

Bioabsorbable Stents

Are bioabsorbable stents classified as drug-eluting or non-drug-eluting? "Patient came in for diagnostic left heart cath, left ventriculogram, and coronary angiogram. Findings include an occluded LAD, which was then treated with angioplasty, and insertion of two partially overlapping bioabsorbable stents."

Infusion for Vasospasm Non-CNS

How do we code verapamil infusion in the lower extremity for vasospasm?

Fluoro now an add-on code, 77002 and 77003

I understand that codes 77002 and 77003 are now add-on codes, but I'm confused why only four of the nerve anesthetic/injection codes are on the list. Do you think that there will be an update that will include all the nerve block codes (64400-64530) and nerve destruction codes (64600-64653)? In your IR book you suggest to use charge the guidance, but we are getting edits that fluoro can't be charged, as the code is not on list (with exceptions for the ones that already include guidance). +77002 (Use 77002 in conjunction with 10022, 10160, 20206, 20220, 20225, 20520, 20525, 20526, 20550, 20551, 20552, 20553, 20555, 20600, 20605, 20610,20612, 20615, 21116, 21550, 23350, 24220, 25246, 27093, 27095, 27370,27648, 32400, 32405, 32553, 36002, 38220, 38221, 38505, 38794, 41019,42400, 42405, 47000, 47001, 48102, 49180, 49411, 50200, 50390, 51100,51101, 51102, 55700, 55876, 60100, 62268, 62269, 64505, 64508, 64600,64605) +77003---(Use 77003 in conjunction with 61050, 61055, 62267, 62270, 62272, 62273,62280, 62281, 62282, 62284, 64510, 64517, 64520, 64610). 

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