Knowledge Base

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Fistula stenosis, proximal and sublcavian, with balloon rupture

"Patient comes in for a fistulogram. Stenosis is found in both the proximal fistula and the subclavian innominate junction. The proximal fistula stenosis is angioplastied and has excellent results. The subclavian stenosis is angioplastied and the balloon bursts. The physician is unable to retrieve the balloon without doing an open cutdown. He then makes an incision, ligates the fistula, removes the balloon, and ligates the fistula in the mid arm as well. The patient will now have to come back and get a PermCath placed." Do we only report code 37607, or would the angioplasties be billable as well (36902, 36907)?

Discharge summary

Will there be a discharge summary for elective procedures with no complication? Should the Dr's bill for them if they stay over night? Can an E/M be billed with venous ablation or is it consider global? What is the global period for a Venous ablation post-procedure? Hospital release angiogram? lower extremity PVI?

99152 bundled with New AV Shunt Codes

We continue to get edits on our accounts with the new AV shunt codes 36901-36909 when billed with code 99152 for MD billing. Per your email, these edits were to be removed April 1, 2017. Do you have any updates on this or links to CMS where this was completed?

Balloon Assessment of RVOT

I need help with a heart cath where the physician did a balloon assessment of the RVOT. It appears they were sizing for a pulmonary valve. What CPT code would be used for the following? "Intervention – Balloon assessment of the RVOT: An 0.035" Amplatzer super stiff wire was positioned in the distal left pulmonary artery, lower lobe brach. A 30 mm x 4cm sizing balloon was prepped and advanced over the wire and positioned across the right ventricular outflow tract. The first inflation was slightly distal and had no waist on the 30 mm balloon, with to-fro movement of the balloon in the RVOT. A second inflation was done with the balloon positioned more proximally, and again there was no waist on the 30 mm balloon with a to-fro motion of the balloon on the wire, suggesting that the balloon was not occlusive in the RVOT."

99152 as a stand-alone code

Can we bill moderate sedation if no other billable procedure codes? I am wondering if the moderate sedation codes (99152, 99153) can be billed as the only service for a physician? For instance, on day 2 of BRTO when balloon is removed after venogram verifies occlusion of varices, and no CPTs can be billed for this portion of the exam, but intraservice time still exists and mod sedation is properly documented. Code 99152 is not classified as an "add-on" code.

EKGs

Occasionally the EKGs will not have a reason why it was ordered on the interpretation or the orders. If the EKG isn't normal, I do not have a problem coding it. However, when the EKG is normal, that's when I need that information. Is it okay to look at a progress note, H&P, consult, or other documentation to find the reason the provider ordered the EKG? Does it have to be on the order or reading itself?

Procainamide Challenge

How does a hospital report procainamide challenge when performed in the EP lab?

Mid-Level Assistant

I am having a hard time locating solid resources for guidelines in regards to documentation requirements for a mid-level assistant during CTS/CV surgical services. Would documenting just the name of the mid-level assisting during the surgery be enough to suffice for the services? Or would our physicians need to document what the mid-levels did, the time spent assisting, and why they were needed during the service? Or, does the mid-level need to have his/her own entirely separate documentation of his/her work? I was hoping you can help alleviate this grey area and help find something solid for me to bring back to my doctors and mid-levels.

Cervical Myelogram

We have a disagreement of whether this is a cervical myelogram or not. "Procedure: Informed consent was obtained. With the patient prone on the angiography table, C1-2 level was targeted posteriorly. Skin was prepped in a sterile fashion and anesthetized with 1% lidocaine. A 22 gauge spinal needle was introduced carefully under fluoroscopic observation into the posterior thecal sac at the C1-2 level. Approximately 12 mL of Isovue 200M were injected. Needle was removed. Several digital spot films were obtained. Patient tolerated the procedure well without immediate complications. Findings: Surgical changes are present consistent with prior anterior fusion at C5-C7. Superior screws at C5 have backed out as noted previously. No fracture of the hardware. No vertebral body fracture. No myelographic block. No obvious stenosis in the opacified thecal sac." I believe that the correct codes for this procedure would be 61055 and 72240; however, I am being told code 72240 is not appropriate. Which is correct?

Iliac Aneurysm Repair with Branched Device

Our physician treated an abdominal aortic aneurysm with a Gore Excluder graft (34802) and also an iliac aneurysm with a branced iliac device at iliac bifurcation into the hypogastric and external iliac (0254T). The hypogastric artery had severe stenosis at the origin, so he also placed a covered stent and did angioplasty. Is the hypogastric stent a billable service, or is it considered the deployment zone of the iliac branched device at bifurcation? If it is billable, would it be an extension limb 34825 (which I don't believe so) or a stent/angio with 37236?

Arteriosclerosis of Carotid Artery

Which would be the correct ICD-10 code for arteriosclerosis of carotid? I70.8, I65.2_ or something else? If I65.2_ is appropriate, does it have to have an occlusion AND stenosis?

"Radiological" Examination surgical specimens

Our radiologists are currently performing “ultrasound exam on the surgical specimen” post breast biopsy. As coders, we have been debating on which is the most appropriate code to capture this service. Some coders believe it should be reported with unlisted code 76999, and there are other coders, like myself, who believe it should be reported with code 76098. Rationale for suggesting 76098: Based on CPT description, this code defines “radiological examination, surgical specimen”. While it's customary for this study to be done via x-ray (radiograph), the term “radiological examination” is very broad and does not restrict us to any particular modality as long as a radiological evaluation is done on the specimen(s) obtained.

Stand alone TPA Infusion

"Patient presents with a malfunctioning dialysis catheter. TPA infusion is ordered by the interventional radiologist, and a 4 mg dose is infused over a two-hour time period. At the end of the infusion, the catheter is flushed and found to be working, and the patient is sent home. No fluoro evaluation or contrast injection deemed necessary." Would this be reported with code 36593, or would it be more appropriate to use 96365 or an E/M code for the facility service?

Nephrourerteral stent (drains externally) vs ureteral (internal catheter)

Could you please review the following and determine if this is an externally draining stent vs. an all internal stent? Our docs are calling this a nephroureteral stent but there is no mention of the external drainage. "Thereafter, a 0.035 Glidewire was advanced down the ureter. A Kumpe catheter was advanced over the Glidewire, and this was then directed into the bladder beyond the UVJ obstruction. The wire was then exchanged for an Amplatz stiff wire. Over this Amplatz stiff wire, the tract was dilated. Finally, the 8.5 Fr nephroureteral stent was placed with appropriate formation of the pigtail catheter in the renal pelvis and bladder. This was confirmed with contrast injection."

AV Fistulogram with anigoplasty and basilic venogram

When an upper extremity brachial artery to cephalic vein fistulogram is performed with angioplasty of the cephalic arch followed by selective catheterization of the basilic vein with venogram of left upper arm to determine whether or not the patient is an adequate candidate for a surgical turndown revision, what would you code for the basilic venogram in addition to 36902?

Coding IVUS (noncoronary vessel): Vessel vs system?

"The IVUS catheter was advanced. It was initially placed through the right groin and advanced towards the IVC at the level of the renal veins. IVUS of the IVC, common and external iliac veins and common femoral vein was performed which demonstrated patent IVC, right common iliac, external iliac and common femoral veins. There was no evidence of a significant compression or stenosis. IVUS catheter was advanced then from the left groin up to the IVC at the level of the renal levels and images were obtained of the IVC, left common iliac, left external iliac and left common femoral veins. There was no evidence of a significant compression of stenosis." The CPT description of the 37252 states "vessel", so can we code for each “vessel”? IVC, RT common iliac, external iliac, common femoral, LT common iliac, external iliac, common femoral vein (7 CPT IVUS codes – 37252, 37253-LT x3 and 37253-RT x 3) Or, Code for the main vessel or system only? IVC and RT and LT iliac systems (3 CPT IVUS codes – 37252, 37253-LT and 37253-RT)

SMA extension of stent due to endoleak seen on postop CTA

"Patient is status-post thoracic endovascular stent graft without coverage of the left subclavian artery with distal extension for chronic dissection of thoracic aorta (Oct 2016) and percutaneous two vessel fenestrated-EVAR to the celiac and SMA with proximal extension of abdominal aortic endograft for AAA (Jan 2017). Postop CTA showed stable size of the thoracoabdominal aorta false lumen/aneurysm sac, but with dreased contrast filling, which is likely type II endoleak. Procedure: A 7x22mm iCast stent was advanced into the SMA an positioned distal to the existing stent to extent the stent." Would you code this as an embolization (37242) or stent placement (37236)?

Atherectomy and stent placement in Iliac territory

"Patient with kissing stents with findings of dense calcification in the infrarenal aorta with mild progressive narrowing in its mid-portion, then abrupt occlusion of a right-sided aortic stent 3 cm proximal to aortoiliac bifurcation, occlusion of right CIA, EIA stents and native femoral artery. Atherectomy of right CFA, then EIA/CIA stents, then finally distal aortic stent and native aorta. Post atherectomy, angioplasties of iliofemoral and aortic segments were followed by re-lining the occluded stents with new Omni-Link Elite stents: 6 x 59 mm in aorta, 6 x 59 in right CIA, 6 x 39 in right EIA." Can we capture code 0238T as well as stent placement in the CIA/EIA even though no reference is made to the "intent" for the atherectomy being to fully treat the stenosis and outcome being unsuccesful with reason of additional stent placements (re-lining of existing stents)? Aortic stent segment looks to be the right iliac "kissing" stent extending into the aorta, which would be included in the CIA stent code(?). Can we capture the native atherectomy additionally with code 0236T? 

Nephrostomy Tube Removal under fluoroscopic guidance

A question has come up whether the radiologist needs to document in the report the reason why a nephrostomy tube needed to be removed under fluoro guidance. Is this required in the report in order to bill code 50389?

Peripheral dialysis stent from remote access

"Arterial limb of graft accessed antegrade towards the venous outflow. Thrombectomy & angioplasty of arterial limb performed. Attention was then turned to the recurrent basilic vein outflow stenosis. A fluency stent delivery device could not be introduced to bare back. Right common femoral vein accessed. Glidewire utilized to select the innominate vein and cross the left basilic vein stenosis retrograde. Exchange length Magic torque wire then placed across the basilic outflow vein stenosis from the common femoral access. 10 x 60 mm fluency endograft on long delivery then advanced across the basilic outflow stenosis and deployed under guidance. The Magic torque wire was pulled back to the innominate vein, allowing advancement of the 8 x 60 mm for in-stent angioplasty. Final angiogram via the sheath demonstrated excellent result with brisk forward flow through the basilic outflow and no residual stenosis or venous injury." Is this 36906 only? Or is the remote access separately reportable?

Difference between 92973 and 92975

I have a note where an AngioJet thrombectomy was performed during an AMI, and the provider see-saws through the note describing it as reholytic thrombectomy vs. reholytic thrombolysis. I'm assuming that treatment of a thrombus with an AngioJet in the standard fashion is considered 92973, and in this note I'm not seeing a description of the service that looks like true thrombolysis to me. Can you describe the details that may be seen in a note if 92975 was performed?

Balloon dilation after thrombectomy for slight deformity? 36905/36904

I believe the correct code should be 36904 for the thrombectomy; however, the physician wants to charge for the angioplasty as well-36905. "The right forearm was prepped and draped in the usual sterile fashion.  A 19 gauge butterfly needle was introduced into the fistula and diagnostic venography was performed. 6-French vascular sheaths were placed with ultrasound guidance at the apex of the graft. Two sheaths were placed. One oriented toward the arterial side in the second sheath oriented toward the venous anastomosis. A 6 mm balloon catheter was used to fragment the thrombus on the venous side of the graft. The same balloon was used to remove the plug from the arterial anastomosis and it was pulled into the graft. The thrombus was then fragmented. Vigorous flushing of the graft was performed with saline. This resulted in restored flow through the graft. No residual thrombus present after completion of the thrombectomy. There is slight deformity of the arterial anastomosis. This was then dilated with a 7 mm balloon. There was good flow through the graft."

Is there a CPT code for HIS bundle lead placement for BiV pacing?

Is there a code when a lead is placed at the His bundle instead of the coronary sinus for biventricular pacing? This may be done along with 33207 or 33208. Code 33225 is not appropriate, as the lead is not placed in the coronary sinus.

Peripheral Angiogram coding of diagnostic codes

I am fairly new to coding peripheral leg angiograms and would like some clarification on if this coding seems accurate for an OBL setting in Texas. "Patient's first angio. Procedures performed: 1) Abdominal angio with distal runoff. 2) Right lower extremity angiogram. 3) Selective injections below knee in the third order. 4) PTA and atherectomy of the right peroneal artery. 5) PTA of the right anterior tibial artery. 6) PTA of the right posterior tibial artery. 7) 70 of contrast was used; zero waste. 8) Moderate sedation monitoring 0715 - 0835. 9) Medication: Benadryl 50 mg, IV Versed 2 mg, IV Fentanyl 50 mcg, intra-arterial nitroglycerin 700 mcg, Plavix 600 mg." Would I code as followsL 75630-XU, 75710-XU, 36247-XU, 37229, 37232, 37232, Q9967, 99152, and 99153 x 4? Can the monitoring of the sedation continue outside of the procedure room? Can I bill for any of the meds listed?

Neuroplasty During Fistula Revision

I'm looking for guidance on the following procedure since we see it every so often with AV fistula cases. "...Once the vein was completely mobilized, it was it was examined and found to have good flow. The median antecubital nerve was noted to split evenly at the mid to distal aspect of the basilic vein, and, instead of dividing one of the branches, I elected to perform a neuroplasty to split the nerve fibers longitudinally all the way to the axilla. This was done painstakingly with fine scissors to split the perineurium and then the nerve fibers with gentle counter traction. After this was performed, the vein was brought up between the two branches without difficulty."

CTO unable to completely cross

I have a case in which the physician was able to cross the chronic total occlusion of the distal RCA stents with a wire, but was unable to fully cross the lesion with the balloon. He inflated the balloon in the proximal portion of the occluded stent, but was unable to advance devices any farther. It appears the previous stent was under-expanded, preventing the device from crossing. Laser atherectomy was also performed. Can I code for the CTO with a modifier since it was the intended procedure and numerous attempts were made?

Medical necessity to code 36581

"Patient with known SVC occlusion, attempt to balloon dilation via his permcath as the primary access. PermCath was accessed, wire placed into IVC. Left common femoral vein was accessed a sheath was placed and then a wire placed into IVC. Confirmation I was in the correct location was performed with imaging. Next, I snared the wire from above and pulled it through the groin. In this way, I wanted to maintain access as the patient's only access for dialysis at this point was his PermCath. PermCath was dissected free using lidocaine and blunt dissection. PermCath was removed and sheath was placed. Through this, a venogram was performed. This demonstrated that we were through the occlusion, and therefore a balloon was placed across SVC and prox innominate vein for angioplasty of the occlusions. After I had exhausted many different attempts, I eventually replaced the PermCath (36581)." This patient did not come for catheter exchange. Should we code only catheter placement with venoplasty (36010, 37248)?

Sinogram of PD Catheter

We are struggling to get a CPT code for this procedure. Our surgeon performed this in the OR, not in IR, thus the two CPT codes we are getting (78291/49427) are not appropriate with a 360 Revenue Code. We need to validate we are reporting the right CPT code. The procedure note reads: "The procedure began by making a fluoroscopic evaluation with injection of contrast into the PD catheter. This had free flow without difficulty. There was a slight bend in the AP view that could have been kinking. Medial lateral oblique images demonstrate curve not kink. Free flow contrast flowed into the abdomen and pooled into the pelvis. I then aspirated 22 cc of the 30 cc I injected back out easily without difficulty. We then hooked up the gravity dialysate bag and she easily tolerated free flow dialysate intraperitoneal followed by free flow out without difficulty. Catheter appeared to be working well."

78454

When I bill code 78454-26 with 99232 they always deny it saying it is incidental to 99232, even if the diagnoses are different. Code 78454 is a Lexiscan. I don't understand why they say it is included in 99232. How do I get it paid?

Fenestrated TVAR

How do you code for a fenestrated thoracic endograft with a subclavian branch? Should it be unlisted or something else?

Ablation for AFib after PVI ablation

Our cardiologist dictates a wonderful PVI ablation and after words states "removed catheter". In the pre report on what was done he states he also did an ablation for A-fib along with the PVI ablation. When I review the cardiology log for this patient, it does look like the ablation for A-fib was done after the PVI ablation. Does the cardiologist need to specify in the report that re-assessment and pacing done showing A-fib after PVI ablation, or is it just needed for addition arrhythmia ablation? When an ablation is done for known A-fib, can we code off the log? If he knows before the surgery that the patient has A-fib, is it necessary to re-pace after the PVI ablation? 

Overlapping Stents performed in 2 Separate Veins

"Severe compression of the right common iliac vein was treated with Wallstent 14 x 90 mm. Right external iliac vein was treated with Wallstent 14 x 60 mm overlaping with common iliac vein stent. Severe compression of the left common iliac vein was treated with Wallstent 18 x 90 mm. Left external iliac vein was treated with Wallstent 16 x 60 mm overlaping with common iliac vein stent. Self-expanding stents were deployed under x-ray guidance, both common iliac vein stents were deployed in the distal IVC at the area of IVC compression, overlapped segment 40 mm. Post dilatation was performed using Atlas 14 x 60 mm non-compliant balloon in the left iliac veins and Atlas 12 x 60 mm balloon in the right iliac veins. Excellent result with 0% residual compression was achieved." Could you please confirm if this follows arterial guidelines and I would only code this as 2 separate interventions due to the overlapping of the stents on each side? Or could I possibly code this as 4 separate interventions because there are 4 vessels named, even with overlapping stents?

MitraClip and Accucinch Implants

I'm using CPT 33418 for both Mitraclip and Accucinch implants; is this correct? Also, in some cases an interventional cardiologist and a cardiothoracic surgeon perform this procedure, would it be appropriate to bill one of them as an assist? In some cases, an interventional cardiologist and a cardiologist perform the px; is it also appropriate to bill one of them as an assist? Are these a part of a registry to where I need to bill these with Q0 mod and Z00.6 dx? I know these are a lot of questions concerning this px. I'm confused by the limited information I was able to find and will appreciate any information you can provide. 

Remote access angioplasty peripheral and central segment

"There was a web-like 99% stenosis of the inflow from the arterial side. There was also outflow stenosis. I proceeded with an angiogram with access from the right common femoral artery. A 5 French sheath was placed in the right common femoral artery after access via the Seldinger technique, and then a catheter was placed into the innominate and then into the subclavian artery. A 5 French sheath was placed into the brachial artery over a wire. Wire was advanced into the central venous system. Angioplasty was performed of the brachial artery junction with the fistula with a 5 mm x 4 cm balloon and a 6 mm x 4 cm balloon. Next, an angioplasty was performed of the outflow anastomosis with a 6 mm x 4 cm balloon. Central venous stenosis angioplasty with 6 mm x 4 cm and 7 mm x 4 cm balloons." Would you suggest 36902-52, 36215, 37248, and 36012? Or just 36902 and 36907? 

Axillary-Bi Fem bypass graft duplex

I am not sure which CPT code(s) would be appropriate for this study: "Real time & color duplex U/S was utilized to interrogate the Axillary to bifemoral artery bypass graft. The proximal anastomosis of the bypass originates in the Axillary artery and is patent. The proximal, mid and distal PTFE bypass graft which runs throughout the left lateral chest wall and lower abdomen is patent with normal flow velocities and monophasic waveforms. The right & left groin distal anastomoses is widely patent. The profunda femoris arteries are patent bilaterally. On the left; The proximal anastomosis of the Superficial fem to pop artery bypass originates in the proximal superficial fem artery and is patent. The proximal, mid and distal vein bypass graft which runs throughout the thigh is patent with normal flow velocities & monophasic waveforms. The distal anastomosis terminates in the popliteal artery below the knee and is patent. The pop artery is patent." Would 93978 be appropriate here or 93925 & 93931?

CPT 37236, 37237, 37238, 37239 bilateral indicator = 1

The 2017 Medicare Fee Schedule has this range of CPT codes with "bilateral modifier indicator = 1". Can you give an example of how this would apply?

Selective Angio 75716 appose to 75774 How would this be coded?

How is this coded correct? I am confused by the word "selective". Code 75774 is an add-on code, so would I just report code 75716 in this case? I do not see 75630 or 75625 documented either. Please advise. "Local anesthetic was administered and access obtained to the left common femoral artery via the modified Seldinger technique. A short 6 French sheath was inserted into the left common femoral artery, and selective angiography was performed. Using a RIM catheter, an angled Glidewire was positioned in the contralateral SFA, and the RIM was then exchanged for a Glide catheter. Selective angiography was performed in the contralateral SFA (3rd order angiogram with angiography of the trifurcation). Right peripheral runoff was also performed. Angiographic findings as above."

Venous Malformation

I am trying to provide the most accurate code in order to get a procedure through pre-determination for insurance. The patient has had two prior sclerotherapy sessions of a right triceps venous malformation. The patient still has residual episodic acute pain, with some component of muscle dysfunction. The pain is not relieved by dependent positioning or by anti-inflammatories. The ultrasound that was done last shows the malformation without flow, therefore the best course would be to perform cryoablation of the lesion. Would this be reported with unlisted code 37799?

Pantheris OCT in the Periphery

We are using an Avinger Pantheris Atherectomy catheter in the lower extremities. It allows the doctor to image using the optical coherence tomography technology. We are charging for the atherectomy. Can we also charge for intravascular ultrasound? I know the OCT codes are specific to coronary arteries (92978,92979).

CPT 33315 Cardiotomy Exploratory for Removal Mitral Mass

Can exploratory cardiotomy code 33315 be used for a separate incision into the left atrium for removal of subvalvular mitral valve mass (mitral valve left in tact) at the same session as an aortic valve replacement (33405)? "An attempt was made to inspect the mass through the aortic valve annulus; this could not be adequately done. Therefore, the left atrium was opened through the roof... mass was carefully removed." NCCI edits bundled exploratory code 33315 with aortic valve replacement code 33405. Should we append modifier -59?

Billing IVUS renal and PTCA stent placement left renal artery

My provider did IVUS of the left circumflex with PTCA stent placement, IVUS of the LAD with PTCA stent placement, and IVUS of the left renal with PTCA stent placement. Can you bill code 37352 for the renal IVUS?

Aspiration of perigraft fluid collection

Would you code the aspiration in addition to the angioplasty of the AV graft? "Intervention: We then used a 7 x 40 mm balloon, and under angiographic guidance balloon angioplastied the venous outflow stenosis. Completion angiogram showed no amount of extravasation or dissection. Sheath was removed and good puncture hemostasis obtained. We then used an 18 gauge needle to puncture the large flow collection. We aspirated about 1 cc from two different areas. The fluid was clear. No blood was aspirated. This was sent for gram stain and culture. A sterile dressing was applied."

Thoracic Duct Disruption

In cases of chyle leak/chylous effusion, in addition to the codes for the lymphangiography, should anything be billed for the disruption of the thoracic duct, which sometimes happens in the attempt to access it for embolization? I question since they state the disruption is often therapeutic in and of itself. I'm looking at code 38794 possibly with a -52 modifier appended? "IMPRESSION: Lymphangiography performed with 20 ml of lipiodol instilled via a bilateral groin nodes. The thoracic duct was well opacified. A small leak is present on the right at the level of T8. I was unable to cannulate the thoracic duct. After numerous passes through both the cisterna chyli and the thoracic duct in the upper abdomen, the thoracic duct and cisterna chyli were disrupted. Stasis of flow in the thoracic duct was noted at the end of the case. PLAN: Follow for reaccumulation." In the setting of low volume leak, lymphangiography with thoracic duct disruption is often therapeutic despite failure to embolize the thoracic duct.

Vasospasm of Cerebral Arteries

Two-year-old child comes with vasospasm of cerebral arteries status post head trauma. The physician does diagnostic angiography in bilateral ICAs and bilateral vertebrals. This is followed by “slow infusion” of verapamil in the bilateral ICAs and left vertebral. The physician was queried to clarify “slow infusion”, and his answer was, “These were injections over 5 minutes or so each.” My understanding is that I can’t bill codes 61650 and 61651 if it’s less than 10 minutes, per CPT guidelines. This is not an iatrogenic vasospasm, and the primary intent of the procedure was to treat it. What codes would assign in this scenario?

Pulmonary Angiogram with Pressure

How would you code bilateral pulmonary angiography with pulmonary arterial measurement? I have 75743 and 36014, but I'm not sure on how to code the pressures. "A 5 French glide Omni Flush catheter was advanced over the wire. The combination of this catheter and the stiff Glidewire was used to gain access into the pulmonary arterial outflow. Initially, the left pulmonary artery was selected. Pressure measurement was obtained in the left pulmonary artery. Left pulmonary arteriograms were performed with filming in multiple projections. The glide Omni Flush was advanced over the wire into the right pulmonary artery. Right pulmonary artery pressure measurement was obtained. Right pulmonary arteriograms were performed with filming in multiple projections. The pigtail was removed, and hemostasis was achieved using direct manual compression. A sterile dressing was applied. Pressures: Left Pulmonary Artery: 73/23, for a mean of 44 mmHg; Right Pulmonary Artery: 52/33 mmHg, for a mean of 42 mmHg."

MRI localization performed with BB placed on the skin

On a case where an MRI-guided breast localization is performed with a BB placed on the skin, how is this coded? The patient has breast implants and contraindicated for percutaneous placement. Not sure if unlisted breast code 19499 or an E/M code is appropriate, or 19287-52? If it is an E/M code, is this billable for the hospital and professional both? Also the patient just had a full breast MRI done two days previous to this encounter of the BB placement. 

Leads Replaced, Attached to Existing ICD

"Patient presents for removal of RA, RV, and LV leads. The old ICD generator is removed temporarily to allow removal of old leads and insertion of new ones. The new leads are successfully inserted, and the old generator is reimplanted." I have coded this scenario with 33244, 33224, and 33217. I am being told by an auditor that it should be coded as 33244, 33224, and 33249 instead. They say code 33249 can be used for replacement with a new or previously existing generator. What are your thoughts?

76937 with Aborted Radial Access

One of our cardiologists attempted to cannulate the right radial artery using ultrasound guidance. He says the vessel was well-visualized, and the needle could be seen within the vessel, but there was no return of flow. After several attempts without success, he used the right femoral artery for the exam. Can we bill for the ultrasound guidance and the radial puncture (76937 and 36140-59)?

Intracatheter infusion vs injection of thrombolytic therapy to the hand.

"A longitudinal arteriotomy was performed, and a Fogarty embolectomy catheter of the hand was performed. The clot was removed. Nevertheless, no flow was re-established. At this point, I decided that intra arterial thrombolysis was required. A catheter was placed in the hand. 2 mg of TPA were injected over 10 units using the pulse technique for 20 minutes." Does this qualify for 37211? The pulse injection is throwing me off.

Coil Embolization

"We then used the RIM catheter to cannulate the left internal iliac artery. An angiogram of the left internal iliac artery was performed. This revealed the iliolumbar branch that was feeding the aortic sac. Using a regalia wire and a rim catheter. We were able to cannulate the iliolumbar artery. We then used the microcatheter to cannulate the iliolumbar artery on its way to the aorta. We had to use a journey wire to navigate a few turns. We were finally able to place our catheter into the aortic sac and demonstrate the endoleak. We placed 3 10 x 10 coils into the aneurysm sac. I was unable to cannulate the outflow vessel despite our best efforts. We then pulled our microcatheter into the lumbar artery and placed 3 coils to occlude this feeding branch. We used a 3 x 2, 5 x 5, and a 6 by 7 coil. We further pulled our catheter back iliolumbar branch of the hypogastric artery and placed a coil in this artery; this was a 3x2 nester coil." What codes would you use? I am thinking 37242.

Iatrogenic vs Congenital ASD and/or VSD closures

We are seeing more cases where they are performing transcatheter closures of iatrogenic ASD and VSD (post procedure or post MI). The procedure is identical to those for closure of congenital defects, but these are iatrogenic defects. The available CPT codes (93580 and 93581) specify they are for closure of congenital defects in the code description. Should we then be using the unlisted procedure codes (93799 or 33999) for the iatrogenic ASD and VSD closures?

Fistulogram and Angioplsty of left arm fistula with a 8mm x100 mm balloon

I’m not sure if 36902 is the correct code for this procedure. If this is not right, what is the appropriate CPT to bill for this? "A micropuncture needle was used to cannulate the fistula in the micropuncture guidewire was inserted under fluoroscopy down into the brachial artery. Micropuncture sheath dilator were then advanced without difficulty. We did a fistulogram including the arterial anastomosis. The arterial anastomosis was widely patent. There was a proximal A 75-80% stenosis about 3 status 4 cm beyond the arterial anastomosis. The previously placed covered stent in the distal cephalic vein was widely patent as was her subclavian vein and innominate vein and superior vena cava. At this point I went ahead and recannulated the vein at the same level but directed the wire up into the arm. This was done with fluoroscopy. We went ahead and exchanged the micropuncture sheath out for a 6 French short sheath. At this point we obtained an 8 mm x 100 mm balloon. This entire area was balloon dilated–I did a prolonged inflation leaving the balloon up for 5 minutes."

Diagnostic Angiogram

Patient had a CT, not a CTA, prior that showed bilateral PEs. Patient was taken for intervention where they performed thrombolysis. Can we bill for the diagnostic angiogram if the report reads? "Hand injection of contrast was performed confirming a massive pulmonary embolism in the main portion of the right pulmonary artery. Hand injection of contrast and confirmed thrombus in the distal left pulmonary artery."

Profunda

My physician did an atherectomy and ballooning of the right mid SFA, and he also ballooned the right profunda FA. Would the profunda be separately billable? If so, would I use code 37224? If not, what would be the appropriate CPT code?

Nephroureteral Stent Placed for PCNL

If a nephroureteral stent is placed in IR the day before a planned (placing it for) urology percutaneous nephrolithotomy or lithotripsy, would code 50395 be used instead of 50433? Also, we are confused on the use of code 74485 in this case.

SILK ROAD TCAR PROCEDURE

"A sheath is placed in the carotid artery and connected to a system that will reverse the flow of blood away from the brain to protect against fragments of plaque that may come loose during the procedure. The blood is filtered and returned through a second sheath placed in the femoral vein in the patient’s thigh, allowing balloon angioplasty and stenting to be performed while blood flow is reversed." The manufacturer is recommending code 37215. However, code 37215 clearly states "distal embolic protection". Is code 37215 appropriate for this procedure?

Diagnositic venous study with stenting

We need clarification if you can bill a diagnostic along with the intervention (i.e., 36012 and 75870 with 61635). The provider is documenting the need for the diagnostic test first. Please advise.

Iliofemoral endarterectomy with 2 accessory arteries PFA

If you have a patient and an ileofemoral endarterectomy was done, and the patient has two accessory PFAs, can you bill code 35372 for the accessory arteries if performed along with 35355?

Doxorubicin

Should codes 37243 and 96420 be used? I have read doxorubicin is a chemotherapy agent. "Chemoembolization of the segment 3 branch of the left hepatic artery. embolization was performed using 40 mg of doxorubicin coated 100-300 beads 1. Celiac axis angiogram demonstrates that the right hepatic artery is not visualized from this injection. 2. Demonstrates the anatomy. The lesion in the segment 3 area is hypovascular. 3. The left hepatic angiogram demonstrates a hypervascular lesion. 4. The segment 3 artery was injected as well as Dyna CT. The lesion is hypovascular. Embolization was performed in this vessel. 40 mg of doxorubicin and loaded LC beads were used. 100-300 beads were used. 5. Post embolization angiogram of the segment 3 branch and left hepatic artery hepatic artery demonstrates decreased flow to the targeted lesions 6. Selective injection of the right hepatic artery arising from the SMA is performed. Along with a Dyna CT in this vessel, there is no feeding to the tumor visualized."

ASD Closure not done

"Patient presents for ASD closure. Patient is sized, but the proper device is not in stock so closure is not done. At the beginning of the procedure anesthesia places the TEE probe, and an intraprocedural TEE was done." Since ASD closure is not done, we cannot use the 93355 because this wasn’t used as intraoperative guidance for an intervention. Can we then just code it to a diagnostic TEE (for congenital heart)?

Multiple Pelvic Angio same day

Patient was in a car accident. Pelvic angio was done showing fracture but no hemorrhage, therefore embolization was not done. Later on the same day, patient still has a persistent drop in hemoglobin. Request for another pelvic angio. This one showed a bleed, so embolization was performed. My question is, can the second pelvic angio be coded?

62267

Is a disc core the same thing as a disc space? "Suspected L4-5 disc space infection. Using fluoroscopic guidance a 17 gauge needle was advanced into the L4-5 disc space from a posterolateral approach. Aspiration was performed. No fluid was obtained. The disc space was biopsied using an 18-gauge automated core biopsy needle. Additional aspiration was performed and again did not produce any fluid. 2 cc of sterile saline were injected and then aspirated. Aspiration biopsy was obtained. Both samples were sent to microbiology for cultures. IMPRESSION: Successful aspiration and biopsy of the L4-5 interspace." Should this be 62267, 77003 or 64999, 77002?

50395

Is it appropriate to use 50395 for anything besides urinary calculus procedures? I have a case where a nephrostomy catheter is being placed at the request of the urologist for subsequent access for chemotherapy. Would this be 50395 or 50432? Also, is there a time frame for the use of 50395? We have many cases where a nephrostomy tube is placed for a renal calculus, but it may be days, weeks, or even never before the patient returns for lithotripsy. 

Nitroglycerin Injection

How would I code a nitroglycerin injection into the left brachial artery? Access code is 36215.

Tomo guidance breast biopsy

What CPT code should we use to code for tomosynthesis guided breast biopsy?

Spinal CT Reconstructions

CT images were reconstructed through the lumbar spine. These are reconstructed from the patient's chest, abdomen, and pelvis CT. We get a lot of these studies. Can you please tell me the correct way to bill for these? 

Unsuccessful catheterization right renal artery

"Right brachial artery cutdown and attempted angioplasty of the right renal artery stent. Modified Seldinger technique with micropuncture, access was obtained and a 5-French sheath was placed. Next glide catheter with support of glidewire, was advanced to descending thoracic aorta. A stiff Glidewire was used to support a 6-French x 90 cm sheath, which was advanced and positioned on top of the aortic abdominal wall stent. Patient systemically hepari. Next, multiple attempts at cannulating the right renal artery stent were made using a variety of wires -angled Glidewire 0.035 followed by 0.014 Choice PT, Journey, Regalia Grand Slam wires. All these attempts were unsuccessful. Multiple shaped catheters were used including SOS, coronary catheheters, angled glide. After an hour of attempts, no further interventions were performed. Sheath was removed and puncture site was repaired with interrupted 6-0 Prolene sutures." Physician is reporting CPT codes 35206 and 36200. I do not agree with these CPT codes. Is the use of 37236-51RT and 36200 appropropriate?

Mitral Valve Replacement

What is the correct code selection when reporting a transcatheter percutaneous “mitral” valve replacement with a prosthetic valve (i.e., Sapien)? Our professional coding counterpart is using the TAVR codes for the mitral valve on the professional claim, and we as the hospital do not agree with that. Additionally, what is the correct code selection when reporting a transcatheter percutaneous aortic valve replacement when the patient has previously had an open aortic valve replacement (valve in valve) that has failed?

Lap band

Please advise. This does not look to be an adjustment, but rather a diagnostic study after adjustment made. What are your thoughts? "EXAM: DX LAP BAND ADJUSTMENT. CLINICAL HISTORY: ABNORMAL WEIGHT GAIN, COMPARISON: DX LAP BAND ADJ NON RESULT PM. FINDINGS: FLUOROSCOPIC TIME 0.6 MINUTES. THERE WAS ADJUSTMENT OF EXISTING GASTRIC LAP BAND. CONTRAST WAS ADMINISTERED, WHICH PROGRESSED THROUGH THE LAP BAND INTO THE STOMACH WITHOUT OBSTRUCTION. MILD DEGREE GASTROESOPHAGEAL REFLUX."

Colon Transit Study

When performing a simplified colon transit study, is there an additional charge we can capture for the capsules/markers given to the patient? Is there a HCPCS code we should be billing, or is it included in the study charge?

Brachiocephalic AV Fistulogram with ligation of venous tributary

Does ligation of a flow-stealing venous tributary via cutdown count as 36909 or open revision 36832? "History: Non-maturing brachiocephalic AVF. Procedure: Angiography of right brachiocephalic fistula reveals 90% stenosis from proximal aspect of fistula, approximately 1 cm distal to the anastomosis. Lesion was ballooned with 4, 5, and 6 mm balloons. Completion angio reveals less than 10% residual stenosis (36902). There was also noted at this time a venous tributary in the mid upper arm that was stealing a significant portion of flow through the fistula. A small transverse mid upper arm incision is made, and the venous tributaries were identified and ligated. Completion angio reveals excellent improved flow with no residual stenosis at the proximal anastomosis and no further flow through the ligated tributary."

LVL 33225 with Upgrade 33229

Our physician removed a single pacemaker and inserted a biventricular pacemaker. He hooked it up to the existing RV lead and inserted an LV lead. Would this still be considered an upgrade when he didn't add the arterial lead? 

Papillary Muscle Sling

What CPT code should be used for placement of a papillary muscle sling with a mitral valve repair?

33340 & 93355

We have a Medicare patient who was scheduled for the Watchman procedure, which was cancelled after general anesthesia was given. The account is now being billed as an outpatient. Department charges are 33340-74 and 93355. A -59 modifier was attached to 93355, but we are getting a claim error, even with the -59 Modifier. Any suggestions would be appreciated.

Open repair (juxtarenal) aortic aneurysm w/removal of Ovation device.

DX: Type I and II endoleak with enlarging aortic aneurysm. My doctor is billing codes 35091, 35102, and 34832, which is not allowed. Note reads: "The aorta was opened. There was brisk bleeding from the middle sacral artery and mixture of various aged thrombus. Clamps were then placed across the Iliac limbs of the device, and then it was transected to allow access to the backbleeding middle sacral artery. Once exposed there were actually several vessels backbleeding into the sac. These were controlled with 3-0 surgipro figure of eight sutures. The incision in the aorta was then carried proximally through the sealing ring. There was thrombus between the wall of the aorta and the ring. The graft was transected above the sewing ring with wire cutters and the membrance was removed, but the stent architecture was left in place." I suggested code 34831, but my provider states EVAR was attempted and completed. What would you suggest?

36832 and Skin Excision

"I marked out the two skin ulcerations using elliptical incisions. I dissected down to subcutaneous tissue using electrocautery. I was very careful to make sure to not enter into the wall of the fistula. I dissected on both sides. Once I had adequately mobilized, I then took a sharp 15 blade and excised the skin ulceration overlying the anterior portion of the fistula. Once this was done, I irrigated thoroughly and inspected the wall of the aneurysm which appeared to be intact. It was not weak and developed. Therefore, I do not feel that an aneurysmorrhaphy or plication was necessary at this time." Will this still be considered a revision of AV graft (36832)? Perhaps with a -52 modifier showing reduced procedure?

Yueh

Per the Cook Medical website (www.cookmedical.com), a Yueh is a centesis catheter needle. This sounds like a needle used for the purpose of getting a catheter into place, as when placing an IV. In reports, our doctors refer to a Yueh as being both needle and catheter. For aspiration or drainage coding purposes, would this be considered a catheter or a needle?

Contralateral right internal iliac and right common femoral coding

I'm unclear if I can code both right internal iliac and right common femoral catheter placements from a contralateral approach. How would you code the following? "A 5 French sheath was introduced over a guidewire along with an Omni flush catheter, which was advanced into the infrarenal aorta. Pelvic flush angiogram was performed. Catheter was then used to select the contralateral right internal iliac artery. Arteriogram was performed. Selective catheterization of the third order branch of the posterior region was then performed with angiogram. Three additional third order branches were selectively catheterized with additional views. Catheter was then used to select the right common femoral artery. Right lower extremity arteriogram was performed. Cobra catheter was then introduced and used to select the ipsilateral left internal iliac artery with arteriogram. Upon completion of the procedure, catheter, sheaths, and guidewire were removed. Hemostasis was achieved using Angio-Seal closure device."

Stone Extraction and NU

Radiologist places nephroureteral catheter in the AM. Later the same day he moves this catheter, dilates track, assists with stone removal (> 2 cm), and replaces NU catheter. What are the correct codes to assign for this scenario, and would they be the same if the initial NU catheter was placed one day prior?

Hybrid EP Ablation

I understand that the hybrid approach first involves thoracoscopy with epicardial ablation, followed by an electrophysiologic study and a percutaneous endocardial ablation. I am not sure which codes to use for this. Would we bill for both procedures separately since one is performed by the EP physician and the other is performed by a cardiac physician? Or would this be considered an unlisted code since it is considered investigational?

Diagnostic at Time of Intervention

I'm wondering if rad S&I can be charged with venous and arterial extremity interventions. The CPT codes in question are: Vein – 37238 (Surgery) and 75820 (Radiology); Lower Extremity Arterial – 37226/37227, 37230/37231, 37221 (Surgery), and 75710 (Radiology). Code 37238 description states “including radiological supervision and interpretation”, and in the summary portion of the CPT book for codes 37236-37239 it states that those codes “include radiological supervision and interpretation DIRECTLY related to the intervention performed”. Would we be able to charge for 75820 with any of those codes? The lower extremity arterial intervention code (37226 and 37230) descriptions do not state that Rad S&I are included, but it does have it in the summary portion for those codes (“include radiological supervision and interpretation DIRECTLY related to the intervention performed”). Can we charge 75710 with the lower extremity arterial intervention codes? Example: "Selective left iliac artery angiogram PTCA and stent of left common iliac artery."

Duplex after Endarterectomy

Is intraoperative color flow duplex following carotid endarterectomy billable? "Using B-mode, color flow, and duplex showed LICA 70/23 cm/s, LECA 123/10 cm/s, and the LCCA 72/18 cm/s with no evidence of intraluminal plaque or debris."

-52 Modifier vs. -53 Modifier

My physician is wanting to bill code 36475-52 for an aborted GSV radiofrequency ablation because the device was opened. The patient could not tolerate the local anesthesia, so a sheath was not even placed. I am unsure of billing for this since the procedure was not even attempted besides some local anesthesia. I advised on billing an office visit for this visit. What are your thoughts?

Intrathecal Chemotherapy Injection 96450

In the past we have always used S&I add-on code 77003 when billing 96450 for intrathecal chemotherapy injection requiring/including lumbar puncture under fluoroscopic guidance. We are now seeing denials for code 77003. Our stance is that since 77003 can be billed with codes 62270/62272, which are included with 96450, we should be okay with billing these two codes together. There are no NCCI edits for these codes as of yet. Would you appeal with this explanation, or should we be billing without the guidance code going forward? Please advise.

Embolization by manipulation of catheter

Can we use code 37244 for this type of embolization (extensive catheter manipulation)? "The catheter was then advanced into the L4 left lumbar artery, and a small blush was encountered, presumably at the level of the spinous process fracture. Extensive catheter manipulation was then performed, without further extravasation identified. The catheter was then advanced into the left common iliac artery, and imaging was performed, which demonstrated extravasation at the level of the left the deep external pudendal artery. Extensive catheter manipulation was then performed, without further extravasation identified. IMPRESSION: Successful catheter embolization of extravasation from the left deep external pudendal artery and the left L4 lumbar artery, as detailed above."

Stent Removal and PNU Placement

A ureteral stent is removed via a percutaneous approach, and a PCNU is placed using that same opening. How do you code this? I am thinking 50384 and 50433, but I'm not sure. I could not find any examples from internal to internal/external only, internal/external to internal. 

Needle lymph node biopsy with injection blue dye

How would you code needle axillary lymph node biopsy with injection of blue dye? Code 38505 is not listed to be used in conjunction with 38900.

96450

The following report was coded 96450 and 77003-26. My understanding is that the radiologist should not be coding this with 96450. Please advise. "The back was exposed and prepped in usual sterile fashion. All elements of maximum sterile barrier were used including mask, cap, sterile gown, gloves, large sterile sheet, hand hygiene, and cutaneous antisepsis with 2% chlorhexidine. Using fluoroscopic guidance, a 20 gauge spinal needle was advanced toward and subsequently into the CSF space at the lumbar 4-5 level. The needle yielded clear CSF, which confirmed intrathecal location. Opening pressure measurement was not performed. The needle was removed, and manual compression was applied. A dry sterile dressing was applied. FINDINGS: Needle position confirmed with fluoroscopy. Static image was saved in patient's medical record. IMPRESSION: 1) Technically successful fluoroscopically-guided lumbar 4-5 CSF puncture. 2) 3 cc of CSF sent for laboratory analysis. 3) Intrathecal chemotherapy administered by Oncology."

Thyroid Cyst Ethanol Injection

How would you code an ultrasound-guided thyroid cyst aspirate followed by injection of ethanol using a 6 French catheter that is then removed?

Hysterosalpingogram

I am questioning how to bill for the radiologist in the following scenario. A hysterosalpingogram is performed by Dr. A of the OBGYN department. One spot image is provided for evaluation by the radiologist, Dr. T. Would the radiologist, Dr. T, bill 74740-26-52? I added the -52 modifier since the radiologist did not supervise but only interpreted the image. Is that correct?

General Information

I am fairly new to vascular coding. I am having a hard time understanding all of it. I attended your conference and have your books. I was wondering if there is any other information out there that will help me get a better grasp of this. I read and read and still have a hard time. Any direction you could give me would be so helpful.

Billing Saline

I've started billing for an outpatient radiology center and am still learning about billing for supplies. If the doctor performed a saline infused hysterosonography, can we bill for the saline? If so, what is the HCPCS code? Would it be J7040?

20225, 62267, 77003

Physician's Impression: Fluoroscopically-guided T4-T5 disc space, fine-needle aspiration, fluoroscopically-guided T5 vertebral body, left transpedicular deep bone biopsy. Should we code 62267 and 77003 with 20225-59?

Impella RP

Do you know of any updates on the Impella RP, or should it still be billed with 33999-GZ? Would we be able to capture the removal of the device on a different date with the same code, or would you advise against that?

G0365 Vessel Mapping

I saw this issue addressed a few years ago, but I wanted to see if the guidance is still the same. Code G0365 has a bilateral surgery indicator of 0, but if right and left extremities are evaluated, can we bill G0365-26 x 2 for the physician interpretation for both sides? Does billing only one unit only pertain to hospital billing?

Carotid Stump Pressures

Can you bill for carotid stump pressures during a carotid endarterectomy? He is placing the catheter in the carotid artery. If so, what are the CPT codes?

Defib Loose Set Screw

New lead is placed with existing defib for lead impedance - normal impedance. Next day, high voltage impedance recorded. Pocket opened, and device pulled to surface. "I was able to make at least one quarter turn before I heard the clicking sound that the set screw had been completely locked in. Obviously, the loose set screw was fixed. . . there is nothing to suggest that there is an inherent problem with the device header of the set screw per se." Would this be reported with unlisted procedure code 93799, or does is qualify as lead repair 33218?

Epicardial Mapping

My physician did epicardial mapping with a VT ablation. Is there a CPT code for this?

Endarterectomy and stent/angio in same vessel

"The patient has developed increasing stenosis in the right external iliac to the point it was subtotally occluded. This was managed with retrograde endarterectomy. Guidewires were passed into the infrarenal aorta prior to this endarterectomy, which allowed us to place stents beginning at the origin of the external throughout the entire external into the endarterectomized area. The stents stopped above the inguinal ligament. The vein patch angio was performed from the distal external to the mid superficial fem. The superficial femoral had an endarterectomy done distally. The 6 mm Epic stents began below the area of severe stenosis in the distal superficial fem and extended to the point of the endarterectomized superficial fem proximally. At completion these vessels were widely patent." My question is regarding whether you can code the endarterectomy (35355) iliofemoral and the stents/angio (37221 and 37226), or can you only bill for one type of procedure? Your book references bypass and endarterectomy being bundled, but I cannot locate information regarding endart and stents together.

ABPM

Can you please tell me what diagnosis codes are acceptable for ambulatory blood pressure monitoring?

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