Knowledge Base

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Lead Removal

I have seen a few cases where a pacemaker or ICD lead is removed and replaced due to the patient having "twiddled" the generator, causing a lead to coil up within the generator pocket. Sometimes the lead is completely coiled, and all of it comes out when the generator is removed from the pocket. I know that removal of the generator from the pocket is bundled into the code for the new lead install, but should I code for lead removal (33234 or 33244) when the lead is completely coiled within the pocket? What about removal of a partially coiled lead?

93355 without probe placement

The anesthesiologist actually places the TEE probe. A separate cardiologist is preforming the guidance. Is that cardiologist (who is NOT performing TAVR only the TEE guidance) allowed to bill 93355, even though he/she didn't drop the probe?

CIA Aneurysm Repair with Iliac Branch Device

Patient with history of AAA repaired 12 years ago now with CIA aneurysm. Repair of same with iliac branch endoprosthesis (IBE) and placement of aortic endovascular bifurcated stent graft Gore Excluder to anchor IBE. Patient does not have current AAA or failure of previous endograft, but patient anatomy requires the anchor bridge of the aortic endograft for the IBE. Can we capture the aortic endograft (34802/75952-26) along with 0254T for the IBE? How do we support medical necessity for the aortic endograft without a current diagnosis of AAA? 

Ascending Aorta and Hemi Arch Repair

Would it be appropriate to bill an ascending arch (33860) and the transverse arch (33870) when only the hemi arch was repaired? These are the details: "Two layers of felt sandwich were placed around the proximal aorta and sewn in place. We trimmed the aortic wall up to the level of the innominate artery and then sewed in two-layered felt sandwich to the distal end of the aorta. The remainder of the aortic arch appeared normal, and we doubled the aortic transection on to the underside of the arch. We then used a 28 hemashield graft and beveled and inserted it into the distal anastomosis using a 3.0 prolene suture."

Kyphoplasty vs. Vertebroplasty

Kyphoplasty was planned at T-11. Vertebral body was too small for balloon, so cement was injected and procedure was completed. I think this should be coded as a vertebroplasty instead of a kyphoplasty with a reduced modifier. Is this correct?

AV fistula declot & stenting failure;TPA and repeat stent for extravasation

Should we code the following with 36906? Or 36906 and 36903-59? Or 36906 and 36906-58? "AV left forearm graft fistulagram showed extensive thrombus in main draining vein up to level of distal third of humerus. Crossing sheaths placed. Angiojet cath used to treat arterial and venous anastamosis. It worked for arterial but not venous. Angioplasty of arterial anastamosis, and arterial flow re-established. Stent was placed across venous anastamosis to improve outflow. Patient continued to clot despite administration of 10,000 units of heparin during the procedure. Multiple passes again made with angiojet. Flow was not re-established. Decision made to initiate TPA therapy for 2 hours with an endhole ciatheter tip at the arterial anastamosis. After 2 hours, imaging demonstrated extravasation from two thirds of the graft, this was treated with an 8 cm fluency stent overlapping the previously placed Viabahns stent, the stent was balloon dilated to 6 mm. Extravasation ceased, arterial flow could not be established despite multiple maneuvers. Decision made to terminate procedure."

Aortic root angiography only

The heart cath was not done with the aortic root angio. How would this be coded? "The area of the right femoral artery was prepped and draped in the usual sterile manner. A timeout was performed. Approximately 10 cc of lidocaine was intermixed in the area of the right femoral artery. Using ultrasound guidance, a Cook needle was used to cannulate the femoral artery. There was resistance in advancing the guidewire; an arteriogram was performed through the needle, which demonstrated a tortuous femoral artery. A guidewire was inserted through the needle, nick incision was made in the skin over the needle, and a 6 French vascular access sheath was advanced into the femoral artery. Dr. X was then asked to assist with vascular access. A 6 French 55 cm Ansel highflex sheath was placed. A J L4 catheter was advanced over the guidewire, but was unable to reach the left main due to residual tortuosity in the femoral artery. A 125 cm JR4 catheter was then advanced over with dilated aortic root; the JR4 catheter was unable to reach left main."

Cyropreserved human aortoiliac prosthesis

My surgeon had an infected AAA status post endograft. Complete resection of AA with removal of infected graft; he also repaired the aortoduddenal fistula with an omental patch flap and inserted the cryopreserved human aortoiliac prosthesis. We reported codes 35907 and 35870. Can we also get a graft placement and omental flap codes with this? If so, what would you use for the placement of the cyropreserved prosthesis?

64530 when bilateral

Physician dictates "Fluoroscopic-guided bilateral celiac plexus block". Should I submit with modifier -50, or only bill 64530 alone?

AAA Repair with Chimney Type Procedure

"Patient with a fem-fem bypass for occluded left common iliac and AAA that is juxtarenal with a short and angled neck and angled suprarenal aorta. Procedure: 1) Left axillary cutdown. 2) Right femoral cutdown. 3) Endovascular repair using Medtronic Endurant-2 aorto-uni-iliac stent 36 x 14 x 102 mm, a right iliac docking limb 16 x 20 x 156 mm and chimney renal stents, 6 x 5 mm right renal artery Viabahn stent, and 5 x 5 left renal artery Viabahn stent. AUI stent advanced and positioned at the perirenal aorta. Viabahn stents advanced well into the renal arteries and the stent graft was deployed with the fabric being a few millimeters above the origin of the renal arteries and then the suprarenal fixation stent was deployed. Flush angiogram of right iliac system, marked level of the hypogastric artery and advanced the right iliac docking limb and deployed that successfully." Would this be coded 34812 for femoral cutdown; 37799 for axillary cutdown; 34805 and 75952 for the AUI; 36245-50, 37236, and 37237 for the renal stents; and 34825 and 75953 for the limb?

76998

Per NCCI edits, code 76998 (with modifier -59) can be reported with a CABG. Can code 76998 also be reported with an aortic valve repair or replacement, a mitral valve repair or replacement, or a tricuspid valve repair or replacement?

Facet Joint Injection with Synovial Cyst Rupture

What is the appropriate code to report the injection(s) for below? I think it is 64999 for synovial cyst involving facet joint, but some coders think that it’s both 64493 for facet joint injection and 64499 for rupture of the synovial cyst. What are your thoughts? “The patient was placed prone on the CAT scan table. The patient's back was prepped and draped in usual sterile fashion. Multiple sections were obtained through the patient's back at the appropriate level. A 20 gauge spinal needle was introduced into the facet joint. The location was confirmed with a second physician confirming the location. 1 cc of Omnipaque contrast was introduced. This was followed by injection of 3 cc of fluid containing 80 mg of triamcinolone mixed with 1 cc of 0.5% bupivacaine. Contrast was noted extending outside the borders of the synovial cyst into the epidural space indicating rupture of the cyst.”

DRIL of lower extremity

We have a patient who has a lower extremity arteriovenous graft (popliteal artery to common femoral vein) that is used for dialysis, as patient has no viable options left on upper extremity. The patient developed severe extremity pain suggesting of steal syndrome, therefore a DRIL procedure was done on the lower extremity. As code 36838 specifies upper extremity, would the coding be 36832 (a revision to AV fistula), or would this be reported with an unlisted code?

Screening or Diagnostic Mammogram

If a patient schedules an annual screening mammogram, and then before the screening exam starts, the patient reports new signs or symptoms that are concerning to her (like lump, pain, etc. on a questionnaire before exam, discussion with tech, etc.), would this still be considered a screening mammogram, or do these patient-reported signs/symptoms cause the patient to be no longer considered asymptomatic from a coding perspective and thus cause the exam to be coded as a diagnostic exam instead of a screening exam? Coders are wondering when to code a mammogram as screening vs. diagnostic when the patient reports signs symptoms at the same encounter as the planned and scheduled annual screening. They have symptoms, which points to diagnostic, but they are also due for an annual exam anyhow, which points to screening. Please advise with the rationale.

TAVR and E&M

Our provider frequently performs TAVR (33362) and wants to also bill for either a consultation or inpatient E&M code on the same day. He feels a modifier to override the edit is warranted, as the decision for the procedure is made during the evaluation. Our coders are disputing this, as code 33362 has a zero-day global period and therefore modifier -57 is not applicable. Would modifier -25 be appropriate as long as the documentation clearly supports the decision for the procedure on the same day?

Documentation for Mod. Conscious Sedation 2017

Is this enough documentation to report codes 99151-99152-99153 with the new codes for 2017? "Moderate conscious sedation was used with an intraservice time of 40 minutes. All monitoring was done by the radiology nurse under my direction." Would the provider have enough documentation to report codes 99152 and 99153 x 2 in this instance? Or does there need to be more specific documentation like what vitals were monitored, the preservice review of the chart, and the preservice exam along with the post service work like what was communicated to the family? After reading the CPT guidelines for new moderate conscious sedation codes, it seems like there is a lot expected for reporting moderate conscious sedation codes, but it's not clear on how much details need to be documented by the provider. 

Excimer Laser Atherectomy - Physician Billing

What CPT code would you recommend for excimer laser coronary atherectomy for physician billing? My first thought was an unlisted code (93799); however, the more I researched and thought about it, would is still be appropriate to use 92924 if the laser atherectomy was performed percutaneously?

One surgical site or two for embolization of AP and rt int mammary?

One surgical site or two for embolization of AP and rt int mammary? The procedure included diagnostic catheterization with oximetry, hemodynamics, angiography, 3D reconstruction on an independent workstation, and agitated saline study. The intervention included stent placement in left pulmonary artery, embolization of two aortopulmonary collateral arteries, and embolization of the right internal mammary artery.

ESI transforaminal

I'm not sure if this is considered two levels 64483/64484 or one level 64483? "The left L5-S1 and left S1 foramina were localized with fluoroscopy, and the skin over these areas was infiltrated with 2% buffered lidocaine. Under direct fluoroscopic guidance, a 25 -gauge spinal needles were advanced percutaneously into the left L5-S1  and left S1 foramina. Contrast injection demonstrates proper positioning of the needles and contrast flow in the lateral epidural space at L5-S1 level as well as along the left S1 foramen superiorly into the left lateral recess at L5-S1 level. Subsequently, 9  mg of Celestone and 1 cc of Marcaine 0.75% were injected at each level. The needle was then removed, and hemostasis was achieved with adequate pressure." 

Subclavian vein stenosis ICD 10

What would be the appropriate ICD-10 for the following findings? "The left subclavian vein is nearly 100% occluded where the pacemaker leads into the subclavian vein. Well-developed collaterals are seen around the stenosis."

Intraaneurysmal Intracranial Angiogram

We have looked for a code for this "intraaneurysmal intracranial angiogram" and cannot find. Can you please lead us in the right direction?

Transthoracic Echocardiography TAVR Coding (TTE TAVR)

How do you code for a TTE (transthoracic) TAVR please? Cardiologist MD performed a complete echo with 3D imaging during a TAVR. (He did not perform the TAVR.)

Exploration for Postop Hemorrhage

"Once we open the below-the-knee incision there was a large hematoma and active pulsatile bleeding. The bleeding was coming from a tear on the vein graft. This was located on the below-knee incision. The area where the bleeding was coming from was very friable; it was where a 6-0 Prolene suture was placed for a vein branch during the initial operation. This was repaired with interrupted 6-0 Prolene sutures." Should we report code 35226 or 35879 or use an unlisted code?

Stress echo in office setting different physicians 93351?

If the "supervising" physician and the "interpreting" physician are different (same group practice/same specialty), is it still appropriate to report the in OFFICE stress echo using code 93351? Our report lists Dr. A cardiologist as the "supervising physician", and Dr. B cardiologist signs the report (interp/report provider). Since Dr. A is overseeing (supervising physician) the tech should he be reporting 93350 and Dr. B be reporting the interp/report stress code 93018?

Percentage stenosis considered medically necessary for peripherals

I see in question ID 9237 dated April 12, 2017 your response on percentage of stenosis for coronary, carotids, av fistula interventions. Is there any guideline that speaks to percentage of stenosis deemed medically necessary for intervention in the extremities, subclavians, and renals?

Hero Device

When coding for placement of Hero device would you use codes 36830 and 36558 together?

Documenting Review of Systems for New Patients

I code for physicians, and I have a question on how they document their review of systems in their notes. Do any of these examples count as complete to code 99204, 99205, 99222, 99223 if other components qualify too? Examples of documentation: "comprehensive review of systems are negative" and/or "as in hpi, otherwise negative" (but they will list only a few not 10 systems or more in the hpi). And what reference could I use to support/back-up what I tell them?

37243 & 37242 Embolization

I've read previous threads and have a question about the surgical field. Coding from a hospital, the procedure was an embolization of the right hepatic artery with Y90 microspheres. (37243) The dx is metastatic liver cancer. During the procedure and prior to the embolization of the right hepatic artery it was determined that the proximal GDA needed to be embolized. Therefore the GDA was embolized with a MVP plug and coils. Once this was done the Right Hepatic Artery was embolized, normal anatomy, with Y90 microspheres. The right gastric artery was previously embolized. The GDA & right hepatic artery embolizations were done on the same dos and same surgical session. Is this considered the same surgical field and only 37243 is coded per the NCCI edits or can we code 37243 & 37242-59 (XE) because the GDA embolization was not done to treat the cancer area. We also coded the selective catheter placements of 36247 & 36248. 

EKG Machine(s) with Interpretation

Our EKG machines have Interpretation software. The EKG is printed off the EKG machine with the interpretation. The MD will confirm the interpretation and sign below it. Is it necessary to include other notation(s) such as "agree" or "okay"? If the MD disagrees with the interpretation he will add his own interpretation and sign below.

Lymphatic System as a Route of Contrast

I wish to refer to an earlier question regarding MR lymphangiography and the use of contrast. (See Question ID: 7416 Answered on 12/29/15.) The answer at that time included information that the lymphatic system is not a route of contrast administration that would allow billing a contrast study. CPT guidelines state that “with contrast” represents contrast administered intravascularly. There are resources that indicate the lymphatic system is a component of the vascular system as a whole. If so the lymphatic system should be an acceptable route of contrast administration. It would be greatly appreciated if you could please review the response to the initial question and provide additional feedback. We are beginning to see more and more MR lymphangiograms and we definitely want to get it right. 

Documentation for 93613

I was trained that it was unacceptable for the provider to only document the brand name of the mapping machine used during an EP study/ablation and not differentiate whether the medium was single plane/2D or 3D. They hate this requirement, and I have always been a stickler for explicit documentation of the type of medium. Now I am unable to identify source for this requirement. Is this an old wives' tale, or is there a credible source you are aware of that mandates this?

LHC and Attempted PTCA

One physician performed a LHC, and another physician attempted to intervene on a CTO of RCA on the same patient at the same setting, but the wire would not cross the lesion. For the first physician I reported code 93458. Can I report code 92920-74 for the second physician? The PTCA will be attempted at a later date.

Coding both 36558 and 36581?

Is it appropriate to code both 36558 and 36581? "A micron shunt was used to access right internal jugular vein. A coaxial catheter was placed. There was difficulty in place a coaxial catheter. Attempts made to place a Bentson wire were unsuccessful. A venogram was performed showing an angle jugular vein and brachycephalic vein. The access site looked low and a slightly higher access point was chosen. A micropuncture used to access the jugular vein. An angled catheter was used to place a wire in the IVC. A tunneling device used to place a tunneled ounces catheter in the subcutaneous tunnel. The right jugular access was dilated. The catheter was then placed via the peel-away sheath. There was an acute angle at the apex of the catheter. Multiple attempts were made to reposition the catheter was unsuccessful. The catheter was removed. A new more lateral subcutaneous tunnel was chosen and a new dialysis catheter was placed in the subcutaneous tunnel. A peel-away sheath was placed in the right neck the new catheter was in placed via the peel-away sheath. The catheter tip positioned in the RA/SVC junction."

Unsuccessful PM upgrade with LV lead not placed or generator replaced

We have a patient where the intended procedure was to upgrade a dual pacemaker to a biventricular pacemaker; however, after a venogram was performed and a wire passed multiple times unsuccessfully into the distal subclavian vein, it was decided to put the original dual pacemaker generator back in, reattach to the current RA and RV leads, and close the pocket. Can you please advise us on the correct coding for this scenario when the original dual pacemaker generator was put back in to the existing pocket, and the LV lead was never inserted/attempted since the venogram and wires were unable to gain adequate access? Is code 33224-74 appropriate for facility coding for this scenario, even though the existing dual pacemaker generator would not be able to accommodate an LV lead? In order to use the 33224 code, does the generator already in place have to be a biventricular generator? Would we only code for a venogram in this scenario if we should not code with 33224-74?

Endomyocardial Biopsy with a RHC and angiography

Would it be appropriate to use codes 93505 and 93454 for an endomyocardial biopsy with a right heart catheterization and coronary angiography when there is no medical necessity for the RHC only that it is a routine follow-up after a heart transplant?

Moderate Sedation Administration

In our hospital facility, the moderate sedation is ordered by the physician performing the procedure, but the medication is administered/pushed and monitored by the RN. Can we report code 99151, or does the MD have to push the medication?

Iliac stenosis with lower leg claudication diagnosis

I recently had a patient that had leg claudication and had angiography selecting the iliac and locating stenosis at the iliac. I used I70.8 for my diagnosis and was told by an auditor: "Common iliac arteries are native arteries in the legs, and when there is PVD with claudication this codes to I70.213 (atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs). You would not code atherosclerosis to the iliac artery; you would code to the extremity." Can you please give me some insight on this?

Repair In-Situ Bypass Lower Extremity

Would you use blood vessel repair code 35226 for suture ligation of branches off an in-situ vein graft fem-pop bypass performed several months after initial bypass surgery?

37253 Coding

Code 37253 has an MUE of 5. When coding in the lower extremity, does it follow the coding rules: three in the iliac territory, one in the SFA/popliteal territory, and three in the tibial/peroneal territory? Or, can we code the profunda separate from the popliteal?

Selecting same blood vessel with two different catheters

If the interventional radiologist catheterizes and images a blood vessel, removes that particular catheter from the body, uses another catheter of a different size to catheterize the same blood vessel as before, and performs images again, can I code for the two catheter placements?

36251 or 75625

If a patient has a renal angiogram performed, would below be considered a selective renal angiogram, or would it be charged as an aortogram?: "Using a 3DRC catheter, the ostium of the left renal artery was engaged, and selective angiogram revealed normal renal artery and no evidence of a stenosis." The catheter going no farther than the ostium is what has us questioning whether or not it is a true selective angio, or if it is considered to still be in the aorta.

76930 for TTE guidance pericardiocentesis? 93308 for limited TTE?

Do we use code 76930 for TTE guidance here? Also, can we get anything for the limited echo to confirm resolution of the effusion? "We used transthoracic echo imaging for the procedure. The left parasternal area was locally anesthetized using approximately 15 mL of 2% lidocaine. Using ultrasound guidance and a micropuncture needle and were able to access the pericardial space under transthoracic echo guidance. We advanced the micropuncture 4 French sheath in the pericardial space. We took 65-70 ml mL of serosanguineous pericardial fluid. We confirmed that the pericardial effusion was almost resolved by transthoracic echocardiogram. Then we removed the 4 French dilator sheath. The fluid was sent for analysis and cell cytology. The patient tolerated the procedure well without any complications."

CT Guided Biopsy of Maxillary Mass

What CPT code should be used? 21299/77012? "Patient was placed supine on the CT scanner. Scanning was performed, and a site for percutaneous access to the left maxillary mass was localized. The skin was prepped and draped in the usual sterile fashion. Skin was anesthetized with 1% lidocaine with infiltration of the subcutaneous tissues as well. Under intermittent CT guidance, a 19 gauge Temno biopsy trocar was advanced into the lesion. Position was confirmed with CT. Subsequently four core biopsy samples were performed with a 20 gauge biopsy needle. The biopsy needle and cannula was removed. A Band-Aid placed over skin entry site."

Thrombectomy of AV graft with fistulogram and removal of AV graft

This patient had a thrombectomy of his AV graft with a fistulogram that showed an occlusion higher up in the arm at the axilla. Decision was made to take down the AV graft. Do you code this to a thrombectomy of the AV graft (36831)? Or is this an unlisted procedure of the vascular system (37799)? "Graftotomy was made in the arterial limb of the graft, and patient was given heparin. A thrombectomy was performed with a #4 Fogarty, clearing the graft material of clot. A fistulogram was performed, demonstrating a total occlusion higher up in the arm at the axilla. After multiple attempts, we still could not clear the total occlusion in the left upper extremity vein. At this point, because of the presumed contact in the outflow obstruction, it was elected to remove the graft material in the forearm loop. Next, a counter incision was made in the distal forearm, the graft material was dissected free of surrounding tissue with the scissors, and then the loop of the AV graft was removed."

0238T Iliac Atherectomy

Recently we had cases where the physician performed iliac atherectomy. First case was an iliac atherectomy with PTA and the second was LHC/Corns DES RCA with Iliac atheretomy and stent placement RCIA. Both of these were Medicare OP patients. First procedure we charged 75716, 0238T, 37220. The second procedure we charged 93458, C9600, G0278, 0238T, 37221. We were notified by our Revenue Department that both of these procedure claims have been denied in their entirety since 0238T is non-covered and considered experimental by Medicare. Our Local MAC is WPS (J8). We added the -GZ modifier to 0238T, and the claims were again denied in their entirety. We were under the impression that by applying the -GZ modifier only that procedure would be denied not all procedures on the claim. Do you have recommendations on how to code/bill for an iliac atherectomy procedures for Medicare OP patients? This is for hospital billing.

Biliary manometry (Whitaker test)

Is there a code for biliary manometry "Whitaker test"? Or is it considered inclusive of other biliary procedures performed at the same time (drain check, drain replacement, etc.)? There is a CPT for a urinary Whitaker test. Would it be appropriate to code the biliary Whitaker test as unlisted comparing to the urinary code (50396)?

Ekos

"53-year-old patient had a right heart cath with only pulmonary pressures documented. Also, patient had two Ekos infusion catheters selectively placed in the right and left main pulmonary artery. Ultrasound vibratory component was inserted, and the catheters were hooked up to thrombolysis and cooling flow." How would I code this?

37184 vs. 36904

"Patient with AV fistula presents with steal symptoms (numbness, cramping), and ultrasound demonstrates thrombus in native brachial artery. Fogarty device is used to pull and macerate the thrombus seen into the fistula." Although the physician describes the thrombus as being in the native artery, does the fact that the clot burden was able to be pulled into the fistula signify that this should be coded as 36904 (no fistula conduit thrombus noted or treated)? Or, because it is into the native artery, can it be coded as 37184? (The physician states, "Thrombus will need to be removed, based on ultrasound findings, and no peripheral intervention.") Thank you for clarifying when 37184/36904 should be used!

Brachial artery access into Dialysis Fistula

I'm not sure how to code this fistula study since the brachial artery was used to access the fistula. "Retrograde access of the fistula was performed and imaging completed. Multiple attempts were made to traverse the critical proximal stenosis of the fistula w/o success. Subsequently access of the brachial artery near the antecubital fossa in an antegrade fashion to access the outflow venous fistula from an ante grade direction. A sheath was placed into the brachial artery. After placement of the brachial artery sheath a glidewire was manipulated down the forearm artery across the arterial anastomosis into the fistula. Using Roadmap technique, the proximal stenosis was successfully traversed and ultimately antiplastied." Would the coding be 36120 and 36902?

HIS Bundle Lead in right atrium at level of His bundle

Does it sound like this His bundle lead is placed in the atrium at the level of the His bundle instead of the ventricle? I have read your Q&A about this in the recent past and thought a His bundle lead was usually considered a right ventricular lead. Here are excerpts from the report: "His bundle access sheath was advanced over wire into the right atrium. This was positioned at the level of the His bundle and a His bundle lead then advanced." And later in the report,"Of note, this is a dual chamber pacemaker with the His bundle lead placed in the atrial port and the right ventricular lead placed in the RV port." 

32666 for VATS wedge

Would you bill more than the 32666 for VATS wedge resection upper lobe with enbloc removal chest wall mass including deep tissue? Maybe a -22 modifier, or would this all be bundled under 32666? "Procedure: LEFT VATS wedge resection upper lobe with enbloc removal chest wall mass including deep tissue. An incision was made in the 7th intercostal space, and a camera was inserted. The mass was identified on the lateral chest wall with multiple adhesions of the lung overlying the mass. Most were loose adhesions. A working incision was made in the 4 ICS. The adhesions were taken down with use of electrocautery until the tumor appeared to be coming from the lung. Multiple firings of a stapler were used to perform a wedge resection of the mass with a negative margin. The mass was then dissected off the chest wall to obtain a wide margin to include soft tissue and intercostal muscle. A ICS neurovascular bundle was divided. The mass was then completely free and was placed within a glove and brought out through the working incision. No other pleural masses were seen."

Open paravisceral aortic septectomy with AAA repair

How would you code this? Our code is 35091, but I'm unsure what else we can code with it. "INDICATIONS: Enlarging AAA and left CIA aneurysm. SMA identified and dissected circumferentially; vessel loops applied. Proximal dissection was completed. Dissected iliac arteries; left iliac was aneurysmal. Both iliac arteries meticulously dissected. We then prepared our dacron graft. A 30 mm unibody graft was sutured with a 24 mm x 12 mm bifurcated graft and tailored to the appropriate length. Ready to clamp the aorta. Segment of aorta was selected, and a clamp was applied just above SMA. Aneurysmal sac opened. Septectomy performed up to celiac artery, true/false lumen divided in paravisceral segment. End-to-end anastomosis. Very challenging d/t aneurysmal change and dissection extended into EIA. Septum divided and end-to-end anastomosis done covering IIA and EIA." Is all of this included in 35091?

Mammo screening with a followup of abnormal mammo

Patient had an abnormal mammo performed 6 months ago. She was asked to return for a 6-month follow-up and is also due for her annual mammo. We are coding this to a diagnostic mammo and the diagnosis code to abnormal mammo. Would this be appropriate?

Cardioinsight

Our physicians are using a new procedure/device called Cardioinsight. It creates 3D mapping using a "single-use disposable multi-electrode vest". The manufacturer, Medtronic, advises us to use 75772, Computed tomography, heart, with contrast material for evaluation of cardiac structure and morphology (including 3D imaging postprocessing, assessment of cardiac function and evaluation of venous structures, if performed). Would you agree with this code assignment. Should it be used with another code?

Repeat Hepatic Angiography

Patient with hepatocellular carcinoma had a complete hepatic angiogram followed by prophylactic coil embolization of gastrodudenal and right gastric arteries three weeks prior. There is variant anatomy with replaced common hepatic arising from the superior mesenteric artery supplying both left and right hepatic and gastro-duodenal arteries. Now patient is coming back for radioembolization treatment of right and left hepatic arteries with repeat of "diagnostic" right and left hepatic angiography. Under findings the provider states, “Diagnostic common, right and left hepatic angiography was necessary to confirm that the gastroduodenal artery that was embolized previously remained embolized.” Would you say this statement justifies medical necessity for repeat diagnostic angiogram for the common, right, and left hepatic?

75984 billable without contrast monitoring?

I would like some help in the coding of the following procedure. My main question is, can 75984 be billed for exchange of a drainage cath if performed under a non-contrast CT? Do we bill 75984 and 75984-52 (since contrast monitoring not performed) or an unlisted procedure code instead? "INDWELLING RIGHT RETROPERITONEAL PERCUTANEOUS DRAINAGE CATH EXCHANGE: Helical non-contrast CT imaging was performed through right lower abdominal quadrant with patient in prone position. The indwelling 10 French right retroperitoneal cath was prepped and draped in sterile fashion. The indwelling cath was gently withdrawn in sequential manner and ultimately positioned with tip more optimally positioned within the residual right lower quadrant fluid collection. Following confirmation of more optimal cath position, a new 0.035 wire was introduced, and the original 10 French cath was removed and discarded. Serial 12 French and 14 French fascial dilators were introduced, with ultimate placement of a new 14 French percutaneous drainage cath. The cath tip was coiled in the original rlq collection, then connected to drainage bag."

Arrhythmia not present during the ablation

"Indications: Patient with persistent symptomatic atrial fibrillation as well as a history of flutter undergoes a cryoablation. The patient is in flutter today. Procedures performed: transseptal puncture, ICE, 3D mapping, PVI ablation, and atrial flutter ablation by CTI." Does the arrhythmia have to be present in order to report the ablation? The physician only talks about the atrial flutter arrhythmia throughout the dictation (no mention of atrial fibrillation); however, the indication portion of the dictation states that the patient has persistent symptomatic atrial fibrillation and that a PVI ablation is performed. Is it appropriate to bill codes 93656, 93655, 93613, and 93662-26? Can you bill for an ablation if the arrhythmia isn’t present at that time?

CYSTOGRAMS

"The patient was catheterized by the radiology nursing service. The estimated bladder capacity is 330 ml, and the patient tolerated 350 ml before voiding. Contrast material was introduced into the bladder by injection and gravity. There are no intrinsic bladder abnormalities, and there is no reflux until initiation of voiding where there is grade 1 of 5 vesicoureteral reflux into a somewhat dilated right ureter." Would code 51600 be billed here with a -52 modifier appended?

Antibiotic Lock Therapy

What is the appropriate CPT code for Antibiotic Lock Therapy (ALT) for treatment of catheter-related bloodstream infections in attempts to salvage the infected long-term catheter? Apparently, this procedure involves instilling a highly concentrated antibiotic and often an anticoagulant into the CVC catheter and letting it dwell 4-72 hours.

Resection of recurrent adventitial cystic mass, right lower extremity

I am new to vascular coding and have come across a case that I cannot seem to find an appropriate CPT for; however, it seems straightforward. Patient is having resection of adventitial cystic mass, right lower extremity. Could you please point me in the right direction for coding?

Embolization right cavernous carotid fistula via SOV

"Dr. A performed a supraorbital cutdown and exposed the superior ophthalmic vein. From here Dr. B was able to puncture the vein using a 20 gauge AngioCath. A micropuncture kit was then used to puncture the right common femoral artery, and a modified Seldinger technique was used to introduce a 5 French sheath. The sheath was double flushed, and a groin was obtained. A 5 French Simmons 2 diagnostic catheter was advanced into the aortic arch and was used to select the left common carotid artery. Microcatheter was advanced over a Synchro 2 soft microwire through the right SOV into the right cavernous sinus. I was unable to catheterize the intercavernous sinus. From here I placed several coils into both the intercavernous sinus and right cavernous sinus with eventual occlusion of the fistula." We have coded 36011, 36215, 61624, 75894, and 75898. Do you agree? 

Geniculate

Can you please assist in finding a CPT code for a geniculate artery embolization for osteoarthritis?

Exchange Dobhoff Tube

Our IR physician exchanged a Dobhoff feeding tube for a new one due to not functioning. He did not place it originally. What code should be used?

Bilateral Pulmonary Artery Thrombectomy

Can I report code 37184 twice when bilateral pulmonary thrombectomies are performed through a single common femoral access?

C Arm

For hospital billing, when a surgeon requests that radiology bring up the C arm to perform intraoperative fluoroscopy check, should this be separately reported? Or is it a component of surgical level/CPT charge? If billable, is it billable across the board or only when the surgical CPT code does not indicate imaging is included within its definition? When billable, should this be coded with 76000/76001 or with a anatomic specific x-ray evaluation code?

Jailed Coronary Vessels

Can we bill an additional intervention for a jailed vessel? In this case we placed a stent in the PDA, mid-RCA, and did a PTCA on the jailed ostial posterolateral branch. Can we bill code 92921 for this? If not, what is the logic?

Mitral valve Reapir and Replaced at the same session

I want to know if it is okay to bill a mitral valve repair and a mitral valve replacement in the same session. The repair failed, so it necessitated the replacement. NCCI edits state they are mutually exclusive, but a modifier is allowed. I don't think that it would be appropriate to bill these two with a 59 modifier.

62323 with kyphoplasty 2017

2017 T9 Kyphoplasty done and L4-5 interforaminal epidural injection. Are 22513 and 62323 bundled and can never be coded together? They are at two totally different levels treating two different problems. T9 fracture and severe lumbar pain. Why are these bundled?

Sternal Closure

The cardiothoracic surgeons whom I code for are often performing sternal plating when closing the sternum during open aortic valve, mitral valve, and tricuspid valve procedures and CABG procedures due to morbid obesity. Would it be appropriate to append a -22 modifier for the additional time spent with dissection and sternal plating repair due to the morbid obesity?

Billing 93306 and 93351 same day same physician

I need to bill 93306, 93351, 93224, and 99214 all done during the same session by one physician in the office. I billed as 93306-59, 93351, 93224, and 99214 and got rejected. I had different diagnoses for 93306 (I10 and I50.30), 93351 (ICD10 R00.2, G45.8). What am I doing wrong?

X-ray Foreign Body

Is it appropriate to charge for an x-ray to see if a foreign body is left in a patient from the OR? I code for the hospital.

Moderate Sedation Documentation

Do you have any guidance as to the required documentation for the physician to bill moderate sedation per CMS? Our office is debating on the proper documentation, and I am unable to find any directives.

Diagnosis coding from a cath report

What is the best way to code diagnosis from a cath report? This area is new to me, and I have been told two different things: 1) code from the indication portion of the report on why the patient is being brought in for a cath procedure, and 2) code from the findings after a cath procedure has been completed. Things like "history of smoking" are not included in the cath report, but are included in a cardiology provider's progress note. Is this a dx code that should be added to the claim? Also the patient may come in with chest pain, which is not documented in the cath report but is documented in the physician's progress note. Is this a diagnosis that would be appropriate to submit for payment? Should symptoms and findings be listed or just findings?

Aborted PTCA, Completed Iliofemoral Runoff

"Patient came for planned PTCA of LAD. Physician inserted the catheter via common femoral. The long sheath was only able to be advanced into the distal abdominal aorta. Next, multiple attempts were made to engage the wire, but were unsuccessful secondary to the severe iliac artery tortuosity. Decision was made to abort the procedure. Abdominal aortic angiogram with bilateral iliofemoral run off was done, which revealed the left CIA, EIA all occluded." Can this be coded using 92920-74 and G0278 or just 36200?

Intracranial vs. Extracranial Embolization

If the ascending pharyngeal artery is embolized, is that considered intracranial or extracranial?

Transcaval and Transcarotid TAVR

We have providers who are performing transcaval and transcarotid TAVR procedures. Coders are using 33999 for these procedures, as there is not a Category 1 CPT code or a Category III temporary CPT code yet. They are comparing the physician's work to 33361. Is there a more appropriate comparison procedure to adequately show the physician's work?

Portal Vein Selection without Portography

I was recently told that portal vein selection 36481 is always coded with portography, even if there was no imaging done. Can you please tell me if this is valid? On this case the patient was brought in for SMV occlusion for placement of a stent. Vessels selected: main portal (36481) (no imaging performed), selective splenic (36011, 76496-59), SMV (36011, 76496-59), stent placement (37238).

Endovasc reconstrct with bifurctd Vasc Prost (2 limbs) & balloon expd stent

What codes should be used for endovascular reconstruction with bifurcated vascular prosthesis, bilateral common iliac artery angioplasty with balloon expandable stents? It was the same technique as an AAA repair, using the same modular bifurcated device (34803), with bilateral cutdowns, but with an atherectomy performed in the obstructed right CIA to gain access to the aorta prior to deploying the prosthesis. Additionally, bilateral balloon expandable LifeStream stents were placed, within the limbs, due to residual stenosis. However, this procedure was performed for a total occlusion of the right CIA, subtotal occlusion of the left CIA, total occlusion of the left EIA with severe and diffuse aortic obstructive disease. The patient has Leriche’s syndrome. According to the CPT book, code 34803 is exclusive to aneurysm repair. Should we use an unlisted code? I have absolutely no idea how to code this. Also, are the associated radiology services, cut-downs and catheter placements billable as with a AAA? 

ILR Repositioning

With the increase in ILRs being implanted, could you please re-address the coding of ILR repositioning? Our encoder comes up with 17999. Do you have a better suggestion? 

PCS coding 02UG3JE

We have guidance from CMS and the manufacturer that MitraClip insertion for the treatment of mitral valve stenosis is to be coded using 02UG3JZ, which makes sense. Our question is, when would qualifier E "Atrioventricular Valve, Left" be appropriate? The qualifier E seems a strange option since the mitral valve is itself the left atrioventricular valve. Any light you can shed on the reasoning and use behind qualifier E for mitral valve supplement would be appreciated.

Mammography Callback

When a patient is asked to come back for additional views following a bilateral screening mammography, the initial screening is categorized as a Birads 0 (incomplete assessment). Should the callback for additional views on these Birads 0 screenings be coded with a screening or diagnostic CPT code? These are generally unilateral. We are coding the first exam as a bilateral screening mammogram (CPT 77067) with diagnosis z12.31 (screening). Should the callback be also coded as 77607 with modifier -52 (reduced) because it is unilateral (not bilateral) with R92.2 (inconclusive mammogram) plus any actual findings from the callback images? Or should this be coded as a diagnostic unilateral (77065) because something seen on that initial screening mammogram led to the need for additional views to end with a Birads score 1-6? What would you consider asymptomatic: just the first screening, or is the callback for additional views still asymptomatic until the Birads score 1-6 is determined after the callback and not at a Birads 0?

Base imaging procedure codes for 76376 & 76377

Am I correct in saying that the "base imaging procedure codes" for 76376 and 76377 are CT scans (but not CTAs), MRIs (but not MRAs), ultrasound, angiogram S&I (NOT PET), or any other nuclear medicine code?

MD stented an LVAD graft with a VSD Occluder device?

What would you bill if physician put a stent in an existing LVAD graft using a VSD occluder device? "A 9 French x 80 cm Amplatzer delivery sheath was advanced through the 12 French sheath over the Amplatz SS wire into the outflow graft. Sheath was aspirated and flushed. Wire was removed, and a 14 mm muscular VSD occluder device (after being prepped) was advanced into the outflow graft. Together with the sheath, the device deployment tool was partially retracted, and the VSD occluder was deployed such that the distal half was situated in the proximal outflow graft and the proximal half in the ascending aorta. The deployment tool was removed, and the delivery sheath was removed over wire. A 5 French pigtail catheter was then advanced to the left ventricle where a power injector was used to perform a ventriculogram, which showed complete exclusion of the LVAD outflow graft by the VSD device. Catheter was then removed over J wire."

Femoral Pseudoaneurysm

"Skin incision was made over the groin. We got proximal control of the common femoral artery and gave 10,000 of heparin. We then opened the pseudoaneurysm, removed all the old clot, and got down to the top of the artery and closed with 4-0 prolene suture in a crisscross fashion. Hemostasis looked excellent. We placed vancomycin powder into the old pseudoaneurysm right on top of the artery and then closed with multiple layers of vicryl and skin clips." One coder would like to report code 35141-52, while another coder would like to report code 35226. How would you code this and why?

Peri-procedural TEE by Anesthesia during prep for PVI's/SVT's

EP physician report with full detail of pulmonary vein isolation. "Central aortic pressure monitoring, right atrial and left atrial pacing and recording, His bundle recording, intracardiac echocardiography, transseptal cardiac catheterization, 3-dimensional catheter mapping. Preop diagnosis: Recurrent paroxysmal atrial fibrillation despite beta blocker drug trials. Description: The patient was brought to the EP laboratory in the postabsorptive and nonsedated state while in NSR. General endotracheal anesthesia was established." In addition, there is a separate anesthesia report for an intra-procedural (done after patient was intubated, prior to PVI ablation) TEE with full findings. Which TEE code should I use? Can I charge ICE and TEE? We have noticed that a commercial insurance company is only reimbursing us for 93312 when billed with other procedures, so I want to make sure we are billing correctly.

U/S guided anesthetic injection into thrombolphlebitic laser ablated vein

"Under ultrasound guidance, a needle was directed into thrombosed great saphenous vein, and lidocaine was injected into three different segments of this obliterated vein. Tumescent anesthetic administrated into thrombophlebitic segments of the laser ablated right great saphenous vein." I could not find a code for this. Should I use unlisted?

Cisternogram

In previous questions it was stated to use code 62311 for the injection for cisternogram. Now, with new codes for 2017, would the correct codes be 62322/62323 depending on if imaging was used? Or would you suggest another code?

MRI of the Brain and Internal Auditory Canals

We had a patient who came in with an MRI script for the brain and internal auditory canals. The MRI was completed, and the MRI report that was dictated reads: "MRI of the brain and internal auditory canals w/o contrast". Is it correct to report code 70551 only once, or is there a more appropriate way to code for this procedure?

Conscious Sedation

We are a radiology group performing conscious/moderate sedation. We are documenting start time, stop time, who provided the sedation and procedure, and pre and post sedation assessment and monitoring. Since we are not billing for the sedation drugs and it is documented in the patient record, is it necessary to document the sedation drugs and the dosage?

Repair of EVAR with deployment of 2 Gore Excluder Limbs

This patient developed a type III endoleak due to component separation of the left iliac limb from a prior EVAR for I71.4. To repair this, our docs first used an Excluder limb across both graft defects followed by a second Excluder limb in the patient's iliac to bridge the separation of components. I would normally code this with 34825, 75953. However, I am not sure how to code for a second graft in this case, or if I can code for it at all because I am not positive that the second graft is considered a separate vessel and qualifies for the 34826. There is no mention of it being placed in either the external or internal iliac.

93655 vs. 93657

We have a question related to charging multiple units of 93655 and 93657 and what supports the definition of “the additional areas”. Are the GP ridge and ligament of Marshall considered a separate area, or are they included with the pulmonary vein isolation? The department believes it to be a separate area, and physician dictates as such, but this would be more than two areas of 93655. The department also believes the roofline is an additional area from pulmonary vein isolation. Thoughts?

Coil Embolization

Procedures: 1) Coil embolization of left forearm AV cephalic vein. 2) Balloon-assisted maturation of left forearm Cimino AV fistula with cephalic vein. 3) Completion of left forearm AV fistula. What are the codes? Please help; I'm new to vascular coding. 

33263 vs 33264 Previous Question (8663) Clarification

This is regarding your response to question ID 8663, where clarification was asked for regarding the scenarios listed in the CPT Codebook for conversion of an ICD system to a biventricular system. Your response was that we would always code biventricular ICD changes/upgrades to 33264. I can understand that if a patient comes down with a biventricular ICD with a RV and LV lead only and only the generator is changed. But, we have always coded an ICD upgrade (patient comes down with a dual chamber ICD, the generator is changed, and an LV lead is added) as 33263 and 33225. We based this on a reference from your coding book stating to choose codes based on leads placed not generator type. Wouldn't this also more correctly capture the work done?

Amplatzer for pseudoaneurysm of aortic arch

Our facility is not sure which CPT code would be appropriate to capture the use of Amplatzer for pseudoaneurysm of the aortic arch. We have only decided on 93799. Please advise.

76998

For intraoperative ultrasound guidance code 76998, does the radiologist have to be present to charge it on the professional side? Our facility has the ultrasound tech and another surgeon in the OR. The radiologist interprets the films only.

Lower Extremity Intervention

Bilateral angiogram was performed (75716). Intervention was performed on left leg; no intervention on right leg. Can we bill a catheter placement (36245-36248) for the right leg since no intervention was performed? I am getting different answers from coders.

Revision of AV Graft

Would it be correct to report codes 36832 and 35236 for this AV graft procedure? "I ligated the graft with 2-0 silks and then divided the graft and traced it down to the venous anastomosis. The vein was controlled proximally, distally, tied, and then divided. Then I harvested the piece of vein segment that I had excised and removed it from the previous anastomosis so I could use it as a patch later. I then turned my attention to the antecubital incision, which I then reopened and dissected down to the level of the venous graft. I then pulled the venous graft through the subcutaneous tunnel back into the antecubital incision. I then dissected down to the level of the arterial limb. Once I was in position there I ligated the graft again, divided the graft, and then I exposed the brachial artery proximally and distally. I heparinized the patient with 6000 units of intravenous heparin. After adequate circulation, I clamped the brachial artery proximally and distally, removed the hood of the graft, and then used a piece of vein from the venous anastomosis as a patch, which I sewed in place with a running 6-0 Prolene."

IVR Angioplasty Declot AV Dialysis Graft

"With real-time ultrasound guidance, the loop graft was accessed in the outflow direction. tPA was administered, and balloon angioplasty was then performed throughout the graft and outflow basilic vein. Access was obtained in the inflow direction, and a 7 French sheath was placed. Catheter wire passed the brachial artery where an arteriogram was performed. Balloon sweep embolectomy was performed across the arterial anastomosis. Fistulogram was performed. 8 and 10 mm angioplasty was performed within the subclavian vein. Wires, catheters, and sheaths were removed, and compression was held for hemostasis." Would code 36905 be the correct CPT code for this procedure?

Medtronic Single Pass Lead Gen Change

We removed and replaced a generator for a Medtronic Single Pass Lead (5038 CapSure VDD-2). My understanding is that this is a single lead system with a sensing electrode in the atrium and a pacing electrode in the ventricle. The lead bifurcates near the generator and connects into both ports of a dual lead generator. Would we bill 33227 or 33228 for the removal and replacement of this generator - single lead system but dual lead function and connections?

Percutaneous balloon venous angioplasty of lower extremities

Balloon PTA of venous lower extremity, right and left external iliacs, common iliacs, and common femoral veins with AngioJet thrombectomy and IVUS bilaterally prior to intervention. Code 37248 is reported only once. Since these vessels are contigious, do you report code 37249 x 1 or x 5? Thrombectomy can only be coded once per day no exceptions, and the IVUS is coded with one initial and one additional. If I report code 37249 more than once it hits an MUE edit. Do we just override and send the operative note to indicate the PTA was performed on different veins since the rules are different for venous than arterial?

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