Knowledge Base

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Brachial approach/celiac artery stent placed

I would like to verify the cath placement for a stent placed in the celiac artery. The approach is left brachial to the aorta. An aortography was done as well as an arteriogram. I know these are both included, since both were previously done. From there the cath was placed in the celiac artery and a stent was placed. 

AVF arterial graft segment angioplasty

I have an op note that states there were stenoses at the "arterial graft segment" as well as the venous anastomosis and venous graft segment. These were all angioplastied, and I was instructed to submit only code 35476 because the "arterial graft segment" is considered venous and not arterial. The explanation was that the angioplasty has to be at the arterial anastomosis or peri- or juxta-anastomosis area to be coded as 35475. Can you please clarify this for me? I have never heard this rule before. ASDIN states, "The arterial anastomosis with the adjacent approximately 2 cm of artery (peri-arterial anastomotic region) is defined as the arterial portion of the access, and the entire remainder of the access is defined as the venous portion for coding purposes."

PD cath revisions

For the following example, should we report code 49325 only? "The abdomen was insufflated with CO2. A 5 mm port was placed in the LUQ. The previous cath was removed with dissection of the subcutaneous cuff and peritoneal cuff through the entry site in the abdominal wall. The catheter was removed after which a new catheter was placed through the infraumbilical incision There was also a large piece of fibrin which was in the previous peritoneal dialysis catheter which was lying over the bowel, and this was removed as well. The catheter was then placed through a puncture wound in the infraumbilical region, placed into the pelvis, and then tunneled and brought out next to the 5 mm port in the left upper quadrant. The abdomen was desufflated, and 1 liter of saline was advanced through the catheter with ease which returned easily on egress."

Q0 modifier on the device charge

Do you need to add the modifier -Q0 on the ICD device code also? Or just for the CPT procedure code?

Urology Procedures

The urology procedures are confusing me on the required documentation for 74420, 74430, 74450, and 74455. What is the difference in documentation we should look for to code these codes correctly? They all appear to be retrograde filling, but I never know what else to look for in the dictation. Here are a few examples: 1) Spot films from OR procedure cysto-stent. The injection shows double-J left ureter stent. Would you code 74430-26-52 here? 2) Technique: Patient was cathed (51600) and contrast injected retrograde. Small reflux in the right ureter. Right stent is seen; no ureter injury. Post void films show normal emptying (74430). Any help you can give would be greatly appreciated. I never know when to use code 74450.

Neuroembolization

Should code 75898 be used for follow-up angiography after coil is deployed prior to detachment, or should it only be coded for follow-up after coil detachment?

VA ECMO

We elected to place the patient on VA ECMO via the RFV and LFA using a 15 French cannula in the RFA and a 25 French cannula in the RFV. A 6 French sheath antegrade distal perfusion catheter was placed in the LFA. What CPT codes should I use?

Distal Aorta Angiogram

"The doctor places a cath in the distal aorta and takes an angiogram of the distal aorta and only images the iliac arteries bilaterally. Decision was made to intervene based on the findings, and bilateral kissing common iliac stents placed." Would I only bill codes 37221-50 and 75716-2659?

CT Myelogram

Exam ordered: CT myelogram lumbar spine. Documentation: Under fluoro guidance, a 22 gauge needle was inserted into the central canal without difficulty. I then injected 15 cc of Isovue 200 with good opacification of the central canal. The need is removed. Findings: Transpedicular interspinous fusion hardware noted at L5 - S1. Intrathecal contrast in satisfactory position. Impression: Lumbar myelogram without complication. The patient will be sent to the CT scan for additional imaging and will be dismissed from the hospital after the appropriate post procedural monitoring. Post lumbar myelogram CT performed and documented." In this scenario, should I report the following codes: 62284, 77003, and 72132?

Transcatheter perm occlusion or embolization

When coding for an embolization (61626 or 61624), and there was embolization in more the one vessel in the same territory, can you report code 75894 more than once?

JW Modifier

In your newsletter dated October 19, 2016, in Question/Answer #6 it states that the -JW modifier is not required for "drugs that are not separately payable, such as packaged OPPS drugs...".I cannot find that documented in the CMS Transmittal 3538 where it only states that the -JW modifier is not used on claims for CAP drugs and biologicals. Is there another document from CMS that states JW is not required for packaged OPPS drugs?

Intrahepatic Tract Emobolization

Should we code a balloon dilation in this case? And how should the intrahepatic tract embolization be coded? "A percutaneous transhepatic cholangiogram was performed. Due to the rapid passage of contrast through the duodenum, a 4 French Fogarty balloon was advanced through the sheath and inflated in the common hepatic duct to allow intrahepatic distention. A percutaneous transhepatic cholangiogram after this showed no evidence of dilated duct or filling defect. At this point, no further cholangiograms were attempted. The intrahepatic tract was embolized with two different 3 x 5.2 mm pushable coils. This was successful. Sterile was placed after hemostasis was achieved."

CPT for Direct Puncture for Embolization of Tonsilar Hemangioma

Would you use code 37241 or an unlisted code for the following procedure? "Sheath was inserted through mucosa of tonsil into central portion of hemangioma. Contrast was injected, showing amorphous vascular lakes. Physician then injected absolute alcohol slowly under digital roadmap imaging until radiopaque alcohol displaced collection with the hemangioma. Total of 3.5 mL of alcohol was injected."

Catheter Selectivity with LE Intervention

The AAPC had the following example: "Rt femoral arterial access, catheter advanced into the aorta, aortagram performed, catheter advanced in the Lt common femoral, imaging obtained. Stent placed in Rt common iliac." They indicate that you could bill catheter placement code 36246-59 for catheter placement in the lt common femoral. I thought catheter placement was bundled into the interventional codes... is the AAPC example incorrect? Or is catheter placement that is bundled into the LE interventional codes only for ipsilateral placement?

76937 Documentation (again)

I have numerous clients that document a permanent recording of the US image. Is it really necessary to document "evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry"? It seems redundant. May we report code 76937 with only image recoding documented? 99% of the physicians from various practices in the US only use this documentation.

10180 or 35860?

Patient had femoral embolectomy and returned for postop infection. Can you also give any guidance as to what is required for 35860 instead of 10180? "A 10 blade was used to incise the previous incision in the left groin. This was carried through the subcutaneous tissue with electrocautery. A large cavity of old hematoma was encountered. In order to completely evacuate the hematoma of the incision was extended distally. The majority of the cavity was unroofed. Once all gross hematoma was evacuated, the wound was copiously irrigated with normal saline. The area of necrotic skin was sharply debrided. Sharp debridement then continued to necrotic subcutaneous fat, muscle, and fascia. This was an excisional debridement of necrotic skin, subcutaneous tissue, muscle, and fascia measuring 100 cm2. Hemostasis of the subcutaneous tissue was then achieved with electrocautery. There was necrosis of some of the muscle fibers of the sartorius muscle. These were manually debrided. The wound was then packed..."

Transarterial Embolization

"Skull Base Glomus Tumor Embolization: The microcatheter was then advanced over a microguidewire into the vessels listed above that supplied the skull base glomus tumor.  Particles or coils were delivered as detailed above in materials or below in findings. Followup angiography was performed.Parotid Tumor EmbolizationThe microcatheter was then advanced over a microguidewire into the vessels listed above that supplied the parotid tumor.  Particles or coils were delivered as detailed above in materials or below in findings.VESSELS CATHETERIZED: Right common carotid artery, right internal carotid artery, right external carotid artery, right ascending pharyngeal artery, right occipital artery, stylomastoid branch, transmastoid branch, right posterior auricular artery, right middle meningeal artery, right transverse facial artery (masseteric branch), right posterior deep temporal artery, right femoral artery." Would this be reported as 61626 x 2?

Congenital LHC

The doctor performed a LHC only with coronary angiogram for ASD on a 4-year-old girl. However, I am not seeing a congenital code heart cath code for just a LHC only. I only see the RHC and the combination code for RHC and LHC. What code(s) should we use in this case where no RHC performed?

Shunt Series non vascular (for VP shunt malfunction)

Per imaging title "shunt series imaging done for possible ventriculoperitoneal shunt malfunction", imaging performed was frontal view of lower skull, neck, chest, abdomen, and pelvis, which was resulted all in one report. No contrast was given. Should this be coded as all separate x-rays (i.e., chest, abdomen, etc.), or should we use 75809? Again, no contrast was given.

-50 modifier on code 37221

When my physician performs a bilateral iliac stent placement, is it correct coding to append a -50 modifier to the procedure code (37221)? Or should it be -LT/-RT with a -59 modifier?

ICD-10-PCS, Open vs. Percutaneous

For ICD-10-PCS, we have differing opinions at our facility on the correct approach for procedures that are performed via a cutdown (i.e., AAA, TAVR, hybrid peripheral with endarterectomy followed by patch graft and then placement of a sheath through graft to perform a PTA of the popliteal artery, popliteal aneurysm repair with covered stent through common femoral cutdown). One opinion is that the cutdown is just the exposure of the vessel, but since it was not exposing the actual procedure site these are percutaneous procedures. The other opinion is since they opened the patient to the vessel these should be coded to the open approach. What are your thoughts?

Removing Tack Buttons

I'm having difficulty finding a code to match the procedure of removal of gastropexy T-tacks and three buttons, with fluoroscopic imaging of the G-tube. I think I can only report code 49465 (tube check, including imaging and contrast) because the buttons and T-tack (49460) are not obstructive, just causing the patient pain. Please advise.

Excision of AVF. Dx aneurysm of right arm dialysis AVF

How would you report this case (37607 or 35190)? "The patient was brought to the operating room and was placed in a comfortable supine position on the operating room table. The right upper extremity was sterilely prepped and draped. A longitudinal incision was made over the proximal portion of the arteriovenous fistula. This included an ellipse of skin that would also be excised with the fistula, removing redundant skin where the large aneurysmal segment was. Using a combination of electrocautery and scissor dissection, the cephalic vein was identified and dissected free. The vein was clamped and divided proximally, just beyond the arterial anastomosis. The proximal end was oversewn with a 2-layer running 5-0 Prolene closure. Distally, after excising approximately 10 cm of the fistula, the vein was clamped beyond the area of aneurysmal dilation and was divided. The distal end was suture ligated with a 2-0 silk suture. Wound was irrigated, and meticulous hemostasis was gained with electrocautery. The incision was then closed."

Left Arteriovenous Fistulogram with Central Venous Angioplasty

Please help; I'm very confused. I would like to know what codes to use for a left AV fistulogram with central venous angioplasty and left brachiocephalic arteriovenous fistula, surgical revision with flow reducing tapered plication of the AV anastomosis. "Patient with left upper arm brachiocephalic arteriovenous fistula with excessive pressure due to presumed venous stenosis and additional excessive arterial inflow. 54-year-old gentleman with longstanding history of end-stage renal disease on hemodialysis. He dialyzes via a left upper arm brachiocephalic arteriovenous fistula. He has undergone previous repair of an apparent bleeding pseudoaneurysm at an outside facility, but continues to have problems with dramatically swollen left upper extremity and wound breakdown at the previous surgical site. He comes to the operating room at this time for further evaluation and treatment as able."

Extracardiac Conduit Fenestration

How is closure of extracardiac conduit fenestration coded?

Cerebral Artery Thrombectomy

Cerebral artery thrombectomy bundles ipsilateral stent placement and angioplasty. What if the stent was placed in the C1 segment of the internal carotid artery in addition to cerebral artery thrombectomy?

Femoral Stent to Stop Bleeding

A patient had a TAVR procedure and had continued bleeding of the femoral artery, so a femoral artery stent was deployed. What code do I use for this service? I see that the CPT book states, "Codes 37220-37235 are to be used to describe lower extremity endovascular revascularization services performed for occlusive disease," so I know that these codes do not apply since the stent was deployed for hemostasis. Is this a billable service?

93656 and 93655

Would ablation codes 93656 and 93655 be appropriate for the following procedures? Procedures: 1. Comprehensive EP evaluation w/ attempted induction and ablation for atrial fibrillation. 2. Cavo-tricuspid valve isthmus ablation for atrial flutter. 3. Left atrial mapping. 4. Intracardiac 3-D mapping. 5. Programmed stimulation with and without IV drug infusion. 6. Intracardiac echocardiography. 7. Transseptal catheterization x 2.

Using a TAA graft limb to fix a slipped AAA endograft

My provider repaired a breach of an AAA endovascular repair that had migrated by using a thoracic endograft limb to cover the breach. He was not repairing a TAA, but he wants to use code 33881. I don't think that's appropriate, and I think we should use 34825 instead. Which is correct?

ICD 10 CM Code: Common iliac artery 100% occlusion

What ICD-CM code should be used to code occlusion of common iliac artery 100% prior to intervention. 

Thrombolysis Subsequent Day

We are on day 4 of thrombolysis. My understanding is that we can only have one subsequent day of infusion. Is this correct?

Peripheral in-stent stenosis, ICD-10

Could you please clarify use for peripheral stent stenosis ICD-10 T82.858A before 10/01/2016 and T82.856A after 10/01/2016? Report states chronic total in stent re-occlusion right popliteal artery (DOS 08/01/2016). We are thinking this is T82.858A. I read that IF progression of atherosclerosis is documented, we should use I70.201, etc. Otherwise, it should be coded as complication with the T codes. 

37242

Patient had coil embolization of a branch of the femoral circumflex and coil embolization of the posterior branch of the internal iliac artery. I would like to bill code 37242 x 2. Code 37242 states that it is done per surgical field. How do you know when it is the same surgical field?

62311 vs. 64483

When the physician does a lumbar/sacral transforaminal epidural injection, would we always use code 64483 based on the needle approach, or if he does a transforaminal approach and the needle is inserted into the epidural space rather than into the nerve root would it be coded 62311? The example below was ordered as an epidural injection in the S1 region not a nerve root block; however, the doctor can’t go in that way, so they use the transforaminal approach. "TECHNIQUE: Using fluoroscopic guidance, a 3.5" 22 gauge B-D needle was inserted percutaneously into the epidural space employing a left posterior S1 neuroforaminal approach. Needle position in the epidural space was confirmed by injecting approximately 1 cc of Isovue-M-300. Epidurogram shows craniocaudal, left-sided flow of contrast material. Betamethasone 6 mg/cc 1.5 cc was injected with preservative-free lidocaine 1% 1 cc and normal saline 1.5 cc. Injectate flowed cranially above the level of the L5-S1 disc. Partially concordant symptoms were produced during injection. images showed washout of..."

"Other Qualified Health Care Professional"

Starting in 2017 the moderate sedation symbol has been removed from the cath lab/EP procedures (including vascular), so I am wondering if we (the hospital) can now use codes 99156 and 99157 for those procedures if hospital cath lab/EP nurses are giving the sedation as ordered by the physician performing the procedure and monitoring the patient throughout that procedure. I am confused on the verbiage "other qualified health care professional" vs. "independent trained observer" in reference to a hospital cath lab/EP nurse.

CO2 Angiography and Contrast

If C02 is used for fistulogram instead of contrast, could I bill the C02 with either A9698 (non-radioactive contrast imaging material) or Q9968 (non-radioactive, non-contrast)? Are either of these codes appropriate for theC02?

MRCP

Is 3D a required element for an MRCP?

C-arm

Our group office recently installed a C-arm machine to help aid in spinal surgeries as well as musculoskeletal surgeries. In addition to the procedure code, what other code may use to indicate that a C-arm machine was utilized during the procedure? Should I add code 61783 for spinal surgeries and 20985 for musculoskeletal procedures?? I don't know if there is a better code than the above listed codes to describe the additional use of the x-ray image guidance. If so please advise on the procedure codes and the correct usage, and if any modifiers will need to be addended. I'm billing for the office. 

Q0 modifier on 33249

Is the -Q0 modifier still effective on 33249? Is there any situation when we should not append the -Q0 modifier to 33249? It is a clinical trial modifier. Do we need any other document such as registration to the trial, etc.?

Fluid Challenge

Patient has CHF. Right heart cath with fluid challenge done. Should 93463 be coded for the fluid challenge? What information needs to be documented to code 93463 for a fluid challenge? (Info that follows was copied from documentation.) "Fluid challenge of 250 mL bolus was performed. No improvement in cardiac output with fluid challenge. Notes: Post fluid challenge. PA: 28/12/16. PCW: 21/26/19. Thermo CO: 4.37 l/min. Thermo CI: 1.65 l/min/m2."

36221, 36252

The physician did selective left and right angiogram of renals, then did an aortic arch with findings that showed no significant stenosis, but tortuous corse. Can a selective (36252) and non-selective (36221) be billed together?

76882, Vascular vs. Non-Vascular

What is the appropriate coding when a complete bilateral duplex scan of extremity veins is being performed with spectral Doppler without color flow Doppler (93970-52)? 

Pacemaker Quick Look

I have a report for pacemaker interrogation from Medtronic for a quick look. The report says "quick look up" in the left hand upper corner. How do I code this?

Calcaneal Nerve Injection Coding

Can you please advise on how to code the following (Marcaine/Celestone Soluspan) injection? "Ultrasound-guided perineural injection medial calcaneal nerve at the right medial hindfoot."

Guidance Concerning Minimal Coronary Stenosis % Amenable to PTA or Stenting

Could you provide a link or point me in the right direction to locate CMS guidance on what percentage of a blockage in the coronary artery is considered too small in order for a PTA or stenting to be medically necessary?

S&I with lower angioplasty

"The left femoral artery was accessed under fluroscopic guidance with a micropuncture needle, wire, then sheath. A 4 French sheath was inserted over a wire. A wire, then catheter was inserted into the aorta. An aortoiliac arteriogram was performed. A bilateral lower extremity arteriogram was performed. The right iliac, then common femoral artery was selectively catheterized, and an arteriogram was performed. The right superficial femoral artery was selectively catheterized and angiography performed. Two severe stenoses were identified in the right popliteal artery, in the P1 and P2 segments. An up-and-over 5 French sheath was inserted over the wire into the right superficial femoral artery after 3000 units of intravenous heparin was administered and three minutes allowed to elapse. Balloon angioplasty of the right popliteal artery was performed using a 5 mm cutting balloon." How would you code the S&I: 75630 or 75625, 75716?

Attempted Access for Nephrsotomy Catheter Placement

"Fluoroscopy showed that a right double J ureteral stent was in place. Ultrasound showed that the collecting system was completely collapsed. The cephalad aspect of the stent could be seen. Following this, utilizing both ultrasound and fluoroscopic guidance with multiple oblique projections, attempts were made to enter the collecting system. However, this could not be accomplished, even when the pigtail of the double J stent was directly targeted. Intravenous countrast was administered; however, this resulted in no opacification of the right renal collecting system, whereas there was opacification of the left renal collecting system." Would we use unlisted code 53899 to report this?

Aspiration of Embolic Protection Filter

"An EmboShield filter is placed during a patient's lower extremity atherectomy/angioplasty. Completion angiogram reveals thrombus within the filter. The thrombus is aspirated, and the filter is removed." Is aspiration of an embolic protection filter considered part of the filter insertion and retrieval and therefore not codeable in CPT? Or can the aspiration be coded with 37186?

Drainage seroma spinal fixation hardware and sclerosis

What do you recommend for the following? "Under ultrasound guidance a 5 French Yueh was utilized to access the collection. An Amplatz 0.035 wire was introduced via the yueh needle and after dilatation with a 6 French dilator, an 8 French 35 cm length skater drain was placed and then sutured into place with 2-0 silk suture. After the drain was placed approximately 270 cc of dark yellow serous fluid was aspirated from the collection. Betadine was then introduced into the collection and the patient was scanned with CT. The Betadine was then aspirated and the cavity irrigated with normal saline. Then 20 cc of 2% lidocaine were introduced into the cavity for local anesthetic, prior to the subsequent sclerosis of the cavity with 60 cc of ethanol. The three-way stopcock was turned off to the patient allowing the ethanol to remain in situ for 30 minutes with the patient changing orientation every 10 minutes to allow uniform distribution of the sclerosant. The ethanol was then aspirated."

Intravascular Ultrasound

I was wondering if you have to bill intravascular ultrasound with code 36005, 36200, and 36245. We have a provider that billed codes 93454, 36225, 37252, and 37253, and we received a denial on codes 37252 and 37253 because we didn't have a primary code.

92941 vs. 92943

I need help determining the different documentation needs of codes 92941 and 9294.. Providers are clearly documenting the total occlusion when doing the stents, but not that the occlusion is chronic or acute. Sometimes there is an MI within the previous 4 weeks, and sometimes no MI is involved. I want to give appropriate feedback to providers of documentation needs to appropriately code these procedures.

Separate Access 36000

Would it be appropriate to report code 36000 in addition to 36569 in this scenario? "Utilizing ultrasound guidance, a 21 gauge micropuncture needle was advanced into the right arm vein. Through the needle, a 0.018 wire was placed. Over the wire, a peel-away introducer sheath was placed. Some resistance was felt in passing the wire centrally, and small contrast injection was performed, which demonstrated extravasation. A second micropuncture access of a right arm vein was performed. A 018 wire was passed, and a peel-away sheath was placed. Through the sheath, a 4 French, 41 cm double-lumen PICC line was advanced to the SVC/RA junction."

93228 vs. 93272

Will the monitor type determine the correct CPT code to bill? For example, would monitor type (LifeWatch ACT-3-Lead MCT) be considered code 93228 for the interpretation? Or is it 93272? I have confusion as to when to code as an event vs. an ACT.

Open thrombectomy AVF with open angioplasty/stent venous anastomosis

Which code(s) would you recommend for an open thrombectomy of right upper arm AV graft with an open angioplasty and stent placement for a tight stenosis at the venous outflow? "Patient had near complete thrombosis of AVG. A graftotomy was performed, and a Fogarty was used for thrombectomy of the arterial and venous limbs. A fistulogram was then performed, which demonstrated tight stenosis at the venous anastomosis. The stenosis was treated with balloon angioplasty and subsequent stent placement. Graftotomy was then repaired and wound closed in layers." Can we assign both codes 37238 and 36831? There is an NCCI edit that says code 36831 is a component of code 37238. Is thrombectomy included in code 37238?

Thrombectomy

"After attempted percutaneous thrombectomy, patient was taken to the OR emergently for open thrombectomy. Incision in distal popliteal artery on medial aspect of leg. Fresh clot retrieved from popliteal, anterior tibial, posterior tibial, and peroneal arteries (34203). Good backbleeding obtained from the anterior tibial and popliteal but not in the peroneal. Arteriotomy closed. Doppler signals in the anterior and posterior tibial and peroneal, but none noted in the foot. Diagnostic angiogram (75710-59) showed just before midcalf level anterior tibial artery is occluded, and there is no flow to the foot. Posterior tibial and peroneal not visualized. At this point an incision was made between the 1st and 2nd metatarsal. Small incision was made in the dorsalis pedis artery, and embolectomy catheter was advanced to the popliteal artery. Fair amount of clot in the anterior tibial artery removed and flow obtained. Despite multiple passes no backbleeding was obtained in the dorsalis pedis. Arteriotomy closed and a palpable pulse felt in the dorsalis pedis." Can I bill code 34203-76 since a new incision was made for the dorsalis pedis artery?

Severed radial artery with end-to-end anastomosis

What CPT code for severed radial artery with end-to-end anastomosis? "This patient arrived to hospital following a bow accident. The patient was induced under general endotracheal anesthesia. He was then prepped and draped sterilely following a tourniquet being placed on his right upper arm. In addition, his left lower leg was shaved and prepped and draped as well. A 7 cm incision was made over the radial artery and the radial artery was explored. It was found to be transected and thrombosed proximally and distally along with the radial vein. No major neural structures were found and no foreign bodies were visualized. The radial artery was then freed approximately 3 cm proximally and 3 cm distally to allow approximation of the artery without undue tension. Approximately 1 mm debridement was performed of the radial artery in the proximal and distal section due to necrotic and torn edges. The vessel was then spatulated proximally and distally. Interrupted 7-0 Prolene sutures were then utilized, following embolectomy of the distal segment. Flushing is performed, and the end-to-end anastomosis was completed."

Aneurysmal Bone Cyst Embolization Sclerosis

Please review and advise: "Ultrasound evaluation demonstrated increased cortex overlying the lesion. With a central area of thin cortex. Images were saved to PACS. Under ultrasound and fluoroscopic guidance, two 4 cm, 18-gauge needles were advanced into the lesion, from medial to lateral, criss-crossing into areas of bony lucency. Contrast was injected and digital subtraction imaging was performed. INTEROSSEOUS VENOGRAM FINDINGS: Contrast opacifies a lesion within the right scapula with several internal septations were noted. No venous outflow was observed. There is much less vascularity compared with prior studies. INTRAOSSEOUS ANEURYSMAL BONE CYST TUMOR EMBOLIZATION: 1 mL ethanol was slowly injected to promote thrombosis within the cavity wall. A emulsion of 1 mL ethiodol, 4 mL sotradecol, and 2 mL air was injected under fluoroscopic guidance. After a dwell time of ten minutes, the sotradecol emulsion was aspirated." What are your coding recommendations?

Intraperitoneal Tract Infection

Patient had an intraperitoneal dialysis catheter that became infected and was removed. The subcutaneous tract was also infected and was therefore excised and sent to pathology. What would we code for the excision of the subcutaneous tract?

Knee Arthrogram

I code for a hospital. The patient had an ultrasound-guided injection of contrast pre-arthrogram, plus a limited knee ultrasound. Would the appropriate codes be 27370, 76942, and 76882?

75898 Denial

My provider performed a difficult thrombectomy on a patient during 2015, when 37214 was still being used to code cerebrovascular thrombectomy. "After numerous attempts the thrombus was finally cleared. Two follow-up angiograms were performed to check if the thrombus had been fully cleared." United Healthcare is saying that they are only covering one. Where might we find the documentation to support the billing of this procedure twice that I may use in my second appeal? You mentioned in your webinar that I studied that "follow-up angiography and intra-vascular catheter exchange during thrombolysis are bundled with codes 37211-37214 (do not use 75898 for follow up)“. Codes 37211-37214 were not reported for this procedure. Codes that were included were: 37184, 36224, 36226, 36223, 36228, 36120, 75898 x 2, and 76377.

AAA Repair Open After Failed Percutaneous 34831

I'm not sure if I can code for the attempted endovascular AA repair or if I should code just the open AAA repair 34831. All work was done for the AA repair, but patient had what appeared to be a type 1A endoleak or type III, given the persistent filling of sac. Provider elected to abort the endovascular repair and perform an open AAA repair. Would it be correct to just code for the open repair?

93656 vs. 93653

Doctor did a previous pulmonary vein isolation (93656), and now they are going in for repeat ablation (billing 93656 again). However I thought it should be 93653. The SVC was isolated this time around, but not a pulmonary vein. “No pulmonary vein electrograms were noted in the pulmonary veins or in the posterior wall consistent with prior ablation with a box isolation with the majority of the left atrium with no viable electrograms. Three-dimensional electro-anatomical mapping of the right atrium revealed intact SVC potentials anteriorly. As this is often a cause of non-PV mediated trigger of atrial fibrillation high output pacing did not reveal any phrenic nerve capture radiofrequency ablation was placed at 20 W anteriorly which resulted in disconnection of the SVC."

MRI Perfuson Study

MRI brain perfusion studies are being requested, and the CPT code I see recommended is 76498. The MRI brain with contrast will be imaged; however, the department doesn't feel a brain with contrast should be charged due to the limited amount of brain images taken. We would like to stay away from an unlisted code if possible. What would you recommend for CPT coding of this procedure?

Cath Placement During an Embolization

When performing a CNS coil embolization, is it appropriate to bill for a catheter placement when an injection is not done?

Cone Beam CT

1) Is 76377 billable when done with theresphere planning? 2) This code requires a base radiology code. Is 76380 appropriate? 3) Is the following sufficient documentation? "Cone beam CT with 3D reconstructions were then performed. Post-processing was performed on an independent workstation." Or must the doctor state "concurrent supervision"? 4) Are 76377 and 76380 only billable once per session? 

Assistant Surgery

Are there any neuro-endovascular procedures that allow an assistant surgery?

93975 vs. 93978

Our physicians are documenting the following for an abdominal aorta duplex: "CONCLUSIONS: 1) Mild atherosclerosis of aorta demonstrated, no evidence of stenosis or aneurysm formation. 2) Patent IVC with unremarkable flow. Study Data-Mid abdominal aorta duplex evaluation. Complete study, duplex scan, and Doppler flow study including spectral analysis, color and gray scale imaging. A vascular evaluation was performed. Image quality was good. ARTERY MAPPING: Measurements of the suprarenal aorta, juxtarenal aorta, infrarenal aorta, right common iliac, left common iliac. FINDINGS: There is a mild atherosclerosis." Is the comment on the patency and flow of the IVC along with the comments on the abdominal aorta enough documentation to report this as a 93978? Are we looking for iliac vasculature documentation in order to report 93978? Does the lack of documentation of the iliac vasculature indicate we should report as 93975?

Doppler Studies

During an EP ablation for A-fib, if a provider uses ICE and Doppler, are there any restrictions with regards to coding for 93656, 93662, 93321, and 93325? The provider confirms no full TEE. Per NCCI, there are no bundling issues, but if a full TEE is not performed, are codes 93321 and 93325 billable without the primary 933XX codes? “The ICE catheter was removed from the 9 French sheath, and then deployed through the Agilis sheath for left atrial access. ICE was employed for a careful assessment of the left atrial appendage (imaging at a frequency of 11.5 MHz), during which no thrombus was identified, though 'smoke' was evident. Color flow and pulsed Doppler revealed low flow at the neck of the enlarged left atrial appendage <0.2 meters/second. ICE also was used to generate spatial shells depicting the left atrium and esophageal volume, in addition to the left atrial appendageal volume. The ICE catheter then was removed from the Agilis sheath, and redeployed via the 9 French femoral sheath to the right atrium for subsequent use in monitoring the patient's status.”

ICD-10-CM Question: No Significant Stenosis

What is the appropriate ICD-10-CM code? The patient has stenosis, but he determines it is not significant. Documentation states: "The patient has no significant stenosis in either carotid bifurcation region, clearly less than 50% stenosis with normal peak systolic flow velocities bilaterally." Can the stenosis code be assigned? What would the code be?

Multiple Liver Biopsies

If a physician performs a percutaneous liver biopsy on the left and right lobe of the liver under ultrasound guidance, can we bill for both biopsies (47000 x 2)? Or is it still considered one surgical site and only one biopsy is allowed during the procedure? If the reason for each biopsy in the left and right lobe is done for different diagnosis, could both biopsies be billed then?

Aborted Endovenous Laser Vein Abalation

We treat patients with great saphenous vein reflux on ultrasound with endovenous laser vein abalation. Lately a few cases the physician has had failed attempts for the wire after access to the vein. "With ultrasound guidance, attempts were made to cannulate the great saphenous vein below the knee and at the level of the knee and slightly above. Ultrasound indicated that the needle was in the vein, and the wire would not pass. The size of the vessel indicated that there is reflux, but unable to pass wire. After adequate amount of time trying, I elected to terminate the procedure." Patient declined any lidocaine for needle access, but the venous laser sterile procedure pack had been opened. Can we charge code 36478-74? If not, can we charge for the ultrasound (76937) and supplies( A4649)? Not sure if the HCPCS code is correct.

Resection venous malformations left forefoot

I was unable to find a code for resection venous malformations left forefoot, so I was considering to use unlisted code 37799. Would that be appropriate? Please help. "Complex venous malformation overlying the 1st metatarsal head. This is resected with tributary ligation at all points possible. There is no arterial component to the venous malformation. After an appropriate timeout procedure, the left foot was evaluated. A 4 cm long longitudinal skin incision was created over the dorsomedial aspect of the 1st metatarsal head down through the center of the region of venous malformation. A tedious dissection was carried through the subcuticular and subdermal tissues and very irregular, friable venous anatomy was carefully teased out of the trabecular tissue. The veins were traced back to normalization proximally, bilaterally, and distally, and feeding/draining branches were ligated with 4-0 silk ties. Dissection of the venous malformation at the medial and plantar aspect was more difficult as the venous dilations were more intimately intertwined with the trabecular connective tissue of the fat pad."

Attempted Thrombectomy

Would you bill the attempted thrombectomy with a modifier -53 or not at all pn the below scenarios? "First patient -I passed the 0.014 wire beyond the area and I used a 4-French Fogarty thrombectomy over the wire to try to do a thrombectomy. We did not extract anything. FINDINGS: Distal SFA and proximal popliteal thrombosis and restenosis, Second Patient -. Next, we removed the Impella catheter Left femoral artery Impella catheter removal and allowed the arteries to back bleed. no thrombus came out, so I used a #4 Fogarty catheter just to path it and make sure there was no thrombus lodged, and nothing came out. FINDINGS: Adequate arterial flow to the foot, no thrombosis of the iliac or femoral arteries, left thigh and calf muscles not responding to electrocautery; however, not grossly necrotic at this point."

Left-Sided Lead, Documentation

My question hinges upon the use of the phrase “left-sided lead”. "Indications: Infected pacemaker with need for AV nodal pacing backup AV sequential pacemaker was inserted in the right subclavian area with leads to the RT atrium and RT ventricle, next.... The left subclavian area then was exposed. After local, the preexisting pacemaker was explanted. Cultures were obtained. The preexisting left-sided lead had traction applied, and it was explanted easily. The pocket was then irrigated. The necrotic tissue was excised.” I coded 33233, 33208, then the lead removal with 33235, believing that a “left-sided lead” referred to a lead to the left ventricle, and thus a dual or multi-chamber device. Some think that code 33234 should be used, which would indicate a single chamber device. No other leads are removed or capped. Does “left-sided lead” always refer to a lead to the left ventricle, or can it refer to any lead implanted in the left chest?

Dual PPM upgrade to BiV PPM with LV port capped

Can you please provide the correct CPT codes for this procedure? "Planned upgrade of her existing dual chamber pacemaker to a biventricular pacemaker to prevent pacemaker mediated cardiomyopathy. An incision was made over the existing pulse generator and carried down to the pocket itself. The device was carefully removed. We then began working on left ventricular lead placement. We then spent the next hour and a half trying to engage this vessel using Whisper wire. It appeared the vessel had an anterior and directly inferior takeoff after tortuosity in the coronary sinus. After unsuccessful cannulation of this vessel, we decided to upgrade her existing pulse generator can to a biventricular pacemaker can and refer to CT surgery for an epicardial lead placement. The RV lead was quickly swapped over to the new device. Following this, the atrial lead was switched over and left ventricular lead port was capped. This was an uncomplicated yet unsuccessful attempt at an upgrade of an existing dual chamber pacemaker to biventricular pacemaker."

Denver Shunt Stripping

We have physicians wanting to bill code 36595 for stripping of the venous limb of a Denver shunt. Do you agree with this?

Pulling peritoneal catheter out - no incision

When a peritoneal dialysis catheter is removed only by pulling it out (no incision made), do you recommend submitting any CPT codes for that? "We then also applied gentle traction on his peritoneal dialysis catheter, and it released the two cuffs. A dressing was placed over the site, and the patient tolerated the procedure well."

EKG's performed in office & hospital need 25 mod with an E/M code?

We are discussing this in our office. When an EKG is done the same day as an office visit or hospital E/M level, do we need to add the -25 modifier to the E/M code? 

37236 vs. 34900 for Iliac Aneurysm

The physician placed an I cast covered stent and a Fluency Plus covered stent in the iliac artery for an aneurysm. Would this be reported with code 34900? And is a covered stent considered an endovascular graft?

TOF with PA and a transannular patch repair is done

Patient has tetralogy of Fallot with pulmonary atresia and has a transannular patch repair done. CPT code 33694 is for a patient who has TOF without pulmonary atresia. Would you recommend reporting code 33694 for this case, or would you go the unlisted route?

0281T Co-Surgeons Modifier Not Allowed

For Watchman procedure 0281T, modifier -62 is not allowed per our coding software. If two providers state they are co-surgeons, can this code be billed as 0281T without any co-surgeon modifier?

Repositioning of Biliary Catheter

Would you just code the cholangiogram (47531) and/or repositioning of biliary drain (47999)? "Procedure: Initial cholangiogram demonstrates contrast opacification of the duodenum with no significant intrahepatic biliary tree opacification. It was therefore decided to reposition the biliary drain catheter proximally. The catheter was pulled back with the tip at the level just distal to the biliary stent. Contrast opacification of the nondilated intrahepatic biliary ducts noted. There is no evidence of contrast leak. Catheter was then sutured to skin. Impression: Cholangiogram performed via existing biliary drainage catheter with repositioning of the catheter as above."

Atherectomy in the Medial Plantar Artery

Can I code for atherectomy/PTA of the medial plantar artery? I know the medial plantar artery is a continuation of the posterior tibial artery. Is it appropriate to assign it code 37229?

Occlusion of Enterocutaneous Fistula Track

"Under fluoroscopic guidance, access was obtained to the patient's fistula tract. The catheter was then placed within the bowel, and contrast injection confirmed position of the catheter within the bowel. Following this, flossing of the fistula tract was carried out. Following this, a bio design enterocutaneous fistula plug was introduced into the colon at the site of the fistula with the distal end of the device deployed within bowel in the plug traversing the fistula tract." Are codes 20500 and 76080 appropriate?

Epidural Injection with CT Guidance

I see CT-guided epidural injections all the time. In another question regarding fluoro-guided epidural injections, you quoted CMS in saying, “After considering comments received, we are finalizing CPT codes 62310, 62311, 62318, and 62319 as potentially misvalued, finalizing the proposed RVUs for these services, and prohibiting separate billing of image guidance in conjunction with these services.” I noticed it just says image guidance and does not specify what kind. Our pain management coder is telling me that only fluoro guidance is bundled, but that CT guidance is separately reportable. Is that true?

Peripheral Coding

Can you please clarify the appropriate CPT codes for these procedures? 1) Selective catheter placement in third order with selective placement in the left brachial, axillary, subclavian, and aorta with DSA imaging via left radial artery access. 2) Selective separate catheter placement in additional second order via right radial artery access in the right brachiocephalic and subclavian artery and DSA imaging. 3) Successful PTA and 8.0 x 37 and overlapping 8.0 x 57 stent to the left subclavian artery. 4) Successful PTA and 5.0 x 40 mm stent of the left brachial into the axillary artery in second arterial territory. 5) Thoracic aortogram.

Balloon Pericardiotomy

What code would you suggest for percutaneous balloon pericardiotomy?

Angio of the Deep Circumflex Artery

Recently I have come across two cases in which they accessed the deep circumflex iliac artery for an angiography: one case for a possible endo leak and the other was for a evaluation of the branch vessels directed towards the right paraspinous and retroperitoneal soft tissues. In both cases they were looking at the L4. For these types of cases what angio code would you recommend? 75705?

Retrograde Ureteral Stent Conduit

Do I report unlisted 53899 code for a ureteral stent placement via the ileal conduit?

Brachial Cutdown Not Involving AAA Repair

I have used code 34834 for a brachial artery cutdown for AAA repair. Can you please advise on what CPT code should be reported for cutdown of brachial artery for repair of SFA aneurysm with a VIABAHN stent?

Repositioning an Implantable LVAD

How would you code repositioning an implantable LVAD on a subsequent day? If unlisted, what do you feel is comparable (33393 for repositioning percutaneous VAD doesn't seem to reflect the complexity to me)? "I opened up her previous subxiphoid incision, exposed the actual outflow portion of the pump, and extended this to her inferior sternal and took out two sternal wires. I took out the previously placed external bolsters and repositioned the pump, and there was no change in her degree of pump malfunction. I did elect to cut the entirety of the bend relief around this pump site to relieve any potential kinking, and as soon as I did this and spread the xiphoid, her pump started functioning appropriately again. At this point, having repositioned this multiple times, I elected to make a small laparotomy to allow the pump to sit intraperitoneal, as well as the driveline, and at this point, I thought it best to also reapply the coupling device, which I did."

Periorbital Cystic Hygroma

I am wanting to code the below example with just code 37242. Is that correct? "Ultrasound evaluation of the right periorbital cystic hygroma was performed, and a permanent recording of the ultrasound image was saved to the patient`s medical record. Using sterile technique and under ultrasound guidance, a 19 gauge butterfly needle was inserted within the cystic hygroma. 3 cc of 3% Sotradecol solution were injected within the cystic hygroma. The Sotradecol was allowed to sit for approximately 10 minutes and was then aspirated from the hygroma. 3 cc of a mixture of doxycycline and contrast were then instilled within the cystic hygroma. This mixture contained 100 mg of doxycycline. Butterfly needle was removed and hemostasis obtained with manual compression."

Inquiry from the 2016 Updates Webinar re: IVUS, slides 64, 65 and 66

We need clarification for a MD, Slide 65 states, “Codes are per vessel imaged however only 1 code is reported for multiple contiguous vessel lesions (DVT eval from POP vein to IVC is reported as one IVUS)”. Slide 66, IVUS Case 71, states, “Venography shows DVT throughout the LE veins. Thrombectomy performed. IVUS of entire venous system on the LT from POP to IVC with findings described.” Coding indicated 37252 as the only IVUS code, no add-on code 37253. Our question: Is the IVUS only coded once IF a contiguous lesion is found crossing the vessels? Otherwise, if no lesion is identified, or separate lesions documented in the separate named vessels then each vessel is coded individually (initial vessel 37252 plus each additional vessel studied with 37253?) Ex: If the MD uses IVUS to view the TP tr, POP and SFA, documents findings in each vessel as separate lesions in each named vessel, would this be reported as 37252, 37253, 37253-59, although they are contiguous vessels? Since there is not a contiguous lesion documented can the IVUS be reported per vessel?

Bedside TQ Placement

An ICU patient needed a temporary Quinton placed for CVVHD and was too unstable to travel. The radiologist performed this procedure bedside, utilizing the cath lab staff, supplies, and ultrasound (properly documented). We feel that codes 36556 and 76937 are the appropriate charges for this procedure. However, our manager (who came from a different hospital system) is telling us that charging for this procedure is fraud because it is built into the ICU room charge. Can you help clarify what is appropriate to charge for these bedside procedures?

Removal of venous component of thrombosed upper extremity HeRO graft

"One of our patients had a thrombosed HeRO graft of the left internal jugular. The procedure started with removal of the venous component by our vascular surgeon. It was replaced with 16 French peel-away sheath. The interventional radiologist then tunneled a hemodialysis catheter from the left anterior chest wall to the left neck incison. The tip was positioned in the superior vena cava under fluoroscopic guidance. Catheter was then flushed and secured to the skin." Is this a co-surgery, and what code should we use? Or are there two separate codes, one for the vascular surgeon's removal and one for the interventional radiologist's placement of a tunneled left internal jugular hemodialysis catheter? And what would those codes be?

Transtelephonic Rhythm Strip Pacemaker Evaluation

We bill codes 93294 and 93296 for remote pacemaker interrogation along with codes 93295 and 93296 for remote ICD interrogation. Is there a tech charge that should be billed with 93293 for transtelephonic rhythm strip evaluation?

Stent Spanning the Lower Abdominal Aorta

I'm not sure the codes the physician is advising us to use are correct. He advises codes 37220-50 and 37236 for aortic stent. Code 37220 seems okay, but I'm unsure of the stenting code he has chosen. Your opinion would be greatly appreciated. Here is the dictation: "With great difficulty, angiographic catheter was maneuvered from each groin through the high-grade at lower abdominal aortic stenoses. Kissing balloon dilation was performed, dilating the lower aorta and proximal common iliac arteries bilaterally. A 40 x 12 mm stent was then deployed spanning the lower abdominal aorta. Completion angiography was then performed. Angio-Seal closure of each groin was performed after fluoroscopy revealed normal appearance of the distal common femoral arteries bilaterally."

Congenital heart cath with angiogram of the brachiocephalic

Should the following congenital heart cath be coded 93533 and 93567? Or 93531 and 36221? Would we need more documentation of the specific vessels visualized to submit code 36221? "Patient has a history of a large VSD, a PDA, LAD coronary artery to RV fistula. A catheter was advanced to the right heart, and a pressure and saturation sweep was performed. The Wedge catheter was also advanced across the atrial septum to the left lower pulmonary vein where pressures and saturations were recorded. A careful pullback from the LV to the descending aorta was performed using a Pigtail catheter. The catheter was placed in the aorta, and two angiograms were performed in the aortic root. Aortic Root: Two angiograms via the Pigtail catheter demonstrate the aortic root and left arch with normal brachiocephalic branching pattern. Both angiograms demonstrate the coronary artery branching patterns, without specific evidence of coronary artery fistula."

Modifier 78 vs. 79

Which modifier is more appropriate (-78 or -79) during a 90-day global period for dialysis procedures? Example: During initial visit patient's graft is thrombosed, and there is also a venous stenosis (36870, 35476, 75978). Patient returns several weeks later, and there is a recurrent stenosis (35476, 75978). Would you use modifier -78 or -79 on code 35476?

75710, 37221

"Abdominal aortogram with left lower extremity runoff. Cannulation of left radial artery using # 6 French slender sheath. Placement of a pigtail catheter in the abdominal aorta and performance of the left lower extremity runoff. Percutaneous transluminal angioplasty and intravascular stent placement in the left common iliac and external iliac artery. Selective left lower extremity angiography. Placement of a terumo band for closure of the left radial artery." What do you suggest we code? 

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