Knowledge Base

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Critical Limb Ischemia

What would be the most appropriate ICD-10-CM for the diagnosis "critical limb ischemia"? My physician always wants to use I99.8, and it is questionable in support of some procedures. I typically make the change to arteriosclerosis of arteries of extremities, etc... but I am wondering if there is a better code to describe the ischemia of the limb.

Discontinued Open AV Fistulogram with angioplasty/thrombectomy

The surgeon was attempting to perform a fistulogram with appropriate intervention (i.e., angioplasty and/or thrombectomy as required) on a direct AV fistula. He was able to insert the wire, but not the catheter. As a result, he opened, dissected out the arterialized vein, incised the vein, and once again attempted to perform the procedure. Again, he was unable to pass the wire completely or the catheter at all. He then discontinued the procedure and closed. Please help. I have no idea how to code this. 


My provider did infrarenal AAA. Using ultrasound guidance, he accessed both femoral arteries. He deployed Gore endovascular stent with careful attention not to encroached the left renal artery. Then, Gore limb was placed into the right common iliac. An extender device was placed from the main body limb just above the left hypogastric. My question is: it is appropriate to report code 34825 since he used another limb extension?

Heart Biopsy for Surveillance of Rejection

Heart transplant patient’s last biopsy result was rejection 6 months ago. The patient came back for surveillance of rejection. Heart biopsy with right heart catheterization was done by Dr. A, and coronary angiogram was done by Dr. B. These procedures were done in one setting. What are the correct codes for hospital in this case? I get an NCCI edit when I report codes 93456 and 93505. 

76942 vs. 76965

We are providing US guidance for the placement of the Ovoid and tandems used in brachytherapy for CA of the cervix. Since the actual treatment source is not being placed, is it appropriate to use 76965 for this procedure?

TAVR & Endarterectomy

For a TAVR procedure (i.e., CPT 33362), it requires an IC and CS to perform the procedure jointly. Each bill with a -62 modifier. If a vascular surgeon does the cutdown, she/he cannot bill separately for the cutdown. However, if the vascular surgeon does the cutdown, the TAVR procedure is performed (IC & CS), upon completion of the procedure, stenosis in the femoral artery is noted and vascular surgeon does the endarterectomy? Can the vascular surgeon bill for the endarterectomy? All based on medical necessity. Thank you!

Pocket Revision Without Relocation

When a pacemaker or ICD pocket is revised but NOT relocated, is the advice still to report an unlisted code, or would reporting the "relocation" code with a reduced services modifier be appropriate for the hospital billing?

Ultrasound-guided Foley catheter balloon decompression w/ catheter removal

How would you code a guided Foley catheter balloon decompression with catheter removal? "The patient was prepped and draped in a sterile technique. 1% lidocaine without epinephrine. Under ultrasound guidance, a 25 gauge needle was advanced from a ventral approach into the proximal penile urethra where there is an inflated Foley catheter balloon. The needle was advanced into the balloon causing immediate decompression of the balloon. The Foley catheter was removed. Four ultrasound images were sent to PACS for documentation. Ultrasound-guided Foley catheter balloon decompression with 25 gauge needle for Foley catheter removal."

Bilateral IVUS

The patient had bilateral femoral access to the vena cava, and IVUS interrogation was performed through both access sites with two pullbacks being performed on both sides (vena cava and external iliac). In coding the IVUS, would we use codes 37252 and 37253 x 3? Or, because there were separate access sites, should we use codes 37252, 37252-59, and 37253 x 2?

Renal Artery Intervention

Patient had stenting on both the right and left renal arteries. Per MUEs, code 37236 can only be charged once per day. Code 37237 is an add-on code for additional arteries, but is code 37237 for additional on the same renal? Or would it be applicable to bill code 37237 for the other renal?

Pre-Procedure Pacemaker

Turning pacemaker on and off during pre and post procedure I would code 93286 x 2 with a modifier -76. We are constantly receiving denials, so I have decided to add this modifier. Is it okay to bill this procedure times two with this modifier?

GI bleed intermittent - angiography with embolization

"Prograde microcatheter was then advanced over a wire into the gastroduodenal artery (third order). A second digital hand injection was performed to confirm good positioning within the descending portion of the gastroduodenal artery. An initial pod 5 mm coil was deployed within the artery in good position. Follow-up injection demonstrated some flow through the coil. A second 4 mm x 15 cm Ruby coil was deployed. Follow-up injection demonstrated near cessation of flow. A 6 French sheath was placed. Through this, a 5 French SOS Omni catheter was advanced over a Glidewire under fluoroscopy. The celiac artery was selectively catheterized, and a digital hand injection was performed. Successful embolization with coils of the gastroduodenal artery centered at the duodenal branches, which are suspected to be the source of the patient's acute intermittent upper GI bleed." Please indicate the ICD-10-PCS codes for this visit. I have 04V33DZ and B4121ZZ. Would that be correct?

Can we bill for TEE ProShield Storage tube?

I have this question from one of my sonographers. Could you please let me know if I can bill patients for a TEE ProShield storage tube? I am told they use this tube on every patient whenever a TEE is done. I have not found any information about it. 

Diagnosis Code for Aftercare of Carotid Stenting

When a patient comes back in for aftercare during the global, following a stent placement in the carotid artery, is Z48.812 the appropriate diagnosis code for the encounter?

Can we code thoracic aortogram w/ right internal carotid stent

It sounds like the surgeon feels the thoracic aortogram is supported for coding as diagnostic separately. CPT code 37215 includes diagnostic imaging of the carotids, but what about the other findings he had from the thoracic aortogram? This patient was transferred from another hospital to this hospital for a stent procedure. The following is from the operative note: "Microsheath was placed, followed by a Magic Torque wire followed by a 6 French 11 cm sheath. The patient was then systemically heparinized to a goal ACT of 300. A pigtail catheter was placed in the patient's thoracic aorta for a thoracic aortogram, which demonstrated patent right innominate artery and right subclavian artery, the right carotid system, with what appeared to be greater than 80% stenosis of the right internal carotid artery. The left subclavian artery was widely patent, the bilateral vertebrals were patentm and the left internal carotid artery appeared occluded. Given these findings, we elected to intervene." Can we code separately for the thoracic aortogram (36221)?

Biopsy Neck Mass

"Ultrasound scanning demonstrated right neck mass. The overlaying skin was prepped and draped in sterile fashion. Using local anesthesia, a total of four 23 gauge FNAs and two 20 gauge core biopsies were obtained. Pathology quick-reading was deferred. Hemostatis was achieved with manual compression. Successful ultrasound-guided right neck biopsy. Full pathology results to follow." Would this qualify for code 21550 or codes 20206 and 76942? 

LHC & Coronary angio with RHC & biopsy s/p transplant

Our physicians have started doing a left heart catheterization and coronary angio on all status-post heart transplant patients at one year out from transplant and then after every two years for graft vasculopathy surveillance as a standard routine. I saw Q&A #9772. Would surveillance for graft vasculopathy support medical necessity to bill the coronary angio? I am assuming the left heart catheterization is not billable, correct?

Bleomycin Sclerotherapy of Submandibular S.T. Ranula

The physician wants to use code 49185 for Bleomycin sclerotherapy of submandibular S.T. ranula, which also included a core biopsy due to solid contents. Does code 49185 only pertain to intra-abdominal procedures, or could you use it for subcutaneous areas? Other options might be 21899 for unlisted with 20206 for biopsy or 20206 with 96401 for non-hormonal anti-neoplastic subcutaneous injection. Any suggestions?

Open and VATS pulmonary wedge resection at same time

What would you code for three pulmonary wedge resections performed: two wedge resections performed on the right lower lobe via thoracotomy and one wedge resection performed on the right upper lobe via VATS. Per the procedure report (abridged): “Posterolateral thoracotomy incision was created… We initially proceeded with wedge resection of the right lower lobe… Two wedge resections were performed in the lower lobe. Once we completed wedge resections of the right lower lobe, we proceeded with the right upper lobe. The thoracoscope was inserted through a chest tube site incision… Once adequate mobilization was confirmed, we were able to identify the lesion that was noted on chest CT. That lesion was easily palpable. It was elevated, and wedge resection was performed with adequate margins using multiple staple loads." Is it appropriate to report codes 32666, 32505-XS, and 32506 to capture different access for one of the wedges? Code 32667 can't be reported with 32505 primary per CPT, otherwise codes 32505, 32506, and 32667 would appear to be the most accurate coding.

HeRO dialysis graft intervention

My physician performed a PTA on 80% stenosis of the venous outflow portion of a HeRO dialysis graft. With the new dialysis codes, would this be considered part of the central segment 36907? Can I get some insight into coding percutaneous interventions for a HeRO graft?

Billing 93455 and 93568 together

I am getting an edit when I try to bill codes 93455 and 93568 together. Can you explain why?

TAVR converted to SAVR

We have a patient who presented for TAVR. The valve was in the body, but was not deployed. A complication arose, and the patient was converted to an open valve replacement. The original valve for the TAVR was removed, and surgical valve was implanted. We are trying to figure out what to code and what to charge for both hospital and physicians. Hospital side we were thinking we would only charge for the surgical repair and code for the surgical repair. Can we charge for the valve that was in the body and then removed as a supply? Does the interventional cardiologist bill for the TAVR with a modifier and the surgeon bill for the SAVR?

Exteriorization of peritoneal dialysis catheter

Would I use unlisted code 49999 for this? If so, what code is it comparable to since there is no repositioning code? "The patient underwent placement of a tunneled and buried peritoneal dialysis catheter about 6 months ago. He now requires dialysis, so I was asked to exteriorize the catheter. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. Only local anesthesia was used. The abdomen was prepped with antiseptic and draped. Xylocaine was infiltrated over the catheter, which was palpable through the skin. The site selected was about 1 cm lateral to the palpable cuff. A small incision was made. The catheter was carefully dissected out and exteriorized. It was not damaged. It flushed and aspirated well. It was connected to tubing with a valve. It flushed and capped. I placed two sutures of 4-0 Monocryl at the exit site to snug it around the catheter. Sterile dressing was placed." 

Right Heart Cath (93451-59) with Biopsy (93505)

Can a right heart catheterization (93451-59) be coded with biopsy (93505) in this case? "A patient with history of orthotopic cardiac transplant, now with mildly reduced ejection fraction and complaining of easy fatigue. Based on patient's mildly reduced EF and fatigue, she was brought to the cardiac catheterization laboratory to evaluate for possible entiology with endomyocardial biopsy and right heart catheterization (RHC). Five endomyocardial biopsies were taken from the right ventricle and intraventricular septum and sent to pathology. Right heart cath was performed with a 7 French Swan-Ganz catheter. The usual pressures were measured along the way. Thermodilution technique was used to obtain cardiac output. HEMODYNAMICS: 1) RA: 11/13, with mean of 10.; 2) RV: 28.5, with EDP of 1-.; 3) PCWP: 16/5, with mean of 13.; 4) PA: 30/16 with mean of 21.; 5. Thermodilution cardiac output: 3.4 L/min with cardiac index of 1.91 L/min per m2. Summary: Normal right and left filling pressures with decreased cardiac index at rest. Result of endomyocardial biopsy pending."

Transvaginal drainage of pelvic fluid coll & Transvaginal bx of pelvic mass

Transvaginal drainage of pelvic fluid collection and transvaginal biopsy of pelvic mass were done transvaginally. Should I use unlisted code(s) for the pelvic drainage and mass (27299) or (20999)? I'm not sure what to use. Please advise, because I don't think I can use 10160 or 20206 or possibly 49180. 

Diagnosis Code for Lead Repaired

Is there a diagnosis code for a lead already repaired (after care)?




With the new technology of subcutaneous ICD implants, would it be recommend to append modifier -Q0 to 33270 when a primary prevention subcutaneous defibrillator is inserted? The NCD 20.4 is not very specific as to what CPT codes require the -Q0 modifier for primary prevention ICD implants, only the diagnosis codes.

4b Branch of Hepatic

I have a case where the left hepatic is coming DIRECTLY off the aorta and not the celiac. "They selected the right hepatic and left hepatic, and then, through the Chung catheter, a microcatheter was used to select the segment 4B branch of the left hepatic artery supplying the tumor. Chemoembolization was then performed of this artery." I cannot find a diagram that shows catheter selection for variant anatomy of hepatics. I have a 36247 for the right hepatic selection, but I'm not sure if 4B is a 36246 or 36247.

CABG with Endovascular Harvest

Could you clarify the guidelines of the CABG section that indicate if the assistant performed the procurement of the graft to assign the codes with an -80 modifier? Isn't modifier -80 only for a physician as an assistant? If the provider indicates the harvest was performed endoscopically, is the add-on code also to be appended with an -80 modifier?

Coding for CAVC when only the common AV valve is repaired

CPT code 33670 for a complete AV canal repair includes the closure of the VSD, closure of the ASD, and the common AV repair. What would you recommend for coding when the ASD and the VSDs are left alone and only the common valve is repaired? There is no CPT code for just a common AV valvuloplasty. What would you recommend: 33670 with modifier -52 because the entire procedure was not completed, or would you choose 33425 or 33463 based on the side of the valve that the MD repaired?

AV graft thrombectomy cutdown then pta percutaneous 36905?

When a thrombectomy through a cutdown using a Fogarty balloon is followed by fistulogram and a separate stick for a percutaneous PTA or PTA/stent for stenosis at the venous anastomosis, is this all covered by CPT code 36905?

Axillo-fem-fem bypass thrombectomy with ligation of fem-fem bypass graft

"Patient noted to have bifurcation at the site with one limb going towards right femoral artery and 2nd medial limb going towards fem-fem graft portion. The medial portion of limb was then ligated and divided and the graft then was repaired using 6-0 Prolene sutures. Next transverse arteriotomy was made with the right limb of graft. Initially Fogerty cath was passed distally and could not go beyond the 30 cm. An angiogram was done through the open portion of fem artery anastomosis. Using glidewire and glide cath, the right SFA was entered and over-the-wire Fogarty used for thrombectomy of SFA. Repeat angio revealed stenosis at right SFA at level of anastomosis. At second attempt at thrombectomy patient noted to have dissection with SFA also. Decision was made to perform angio and stenting SFA extending into bypass graft. Second stent was deployed at anastamosis. Next, thrombectomy was done of proximal graft. #6 Fogarty cath was used to remove the clot from proximal graft. Graft arteriotomy performed and repaired." Should CPT codes be: 35875, 37226, and 75710? Or 35876 and 37226?

Pseudoarticulation Joint Injection

The service is described as a fluoroscopically-guided injection of pseudoarticulation of lateral L5 transverse process on the left and the sacrum. How would you recommend this be coded? 

Billing for Kissing Iliac Stents

I recently entered charges for kissing iliac stents with a modifier -50 appended to code 37221 per your text and the CPT Codebook. We have facility CDMs that are assigned to a CPT code, and in this case code 37221 is built for a unilateral stent placement. Should I attach the -50 modifier to unilateral code 37221 or request a bilateral CDM with the -50 modifier? We don't want to just get paid for a unilateral placement, but I don't want them to bill it twice either.

Tunneled rt sided Aspira Cstheter Placement using US & Fluoroscopic guidan

"Indication: Recurrent right side pleural effusions with history of pneumonia. Physician performed a skin incision four fingerbreadths away from pleural access site and tunneled the catheter to the pleural access site from the anterior abdominal wall. Over a 035 wire under fluoroscopic guidance, a series of skin dilators were utilized followed by a large peel-away sheath. The physician then tunneled a 14.5 French Aspira catheter from the anterior abdominal site to the pleural site and placed it through the peel-away sheath into the pleural space using guidance. This was then closed, and the catheter was affixed to skin. The physician then performed a thoracentesis; fluid was dark amber and was discarded." I'm been told by an old coder to use code 49418, but the coder who replaced her said you code where the catheter stops (i.e., pleural space), so she thinks it should be reported with code 32557. The more I look at it the more confused I become.

TCAR and US assessment

Can you bill for ultrasound assessment prior to TCAR? Note states: "Ultrasound assessment was performed, and skin was marked. Distance from CCA at the clavicle to the bifurcation (lesion) was measured at 5 cm, and this was documented in a hard copy by ultrasound performed by me. The patient was prepped and draped in the usual sterile fashion."


I suggested to one of my physicians that code 93284 be changed to 93289 because there was no documentation of reprogramming or iterative adjustments. He replied that they are reprogramming the device when they "clear the counters" (which was documented in the report) and thinks 93284 should stand. Do you agree? 


How would I code the below scenario? Please help!! "Initially, we had trouble negotiating the right coronary artery into the fistula due to the 180-degree turn; however, once we were able to accomplish the AV loop, we were able to take the Neuro catheter all the way into the mid segment of the fistula. Once we had accomplished this, we removed the AV loop and then advanced the 9 mm microvascular plug. We then deployed the 9 mm microvascular plug successfully and performed an additional angiography conforming that the microvascular plug was in position prior to its release."

CPT 20206 and 20611

"Patient had a left hip arthrocentesis and also aspiration of complex fluid collection along the lateral proximal femur. Spinal needle was inserted into the hip joint and fluid aspirated. There was also fluid collection adjacent to the prosthesis along the lateral aspect of the proximal femur near the hip." Can both codes 20206 and 20611 be reported?

Is this 93923?

The following patient was evaluated bilaterally in digits only for steal syndrome. The physician notes, "Bilateral upper extremity PPG waveforms were obtained of the bilateral upper extremity digits at rest. PPG waveforms are symmetrical. The left upper extremity AVF was than manually compressed with simultaneous PPG waveform of the 1st digit. Upon compression of the arteriovenous fistula, there was no significant increase in the waveforms amplitude." Does this meet 93923 since waveforms were evaluated, or does it still also have to be multiple levels (forearm, wrist, digits, etc.)?

Intraoperative Echo 93355 with 33340

Any word on the NCCI edit change between codes 93355 and 33340 that was supposed to be implemented on October 1st?

Venous Angioplasty

"Patient presents for hemodialysis catheter exchange due to catheter not functioning properly. Catheter was removed, venous angioplasty was performed along tract to disrupt possible fibrin sheath, and a new catheter was placed." In addition to the replacement code, is it appropriate to bill code 37248 for the angioplasty due to this being the tract and not the dialysis circuit itself?

Fibrin sheath through CVC with replacement

If the physician uses CVC to access and clear fibrin sheath and then replaces the CVC, is code 36595 or 36596 bundled into code 36581 for facility coding? "The pre-existing dialysis catheter was dissected free of the underlying soft tissues and partially removed over a 0.035 inch glide wire. Contrast was injected into each lumen, which demonstrated a fibrin sheath surrounding the catheter within the superior vena cava. The catheter was then removed. The sheath was disrupted with inflation of a 14 mm angioplasty balloon. A follow-up superior cavagram was performed. The new catheter was then placed over the guidewire into the superior vena cava such that the tip was at the SVC/right atrial junction."

Medicare Split/Shared Evaluation Services

For Medicare patients seen in outpatient hospital/inpatient hospital place of service, are we allowed to combine the documentation of the same day, face-to-face EM services of a hospital employed NPP and our private practice MD as a split-shared service under our MD provider number? Our coding compliance department has always interpreted the Medicare rules to mean the NPP and MD must be employed by the same practice. Are we correct in our interpretation? 

Iliac aneurysm closed using coils

I am hoping to get help on how to code a specific peripheral procedure. The patient presented with a large right iliac artery aneurysm. My physician accessed the right common femoral artery and was able to successfully close the iliac aneurysm with coils. I am unfamiliar with the use of coils, and I'm not sure which CPT code would be the most accurate to use. Any help with this scenario would be appreciated.

MRI Arthrogram Supply Q9967

Can we bill for the supply of Optiray (Q9967) when used for localization prior to Dotarem injection for MRI arthrogram? "Under CT guidance, a 27 gauge needle was directed into the radiocarpal joint space. 1 cc of Optiray 300 was used to verify intracapsular location. Next, 2.5 cc of 1:200 Dotarem was injected into the left wrist joint. Needle system was removed. There were no immediate complications. Patient was transferred to MRI for further imaging."

Gore Excluder iliac branch endograft 0254T

We are not getting reimbursed for code 0254T in Florida or Michigan by Medicare carriers (considered experimental). Can we recoup and charge 34825 for the external iliac and 34826 for the internal portion? Plus the catheter? These are being performed quite often with AAA repair and Excluder 34802, so code 34900 is not an option. But the iliac branch device is being performed to repair iliac aneurysm. 

Stents in LAD

Can you report code 92928 for stent to the diagonal branch of the LAD and then 92929 for stent to the mid LAD? Or would this only be 92928?


My provider did IVUS of aorta, right femoral artery, right popliteal artery, right tibial artery, and left peroneal artery during revascularization procedure. Can I report 37253 x 4 (right femoral, right popliteal, right tibial, and left peroneal)?

TEE during structural intervention by both interventionalist and anesthesia

This question is in regards to code 93355 for facility billing, when the anesthesiologist places the probe and the interventional physician does the rest. For facility coding, can we charge anything for this TEE since the physician who did the intervention was involved? Just verifying, but we cannot charge a regular diagnostic TEE, correct? 

Brachial artery median cubital vein AVF creation

"A transverse incision 2 cm below the antecubital crease was made. I dissected out the median cubital vein and cephalic and basilic inflow and outflow. I divided the distal basilic and cephalic veins as well as the proximal basilic vein. This created a pedicle out of the median cubital vein. Next we incised the fascia adjacent to the biceps tendon in the cruciate manner. The brachial, radial, and ulnar intercosseous arteries were dissected out and prepared for control. I elected to use a 3-4 mm proximal radial artery as my inflow in hope of preventing ischemia distally. After control of the radial artery and longitudinal incision, I used the basilic vein as a Carrel patch and sewed the median cubital vein to the right radial artery with running 6-0 Prolene. There was excellent thrill in the AVF. The subcutaneous fat was reapproximated with 3-0 Vicryl. Skin was closed with subcuticular 3-0 Monocryl." Should I report code 36821 for this?

CRT-D Downgrade to CRT-P

Would it be appropriate to use code 33229 for downgrade of a CRT-D to a CRT-P? "Procedure: Blunt dissection was used to access the device. The CRT-D device was explanted. The leads were physically and visibly inspected and appeared free of defect. The right atrial, right ventricular, and coronary sinus leads were disconnected from the explanted device and affixed to the new biventricular permanent pacemaker. Conclusion: Successful generator change from a CRT-D to CRT-P."

77012 billed with 20552 Trigger Point injection

I have multiple accounts that hit for a modifier -59 edit for the 77012 against the trigger point injection. Should the -59 modifier be applied to the charge if performed under CT? I cannot find any material on this stating it cannot, and nothing says it is bundled into the charge. Please advise if this can be performed together and reported together appropriately with modifier -59. 

Heart Failure and HTN combination codes I11.0 and I11.9

Please clarify the necessity of using a heart disease code sequenced after I11.9 when the heart disease falls within I51.4-I51.9. I understand that with I11.0 I am to specify the heart failure code following the I11.0... but if I submit code I11.9 for heart disease in the I51.4-I51.9 category, should I code the specific heart disease code following the I11.9 or is it not necessary? Code I11.9 does not have a "use additional code" note following it the way code I11.0 has "use additional code to identify the HF" following it. 

Gallbladder Fossa

How would you code CT-guided placement of an 8 French drainage catheter within the gallbladder fossa biloma? We know the gallbladder fossa is not part of the gallbladder. However, we are having a debate between codes 47533, 49406, and 49405.

FFR 93571--new trend without Adenosine if baseline not below 0.92

It has come to our attention that a new trend has started to not use adenosine on FFRs if the baseline is not below 0.92. I would assume the recommendation is to still bill these as 93571-74 for facility and 93571-52 for the physician coding. Is this correct? 

CPT 33860 and 33870

Can we report codes 33870 and 33860-33864 when total arch replacement is performed? The physician replaced the ascending aorta as well as the transverse arch with re-implantation of the head vessels.

Jump graft from a bypass

Patient had a left brachial artery pseudoaneurysm. A resection was done, and then a left brachial to radial bypass with basilic vein was performed. (I have this coded as 35523.) Then a jump graft was performed from the brachial/radial bypass to the ulnar artery. Can I bill for the resection? I am also unsure if I should code the jump graft as 35523 with a -59 modifier or submit an unlisted code instead.

Midline Catheter Insertion

Is it appropriate to bill code 36568 or 36569 for a midline insertion with a modifier -52?


What information should be documented in an IVC venography report when performed alone or in conjunction with lower extremity venograms? Many times catheter placement is in the iliac vessels, and the reports state, "IVC patent." Is this sufficient to bill 75825? Is it necessary for the IVC venograms to be documented as a full and complete study?

PCI for under-deployed stent

Patient presents with chest pain, status-post stent in the LAD several months ago. Coronary angiogram was done, and IVUS shows under-deployed stent in LD; angioplasty was done to expand the stent. Can we show an angioplasty here? There was no documented stenosis in the report, only the under-deployed stent. 

EKOS Procedure and Pulmonary Angiography

Can I use code 75743 when the physician dictates EKOS done under fluoroscopy (no injection)? "INDICATION: Dyspnea, saddle pulmonary embolism with right heart strain. RECENT HISTORY: ECHO and CT scan show significant PE burden and right heart strain. PROCEDURE: Placement of ultrasound-accelerated catheter-directed thrombolysis to bilateral pulmonary arteries via right femoral approach. TECHNIQUE: Right femoral vein was cannulated using micropuncture, followed by insertion of 6 French sheath. With similar technique, another 6 French sheath was introduced just distal to first sheath, then pigtail cath was advanced into the pulmonary artery with pressures recorded (32/11 with mean 20 mmHg). Following this, two EKOS catheters were placed in each pulmonary artery bilaterally under fluoroscopy and secured in position. The patient was then given 1 mg of tPA through each EKOS catheter for a total of 2 mg. At the end of the procedure, the sheath was then sutured in place, and the patient was transferred to the ICU for 12-hour tPA continuous infusion via sheath." I plan to report codes 37211-50, 36014-50, and possibly 75743. Is that correct?

Diagnostic arteriography during angioplasty or stent.

"The patient is a 74-year-old woman. Approximately 6 months earlier patient underwent treatment of left lower extremity femoral popliteal artery occlusive disease and disabling claudication with placement of covered stents in her left superficial femoral artery. She has developed recurrent disabling claudication symptoms. A recent ultrasound study revealed a new stenosis near the distal end of the stent in the popliteal artery. The decision was made to proceed with further evaluation with diagnostic arteriography and possible percutaneous reintervention. There was no CT scan done." Can I bill 75710-2659 as diagnostic study during the intervention, or would that be considered run-off angiography and bundled with stent placement? We are performing selective left lower extremity arteriography and left lower fem-pop balloon angioplasty.


The CPT descriptions for both codes 93975 and 93976 contain the wording: "Duplex scan of arterial inflow and venous outflow of abdominal....organs" limited or complete. Do both codes require documentation of arterial inflow and venous outflow? If either one of those components is missing, do we code the limited exam, or do we not code the duplex exam at all for lack of documentation?

Vascular Study Question/Technician vs. Reading Physician

For vascular study readings, our workflow is as follows: A vascular test is done. The technician enters the information into the report. The report has his/her name and time listed directly below the impression on the report. Then the reading physician signs each report electronically after he/she reviews the report and the attached images. The physician may or may not make changes to the documentation. If changes are made, the original person (technician) who added the documentation will be removed at that time; however, if no changes are made, the technician’s name will remain on the report. My question is, since the impression was already originally entered by the technician, can we bill for the reading physician since he/she is reviewing the findings? Example: "Conclusion: Negative study for deep vein thrombosis within the left lower extremity [10/6/2017 7:17:25 AM - Doe, John]."

Failed Watchman

Patient arrived for Watchman. Transseptal puncture was done along with left atrial angio and left atrial appendage angio. After reviewing the angios and intra-op TEE, it was determined there was not enough depth to place the Watchman. The hospital updated the patient's status to outpatient and billed 93452. I'm not sure the coding is correct for this failed Watchman. I was thinking of 33340-Q053; however, this must be billed as inpatient. Please advise.

Procainamide Study

What is the appropriate coding for procainamide challenge to rule out Brugada syndrome?

Treatment for in-stent restenosis

Situation: 64-yr-old female with left lower extremity claudication (lifestyle limiting), status post SFA recanalization and stenting. On follow-up, U/S velocities were 600 cm/sec, suggesting high grade stenosis. Patient was asymptomatic at the moment. We performed an angiogram showing 80% stent restenosis, treated with angioplasty/re-stenting. How would you code this?

Stent in RC and then angioplasty in 2 branches of the RC

Physician placed a stent in the RC (92928-RC), followed by angioplasty in the RPDA (92921-RC). Then, he did kissing balloon angioplasty in the RPDA and RPLV (92921-59RC). Can I bill for the third procedure in the right coronary?


A patient is scheduled for a ventral hernia repair. Patient comes in on a separate visit than the surgery for a Botox injection into six different abdominal muscles to relax them prior to the scheduled surgery. Should this be coded with 64647? Or would it be coded with 96401?

Portal Vein Thrombectomy

What code would be used for an open portal vein thrombectomy? The portal vein thrombosis was found at the time of another abdominal surgery. Provider is trying to bill code 34401.

AV Fistula Creation and Ligation

We have a case where the patient had a synthetic AV graft. "Dr. X removed the graft and performed thrombectomy and angioplasty of stenosis to re-establish flow, but due to poor pulsation they harvested the basilic vein and performed an interposition graft. They then created a new direct AV graft, but due to the fact that they found it had poor flow, they tied off the fistula in order to divert all blood flow to the upper extremity." All this was performed during the same operative session. We're looking at code 35236 for the repair and code 37607 for tying off of the newly created AV fistula, but it seems like we're missing something. Since the AV fistula was created and left in (albeit ligated) at the end of the procedure, can we report those codes? And the thrombectomy and angioplasty performed prior to the interposition graft, do we lose those codes because it wasn't successful and therefore the doctor decided to perform the interposition graft and created a new AV graft at a different location instead of replacing the AV graft that was there?

Coil Embolization

Can code 37241 be reported for coil of the right and left perforator veins if the diagnosis is venous stasis ulcers and vein reflux?

37218 or 37236?

For the documentation that follows, how would you code the subclavian stent via femoral access: 37218 or 37236? "We exchanged the 5 French sheath for a 9 French sheath. We then accessed the left subclavian artery with a 6 French Neuronmax access catheter and performed multiple angiograms to better characterize the area of stenosis. We coaxially advanced a 6 x 30 balloon with a Transend wire into the left subclavian artery and performed an angioplasty. Using the rapid exchange system we then advanced and deployed a 6 x 8 x 30 XACT stent at the origin of the left subclavian artery. A follow-up angiogram for surveillance and interpretation demonstrated excellent flow through the left subclavian artery and visualization of the left ascending cervical arteries."

Transcarotid TAVR Approach

Is unlisted code 37799 still the recommendation for TAVR delivered through transcarotid approach? Would code 33366 apply?

Sacral Bone Biopsy

Would a sacral bone biopsy be considered deep or superficial (20220 vs. 20225)?

Ultrasound Guidance

Would you bill the ultrasound guidance in the following scenario? "The patient's groins were prepped and draped in the usual sterile fashion. Given the patient's prior history of a difficult aortic arch and tortuous anatomy, it was decided to obtain access via the right radial artery. The right wrist was prepped in the usual sterile fashion using Chloroprep, and the arm was positioned on an arm board. Under ultrasound guidance the right radial artery was punctured, and a 6 French radial sheath was inserted. This was followed by administration of 500 microgram of verapamil and 3000 units of heparin."

Ultrasound-guided direct puncture of native AAA

History: Patient with AAA with EVAR with type II endoleak. Procedure: Right common femoral arterial access. Distal aortogram. Ultrasound-guided direct puncture of native AAA. A distal aortogram was performed, which demonstrated no feeding vessels supplying the aneurysmal sac. Other attempts were made to undermine the graft but were unsuccessful. Catheters and wire were removed. Anterior abdomen was prepped and draped in sterile fashion. The native aneurysmal sac was accessed with acupuncture needle utilizing ultrasound guidance. Sonographic image was retained. A 0.018 Mandrel wire was advanced and curled in the native sac. A Neff set was advanced over the wire and utilized as access sheath. Contrast was injected, demonstrating thrombus throughout the sac. A Bentson guidewire and glide catheter were used to select various portions of sac, and contrast was injected, demonstrating thrombus within each area; however, no definitive feeding vessels were identified. Wires and catheters were removed." How would the direct puncture of the AAA sac be reported? With unlisted code 36299?

Charging 3D mapping with Biventricular Pacemaker Insertion

Is there a specific CPT to report when 3D mapping is done with biventricular pacemaker insertion, or is this considered inherent to the work of the pacemaker insertion? Example report: "Using mod Seldinger technique, axillary vein accessed x3. We first advanced a St. Jude 2088TC to the RV, but did not actively fixate it. We made sure we had capture and used this as temporary pacer wire in case of heart block. Coronary sinus was cannulated without difficulty. Selective venography showed anterolateral and mid lateral branch and middle cardiac veins. No posterolateral branch seen. Anterolateral branch was mapped with a quadripolar catheter on the 3D electroanatomic mapping system. QLV was 60 milliseconds. Midlateral branches anticipated with much later. Apical portion of this mid lateral branch was much later and yielded QLVF of 140 milliseconds than more proximal and basal aspects. St. Jude1458QL was advanced. We were able to bracket latest activity region on the 3D map with distal 1&2 poles. Bipolar with threshold 2 voltage @ 0.5 milliseconds, impedance of 510 ohms."

Sacrococcygeal Injection for Coccydynia

Which CPT code should be assigned for sacrococcygeal injection? We are considering 20600, 20605, or 64999. "Fluoroscopy was used to identify the bony landmarks of the vertebrae and the planned needle approach. The skin, subcutaneous tissue, and muscle over the area were anesthetized with 1% lidocaine. With fluoroscopy, a 25 gauge 2.5 inch spinal needle was gently guided to the sacro-coccyx joint. Approximately 0.5 ml of non-ionic contrast agent was injected under direct real-time fluoroscopic observation. Correct needle placement was confirmed by production of an appropriate arthrogram, and then the medication (including 40 mg of depomedrol and 0.25cc of 0.5% ropivicaine) was injected. All injected medications were preservative free. Sterile technique was used throughout the procedure."

Bilateral Internal Mammary Artery Duplex

I am having trouble finding the correct codes for the following procedure. I am not finding an IMA duplex study code. "VASCULAR DUPLEX REPORT INDICATIONS: Pre-op CABG. EXAM DESCRIPTION: Bilateral internal mammary artery duplex. FINDINGS: Right IMA Prox 78cm/sec 3.2 mm in diameter Mid 64cm.sec 2.8mm in diameter Dist 56 cm/sec 3.4mm in diameter Left IMA Prox 73cm/sec 2.9mm in diameter Mid 61 cm/sec 3.1mm in diameter Dist 63cm/sec 2.5mm in diameter. CONCLUSIONS Patient s right IMA appears to be WNL per arterial color duplex and doppler flow imaging. Patient's left IMA appears to be WNL per arterial color duplex and doppler flow imaging."

Therapeutic Knee Arthrogram

A patient is seen for knee pain and gets a diagnostic knee arthrogram on the first visit, which is charged with codes 27370 and 73580. The patient is scheduled to come in for the 2nd-5th visits for the pain knee injection. The physician is injecting contrast prior to the drug injection on each of the subsequent visits. The physician is calling this a "therapeutic arthrogram" and would like to charge codes 27370 and 77002 for each of the 2nd-5th visits. I would recommend charging codes 20610 and 77002 instead, since the patient is coming in for the pain injection. What are your thoughts?

Duplex Documentation Requirements

What are the documentation requirements for duplex studies? Can a duplex (93970) be billed if documentation only states, "Bilateral lower limb venous duplex with no evidence of acute DVT"? Or does the provider need to document, “Gray scale imaging, spectral analysis, and color Doppler flow”? Also, do you recommend downcoding from 93970 to 76882 if the needed documentation is not supplied? 

Pacemaker firmware update for cyber security

Our hospital may be having patients come in for pacemaker firmware update for cyber security. When this happens, would we use unlisted code 93799 for this, or is there a specific code that we can use for these updates?

Resection of Infected Saphenous Vein, lower left leg

I've not been able to find a suitable code. Please help. "Patient has phlebitis. Incision to the left leg below the knee. Resection of the infected part of the saphenous vein. The wound was cleaned completely and irrigated using pulsavac. Dressing applied."

Limited femoral angiogram w/cardiac cath

Should code G0278 be reported for the limited femoral angiogram with cardiac cath? We submitted codes 93458 and G0278. "Planned for right femoral arterial approach. The right groin was prepped and draped in the usual sterile fashion. Under Lidocaine 2% local anesthesia a mini-stick needle was then used to access the right femoral artery. The mini-stick sheath was inserted. Limited femoral angiography was performed with hand injection. The mini-stick sheath was then exchanged over a J wire for 5 French pinnacle sheath. A 5 French JL 4.0 diagnostic catheter was used to engage the left coronary artery. Left coronary angiography was performed in multiple views by hand injections of Omnipaque. A JR 4 diagnostic catheter was then used to engage the right coronary artery. Right coronary angiography was performed in multiple views by hand injections of Omnipaque. The JR4 catheter was used to cross the aortic valve and LV pressure measurements were obtained. The catheter was then removed over the J wire." 


Would the code for the aspiration be 10160? "Small dermatotomy was made. A 19 gauge needle was passed into the fluid collection under CT guidance. Approximally 70 ml of clear yellow fluid was apirated from the left apical pneumatocele and was sent for analysis. The needle was removed, and hemostasis was acheived with manual pressure." 

Fistulogram with Two Access Sites

"Once this was completed, we then accessed a second site more proximal in the arm, this time directed toward the arterial anastomosis and passed a wire through the anastomosis into the pulmonary arch hand injection arteriography through a catheter. We then performed over the embolectomy and Angioscore sculpting balloon angioplasty of the anastomosis using a 5 mm angioplasty balloon. As we performed over the wire embolectomy, we brought the clot within the system toward the tip of the opposite sheath where Penumbra When that was completed, hand injection fistulography showed excellent result proximally with a widely patent arterial anastomosis. More centrally, however, there had been re-occlusion with what appeared to be fresh clot, and we retrieved more clot in this location. We also identified a small venous anastomotic stenosis and angioplastied this with a 6 mm angioplasty balloon. At the completion of this, fistulography showed an excellent result." Should this be reported with codes 36905 and 36909? Or 36905 with 36215 and 75710?

Mitral Valve Replacement Code

Successful transcatheter mitral valve replacement using a transfemoral route and a #26 mm SAPIEN 3 device. What's the correct code for this procedure? 

Reoperation before leaving room

This is in follow-up to question #7320 (post-operative complication). "Patient has a carotid endarterectomy. After arterial and skin closure while still in surgery, patient is awakened and cannot move left arm. Patient's neck is opened back up. Patch was removed, and some platelet debris was removed. A cerebral and carotid angiogram was performed, which showed some haziness along the bifurcation but no clear abnormalities." This was a 36223 due to perioperative stroke while still in surgery. Can we charge this? The doctor wants to bill 35800, but as the patient was still in surgery, we are assuming we cannot charge this. These were both performed after patient was completely closed. What are your thoughts?

Descending Thoracic Aneurysm Repair

The report is way too long to type, but this is the basics of this exam: "Ultrasound-guided bilateral common femoral artery access. Endovascular thoracic aneurysm repair with Gore 40 x 10 graft (x 2), left iliac artery repair with 10 mm x 10 cm Viabahn (x 2), completion left iliofemoral bypass." This doesn't cover the vertebral.

Edit - Do Not Report 37215 with 36223?

We reported codes 36223-RT and 37215-LT, but we're hit an edit stating, "Do not report 37215/37216 with 36222-36224." The book states, "If not previously studied, the carotid vessel not being stented may be imaged and reported separately as a unilateral study." Are we wrong? Report: "Access to the right common femoral artery. A Sim 2 catheter was placed at the RCC and into the LCC. Bilateral carotid and cerebral angiography was performed. RCC is free of significant disease. RIC is 100% occluded. LCC has mild luminal irregularities. LIC has a 70% to 80% stenosis. Decision was made to intervene on the LIC artery. Over an Amplatz wire, I placed a 90 cm Penumbra sheath using a Sim 2 catheter. The tip of the sheath was in the distal LCC artery. I put a filter in the petrous portion after starting Angiomax. I pre-dilated with a 3.0 x 30 mm balloon up to nominal pressures that are better luminal expansion and positioned an 8 x 30 mm Precise Cordis carotid stent. The stent was post-dilated with a 4.5 mm balloon. The 80% stenosis reduced to less than 10% stenosis, excellent flow before and after."

Stent-Assisted Coiling

Can you bill codes 61635 and 61624 for the stent-assisted coiling? "Diagnostic cerebral angiogram and stent-assisted coiling. Subsequently the stent was placed and unsheathed through the supraclinoid and ophthalmic segment of the ICA. DSA AP and lateral demonstrated optimal wall apposition. At that time the coil was introduced completely into the aneurysmal dome. Under new roadmapping a 5 x 15 hydroframe coil was introduced into the dome."

Can you bill the femoral angiogram when performing a cerebral angiogram ?

Can you bill the femoral angiogram when performing a cerebral angiogram? "Vessels selected and injected: right vertebral artery, right common carotid artery, right internal carotid artery, left common carotid artery, left internal carotid artery. Findings: Femoral injection: The external iliac artery, common femoral artery, proximal profunda and proximal superficial femoral arteries were normal in caliber and branching. There was no significant atherosclerotic obstruction."


"Patient presented with hematoma rt thigh after foam sclerotherapy; with ulcer. The physician decided to do debridement of the draining hematomas and ulcers. After general anesthesia was administered, the open ulcer was probed; it was draining old blood as was the second ulcer. The bleeding and ulcer tracked along the thrombosed varicosities; it was decided to excise the varicosities en bloc. The physician deepened the elliptical incision and excised them, closed the subcutaneous tissue with sutures." Not sure what the correct code is for this procedure. Nothing really seems to fit. Any suggestions?

Anticipated complete AV block due to catheter ablation of the AV junction

I know you addressed this question in 2016. Since then, our Medicare MAC created a coverage article for single and dual chamber PPM. The article says that the -KX modifier is appropriate for catheter ablation of the AV junction and post-operative AB block that is not expected to resolve after cardiac surgery. Do you think this covers being able to use the AV node block diagnosis code on a PPM even if the PPM is implanted the day before the ablation?

3 Branches in same Major Coronary tree Circumflex

A response to a question posed in 2016 was similar to my question only in regards to interventions of the D2, LAD, S1, where you advised to code all 3 branches using a base code and two add-on codes. When reading the CPT Codebook, "PCI is reported for up to two branches of a major coronary artery. Additional PCI in a third branch of the same major artery is not separately re portable." This seems to say that only two PCIs in the coronaries would be reported per area. Is your advice still valid? I have one I continue to get back and have been asked to clarify this by finance. Does this mean one major (i.e., LC and two branches of it) for a total of three? I have a case where the patient presents with total occlusions his mid-CIRC noted as a CTO, total occlusion of his third obtuse marginal (not noted to be chronic), and stenosis in his second obtuse marginal (this was treated with stent). The circ was treated with stent, and the third obtuse was PTA. I used 92943-LC, 92944-LC, 92929-59LC. Thanks for any advice you have or other sources you may have found. 

His Bundle Lead Placement

Looking for some guidance on a His bundle lead placement for biventricular device. Other leads placed were in the atrial and ventricular. Is unlisted recommended?

Clarification on 76937 "permanent recording"

Does the permanent recording have to be a picture in the medical record, or can it be an uploaded image saved under patient's encounter identifier for date of service that can be accessed if necessary?

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