Knowledge Base

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CPT code 35883 used alone or with other codes?

I am having trouble deciding when it's appropriate to use code 35883 alone or with other codes. What all does this code include? One case - previous iliofemoral bypass, which was aneurysmal. "After dissection and mobilization it avulsed off the proximal anastomosis. The entire graft was removed from operative field, and a new 8 mm graft was placed in the same location, distal external iliac to distal common femoral." Is this reported with code 35883 alone or just removal of graft (37799) and 35665? The other case was similar, ax-fem-fem bypass with aneursym on left femoral artery. "Patent ax-fem on the right, occluded fem/fem. Thrombectomy of right to left fem/fem. Aneursym of left femoral artery resected and interposition graft was placed left femoral artery to left profunda artery after it was thrombectomized." Is this codes 35883 and 35875-59 (for fem/fem thrombectomy)??? Also considered 35876. Can you please advise on these cases and how to determine when to use 35883 alone or with other codes.

Atrial Flutter

Would the following be coded as an unlisted procedure? "Patient scheduled for atrial flutter ablation. Patient presented to EP lab in AFL. Due to patient comorbidity, (coincident AF, recent Watchman implant) physician decided (prior to procedure) he would not pursue AFL ablation if circuit was left-sided. J-wire was advanced to IVC. Repeat access, repeat to 1 cm above the last, and 3rd access to 1 cm above, and J-wire advanced to level of right atrium. Sheath was introduced. SRO sheath was advanced into right atrium. Halo cath was advanced and draped across the tricuspid valve. SC cath was advanced into body of coronary sinus. Baseline findings recorded. Physician decided not to ablate. Conclusion: left-side AFL. Unable to pace terminate."

FEVAR with scallop

Dr states 34847. Cath advanced into bilateral renals through the renal fenestrations. Then, soft cath, the SMA scallop was cannulated, a wire was advanced down SMA. Balloons inflated for release of constrainment of fenestrated body. Does the scallop count as the third opening? Or is this just a two opening (34846)?

MODIFIER KX ON PACER IMPLANT

I'm having a disagreement with my auditor. Per MLN Matters, I think I should only append modifier -KX to a pacemaker code if I see the blurb "non-reversible symptomatic bradycardia" somewhere in the chart. She doesn't think that is needed and believes you can add the -KX as long as the claim contains one of the following diagnosis codes: I44.2, I44.1, I49.5, or Q24.6. What is your interpretation please?

Arterial Patency

The long description for code 76937 describes US assistance for vascular access. CPT Assistant, December 2004, describes assessment of venous patency and needle passage to the venous lumen. My question is whether this code can be reported for assessment of arterial patency and arterial passage to the arterial lumen. Or, is this code limited to venous line placements?

Modifier SC

Can we append modifier -SC to pacemaker implantation claims when we are doing the implantation prior to an AV node ablation?

PTEG venting tube

How would I code PTEG tube check, and how would I code placement of a PTEG tube? Should the placement be an unlisted code? Should the check to go code 49465?

27590 vs. 27596

"Periosteal elevator was used to dissect the femur to a position higher than the soft tissue amputation. This level was at the upper third of the femur. We then used the pneumatic saw to divide the femur. We then trimmed the anterior aspect of the femur so that it was beveled and had a smooth edge. We then divided the posterior flap of soft tissue. As he has become more cachectic, the soft tissue around his prior left above-knee amputation has atrophied. In addition to this problem, he has developed hyperostosis of the distal aspect of his femur. This has caused severe ulceration with exposed bone of the distal aspect of the left above-knee amputation site." The provider used code 27590, and the coder used 27596... can you tell us when it is appropriate to report code 27596? This was done two years after original amputation.

Fistulogram with AVF or AVG revision

With the new 2017 dialysis circuit codes, when a revision or thrombectomy/revision is performed, can you code an extremity arteriogram or extremity venogram with the open procedures?

93621

Can add-on code 93621 be reported for catheter advanced from the LFV to the CS for mapping of mitral valve annulus? (CPT 93653 is my primary code). "A Bard dynamic decapolar 6 French catheter was advanced from the LFV to the CS for mapping of the mitral valve annulus. A St Jude 6 French Daig quadripolar catheter was advanced to the right ventricle from the RFV. A St. Jude duo-decapolar BDB Livewire catheter was advanced via a 7 French LFV sheath, and the entirety of the right atrium while in the flutter was mapped. The TCL was 220 msec."

Thoracic Duct Stent

I'm looking for some assistance regarding thoracic duct stenting. "Viabahn covered stent deployed across cranial aspect of thoracic duct in area of lymphatic leak." I'm wondering if this would follow the same logic as a lymphatic embolization and be coded as a venous stent, or are we looking at unlisted code 38999?

Selective or non-selective

My doc places the catheter in the posterior tibial vein (this is where he starts procedure), goes up to CF, does a venogram of leg, and then goes into the IVC and images the IVC. This is all ipsilateral. Is the catheter placement 36011?

Can 37215 be coded more than once ipsalaterally?

MD placed a stent in the right common carotid with EPD, then performed angioplasty and placed two more overlapping stents all the way to the distal cervical right ICA. Patient had "near occlusive stenosis". All three stents overlap each other, so we are inclined to report code 37215 once, but I wanted to verify that we aren't missing any codes. EPD was used in all three stent placements.

Intercostal Artery Fiducial Marker

Can you please tell me if unlisted spine 28999 or 37799 should be reported for the following procedure? "IMPRESSION: Spinal dural arteriovenous fistula arising from the right T5 intercostal artery at the right T5 neural foramen. There is also an anterior spinal artery arising from the right T5 intercostal artery. To assist with surgery, platinum fiducial marker was placed in the left T5 intercostal artery."

Sclerotherapy reticular veins

What would you code for sclerotherapy reticular veins and why?

Mechanical Thrombectomy

If a patient presents in the morning for a thrombolysis recheck and has a thrombectomy performed with continuation of thrombolysis and returns later in the day for recheck and additional thrombectomy, what is billable for the second visit to the lab on the same calendar day? Thrombectomy and thrombolysis have an MUE of 1 per day. Are we able to bill thrombectomy each additional vessel for the second visit to the lab?

Mechanical Thrombectomy and Dialysis Circuit

I'm billing the following to Medicare: 36903, 37186, and 76937-26. Medicare denied code 37186 because its "parent" code was not billed with it; however, the provider did it after the initial angio of the HeRO showed thrombus and the end result was a placement of a stent within the AVG, which justified the 36903 coding. Code 76937-26 was also denied, but the claim didn't identify the AVG site as failing, I'm sure I could add that info, but I don't understand the Medicare denial of 37186... do they bundle it all with code 36903? The secondary commercial plan's claim checker allowed all 3 lines, but when it crossed to them they denied it as failure to follow the primary payer rules. How should mechanical thrombectomy be coded when done with codes from the dialysis circuit?

Generator change with Bundle of His Lead

Our patient already had a biventricular ICD in place with LV lead failure. Physician is documenting that we changed out the generator, capped the LV lead, and placed a new HIS bundle pacing lead in what is documented as across the tricuspid valve and positioned in the lower right atrial septal wall. So I believe this means I now have one RV lead and two RA leads. Provider is requesting to bill codes 33264 and 33216. I know that typically when we replace the generator and add a lead at the same time we switch to the insertion codes. I am wondering if code 33206 is appropriate in this case or if we should be using unlisted code 33999. I know we capped the LV lead, but I do not feel that the new lead is trying to take the place of the LV function, but stimulating the atria. 

BiV ICD downgrade to BiV pacemaker with left ventricular lead repair

"Patient presents with end-of-life biventricular ICD, no longer requiring the ICD. ICD generator is removed and leads checked. The LV lead requires repair using a portion of lead cap and medical silicone adhesive tied on with silicone. A biventricular pacemaker was then implanted." Is the correct coding 33241 for ICD generator removal, 33218 for lead repair, and 33221 for placement of pacemaker generator?

Visualase Procedure Done in MRI

We have neurosurgery using our MRI machine to perform Visualase procedures. They are placing neurostimulators for Parkinson's. Right now we are billing the MRI with the brain MRI code, but when I found some info on the Medtronic website they recommend using 64999. These are hybrid procedures done in conjunction with neurosurgery that can take up to 6 hours. Should we be billing unlisted 64999 code instead of an MRI scan?

Femoral Vein access to AV Fistula with Advancement to Brachial Artery

"Access in the right brachial artery with fistulogram. Second access in the common femoral vein through the IVC, right atrium, SVC to the AV fistula and then advanced into the brachial artery with PTA of stenosis in the fistula." I would code 36120 and 36902-52 for the brachial access and PTA. Would the catheter placement code for the common femoral vein access through the fistula to the brachial artery be 36012 and 36215, or just 36012?

Right Axillary-femoral-femoral changed to axillary-femoral-iliac

This patient has an occluded aorta resulting in non-viable left lower leg. The plan was to perform an axillary-femoral-femoral bypass prior to performing the AKA in the near future. In prepping the patient he had an ischemic ulcer high on the left thigh therefore they performed an femoral to iliac vs. femoral to femoral. This is my dilemma... because it was a planned procedure, should I code it as an incomplete axillary fem-fem 35654-52 or should an unlisted procedure code 37799 be used?

PTFE BYPASS GRAFT FROM COMMON FEMORAL ARTERY TO MID SFA

What would be the correct code for a PTFE bypass graft from CFA to the mid SFA? The only code that I can find that is close is the femoral to popliteal PTFE bypass (35656), but that is not what was done.

Peripheral with cath

Left heart cath is ordered for patient with unstable angina. Operative report reads that the patient also has a small ulcer on foot, history of arthrectomy to SFA, reassuring ABI. Cath is done through right radial access, then catheter is moved down to right CFA and runoff of right leg with digital subtraction at 2 levels is performed. CFA is normal and arthrectomy site is patent. Would this be reported with codes 93458, 36247, and 75710?

Rhythms provoked by administration of medication and/or catheter manipulati

When coding for EP studies/ablations, is it appropriate to assign ICD-10-CM codes for provoked arrhythmias? Example 1: Patient presents for successful ablation of SVT. Should AV block be coded from the following? “There were no inducible arrhythmias with ventricular pacing protocol. Adenosine 9 mg resulted in AV block with no ventricular pre-excitation but eccentric VA activation persisted” Example 2: Patient presents for ablation of ventricular preexcitation, none was found. AV/VA block and RBBB noted as below. Should these be coded separately? “Ventricular extrastimulus was performed with no inducible arrhythmias or eccentric VA conduction. Adenosine 12 mg was administered resulting in both AV and VA block with no ventricular pre-excitation. There was intermittent junctional rhythm at baseline. There was development of right bundle branch block due to His/RVA catheter. There were intermittent wide complex beats noted during atrial pacing that were found to be due to His/RVA catheter movement.”

Interrogation of Pacemaker

For this case we are not sure how much needs to be documented to code for interrogation of pacemaker and what code would be best with this documentation. "Right femoral region was prepped and draped. See cardiac cath log sheet for sedation. The patient's device was interrogated and programmed to a lower rate of 30 BPM. An 8 French sheath was placed in the right femoral vein using modified Seldinger technique. Radiofrequency energy was applied to the AV node with an 8 mm tip ablation cath, resulting in complete heart block. Sheath was removed, and the device was then programmed to a lower rate of 80 BPM." I am thinking of code 93650, but I'm not sure what to code for interrogation of pacemaker. Is there enough documentation to report codes 93286 and 93286-59? Or is code 93288 or 93279 best? We are confused on when to use the interrogation device codes and what is supposed to be documented for each code. Can the cardiology nurses report code 93279 the day after a pacemaker is put in? 

In-situ vein bypass femoral to tibioperoneal trunk

My doctor states he is doing an in-situ femoral-distal popliteal bypass. He documents the end-to-side anastomosis at the tibial/peroneal trunk. In this case, would you consider the tibial/peroneal trunk as part of the popliteal (35583) or the posterior tibial, anterior tibial, peroneal (35585)?

Date of service for remote device interrogation

Our office had a remote interrogation come into the office over the weekend, and we are not technically open on the weekend. The interrogation was recorded on Saturday and interpreted the following Monday. The codes assigned were 93294 and 93296. What date of service should be assigned for these CPT codes, particularly when the remote interrogation (93293-93299) is received on one day and the interpretation is signed on another day? Going one step further, for the in-person interrogations (93279-93292), we are using the date of the encounter/interrogation/reprogramming as the DOS as opposed to the date the interpretation was signed. Is that correct? 

Revision w/w/o Thrombectomy

Is it appropriate to report code 35876 for the procedure that follows? "Extensive clot was noted and removed. Some old hyperplasia was also removed. A 5 Fogarty was passed into the graft and pulled a large plug out with significant return of inflow. The fem-fem was flushed and occluded. The profunda was reopened with excellent return of back flow. A Fogarty was passed down the SFA with thrombus removed and good return of back-bleeding. A Gore-Tex patch was cut to fit and sewn in place with running Gore-Tex suture."

Soft tissue biopsy of abdomen

Would you use code 49180 or 20206 for soft tissue biopsy of the abdomen?

Kyphoplasty and a Vertebroplasty

The physician performed T5 vertebroplasty under fluoroscopic guidance and T9 kyphoplasty vertebroplasty under fluoroscopic guidance. Can you report codes 22510 and 22513 together with modifier -XU appended?

MRA and MRV

If a physician orders and performs, in the same session, an MRV of the head without contrast and an MRA of the head with contrast, is 70546 the correct code to use? 

32208 global period with 93650

When our doctors perform an AV node ablation (93650) with pacemaker implant (33208) on the same date, we have been getting denials for code 93650. Specifically because code 93650 was billed in the global period for code 33208. I believe this may be payer specific. Should I append a modifier -78/-79, or should I appeal to the payer?

3D mapping for CS lead insertion

We have a physician who will be using the NavX mapping system to map the coronary sinus and its branches for CS lead insertion for his Bi-Vs. Can we bill anything for his, or would it just be considered guidance during the procedure?

PM system removal with perforated vein

I need help coding this case. "Patient is having pacemaker system removed due to infection. A temporary pacemaker was placed via the right femoral vein, and an active-fixation (screw-in) lead was attached to an externalized pacemaker via the right IJ vein. ICE was performed during the procedure, visualizing the right ventricular lead during the extraction. Leads were clearly adherent to the subclavian/innominate veins. After removing the right ventricular lead, contrast was injected in the innominate vein, demonstrating a tear in the distal third of the vein. Atrial lead was then removed. I elected to place a covered Wallstent covering the entire innominate vein. Pocket was irrigated with antibiotic solution, and wound VAC was applied." I was thinking about reporting codes 33233 pacemaker removal, 33235 lead removal dual system, 33216-59 fixation (screw-in) lead, and 97605 for wound VAC. I don’t think ICE can be reported due to no primary procedure code associated with it being billed. Also, I'm thinking that the stent placement would be inclusive with procedure due to perforation created by physician, but I'm not sure. Thoughts?

LV lead only no other leads and BiV upgrade

Patient had upgrade from VVI pacemaker to biventricular pacemaker, with old LV lead capped and new LV lead inserted. No lead in the RA or RV. Since there is no RA or RV lead, what code do I use for the upgrade to biventricular? 33208 & 33225 or 33229 & 33225? I am confused on what to code for the generator when there are no right-sided leads.

US Guidance 76937 for multiple accesses

Can you report code 76937 multiple times for the same access site? For example, our EP physician puts two sheaths in the right femoral vein and uses ultrasound guidance for each access. Do we submit code 76937 once or twice? There are also situations where ultrasound is used to place an access in the right femoral artery and again for the right femoral vein. Would we bill 76937 once or twice for that?

ERCP

Occluded right hepatic and migrated bifurcation stents both replaced. Selective cannulation and stenting are done on the second right hepatic duct branch and a replacement of the bifurcation stent. Should I use 43276 x 2, as this is the “same anatomical area”?

Soft Tissue Structures 93998 or 76881-76882

If we are doing vein measurements for CABG, what code is used for this? Do you consider veins to be soft tissue structures (76881-76882), or is unlisted code 93998 more appropriate?

33210 with Valvuloplasty

Is a temporary pacemaker included in the procedure when you bill an aortic valvuloplasty?

Angiovac thrombectomy with veno-venous extracorporeal bypass

The physician performed an AngioVac thrombectomy with extracorporeal veno-veno bypass from the suprarenal IVC to the level of the iliac bifurcation. Is the bypass separately reportable, or is it included or bundled with the thrombectomy procedure code? If separately reportable, would it be an unlisted code?

LP with Spinraza Injection

LP with Spinraza Injection is very similar to 96450 (intrathecal chemo injection), but Spinraza is not a chemotherapy drug. What CPT code would you suggest for this injection? "CLINICAL INFORMATION: __ days old girl with spinal muscular atrophy presents for Spinraza administration spinal muscular atrophy, spinraza injection. The anticipated puncture site was anesthetized with lidocaine. A 20 gauge spinal needle was advanced into the thecal sac via the interlaminar space of the L3-L4 vertebrae with fluoroscopy and ultrasound guidance. The stylet was removed, and spontaneous flow of clear CSF was observed. A short catheter was attached to the spinal needle, and 4 ml of CSF was collected. 5 mL of Spinraza were then injected. The needle was then removed and the puncture site dressed. IMPRESSION: Successful fluoroscopic and ultrasound guided lumbar puncture with Spinraza injection."

93042 with 99223

I'm seeing denials for missing "qualifying procedure code" when reporting codes 93042 and 99223 together. Payer is Medicare. Error code is B15. What is the qualifying procedure code for this scenario? Or what is missing from this scenario?

CPT 33877 with Existing Stent Removal

Surgeon performed thoracoabdominal aneurysm repair and removed old infected stent on the same site. Is the stent removal separately billable? If so, what is the appropriate CPT code?

Prophylaxis of Vasospasm

Should we bill for Verapamil administration performed for prophylaxis of vasospasm during neuroembolization?

CardioMems Implant with RHC, and Pulmonary artery angiography

Would it be appropriate to report codes 93451-26 (right heart catheterization) and 93568 (for the pulmonary artery angiography) in addition to 93799 for the implant of the CardioMems for physician billing?

Bone Core vs. Bone Marrow Core

Can you please help me understand this report. The patient has erythrocytosis. The "order" was for "BMBX" (all done same needle path/location). My doctor goes back and forth with his terminology, and it's confusing me. He says at the beginning of report he is doing a "CT-guided bone marrow aspiration of right posterior iliac crest and a CT-guided core needle biopsy of the right posterior iliac crest". In the body of the report, he says, ".20 mL of bone marrow aspirate was obtained and sent to lab for analysis. In order to obtain adequate bone marrow sample, a core biopsy was required. Next a single core bone biopsy sample was collected in formalin using the 11 gauge introducer needle. Impression: Successful CT-guided bone marrow aspiration. Successful CT-guided bone marrow core." I want to bill codes 38221, G0364, and 77012-26 because he keeps going back and forth with "core bone" and "bone marrow core", but I'm not sure.

93568 with PDA device closure 93582

Can PA angiography (93568) be coded also if performed with PDA device closure (93582)? In the CPT book it states that code 93568 can be used as appropriate with 93582, and recently a physician shared a letter with the facility from SCAI that stated this could be coded together and that we could begin to receive reimbursement for PA angiography (+93568) if performed with PDA device closure (93582). Coding these together, however, creates an edit that the add-on code 93568 is reported without base procedure code. Can these two CPT codes be coded/billed together?

Regarding ID 9663

New IR coder here. Can you please explain why the right atrium pressures are not coded if the intent of the procedure was to do the liver biopsy?

CPT 37232

My provider did angioplasty on the left tibial artery (one on the mid posterior and another on the proximal posterior tibial artery). Can we report code 37232 with 37228? I'm thinking it has to be another artery like the peroneal or anterior tibial in order to use 37232. 

Two PCN Placed in Same Kidney

Is it appropriate to bill code 50432 x 2 when PCN catheters are placed in the same kidney, one in the upper pole and the other in the lower pole (no duplicated collecting system), same session? If so, would you append the -59 modifier to the second? 

Intraoperative images

Do you have any info from CMS regarding intraoperative x-rays? I'm working on creating orders that are statistical only so we at least get the productivity. We have a statistical only fluoro charge as well since we cannot charge for the use of the c-arm. This would be for facility billing only. I need resources so radiology gets credit for productivity that can't be charged due to CPT codes being bundled into the main procedure. Your help is deeply appreciated.

Follow-up to question ID 9329

My question is basically the same as the one in question ID 9329, specifically the CPT code for cryoablation of a venous malformation. I was confused that your answer seemed to address the sclerotherapy CPT code but not a cryoablation CPT code. 

75625 and 75726

I understand code 75726 is with or without flush aortogram. But would there be a situation where code 75625 can also be reported? Example: "An aortogram was performed to delineate the anatomy, as pre-operative CT scan was not adequate in defining the extent of spill-over disease into the celiac and SMA." Then a catheter was advanced into the SMA and imaging was done." Can we report both codes 75625 and 75726, or would only code 75726 would be allowed?

36010 and 36005

When doing subclavian venoplasty, if upper extremity venography was performed and then the catheter was advanced to the IVC, can both codes 36005 and 36010 be reported? Or is code 36005 inclusive to 36010? Do we not code the injection, along with radiological supervision and interpretation code for extremity venography?

Valsalva Maneuver

Would there be a separate code when Valsalva maneuvers are done during a right and left heart catheterization? Or is that included in the diagnostic cath codes?

33228 vs. 33229

A patient received a dual chamber pacemaker replacement. However, the initial DDDR pacemaker had coiled leads and Y-adapter in the capsule. They were dissected out; old generator was removed. New DDDR pacemaker was implanted using the previous RV lead, AV lead, and LV lead via the Y-adaptor. How does one code a dual chamber implant being used for biventricular pacing? We have a discussion of 33228 versus 33229. Code 33229 was apparently submitted, but CMS kicked back a device-to-claim edit since HCPCS code C1785 was (correctly) indicated on the claim. Any thoughts?

Intraoperative ultrasound and carotid endarterectomy

Is it okay to bill intraoperative ultrasound (76998) in conjunction with a carotid endarterectomy? Or is it included? NCCI shows that it doesn't bundle, but it is being used to evaluate the carotid artery after revascularization.

Cancelled Cases

We have a patient who was brought to the hospital for an ICD implant. The case was cancelled while the patient was still on the floor. She was never brought to the EP lab. She was given solumedrol and Benadryl by the floor nurse in preparation for the procedure, but her labs came back with a UTI and the MD cancelled the case. Should this be billed with a -73 modifier or not billed due to her never leaving the floor?

Breast Lump Diagnosis Quadrants

How do we know what quadrant to use when the provider states the breast lump is at the 3, 6, 9, or 12 o'clock position? Those positions are right on the line. With the new updates in ICD-10 the diagnoses are by quadrant. The codes I am referring to are N63.11, N63.12, N63.13, N63.14, N63.21, N63.22, N63.23, and N63.24. Medicare does not have the unspecified quadrant as a payable, and I could not find any documentation that would state what quadrant those locations would be.

NCCI edit for 93990

If there is an NCCI edit for 93990, and we have to remove the 93990... can we report code 93931 instead? "Reason for Study: Left arm radial-cephalic vein fistula. Interpretation Summary: The left radiocephalic AVF is patent with only mild stenosis at a valve cusp in the proximal forearm. Volume flow is excellent. Procedure: A fistula duplex exam was performed on the left. Left arm radial-cephalic vein fistula. Left Arm: Left radial artery Doppler waveform shows low resistance. The fistula is patent. There is a mild (422ed263cm/sec) stenosis proximal forearm cephalic vein cusp. The volume flow is1224cc/min."

34151 x 3

"The physician performes exploratory laporatomy with celiac, aortic, and SMA embolectomies for aortomesenteric thrombosis with organ and bowel ischemia. Mid-line laparotomy was made. Longitudinal arteriorotomy was made over origin of hepatic artery onto the splenic artery. Immediately a large amount of clot was extruded and extracted with both forceps and by passage of #4 embolectomy catheter with restoration of vigorous backbleeding. Thrombectomy catheter was placed proximally into the aorta, and a large thrombus tail was extracted consistent with free-floating thrombus. Arteriotomy was closed with running 6-0 prolene sutures. Next, transverse colon reflected cephalad and SMA origin sharply dissected at base of transverse mesocolon controlled with vessel loops. A transverse arteriotomy was again made, and a large amount of thrombus was extracted. Thrombectomy catheter was passed with restoration of backbleeding and with restoration of arterial inflow. Transverse arteriotomy was closed with running 6-0 prolene suture wth restoration of mesenteric pulse distally." Can code 34151 be reported three times (x3)? 

ECA Angiography with ICA Stent

If you perform an extracranial stent placement (37215) in the distal right ICA, does this also include a diagnostic angiogram of the ECA and vertebral arteries on the same side?

AAIR His Bundle Pacing

"A 4 French lead was advanced and placed at the Bundle of His. The lead was fixated, and a stable position was attained. A 7 French lead was advanced into the right atrium and screwed into position. The pacemaker generator was then attached and the pocket closed." My thought is that this is a dual chamber (33208) even though both leads were placed in the right atrium. But the manufacturer has a "suggested" CPT code of 33206 because of the physical position of the leads. Which one is correct?

75572 or 71275

We are trying to code a CT angiogram of the pulmonary vein with 3D reconstruction. Our radiology coders used code 71275, but the physician office used code 75572, and we are being questioned to review and change our code to 75572. I read references on both codes, and I think we should go with code 75572 because of the 3D imaging part. Am I correct to use code 75572 because it includes the 3D part (since code 71275 does not include the 3D imaging)? Here is part of the report and the areas they reviewed. After reviewing the procedure report, it looks like this was done for evaluation to do an ablation procedure. "The patient had an ablation later on 11/14. FINDINGS: Pulmonary veins: There are three right pulmonary vein ostia and two left pulmonary vein ostia into the left atrium. There is an accessory right upper lobe branch originating very proximally from the right superior pulmonary vein. RT/ LT superior, RT/LT inferior, RT/LT middle heart coronary arteries, LT atrium pulmonary arteries."

Modifier 58 vs Modifier 79

When a patient is seen on first office visit and doctor is going to do a right EVLT/phlebectomy and then a left EVLT/phlebectomy later, but within 90-day global, would modifier -79 or -58 be more appropriate on the second procedure?

MR-Lymphangiogram with Contrast

Procedures: 1) Ultrasound-guided cannulation of bilateral groin lymph nodes. 2) Contrast enhanced MR lymphangiography. Now that we are seeing MR lymphangiography more often, we weren't sure if we could bill MR with contrast. I see that there are no NCCI edits, but what would you suggest? Are there any references we can look up?

Biceps muscle flap coverage of right arm arteriovenous graft

Would you recommend code 14020 or 15736 for the following procedure? "We then mobilized the biceps muscle for a distance of approximately 2 inches. The biceps muscle was pink, and there were no signs of ischemia. We will mobilize enough muscle for flap coverage of the graft. The muscle was then brought laterally over the exposed area of the graft and sewn to the soft tissue laterally. This completely covered the graft."

Multiple chest xrays after thoracentesis

We do not charge for the immediate post procedure chest x-ray. However, typically we do another x-ray one hour later and wanted to know if we can charge for that. Is there a timeframe after the immediate post x-ray that another one can be coded/charged?

Unsuccessful LV lead delivery with modifier 22

One of my providers attempted an LV lead delivery and, after spending 4 hours, was unsuccessful. He feels because of the time spent, a modifier -22 is justified. Because this was unsuccessful, can we still use modifier 22? "...A 9 French SafeSheath was placed in the vein to use as a workstation for the left ventricular lead delivery. I then spent nearly 4 hours of time trying to access the coronary sinus using a combination of different techniques, and ultimately I was able to access the coronary sinus, which had been hampered by a markedly enlarged right atrium with a significant reach from the superior vena cava to the interatrial septum. Conclusions: 1) High grade left subclavian stenosis. 2) Failed attempt at left ventricular lead delivery." Given the time spent between the left subclavian vein stenosis and the difficult cardiac anatomy and making an attempt to place the left ventricular lead, which was easily 4x the normal amount of time spent during these procedures, we feel that this is justified to request a -22 modifier. Thoughts?

Transection of gastrocnemius for popliteal artery entrapment syndrome

Can you please help with coding this? I am stuck. "We tracked down and came across a large gastric band from the gastrocnemius muscle that was compressing the entire popliteal fossa including segments of the nerve as well as the artery and vein. They were all encompassed below this compressive band, which was compressing the entire popliteal fossa. We then dissected distally to identify the popliteal vein and artery past this segment as well as released all the subcutaneous tissues holding portions of the tibial nerve in place. Once we were able to release the nerve, we then did a meticulous dissection both proximally and distally of all the popliteal vessels as well as the gastric band. Once we identified the gastrocnemius band, I was able to get a right angle below all these segments, and then we transected the medial portion of the gastrocnemius muscle as well as the gastric band, and, immediately upon doing this, we released the entire popliteal entrapment, and then there was good revision and dilation of the of the popliteal."

99152 billed on two separate procedures

We have had several cases where the patient returned to IR for another procedure and it needed to be performed with moderate sedation. Can moderate sedation code 99152 be billed twice in one day since the procedures were performed at different times?

Drug-Eluting Balloon C2623 with CPT 36902

Our facility is performing the AV angiography of the dialysis circuit as described in CPT code 36902. The surgery department is using the device code C2623 for the drug-eluting balloon that is documented as being used by the surgeon. We are receiving denials that the drug-eluting balloon code does not have a matching CPT code. From what I can find it appears that the drug-eluting balloon code (C2623) can only be used with fem/pop procedures, is this correct? 

MUGA Study for EF Calculation

I am having difficulties determining the correct CPT code for this procedure. I am coding for the interpreting physician. This is all I have: "MUGA study for EF calculation. Indication: CMP. Procedure: Tc-99m tagged RBCs were administered IV, and MUGA images were obtained. Findings: The calculated EF on MUGA is 52%, which correlates with the visual estimation of EF. Impression: Calculated EF of 52% on MUGA."

Removal of Metallic Foreign Body from Abdominal Wall

"Under fluoroscopic guidance, the metallic foreign body located in the anterior abdominal wall was located and removed via a small anterior abdominal wall incision. Removal of the entire wire was confirmed with fluoroscopy. The incision was then closed with a double layer closure." Would unlisted code 49999 be correct for removal of metallic foreign body from anterior abdominal wall?

Congenital echo 93303

If color flow and Doppler are used while doing a complete congenital echo (93303), should they be billed separately (93320 and 93325), or are they included in code 93303?

Billing incidental resections for access

Can you provide clarification on whether or not it is appropriate to bill for incidental resections for access during a surgical procedure? For example, a surgeon performs a sternotomy and thymectomy as part of access for a CABG. The report states, “The thymus tissue was excessively redundant and completely filled the anterior mediastinum and was removed in order for the CAB surgery to continue.” Is the thymus resection billable because the surgeon documents that it was necessary to perform the procedure? Example 2: Prior to the sternotomy performed as access for a CABG, a lipoma was resected. The report states, “A lipoma was encountered upon entering the skin of the chest and was resected. The lipoma was excised in order to adequately expose the sternum and necessary to proceed with the sternotomy and was found to be 2.5 cm x 2 cm in size.” Is the lipoma resection separately billable? The surgeon would like to bill for these services, but I am uncertain if this is appropriate since these procedures were performed to facilitate access for the larger procedure, the CABG.

Diagnostic heart cath w/PCI

Our cardiologists want to charge for diagnostic heart/coronary angiography in a patient with known CAD, done at the same time as a PCI, if the previous heart cath was done at an outside facility and we do not have the reports. Is this acceptable? When is it acceptable to bill for diagnostic angiography in a patient with known CAD? 

Billing 2 stents

I am new to billing and would like to know why I get denials when billing for two stents in TWO different vessels. I am using 92928, 92929, or 92933... same thing when stent and/or PTCA. Please advise.

Provocative measures for Doppler

Can you please advise what is considered a "provocative maneuver"? (ABI being performed for steal syndrome on upper extremity)

Multiple thromboembolectomies same leg

I'm looking at 34201 and 34203 for thromboembolectomy with patch angioplasty of the following locations: left common femoral, profunda femoral, popliteal to tibioperoneal trunk. Plus lower extremity angiography, antegrade and retrograde SFA thromboembolectomy common femoral artery, and from below-knee popliteal artery. Treatment for thrombus in left profunda femoral artery, popliteal and tibial arteries. Intraoperative coagulopathic state. I looked at medically unlikely edits, and both of these codes only show allowed once per day. Are these the appropriate codes?

Fluoroscopically-guided AD manometry tube placement

What are the codes for fluoroscopically-guided AD manometry tube placement? "With the patient supine, a combination of a Bernstein catheter and Glidewire were used to obtain purchase into the proximal duodenum. No contrast was seen to flow past the second/third portion of the duodenum across the spine raising the possibility for external compression such as superior mesenteric artery syndrome versus intrinsic small bowel problem. JAG wire could be advanced slightly more distally, but given the distension of the stomach and anatomic consideration the antroduodenal tube could not be advanced towards the ligament of Treitz, and the distal marker was advanced to the level of the second/third portion of the duodenum and the proximal multichannel markers within the fundus of the stomach. The tube was flushed. It was secured in place. Fluoroscopy time: 25 minutes."

33508 performed, but no graftable arteries

My surgeon wants to report code 33508 for endoscopic harvest. He was unable to use the vein, because there were no graftable coronary arteries. He did perform 33427. Should I code for a discontinued CABG (33510-53)?

G0278

Some of our coders are conflicted on when it is appropriate to use code G0278. Is this for Medicare only, or is this meant for all carriers and used on the professional side as well as the technical?

Cardiac Ultrasound

One of my cardiologists desires to bill handheld echo exams as a "limited exam". After research, I have discovered this exam is included in the E&M. My physician states, "We will have to find out eventually what it takes to bill for handheld echo exams appropriately since the new devices: A) now allow storage of the images, and B) can perform all measurements needed for a limited echo exam documentation. Hence, I would see no reason why that is not possible. I'm anxious to hear what you find out." Please advise.

Medically Unlikely Edit Review

Our cardiologist performs EKGs in office, and our office bills code 93000 along with A4556 x 5 units. But currently a message appears for NCCI MUE... should this procedure (A4556) be billed along with the EKG if the provider owns the equipment? Or will it be inclusive? Also, under what circumstance can these two codes be billed as such?

Perisciatic space and scatic nerve injection CPT 64445

Is perisciatic space injecion the same code as sciatic nerve injection? "Right perisciatic steroid injection. We injected 40 mg kenalog 3 cc lidocaine into the right perisciatic space utilizing a 25 gauge needle in the posterior approach."

CPT 93286

When is it appropriate to report code 93286 or 93287? "This patient was brought to the facility for elective DC cardioversion for the diagnosis of persistent atrial fibrillation. After the patient was adequately sedated, transthoracic, synchronized, biphasic shock was used to successfully convert the patient to sinus rhythm (please refer to the Procedure Grid for details). The patient tolerated the procedure well with no complications. In summary, pre-op and post-op diagnoses were persistent atrial fibrillation with unsuccessful cardioversion of the above. This was attempted three times, without conversion. She did appear to organize to an atypical atrial flutter, which I tried to pace terminate with the pacemaker, which also was ineffective. I interrogated and reprogrammed the pacemaker with a more aggressive sensor setting (low threshold)." Would it be appropriate to report code 93286 with the cardioversion in this scenario?

Percutaneous paraspinal mass biopsy

CT-guided percutaneous biopsy of right paraspinal mass... Would I code as soft tissue biopsy (20206) or lung (32405)?

99211 with 93284

I'm wondering about appropriate usage of 99211 here. MA did brief HPI, no blood pressure taken, and a statement that a 93284 was performed. No report or interpretation. Can code 99211 be billed with 93284? It doesn't seem appropriate, even with the -25 modifier. 

Embolization of Segmental Left Hepatic Artery

I don't understand how to report catheterization of multiple segmental arteries of the left hepatic artery. Here is an example... The patient has HCC and presents for embolization. The OP report states: "Catheterization and arteriogram of segmental branch of the LHA and additional segmental branch. Also catheterization and arteriogram of segmental branch of replaced RHA. Embolization of both arteries was then performed." Am I correct to report 36247-LT, 36248-LT, 36247-RT, 37243? 

Transjugular Liver Biopsy

"The doctor was not able to biopsy liver, gained access in jugular vein, US done, access into IVC, access to right hepatic lobe. Wedge pressures obtained. Attempts made to biopsy, but could not because of a sharp 90 degree turn." I cannot report code 37200... I have 36011, because biopsy was not done. Or should I code 37200 with a -52 modifier?

Peripheral Selective 2nd Order Catheter Placement Clarification

I am in need of coding clarification in regards to peripheral coding from a right femoral artery access site. "Access placed in right femoral artery, and a catheter is advanced to the right common iliac artery for selective angiogram. Catheter is then withdrawn to the right external iliac for selective angiogram." Would it be appropriate to code for the 2nd order catheter placement in the right external iliac even though the access was from the right femoral artery?

ERCP with clearance of blood clots from bile duct

Patient had an ERCP with balloon sweep of the main bile duct, which removed air bubbles and old blood clots. Would air bubbles and blood clots be considered debris? Would 43264 be the correct code for this procedure? If not, what would?

Left Colic Branches

I have a report that says the IMA and its distal branches were selected. Then he gives findings of left colic and a branch for catheter placements. I get confused he went into the left colic and then a branch. Would it be 36246 and 36248, .r would it just be 36247?

Angioplasty in a failed AV fistula

What is the appropriate ICD-10-PCS coding for an angioplasty in a failed AV fistula?

Discharge or E/M visit code next day after Routine Afib ablation?

Patient has elective ablation and is kept overnight. Patient is stable and no complications. The physician wants to bill code 99214 for his follow-up visit the next day after ablation. The note reads like a discharge next day after routine ablation. The provider insists that because the procedure is a 000 global period he should be able to bill either a discharge or E/M follow-up code for the next day visit. My understanding is patient in bed after routine surgery with no complications means the provider cannot bill for an outpatient discharge the following day. I don't think it would be correct to bill an outpatient E/M the next day either, but I cannot find anything that supports this. Now I am confused! Please help! Patient is POS 22, and there was no order to admit to observation or inpatient.

Harvested Saphenous Vein Graft

If a physician harvests both saphenous vein and an artery graft and only ends up using the artery graft in the CABG, can you code/bill separately for the harvested saphenous vein graft that was not used? Or is this still considered bundled?

Closure Device (G0269)

For 2017 when is it appropriate to charge G0269 (placement of occlusive device)? Specifically, is it appropriate to charge G0269 when doing an aortogram with run-off (75625, 75716, 36245)? Also, do you know if there will be changes regarding G0269 in 2018?

Does a small bowel series equal 4 abdominal AP xrays?

Our surgeons want to order a small bowel series. Our radiologists would prefer that each KUB that is in the series be ordered individually, as the same radiologist is not always available to read. Is it appropriate/compliant to change 74000 x 4 into 74250??? If not, why not???

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