Knowledge Base

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Set Descending Direction

Non coverage of 3D rotational angiography

What exactly needs to be stated in the report for the use of Rotaional angiogram with 3-D? Pt. had a stent assisted endovascular coiling done. The dictation states Rotational angiogram with 3-dimensional reconstruction with postprocessing on a separate work station. The payor denied 76377 stating related or qualifying service not paid or identified on claim. I'm not sure how to appeal this? thanks for your help.

Non-NSTEMI

Is a non-STEMI equal to an acute MI? The last response seen on this website was in January 2013 (question ID #4429).

Non-payment for sacroplasty issue

Dr. Z, We are receiving rejections for our Medicare patients who are having sacralplasty. We are submitting 0200T or 0200T affective July 1, 2009. Medicare is stating this procedure is experimental. I've contacted Medicare to see if they could point me to something in writing that I could pass along to our Interventional radiologists however, they simply state that they consider "T" codes experimental. Both the facility/hospital and professional components are not being paid. We were being paid prior to July 1 with the unlisted spine codes. Our denials management department would like to write a letter of appeal, but I cannot put my hands on anything to back up this claim. Would you please share your thoughts and point me in the right direction if you have any suggestions on how we should proceed? Thank you!

Non-selective catheter placements and stents

Dear Dr. Z: It just came to my attention that non-selective catheter placement is not billable with stent placement codes 37205, 37206. It is unusual for the stent to be placed on the same side as vacular access but is it incorrect to bill 36299 for non-selective venous catheter placement when a stent is placed in an extremity vein (no diagnostic venogram is performed)? Thank you. mlb.

Non-Selective Renal Angiogram with Heart Catheterization

With regards to Question ID #5346, when we have a heart catheterization (for instance 93458) with non-selective renal angiograms, and we assign code 75625-52, we get an NCCI edit on 93458 - that a comprehensive code is paired with another CPT component code to trigger OCE edit 0040 plus 75625-52 with edit of code 2 of a code pair with 93458 that would be allowed if an appropriate NCCI modifier were present. Our options are adding a -59 modifier to 75625-52 or not billing for 75625-52. Will code 75625-5952 be our best choice?

Non-tunneled catheter exchange 49423

Here's a quick question. Patient with liver cancer and ascites undergoes parcentesis with placement of an indwelling, non-tunneled catheter. The next day the patient returns with leakage around the catheter site. The abdominal catheter is removed and a new catheter placed under fluoroscopic guidance. I believe 49021 would be used for the first admission but what should be assigned for the catheter exchange on the second day? Can 49423 be assigned even thought this is not an abscess or cyst drainage catheter? Thanks again.

NSTEMI for Coronary Intervention Definition

I have a question in reference to Question ID 4429. There the question is posed: "I have a question for you from the webcast on Tuesday regarding the acute MI code. There is much confusion on whether or not a non-STEMI is an acute MI. Are we to assume that a non-STEMI is an acute MI? If so, what clinical indications (documentation) would need to be present?" Your response was: "We have asked the societies that created the code and left out their definition of MI. I know this is an issue with MDs. We will let you know when that definition is published." Could you tell me if this has been clarified, and if so, what is the definition?

Nuclear intrathecal injection with a blood patch

"Nuclear cisternogram blood patch" ordered for CSF leak. Procedure report reads, "...spinal needle was advanced into the thecal sac. 1.1 mCi indium0111 DTPA radiopharmaceutical is injected into the thecal sac. Subsequently, the needle is retracted into the epidural space." Blood patch px is performed. "Impression: Under fluoroscopic guidance, nuclear medicineradiopharmaceutical placed in the thecal sac. Subsequently, blood patch performed at the L3-4 level..." I am considering coding 62273, 77003 and 78650. Any advice is greatly appreciated!

Nuclear Medicine myocardial perfusion study performed by two physicians

Lexiscan Cardiolite tests are often done at the hospital, of course using their equipment and their radiologist reports the xrays. The cardiologists read the EKG's and look at the xrays. I think the proper codes are 93016, 93018 and 78451 or 78452 depending on the rest or stress part being done. Will you verify these codes and tell us if the inclusion of EKG's as Status B for HOPPS will have any effect on these charges? Thank you, Sharon

Nuclear Medicine vascular catheter patency.

Dr Z, Hello, I have a client that checks vascular catheter patency using radionuclide in Nuc Med department. History:Left neck pain with flushing port-a-cath "Immediately after radionuclide injection images were obtained at 2-second intervals during the radionuclide phase. During the first 8 seconds, the port-a-cath was not opacified. radionuclide promptly opacifies at 10 seconds. The superior venacava is patent. Radionuclide promptly opacifies the right atrium, right ventricle, pulmonary outflow tract and lungs. Impression: no reflux into the left internal jugular vein was seen. I appreciate any suggestions, Judy

Nuclear Shunt Study, Code 78645

Occasionally, a neurosurgeon will order a shunt survey on a previous placed shunt. At my hospital, the radiologist just has the technologist x-ray the skull, c-spine, chest, and abdomen to view the entire shunt. We do not inject contrast. Currently we have a bundled charge that includes each of these codes (and charge a lesser dollar amount). Should we use CPT code 78645 instead?

Number of time EP add-on code may be used

For 2013, how many times can you use the EP add-on code for additional atrial ablations? We are trying to train staff and don't want to mislead them from the beginning. Thanks!

Nurse procedures

What type of situations could you use an E&M code and code this represent services provided by the nurses? Example: Patient comes into the hospital (outpatient) for a non-working gastrostomy. The nurse pours coke down the gastrostomy tube to unclog it. The radiologist is not involved as the nurses resolves the problem. Example: Patient comes into the hospital (outpatient) for a non-working PICC. The nurses flushes the PICC and the PICC starts working. No further procedures were done.

Nurses performing PICC line placement

Hello Dr. Z. Your response to this question is very important to us. We are receiving many reports describing PICC line placement for inpatients by a nurse supervised by a physician who is available if the nurse needs help. A physician reviews films before and after the procedure, makes suggestions to the nurse, and sometimes evaluates the patient. Is it OK for the physician to charge 36569? If he cannot code for the PICC placement, is there another more suitable code? Thank you very much for your help.

O2 sats with right heart catheterization

Can you charge extra for oxygen saturation when performed with a right and left heart catherization?

O2 Saturations with right heart catheterization

I have a question regarding O2 saturations during a right heart catheterization.  The question was asked of me “how are we charging Avoximeter testing (O2 saturations) and what is the billcode (internal facility code)”.  Our charge sheets have O2 sats on there, but only to keep count, and is marked as “non-chargeable”.  My question is, is there a separate code for just O2 saturations?  Also, if we do a RHC without cardiac output (just record pressures) is there a different code, other than 93451?

Observation consult visits

Please do NOT include any actual patient medical records with your question. We need clarification on correct Observation Consult Codes and Subsequeent visits in Observation status for Medicare and Medicare Replacement Plans. For Obs Consult for Medicare Patients It is correct to use 99201-99204 or 99211-99215 if is an stablish patient in the onservation Hospital setting. For Observation Subsequent visits for Medicare and Medicare Replacement Plans is it correct to use 99213-99215 as Consulting Dr's., if Admitting Dr.99224-99226. Can You please clearify if this is correct if not can you advise. Thank You

OCT

I am seeing a lot of denials for when we bill the OCT (0291T/0292T) concurrent with the heart catheterization codes. Currently there is not an LCD for this procedure other than the "L31832" for Category III codes. The denials are basically stating that "the effectiveness of this service has not been established and is considered to be investigational". I was curious if you had any tips on how to get these paid? Or are they going to continue to deny because the procedure still does not have an LCD specific to these codes?

OCT of renals

Dr Z, Would you still suggest CPT 93799 for optical coherence tomography of the renal artery at time of stent placement? I know new category III codes (0291T & 0292T) have been created but believe those are for use on coronary vessels only. Thanks.

Ommaya Port Access by Interventional Radiologist

Could you please tell me if I can charge for our radiologist's following procedure?  And if so, what is your suggestion?  "Non-imaging access of an Ommaya port along the midline of the vertex subcutaneously of the skull.  He withdrew 5 cc of spinal fluid then infused methotrexate at 1 cc/min."

One Catheter Placement, Two codes

MD selects the right innominate artery and describes the right common carotid and the right vertebral. Can both codes 36222 and 36225 be submitted from the one catheter placement?

One night inpatient admissions

Dr Z. We are continuing to have physicians who admit their cath lab patients as inpatients rather than outpatients and then send them home the next day. In your seminar you addressed this issue however I am unable to find written documentation of what you said. So, would you please cover this topic in this format? Thank you!!

Open ablation procedures performed in the OR by radiology and a radiologist

Dr. Z, In your book there are codes for Open RFA and Cryo Ablations. Am I correct in using this code for when the Radiologist goes to the OR suite and does an ablation with ultrasound guidance, after the surgeon has opened and exposed the liver-- 76940/47380 or 47381? We ususally do the ablations in our department, but I think that these codes should be built in the chargemaster for these types of procedures in the OR. Our department provides the ultrasound guidance and the supplies for the ablation. Thank you, R Mercer

Open and percutaneous AV dialysis graft intervention

Hello - If an open thrombectomy of an AV graft was performed in the OR and took care of the thrombus, and the patient was then transferred to the CATH lab immediatley after open procedure and angioplasty and stenting was also performed of the AV graft to treat the stenosis causing the thrombolysis. Can we code for all the procedures? 36831 open thrombectomy of AV graft 35476 Angioplasty of AV graft 75978,26 37205 Stenting of AV graft 75960,26 Shouldn't the Dr. have to state that after the angioplasty flow there were suboptimal results therfore they proceded with stenting in order to bill for angioplasty and stenting? Also, can we code for the open thrombectomy with the percutaneous angioplasty and stenting? Thank you for your help! We found this in the CMS NCCI guidelines: 7. If a failed percutaneous vascular procedure is followed by an open procedure by the same physician at the same patient encounter (e.g., percutaneous transluminal angioplasty, thrombectomy, embolectomy, etc. followed by a similar open procedure such as thromboendarterectomy), only the HCPCS/CPT code for the completed procedure, which is usually the more extensive open procedure may be reported. If a percutaneous procedure is performed on one lesion and a similar open procedure is performed on a separate lesion, the HCPCS/CPT code for the percutaneous procedure may be reported with modifier 59 only if the lesions are in distinct and separate anatomically defined vessels. If similar open and percutaneous procedures are performed on different lesions in the same anatomically defined vessel, only the open procedure may be reported.  

Open Angioplasty of AV Shunt, Arterial Side

What is the correct code for reporting open angioplasty of AV graft, arterial side?

Open aortic access for thoracic stentgraft access

Dr Z or Dr Dunn, Patient has descending thoracic aortic aneurysm. Patient is an endovascular candidate but upon review of imaging it was apparent that patient could not do ileofemoral access. So an retroperitoneal approach to the infrarenal aorta with direct aortic access for conduit purposes would be necessary. Open access of retroperitoneal plane and access to the infrarenal aorta was obtained. Also, percutaneous access to right common femoral artery was obtained with cath to aorta for diagnostic imaging of the of arch and thoracic artery. Medtronic Tallent thoracic graft with delivery system is placed from the aortic access along with two distal extensions just proximal to the celiac axis. After placement of thoracic graft retroperitoneum was closed and R femoral puncture site was closed. I'm not sure what codes to use for this case. 33881 75957 are endovascular codes and clearly the graft was placed through the aortic access. The only artery exposure codes with creation of conduit I can find are 34833 (iliac artery) 34834 (brachial) which does not fit in this case. Any help in coding this case would be very much appreciated.

Open carotid stent

How would you code placement of a left internal carotid stent with distal protection device via a left common carotid cutdown (due to prohibitive left internal carotid and aortic arch tortuosity)? (Also carotid endarterectomy was prohibited for this patient.) Left carotid and cerebral arteriography were also performed. Thanks so much for your help on this one.

Open femoral vein transposition AV

HI Dr. Z, My doctor did: left superficial femoral vein transposition av fistula. I can't find the code for this. In the past we used 37799 but the reimbursement was very low. Please advice. Thank you.

Open Revision/Trombectomy vs. Percutaneous Fistulogram/venous angioplasty vs Ligation/AV Fistula Creation

I hope you can give some insight into this procedure. Basically the physician performed open revision with thrombectomy (36832), then performed fistulogram (36147), followed by percutaneous venous angioplasy (35476 and 75978-26), and then decided to ligate the entire fistula (37607) and create a whole new graft (36830).  Based on the below documentation, would you bill all those codes? Or should only the open procedure be coded as per NCCI Chapter 5, Section D, #9? Any assistance will be appreciated! A linear incision was made in the fistula at the arterial anastomosis. I noted immediately that the thrombus was well organized and adherent to the fistula walls. It required mechanical removal. I carefully inspected the area of the arterial anastomosis, removing the fibrin plug. I passed a #3 Fogarty catheter distally in the brachial artery and retrieved no additional thrombus. I sounded the proximal brachial artery with the right angle, and there was no evidence of a stricture at the arterial anastomosis. I removed as much thrombus from the body of the fistula as allowed by the arterial cuff, which had been placed proximally. In order to control the arterial inflow and to avoid stricturing of the fistula, I acquired a bovine patch and partially closed the fistulotomy with the bovine patch and 6-0 Prolene suture. This allowed for application of an atraumatic clamp at the arterial anastomosis and removal of the proximal arterial tourniquet. I evacuated the clot from the remaining portion of the fistula body by vigorous manipulation beginning at the axilla. I removed a relatively small amount of clot. I did retrieve venous backbleeding. Heparinized saline was instilled, and an atraumatic clamp was placed on the body of the graft. The patch angioplasty was completed. There was a pulse within the graft with removal of the arterial tourniquet. This was not accompanied by a thrill though there was a continuous Doppler signal. I cannulated the patch with a 21 gauge micropuncture needle. I advanced the 0.018 guidewire under fluoroscopy. The needle was exchanged for a 5 French transitional dilator. I removed the inner stiffener and 0.018 guidewire, and through the transitional dilator, I performed a fistulogram. Although there was continuous flow in the fistula the fistula was noted to be quite sclerotic. This did not appear to be thrombus. A retrograde filling of the brachial artery revealed the arterial anastomosis to be widely patent. I attempted to pass a short 0.035 guidewire through the transitional dilator, but it would not negotiate the fistula. I acquired a 0.035 Glidewire, and with some manipulation the Glidewire traversed the fistula and was placed in the superior vena cava. I removed the 5 French dilator and advanced a 6 French short sheath. I advanced a 5 French Kumpe catheter over the Glidewire and exchanged the Glidewire for a 0.035 Rosen wire. I repeated the fistulogram documenting the fairly extensive sclerotic changes within the fistula. Again, these did not appear to be thrombus. I acquired a 5 French and subsequently a 6 French x 4 centimeter balloon catheter and proceeded to dilate the entire fistula from the end of the sheath to the basilic vein junction with the brachial vein. There was no evidence of a central stenosis. The balloons were inflated to pressures of 14 millimeters of mercury. Following the balloon angioplasty, I repeated the fistulogram. While there was some improvement in the luminal diameter of the fistula, it remained quite ratty and there was sluggish flow. I did not feel that further efforts at maintaining the fistula would be productive. I ligated the fistula just beyond the arterial anastomosis. I proceeded with an AV graft insertion. A short incision was made in the axilla, and I identified a 12 millimeter brachial vein. I carefully dissected between the nerve trunks and identified a 6-7 millimeter axillary artery. The artery lies medial and deep to the vein. A counterincision was made on the upper arm to allow for tunneling in a loop configuration. The patient was given an additional 1000 units of heparin. I carefully exposed the artery, placing no tension on the nerve trunks. An end-to-side arterial anastomosis was completed with 5-0 Prolene suture. Two of the three large nerve trunks lie medial to the graft and one lies lateral. Upon completion of the anastomosis, there was no anastomotic bleeding. The bovine graft was then withdrawn through the subcutaneous tunnel in two movements. It was allowed to lie in a gentle loop configuration. A partial occlusion clamp was placed on the axillobrachial vein, and an end-to-side anastomosis was completed between the bovine graft and the vein with a 5-0 Prolene suture. Whereas the arterial anastomosis is 5-6 millimeters in length, the venous anastomosis is 8-10 millimeters in length. Prior to completing the anastomosis, the vessels were vented and were flushed with heparinized saline. There was minimal anastomotic oozing. This was readily controlled with Fibrillar. Once hemostasis was confirmed, the three operative wounds were closed with two layers of absorbable suture.

Open SMA Thrombectomy via Brachial Artery Cutdown

How would I code an open SMA thrombectomy that was performed from a brachial artery cutdown?

Open thrombectomy of AV graft

Greetings, This patient has a AV graft. The physician does a open thrombectomy of the arterial and venous sides of the graft. Following this a AV shuntogram is performed. This shows irregular calcifications in the graft. A curettage of the graft was performed to remove calcifications. Follow up angio showed a stenosis at the venous anastomosis which is ballon angioplastied. Due to pt history of strictureplasty a stent was placed. I think I can code 36831-59 thrombectomy / the shuntogram with code 75791-26-59/ Angioplasty is bundled with the stent placement / Stent codes 37207, 75960-26. What about the curettage? I'm not sure about the curettage. Would I code this as a 36833 and think of the curetage as a revision with thrombectomy along with code 75791-26-59 and then the angioplasy and stent are bundled as they are completed in the same zone as the revision. Any clarification would help. Thanks, LW

Open thrombectomy with a Fogarty catheter

Dr. Z, Doctor makes incision in leg and does thrombectomy(34201).Then places catheter in aorta,does aortagram multiple areas of thrombus. Removes thrombus from right renal(37186), removes thrombus from left renal(37186), catheterizes the celiac(36245 75726)cannot remove thrombus, catheterizes the SMA (36245 75726)no thrombus found. Dr. then opens arm and removes thrombus(34101. Dr. marked his bill 36245, 36245,36245,75625,75710, 37186 x 2,34101 and 34201. How would you bill this? Thank you

Open Vascular Access by Surgeons

Our vascular surgeon was asked to place a sheath for a cardiology intervention for VAD and RFA with a percutaneous placement on day 1 and an anticipated open closure on day 2. Please kindly review the reports below, as we would appreciate any guidance on appropriate code selection for these. Day 1: Under ultrasound guidance, micropuncture needle was used to gain access into the common femoral artery. Micropuncture wire micropuncture sheath was placed. Oblique angiogram was performed confirming my entry site in the common femoral artery and a patent SFA, common femoral, and profunda over a 0.035 and then 10,000 units of systemic heparin was given. Over a 0.035 stiff wire serial dilatation was performed and a 14 French sheath was placed. At this time, I had stepped out and Dr. X is going to continue with his ablation and ventricular assist device and I will be back for the open closure of this arteriotomy. The sponge and instrument count for my part of the procedure was correct. Day 2: The right groin, including the sheaths were prepped and draped under aseptic precautions. An oblique incision was made including the sheaths in the artery and the vein. Subcutaneous tissue was dissected. There was significant hematoma. There was a tear in the arterial sheath outside the artery that probably caused all this groin hematoma and scrotal hematoma. The common femoral, profunda and superficial femoral artery were controlled with vessel loops, clamped, and then the sheath was removed. Arteries were flushed antegrade and retrograde, and then the arteriotomy was closed with 6-0 Prolene interrupted sutures. Before finishing the closure, vessels were flushed antegrade retrograde and then flow was resumed into the leg. Then on the sheath in the venous part, the vein was controlled proximally and distally with vessel loops and an occlusion clamp was applied. The sheath was removed. Venotomy was closed with 6-0 Prolene interrupted sutures.  Irrigation was performed. Hemostasis was confirmed. Deep tissue was approximated with 2-0 Vicryl interrupted sutures. Subcutaneous tissue was approximated with 3-0 Vicryl interrupted sutures. Skin was approximated with 3-0 nylon vertical mattress sutures. Antibiotic ointment and a dry dressing was given. The patient was returned to the intensive care unit in stable condition. Sponge and instrument count was correct.

Open vascular surgery

Hi Dr. Z! We have a question regarding online Q&A 1768 from 2008. Our office recently went through an external audit and our auditor marked one of our charges incorrect for not billing the additional endarterectomy of the iliac/femoral along with the bypass. In the procedures performed the provider listed them as 1. Right iliac and right femoral endarterectomy with patch angioplasty and 2. Right above-knee femoral to popliteal bypass with 6 mm Gore-Tex graft. As we know some coding rules change, we are wondering if something has been updated from the date this Q&A was published or if you have any other advice. I know it’s long, but I have pasted the report data below. We coded only 35656. What is your opinion about the use of 35355 as well? Thanks, TN Subscriber 9.1.10 DESCRIPTION OF PROCEDURE: A right groin incision was made. The dissection was carried out through the subcutaneous tissue down below the femoral sheath. The femoral sheath was then opened. There was a modest amount of scarring around the area of the previous puncture site where the closure device had been inserted. The common femoral artery was then dissected free along the entire length for clamping. Next, dissection was then carried up underneath the inguinal ligament as adequate retraction was obtained with a Martin Arm. The distal external iliac artery was then dissected free with the crossing vein across the external iliac artery was ligated and divided with multiple hemoclips. Next, once I had obtained adequate exposure for iliofemoral endarterectomy a skin incision was then made on the above—knee medial aspect of the leg. Next, dissection was carried down through the subcutaneous tissue down to the level of the sheath. The sheath was then opened. The popliteal space was then entered. Dissection was then carried down to the level of the popliteal artery, it was then dissected free circumferentially. Potts tie, silk ties were placed around multiple side branches of the vessel. The vessel was small in caliber, probably 4 mm. Next, a 6 mm ringed Gore-Tex graft was then obtained and tunneled subsartorially between the 2 incisions. Next, the patient was then heparinized and following an appropriate time the external iliac artery was then clamped with a Satinsky clamp. Then, the common femoral artery was then clamped with a profunda clamp distally. Next, an arteriotomy was made and extended with the Potts scissors. Next, the endarterectomy was then performed with the common femoral artery and external iliac artery. Next, the remaining debris was then removed and the distal plaque within the common femoral artery was tacked down with 6-0 Prolene sutures. Next, a Vascu-Guard patch was obtained and soaked appropriately and then subsequently used and sewn in place with a running 5-0 Prolene stitch. Prior to completion of the patch angioplasty the lumen was flushed and heparinized with saline solution. The artery was allowed to back-bleed proximally and distally by virtue of removing the clamps. Next, the anastomosis then completed. Three interrupted repair stitches were used to control some suture line bleeding. Next, the vessel was once again clamped proximally and distally. A patchotomy was made standard with the Potts scissors. Next, the graft was then cut to fit and sewn to the patch repair in an end—to-side fashion with a running 5-0 Prolene stitch. Following completion of anastomosis the proximal and distal clamps were removed. A distal graft clamp was placed. Next, there were no repair sutures needed. Next, a graft clamp was then placed proximally. Next, the popliteal artery was then clamped proximally and distally. An arteriotomy was made and extended with Potts scissors. Next, the graft was then cut to fit and sewn in place in an end-to-side fashion to the popliteal artery with a running 6-0 Prolene stitch. Just prior to completion of the anastomosis, the lumen was flushed with heparinized saline solution. The artery was allowed to back-bleed proximally and distally as well as the graft by briefly removing the clamps. Next, the lumen was once again, flushed with heparinized with a saline solution. Next, the anastomosis was then completed. Next, the proximal and distal clamps are removed. The graft clamp was then removed. There was a palpable pulse in the foot upon completion of the anastomosis. Next, protamine was given. Adequate hemostasis was obtained with Surgicel and thrombin spray. Next, all wounds were then irrigated and closed with 2 running 3-0 sutures in the above-knee popliteal incision and in 4 layers in the groin with Vicryl sutures. Skin clips were used in the skin. Sterile dressings were applied. The patient was awakened, extubated, returned to the recovery area in satisfactory condition. All instrument, needle and sponge counts were reported as correct on 3 occasions.

Opening a Vessel Occluded by Plaque Shifting

Can you code for opening a vessel that was occluded when plaque shifted frm the inital vessel being revacularized (e.g., stent in the LAD plaque shifted and occluded the diagonal branch)? The diagonal branch was ballooned opened. I've never heard that you couldn't code for it. Could you please confirm?

Operative Site for Aneurysm

I am having a rough time understanding operative site when coding for percutaneously embolized aneurysms. How many operarative sites are there in the brain? Is it one because we only have one brain, two for left and right side, or can we code per aneurysm? I keep getting different opinions on this and need to get this clarified.

Ophthalmic artery infusions

DX is retinoblastoma,some lesions in the eye were inoperable,was brought in for intra-arterial chemotherapy. Angiogram done: Left internal carotid artery injection,superselective left ophthalmic artery injection. Endovascular Procedure-intra arterial chemotherapy,intra-arterial Nicardipine infusion for vasospasm. To prevent vasospasm.3mgNicardipine was slowly infused into the opthalmic artery.Melphalan was then slowly infused into the opthalmic artery over 20min. Should I only code for the angiogram? control run showed no evidence of thromboembolic occlusions or vasospasm.

Optical Coherence Tomography for renal

Dr. Z, What do you suggest for Optical Coherence Tomography during selective renal catheterization (36251-36254). Thanks

Order specific for with or without contrast that change

I code outpatient procedures for an OPPS hospital. We frequently receive MR and CT orders, and based on the diagnosis stated on the order, the radiologist believes that the exam would be more beneficial if performed without contrast or with contrast, however, the order requests the opposite. Do we need to obtain another order for "without contrast" or "with contrast" or can the study be performed per the radiologist's request as test design? Does Medicare offer specific guidance on this topic?

PA stenosis treatments 92997, 92998

Hi Drs. Zielske & Dunn, A physician did dilation of the right lower pulmonary artery, superior segment of the right lower pulmonary artery, anterior segment of the right lower pulmonary artery, posterior segment of the right lower pulmonary artery, and the right upper pulmonary artery. When researching this subject in the Diag. & Interventional Cardiovascular Coding Reference book, I found the statement "Code 92998 for each additional separate pulmonary arterial branch treated for stenosis with angioplasty." How many arterial branches are there? Is it a separate arterial branch after each bifurcation or is it referring to the bifurcation which leads to the right upper lobe pulmonary artery, right middle lobe pulmonary artery and right lower lobe pulmonary artery? Should I only code 92997 and 92998 or should I bill 92997 and 92998 X4? If I only bill 92998 once, I assume I can't bill for each cath placement either? Thanks so much for your help!

PA Thrombectomy

Hello Dr Z One of our surgeons performed a aspiration thrombectomy of the pulmonary arteries, along with a coronary angiography and other procedures. What code would you use for the aspiration thrombectomy? They also used an angiojet to perform a rheolytic thrombectomy in the right main pulmonary artery after the aspiration thrombectomy. Thank you for your help.

Pacemaker Dual Replaced with Biventricular ICD

These cases still confuse me. Patient had a dual pacemaker and right ventricular lead replaced with a biventricular ICD with left ventricle lead. It's the replacing of the generator that throws me off because we are replacing a pacemaker with an ICD.

Pacemaker insertion followed by EP followed by programming

Please do NOT include any actual patient medical records with your question. Dr. Z, Indication: A-Fib with rapid ventricular responsse refractory to medical therapy with amiodarone and rate slowing drugs. Referred to EP physician for AV nodal ablation and single chamber PPM. First performed PPM insertion then proceeded to AV nodal abaltion at the end of the procedure reprogrammed to VVIR mode. Is this enough to code 99286 even though it is included in the initial insertion since this scenario is different that they have to reprogramm because Of AV nodal ablation? Thanks

Pacemaker pocket revision

Dr Z, Could you take a look at the below case and advise how you would code it? I am thinking 33999 as leads were only repositioned in the pocket and pocket revision was performed. Thanks. The pocket was opened and generator removed. Pacing thresholds of both the ventricular and atrial leads were checked and found to be acceptable. The pocket was then flushed with antibiotic solution and the generator was replaced with the leads being moved on the top of the generator instead of the bottom. Pocket was closed.

Pacemaker pocket revision

Dr Z, Could you review the below procedure and advise how you would code? The patient had a pacemaker inserted two months ago and was complaining of pain at the generator site. The pocket was opened and the generator removed. Thresholds were tested and noted to be within normal range. The pocket was flushed and the generator was then reinserted but with pacemaker wires repositioned on top of the generator instead of the bottom. If I understand correctly, this would not be a lead repositioning since the leads were moved in the pocket and not at the heart so was leaning toward unlisted 33999. However, in reading the Q&A from November 22, 2011, should this be considered a pocket revision although only the leads were "revised" within the pocket? Please explain. Thanks.

Pacemaker to ICD 33249

Please do NOT include any actual patient medical records with your question. The patient had a biventricular implant AICD with removal of permanent pacemaker generator and right ventricular lead. The pacemaker and leads were carefully dissected out. Modifierd Seldinger techniques was then used to place two 9-Fr sheaths in the left subclavian vein. Therough these sheaths passed the endocardial leads. Right ventricular lead was positioned under fluoroscopic guidance in the right ventricular apex. Attempts were made to cannulate the coronary sinus with an Attain guide - cannulation was difficult. Using combination of catheters he was able to tie down the coronary sinus os. Once this was identified a deflectable-tipped catheter and a extra large curved Attain guide was used to cannulate. balloon tip catheter was placed in the coronary sinus. Coronary sinus venogram was performed in the LAO position. I was unable to pass the balloon catheter past the thebesian valve, but the coronary sinus venogram demostrated small lateral and anterolateral branch and a moderate size posterolateral branch. Initially, the left ventriculat lead was placed in the anterolateral branch, but after removal with Attain sheath there was evidence of dislodgement with elevated pacing threshold. Because of this, this was not felt to be a viable branch and the coronary sinus was recannulated and using Attain Select II catheter posterolateral branch was cannulated. The left ventricular lead was placed over a guidewire into the posterior lateral branch. After appropriate sensing and pacing parameters were confirmed, leads were secured. Once the leads were secured, the existing right ventricular lead was freed up and this was removed under fluoroscopic guidance with gentle traction w/o any resistance. The pacemaker was disconnected from the pacemaker leads and the pacemaker generator was removed from the pocket. The leads were connected to the defibrillator. Defibrillator was then placed in the packet. Defibrillation threshold testing was performed. I coded as follows: 33249, 33234, 33233, 93641 should I also charge for the fluroscopy as well as the venogram? Thanks, margie.clarkrn@yahoo.com

Pacemaker upgrade

Hi Dr. Z - We can't wait to see you in Boston this year but until then we are confused as to how to code this scenario using the 2012 CPT codes. What are the CPT codes for upgrade of a dual chamber pacemaker to a biventricular pacemaker with insertion of an LV lead? (Patient retains RV and RA lead with removal of Dual chamber generator, insertion of new Biventricular generator and insertion of new lv lead). Thanks so much!

Pacemaker/AICD Pocket Revision

We are having trouble with how to code for a pocket revision when the pocket is not relocated. It is our understanding that the revision is bundled into the placement or replacement of the pacemaker/AICD. What do we code if all that is performed is a revision of the pocket?

Pacemaker/CRT-P

"Patient initially presented for insertion of a dual-chamber pacemaker. Right ventricular lead is placed. However, physician could not get the right atrial lead to capture anywhere. After attempting pacing at five different positions, physician stopped attempts to place a right atrial lead. Instead, physician decided to place a left ventricular lead since patient was going to be paced 100% of the time. Left ventricular lead was implanted and advanced into the coronary sinus. Then an Evia HF-T generator was connected to the leads."  Would codes 33207 and 33225 be used in this case since this is a CRT-P? There is an edit coming up that indicates because we are billing C1882 as a device code we would need different codes. Will you please comment on how to appropriately code this case? Should it be coded as though the atrial lead was placed and then add a -74 modifier on the code? This one has me stumped.

Pacemaker/Lead Replacements Separate Sessions

A documented pacemaker dependent patient was brought in for end-of-life pacemaker generator replacement. A temporary pacemaker single chamber was inserted, and the dual pacemaker was replaced. The patient was placed in observation where it was noticed that there was a sudden loss of ventricular capture due to the chronic ventricular lead being displaced. The patient was taken to the special radiology suite emergently and had a temporary pacemaker wire placed and then was taken to the cardiology suite where the chronic ventricular lead was replaced. This was originally billed as two sessions (33228 with 33210-59, and 33234 with 33216 and 33210-59). Code 33228 is not allowed with 33216 even with an appropriate modifier. Can we bill codes 33207, 33234, and 33210-59 x 2?

Pacing AICD without Pacing Function

The patient has a pacing defibrillator with the tachycardia detections turned off for several years. The underlying rhythm is complete heart block, so he relies on the pacing function, and the device is at elective replacement indicator status. He comes in to get this replaced with a dual chamber pacemaker. Leads are atrial and ventricle, and only the generator was changed. Would you recommend coding it as a downgrade from AICD to pacemaker or as a pacemaker change?

Pacing System Analyzer

My question concerns the coding of a temporary pacemaker during a pacemaker or ICD change out for patients who are pacemaker dependent.  If during the change out the physician documents that the patient was "quickly connected to a pacing system analyzer", is this codeable in CPT?  The PSA is used rather than the insertion of a temporary wire.  I'm not clear as to when this would be used rather than an actual temporary pacemaker.  Can you explain?

Pancreatic transplant 36245, 75726

Patient with status post pancreatic and kidney transplant with dropping hemoglobin. A cobra catheter was used to select the pancreatic artery which came directly off the right common iliac (access was right femoral artery). An angiogram was performed. I coded 36245 and 75726. Is this correct?

Paracentesis and Biopsy with Guidance

I am aware of the rules surrounding multiple guidance; however, I had a case that caused me to pause. If a paracentesis or thoracentesis is performed along with a biopsy with guidance, will the guidance used with the biopsy not be coded since the guidance is bundled with the para/thora? My case was a para with ultrasound and a liver biopsy with CT guidance. Since CT is higher than the ultrasound, am I overthinking how this should look? Would it just be codes 49083 and 47000?

Paracentesis with tPA of Denver Shunt

"An 18 gauge Caldwell needle was advanced into the peritoneum. Appropriate needle location was documented with cont. sonographic and a paracentesis was performed. The patient's skin was cleaned and dressed. The pt. tolerated the procedure well and was discharged in stable condition. At this time, the Denver Shunt along the left lateral chest wall was accessed with a Huber needle. Manual aspiration demonstrated free flow of ascities. 6 mg tPA was then infused through the upper port of the Denver shunt. Post tPA infusion with contrast under fluoroscopy demonstrated patency of the Denver shunt. The Huber needle was then removed." I planned to report codes 49427, 75809, and 37211, but wanted your opinion regarding my code selection.

Paravalvular Leak Treatment

What CPT code can be used for percutaneous paravalvular leak repair of a prosthetic aortic valve with an Amplatzer vascular plug? Is there anything other than unlisted? The physician office suggests embolization code 37242.

Parotid Biopsy with -52 Modifier

We (facility) had a patient come in for a parotid biopsy. The procedure was cancelled after the neck was scanned with ultrasound and no mass was found. This is how the report reads: "By ultrasound exam and palpation, no pathologic discrete lesion was found, and therefore, no attempts were made to perform a biopsy at this time. The area that he pointed out to me appears to represent a strained muscle with no underlying lesion by ultrasound. A thorough exam of the full neck by ultrasound including the parotid area was also conducted." The department wants to charge guidance code 76942 with a -52 modifier. This seems incorrect to me. I think that either we report codes 76942 and 42400-52 or 76536. Can you please give us some guidance for this?

Payment for new procedures

Please advise the propert way to get reimbursement from Medicare or private insurance when billing for insertion and removal of impella device VAD using and unlisted procedure code 33999 not getting any luck

PCI in Major Coronary and PCI in a Branch not of the Major Coronary Artery

I have a question regarding the use of the "branch" add-on codes for coronary interventions. If the patient has a stent placed into the RC and also has an angioplasty of the OM, would the OM be reported as a "branch", even though it is not a branch of the RC? Would this be reported with codes 92928-RC/92920 (OM), or would it be reported with codes 92928-RC/92921 (OM)? Thank you! You are our go-to guru!

PCI of Bypass Graft and Native Coronary Arteries

Our physician did a diagnostic left heart catheterization with left ventriculography, coronary artery angios, and bypass graft angios. He then did an angioplasty at the anastomosis of the LIMA graft to the distal LAD. Following this, he placed a drug eluting stent in the circumflex artery and performed a kissing balloon angioplasty of the proximal circumflex and the proximal LAD. I am thinking of reporting codes C9600-LC, 92937-LD, and 93459-59. Could I also report code 92921-LD for the proximal LAD kissing balloon angioplasty since it was via the native arteries and not through the bypass graft?

PDA Closure Code 93582

Can we bill the PA angiogram (93568) if done as a follow-up to verify the occluder is in the appropriate position after a PDA closure? My concern is that this is a follow-up, and a PA angiogram is not done prior to device placement.

PDA Ductal Occlusion Coding

For 2009-2013, was it incorrect to use codes 37204, 75894, and 75898 for PDA occlusion with an Amplatzer plug device through either the femoral venous or femoral aortic approach? Follow-up angiography was performed in the descending aorta with each procedure.

Pedal access 36140

Dr. Z- Could you please direct us on a catheter placement code. The physician did a right pedal access and selected the right SFA. Thank you in advance for your help!

Peg Tube Removal in Radiology

The radiology department has submitted code 49460 for the following case, which we are not sure is correct. Will you review and offer how this service should be reported? "History: G tube removal, unable to deflate balloon at bedside, no longer needed. Using sterile technique, the existing PEG tube was injected with contrast and multiple images were obtained catheter within the gastric lumen. A 035 Amplatz guidewire was then advanced through the catheter into the stomach lumen. Gentle pulling traction was applied to the catheter coupled with the Amplatz guidewire. The retention dome was then easily pulled through the gastrostomy site. The catheter was removed intact. A sterile dressing was applied."

Pelvic drainage

Hello! I recently purchased the 2012 coding charge sheets from ZHealth (which, by the way, are wonderful!!)and had a question regarding the updated coding suggestion for an abscess drainage of the pelvis via transrectal approach (for males). It lists the code as 49021, shouldn't this be 49061 since it is labeled as a pelvic abscess;transrectal approach? I understand that a pelvic abscess could extend into different areas such as the peritoneal cavity, however wouldn't the code depend on what area the catheter ended up in? Example-anterior pelvis and/or peritoneal would be 49021 and 49061 for retroperioneal and/or transgluteal abscess.

Percutaneous Arteriotomy Closure

Is there anything that can be coded for the physician in the following scenario?  "Patient has a left femoral arterial line that is no longer needed for monitoring in the ICU. The patient is taken to the interventional suite, and angiography is performed for placement of an Angioseal plug. No other intervention is performed on this day. The patient had intracranial embolization five days earlier with Angioseal placement on the contralateral side (right side)."  I don't see a way of coding anything, but I want to be sure I'm not missing anything.

Percutaneous laminotomy

There is a new category three code for a percutaneous laminotomy of 0275T which I am using as of July 1st however what code should I have been using prior to July 1st?

Percutaneous placement of a drainage cathter into an anterior abdominal wal

How would you code percutaneous placement of a drainage cathter into an anterior abdominal wall fluid collection? The fluid is located between the abdominal wall and the peritoneal lining. The CT scan prior to this procedure says the fluid collection is adjacent to the inner abdominal wall in the midline and extends inferiorly to the left into the pelvis. There was spontaneous drainage of brown, partially clear fluid from the tube when it was placed. Is it unlisted CPT 49999 and 75989?

Peri-Appendiceal Drain Placement

If a patient has an appendiceal abscess and a drain is placed in the peri-appendiceal area, would this still be coded 44901 per indication? Or would it be 49021 since drain not placed in appendix?

Periaortic Fistulous Tract Occlusion with Deployment of Amplatzer PDA Occlusion Device

Per the physician's dictation, aTEE was done, which demonstrated a jet of eccentric severe periprosthetic aortic valve insufficiency. The fistulous tract was crossed with a slip-tip catheter. Through this catheter an AGA patent ductus occluder was deployed through the fistulous tract. Upon release of the occlusion device significant reduction in the periprosthetic valve regurgitation was seen on the TEE and was confirmed by left aortography. The procedure was then concluded without complication. This is not a procedure that we have done in the past and therefore need your advice on how this should be coded/billed.

Pericardial Fluid Aspiration During VT Ablation

I have a report for an epicardial VT ablation. The physician advanced a Biosense-Webster NaviStar ThermoCool ablation catheter into the pericardial space and ablation was performed. The dictation states, "The pericardial space was periodically aspirated throughout the procedure and the fluid remained clear." The physician has checked off 33010 on the encounter form. I did a little research on the catheter and it sounds to me like the physician is aspirating fluid accumulated from the irrigation catheter. There was no mention of an effusion and, in fact, an echo earlier in the day stated that none was found. Should I bill code 33010? Or in this case is the aspiration just part of the ablation?

Pericardiocenesis

Please do NOT include any actual patient medical records with your question. When a pericardiocentesis is done (33010) and Ultrasonic Guidance (76930) is utilized, does 76930 get a modifier 59? Thank you, Maria (CCA)

Peritoneal catheter tpa injection

In the following example, how would it change if only a fibrin sheath was demonstrated and the tPA was injected but the brush wire was not used. Everything else the same. 2011 case. 1) Patient with a poorly functioning peritoneal dialysis catheter presents for evaluation. In a sterile fashion, the tube is injected with contrast and evaluation of the peritoneal cavity is performed (49400, 74190), demonstrating fibrin sheath around the catheter and multiple adhesions in the abdominal cavity. 8 mg tPA is mixed with saline and injected through the catheter. After thirty minutes, the area is reevaluated, and a wire is placed through the catheter with subsequent disruption of the fibrin sheath (49999, 76496). A repeat injection demonstrates free spill of contrast throughout the peritoneal space.

Peritoneal drainage catheter TPA injection, 49999

Dr. Z, How would I code the following report? I'm not sure if 36596/75902 is correct. History‎: ‎Recent abdominal Pleurx drain placement, now no longer draining‎. ‎Please check tube‎.‎ Technique‎/‎findings‎: ‎Limited ultrasound of the abdomen revealed the Pleurx catheter within anechoic fluid within the peritoneal ‎ cavity of the patient's pannus‎. ‎Limited ultrasound of the remaining abdomen reveals no significant ascites‎. ‎Fluoroscopy of ‎ the drain revealed no kink‎. ‎Aspiration of the Pleurx catheter yielded nothing‎. ‎Contrast injection of ‎10 ‎mL of Isovue ‎200 ‎was ‎ performed under fluoroscopic guidance into the Pleurx drain, confirming contrast extravasation out of the side ports into the ‎ peritoneal cavity‎. ‎A stiff glide wire was inserted vigorously through the Pleurx catheter out multiple sideholes under ‎ fluoroscopic guidance‎. ‎Aspiration of the Pleurx catheter still yielded nothing‎. ‎Next, TPA ‎4 ‎mg was administered into the ‎ Pleurx drain and the drain was capped‎.‎ Impression‎:‎ 1‎. ‎Persistent occlusion of the abdominal Pleurx drain‎. ‎Following TPA infusion, repeat attempt at aspiration will be performed ‎ in ‎2 ‎hours‎. ‎If this attempts still yielded nothing, the abdominal Pleurx drain will likely not function and may be scheduled to ‎ be removed‎.‎ Thank you... my email address is shirley.sweet@vtmednet.org

Permatemp Pacemaker Placed Post TAVR

Recently our cardiologists have started prophylactically inserting a "permatemp pacemaker" at the end of all TAVR procedures as part of a new guideline (I'm not sure whether this is an internal policy or a new guideline for standard of care on all TAVR). If no significant heart block develops, they are removed later. I feel that we should not bill for prophylactic care and that code 33216, and then the subsequent 33234, should only be billed when the patient is documented as having heart block necessitating the continued pacing after the removal of the pacing wire/balloon used during the TAVR. What are your thoughts?

PermCath insertion for hemodialysis

Hi Dr. Z, Could you please help me with this procedure? Our interventional radiologist reason is PermCath insertion for hemodialysis. In his impression he says it was a successful right subclavian dual port dialysis catheter insertion via skin tunneling on the right. It was a 14.5 French dialysis catheter. Thanks for your help!

PET non-covered codes

In what circumstances would you use the following codes? 􀂃 Level ll Codes G0219, G0235, or G0252 for Medicare non-covered indications. Thanks

PFO closure and congenital cardiac cath codes

Pt had RHC with pulmonary artery angiogram, bilat selective pulmonary vein angiogram and lt atrial angiogram. The next day had ASD repair. We billed 93451-26 and 93568 for cath and angio and for ASD billed 93580. We were told you could not bill congenital codes for PFO but according to your book if diagnostic cath is done prior to PFO closure device placement you can code w/congenital codes. It also states an isolated PFO is not considered congenital. What is an isolated PFO? Also, our physician states the ASD repair was much more involved than the PFO, it was a hole in the heart rather than a "flap" but the diagnosis code is the same (745.5) so don't see how you can get around it. Would appreciate any help you can give in clearing up the confusion.

PFO closure and heart cath

Under what circumstances can I bill 93580 ASD closure with 93531 Right and left heart cath? I code/bill for hospital and I get NCCI edit 0020 when I put the two codes together, however the physicians office coder tells me that she has billed the two together without any problems. I would certainly like to code/bill the heart caths because they are definately done. Thanks

PFO Closure Not Done

"Patient with recurrect CVAs. Hypercoagulable workup negative, TEE with postive bubble study, thought to have PFO. Presents for closure. PROCEDURE: 10 French venous sheath was placed in left femoral vein, and 8 French Lamp catheter was advanced with wire into SVC. Bolton catheter was used, and intra-atrial septum was interrogated with ICE catheter. We were unable to cross septum with multiple catheters. Lamp catheter was advanced and demonstrated tenting. Agitated bubble study x 3, 2x with Valsalva maneuver, and we saw no bubbles across septum. Detailed interrogation of septum showed no evidence of PFO. Agitated bubble study negative, and septum couldn't be crossed. Procedure was discontinued. Impression: No intra-atrial septal defect, no PFO identifed." Not sure how to code 93462-74 and 93662, but these are add-on codes with no base code. No pressures were taken. What are your suggestions on how to code?

Physician documentation regarding 76937

Dr. Z: I have a question regarding CPT 76937. The radiologist documents the following: "A limited ultrasound examination was performed to confirm the existence and patency of the right internal jugular vein. An image was saved in the chart. The skin was anesthetized with 1% lidocaine. Under direct ultrasound guidance the vein was punctured with a 21-gauge micropuncture needle." Must the radiologist specifically state that permanent US recording was made of the needle access? Thank you for your assistance!

PICC Insertion with Sherlock ECG Tip Confirmation System

Can you give me your opinion on this type of situation? Our facility is starting to use the Sherlock ECG monitoring device with our PICC lines. Do you know the appropriate codes that we are supposed to use for the ECG? So far I have the PICC line code 36569, then they are doing an ultrasound with hard copy 76937... and what would we code for the ECG?? Would any of these be appropriate: 93000, 93005, or 93010? Or something else? 

PICC line placed by nurse in hospital setting

Hello, If i have a nurse inserts a PICC line can the hospital bill for that service. Thank you

PICC placement 36569

Dr. Z I would greatly appreciate your guidance with the following situation. In our hospital facility we have PICC line Rns that place PICC lines with fluoro guidance (36569, 77001). The PICC team performs PICC placements in a special procedure room and has an agreement with the radiologists to use fluoro. Occasionally the PICC RN cannot successfully advance the line and a radiologist is called for assistance. The radiologist will go to procedure room and advance the PICC line under fluoro. Is it appropriate for the Radiologist to charge for a PICC reposition (36597, 76000) or for a PICC placement(36569-59, 77001-59)? Does the PICC Team need to modify any of their charges? I was told we could not bill for a reposition during an initial picc placement. Thank you for your assistance.

PICC Replacement Same Access with Venography

Can you take a look at this one for me? Do codes 77001 and 36584 fit this case? Anything else? "Superior venacavography and right upper extremity venography via the existing PICC site.  Exchange of existing 6 French PowerPICC line for same. The existing catheter was cut over a wire, and a sheath was placed. A 5 French diagnostic catheter was placed to the level of the axillary vein, and venography was performed. The right internal jugular vein was catheterized as well, and venography was performed. This revealed a widely patent central venous circulation. A new 6 French PowerPICC line was placed over a wire  with its tip residing at the cavoatrial junction. The line was sewn to the skin with 2-0 Ethilon, sterilely dressed, and flushed with sterile saline. Spot and digital subtraction angiography was sent to PACS archive. Total fluoroscopy was 7.4 minutes.  Findings: Normal central venography. No evidence of hemodynamic significant stenosis or thrombus. The right internal jugular venin is patent. No evidence of thrombus in the right upper extremity venography."

Pigtail Catheter

Can a doctor image or see the aorta on an angio with the pigtail in the proximal iliac? Not very sure if being a pigtail makes a difference. Does the pigtail need to be within the aorta for the doctor to see the aorta? I have a doctor who doesn't explicitly state that the pigtail was in the aorta when he did an aortoiliac angio (he was treating an ilaic aneurysm). I have read here before that the aortogram could be done with the catheter (or even sheath) in the proximal iliac, but I am not sure if "pigtail cath" makes a difference.

Pigtail Catheter into Left Ventricle with Measurements

What is the correct CPT code for the following?  "Pigtail catheter was advanced into the left ventricle, and pressure measurements were done."

Pioneer Catheter

Can we charge for non-coronary IVUS when using the Pioneer catheter to re-enter a peripheral vessel during peripheral intervention? The Pioneer utilizes Volcano IVUS technology; however, no images are archived to WITT/PACS. Basically, the IVUS helps guide the physician to enter the true vessel when they are sub-intimal.  I don't think so, based on the premise that ultrasound procedures generally must have images, but I wanted your take on this. Thanks!

Pipeline embolization device 61624

Dear Dr. Z, Would the use of the "Pipeline Embolization Device" for treatment of carotid wide-mouth aneurysm be considered 61626 / 75894? No coils are placed so I'm wondering if it is still considered an embolization. Thank you. mlb

Pipeline reconstruction device

What code do you suggest for endovascular treatment of an aneurysm using the Pipeline reconstruction device?

Pipeline, 61624

Should treatment of an intracranial aneursym with a flow diverter be coded as an intracranial embolization or a stent placement (61624/75894 or 61630)? The device seems to be considered an methof of embolization in some the literature I have found online about them but the device is a stent, correct?

Place generator and lead array 33249

Hello! (again!) We have this scenario, the procedure was removal of ICD, revise the ICD pocket, added a new ICD, tested the defibrillator threshold, and added a subcutaneous anterior chest coil array was added to the vector after the new ICD and old leads weren’t providing optimal results. This is what we coded – 33249, 33241, and 93641 with device codes C1894, C1721, and C1896. Is there something else that you would suggest? Thanks for your continued advice!!! Melinda Neeley Nebraska Methodist Hospital

Placement and removal of an event recorder on the same day

Dr. Z, In the outpatient setting, how would you report the replacement of an implanted cardiac event recorder at a single session due to its end of life? There is a CCI edit for mutually exclusive procedure between 33282 and 33284. Thank you!

Placement of a carotid stent via an open approach

Dr. Z, My question concerns placement of a carotid stent via an open approach. I do not think we can use 37215 because it states "percutaneous" in the code description. Here is his dictation: An oblique incision at the lower neck level, I dissected out the common carotid artery and isolated with a vessel loop towards the cranial end. I then placed a 7-French sheath over a wire and performed diagnostic imaging demonstrating the stenosis and then crossed it primarily stenting with a 7 x 22 iCAST covered stents. We then postdilated to 8 mm and then removed the sheath and balloon and opened the arteriotomy a little bit wider so that we can get good antegrade flushing of the artery. The performing physician did dictate an addendum (to document distal protection, he said): The common carotid artery had been clamped cephalad of the entry site for placement of the sheath. After deploying the stent, the artery was flushed aggressively in order to remove all debris prior to closing the arteriotomy and then restoring flow antegrade to the brain. I cannot find a CPT code for an open placement of a carotid stent. Am I missing it or should this be an unlisted procedure code? I have tried to contact his office coder to see how it was submitted from his office, but I haven't had any success to date. Thanks, Chris McCoy

Placement of a Ureteral Stent via Ileostomy

If a patient is having a ureteral stent placed via an ileal conduit, is it still reported with codes 50393/74480 since the code states the catheter is inserted through the renal pelvis?  Or would it be unlisted since it is via the ileal condiut? Report: Conversion of a left nephrostomy tube to a left nephroureteral stent through the patient's existing urostomy. Clinical Information: This patient is an 80-year-old gentleman has a history of left renal obstruction. He is pulled out his tube from the urostomy in and now presents for conversion of his existing left nephrostomy tube to nephroureteral stent. Procedure: After the procedure was explained and consent obtained from the wife, the patient was placed in a decubitus position on the fluoroscopy table. The patient had the urostomy site and nephrostomy tube exit site prepped and draped in the sterile fashion. The patient was numbed with 1% lidocaine solution around the nephrostomy tube exit site. The nephrostomy tube was removed over a 0.035 guidewire and a 5 French vertebral catheter was then placed within the renal collecting system. This in conjunction with a 0.035 hydrophilic guidewire was utilized to access the left ureter. This is also used to pass the anastomosis and enter the ileal conduit. After this was then, the catheter and guidewire combination were used with fluoroscopic guidance to traverse the conduit with the catheter and wire protruding through the ostomy site. Exchange was made for a 0.035 Amplatz guidewire. After this was done, the catheter was removed. The patient was then placed in the supine position on the fluoroscopy table. A 10 French drainage catheter was then placed over the guidewire using fluoroscopic guidance into the proximal loop is located within the renal pelvis. The guidewire was then removed. A contrast injection with gadolinium demonstrates the tip of the catheter to be located within the renal pelvis. The patient tolerated the procedure. The patient received Versed and fentanyl intravenously for conscious sedation. Impression: Conversion of the left nephrostomy tube to a left nephroureteral stent which extends in a retrograde fashion through the urostomy site.

Placement of infusion wire beyond location of LE revascularization

Patient was brought to IR suite with an ishemic foot. A pelvic angiogram was performed and the catheter was advanced to the right external iliac and a lower extremity angiogram was performed. The catheter was advanced into the fem-pop graft an angiogram was performed showing thrombosis. Catheter advanced to the above knee jump graft to below knee angiogram showed a 90% stenosis. Angioplasty was performed at the jump graft anastomosis. Next an infusion catheter was placed in the fem-pop graft and an infusion wire was then advanced through the infusion catheter to the peroneal artery. Overnight thrombolysis was performed. I know catheter placements are bundled into angioplasty codes. Can we code 36247 for placing the infusion wire in the peroneal artery since it is past the location of the angioplasty?

Placement of sheath for CT scan

Pertaining to a previous Question below. If the Physician places a sheath or a dilator to be used for CT would you use 36410/76937? Thanks Question: If a patient comes in for a CT scan and requires an IV access to be placed by IR due to "poor venous access", is the 36000 and 76937 seperately reportable? Typically the 36000 is bundled, but due to the poor access and the fact that they are taken to IR for the procedure, does that warrant the charges? The fact that is performed for the sole purpose of administering the contrast, regardless of the reason they have poor access, does that void charging the 36000/76937 seperately? Answer: I would not code additionally unless CVC catheter was placed. An IV, no matter how hard it is, is part of a CT scan. Dr.z

Platelet Rich Plasma Injection 0232T

We are going to be doing a platelet rich plasma injection with ultrasound guidance. Code 0232T includes guidance, harvesting, and preparation. The harvesting and preparation are going to be done in a physician's office and then the patient will be sent to our outpatient radiology department for the injection with ultrasound guidance. Any suggestions on how to make sure we get paid for the guidance portion of this procedure?

Pleurx catheter exchange

Dr. Z, I can not find a CPT code for an exchange of a PleurX pleural catheter? Can I use 32552 for the removal, and 32550 for the re-insertion? Thanks in advance,

PM/ICD Programming and Interrogations

We are going to start doing PM/ICD progamming and interrogations. Do codes 93279-93289 require a physician interpretation/report?

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