Knowledge Base

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37253 Coding

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

Selecting same blood vessel with two different catheters

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

36251 or 75625

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

76930 for TTE guidance pericardiocentesis? 93308 for limited TTE?

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

CT Guided Biopsy of Maxillary Mass

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

Thrombectomy of AV graft with fistulogram and removal of AV graft

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

0238T Iliac Atherectomy

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

Biliary manometry (Whitaker test)

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

Ekos

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

37184 vs. 36904

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

Brachial artery access into Dialysis Fistula

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

HIS Bundle Lead in right atrium at level of His bundle

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

32666 for VATS wedge

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

Open paravisceral aortic septectomy with AAA repair

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

Mammo screening with a followup of abnormal mammo

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

Cardioinsight

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

Repeat Hepatic Angiography

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

75984 billable without contrast monitoring?

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

Arrhythmia not present during the ablation

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

CYSTOGRAMS

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

Antibiotic Lock Therapy

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

Resection of recurrent adventitial cystic mass, right lower extremity

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

Embolization right cavernous carotid fistula via SOV

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

Geniculate

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

Exchange Dobhoff Tube

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

Bilateral Pulmonary Artery Thrombectomy

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

C Arm

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

Jailed Coronary Vessels

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

Mitral valve Reapir and Replaced at the same session

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

62323 with kyphoplasty 2017

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

Sternal Closure

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

Billing 93306 and 93351 same day same physician

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

X-ray Foreign Body

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

Moderate Sedation Documentation

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

Diagnosis coding from a cath report

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

Aborted PTCA, Completed Iliofemoral Runoff

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

Intracranial vs. Extracranial Embolization

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

Transcaval and Transcarotid TAVR

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

Portal Vein Selection without Portography

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

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

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

ILR Repositioning

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

PCS coding 02UG3JE

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

Mammography Callback

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

Base imaging procedure codes for 76376 & 76377

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

MD stented an LVAD graft with a VSD Occluder device?

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

Femoral Pseudoaneurysm

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

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

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

U/S guided anesthetic injection into thrombolphlebitic laser ablated vein

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

Cisternogram

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

MRI of the Brain and Internal Auditory Canals

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

Conscious Sedation

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

Repair of EVAR with deployment of 2 Gore Excluder Limbs

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

93655 vs. 93657

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

Coil Embolization

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

33263 vs 33264 Previous Question (8663) Clarification

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

Amplatzer for pseudoaneurysm of aortic arch

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

76998

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

Lower Extremity Intervention

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

Revision of AV Graft

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

IVR Angioplasty Declot AV Dialysis Graft

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

Medtronic Single Pass Lead Gen Change

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

Percutaneous balloon venous angioplasty of lower extremities

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

Fem to Fem ARTERY bypass with grafft

What would be the appropriate CPT code for fem to fem artery bypass with graft?

Thrombectomy with Bypass

I have a case where a patient came in and an open embolectomy of the brachial artery was performed (34101), during which they were able to remove large amounts of thrombus. The wounds were closed and then percutaneous angiography showed there was occlusion at the level of the elbow. They then decided to perform a brachial-ulnar bypass graft (35523) and proceeded to do so via new and separate incisions. Is there any issue billing these two procedure codes together since they were performed via separate incisions?

Charging for sedation when Fentanyl is only given

There is a discussion at our facility regarding whether or not we can charge for sedation if only fentanyl is given. Typically both fentanyl and versed are administered to patients, but on occasion we will only give fentanyl. Do we still charge for sedation?

RPLV embolization

We don't normally perform cardiac procedures, so I'm VERY unsure here: "The case was done on an emergent basis, as there was coronary perforation during cardiac catheterization. A program microcatheter was advanced over the existing cardiology wire into the RPLV coronary branch. Injection demonstrated large active extravasation from this branch. The perforation was successfully treated with three 2 mm while coils. Repeat injection demonstrated no further active extravasation from the branch." Is the correct cath code 93456? I can't locate how to code the embolization. 

64530 and/or 64420 used with chest tube placement for patient comfort

For patient comfort, one of our new radiologists sometimes does an intercostal nerve block (64420) or a celiac plexus injection (64530) during chest tube placement, biliary drain placement, and like procedures. Codes 64530 and 64420 seem to be primary pain procedures. When he uses them in this way, are they considered “part of the procedure” and unbillable? The radiologist would like to know if these injections are billable for his professional side. I work for the hospital and would also like to know if billable for the hospital side.

MitralClip 33418

I need clarification on billing for MitraClip. I have an interventional cardiologist and a cardiothoracic TP surgeon performing MitraClip. Can they both bill with -62 modifier, or should one be an assistant? (They each have their own assistant involved in the case as well.) 

Cardiologist and Cardioelectrophysiologist

Can we bill Medicare and other insurances for these two types of physicians on the same day without it bundling together? Or are they considered to be part of the same group/specialty?

Evaluation of cholecystostomy catheter tract

Would you report code 47531 for the evaluation of the tract? "HISTORY: Patient pulled out existing cholecystostomy catheter. PROCEDURE: The patient was placed in the supine position on the fluoroscopic examination table. The right abdomen and skin overlying the catheter tract were cleaned and draped in usual sterile fashion. A small dilator was placed in the peripheral aspect of the tract, and contrast evaluation was performed, demonstrating no residual catheter tract. At this time, the procedure was canceled and sterile dressing applied. The patient tolerated the procedure well without immediate consultation. IMPRESSION: No residual tract; catheter not replaced." My thoughts are that code 47531 states injection procedure for cholangiography existing access. It does not state what is required to be injected (catheter vs. tract). 

Diagnostic Angiography at time of intervantion

I thought you had a great article on the definition of "known pathology" versus diagnostic imaging. My co-workers and I disagree on what is a known pathology and what we find on angiography. If the patient has a known GI bleed confirmed on a nuclear medicine scan, are the injections considered diagnostic imaging? I personally believe these to be confirmation shots, but I may be wrong. Do all diagnostic findings need to be confirmed by CTA/MRA or angiography to be considered diagnostic as in no other imaging is a diagnostic image?

Cath placements with venous stent placement

The physician accessed the right and left common femoral veins and performed angioplasty in the right and left common iliac vein and the left external iliac. We reported codes 37248 and 37249 x 2. Would you also report codes 36005 x 2 or 36000 x 2?

IVUS post-stent sizing

Patient had recent MI and residual CTO LAD. Had RCA stented during MI, but brought back a week later for staged intervention for the LAD. Had one DES placed to the 100% occlusion. Op report mentions, "I was concerned about a size in the most distal part of stent and proximal LAD. I therefore performed IVUS which verified that this was at least a 3.5 mm vessel." Then used balloon to dilate the stented segment and placed another DES and dilated the stent aggressively to close to 3.5 mm. MD calls it ''IVUS post-stent deployment for sizing'' in op title. Would IVUS be coded in this instance? Can IVUS be coded with C9600?

Coiling a vein graft

I am billing a left heart catheterization and stent to the RCA. The physician mentions in his note that the "SVG-RCA coiled due to competitive flow". I have not seen this before. Is there a code for this?

Ablation not done after ICE

"Patient has atypical A-flutter. ICE was done to LAA to assess for thrombus. No thrombus was found, but there was evidence of moderate to large circumferential pericardial effusion with evidence of septal bounce. Procedure was terminated." I get 93653 with modifier -54, but can I bill for ICE as well? I bill for physician, but the hospital would like to know what they can bill for too.

Cath Lab procedure log

If a provider wants to use the cath lab procedural log (which he signs) in conjunction with a written note specifying his findings as his procedure report, is that acceptable documentation for a cath lab procedure? Or is a full physician authored procedure report required? If a full report is required, is there a reference that I can give to the physician to support the need for a full report?

36905

A patient has thrombolysis of the AV graft. The next day the patient returns, and contrast injection is performed via the indwelling thrombolysis catheter, as well as angioplasty of a stenosis in the graft. Would the correct code be 36905 for the follow-up injection and angioplasty of the graft?

Uterine fibroid embolization, both sides, different arteies

I am reviewing a report describing embolization of the right uterine artery and left ovarian artery for uterine fibroids. Per anatomy, I know that the uterine artery usually connects with the ovarian artery, but in this case, would I capture two embolization codes (37243, 37243-59)? Or would it be considered the same surgical field as your case of the month describes?

Subcutaneous Generator Removal

Patient had post implant pain at ICD site. Generator and lead (33272) were removed. Nothing was placed. What code would be used for the removal of the SICD?

Nuclear Medicine Lymph Gland Non-Imaging

"Nuclear medicine breast SCINTIGRAPHY scan is obtained. Medial distal left thigh above the knee was injected with five mCi of Tc-99m filtered sulfur colloid. The purpose of injection was for identification of a sentinel node chain. Radiotracer is seen in the left inguinal lymph node chain." Nuclear Medicine is coding it on technical (facility side) as follows: A9451, 78195, 38790, 96374. I think it should only be coded with A9541 and 78195, since CPT code 78195 includes the work of injection of the radioactive material and scanning of the region. Thoughts?

Prior catheter-based study

How far back does the prior catheter-based study have to be to allow us to report a diagnostic study with the interventional?

Attempted TAVR vs. Valvuloplasty

I am coding for a hospital facility. Patient was scheduled for a TAVR procedure; however, the procedure was aborted because the aortic valvuloplasty balloon would not cross the valve. Do I code the TAVR procedure with a -74 modifier appended, or do I code the successful procedures leading up to the TAVR, such as left heart catheterization, etc.?

93454 vs. 93458-74

"Hospital outpatient cath lab patient scheduled for diagnostic heart catheterization and coronary angiograms. Selective right and left coronary angiograms performed. The catheter was placed in the left ventricle, but unable to obtain LV hemodynamics due to arrhythmias." Per code description for 93458, heart pressures must be documented. Since no pressures were obtained, would we report code 93454 or 93458-74?

Pressure measurement with catheter during LE revasc

Can a physician report code 36625 for checking arterial pressures pre- and post-stenosis during a lower extremity revascularization case?

CPT 37249 - MUE x 2 - Per Extremity?

"Patient with DVT right-sided common femoral vein, popliteal vein, common iliac vein, and left-sided common femoral vein and common iliac vein. Placement of 50 cm lysis catheter in vena cava via left-sided popliteal and right-sided popliteal posterior approach (37212, 36010-50). Balloon angioplasty of IVC (37248). Balloon angioplasty right-sided common iliac vein, external iliac vein, common femoral vein. Balloon angioplasty left-sided common femoral vein, common iliac vein." Would we submit code 37249 x 2 per extremity? 

Leg vein thombolyis/ thrombectomy

I am not sure how you would code this case. I used 76937 x 2, 75822, 36005-50, 37187-50, and 37212-50XU. Where the tips of catheters are is confusing or just not documented well. “Bilateral knees were prepped. US guidance into patent bilateral small patent saphenous veins with images sent to PACS. Venograms were performed, showing extensive thrombus of deep veins bilaterally from upper calf to pelvis. Third puncture was done under ultrasound in medial right gastrocnemius vein. With fluoroscopy, guidwire was advanced into pelvis, and bilateral sheaths advanced at the knees. A glide catheter was then advanced to left CIV and EIV bilaterally. Venogram showed occlusive thrombus in iliac system with collateral seen to the retroperitoneum, which also has thrombus. A very diminutive IVC was seen to the RA. Possis catheter was advanced for mechanical thrombecomy on veins from knee to pelvis bilaterally. Bilateral long infusion cath was advanced over wire and left across residual thrombus for tPA infusion overnight.” 

Empiric cavotricuspid isthmus ablation for atrial flutter

My provider wants to report code 93653 for an empiric cavotricuspid isthmus ablation for atrial flutter, but I thought code 93653 was just for treatment of SVT. Thoughts?

Thrombectomy

"Open thrombectomy/revision of AV fistula in upper arm. Femoral vein was tunneled (U loop) up from the thigh, across the abdominal wall up to the deltopectoral region, and was bridged with Gore-Tex." Would this simply be 36833?

Basilar Artery Embolization

We are having some confusion with codes 61624 and 61626. Which code would be used when doing an embolization of the basilar artery? I feel that 61624 should be used since the basilar artery is part of the blood supply system for the brain and CNS. My coworker feels 61626 should be used since a basilar aneurysm codes out to diagnosis code I72.5 (precerebral aneurysm). Do you have any tried and true info regarding which arteries are included in 61624 and which arteries are included in 61626?

75625 vs. 75716

We have been coding 75716 for aortic angiography when the aorta, iliacs, and femorals are the only documented results (no visceral results). If catheter is placed infrarenally, and abdominal angiography is performed, would that change the code to 75625? The same results are documented (peripheral only), but the catheter is clearly stated to be located infrarenally. 

Subclavian artery stenosis

What would be the appropriate ICD-10 code for subclavian artery stenosis? I70.208, I70.8, or something else?

Ultrasound Lung

My provider is doing an actual ultrasound to measure water in lung, not for effusion. Is code 76604 appropriate for this limited ultrasound?

ICD Upgrade

If a physician replaces the generator and the lead, would you code this as a new ICD?

Transjugular liver biopsy with pressures

Would the correct coding be 36012, 37200, 75970, and 75889?? Or would it be 36011?? Also, does it need a reduced service modifier for pressures?? "Using 1% lidocaine as local anesthesia, real-time ultrasound-guided micropuncture of the right internal jugular vein was performed, with hard copy documentation of sonographic venous patency. A 5 French sheath was placed over a guidewire, and selective catheterization of the right hepatic vein was performed with a Bentson wire and Kumpe catheter. Over-the-wire exchange was performed with placement of a long sheath into the right hepatic vein, through which a balloon occlusive catheter was placed. Free hepatic vein pressures, hepatic wedge pressures, and right atrial pressures were obtained. The biopsy device was then placed through the sheath, and three 18 gauge core biopsies from the right liver were obtained. The samples were placed in formalin. FINDINGS: Pressures (mm Hg): Free right hepatic vein: 7/7/7; Wedged right hepatic vein: 12/12/12; Right atrium: 11/9/9."

CPT code for angio of native internal mammary artery to check for patency?

My provider accessed the right femoral artery and selectively advanced the catheter into the left and right coronary arteries. A pigtail cath was then used to cross the aortic valve. The left ventricle was injected and imaged. The left internal mammary artery was then selectively cannulated and injected to ascertain its suitability as a potential bypass conduit. We have coded 93458 for the left heart cath. How would we correctly code the cath placement and imaging of the left internal mammary artery?

Cardioversion with TEE

The patient was scheduled for a cardioversion (92960) with TEE. The TEE was performed (and charged), but due to the results the cardioversion was cancelled. Can the cardioversion still be charged and coded with a modifier for cancelled procedure?

Aborted Radiology Inpatient Procedures

We have a patient who presented to Radiology for a thoracentesis/paracentesis/abscess drain placement, and following the initial scan it was determined the procedure couldn't be done or didn't need to be done. Should we be charging for the intended procedure and adding the ICD-10-PCS code for as far as the procedure went (ultrasound), or should we be doing something else?

Carotid to carotid bypass coding with graft

I performed a right CCA to left CCA retropharyngeal bypass with Dacron graft and a left CCA to left SCA bypass with Dacron graft the day prior to a TEVAR for a very complex dissection. I believe the code for the CCA to SCA bypass is 35606, but I am unable to find the correct code for the CCA to CCA bypass with graft. Once again this was done the day prior, so I don’t think that code 33891 fits.

Thrombectomy of AVG and Thrombectomy of native artery

"Patient with brachial axillary AV graft, occluded. Open thrombectomy of AVG performed with return of clot, but couldn't get forward flow, decided to "take the graft down". Bovine patch angioplasty axillary vein. Multiple attempts at thrombectomizing the brachial artery were unsuccessful. Bovine patch angioplasty brachial artery. Moved to radial artery and performed open thrombectomy with return of forward flow. Arteriotomy was closed with suture." Would it be correct to use 36831, 34111-59, and 37799 (removal of AV graft, not infected)? OR is the entire arm the "dialysis circuit" even though the radial artery was not part of the AVG? What about patch angioplasty? Is that included in the closure of artery/vein? If it is used to make the lumen larger could you bill for it then?

Unable to do PVI Ablation-only Intracardiac Echo performed

How would you recommend we code for a procedure where a PVI ablation for a-fib was the planned procedure, but after intracardiac echo there was an IVC dissection, and so procedure was aborted? "While advancing the intracardiac U/S catheter into the inferior vena cava, I felt some resistance. I injected contrast through the sheath, which revealed a dissection of the inferior vena cava. I withdrew sheath a fem cm inferior & injected again-this confirmed presence within the true lumen of the IVC with no additional flow into the dissection. Protamine 50mg was given as a slow IV push." Sheaths were pulled after more observation. An EP study was never performed, nor an ablation. We can't code 93662 without a main procedure code. Do you recommend coding 93656-74 with 93662, or how would you advise us to code this scenario for a hospital outpatient encounter?

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