Knowledge Base

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Accuracy of Coding

I was brought into an organization due to concerns regarding loss revenue, lack of clinical documentation, and poor procedure charging. I am new to this facility. I have used your resources for a long time now in my role roles of a radiological technologist in cath lab, IR, and EP. In my new role I am required to become more aware of Medicare reimbursement. My main issue I have had in the short time I have been at this new facility is that when reviewing cases there are many small coding mistakes that are taking place. Examples being 77001, 76937, 75625, 75630, 75716. In the last year, no CVC cases had code 77001 attached to procedure when they were all done with fluoroscopic guidance. Code 76937 is charged with no documentation of recorded image, and codes 75625 and 75716 are being charged without documentation of catheter placement, which should have been coded as 75630. When asked about these practices I am told we have almost 100 percent Medicare patients and we get reimbursed the same no matter how we code it. How do you overcome this mentality? I'm so frustrated.

AV Shunt Placement

Patient has 403.90 and 585.9. Patient comes in for AV shunt. The MD plans to create the AV shunt at the wrist area. He makes his incision and explores the area and decides the vein is too small. He closes here and then moves to the upper arm and creates the AV shunt there. I did refer to your Q&A # 6128, but this was for two unsuccessful attempts.

Billing 72265-59 with 72132

Would you consider this documentation sufficient for billing a lumbar myelogram (72265-59) with LS spine CT (72132)? The physician orders a CT spine and lumbar myelogram. Documentation for the myelogram in the first example states: "Myelogram without significant compression on the thecal sac or exiting nerve roots, osseous structures are unremarkable." In a second example the documentation states: "Conus/Cauda: Tip of the conus is typical at L1. Individual nerves of the cauda equina are unremarkable. There is no evidence of arachnoiditis or other pathology." All elements of the LS CT are well documented in both instances. In either instance, can the lumbar myelogram be separately coded?

Arterial Thrombectomy

I have a case where the physician did a primary percutaneous mechanical thrombectomy of the following areas (right common femoral approach): left common iliac, left external iliac, left common femoral, left superficial femoral, left popliteal, left anterior tibial, and the left posterior tibial/tibioperoneal trunk. How many times should codes 37184 and 37185 be submitted in order to cover all these areas?

Biopsy of Leg Mass

For the following example, I'm not sure what to code for this because it is not muscle or bone.  What are your thoughts?  "Physician performed a venogram of the right common femoral vein, that had been previously stented. The venogram showed limited flow from a mass pressing on the stent. With percutaneous access, a biopsy guide for 16 gauge core biopsies were then placed through the stent into the mass. Three good core biopsies of the mass were obtained and placed in formalin."

Foreign Body Removal - Open

I’m not sure what to do with this one. Patient came to cath lab to have an angioplasty of his AVF. While ballooning the subclavian and innominate vein, the balloon ruptured. Due to aspiration of blood from the inflation port of the balloon, the surgeon decides to take the patient to the OR for emergent surgery. In the OR he opens the arm, creates a venotomy in the fistula, and removes the balloon. It is noticed that there is some thrombus, so he removes the small amount of clot present and closes the venotomy. I don’t like code 37197 since this is open instead of percutaneous. I was thinking of reporting the exploration with code 35761 (which includes foreign body removal) (or possibly 35860 since there was bleeding) with modifier -XU or -59, as well as the open thrombectomy with code 36831 since they shouldn’t have had to do a thrombectomy as well. My other thought was unlisted code 37799. What are your thoughts?

Billing 93286 or 93287 twice

When billing code 93286 or 93287 twice, for before and after another procedure (such as an ablation), Encoder Pro states we should bill the code x 2, but I have seen it also billed on two lines with either a -76 or -59 modifier. Which way is correct?

AV Fistula Transposition

Does your previous answer to a question from years ago regarding code 36818 still apply - must this procedure still require two incisions to code for it? "Procedure: We made incision a fingerbreadth above the elbow crease where the vein and artery had been mapped. We dissected first the cephalic vein circumferntially and exposed at least a segment of around 5-6 cm both proximal and distal to our incision so that we could swing it over. We divided a little part of the biceps muscle to allow for no compression with the transposition of the vein towards the brachial artery medially. The brachial artery was exposed proximally and distally. She had some scarred valves in the vein walls which were trimmed at the level of the anastomosis to allow no problem with the venous anastomosis for the future. We then clamped the artery distally and proximally and made an incision with 11 blade and dissected with micro Potts in oblique fashion. The vein was then anastomosed using 6-0 prolene in a running fashion." What code would you use if not 36818? Unlisted?

Code 93623

Patient comes in for EP study in arrhythmia. Physician administers isuprel. Is it appropriate to bill code 93623 if the patient is already in an arrhythmia BEFORE drug infusion?

Internal Biliary Stent, No Safety Catheter Left

How do I code this report? "Technique: The internal/external biliary drain was prepped and draped. Contrast was injected, and a cholangiogram performed. This revealed a malignant obstruction of the distal CBD. No contrast enters the duodenum. Guidewire was advanced through the drain and into the duodenum. Sheath was placed at the insertion site. Under fluoroscopic guidance, a biliary covered stent was deployed at the level of the malignancy. It was then dilated with a balloon. Excellent result with brisk flow into the duodenum. No safety catheter was left. Impression: Successful internal biliary stent placement. No safety catheter was left."

Kommerell Diverticulum and Medical Necessity

I have never seen a procedure like this, so I am in need of your advice! The procedure is a left subclavian bypass and endograft covering of the original of subclavian and diverticulum with Kommerell and orgin of the left subclavian artery. A graft was deployed just at the distal margins of the origin at the right subclavian artery and completely covered the origin of left subclavian artery and diverticulum Kommerell. I am looking at codes 33880 and 35621.

Esophagram

I hope you can help with this unique request. The patient’s condition warranted a bedside esophagram. Fluoroscopy was NOT used. Instead, the tech used a digital portable x-ray machine with cassette placed behind and on the side of the patient to take 11 or so images in the AP and lateral projections in the chest area. This was done before, during, and after ingestion of contrast material, which was injected via GI tube at the level of mid esophagus by the patient’s physician (not the radiologist). What is the appropriate way to code this? Scout film demonstrates evidence of pneumomediastinum and soft tissue emphysema in the neck and supraclavicular regions. No pneumothorax is evident. Extensive bilateral pulmonary parenchymal disease is noted with diffuse infiltrates. Administration of contrast opacifies the mid to distal esophagus, which demonstrates no evidence of obstruction or extravasation of contrast. We are concerned if we need to report this as a chest x-ray or as an esophagram.

FIRM and PVI Catheter Ablation

Can we report both codes 93655 and 93656 for FIRM (focal impulse & rotor modulation) and pulmonary vein isolation catheter ablation to treat atrial fibrillation? Usually these rotor ablations are done in both the right and left atrium prior to PVI. If reportable, should we assign code 93655 twice for left and right no matter how many rotors/lesions were ablated? Or do we code based on the number of lesions ablated? Here's an example: "The 60 mm basket catheter was deployed in the left atrium and Epoch 3 created, which appeared to show rotors on the mitral annulus just anteroinferior and posteroinferior to the left lower vein. These rotors were ablated and ablation lesions connected. Epoch 4 showed a posterior wall rotor, which was over the esophagus and was difficult to ablate extensively due to heating. Epoch 5 and epoch 6 were created after adjusting the basket to better contact the posterior wall. These revealed rotors in similar areas as the prior rotors. Ablation lesions were delivered extending the prior lesions along the mitral isthmus and on the posterior wall. During ablation, atrial fibrillation terminated."

Transcaval Aortic Access

Physician is doing a transcaval aneurysm sac embolization for an endoleak after an abdominal aortic aneurysm endovascular repair. He is accessing the vena cava, placing a TIPS needle, and gaining access into the aortic aneurysm. How should I report catheter placement? Should I just report code 36200 since that is where the catheter ultimately landed? Or do I report both codes 36200 and 36010?

Echo Guidance for Temporary Pacemaker Insertion

A cardiologist recently asked for echocardiography to assist with a temporary pacemaker insertion. My understanding is that transthoracic echo guidance was utilized for intracardiac RV lead placement. How would you suggest this be reported? Is a UPC the most appropriate? Thank you for your expertise.

Angioplasty of Vein Graft Stenosis

Patient is status of femoropopliteal bypass for his critical limb ischemia, resulting in the setting of a thrombosed popliteal artery aneurysm. He has had some increased claudication symptoms of difficult-to-heal wounds that appear to be primarily of venous nature in the right leg. So, the physician performed an angioplasty of the proximal vein graft stenosis. My question is, should I use the code for venous angioplasty of the fem-pop bypass graft for lower extremity? Or the arterial angioplasty code?

36147, AV Shunt Studies

I have a physician who wants to limit radiation dose in patients with frequent dialysis interventions, therefore he is considering limiting the shunt study to the region of concern. The physician is wondering if he does not discuss findings of ENTIRE outflow, will this be a reduced service? Does code 36147 require discussion of findings of entire outflow to the vena cava to substantiate billing the charge?

Unsuccessful Biventricular Upgrade

We attempted to upgrade a dual ICD to a biventricular ICD; however, the physician was unable to implant the CS lead after multiple attempts. He implanted the biventricular ICD and plugged the CS port. Can we still report code 33264 since the biventricular ICD generator was implanted even though it's only with the existing atrial and ventricular leads? Would we use a -52 or -74 modifier on code 33225 for the facility bill?

TAVR Via Carotid Artery Access

Would a TAVR px via left common carotid artery cutdown for placement of CoreValve be reported with code 33363?

Cauterization

I have case where the physician opened up a PPI pocket and cauterized a bleeding vessel. No mention of a hematoma. Any ideas if there is a code that might apply here?

49185 Sclerotherapy

I have a question concerning code 49185. In the CPT descriptor it states sclerotherapy for fluid collection (eg., lymphocele, cyst or seroma). Is this code also used if it is for an abdominal or other abscess sclerotherapy? Or would code 20500 be utilized? I am a bit confused on this and need clarification.

Biopsy vs. FNA

When a patient is seen for biopsy and "core biopsies" were not possible due to nearby vessels, would it be appropriate to bill biopsy if report calls it such? In this example, the title of report is "Image-Guided Biopsy of 1 cm Left Common Iliac Lymph Node Lesion". "Using a lateral approach under CT guidance, an 18 gauge needle was advanced down to the lesion of interest. A 22 gauge needle was used to obtain samples for cytologic assessment. The lesion is not amenable to core biopsy because of the close proximity of the arterial vessels and ureter." Would this be billed as an abdominal biopsy (49180), a lymph node biopsy (38505), or an FNA (10022)? It is titled "Biopsy", yet the report states "core" not collected, rather a needle "biopsy" was. Is this a needle biopsy or an FNA? If it is a biopsy, would "common iliac lymph node" be reported with code 49180 or 38505? It would seem that the work of accessing an area that is deep (such as abdominal or visceral) would be more involved than just an FNA. I would really appreciate your input!

Cerebral Angiogram via Internal Carotid Artery and Embolization of Middle Cerebral Artery

For the following scenario, can I report code 36244 along with codes 61624, 36217, and 75894? "Cavernous carotid artery aneurysm was found on CTA. Therefore, selective catheter was placed in right internal carotid artery, and cerebral angiogram confirmed aneurysm. Catheter was then navigated into the right middle cerebral artery, and Pipeline embolization device was placed across the neck of the aneurysm. Angiogram showed endoleak, so the second pipeline embolization device was placed."

19287/19288 vs. 19287

For the following example, would you report codes 19287 and 19288? Or just code 19287? "Pre-operative MRI-guided bracket 2-wire localization of the right breast, with the target R1 (a 4.1 cm linear clumped non-mass enhancement at the 8:00 position in the anterior to middle depth, 7.4 cm from the nipple) located between the two wire tips and their distal segments."

Congenital vs. Non-Congenital Heart Cath Codes

There has been lots of back and forth over the years on whether or not congenital heart transplant patients should continue to be reported as congenital for heart cath coding purposes. Physicians state that once congenital always congenital, but I've understood from consultant recommendations that unless the new heart has a congenital defect or complex re-routing of vessels due to congenital cardiac anatomy, then all heart caths for transplant patients are coded as non-congenital. Can you please clarify?

35475 vs. 35476

When the report states that the anastomosis was treated with PTA, are we to assume that this graft is a direct anastomosis between vein and artery (which is reported with code 35475)?

Vertebral Occlusion

For the following example, we assigned codes 36216-LT, 75894, and 75898.  However, I'm questioning if this should be 61626 or 61624. Please advise.  "Previous recent angiogram showed sluggish flow within distal left vertebral artery concerning for thromboembolism. Via right CFA, a 5 French straight guide cath over a guidewire selectively catheterized proximal left subclavian artery. DSA showed proximal LVA occluded approximately 15-20 mm from its origin. Microcath over microwire through guide cath was advanced into left subclavian, then LVA just proximal to the occlusion. I then advanced a TruFill DCS Orbit Complex Fill 5 mm x 15 cm coil into the LVA just proximal to the occlusion. After confirming stability with fluoroscopy, coil was successfully detached. Embolization continued with additional coils, and stability was confirmed prior to successful detachment. DSA showed occlusion of LVA approximately 10 mm distal to its origin with no filling of the more distal LVA and no filling defect in left subclavian to suggest thromboembolism. Cath withdrawn and closed with a Mynx."

Contralateral SFA with Ipsilateral Iliac Stent

For the following example, is code 36247 billable for the selection of the right SFA because it was more distal than where the intervention was performed? Also, is it acceptable to bill for the retraction of the catheter into the left CFA with subsequent run-off (36140)?  "Access via left groin, catheter placed into aorta for dx aortogram (75625). Catheter advanced to the right SFA for selective RLE run-off and catheter retracted to ipsilateral left common femoral artery for LLE run-off (75716). Access then warranted on the right side for kissing angioplasty and stenting of the common iliacs (37221-RT & -LT)."

Mammogram Post Axillary Lymph Node Biopsy

For the following example, would you charge as a lymph node biopsy or breast biopsy? If lymph node biopsy, is it appropriate to charge for post procedure mammogram? "52 year-old with newly diagnosed right breast malignancy and prominent right axillary lymph node. The procedure and risks of ultrasound-guided core biopsy and ultrasound-guided metallic localizer clip placement for a right axillary lymph node were discussed in full with the patient. Both oral and written consents were obtained. With ultrasound guidance, aseptic technique, and 1% lidocaine and lidocaine with epinephrine as the local anesthetic, the mass of concern was sampled 3 times with a 14 gauge Achieve biopsy needle. Immediately thereafter, a metallic localizer clip was placed within the mass. Direct pressure was applied to the site immediately post procedure, and hemostasis was achieved. The site was bandaged with antibiotic ointment. POST PROCEDURE MAMMOGRAM was performed in a separate room: The localizer clip is in the expected location of the axillary lymph node."

36002, 76942

If the patient has two separate pseudoaneurysms in the CFA, and the physician does two separate punctures to treat each, can we bill codes 36002/76942 twice?

Doppler Edits

I get an NCCI edit for code 93976. When a female patient comes in for pelvic pain, we do a pelvic ultrasound (76856). If nothing is found, we check for arterial and/or venous flow through the ovaries. Can I add modifier -XU if done on the same encounter?

Hepatorenal Bypass Graft + Addition of Synthetic Bypass Graft

"During the procedure the physician harvested the GSV and attempted to create a proper hepatic to right renal artery end-to-end bypass. The anastomosis was completed, but failed once, and following a revision and re-attempt was found to be too diminutive on arteriography and was removed and abandoned. A 6 mm PTFE bypass graft was then used as the conduit." My question is, with PFTE graft vs. 35535, should I report code 35535 alone with a -22 modifier (assuming documentation states as such) and/or another code for the PTFE graft that was ultimately left in place? (It appears that code 35535 only covers vein, and I cannot find a synthetic.) I would also like to code the arteriography (75726). What are your thoughts?

50393 vs. 50395

I am leaning towards code 50395 for this example, but I have read conflicting opinions that code 74485 should/should not be reported. Could you provide your guidance and opinion? "Indications: Pre-op access for lithotripsy; nephrolithiasis. After injection of 1% subcutaneous lidocaine, an 18 gauge x 15 cm Hawkins needle was used to access a right posterior, inferior calyx under fluoroscopic guidance (after inflation of a proximal ureteral balloon and injection of approximately 5 cc contrast). The stylet was removed, and reflux of urine was confirmed. A 0.035" stiff Glidewire, with the aid of a 5 French Berenstein catheter, was placed in the urinary bladder to maintain access. The Berenstein catheter was then exchanged for an 8.5 French nephroureteral stent. A small amount of contrast was injected to confirm placement. The wire and stylette were then removed. Final sonographic image was obtained to confirm placement. The catheter was sutured into place using a 2-0 silk suture,and it was then capped. Sterile dressings were applied."

Transverse Process Biopsy

Which is the appropriate code for needle biopsy of T9 transverse process? 20220 or 20225?

75710 with 36147

Patient has AV fistula, and physician documents medical rationale for advancing the fistula beyond the anastomosis (i.e., steal/embolus). I am comfortable in the concept that code 36147 includes imaging of the adjacent fistula. However, the question came up that if the physician evaluates only one other artery, is that sufficient for code 75710? Or does it have to be multiple arteries? It's a weird question, but the physician has it in his head that to qualify for 75710 beyond 36147 there should be at least three vessels visualized, but that seems to imply that there is a minimum to use the code. Thanks for any insight.

Conversion of PCN to PNU

I'm not quite sure what codes should be used for this. The radiologist is stating that this is a conversion of an existing nephrostomy tube to a nephroureteral stent. "A scout image demonstrated the existing catheter in place. Contrast was injected into the tube, which demonstrated filling of the renal collecting system. Contrast flowed into an irregularly opacified bladder. A suprapubic catheter was in place. A wire was passed through the catheter, and the catheter was removed. A new 10 French nephroureteral stent was advanced over the wire, and its distal loop formed in the bladder, with the proximal loop in the renal pelvis. The catheter was sutured to the skin, and a sterile dressing was applied. The tube was capped. A drainage bag was provided to the patient in case the tube becomes obstructed."

Graft Angiography, 93459

How do I code left heart catheterization, left ventriculogram with LVEDP measurement, selective coronary angiography, and non-selective LIMA angiography?

ICD9 Code for Chemoembolization

When performing chemoembolization, do you use V58.11 (encounter for antineoplastic chemotherapy) as your primary dx? These encounters are not your typical “chemotherapy”, but I believe they would qualify as antineoplastic chemotherapy. If that is true, then would you also use V58.0 (radiotherapy) when performing a radiofrequency ablation?

Lower Extremity Stent Placement When Performing TAVR

I am finding several of our TAVR procedures where a stent is being placed to access during the TAVR procedure. In the following example, would this be separately coded? Procedure: "We then directly stented with a 9 x 38 mm Atrium covered stent in the right common iliac and a x 59 mm Atrium covered stent in the left common iliac extending into the left external iliac. Of note, the internal iliac on the left was occluded. The stents were deployed at 10 atmospheres. We post-dilated with a 10 mm balloon in the left iliac. We performed another pelvic angio and had an excellent result. We then used the serial dilators, and after applying Rotaglide to the 18 French Edwards E sheath we advanced it into the abdominal aorta. It advanced without significant difficulty. We then crossed the aortic valve, utilizing an AL1 diagnostic catheter and a Terumo Glidewire. We then upgraded to an Amplatz extra stiff J-tipped wire. We performed balloon aortic valvuloplasty with the 23 mm balloon from the Edwards kit. We performed an aortogram to help 'balloon size'."

Epidural Plasma Rich Protein Patch

For the following example, is it appropriate to report codes 62273 and 0232T? "Patient with suspected CSF leak. L1-2 level was localized with fluoroscopy. Needle was then placed in the posterior epidural space under fluoroscopic guidance. Contrast was injected to confirm epidural position. 60 mL of peripheral blood was withdrawn from the IV catheter, which was then centrifuged to obtain 7 mL of platelet rich plasma that was slowly injected into the spinal needle. The patient maintained normal motor function in both feet and denied significant radicular symptoms throughout the injection."

Congenital Echo

Do the same rules apply for a congenital echo that apply for congenital heart caths for patients with a diagnosis of coronary anomalies, PFO, etc.? In other words, for patients with PFO/coronary anomalies, would I code the echo as congenital or non-congenital?

TAVR with Sentinel Device Embolic Protection

Our physicians have begun using a research device called Sentinel for embolic protection, placed in the right brachiocephalic and left carotid arteries during TAVR procedures. The use of embolic protection is not separately reportable with various other coronary and revascularization procedures, but would an additional code (93799) for the placement of the device be allowed when it is performed as part of a TAVR?

Vertebral Fistula

In question ID 5037 from the Ask Dr. Z Database, you suggested code 61624. Does the same hold true for this report? "The right vertebral artery was catheterized with a balloon microcatheter. Balloon was positioned in the high cervical vertebral artery segment. A microcatheter was introduced and navigated into the right vertebral artery and into the origin of the vessel dissection and into the fistulous pouch. Several attempts were made to deploy 3 x 6 mm helical and three-dimensional coil under continuous balloon inflation. Once the balloon was deflated it was noted that the coil was very unstable. The coil was removed. Several attempts were made to reposition the catheter more optimally within the fistulous pouch. When catheter was positioned within the origin of the fistulous pouch, injection was performed to confirm position of the catheter and to evaluate flow through the fistula. During the process of multiple attempts to the further coils within the fistula's pouch, it was noted that after last attempt the fistula was longer present and likely spontaneously thrombosed."

Upgrade to ICD from a Biventricular Pacemaker

Generator and lead isolated. Add leads and connect to new generator. Please suggest CPT codes.

Amplatzer Plug for Biliary Tract

If an Amplatzer plug is placed after the removal on an internal/external biliary drain, would this be an embolization of the hepatic parenchyma? What code would we use for the embolization of parenchyma? "Removal of internal/external biliary drain and placement of metallic biliary stents in a patient with malignant distal common bile duct obstruction. Because the tube tract was not mature, and because the patient has ascites, the hepatic parenchymal tube tract was occluded with an Amplatzer plug."

Balloon Angioplasty Sciatic Artery for Pseudoaneurysm/AV Fistula

Could you please assist with the correct procedure code? I am unsure of which code is most appropriate (37799 or 37220). "5 French Cobra Glidecath was advanced through the sheath into the distal aorta and advanced over a Glidewire to the contralateral left internal iliac artery. Digital subtraction arteriography was performed over the pelvis and upper thigh. Cobra catheter was exchanged over a guidewire for a 12 mm diameter by 4 cm long angioplasty balloon, which required exchange of a 5 French angiographic sheath, a 4 a 7 French Balkan cross-over sheath, into the contralateral persistent sciatic artery. The antiplastic balloon was inflated across the arteriovenous fistula in the distal persistent sciatic artery, and digital subtraction arteriography of the popliteal and lower leg region was performed to the level of the hindfoot. The balloon was deflated and exchanged over a guidewire for a 5 French Davis catheter, which was advanced into the pseudoaneurysm arising from a persistent sciatic artery, and digital subtraction arteriography was performed."

Drainage of Gluteal Seroma with Ablation

Which code (49406 or 10030) should be used for drainage of a gluteal seroma followed by alcohol ablation? And would code 20500 be correct for the ablation? Procedure details (partial): "Following preparation of the right gluteal region and administration of 8 mL, 2% lidocaine local anesthesia, a 12 French pigtail catheter was introduced into the collection using serial CT guidance and Seldinger technique. A total of 480 mL of turbid dark brown fluid was aspirated, and CT scan was performed to confirm coaptation of seroma capsular membrane. Next, 50 mL of absolute alcohol was introduced into the collection. The alcohol was allowed to dwell within the cavity for 5 minutes, during which time the patient was repositioned, and the cavity was compressed externally to distribute the sclerosant CT-directed, catheter drainage, alcohol ablation of pelvic, seroma..."

Indwelling Stent Exchange through Urostomy

What is the correct coding for this case? "The urostomy site was prepped and draped in the usual sterile manner. A scout image demonstrated ureteral stents in place. A 0.035 Coons wire was advanced through the indwelling ureteral stents, which was subsequently removed. Bilateral 7 French Bander catheters were placed over wire. Impression: Fluoroscopic-guided retrograde bilateral ureteral stent exchange for 7 French Bander catheters."

100% in-stent restenosis: Can this be coded as a chronic total occlusion?

The patient had a "100% total occlusion without thrombus in-stent" of a coronary artery stent. The doctor described it as a CTO/chronic total occlusion, and an angioplasty was performed. Would you recommend using diagnosis code 414.2 to describe the CTO and procedure code 92943 for the angioplasty? I am confused as to whether an in-stent restenosis can be coded as a CTO or whether that description can only be used for a chronic total occlusion in a coronary artery that has not been stented.

Renal Vein to IVC Bypass Using Cryovein

A previous question answered to use unlisted code 37799 for renal vein transposition; however, my physician did a renal vein bypass to the IVC using cryrovein. Does this fall under code 37799, or could you use code 35281 intra-abdominal repair with other than vein (for nutcracker syndrome)? "Procedure: I was able to expose the renal vein back towards the left kidney. Meticulous dissection was performed with blunt sharp dissection, and I was able to expose the renal vein to level of both gonadal vein and adrenal vein. I placed Satinsky clamp on the inferior vena cava where renal vein joined. Also placed Satinsky clamp on the left renal vein at level of adrenal vein . The renal vein was divided at its junction with IVC. The IVC was oversewn with 5-0 prolene. We then did end of renal vein to end of cryopreserved vein anastomosis, as we did not have enough mobility in renal vein itself. We brought this down more distally on the IVC and placed a second clamp. We performed longitudinal venotomy, beveled the cryovein, and performed end to cryovein to side of vena cava anastomosis."

Three Acute MIs C9600

Patient has severe coronary artery disease to left main, LAD, and circumflex. Stents were placed in each vessel during myocardial infarction. Patient expired. Can code C9606 be reported three times?

Revascularization of Chronic Total Occlusion (CTO)

I have patient with CTO of the LAD and left circumflex. To bill out to Medicare Advantage plan, would I use codes 92943-LD and 92943-59LC? Or should I bill codes 92943-LD and 92944-LC?

Angioplasty of Superior Gluteal Artery

For the following case, would you code additionally for the superior gluteal artery angioplasty? If so, what code would you use? "Thrombectomy (37184) is perfomed of the superior gluteal artery and the main trunk of the internal iliac artery. Following thrombectomy, there is residual thrombus at the origins of both anterior and posterior division branches, in addition to superior gluteal stenosis and weblike origin stenosis of the internal iliac artery. 4 mm angioplasty was performed of the entire thrombectomized segment, including the two stenoses. The internal iliac artery is stented (37221). Additional thrombectomy was performed of the superior gluteal artery followed by additional angioplasty. tPA is infused along with additional angioplasty. No significant change. Follow-up angio is performed again, and an acceptable result was obtained with good flow."

Occlusion of Left Iliac Limb of the Endovascular Aneurysm Stent Graft

Please advise on the following case example: "Cutdown left common femoral artery. AngioJet device was positioned in the iliac limb. 10 mg of tPA was infused with the pulse generator of the AngioJet into the thrombus of the left iliac limb. We then ballooned that area with a Reliant balloon. We still had thrombus at the top of the main body of the graft overhanging the origin of the left iliac limb. We decided to extend. We got percutaneous access using ultrasound guidance on the right side. We then deployed an aortic extension cuff just below the renal arteries. We then deployed a right and left iliac extension. We pulse dilated with kissing Reliant balloon."

Unsuccessful Placement of ASD Occluder Device

Is the following considered a reduced or discontinued service, as the closure was not completed? "Device was deployed across the AS defect; however, after the sheath was sutured in place, a quick fluoroscopy revealed the device was freely moving in the left atrium. Multiple attempts were made to snare the ASD device, but we were unable to pull the device into the sheath. Emergent CT surgery consult and sent to OR for retrieval."

FFR Repeat Coronary Angiography

The patient first had a left heart catheterization with angiography at his doctor's office owned by our hospital (93458). The patient then was sent over to the hospital for FFR of the LAD and RCA. Our hospital cath lab charged code 93454 for the coronary angiography and codes 93571, 93572 for the FFR. When computing, we are getting an edit stating that code 93454 is a component of 93458 (because the charges for the two facilities are being combined). Is it acceptable for the hospital cath lab to charge for the coronary angiography once again (with the -59 modifier) since it was already performed by the physician office during the heart cath the same day? Or should the hospital cath lab only charge for the FFR? Current charges are: 93458, 93454, 93571, 93572.

CPR with Heart Cath

If while performing a diagnostic or interventional heart cath the patient requires emergent CPR, do we code for the CPR separately in addition to the heart cath procedure? Or is it considered part of the procedure?

XU Modifier

With the new modifiers that go into effect starting on January 1, 2015, could you clarify which modifier we would use in a case where the physician performs a bilateral lower extremity angiogram (75716-26) and then crosses over the bifurcation and performs a POP angioplasty (37224)? Would we still use the -59 modifier on code 75716-26, or would we need to use one of the new modifiers? If so, which one would be appropriate?

ECMO

Are codes 33946 and 33947 for physician use only? Should codes 33951-33954 be used for facility billing of placement of cannula in the cath lab setting even on first day, or are they only for subsequent cannulas (after day 1)?

35883

Patient with common femoral thromboendarterectomy with patch graft performed above the fem-pop bypass. The artery was severely degraded and fell apart during patch angioplasty necessitating the need to go higher in the iliac requiring conversion to ilio-fem bypass. An 8 mm Gore-Tex graft was brought to the table. It was beveled and attached to the iliac with the distal end extending into the bypass graft and sliding nicely together. Would I code for both the endarterectomy and, say, a revision of the graft? Codes 35371 and 35883? Or 35876 alone?

Intended Procedure Cancelled After Anesthesia

I know I can report the intended procedure code using modifier -74, but can I also report the S&I if there is one?

Replacement of One Lead of a Dual Lead Pacemaker

Patient had dual lead pacemaker with RA lead dislodged. Generator was removed, and RA lead repositioning was attempted but was not effective. The RA lead was removed and replaced with an active fixation lead. Both leads were positioned carefully and the device returned and attached to leads. Only one lead was removed, but because this is a dual lead system, should I use code 33235? It was suggested to me that code 33234 should be used since only one was removed. Could you clarify please?

Electroporation with Nanoknife

I've done my share of research, but I can't find much information on the use of NanoKnife for tissue ablation. My initial thought is to use an unlisted code, but I just wanted to run it by you.

Repeated Stress Test

We have an EP physician who wants to do multiple treadmill stress testing (weekly, for approximately 3 to 4 weeks on same patient) for patients starting Flecainide. He is watching for QRS widening under stress. Is it appropriate for our physician to bill codes 93016 and 93018 (93017 for hospital) each time we do this test?

Stroke Protocol

With patients who have possible symptoms of stroke, we perform an MRI and MRA to rule out a stroke. If the MRI comes back negative, we then do an MRA. Can we charge for both or only one? If yes, what modifier would we use?

Nuclear Stress Test, Hospital Coding

The cardiologists in our practice have recently become employed by the hospital, and we need to start billing the nuclear stress test as a global procedure. The hospital was billing codes 93017 and 78452, as well as the radiopharmaceuticals and other drugs used. What codes should we be billing now to cover both the physician charges and the hospital charges? Also, are the injection and infusion codes billable from the hospital side? The place of service is hospital outpatient.

New Modifier Usage, XU Modifier

With the implementation of the new modifiers -XE, -XS, -XP, and -XU, which would be used to report when no previous diagnostic imaging was recently performed? Would modifier -59 still be used in this instance?

Breast Mammograms with Tomosynthesis, Coding CAD Additionally

If a hospital department is performing breast mammograms with tomosynthesis, would you say across the board that the CAD codes should not be coded additionally? The mammogram coded with the tomography code would become the base code for the CAD add-on code. We have checked, and some of the coding pairs (77062 & 77052 and 77063 & 77052) are on the NCCI edit list preventing their use together, but others (for e.g., 77061 paired with 77051) appear to be allowable. I have not been able to find any further guidance to help clarify. I would appreciate your help and expertise.

Femoroperoneal Bypass Graft with Graft Revision

I am hoping you can help with the following case. I don't believe that code 35879 should be billed at the same time as code 35566, but I am considering the use of a -22 modifier. "Once femoroperoneal bypass was completed, ultrasound Doppler was used to evaluate graft, and the graft was found to have relatively low velocities of 15cm/sec in the thigh. There was a significant flow difference noted with velocities of 80 cm/sec in comparison to adjacent velocities of 15cm/sec. Incision was made over the graft, graft was mobilized, and it was decided to proceed with patch angioplasty since abnormality was likely a frozen valve. A segment of residual GSV was harvested and opened longitudinally for patch purposes. Arteriotomy was made through the valve and fibrotic tissue debrided away from the wall. Standard onlay vein patch angioplasty was then performed. Repair was complete, flow restored, and duplex showed no abnormalities with significantly improved velocities. Total procedure time was 7 hours."

Documentation Issue, Paracentesis with Catheter Not Removed

We would sure appreciate your advice. We have a physician who performs paracentesis with an angiocatheter. She does not feel that is necessary to document that the catheter was removed at the end of the procedure because she states that "it is common sense that an angiocatheter cannot be left in the belly". Can we report this to as a paracentesis with code 49083, or do we need to use code 49406 because the documentation doesn't reflect that the catheter was removed? We also have a similar situation with a thoracentesis. She doesn't document removing the catheter (angiocatheter), and she is tellling us that "if she doesn't state it was sutured to the skin then she removed it". Please advise.

Stent of the Common Carotid Origin

One of our surgeons placed a stent at the origin of the left common carotid artery by open cutdown along with aortic arch angiogram. Pre and post angioplasties were performed of the common carotid origin as well. A filter was not used for this case, and the patient has Medicare. The question is, do we consider the procedure of the left common carotid artery origin to be a carotid stent code or unlisted code? Not sure how to properly code this one.

Midline Peripheral Catheter Placement

What is the correct for midline (peripheral) catheter placement? I keep hearing either that codes don't exist or they haven't been clarified. I'm having trouble getting clarification from anyone.

59 Modifier in 2015

I have cases in which two separate procedures were done on the same day by the same physician. For example, a GI tube was placed, and a port-a-cath was done. I have codes 49440, 36561, 77001, and 76937. The documentation is appropriate to what was done. Now I have an edit of code 77001 needing a modifier due to code 49440. With the new 2015 modifiers (-XE, -XS, -XP, and -XU), which one would I use instead of modifier -59?

Biliary Tube Removal

Which unlisted code would you use for this case: 47999 for biliary or 44799 for intestine because they went into the duodenum? Also would I skip coding the conscious sedation because the ERCP immediately  follows? "Procedure summary: 1. Informed consent. 2. Conscious sedation with continuous vital sign monitoring provided by the nursing staff with physician supervision. 3. Injection of existing PTC catheter with small volume of contrast. 4. Removal of the existing PTC catheter over a 0.035 C-wire. 5. 4 French Kumpe catheter advanced over the wire to the level of the mid common bile duct. 6. Mid/distal common bile duct stenosis crossed with the Kumpe catheter and 0.035 Glidewire. 7. Kumpe catheter advanced to the level of the third portion the duodenum. 8. Placement of a 0.035 Jag wire to the level of the ligament of Treitz. 9. Jag wire secured to the skin and patient transferred to the endoscopy unit for further intervention."

Cerebral Venous Catheter Placements and Imaging

Below is an operative report from one of my providers. The provider is indicating we bill as indicated below; however, I think there may be more catheter placements or angiographies. What are your thoughts? • Digital subtraction cerebral venography. • Introduction of needle catheter into the right femoral vein under continuous ultrasound guidance (76937). • Selective catheterization/venography right jugular bulb. • Selective catheterization/venography anterior third of the superior sagittal sinus (36012/75870). • Selective venography torcula second order vessel venous system, AP and lateral views centered over the skull. • Selective catheterization/venography left jugular bulb across the bilateral transverse sinuses (36012/75860 only billing once, not bilateral). • Selective venography left transverse sinus second order vessel venous system, AP and lateral views centered over the skull (36012/75860). • Venous sinus pressure measurements through catheter of the anterior middle and posterior superior sagittal sinus torcula, left jugular bulb, + 9 other vessels (75898 x 1).

Ileal Conduit Stent Placement

We are hoping for guidance on a CPT code for when a stent is placed through the ileal conduit. I have a case where the patient presents with a stricture in his ileal conduit at the ureteral anastomosis causing hydronephrosis. "Through the Berenstein catheter, a Super Stiff Amplatz wire was advanced until it passed through the urostomy orifice. The wire was partially pulled through, and the catheter was removed. A pigtail catheter was then advanced in a retrograde fashion such that the pigtail loop was located in the renal pelvis. The wire was removed, and the catheter was locked into position. Final imaging shows the pigtail loop appropriately positioned within the renal pelvis."

Ileal Conduit Dilation

I'm not sure how to code this. Would it be unlisted, urinary, or intestinal section? "PE: Abdomen/Flank: Soft, non-tender, non-distended. Positive for bowel sounds. No palpable masses or flank tenderness. Well-healing incisional wound. Ileal conduit with clear urine. Stoma somewhat retracted but reddish mucosa visible. The skin may have pulled away from the bowel mucosa. She was experiencing continuous urinary leakage due to a large vesicovaginal fistula at the trigone of her bladder. Patient is now s/p an ileal conduit urinary diversion and closure of VVF defect with democusalized detrussor flaps and concomitant ventral hernia repair. She had revision of her stoma for stenosis, and the stoma unfortunately re-stenosed. Has been staying relatively open - dilated to 28 French today without issues. Patient instructed on how to use self-dilator and will continue to do this several times per week."

Micropuncture Via Open Access Site

Does using a "micropuncture" needle/sheath mean that a procedure was done percutaneously, or can it sometimes mean open? Examples: 1) Dissected out the fistula and then accessed the aneurysm with a micropuncture 6 French sheath. 2) A right upper arm incision was made distal to the axilla. The brachial artery and vein were identified. The brachial artery was circumferentially dissected and encircled with Vesseloops. Needle access to the brachial vein was obtained with a micropuncture needle, allowing placement of a micropuncture sheath. Right upper extremity and central venograms performed, showing occlusion of a previously placed right innominate vein stent. A 6 French sheath was inserted. A guidewire was advanced across the right subclavian and innominate vein occlusion. Balloon angioplasty of the stent performed. The 6 French sheath was exchanged for 12 French peel-away sheath. Gore hybrid stent graft was inserted using the introducer sheath. It was placed into the right brachial vein and deployed after removing the peel-away sheath. The graft was tunneled in a loop fashion.

Lumbar Medial Branch Blocks

For the case below, the coder reported codes 64493-50 and 64494-50. However, the provider wants codes 64493-50, 64494-50, and 64494-59 to be reported. Which, if either, is correct? "Procedure: Lumbar medial branch blocks, BILATERAL L3, L4, L5. The lumbosacral area was prepped with Chlorhexidine and draped in sterile fashion. The skin over the target medial branch nerves was anesthetized with 0.5% lidocaine. A 22 gauge 3.5-inch needle was inserted into the target medial branch nerve under fluoroscopic guidance at each level and location. No paresthesia was elicited with needle placement, and aspiration was negative for blood and CSF. Next a mixture of 40 mg of Triamcinolone mixed with 5 cc of Bupivicaine, 0.25% was evenly divided and injected at each level. An additional 0.5 ml of lidocaine was injected in the needle tract as the needle was withdrawn. The identical procedure was performed at the remaining levels. The skin was cleansed and a sterile bandage applied. Following the procedure the patient's vital signs were stable. Patient tolerated procedure well, and no complications were encountered."

FRED Device

Would placement of the FRED (Flow Re-Direction Endoluminal Device) be coded as an embolization or a stent? It looks like a stent, but it is used to occlude an aneurysm.

Aortic Cuff Placement with IVUS for Endoleak

How would you code repair on Type I endoleak with aortic cuff and IVUS of one vessel?  "Procedure(s): Repair of Type I endoleak with 32 x 39 mm Cook Aortic cuff. Right femoral artery cutdown. Left femoral artery percutaneous access with ultrasound guidance. Intravascular ultrasound of aorta."

Thrombectomy and Atherectomy at the Same Place with Same Device

What is your opinion of reporting code 37186 as add-on to 37225 when thrombus is identified and documented in the primary atherectomy site (NOT in distal anatomy)? Single rotational/aspiration device is used.

Neuro Codes 36215, 36222

My physicians perform femoral cerebral angiograms with endovascular embolizations for maxillofacial AVM. I am not clear on the difference in these codes and which would be a better selection. Please explain because this is unclear to me.

Limited Aortography

I am not sure what I should be coding for this procedure. My physician did a limited aortography. "The sheath was placed in the right femoral artery using the Seldinger percutaneous technique. The catheter was used to perform an ascending aortography, and limited views were obtained. Once he ascertained that there was an aneurysmal dilation of the aortic arch, the procedure was terminated. Conclusion: Aortic arch and descending aneurysm." Since he only did the aortography, I wouldn't be able to report code 93567 due to being an add-on. I was maybe thinking codes 36200 and 75605-26, but I'm not sure. What are your thoughts?

IVUS of IVC and Catheter Placement

Does the IVUS catheter placed at the IVC get reported with code 36010 along with 37250? Here is the verbiage from the operative report: "A venography was performed via the sheath placed in the left common femoral vein with manual injection. I then advanced a Storq wire, after 3000 units of heparin were given, into the inferior vena cava. A peripheral intravascular catheter was then advanced and placed in the mid IVC. Manual peripheral IVUS was then performed from the IVC down to the level of the sheath." Am I correct to report the following: 36010, 37250/75945 (IVC), 37251/75946 (iliac), 37251/75946 (femoral, level of sheath)? The physician did report on the findings of the IVUS at the IVC, iliac and common femoral veins.

Dual Box Change Attached to a Single Existing RA Lead

Per Ask Dr. Z question ID #6250, Dr. Dunn advised coding based on the type of generator replaced. For the case below, will we use code 33228 (dual chamber pacemaker generator) for what was placed, or should we use code 33227 (single chamber) for what it is pacing? "Patient came in for replacement of dual chamber pacemaker battery, which was carried out. Right ventricular lead was left in place and capped. Right atrial lead was left in the right atrial appendage. Guidant Model 1298 generator was removed from the chronic leads. Leads were inserted into the header of the new generator, Boston Scientific Ingenio Mode 390813 (C1785), tightened in place with immediate pacing,  sensing noted, and pocket closed." Later the same day, an addendum was added to supplement the operative note: "Severe scar tissue over leads and generator. When checked, ventricular lead was not capturing, but atrial was working. We were unable to advance wire into proximal subclavian. When given contrast, vein appeared occluded. Instead of going to right side, we assessed the AV, and it was conducting 1:1 even at rate of 140. We implanted generator on this side and put patient on AAI mode." 

Aortic Atherosclerosis Diagnosis

When ordering an aortic study and an ABI study, is it acceptable to use dx code 440.0 for both studies?

Status Indicator N Specifically on 95940

We report code 95940 for IOM monitoring in the operating room. In our system the techs are reporting the total number of minutes of monitoring. I think this should be converted to 15 minutes = 1 unit for reporting on the UB04. Since it is status indicator N, Medicare is not going to pay. Is the correct way to report this in units or minutes? I see in your book that it is important to be reported accurately. Can you explain so that I can explain it to them?

Lead Interrogations

There are several different CPT codes for pacemaker and defibrillator interrogations, and they are separated by the description of single, dual, and multiple leads. Sometimes we have a patient who has a biventricular device with three leads, but one of the leads is turned off, so during the visit you only do threshold testing on two of the leads. Should this be coded as a dual lead check instead of a multiple lead check?

VP Shuntogram

I have a patient with a diagnosis of hydrocephalus. We are performing an injection of the indwelling ventriculopleural shunt. The only code I see is for the peritoneal (78291 and 49427). What are your thoughts?

Thrombectomy, Fasciotomy, and Arteriogram

I need assistance please. Is the arteriogram considered a separate procedure and billable? I'm thinking of codes 34201, 27602, 75710-2659. The thrombectomy was descrbed in detail. "After completing thrombectomy and we had good inflow, we closed the common femoral with running 5-0 prolene sutures and restored flow to the right lower extremity. The patient, however, had no improvement in perfusion and no signals in the right foot. Having found this disappointing outcome after thrombectomy, we removed the prolene sutures and placed a sheath into the right common femoral artery and then did an arteriogram. C-arm came in for this procedure, and we did a number of studies of the right lower extremity using visipaque. Superficial femoral and popliteal arteries were essentially clot free, then we had a "string sign" of the remaining vasculature with what appeared to be vasospasm. After giving verapamil into the sheath and repeat arteriogram, there still showed vasospasm. We decided to perform four compartment fasciotomy." (This procedure is explained in detail.)

Fluoroscopially-guided Balloon Dilation of Esophagus

Could you please tell me if unlisted code 43499 should be used in this scenario, or can code 43453 be used? I am thinking of the unlisted but need help. "A 5 French Berenstein catheter, in combination with a 0.035 inch Amplatz guidewire, was advanced through the oropharynx and cervical esophagus across the anastomosis and into the thoracic stomach. A 14 mm Atlas balloon was advanced over the guidewire and into appropriate position. The balloon was inflated. The waist resolved with inflation to 20 atmospheres. The balloon was left inflated for 1.5 minutes. The balloon was then deflated and removed. Repeat dilation was performed using a 16 mm balloon and inflated to 20 atm for 1.5 minutes. A repeat esophagram was performed. This demonstrated improvement in luminal caliber. There was no extravasation demonstrated."

Fetal Echos

Pediatric cardiologists bill codes 76825, 76827, and 93325 for fetal echos. They also look at the umbilical artery. They want to bill code 76820 in addition to the three above codes. Looks like there is a bundling issue with codes 76820 and 93325, but 76820 pays more. I can't seem to find anything about billing these codes together. I'm assuming code 76820 cannot be billed in addition to these codes, but I would like to confirm.

X-ray of skull and X-ray of orbit in the same day

We had a patient come for X-rays. The patient had an X-ray of the skull 70250 and an X-ray of the orbit. Per coding guidelines it states to use cot code 70250 when less than four views are taken of the orbit. This patient's orbit X-ray was less than four views. Please advise me of how to code this since both an X-ray of skull and orbit were done on the same day. Please advise me of the appropriate CPT code usage along with the correct modifier. If a modifier is necessary please provide me to which procedure code the modifier should be attached to.

Q0 Modifier with Box Change

Could you help to clarify the use of modifier -Q0 in certain circumstances? Let’s assume the patient had the original acid placed for primary prevention and is coming in because the acid is at the end of life and the dx v53.32 is coded on chart. If patient comes in to have only the generator replaced, do you add modifier -Q0 to codes 33262-33264? If patient comes in to have a lead replaced to the existing generator, is modifier -Q0 added to code 33224? If the total system is replaced or upgraded, do you add modifier -Q0 to the CPT codes? Or are the above examples considered secondary intervention and modifier -Q0 not assigned because you have a qualifying dx on the claim (V53.32)?

New Modifiers XE, XS, XP, XU vs. 59

I'm confused as to what modifier would be appropriate for a diagnostic coronary angiogram that leads to the decision to do an intervention. It doesn't seem like any of the new modifiers fit the bill. Would you suggest still using a -59 modifier or using -XU (as that seems closest)?

37236 and 37237 for Aortic and Celiac Stents

Our physicians have placed stents in the celiac artery and lower abdominal aorta due to high grade stenosis. Is 37236 the correct code for the stent placement? The LCD for our area does not include coverage information for the celiac artery or abdominal aorta like it does, for example, the renal and mesenteric arteries. Since it is not included in the policy, does that mean it would be considered investigational for the celiac and aorta or just not covered? Is there any way to be reimbursed for these procedures?

Ventricular Lead in the CS

We have had a few patients with tricuspid valve issues that require our MDs to put the ventricular lead in the CS (using a CS lead), rather than the RV, for a dual chamber pacemaker. How do we code this?

Catheter Placements with EVARS

I am having issues with insurance companies (multiple) denying 34812-50-62-59-51, 36200-50-59-51 with code 36245 on the AAA procedures. The CPT codes that I am charging are: 34802-62, 34825-62, 34812-50-62-59-51, 36200-50-59-51, 36245, 37250, 37251, 37251-76, 75952-26, 75953-26, 75945-26, 75946-26, and 75946-26-76. I am at a loss because I have always charged this and have had no problem before.

Evaluate/Drain Tunneled Pleural Catheter

We have a patient who was brought to the IR department and had an ultrasound scan performed of the left chest to evaluate pleural effusion. The patient was then positioned in right decubitus and had the drain attached to suction to remove fluid. Would you recommend billing for a limited ultrasound, unlisted procedure, or a clinic visit for this service? The order was for a pleural drain evaluation, possible removal versus tPA of loculated collection.

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