Knowledge Base

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Artery repair after percutaneous procedure

I have seen this scenario more than a few times now, and I am wondering if 35226 is appropriate to code. "Patient has intervention on contralateral leg, and a Mynx closure device failed on ipsilateral side where access was. After pressure was held for 20 minutes, the surgeon had to convert to general anesthesia. A femoral cutdown was done to stop the significant bleeding with direct suture control of the puncture site in the common femoral." Would this be separately billable, or would you say that is incidental and included in the procedure?

ECMO Coding

I hope you’re having a nice summer! I know we get a question we can submit as part of our membership, but I’m not sure if this will end up being more than one question based on your answer, ha! I am trying to understand PCS coding for ECMO. In CPT there are separate codes for peripheral insertion and sternotomy insertion but they both map out to: 5A15223-Extracorporeal Membrane Oxygenation, Continuous which maps out to DRG 003. I don’t understand this. Is there another code in PCS for peripheral ECMO that I’m missing? I read and re-read the intro in the chapter of your book talking about the different types of ECMO and it seems like there should be more than one option in PCS.

Mandible Specimen

I have a report for a mandible specimen (six images of resected mandible were obtained). Is it appropriate to report code 76098? If the radiologist is not the one performing the resection, is he/she able to code for the specimen at all?

Appendix B codes and moderate sedation

Many of the codes listed in Appendix G have been moved to Appendix B with a bulls eye strike through symbol meaning moderate sedation would not be reported with the code. Example 93458 is in Appendix B with a bulls eye strike through symbol. According to the notes in the index, moderate sedation would not be separately reported when performed at the same session by the same individual. I interpret this to mean that we cannot report 93458 and 99152 together for either the technical or professional component. Am I interpreting this correctly?

33010 vs 33015

Would you use code 33010 or 33015 for the following example? "Sheath Introducer Kit was inserted into the Pericardium. The sheath kit was removed. Pericardial tap performed & cath inserted into the pericardium. Removed fluid 600cc. Cath sewn in with JP drain. I'm confused because your 2017 book states Use code 33010 when pericardiocentesis is performd through a catheter and left in place for conintuous drainage., but encoderpro's lay terms for 33010: physician places a long needle below the sternum and directs it into the pericardial space.; When fluid is aspirated, the physician may advance a guidewire through the needle into the pericardial space and exchange the needle over the guidewire for a drainage cath. Lay terms 33015 ;When pericardial fluid flows back through the needle, the physician passes a guidewire through the needle into the pericardial space. The physician exchanges the needle over the wire for an indwelling drainage catheter. The physician attaches the catheter to a drainage bag, sutures the indwelling catheter into place on the chest wall, and dresses the wound."

ECA and ICA Endarderectomies

Should we bill endarderectomy x 2 of the ECA and ICA on the same side? "The endarterectomy was initiated. This was created in a subintimal plane in the common carotid artery. The plaque was divided at the proximal point of the resection using the endarterectomy scissors. The endarterectomy was then extended out into the internal carotid artery. The distal portion of the plaque was carefully debrided. After removing this, there was no identifiable flap of tissue in the more distal ICA. An eversion type of endarterectomy was created out into the external carotid artery. There was good backbleeding through the external carotid artery. After completing the endarterectomy, the entire system was irrigated with heparinized saline. After assuring no residual debris at the endarterectomy site, a Core Matrix patch was chosen for the angioplasty. Using a 6-0 Prolene suture, the patch angioplasty was initiated at the distal ICA. A continuous suture of the 6-0 Prolene was used to secure the patch angioplasty circumferentially."

36907-37248

If a physician accesses the juxta anastomosis retrograde and does a fistulogram, and then, because of needing to replace a dialysis catheter, he does a venogram (75860) as well as angioplasty of innominate vein and SVC in the central segment due to stenosis, would he use codes 36901, 36907, and 36581? Or are codes 36901, 37248, 37249, and 75860 appropriate instead?

Axillary vein to femoral vein bypass

We did a left axillary vein to femoral vein bypass using a Gore-Tex graft. Since the bypass graft codes are specific to arterial bypasses, would I use unlisted code 37799?

TAVR with Right Ventricular Pacing

We bill for the hospital, and we were wondering when we bill a TAVR (33361). Can we bill for the right ventricular pacing (93612), or is it also included in the TAVR code?

Cisternogram with Spect

I have a question about the nuclear medicine aspect of the cisternogram. Everything from the lumbar puncture procedure in which they inject DTPA is fine as far as coding. "TECHNIQUE: Following the intrathecal administration, at the level of the lumbar spine, of 1.17 mCi of In-111 DTPA, planar scintigraphic images of the brain were recorded at 24, 48, and 72 hours post radiotracer administration. SPECT imaging was obtained at 24 and 48 hours post radiotracer administration. This study was supervised and viewed for interpretation by the staff and resident physicians. FINDINGS: There is no increased accumulation of radiotracer demonstrated within the ventricles. There appears to be normal ascent of radiotracer over the hemispheres." How would the nuclear medicine portion be coded? They are coding 78647, so medical necessity is an issue. Is SPECT an integral part of doing a cisternogram?

Holter Monitor Date of Service Reporting

What is the correct date of service to report for Holter monitors and Zio Patch monitors? Our department cannot seem to agree whether the date of service reported should be the date the device is put on the patient, the date the device is taken off the patient, or the date the data is read and interpreted. We bill the physician side only, not the facility.

Left Translumbar AAA Endoleak Embolization

How would I code for a pseudoaneurysm repair using only a Chiba needle and the placement of glue? Since 37242 is on the device intensive procedure listing, no device from the list is used. There are no HCPCS codes for Chiba needles. Would we just code the radiology CPT code and 36002?

Chest 71010 following Lung Biopsy 77012/32405

We have been questioned for charging a chest film (71010) post lung biopsy (77012/32405). In your Diagnostic Radiology Coding Reference it discusses that chest film is not separately billable to assess potential complications or completeness of a procedure (e.g., post intubation, post catheter placement). Post lung biopsy chest is not listed. I searched for an NCCI edit between 32405 and 71010 but did not find one. Are we incorrect in charging for the chest 1-view post lung biopsy? Would this be considered assessing possible complications and therefore be included in the biopsy charge?

Injection for 70390

Is any injection code that needs to be reported along with code 70390 (sialography)?

Peripheral Intervention & Cath Placements

When a peripheral intervention (37226) is performed, can you bill a catheter placement (36245-36248)?

PTA to improve poorly maturing RT upper arm cephalic vein fistula.

"Under ultrasound guidance, a 21 gauge needle was advanced into the fistula just above the arterial anastomosis. Over guidewire, a 5 French catheter was placed. Through the catheter, contrast was injected with imaging over the arm and chest. Each was made over a guidewire for a 6 French sheath. Through the sheath, a 6 and then 7 mm balloon were used to dilate the length of the body of the fistula from just above the arterial anastomosis to the upper humerus level. A completion angiogram was performed. The sheath was removed. Manual compression was applied to achieve hemostasis. Findings: Initial ultrasound examination showed a diffusely small, immature right upper arm brachial artery to cephalic vein fistula with two focal severe stenoses in the inflow and body segment. The body of the fistula measured less than 5 mm throughout. Impression: Balloon-assisted maturation of immature right upper arm cephalic vein fistula with dilatation up to severe stenoses as well as length of the cannulation segment." The physician reported codes 37799 and 76937, but shouldn't it be codes 36902 and 76937 instead? 

Exchange of biventricular ICD for a biventricular pacemaker

"Patient's biventricular defibrillator is removed, and a biventricular pacemaker is inserted. Existing leads are reused or capped. No new leads are inserted." We are reporting code 33221 for insertion of a pacemaker with existing multiple leads and 33241 for removal of the defibrillator generator only. How do we indicate that this is a biventricular pacemaker?

Profundoplasty with V-Y Advancement

Our doctor is now performing profundoplasty with VY advancement. Example 1: "The back wall of the profunda and the superficial femoral arteries were trimmed with Potts scissors and then sewn together with running 6-0 prolene sutures." Example 2: "A Y-advancement of the profunda branches was done by bringing together the lateral and medial edges of the two main branches of the profunda with 6-0 prolene sutures in a running fashion." Sometimes this is performed in conjunction with a graft placement; sometimes this is performed with an endarterectomy. How would this be coded? Would this be reported with 35226? Or unlisted code 37799? Or, is this just included in whatever other procedure they are performing?

Replaced Right Hepatic Artery

"A 5 French sheath was placed and attached to a heparinized saline infusion. Exchange was made for an SOS catheter, and selective DSA was performed in the superior mesenteric artery. Superselective catheterization of the replaced right hepatic artery was then performed using a 3 French Progreat microcatheter and wire." Can a catheter reach the right hepatic artery from the SMA, or does it need to go through the celiac artery?

Removal of Trapped Blood

What CPT code would I use for this case done in the OP Wound Clinic? "DIAGNOSIS: Venous insufficiency with symptomatic varicose veins, right. PROCEDURE: Ultrasound-guided thrombectomy, multiple veins right leg(s). The veins were marked using ultrasound with the patient in the standing position. The patient was placed on the treatment table and the right leg(s) was cleaned. Varicose veins were visualized using ultrasound. With the veins localized using the probe, a skin wheal of buffered 1% lidocaine was created at each site.Thrombi were localized using ultrasound and then using an 18 gauge needle, were evacuated. A total of 4 thrombi were removed. Compression was then applied to the treated areas and the patient returned home in good condition. PLAN: Next procedure recommended: USG sclera."

Pipeline Stent 61635 vs 61624

Can you tell me which CPT code (61635 or 61624) is appropriate for the following report? "Using standard technique a 4.75 x 15 mm Pipeline flex embolization device was deployed across the neck of the right paraclinoid internal carotid artery aneurysm proximal to the origin of the PCA and terminating in the midportion of the cavernous segment of the internal carotid artery. After placement, stagnation was noted in the aneurysm, and there was excellent apposition of the device to the parent vessel..."

ICD-10 for Intracardiac Mass

We have run into a conundrum among the coders in our clinic, and we are wondering if you could help us in assigning a diagnosis for "intracardiac mass". Here is what the echo report states: "Normal right ventricular size and systolic function; large right ventricular free floating mass consistent with thrombus or tumor extends through the pulmonic valve; pulmonary arterial systolic pressure estimate 40 mmHg. Discussed with Dr. XXX: intracardiac mass is reportedly known." I appreciate your help.

IVUS

Is there ever a time you would report code 37252 more than once? The code says "initial non-coronary vessel", and MUE is 1 with MAI 2.

Segments of the right hepatic artery

Physician selected segment VI and segment VII of the posterior division right hepatic artery. How do you code it? Is it just 36247? Or is it 36247, 36248, 36248?

Code for LHC w/coronaries w/imaging of the LIMA for potential graft

What is the proper coding for a left heart catheterization with LVEDP measurement, selective coronary angiography, and LIMA angiography (selective or non-selective) for potential graft use in a patient WITHOUT prior bypass surgery or radiation therapy?

34808 or 37242

When would you use 34808 over 37242 in the iliac artery?

35305 & 34203 & 35256

"Patient previously underwent lower extremity fasciotomy and pop-tibial embolectomy and thrombectomy. Three days later he returns to OR for left tibial artery thrombectomy, proximal tibial artery endarterectomy, and repair of the tibial artery wounds with saphenous vein. Exposure made left tibial artery at ankle, patch removed #2 Fogarty catheter, and thrombus removed. Decision made to explore left popliteal artery. Pop artery clamped proximally and tibial artery distally. Arteriotomy made from pop artery into posterior tibial artery. Previous vein patch also removed from site. Patient noted to have plaque at the origin of posterior tibial artery. Vein patch applied at this site using greater saphenous vein. 6-0 prolene sutures applied to patch at pop artery proximally and posterial tibial artery distally. After repair completed, the distal posterior tibial artery was also repaired using a vein patch. 7-0 prolene sutures used for placement of distal vein patch." Can we code 35305, 34203, and 35256? Or is code 34203 included in 35305?

Leadless Pacemaker

Our labs just started doing the lead less pacemaker implants, which I know is 0387T for the implant. We also have the removal (0388T). We have a case where they did a leadless pacemaker change. In this case, would I code for the removal and then the implant (0388T and 0387T)? I could not find any other information on coding these. 

37221/35656?-iliac stent/thrombectomy, fempop bypass w/angioplasty

Help please! I'm coming up with codes 37221 and 35656... do you agree? "We did a longitudinal arteriotomy through the profunda into the common femoral patch, and noticed a very tight stenosis of the origin of the profunda artery. We ran a 4 French Fogarty embolectomy catheter up the iliacs, removed a large amount of thrombus, and re-established some flow back into the femoral. A 7 French sheath was placed into the femoral, and an angiogram to look at the aorta and iliacs showed a long segment left iliac occlusion. We placed an iCAST stent 8 mm diameter, 38 mm length, at the origin of the common iliac on the left, and then angioplastied the remainder of the iliac common femoral with an 8 mm balloon. We then sewed a Hemashield patch over the profunda for the profundoplasty portion. Left lower extremity angiogram showed reconstitution of left popliteal artery above the knee with two-vessel runoff to foot. There wasn't good pulse to foot, so we did a left fem-pop bypass. There was still narrowing at the anastomosis, so we ballooned it." 

Patient underwent EVAR for AAA and LT EIA stent for EIA dissection

"Both CFAs were explored with open technique to gain access to both femoral arteries. Both arterial sheaths were inserted, and then on right side we inserted Floppy wire all the way until it was into the descending thoracic aorta. On the left side, we started by Floppy wire, but it did not go through. Then we tried a more stiff wire, but also at the same time it did not go through because there was severe stenosis at the origin at the bifurcation of the anterior and external iliac artery, and at that point I think there was a small area of dissection in the external iliac artery that happened during the wire placement. Eventually, the wire went through into the descending thoracic aorta. Endovascular repair of AAA with Endurant IIs and additional balloon-expandable OmniLink Elite stent placement to left external iliac for dissection." Please advise on coding. 34812-50? Oor 34812, 37221? Or 37236, 34803, 75952, 36200-50? Is modifier 050 valid with 34812? Which CPT code is correct in this case: 37221 or 37236?

Endarterectomy of radial artery w vein patch angioplasty

"This is in a prior AV fistula that has developed stenosis just above the previously ligated fistula. Patient now has ischemic right hand pain with mild radial artery stenosis. Arteriotomy was made in the radial artery and endarterectomy was performed with removal of plaque from the primary area of stenosis and from the site of the previous arterial venous fistula. The remainder of the plaque was left intact as to not create and end point that would be difficult to manage, because the arterial wall was rather thin." Would you code this with 36832?

Stress Echo CPT 93350 vs 93351 hospital charging

This issue has been an ongoing discussion regarding how the hospital should bill for echo stress with EKG tracings. Current practice for the facility is to charge (bill) 93350 for the echo portion and 93017 for the tracings. There is some confusion if the hospital should be billing 93351 instead. The facility believes that 93351 is physician billing only. Code 93351 is a combined code of the stress echo and the EKG tracings. Can you provide clarification and recommend how the hospital should bill for this procedure? My understanding is that it should be billed with CPT code 93351 when same physician supervises and interrupts the echo and stress EKG. It is noted in your 2017 Dr. Z coding books that the recommendation of the AHA is for hospitals to use 93351 and not the separate codes. However CPT Assistant states: "In the facility setting, CPT code 93350 is always used to report the performance and interpretation of a stress echocardiogram since the alternative stress echocardiography code 93351 is reportable only in the non-facility setting."

93325 billed without 93320 or 93321

A few things in Dr. Z’s Diagnostic & Interventional Cardiovascular Coding Reference lead me to believe that 93325 should not be reported without 93320 or 93321. Like on page 579, #11, it says: “Color flow velocity mapping is an add-on code and, if documented, should be reported in addition to Doppler code.” And page 585, #9, says: “ Add-on code 93325 (color flow velocity mapping) should be reported in addition to the Doppler code (do not use with 93306 and C8929)." And on page 571 towards the bottom, in describing Doppler, he says: “Doppler is displayed in black and white. Color flow may be added to enhance the image by assigning colors to differentiate the direction of blood flow." I am being told that 93325 can be reported alone with its primary code. Can you please clarify the statements from the reference book, and if it's true, in what circumstance does color flow not have to be reported with 93320 or 93321?

Mammogram, one side screening one side diagnostic

We are wondering if there is any coding guidance that would allow us to code a diagnostic mammogram on one side and a screening mammogram on the opposite side as follows: Diagnostic mammogram, unilateral (one side); Screening mammogram, bilateral - with modifier -52 (for the other side). We believe we would code a unilateral screening as screening bilateral code with a -52 modifier if the patient only had one breast, so we are thinking similar logic could be applied to the scenario when one side is clearly done for diagnostic purposes and the other is documented as an asymptomatic screening. We saw the 2012 Q&A on your site, but, since then, we thought we should ask about the -52 modifier for the one-sided screening, one-sided diagnostic scenario. 

Endovascular repair 33881 or stent placement 37236?

The hospital coded 33881, but I see 37236, followed by embolization of a pseudoaneurysm. Am I missing something? M.D. mentions proximal end of stent extending to the takeoff of the left subclavian and stent "flared proximally". HELP! "CATH REPORT: 18 y.o. has history of coarctation with pseudoaneurysm formation, presents for stenting of coarctation and pseudoaneurysm. After informed consent, the patient was brought to the cath lab and prepped and draped in the usual fashion. The RFA was entered and a 6 Fr sheath introduced. Aortic arch angiography was performed. The sheath was upsized to a 12 Fr long sheath for stent placement. The aortic arch was stented with 3.9cm premounted CP covered stent with proximal end extending to the takeoff of the L subclavian artery. No residual gradient. Due to tiny amount of residual flow into the pseudoaneurysm above edge of the stent, an AVP-4 device was used to occlude the ductal ampulla which communicates with the pseudoaneurysm. Stent was flared proximal with 18mm Tyshak balloon. No residual flow." Is this 33881?

TR Band for Radial Closure

Can the TR band or other radial compression device be coded with G0269 (closure device)?

Billing Foreing Body Retrieval 37197

Is it appropriate to bill 37197 in addition to a procedure when using a snare to retrieve a wire that is purposefully used to gain through and through access from two separate points?

Arterial cutdown with peripheral intervention

I was curious as to possibly coding for arterial cutdown with peripheral intervention. Is there a code that can be charged, and why would that be included with the intervention? I would think it would be like using ultrasound guidance to obtain access to the artery. Can you help clarify for me please?

CPT 76932 Ultrasonic Guidance for Endomyocaridal Biopsy

Should we use code 76932 for ultrasonic guidance of endomyocaridal biopsy if the only mention of ultrasonic guidance was of the jugular vein access? Example: "The right neck was prepped. Under direct visualization using ultrasound, the right internal jugular vein was noted to be widely patent and then was accessed under direct ultrasound visualization using a modified Seldinger technique. After which, a 7 French 25 cm venous sheath was then introduced into the right internal jugular vein, and the sheath was drawn and flushed. A 7 French 50 cm Argom Jawz bioptome was introduced into the right internal jugular vein and advanced into the right ventricle. The bioptome was deployed in its normal fashion, and samples were obtained from the RV septum. There were four passes, and four samples were obtained. A 7 French Swan-Ganz catheter was advanced through the sheath, and balloon inflated and advanced to the RA, RV, PA, and wedge positions, with pressure recordings taken at each position. The thermodilution and FICK method were then used to measure the cardiac output."

Catheter placement with lower extremity angiography

Can we bill a catheter placement (36246) with lower extremity angiography (75710, 75716)?

Fiducial Marker Placement

I work for a hospital. I would like to know how to code a case for CT-guided biopsy of right internal obturator muscle soft tissue mass with fiducial marker placement. I plan to use 20206 for the biopsy portion, which I think is appropriate, but I am a bit stumped on the correct code for the fiducial marker placement. The physician states that the location of this muscle is extra-pelvic, so I am thinking that 10035 might be most appropriate. Thoughts?

Extracranial arteries and extremity arteries study

When an extracranial artery study is done and the subclavian artery is also included, can both codes 93880 and 93931 be billed from one report? The report contains the details of the extracranial study, but has just one line of information regarding the subclavian artery. It is my understanding that there would have to be two separate reports to substantiate billing for both studies. Please advise.

Modifier -58 vs. -79

I need help with a modifier question. We've been discussing the use of modifier -58 vs. -59 in the following scenario: A patient with ESRD has an AVF placed. Later, prior to the fistula maturing, the surgeon has to place a DLDC so that the patient may start dialysis treatment immediately. This procedure is in the 90 day global for the AVF creation. I can see possibly using a mod -58 because the reason for placing the DLDC is the ESRD, same reason for placement of the AVF (they are related by those means). However, the procedure itself is not staged or related to the placement of the AVF. In that aspect, I can see using mod -79. Our office is split on what modifier should be used when coding for the placement of a DLDC during the global period of an AVF placement. Can you please give us your recommendation on what modifier to use and why you would choose that one?

Clarification of "same venous access" for 36581/36582

Does "same venous access" mean the same vein? Or does it mean where the catheter enters the vein? For instance, a right IJ TCC is to be exchanged, but it's too high up in the neck to be exchanged, so the old is removed and the new TCC is placed in the same vein, just lower in the neck. Is this an exchange because it's the same vein, or is it a removal of one and a placement of new because the entry access site of the catheter is lower than the previous one? 

Carotid/Aortic angiography

How would you code this angiography performed for additional PDA stent placement procedure with left carotid access? Are codes 36221 and 75605 appropriate? "Multiple diagnostic angiograms were performed in the ascending aorta with a 3 French sheath in the left common carotid artery with different angulations that show previously placed PDA stent in position, protruding into the PAs with unobstructed flow to both right and left branches. There is a left aortic arch with normal branching and no irregularity in the left common carotid artery. The stent is well expanded with no evidence of obstruction. The prior stent extends into the branch PAs almost to the inferior surface of the PAs. At the ductal ampulla, there is an area of ductal tissue not covered by the stent. Also on the aortic end, the PDA stent is not fully opposed to the ductal wall, but there seems to be good flow of contrast through this area. The aortic ampulla is dilated. A diagnostic angiogram in the descending aorta with a 3 French sheath shows no coarctation of aorta. Filling of the arch and PAs through the PDA stent is seen."

PEG tube evaluation with retention disc advancement

How do you code a PEG tube evaluation with retention disc advancement? The report states, "After a contrast injection, the balloon was pulled back against the anterior abdominal wall, and the retention disc was advanced to the 4 cm mark. This was tightened place using 2-0 silk suture."

Catheterization Coding

If you enter the right common femoral artery and advance your catheter into the aorta, take images, and then pull back into the right common iliac, take images, and then remove the catheter, what is your catheterization CPT code? Is it 36200 or 36245?

FEVAR with Endarterectomy

This is a FEVAR with a right iliac dissection and a left distal iliac avulsion. "RCIA dissection was treated using LT radial approach & RCF access for through/through access across LT iliac occlusion. From the LT sheath angioplasty was performed to the LCIA/LEIA - allowing access for sheath. 3 vessel FEVAR (34847) performed. With placement of LT iliac limb, avulsion is revealed and the decision was made to place conduit- subsequently LCIA & LEIA overlapping stents were placed to previous iliac limb and brought down to the groin incision. Placed RT ipsilateral extension (or limb?) terminating within the REIA beyond the level of known occlusion. Returned to LCF to perform endarterectomy-endpoint was created. Next, a Viabahn graft was trimmed to size to allow end-to-end anastomosis with the LCFA." We weren’t sure if we could bill 37221 for the stents on the LEFT. Also, for the avulsion on the LEFT, 35371-endarterterecomy with graft included or would it be 35286 blood vessel repair with graft?

Midline Catheter Insertion

I code for a hospital. We have a Vascular Access Team that performs many midline catheter procedures using a Powerwand. The physician's order is specifically for a midline catheter. The intent is to place a midline catheter, NOT a PICC line. The procedure is performed with the catheter tip in the axillary vein. I code these procedures with 36000, but this code is not authorized by insurance. Many coding authorities suggest coding these midline catheter insertion procedures with 36569 with a modifier -52 for reduced services. I do not feel this is appropriate/compliant since this is not a central venous catheter insertion, nor was that the intent. Your clarification will be greatly appreciated.

G0278

To follow up on a previous question regarding denials on G0278, iliofemoral run-off during cardiac cath... In many cases, the iliofemoral vessels are being assessed because the cardiac cath is being done prior to a TAVR procedure and the doctors want to assess, along with the cardiac cath, if the iliofemoral vessels are suitable for a TAVR procedure. If the patient does not have peripheral disease, the G0278 is being denied. Should I just write off the G0278, or should I be using the pre-procedural examination diagnosis codes such as Z01.810?

Renal Vessels and IVC

For the following, would you use 37799? "Incision was made and vena cava exposed. Right renal vessels were explored. The right renal artery was dissected free for adequate length, doubly ligated, clipped and divided for reduction of inflow. The vena cava was the uncontrolled and tumor was noted to be localized to the segment just above the renal vein. The clamp was able to be manipulated around this area and the tumor milked back into the renal vein. The clamp was secured so no tumor movement was possible. The proximal vein was then readied for control. The right renal vein was divided right at its origin into the cava and the tumor was milked out of the IVC in continuity. The renal vein was then fully divided and the side wall of the vena cava repaired with running prolene suture. Prior to completing the final suture, proximal and distal flush maneuvers were performed. No significant narrowing of the cava was noted. The renal vein was then isolated slightly farther with the tumor intact and the case turned back over to Dr. X for dissection and removal of the kidney."

CT

Can you please provide some guidance on how to charge for this scenario? "A CT urogram was done. A CT lumbar was ordered the same day, but after the CT urogram was completed. They were able to take the data from the CT urogram and reconstruct the data for the CT lumbar." How would you code for this? 

Celiac Stenosis vs Compression

I know you don't usually do a lot of diagnosis information, but I have a question on celiac. When you go to stenosis in the ICD-10 book it takes you to I77.4 for celiac. I don't agree with coding this when we are doing an angio and it is confirmed stenosis and not compression. Is it appropriate to code to mesenteric (K55.1)? I know in a previous question it was stated that it would be considered mesenteric for stent placement, but we wanted to verify that it means to code diagnosis to K55 and not I77. 

CPT code for preplanning artery mapping

My provider is trying to determine donor graft candidacy after a Moyamoya craniotomy. He has ordered a preplanning artery mapping. Is there a CPT code for this?

APUS Tack

Is there a code for placement of Aptus tacks? We have been using an unlisted code (37799) for this procedure. It is for repair of aortic aneurysm attachment using Aptus tacks.

AV Fistulogram, Central Venogram, and Cephalic Vein Angioplasty and Stent

These are so confusing with the new codes. Please help. 1) Initial left upper extremity diagnostic fistulogram reveals a widely patent left cephalic vein except for a 99% stenosis due to a kink at the peripheral side of a previous cephalic vein stent. This is severely limiting outflow from the upper arm cephalic vein AV fistula. 2) Cephalic vein kinked stenosis is crossed with mild difficulty and subsequently plastied to 7 mm diameter and then stented with a 10 x 6 mm Absolute Pro Self-Expanding bare metal stent dilated to 10 mm with an excellent end result and no residual stenosis. 3) Central venogram revealed no central venous stenosis.

Retinoblastoma via extended ophthalmoscopy and fluorescein angiography, etc

"Selective catheter placements and angiographies of the patient's left internal carotid artery, external carotid artery, and ophthalmic artery via a right CFA access. Angiography reveals both extracranial and intracranial internal and external carotid arteries and their branches are of normal course and caliber without atherosclerotic disease, aneurysm, focal area of stenosis, or early draining vein. Ophthalmic artery and its branches reveal a chorodial blush. No significant washout of contrast is noted into the supraclinoid internal carotid artery. 1 mg of topotecan was injected into the ophthalmic artery with follow-up angiography performed with no changes from initial angiogram. 5 mg of melphalan was injected into the ophthalmic artery with follow-up angiography demonstrating no change from initial angiogram. Follow-up internal carotid artery angiography was performed with no changed from initial angiogram. No branch occlusions are seen." Is this coded 61624, 36217, 36218, 75898 x 3, 75894, and 96420 (hospital only)? There is no example of this in your database.

LHC with OPEN aortic pressures

When documentation only supports OPEN aortic pressures, does this equal a LEFT heart cath? My coders are wanting to code a LHC, as they indicate the left heart chamber is accessed for OPEN aortic pressures. Below is an example of what is found in the documentation. "Hemodynamics: Body mass index is 28.7 kg/(m^2).; Body surface area is 2.59 meters squared.; Opening aortic pressure is 124/41 mmHg; mean 70 mmHg."

93571-74, FFR without adenosine

Left heart catheter was done with coronary angiography. FFR on LAD without adenosine was also done during the LHC. How should I code this case for the hospital outpatient facility coding? Should I code 93458 and 93571-74? I am not sure if I can add the fully completed procedure and the procedure with -74.

36593 for thombectomy of vena cava filter?

Could I use code 36593 for the following? "Given thrombus detected on intravascular ultrasound, rheolytic thrombectomy was done with the AngioJet device within the basket of the inferior vena cava filter for 20 seconds. Final intravascular ultrasound was performed, demonstrating marked improvement in volume of thrombus within the filter. Therefore, decision was made to remove the filter in the same setting."

Vertebral Stent Code

I just wanted to verify which code is correct for vertebral stenting: 0075T or an unlisted code? The patient has severe peripheral arterial disease, with occlusion of common carotid arteries, as well as the left vertebral artery. He has had prior left subclavian artery stenting and has intermittent episodes of near syncope and drop attacks. The entire cerebral circulation is supplied by the right vertebral artery, which has a critical proximal stenosis of approximately 80%. He now presents for angiography and possible vertebral stenting. The physician proceeded to do angiography and placed a stent in the right vertebral artery after deploying an Emboshield distal embolic protective device. They PTA'd the stent and removed the filter.

Ablation of Parathyroid Glands

How would either an alcohol or RF ablation of three independent parathyroid glands under ultrasound guidance be coded if performed in a single session? Would 60699 x 1 and 76942 be the correct codes?

Dual chamber PM upgrade to Bi-V ICD using existing leads

Patient with a dual chamber pacemaker is being upgraded to a biventricular ICD. Existing RA and RV leads are functioning properly and will not need replacing. Pacemaker is removed and replaced with a new ICD, and a new LV lead is attached. Should we report codes 33233, 33230, and 33225?

Bilateral Arthrogram

Bilateral shoulder arthrogram done with fluoroscopic guidance and only spot film. I know I can bill for 23350-RT and 23350-LT, but can code 77002 only be billed once per encounter? Or can I bill for each side with an -XS modifier on the second 77002? 

US Guidance with Embolization

Can ultrasound guidance for vascular access (76937) be coded separately with vascular embolization (37241-37244)? The code descriptor states “and imaging guidance necessary to complete the intervention”; however, CPT Assistant, Nov 2013, pg 6-8, states: "US guidance for vascular access is NOT included and separately coded." Also, MedAssets (Code Correct) does not provide bundling issues between the two codes. Is this different from TIPS or IVC filter where the code descriptor states “all associated imaging guidance”?

Angiogram of Fontan Conduit

I understand that contrast injection for atrial and ventricular angiograms is included in 93580, but how can we report contrast injections of the conduit from a previous Fontan procedure when performed at the same session as 93580? Would code 93564 be appropriate?

Angiogram after Bypass Surgery

When a patient has a fem-pop bypass performed, for example, and the surgeon does a completion angiogram and notices stenosis further down the leg and decides to put in a stent based on the completions angiogram, would this be billable with 75710?

93621 Documentation

This is an old question, but I wanted to check again with you. What documentation must be present in order to bill code 93621 (left atrial pacing and recording from coronary sinus or left atrium)? Is a sole statement at the top of the report indicating "comprehensive electrophysiologic studies with coronary sinus mapping and pacing" sufficient? I'm under the impression the CS catheter can be used for multiple different pacing maneuvers for multiple locations, and its presence cannot necessarily be solely equated with left atrial pacing and recording. Is that correct?

36005 and 36011

Can you please explain when it is appropriate to use codes 36005 and 36011? The physician performed a right and left congenital heart cath through existing septal defect, did angiograms, and then did a pulmonary valvuloplasty. Per report: "A hand injection angiogram in the left innominate vein and SVC demonstrates normal venous anatomy and return to the right atrium." Is that statement enough to report codes 75827/36011? I am confused when I can add code 36005 or 36011 and what documentation needs to be in the report. 

Diagnostic angiogram vs. road mapping

If the physician documents the following, would you consider it selective catheter placement with diagnostic angiogram or roadmapping? "A 5 French EnvoyO.056 inch, 90 cm guide catheter was prepared, advanced over a Terumo glidewire (.035in) to the descending aorta, double flushed, and used to select the following vessels: The catheter was then repositioned into the left common carotid artery, and selective angiogram was performed in the cranial views. The catheter was then repositioned into the left external carotid artery, and selective angiogram was performed." Later on in the operative report, physician dictates: "Microwire was inserted into a Prowler select plus, 150 cm, 450 microcatheter, and this system was advanced under roadmap fluoroscopic guidance into left sphenopalatine artery. An angiogram was then performed." I think it should be coded as 36223 and 36227. I would not code the catheterization and angiogram for left sphenopalatine artery. What is the difference between diagnostic angiogram and roadmapping?

Mapping with VT Ablation

Can you bill code 93613 with 93654? I was told this is bundling, but 93613 can be billed with 93656. Is this true? We are billing physician charges not hospital. Also do any modifiers have to go on any of the codes?

36227 without 36222, 36223, or 36224

We have a patient whereby the doctor only did a 36227 (50). In the AMA/CPT book it says this code cannot be used without a 36222, 36223, or 36224, but the doctors are insisting that they were able to look at the externals without having to go into the internals, and because this patient has kidney issues, the internals were looked at during the previous diagnostic angiogram around 10 days ago. The physician could not do the full diagnostic in one day because the contrast is very dangerous for patients with kidney problems, so it needs to be limited and done in pieces. How do I code this then?

32557

For the following, is code 32557 appropriate? "Informed consent was obtained prior to the exam after discussion of risk and benefits of the procedure. No sedation was administered during the exam. CT demonstrated a small hydropneumothorax within the right hemothorax. The skin was prepped and draped under sterile conditions, and 1% lidocaine was used for local anesthesia. A 19 gauge needle was used to access the fluid collection. There was return of a small amount of fluid, which was serous to serosanguineous. A wire was advanced. The tract was dilated to 8 French, and an 8 French APD drainage catheter was placed and connected to a pleuro-vac. The patient tolerated the procedure."

3D Cerebral Embolization

I have a 3D cerebral embolization case, 61624, 75894, with multiple follow-up angios 75898, and I need clarification regarding your instructions on codes 75898 and 76377. Per your 2017 Interventional Radiology Coding Reference, regarding follow-up angiography code 75898, the manual states: "Intracranially, code 75898 may be used as often as medically necessary and requires excellent documentation." Also, page 297, #49 states: "Documentation must support these separate and distinct follow-up angiograms." Could you elaborate further on this type of documentation and what is required? There were also two Q&As from March 3rd and March 9th, 2017 that state 3D reconstruction (76377) should not be reported separately when performed during intracranial embolization with or without imaging. Since there are no NCCI edits on these code combinations can you explain why the 3D imaging is inclusive and should not be billed?

AV Fistula

Can you please advise what CPT codes would be appropriate for the following procedure report? The main question we have is: do we code the PTA of the central subclavian vein, or is it included in 36907? "Procedure report: 1) Ultrasound access to the outflow limb initially with a 5 French, then upsized to an 8 French for Angio-Jet suction. 2) Ultrasound access to the inflow with an 8 French. 3) Balloon angioplasty of the outflow using an 8 x 80 using up to 10 ATM. 4) Angio-Jet suction to the inflow. 5) The inflow 8 French was pulled out and hemostasis obtained with a Z-stitch. 6) Angio-Jet suction of the outflow. 7) Balloon angioplasty of the graft using a 7 x 60 to 10 ATM. 8) Balloon angioplasty of the central subclavian vein using a 12 x 6 initially, and then 14 x 6 up to 6 ATM. 9) Z-stitch to the outflow 8 French catheter." I tried sending the entire procedure note, but it will not allow me to send the complete note.

Unsuccessful attempt to recanalize CTO of RCA

"The patient is with recent cath found to have CTO of the RCA, and is scheduled for attempt to recanalize this occlusion. Access was gained into the right CFA, and a sheath was placed. Through this sheath, an attempt was made to advance a guide catheter, but it was too large for the ostium of the right coronary artery. Eventually, a smaller guide catheter was advanced and selectively engaged the ostium of the RCA. Repeated attempts were made to recanalize the CTO in the distal RCA, but were unsuccessful, as different wires were going subintimal into the distal vessel. The procedure was aborted, and the patient will be considered for medical management versus re-attempt through retrograde access at CTO occlusion dedicated stent there. Conclusion: Unsuccessful attempt to recanlize CTO of the RCA." Would this be considered 92943-53RC? If not, what would it be considered? 93454-53? These unsuccessful attempts really confuse me.

Conventional Myelogram vs. Digital Subtraction Myelogram

"First day, spinal needle was placed in thecal sac under fluoroscopic at L2-L3. A needle was placed over left pedicle of T10 vertebra. Omnipaque was injected to confirm subarachnoid position. 12 mL intrathecal Omnipaque was administered for biplane digital subtraction myelography centered at the thoracic level. Normal saline was then administered. Cervical, thoracic, and lumbar conventional myelographic images were then obtained. FINDINGS: Biplane fluoroscopy confirms appropriate position of the needle at the L2-L3 level. Digital subtraction myelography of the thoracic spine demonstrates no findings specific for CSF leak. Conventional myelographic images of the cervical, thoracic, and lumbar spine exhibit no findings specific for CSF leak (62305). CT post myelogram follows. Next day, repeat complete spinal myelogram (62305)." The conventional myelogram is documented as complete for both days, but the digital subtraction myelogram is thoracic (on first day), then cervical (on second day). Does this documentation warrant coding two complete myelograms for two sequence days?

75710 or 75716 and/or 75774

Can you help some newbies code this procedure? We are in conflict with the pro coders and can’t agree on a correct set of codes. We are unsure if 75716 is appropriate or if 75710 and 75774 work. "Patient has right iliac stent and left-sided sx with probable dz in the left iliac now. Access to right CFA. Abdominal aortogram done. Left LE runoff through the catheter. With the sheath in the right EIA, the right CIA and EIA were ballooned. Then a stent was deployed in the right CIA and in the right EIA in an overlapping fashion. Repeat retrograde angiogram. Advanced sheath over the aortic bifurcation into the left CIA. Angiogram through the sheath. PTA of the left common/external iliac artery high-grade short length stenosis with a balloon. The sheath was withdrawn to the right EIA and then repeated a retrograde angio, then closure."

How to bill 37187 and 37252?

Venous thombectomy was done on right external iliac, right common iliac, right tibial, and IVC. How many times can we bill code 37187 on the same leg? How would we bill an IVUS done on right common femoral, right superficial femoral, and right popliteal femoral? 37252, 37253 x 2?

Venous Malformation of Head and Neck

For performing percutaneous sclerotherapy of a venous malformation in the head and neck, if a digital subtraction venogram is performed through the needle, to confirm the diagnosis prior to sclerotherapy, is there a procedure code that can be billed separately from 37241?

Moderate sedation 99153 as a technical only service

I have a physician who is asking for clarification on where this code is listed as a technical only code and why he can not bill this when he is doing the time at the hospital. Where can I find the guidance on this being only billed by the facility and not the physician when it is an facility setting?

Nuclear Medicine Imaging with Mapping and Y90

The IR physicians are nuclear medicine imaging twice in NM: once for the mapping study with Tc-99m MAA (they charge a liver SPECT) and once after treatment Y90 (they charge a liver SPECT). They charge 78205 and for the SPECT. (It's a zero charge?) I have always used the 78xxx codes for tumor localization, 78801 for multi, and 78803 for SPECT. Which NM code should I be using?

Stand-alone Vascular Lab

I was wondering if you could refer me to where I can get information about coding for the stand-alone vascular lab. Such as what we can bill out over and above the procedure code? We will be billing out in POS 11. Can we bill for supplies, drugs, injections? Will you have a session on this at your seminar, or will you be addressing this in one of your webinars? With these being more common, I need help in making sure that I am billing out everything that I can for our company.

93650 with 93609

I am getting some conflicting information that I was hoping you could clarify. If mapping is performed/documented at the time of an AV node ablation, is it acceptable to report code 93609 with 93650? I am being informed that it is not bundled into 93650 and can be separately coded, but the coding guidelines make no mention of 93650 as a code 93609 can be used in conjunction with, even though it is an ablation procedure.

LINQ procedure provided at the same session of an Ablation procedure

Our providers are performing an ablation (zero global days) during the same session as the LINQ (90-day global) in the hospital outpatient area. What advice can you provide regarding performing and reporting together in the indicated setting?

Sclerotherapy at the same time as RF or ELVS

Additional coding of sclerotherapy at the same time as an RF or ELVS procedure must be in a separate or additional vein that was not treated or it is included. Is this correct?

Left Heart Catheterization with Stent

"Left heart catherization, coronary angiography and left ventriculography. Percutaneous transluminal angioplasty with coronary stent placement in the mid LAD. Percutaneous transluminal angioplasty of the diagonal branch of the LAD. Femoral angiography and placement of the 8 French Angio-seal. Fractional flow reserve study of the LAD." Please tell me if the coding is correct. I have coded: 93458- 2659, 92941-LD, 36245-59, 36140-59, 75710-2659, and 93571-26LD.

Diagnostic VATS 32601

"Decision for VATS for decortication in ER day prior. On insertion of thoracoscope, it was noted that there were significant adhesions with purulence throughout the chest cavity and a trapped right lower lobe and right middle lobe. Based on this, it proved to be difficult to do a decortication through a VATS approach. It was decided to perform a posterolateral thoracotomy. A posterolateral thoracotomy was performed." The provider wants to bill the VATS in addition to the open procedure. Referring to Chapter 5 of NCCI: "However, a diagnostic thoracoscopy is separately reportable with an open thoracotomy, thoracostomy, or mediastinal procedure if the findings of the diagnostic thoracoscopy lead to the decision to perform an open thoracotomy, thoracostomy, or mediastinal procedure, ...with modifier 58."

Cryo Amputation

"Patient came in with infected amputation stump. Physician took patient to OR to debride amputation, but he became unstable and they decided to do a cryo amputation. Stump was packed with dry ice and then wrapped in towels. Patient was taken back to the ICU to see if he would stabilize so that they could then go back to OR for a higher formal amputation." I was planning on coding the debridement, but I'm not sure if we can bill for the cryo. I have researched and can't find anything about billing for this. Any suggestions?

Brugada Procainide Challenge

I know you have answered several questions on this subject before, but, now for 2017.... The coding desk reference for 93024 says: "The purpose of the study is to evaluate for coronary artery spasm. If ergonovine is not available, certain other ergot medications may be infused for the same purpose." So, can I now use 93024 instead of the unlisted code?

Diagnostic Cerebral Angiogram

My physicians often do a bilateral ICA, vert, and ECA with right and left thyrocervcial trunk and right and left costocervical trunk. Is it correct to code 36224-50, 36226-50, 36227-50, and 36218 x 4 with 75774 x 4?

Injection for Pain after Myelogram

I have a patient who was in the hospital (outpatient) for a lumbar myelogram. The procedure was performed and also the post CT scan. Lately I've noticed that I'm getting a report (usually several hours later) for a CT-guided translaminar epidural lumbar spine steroid injection for chronic pain. I billed 62323 for the steroid injection, 62304 for the myelogram, and 72132 for the post CT L spine. I am getting edits between codes 62323 and 62304. NCCI says, "No modifier allowed." My first question is, did I use the correct codes? Is this normal that the radiologist who performed the myelogram would go back and do a spine injection for pain? Like I've said, I've never seen it before, but we do have a newer doctor in the group, and it seems to be his reports. Can you give me any insight on this? 

Ablation not completed

Can you let me know if 93654-52 is the correct way to code this report? "Mapping and ablation of PVC/VT frequent PVC was seen at baseline. 3D mapping in the the RVOT area showed earlier activation in the high septal sit but only had 10-15 ms before the onset of QRS. Ablation at this sirte was not effective. Mapping was then performed in the the LVOT area using retrograde approach. The early site was mapped to the aortic valve area, next to RVOT early site. But the activation time was 10-15 ms before the onset of QRS, suspected on the epicardial site. This sit is also close to the LAD, ablation was not performed. It was determined to treat with bb. Summary: The results of the EP study showed that patient had LVOT PVC near the aortic cup and likely on the epicardial side. It will treated by bb."

2 First-Order Upper Extremity Artery Selections in Same Vascular Family

We have an interesting scenario and are seeking guidance on the correct way to code. If a patient is accessed via the right brachial artery, and the right radial and right ulnar arteries are selected, would that be coded as 36215-RT and 36215-RT for two first order selections in the same vascular family (since 36218 is for additional selections of the second and third order and beyond selections)?

Separate SVC injection/access site from PM upgrade to BiVen ICD

If there is a separate access site/injection for imaging of the SVC and coronary sinus to evaluate the placement of an LV lead during a dual pacemaker upgrade to a biventricular ICD (with LV port capped), can we code separately for the SVC imaging/catheter placement? Ordinarily we know this is included with lead placements, but if the lead was not placed via this injection site, can we code 36010/75827 along with the dual pacemaker upgrade to biventricular ICD (LV port capped) with replacement of right ventricular lead (33249, 33233, and 33235)?

Resection of aneurysmal AV fistula

"We proceeded to dissect down to the brachial anastomosis. We used the same 1.5 cm incision that was placed originally. We dissected down to the aneurysmal portion of the anastomotic region, and the brachial artery was sharply dissected free in addition to the proximal end of the vein, proximally and distally. We transected the venous outflow off the arterial end. We left the cuff and over-sewed. We turned our attention to the venous portions of the vein graft, which is causing symptoms. We incised over the aneurysmal portions and created flaps around the vein since it was fairly superficialized to the skin for multiple areas. There was a thin plane in which we maintained all compromising skin. We dissected down the flaps to create the flaps circumferentially, and the vein was mobilized towards the distal anastomosis. We dissected this free and sharply ligated with sutures. We then removed all the aneurysmal venous portions en bloc." Code 36832 doesn't apply since AV was removed. CPT 37607 or 35011?

Epicardial Leads

I am unable to find anything. For unlisted codes my organization requires a code to compare price to. "INDICATIONS FOR PROCEDURE: Pocket erosion with ICD exposed and infected. The epicardial leads were placed in 2004. FINDINGS AT THE TIME OF SURGERY: No evidence for infection at entry site into chest cavity of epicardial leads. They were divided as the entered the chest cavity to avoid performing thoracotomy and risk of unscrewing leads off the surface of the heart. DESCRIPTION OF PROCEDURE: After successful induction of GETA, sterile prep and drape was performed. She was already on antibiotics. A small incision was made superficially in the area of the previous mini-thoractomy back in 2004. The two epicardial wires were easily identified. No fluid or purulence was noted. Under gentle tension, each wire was cut as proximal to the heart as possible and allowed to retract back into the chest cavity. EP physician will pull out the wires from the pocket. A 2-0 Vicryl, 3-0 vicryl and 4-0 Vicryl were used for closure."

Provider billing 93531, 36299, 93565, 92997 & 92998 is this accurate?

"TAPVR patient, catheter through left jugular vein into innominate vein, angiogram performed, catheter advanced to left lower pulmonary vein & angiogram performed. Catheter withdrawn into left pulmonary venous confluence & angiogram performed. Catheter exchanged for mini-trek balloon & advanced into left pulmonary confluence & inflated two times. Balloon exchanged for larger balloon & inflated two times. NTAG reinserted & advanced to left pulmonary confluence, pressure measurements recorded in LPV & LA. An attempt to advance NTGA was unsuccessful. Catheter exchanged to 4 French Cobra & advanced into RUPV and angiograms performed. Cobra exchanged for Mini-Trek balloon & advanced to right pulmonary confluence and inflated, balloon removed. Cobra cath reinserted & pressures obtained in RLPV & LA." I'm at a loss, as I don't see any documentation for the codes the provider wants to bill. Please help.

Gore-Tex Acuseal Patch Angioplasty

What CPT code would I use for Gore-Tex Acuseal patch angioplasty done at the same time as an AV graft?

LIMA Steal Syndrome s/p CABG

The LIMA to the LAD is noted to have large branches with significant steal. Would you code LIMA steal syndrome to T82.898A?

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