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Thoracic Duct Leak

How would you code a thoracic duct leak? "The radiologist performed bilateral lymph node injections in the groin area with Lipiodol. A guide wire was advanced into the thoracic duct, and the leak was embolized." How would I charge for the supply of Lipiodol used? Do you have any recommendations on HCPCS/revenue codes?

Cardiac Cath Documentation

I was wondering if there are specific requirements for what needs to be in the documentation of a cardiac cath. An outside resource disagrees with documentation requirements, and we are asking for your help to clarify. The physician includes the pre-procedure diagnosis, the findings and plan, contrast used, blood loss, fluro time, etc. This is an example of the main part of the procedure dictation: "Catheter: JACKY, JL4, PIG, 3DRC Sheaths: 5 FR, right radial artery Closure device: TR Band Dominance: right Pressures: Aorta: 136/75/101 LVEDP: 21 Coronaries: Left Main: Large caliber. Free of obstructive disease. LAD: Heavy proximal calcified plaque but no significant obstructive disease. Moderate caliber Diagonal. Free of obstructive disease. LCX: Moderate caliber, nondominant LCx. Moderate caliber OM. Free of obstructive disease. RCA: Moderate/large caliber. Dominant. No obstuctive disease. Moderate caliber PDA. Free of disease LVG: EF: 65% Findings: Calcified but nonobstructive coronary atherosclerosis Normal LV systolic function. EF 65% Mildly elevated LVEDP."

Endurant IIs

Would you still use code 34802 for the Endurant IIs for AAA repair?

Prevention of Atrial Flutter

"Patient had ablation for atrial fibrillation with ICE, 3D mapping (93656, 93662, 93613). The subeustachian isthmus was then ablated for prevention of right atrial flutter." Can we also report code 93655? Patient did not have flutter in history; this was simply preventative.

Anti-Embolic Protection Filter Wire Lower Extremity

Patient undergoes lower extremity endovascular revascularization for arterial occlusive disease (angioplasty and atherectomy) of the popliteal artery. A left popliteal anti-embolic protection filter wire (4 mm Spiderx EV3) is placed via right common femoral artery approach. For PCS I coded as 04HNDZ. However, I could not find an appropriate CPT code or CPT coding guidelines.

Debridement of AV Fistula

"For an area of infection in midpoint of AV fistula, incision was fashioned proximally over basilic vein and of distal basilic vein. The vein was dissected free. Once dissected free it was clamped proximally and distally at the arterial limb of basilic vein, divided, and oversewn with sutures. Then ligated the venous outflow tract to prevent back bleeding. Wound irrigated and closed in layers with sutures. Attention was turned to midpoint of fistula, where obvious infection was. An elliptical incision was fashioned and deepened down to the skin and subcutaneous tissue. The anterior wall of the fistula was completely resected involving the area of obvious infection. Was irrigated and sutured." Is this enough documentation to only use code 36832 as a fistula revision, or should this be reported with codes 37607 and 37799?

Entrapment of Percutaeous Wires

Patient had a CTO done and the wires became stuck. It was stuck entering the left common femoral artery, traveling through the heart, and exiting the right common femoral artery. Surgeon was called to do coronary bypass (saphenous vein taken from left thigh and internal mammary), extraction of the wires, and repair of the left femoral artery. The codes I came up with so far are 33533, 33517, and 35226, but I'm not sure about the wire extraction. Can you help me with this?

Selective Coding

If you selected and imaged the left common iliac from the right common femoral and then backed out to select and image the superior mesenteric artery, would you report code 36246 for the iliac and code 36245 for the mesenteric?

Cerebral Stent

Is there a CPT code for removal of a migrated microcoil stent from the middle cerebral artery?

Catheterization of Occipital Artery

During a cerebral angiogram the provider documented that he selectively catheterized the following arteries: left vertebral, left common carotid, left internal carotid, left external carotid, left occipital, right common carotid, right internal carotid, and right external carotid. My codes so far are 36224-50, 36227-50, and 36226. Is there a code for the selective catheterization (and imaging) of the left occipital artery? It is my understanding that it is a branch of the left external carotid.

Carotid Angio and MobiusHD Implant

What CPT codes do you recommend for this procedure? "The patient presented to the cath lab for resistant hypertension. Sheath was inserted into the right femoral artery. Angiography was performed in the right femoral artery. The 5 French Bernstein catheter was positioned into the right CCA. Angiography was performed in the right CCA. MobiusHD size B 6.25-8 mm was inserted into the right internal carotid artery. Angio performed in right internal carotid artery. MobiusHD deployed in right internal carotid artery. Post angiography was performed in the right CCA. Sheath was removed. Diagnostic: Intracerebral Arteries: The right intracerebral arteries are normal. Carotid Artery: The right bifurcation of the carotid is normal. Right Common Carotid Artery: The right CCA is normal. Summary/Post-Operative Diagnosis: The device was successfully deployed in the right carotid bulb. Position of deployment confirmed angiographically."

Percentages on Coronary Angiogram

We are wondering if the below documentation is enough to bill out a coronary angiogram. Or do we need to have documentation that the provider selected the coronary arteries? "Left circumflex: The left circumflex is a large but non-dominant vessel. This vessel gives off a large prominent obtuse marginal with multiple sub-branches. This vessel is calcified. There is a proximal stenosis of 90% in the AV groove portion of the vessel prior to the takeoff of any branches. The obtuse marginal is diffusely diseased with a 70% stenosis in the distal portion of the obtuse marginal main branch. An upper tertiary branch of that obtuse marginal, which is distal, has an ostial stenosis of 80%. There is diffuse distal disease. A more proximal branch of this obtuse marginal has an ostial stenosis of 80%."

Aortic Angioplasty of Two Separate Areas

If aortic angioplasty for ascending aortic stenosis was performed, as well as angioplasty for coarctation at the aortic isthmus, can I report codes 35476 and 75978 twice? Is billing per vessel or per lesion in this case?

Revision/re-do fem-pop bypass

"The patient had a previous fem-pop bypass using an in situ vein. He has now developed a tight stenosis in the segment of the vein from the knee down into the anastomosis and has had two catheter interventions, so that part is pretty much stented all the way into the native artery. Decision is made to revise this with a new bypass from the old bypass down onto the native posterior tibial artery. Cephalic vein is harvested for the bypass." We are unsure how to code the new bypass that is attached to the old (fem-pop) bypass down onto the native posterior tibial. Revision or new bypass? Can you please help with the codes?

IABP Placement at Same Session as Removal

Is it appropriate to code intra-aortic balloon during a cardiac catheterization and/or PTCA when the balloon is inserted and removed during the procedure?

TAVR with Insertion of Intra-Aortic Balloon Assist Device

Can code 33967 (insertion of intra-aortic balloon device) be billed with code 33361 (TAVR procedures)? "Through the 18 French left femoral sheath, an al1 diagnostic catheter was advanced into the ascending aorta. After wire exchange, a straight wire was advanced across the aortic valve into the left ventricular chamber. Catheter was advanced and again exchanged over a J wire for a pigtail catheter. Simultaneous pressures were then measured and hemodynamics were summarized. An Amplatz super stiff wire with its distal tip coiled was then advanced through the pigtail catheter positioned optimally in the left ventricular apex. An 18 x 40 z Med II balloon was then advanced across the aortic valve orifice, and, during rapid pacing at 160 paces per minute, the balooon was inflated to nominal dimensions. Balloon was deflated. Pacing was terminated, and the patient tolerated the procedure well. Balloon was removed in favor of corevalve transcath aortic valve implant advanced across the valve."

Cerebral Vasospasm 61650

Per the CPT Codebook, code 61650 is for the prolonged therapeutic administration of non-thrombolytic agents of at least 10 minutes continuous or intermittent duration. Is there authoritative guidance from the AMA or SIR on how to code when the duration is less than 10 minutes?

Tunneled Catheter Exchange via Same Access

For purposes of catheter exchange, is "same venous access" considered same vein (RIJ to RIJ)? If catheter is removed from RIJ and inserted in RIJ but with creation of new tunnel/exit site, does that make it a removal/insertion since it is not the same "entry site"? I have a physician disagreeing with me and just want clarification if possible.

Intracranial Thrombectomy Territories

My doctor selected the left vertebral and then accessed the basilar trunk and performed thrombectomies within the left basilar trunk and PCA. My reference states that the PCA is part of the left carotid territory. If the PCA is accessed like it is a branch off of the basilar artery, is it coded as the vertebro-basilar territory? Or is it appropriate to code thrombectomies for both the left vertebro-basilar and left carotid territories?

Cholecystostomy Tube Check and Removal

I've been using the new biliary tube check code 47531 as shown on page 395 of your Interventional Radiology Coding Reference for cholecystostomy tube checks. However, if the cholecystostomy tube is removed after the check, should I report code 47537? The example states (no code, watch for errata), but I do not see a errata listed on the website either. So, has there been further discussion on the new biliary tube removal code? And would I use it in this case, or just code it as a biliary tube check?

Cardioversion with Chemical IV Push

On the facility side, should code 96374 (IV push, single or initial substance/drug) be reported along with a cardioversion? In this particular case, Covert was administered.

VATS for Drainage of Pleural Effusion

What is the correct CPT code for VATS for drainage of pleural effusion? I've been using CPT code 32653. One of my co-workers disagrees because she thinks that pleural effusion is not foreign body. What are your thoughts?

Repositioning of an IABP

Our physician performed an IABP reposition. What is the appropriate CPT code to use? I only find one listed for VAD repositioning.

Access Billing with EVAR

I am new to cardiovascular interventional coding. Do you lose catheter access code 36200 when you perform a cutdown? Also, what type of dictation indications will lead me to choose the cutdown access code 34812?

Complications Following Fem-Pop Bypass

My question is related to post-operative care. Patient has fem-pop bypass IH and develops post-op hemorrhagic shock and acute respiratory failure on days 2, 3, and 4. Are these visits billable, or are they considered complications of the surgery?

Varicose Veins of the Lower Extremity

Assuming our patient meets medical necessity guidelines, can we can bill codes 36478 and 36479 for the perforators and tributary veins, in the same session/encounter, when treated in the same extremity through separate access sites? Procedure example: “Endovenous laser ablation treatment of 3.5 cm of the anterior division tributary, proximal to mid shin; 3.5 cm of the small saphenous vein (SSV), popliteal fossa to distal calf; 3.5 cm of the intersaphenous vein, postero-medial mid calf; 5.0 cm of the superficial accessory great saphenous vein (SA-GSV) proximal calf; and 2.5 cm of the lateral accessory small saphenous vein (LA-SSV), distal calf.”

37607 vs. 37799

I know that code 36832 is for revision. What code is appropriate for excision of AV graft/fistula that was created for dialysis? This graft/fistula is not infected, so I feel that code 35903 is not correct.

Axilla to Axilla AV graft

Is there a specific CPT code for creation of an axillary to axillary AV graft for dialysis?

Exchange of Biliary Catheter for Stent to Assist Endoscopist

"INDICATION: Patient has a benign biliary stricture status post Whipple procedure. Serial angioplasty and upsizing of external biliary drainage catheters have been unsuccessful in obtaining appropriate biliary drainage. Therefore, decision was made to place a metallic internal biliary stent for gastroenterology to manage with future EGD. The patient's indwelling biliary drainage catheter was prepped and draped in normal sterile fashion. The catheter was cut and wire was advanced into the jejunum. A 9 French sheath was advanced into the distal common bile duct and cholangiogram was performed, identifying the region of stenosis and landing zone for a stent. Next, a 4 cm x 10 mm covered biliary stent was deployed across the anastomotic stenosis. Follow-up cholangiogram showed excellent flow into the bowel." Would this be reported with code 47541, 47537, or 47538? It's not a new access so we're thinking about 47537/47538, but we are confused about those two codes.

Q0 and NCT Number for ICDs

For hospital billing, do ICD generator change-outs need the -Q0 modifier applied to the CPT/Claim? Does the rule that the -Q0 is applied only on cases meeting primary prevention status still apply? Or should the -Q0 modifier be applied to all cases, primary or secondary, because data is being collected on them via the ICD registry?

Oral/Rectal Contrast with Q9963 and Q9966

We occasionally use Gastrografin or Omnipaque for oral and rectal contrast instead of Barium. Can we report the appropriate HCPCS code (Q9963 or Q9966) when contrast is administered orally and/or rectally?

Unsuccessful Upgrade

The intended procedure was a dual chamber ICD upgrade to biventricular ICD. However, after to several attempts, the CS lead placement was abandoned, the same generator was kept, and the RA/RV leads were put back in. No DFT testing was done. My physician spent several hours on this case. Would I code the attempted procedure as aborted with codes 33264-53 and 33225-25?

Intravascular Ultrasound (Non-Coronary Vessel)

I know that code 37252 is an add-on code, but I would like to verify if it is allowed to be billed with codes 36215, 75605-26, 75710-26. A stent was going to be placed, but there was not one long enough, so no intervention was done. My system is telling me I can't bill code 37252 since there is not a code for it to go with in this transaction. I don't see this a lot. Also, a filter was placed, but it was retrieved, so can I report code 37197 for this?

Nerve Block with Embo

In the 2016 Interventional Radiology Coding Reference, on page 546, coding instruction #7, you state that a nerve block for post-operative pain control is billable unless it's through an existing catheter. There is an NCCI edit stating you can't bill codes 37243 and 64517 together or use a modifier. Can code 64517 be billed after 37243 for uterine artery embolization in this case? 

FFR and IVUS Billing

Is the -26 modifier applicable to codes 93571/93572 or 92978/92979? We are getting denials, and the finance committee insists it has to be billed with the -26 modifier.

Transcatheter Tricuspid Valve Implantation

Would transcatheter tricuspid valve implantation be coded as unlisted (33999), or is there a better code for this procedure?

PCS Basilic Vein Graft Transferred

Procedure:Left Common femoral to posterior tibial bypass using the greater saphenous vein and right basilic vein. During repair with the saphenous vein there was insufficient material so the basilic vein was excised to lengthen the remainder of the graft. We are stuck with this portion, and initially went with 04RS07Z (the "replacement" is the quandary). Whatever input you may offer is greatly appreciated!

Stenting Right Inferior Gluteal and Superior Gluteal Artery

How would you code this procedure? "Indication: PVD with hip claudication and inferior/superior gluteal artery stenosis. Procedure: Selective internal iliac angiography, PTA, and stenting of both the inferior gluteal artery and superior gluteal artery." Would you utilize the iliac revascularization codes 37221 and 37223? Or would you use codes 37236 and 37237 with the catheter selection codes?

Venogram of the Pulmonary Vein

What CPT code would I use for venogram of the pulmonary vein? "A 7 French Goodale catheter was advanced into the left atrium, and the superior branch of the left lower pulmonary vein was relatively easily accessed with a 0.018 Thruway wire. The GL catheter could not be advanced due to the severe stenosis and was exchanged for a 4 French glide catheter. A hand injection venogram over the wire demonstrated severe stenosis with essentially complete occlusion of the origin by the 4 French catheter and a severely hypoplastic superior branch of the left lower pulmonary vein measuring 3.2 mm in diameter. Balloon dilation of this branch was performed with a 4 mm savvy balloon followed by a 5 mm savvy balloon to 8 ATM, and post-dilation venogram demonstrated no residual stenosis."

Scout Film/Spot Film

I am looking for a firm answer on whether a scout film or spot film includes fluoroscopy. In a case where only a scout/spot film is done, is it appropriate to bill code 76000? According to Dorland’s medical dictionary: spot film, a radiograph of a small anatomic area obtained either by rapid exposure during fluoroscopy to provide a permanent record of a transiently observed abnormality, or by limitation of radiation passing through the area to improve definition and detail of the image produced. 

Sphenopalatine Ganglion Block Delivered Intranasally

We have a physician who would like to perform a sphenopalatine ganglion block delivered intranasally under fluoroscopic guidance for patients with migraines. How would this be coded? I found a CPT Assistant article from July 2014 suggesting 64999 as the only reportable code, but the vendor is recommending codes 64505 and 77002 be reported. Any guidance you can provide would be greatly appreciated.

Genicular RFA

There is a CPT Assistant article that addresses a genicular nerve block. Briefly, it states that if the superior medial and lateral branches and the inferior medial branches of the genicular nerve are blocked that code 64450 is only reported one time rather than times three. Does this guideline hold true if RFA is done of the same branches of the genicular nerve as well? That it is only coded one time rather than three times?

Duplex Doppler Studies 93975/93976

Can you please explain the documentation requirements for codes 93975/93976 as it pertains to gray scale imaging, spectral analysis, and color flow? Most ultrasounds are 2D imaging. Is it required that the radiologists dictate all three?

ER Thoracotomy with Aortic Clamp

Patient had multiple gunshot wounds to the abdomen. He received emergency thoracotomy in the ER where they clamped the aorta. He was then taken to the OR and had experimental lap. Is there a code to bill for the emergency thoracotomy and clamp in ER? We found 32110, but in the details it says it is for actual repair of bleed not just control to.

Parathyroid Venous Sampling

I received the following report, and I'm not sure if I should only report codes 36500 (x 2) and 75893 (x 2). "Technique: Right common femoral vein accessed under UL guidance. Using a combination of a glide cath and H1 cath, multiple bilateral veins were cannulated and blood was withdrawn in multiple locations and sent for PTH testing. Venography was performed at each location to confirm cath placement. Once the samples were obtained, the catheters were removed. Findings: Bilateral IJ, subclavian veins as well as the vena cava and azygos vein are widely patent. There is cross collateral filling from the external jugular vein to the contralateral side. Results: RT atrium 42.1, SVC 67.4, Azygos 40.2, distal left brachiocephal 42.5, cent left brachiocephalic 81.3, left subclavian vein 56.4, left IJ 56.4, right internal jugular 52.7, left superior intercostal 62.8, left inferior thyroid 57.8, etc… Impression: Uncomplicated parathyroid venous sampling. The results do not clearly localize to a specific site."

Stent Graft Placement for Thoracic Aorta Stenosis

Procedure was performed percutaneously, and a Gore TAG 31 mm x 26 mm TEVAR stent graft was deployed and centered at T10, well away from the left subclavian artery. Procedure was for thoracic aorta stenosis and not an aneurysm. The physician wants to bill codes 33881, 75957, 36200, 37252, and 75945. Do you agree with the physician's codes, or would code 37236 be more appropriate code for stent placement? 

Subclavian Artery Conduit for Endo AAA

Is there a code for creation of a subclavian artery conduit when performed for endo AAA repair? My physicians usually access bilateral CFAs, but will sometimes create a subclavian conduit for access. Is there a separate code when this is performed?

Drug-Coated Ballons

When doing an angioplasty with drug-coated balloons, do you bill the procedure as an angioplasty or as an atherectomy?

Procainamide Challenge Testing

Our physicians have been submitting add-on code 93623 when using a drug called Procainamide for the following situations: 1) to assess if someone has Brugada pattern ECG, 2) to assess for conduction system disease, which is pretty rare nowadays. There are two ways to perform Procainamide challenge for diagnosing Brugada disease: 1) in the lab after doing an EP study with catheters, 2) in the lab as a stand-alone procedure where patient is infused with the drug and serial ECGs are done for about 20 minutes (in that case, no catheters are inserted; it is simply an IV drug infusion with blood pressure monitoring and continuous ECG monitoring). Is code 93623 appropriate? I've found information that advises that if these tests are IV infusion and when performed in the hospital the infusion is not separately billable and we could only bill for the ECG interp and report separately. Is this correct?

Angioplasty and Stent of the Left Subclavian Artery Origin

"We then accessed the anterior wall of the artery with a micropuncture needle and wire, then up-sized it to a 5 French sheath using modified Seldinger technique. We then used a Glidewire and Quick-Cross catheter to cross the critical lesion at the origin of the subclavian artery and made our way into the ascending arch of the aorta. We then pre-dilated this area with a 5 mm angioplasty balloon so that we could deliver the pigtail catheter and later the stent. We angioplastied the area of critical stenosis with a 5 x 20 mm balloon with the inflation taken up to 8 atmospheres and left up for 1 minute. We then advanced the pigtail catheter over the wire and positioned it in the proximal ascending aorta and hooked it up for power injection angiography. We then advanced a 6 x 45 cm destination sheath across the lesion into the arch of the aorta, and then delivered a 6 x 22 mm iCAST stent through the sheath and then un-sheathed the stent. We then expanded the stent in the location of of the critical stenosis." Are codes 37236, 36215, and 75710 appropriate?

36217 with 75710

"INDICATION FOR PROCEDURE: Right upper extremity pain and pulselessness with evidence of occlusion of the right axillary artery on Doppler. PROCEDURES PERFORMED: 1) Right femoral arterial access. 2) Right axillary artery angiogram. PROCEDURE TECHNIQUE AND ANGIOGRAPHIC FINDINGS: After informed consent, the patient was brought to the cardiac cath lab and was placed in a supine position. The right femoral artery was accessed, and a 6 French sheath was advanced. A 6 French multipurpose catheter was then advanced into the brachiocephalic trunk and then selectively into the right subclavian artery and then pushed into the right axillary artery. Right axillary angiogram was done after that. The angiogram showed total occlusion of the right axillary artery with a large amount of thrombus and a very faint collateral circulation with very slow flow distal to the occlusion." The fee sheet says 36217 with 75710. Is this correct?

Thrombosed AV Access in Lower Extremity

Patient had thrombosed AV graft for dialysis in lower extremity. She underwent thrombectomy of AV graft, fistulogram, angioplasty of arterial anastomosis of the femoral artery with 6 x 4 Conquest, angioplasty of femoral vein with 8 x 8 balloon, and bilateral upper extremity venogram to assess veins for future AV graft placement. I would report codes 36870, 36147, and 36148. Should I code arterial or venous angioplasty? Also, what codes would I use for bilateral upper extremity venogram?

Pulmonary Valvuloplasty and Angioplasty

I am in disagreement with the physician on this one. I am thinking either code 92990 or 92997, but not both. He is thinking both. What would you code? "4 French Glide catheter was exchanged for an 8 mm x 3 cm Tyshak-II balloon dilation catheter, which was advanced and positioned across the pulmonary valve, supravalvar narrowing, and proximal right pulmonary artery, where it was inflated on one occasion with a trivial residual waist at the supravalvar main pulmonary artery narrowing and persistence of a waist at the proximal right pulmonary artery."

LE Intervention, CPT and PCS

Do we have the same guidelines with CPT? Need help on CPT and PCS. "Ischemic right foot ulceration with arterial occlusive disease. History of prior left left revascularization, gangrene, and foot salvage. Procedures performed: Abdominal aortoiliac angiogram and right left runoff via left common femoral artery approach. Selective right common femoral artery angiography and right leg doralis pedis artery angiography. Percutaneous right leg superficial femoral artery and above-knee popliteal artery atherectomy (SXC Turbohawk). Percutaneous right leg superficial femoral artery and above-knee popliteal artery cutting balloon angioplasty (4 mm x 6 cm VascuTrak Bard balloon. Percutaneous right leg anterior tibial artery and dorsalis pedis artery atherectomy (EXL SilverHawk and SXC TurboHawk). Percutaneous right leg anterior tibial artery and dorsalis pedis artery cutting balloon angioplasty (2.5 mm x 10 cm VascuTrak Bard balloon). Left femoral retrograde, angiography with interpretation and supervision of direct fluoroscopy, radiography, and intervention. Total contrast volume used: 60 mL of diluted Visipaque."

Biopsy in the Office with Patient Observation by Physician and Nurse

When we perform a liver biopsy in the office (POS 11), can we charge separately for the 4+ hours that the patient is being monitored by the physician and RN? If so, what CPT code?

Cutting Balloon: Angioplasty vs. Atherectomy

The patient has an indwelling subclavian and axillary vein stent with thrombosis. The physician ballooned the area with a cutting balloon. Would this be considered angioplasty or atherectomy?

Angioplasty of the Iliac with the Sheath

Can we bill code 37220 for an angioplasty of the iliac artery with the sheath? I don't think so, but I just wanted to double-check because the CPT description does not use the word "balloon".

UGI Contrast Injected

If during a UGI the contrast is injected through the PEG tube and there is no visualization of the esophagus, is there a reduced charge? Or can we report code 74241? Reason for exam was gastric distention. "240 cc of Gastrografin water-soluble contrast was injected through the patient's gastrostomy tube. Impression: Unremarkable upper GI series. The stomach is normal in morphology. No gastric outlet obstruction or leak."

Removal of Left arterial A-line in Femoral Graft Under Fluoroscopic Guidance

What is the best code to report this procedure? "The patient underwent prior lytic treatment. Because of the elevated ACTs, we elected to remove her left groin arterial access catheter in the operating room for definitive closure. In the operating room, following induction of anesthesia, the patient's left groin line was prepped and draped in the usual sterile fashion. First using fluoroscopy, we demonstrated that there was a good arterial flow through the left external iliac to profunda femoral bypass graft, which there was. We then used a closure device to assist with closure. A 5 French sheath Exoseal device was advanced through the catheter and drawn back and then used to assist closure of the 5 French sheath. Manual compression was held until adequate hemostasis was achieved. The patient otherwise tolerated the procedure well, and a sterile dressing was applied. She was returned to the recovery area in good condition."

IABP in Different Sites

A patient came into the cath lab with an existing IABP via the left CFA. The existing IABP is removed from the left CFA, and a new IABP is inserted via the left axillary artery. Can we bill codes 33967 and 33968 for the removal of the left CFA IABP and the insertion of the left axillary IABP? This was the same session, but different sites.

Aortogram with Bilateral Lower Extremity Run-off

I have coded aortogram with bilateral lower extremity run-off as 36200, 75625-26, and 75716-26. Lately our Medicaid Carrier has been denying code 36200 for procedure and modifier restriction. Am I missing something? 

Nephroureteral stent versus nephroureteral catheter

What is the difference between a nephroureteral stent versus a nephroureteral catheter? They seem like the same thing. Is the stent purely internal and the catheter has tubing that also drains to the outside? So when would I use CPT code 50433 versus codes 50693-50695?

Port-a-cath Repair vs. Revision

"Patient had a port-a-cath inserted last week. It was not functioning properly. On flouroscopic exam they notice a kink in tubing. They took her back to the OR and to release two adhesive bands. Then the port sat well." Do I code the release of the bands? Surgeon is saying 36576, but we didn't repair the port-a-cath. What are your thoughts?

Multiple Units 75898

Is it possible to bill multiple units of 75898? I see the MUE is 2, but are there circumstances that would allow this code to be billed upwards of 13 times? These are cerebral embolization cases.


With the new code 61645, is all of this inclusive? "Mechanical/aspiration thrombectomy: A coaxial Reperfusion catheter, microcatheter, and microwire were taken to the lacerum portion of the left internal carotid artery. Then, the microcatheter and the microwire were advanced to the left M1 segment of the MCA. A Solitaire device was advanced in the M1 trunk of the left middle cerebral artery, using roadmap and fluoroscopic guidance. Control angiography was performed. The Solitaire device was then deployed within the M1 segment and was left in place for about 5 minutes. Then, under continuous suction the Solitaire device was removed from the system. This process was repeated for the thrombus within the inferior M2 division of the left MCA. Intra-arterial infusion of thrombolytic: Small thrombi remained in the distal left inferior M2 and left ACA, which were treated with 10 mg of intra-arterial tPA from the left ICA. The total duration of infusion was less than 10 minutes. Vessels catheterized and angiogrammed: Left CCA, left ICA, left MCA M2 segment, right common femoral artery.

Thrombosis in saphenous vein graft in earlier CABG

Patient underwent CABG, and later in the ICU it was noticed the saphenous vein graft was thrombosed. 1) Re-exploration of mediastinum. 2) Initiation of cardiopulmonary bypass. 3) Takedown of prior saphenous vein graft to right posterior descending artery. 4) New saphenous vein graft to acute marginal. 5) Temporary closure with open sternum. Would this be reported with code 33510?

Spinal Angiogram 75705 MUE

Patient presents for spinal angiogram from T3 to L3 bilaterally, with a couple of common trunks. The total units for this case of 75705 was 23, but the Medicare MUE is 13. How are you supposed to bill these cases with an MUE that low? The bilateral surgery indicator for code 75705 is 0. Are you supposed to appeal these with report every time, or is there a different way to code them?


How would you code for a digital 3D fractional flow reserve model (super-computer; analytically derived) of the arteries derived from a standard CT scan? Would you consider this a component of a coronary CTA (75574), or is this separately codable?

Modifiers -SC and -KX for Pacemakers

In regards to the ZHealth Online Member Newsletter from March 31, 2016, I have a few questions regarding the -SC and -KX modifiers. When we have one of the following codes (33227, 33228, 32229, and 33233) should we be adding both the -SC and -KX modifiers to both the CPT and pacemaker C-code?

I&D Removal/Drainage of Superficial Thrombosis

I am not very familiar with this procedure and would love your assistance with CPT codes. Here is the report: "Pre-procedure diagnosis: 1) leg pain/tenderness, 2) superficial thrombophlebitis, 3) varicosities/reticular veins. The patient was taken into the procedure room for pre-op procedure limited ultrasound on the segment to be treated. The treatment areas were prepped and cleaned with isopropyl alcohol or chloroprep. Lidocaine without EPI was injected under the skin overlying the superficial thrombosis. Access was then gained with an 18 gauge 3/4 needle under ultrasound and visual guidance. The thrombosed area was then aspirated or expulsed with mild pressure, removing the superficial clot. Post treatment: The treated areas were cleaned and compressed with Cast Padding and Coban and a thigh high, 20-30 mmHg graduated compression stocking was placed on the patient's lower extremity."

Heartflow FFR-CT

Our facility is going to begin utilizing the recently approved Heartflow CTA-based FFR calculations. Is there a separate code for this? My initial thoughts were that it was just another piece of post-processing.

Extracorporeal Venous Circulation

What are the appropriate codes for extracorporeal venous circulation? "Patient was placed in prone position, and right popliteal venous access was obtained under ultrasound guidance. After that, a venogram was done, showing a total occlusion of the right femoral vein with extensive clotting throughout the vessel. A venogram from the left popliteal vein showed clotting of the femoral vein all the way up to the IVC. After that, a wire was advanced from the right popliteal access to the IVC. The wire was able to cross the area of total occlusion, and exchange catheter was put in place. Patient was turned into supine position and bilateral venous access through right and left IJ was done under sonographic guidance. An 18 French sheath was placed via the right IJ. A 26 French sheath was placed via the left IJ. Angiovac aspiration catheter was advanced to the IVC, and extracorporeal veno-venous bypass circulation was started. Using left popliteal venous access, wire was advanced to IVC and treatment was started from IVC to popliteal venous access. After flow improvement, PTA of IVC, left Iliac, and femoral vein was done. After adequate results on the left side, we concluded. Successful EV treatment for extensive clotting."

93613 and 93615

When the documentation supports it, is there any reason that we should not bill both the 3D mapping (93613) and esophageal recording (93615) with 93620, 93653, or 93656?

Removal of Stent Fragment

If a fragment of a vascular stent is protruding from the patient's skin, would code 10120 be more applicable than 20670? "The fragment of stent was then grabbed with a Kelly clamp and pulled from the skin. The fragment was cut with a heavy scissor at the base of the skin. This essentially removed the protruding fragment."

Drainage of Groin Lymphocele

I work for a hospital. I would appreciate help in coding the following lymphocele drainage procedure: "Under sonographic guidance, a 5 French Yueh centesis catheter needle was advanced into the fluid collection, and over wire (Amplatz) exchange was made for an 8 French Dawson Mueller drainage catheter. A total of 50 cc of clear yellow fluid was manually aspirated. A sterile dressing was applied."

Humulin Insulin

When the patient has a procedure performed, there are drugs that the physician can bill on the claim. My question is, when the physician gives the patient Humulin Regular Insulin during the operative session in the office setting, what HCPCS code would be billed? And, is it reimbursable under the physician fee schedule, or is this a drug that would only be billed under DME guidelines? We do not have a DME contract, so I am interested in your opinion.

A-fib Ablation Without PVI

Would code 93656 be appropriate for persistent a-fib ablation without PVI? Or does code 93656 require that PVI be done?

In Situ Bypass Graft with Endarterectomy

Physician did a left fem-pop in situ bypass, left profunda femoral endarterectomy, silver profundoplasty with SFA endarterectomy and vein patch, and common femoral artery endarterectomy. How would this be coded?


We currently bill A9500 (Tc-99 sestamibi) to Medicare for our nuclear stress test. A company has approached us about converting to Tc-99 non-highly enriched uranium (Q9969). They are telling us we can use Q9969 non-highly as a substitute drug, but continue billing code A9500. Currently Medicare hasn’t approved Q9969 as a billable code. Would that be acceptable Medicare billing? I have concerns, so I want to see if you have already had other questions about the newer drugs coming out. I didn’t find anything in the topic search.


In our hyperbaric wound clinic, we have started performing ultrasound duplex scans of a unilateral leg along with TCPO2 or TCOM measurements. Would you submit codes 93926 and 93998 if both are done at the same setting?

Left common carotid and innominate artery stenting.

Operative report indicates aortic arch, selective innominate artery, left common carotid, and selective left subclavian angiography. In addition, balloon angioplasty and stenting of the ostium of the innominate and ostium of the left common carotid. Greater than 80% stenosis in innominate and left common carotid verified by CT angiography sometime prior to procedure. Procedure included access from right radial and right femoral. It appears that code 37216 has an MUE of 1, and it is not appropriate based on Medicare Fee Schedule to use modifiers -RT/-LT. Should code 37216 be reported separately for the right common carotid and the innominate? Would modifier -59 be appropriate? Is everything else performed bundled?

38792, Modifier Usage

We are coding for breast procedures where the surgeon is injecting the isotope and placing wires in a stereotactic suite. After the appropriate time frame the patient is then brought to the OR, where a lymphatic mapping injection is performed along with excision of sentinel nodes. We are currently applying the -XE modifier to CPT code 38792 for an edit with code 38900. We are being advised by our facility that this is not truly a separate encounter and therefore an -XU modifier should be used instead. We currently code for both facility and professional charges. Is there a difference in modifier guidelines? Can you please advise on which is the correct modifier usage?


If I'm billing codes 93225 and 93227, do they need to be billed on separate days? Or together on the same day the Holter is put in?


When is it appropriate to use CPT code 76140 as opposed to billing the specific procedure code with modifiers -26, -77 for a re-read of imaging? Scenarios: A) Patient is referred from a different healthcare provider for another opinion, requesting re-read of radiology services. B) Patient presents from an outside provider with images but no interpretation. Our provider needs to re-interpret the original images since no report is available. C) Other?

AVF Thrombectomy/Revision with PTA/Stent of the newly created anastomosis

I have a question regarding a thrombectomy/revision of a brachiocephalic AVF followed by PTA/stenting of the newly created anastomosis. "The surgeon performed a fistulogram, revealing occlusion/thrombus of the cephalic vein. He then removes the thrombus. Further occlusion was found near the shoulder. Incision was extended to dissect out more of the cephalic vein. A second incision was made in the axilla, and the basilic vein was dissected out. The basilic vein was then anastomosed to the cephalic vein. Another fistulogram was performed, revealing stenosis in the area of the end-to-end anastomosis. The surgeon then angioplastied and stented this." Would the correct coding for this be 36833 (thrombectomy/revision) and 36147 (fistulogram) only? I do not believe that I should code for the stenting (37238) due to it being done at the anastomosis just created. I was looking at it as an inflow/outflow type issue. Am I correct in my thinking?


One of our vascular surgeons routinely orders 93971 for "swelling". The established protocol is to image both the upper and lower extremity on the same side (charging 93971 x 2). I have been adding the -59 or -XS modifier since it is a different extremity and it is not bilateral. Is this appropriate?

Bone Biopsy, Deep vs. Superficial

Do you have a chart or document that identifies which bones would be considered superficial versus deep? The CPT book gives examples, but I’m looking for a bit more.

US in Emergency Department

Recently one of our facility has requested to implement ultrasound in the ED performed by the ED physician. This has been endorsed by ACEP, and the only argument I can defend is that revenue code 320 or 402 would not define the area where the service was provided. How medicine is practiced is evolving, so if a report is produced and images are stored in PAC system, would attaching revenue code 320 or 402 be appropriate in the ED? 

92941 Clarification

Does the following documentation/example support the use of code 92941? Indications listed in the procedure note include known history of CAD, status post prior stenting of LC, typical chest pain, EKG suggestive of inferior wall ischemia, and cardiac enzymes that became positive. Because of her increase in enzymes and her acute EKG change, she was taken emergently to cardiac catheterization laboratory. Findings consist of 70% hazy lesion of the LC as the culprit lesion and is type A or low risk. Procedure performed was angioplasty of the circumflex artery. 

Diagnostic Cerebral Angiogram Pre and Post Hematoma Evacuation

A diagnostic angiogram was done prior to planned hematoma evacuation. The catheter was removed, and the sheath was left in place for performance of a completion angiogram after the evacuation of the hematoma. Can the angiogram be billed twice (pre and post)?

FB Retrieval of Fractured Neph Cath

"Neph tube is fractured. MD retracted tube for removal of the fractured fragment remains left in the renal pelvis. Using the strings which are attached to the fragment and blunt dissection and a hemostat the retained fragment was successfully retrieved. Under fluoro guidance a new neph tube was placed." Can anything be coded for the retrieval for the fractured cath, or is it considered part of the tube exchange code (50435)?

Percutaneous Paravalvular Leak S/P TAVR

We are having a discussion about which code to use for percutaneous paravalvular leak status post TAVR. According to a previous question posted on January 28, 2016, the code to use is 33399. Is this still correct, or have they created any codes for the closure of the leak for 2016?

Angioplasty in the Venous Outflow with Revision

Can you clarify the definition of "within the graft" as it relates to open surgical revision of an AV fistula/graft with balloon angioplasty in the venous outflow? Is the entire peripheral segment considered "within the graft" or just the anastomoses, graft material between the anastomoses, and the immediately adjacent areas? For example, a physician creates a surgical incision over the venous anastomosis of an AV graft. He opens the graft and retrieves thrombus using a Fogarty and places a patch angioplasty at the venous anastomosis to treat an area of stenosis there. He then performs a balloon angioplasty of an area of stenosis in the venous outflow in the cephalic vein through the same surgical incision (the stenosis is proximal to the venous anastomosis and not immediately contiguous with the anastomosis). Would you agree with 36833, 35460, and 75978 here? Or can I only report the angioplasty and radiology S&I (either 35460/75978 or 35476/75978) if these additional procedures are performed in the central segment?

PCI on Two Sub-branches of an Obtuse Marginal

"Patient had 80% stenosis of a main superior sub-branch of OM3 and also had 60% ostial stenosis of an inferior sub-branch of OM3. The 80% superior was treated with a drug-eluting stent across the lesion, jailing the inferior sub-branch. Angiogram then revealed a 90% inferior side branch stenosis, not improving after nitroglycerin administration. Plain balloon angioplasty then was performed at ostium of inferior branch. Then kissing balloon inflations were done in the superior sub-branch and ostium of inferior sub-branch, resulting in 0% residual in the main superior and 5-10% residual in the inferior sub-branches." Would it be appropriate to report codes 92928 and 92921? Or should I only report code 92928 since these were both sub-branches of the OM3?

Iatrogenic Procedures

If we are doing a procedure and cause a dissection that needs to be treated with a stent, can stent device and/or pro fee for placement be charged? Is there a CMS or ACR directive on billing an iatrogenic procedure caused during a procedure?

Transvenous Lead Extraction

We have started doing lead extractions, which are new to me. If we extract an ICD right ventricular lead (33244) and insert a new right ventricular lead, can we bill for both removal and insertion? Or is it all included in the insertion code?

Epicardial Lead and Generator

Procedures: 1) Epicardial lead implant x 1, 2) VVI pacemaker implant in LUQ, 3) Dual chamber pacemaker explant, 4) Pacing lead extraction x 2 with laser, 5) Right femoral a-line placement, 6) Exploratory left thoracotomy. Our coding tool bundles code 33212 (insertion) with 33233 (removal) with no modifier allowed; however, these were two different areas. Do you have any suggestions? (We reported codes 33202, 33212, 33233, and 33235.) 

Internal Carotid Embolic Filter

Patient has bilateral stenting and now there is evidence of narrowing in the left stent. The physician performed selective views of right and left cervical and cerebral (36223-RT), selective view of internal carotid (36224-LT), selective view of vertebral left and right (36226-50). He is also placing embolic filter device into the internal carotid. What code would I use for the filter? I only come across codes 37215-37218, but these include the stent.

Subclavian Vein Stenosis Treatment During AV Fistula Evaluation (36147)

If the subclavian vein is selected during an AV fistula exam evaluation of a brachial artery to axillary vein PTFE graft), and severe stenosis is found and treated with angioplasty, can you add selective code 36011 in addition to codes 36147, 35476, and 75978?

Code Edits with 76937

We use coding software that's showing OCE edit when reporting 76937 with any procedure outside of the 34001-37799 range. The edit is as follows: "76937 is an add-on code and must be reported in conjunction with 34001-37799." The CPT Codebook does not indicate what base code(s) would be acceptable to use with 76937. Do you have any current guidelines on the appropriate use of code 76937?

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