Knowledge Base

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Secondary Prevention, sequence of codes

I am having a dispute with an auditor regarding the sequencing of codes on an ICD device installed for secondary prevention. Patient suffered an acute MI followed by sudden cardiac death six days prior to the device install. I remembered a CMS rule stating that Z86.74 is a status code that is unacceptable as a principal diagnosis, so I coded I21.4, Z86.74. The auditor coded Z86.74, I21.4. This despite a company policy of "always coding to CMS rules". Does Z86.74 have to be in the principal position for the claim to be paid? Does the CMS "unacceptable" rule apply equally to IP and OP claims? See Definitions of Medicare Code Edits, ICD-10 Version, v 33 October 2015, page 217.

Breast cyst aspiration with catheter left in for drainage

Do I code 19000/76942 for an ultrasound -guided breast cyst aspiration if they leave the catheter in the breast for continued drainage, or do I use code 10030?

36590 with Hematoma Removal

Would you report codes 36590 and 10140 for this? "Patient with port has a growing hematoma. Decision was made to remove the port because of the small number of chemotherapy sessions prior to anticipated transplant. Pocket was opened, and port and catheter were removed. Extensive chronic hematoma/clot was manually removed from the port pocket. Pocket flushed and packed with Gelfoam."

93931, 93971, G0365

Can we bill codes 93931, 93971, and G0365 for these studies? If not, which codes we should bill? "Reason For Study: Failing left upper extremity fistula. History: Pre-operative mapping right upper extremity for dialysis access fistula placement. Patient states he is asymptomatic on todays exam. Conclusions: 1) Patent right upper extremity arterial inflow with complete Palmar arch. 2) Patent right cephalic vein measuring 5 mm in the upper arm and 2-3 mm in the wrist to forearm, respectively. 3) Patent right basilic vein but diminutive starting at the proximal biceps measuring 2 mm in diameter. Procedure: complete duplex scan was performed using B-mode gray scale imaging, Doppler spectral analysis, and color flow."

Cardiomems Insertion- new updates for 2017?

In reference to question ID# 6772, have there been any changes in the coding and billing procedures in respect to 93799 and C9741 where 93451 and 93568 are now additionally billable? Physician coding being 93799 and hospital C9741.

CS Venoplasty with failed Bi-V uprgrade

During an attempted upgrade to an existing dual chamber ICD, the CS was accessed, and the LV lead was inserted, but our EP physician could not get it past a very tight stenosis. One of our interventional cardiologists scrubbed in and performed multiple venoplasties on the very tight CS lesion. The LV lead was reinserted and advanced, but still could not pass the stenosis. The attempt was aborted. My thought is to bill code 33224-74. I normally would not bill for the venoplasty, as it would be included in the lead placement, but since the lead attempt was aborted, would it be appropriate to bill it in this case?

AV Shunt Inflow Artery Imaging

Do you have specific criteria/documentation suggestions we can use to help us determine when arterial inflow imaging codes 36215 and 75710 are allowed to be used in addition to 36901-36906?

Puncture AV Fistula Outflow Vein w/ Cath of Native Brachial Artery

Puncture of AVF basilic outflow vein with selective catheterization of the native brachial artery. LUE arteriogram performed, and then angioplasty of the brachial artery and mechanical thrombolysis of the brachial, ulnar, and interosseous arteries. Infusion catheter placed in the ulnar artery for overnight thrombolysis. Is it appropriate to bill 36901-52 for the initial puncture in the graft, along with 36215 for the catheter placement in the brachial (and subsequently the ulnar and interosseous arteries)? We believe the correct codes for the procedure are 36901-52, 36215, 75710, 37246, 37184, 37185, 37211. Please confirm. 

Does seperate incision allow 36833 and 36902?

For the following, is it appropriate to report codes 36833 and 36902? "Using #4 Fogarty catheter, outflow thrombectomized, flushed, clamped. Then, the arterial plug was removed using again the Fogarty catheter. Graftotomy repaired with interrupted sutures. Upon restoration of the flow, patient had pulsatile flow within the graft. Graft was cannulated through separate skin incision using entry needle. It was upsized to 7-French sheath and a fistulogram was performed, which revealed patent graft. There was high-grade stenosis in the venous anastomosis. Subclavian, axillary vein, brachiocephalic vein was widely patent all the way to the right atrium. Glidewire was introduced, parked in the right atrium and high-grade stenosis within in-stent was angioplastied using 8 x 200 angioplasty balloon catheter. During inflation of balloon, contrast was refluxed in the arterial system, which revealed absence of any hemodynamically significant stenosis of arterial anastomosis. Balloon was deflated and another fistulogram was performed, which revealed excellent flow through the angioplastied area." 

Mediastinal Abscess

"Cervical abscess extending down into the posterior mediastinum: LT lateral thoracotomy performed - there was a walled off process at he apex as predicted and with dissection of the lung the purulent pleural process was encountered just above the arch posteriorly. Cultures were taken and irrigation of the thoracic cavity performed. lung reinflated and no visceral pleural air leak noted. Three chest tubes left in pleural space, one posterior apical tube into the abscess cavity." Would code 39010 be appropriate for this case?

Endarterectomy bundling question

Would an endarterectomy of the femoral artery be separately billable during a fem-pop bypass if the endarterectomy was performed to improve flow to the profunda rather than being performed for inflow to the bypass?

Tunneled catheter vs VAD

I see a new Coding Clinic as of May for the tunneled catheter and how to code. It seems to me the VAD would be for ports that are placed in a pocket, and the tunneled line would be coded the same as the non-tunneled line. It says the revised codes will become effective October of this year. Will you send out updates to membership holders?

Fistula Duplex Ultrasound

Patient comes to our office because he is having problems getting dialyzed. Patient is evaluated by the physician and sent for ultrasound imaging. After scanning the patient's fistula, the physician reads the ultrasound and determines that the patient will require an intervention. Can we still bill code 93990 for the scan as well as the intervention if performed on the same day or week? If so, what diagnosis code should we use with the 93990? We have not been billing them due to denials.

Vasodilator or catheter placement for acute mi treatment

Our doctor is wanting to charge an acute MI intervention (92941), but the following text is from the report and this was all that was performed. "Placement of Pronto catheter intracoronary in the ramus intermedius with direct delivery of vasodilators including nitroglycerin, veramil, and nipride with improvement of vasospasm. Intervention on the ramus intermedius was performed as detailed above with no balloon angioplasty or stent placement." Would any of this warrant the billing of 92941?

CPT/HCPS for sacroiliac injection with US guidance

Can you please provide us with information regarding CPT/HCPCS code(s) for the hospital side and MD side for sacroiliac injection with ultrasound guidance for the purpose of a pain injection with lidocaine and steroids?

20610 with 20605

If the provider injects the right glenohumeral joint and right acromioclavicular space or bursa under fluoroscopic guidance, can we report codes 20610 and 20605? Or can we only report code 20610 once for the shoulder joint?

Posterior Auricular Artery Catheterization with Angiogram

Would you report code 36228 or 36226 for superselective catheterization with angiogram of the left posterior auricular artery at the origin of the transosseous branches? Here is what the physician documented: "There was successful embolization of large segment of the dural arteriovenous fistula and the tentorial sinus from this pedicle. We then prepared another scepter 4 mm x 11 mm balloon catheter and used the mirage wire to position the balloon catheter in the distal left posterior auricular artery at the origin of the transosseous branches. Superselective angiogram was then performed."

Breast Biopsies performed at IDTF

The facility my radiologists contract with just changed their accreditation at one location, from an outpatient hospital department to an IDTF. Breast biopsies are being performed at the “new” facility. We are having trouble getting reimbursed for the surgical codes of the breast biopsy. The remit states: “Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.” From what I have read, only the physician performing the biopsy can bill for the surgical codes for a breast biopsy. This is split billing of course, not global. Can you please give information and guidance on this situation?

His lead Pacemaker

Our cath lab department is now inserting His leads when performing pacemaker insertion. "Operative note: Through this sheath, a 5 French His bundle catheter was placed in the bundle of His. The left pectoral region was prepped and draped in the standard fashion. The skin and periclavicular region were anesthetized with 1% lidocaine. An infraclavicular incision was made and carried down to the prepectoral fascia using electrocautery. Using blunt dissection and electrocautery, the generator pocket was created and hemostasis assured. Micropuncture needle was used for axillary vein access x 1. A 7 French safe sheath was placed. Via this sheath, a His bundle introducer sheath was placed in the right atrium. Using the His bundle lead, the His bundle was mapped. The lead was secured to the His bundle tissue, and pacing characteristics were reevaluated. Under fluoroscopic guidance, the guiding sheath and safe sheath were removed." Would we code this as 33206, or are these procedures reported with unlisted code 33999?

Soft Tissue Cryoablation

What code would you recommend for cryoablation of soft tissue mesenteric mass? Access organ: soft tissue. Additional access organ information: mid-line mesenteric mass. Access side: right and left.

Minimally invasive valve replacement w/bypass and femoral vein repair

Can you code for the repair of the femoral vein (35226) with primary procedure of mini sternotomy approach-minimally invasive aortic valve replacement (CPT 33405)? Since this was a minimally invasive procedure and bypass was performed (the femoral vein was repaired due to the cannulation of the vein for bypass), I wanted clarification whether the femoral vein repair could be reported.

Modifier -52 vs. -74

In your 2017 Interventional Radiology Coding Reference, you stated: "In 2017, the S&I code (75791) is deleted, so when imaging of the dialysis circuit is performed from a remote access (not via direct access of the circuit), use code 36901-52 (or -74 for hospital billing) as well as the remote arterial access catheter placement code (e.g., 36217 for right brachial artery injection of fistula when access is via the common femoral artery). When imaging is performed via pre-existing shunt access, only report code 36901-52 (or -74 for hospital billing)." My question is, why change the modifier for the hospital when both modifiers are valid for hospital use?

Fluoroscopic evaluation of NG tube

How would you suggest to code a fluoroscopic evaluation of an NG tube? "PROCEDURE: Fluoroscopic evaluation of NG tube. FLUOROSCOPY TIME: 0.6 minutes. FINDINGS: No contrast was able to be instilled via the NG tube. Visualization of the upper portion of the tube reveals there was a kink in the oral pharynx. This was removed under direct fluoroscopic visualization. The tube was resecured with tape. Instillation of contrast revealed filling of the stomach. IMPRESSION: Initially malpositioned NG tube with kink. This was repositioned. Functioning NG tube."

Removal and replacement of existing right ventricle lead for ICD

"Relocated pocket and ICD from the right to left side of the chest using the same generator and same RV lead. After this, I proceeded to the right side where I reopened the previous incision going through the same scar. The device was delivered out of the pocket. The pulse generator was disconnected and washed with antibiotics. The old lead was freed of any of the stitches around it, and, under fluoroscopic guidance, I unscrewed it and then pulled the lead out. It came out in its entirety. The lead was visually intact. I irrigated it also and cleaned it completely with antibiotic solution. The same lead was now already introduced through the introducer sheath that is in the left subclavian vein. I navigated that lead under fluoroscopic guidance into the apex of the right ventricle cavity. I actively fixated it. Pacing and sensing functions were assessed and were adequate. I thus fixed that lead to the fascia of the first and second ribs with multiple stitches of 2-0 silk." Would the lead relocation be 33215, or removal 33244 and replacement 33216, and 33223?

36831 and 36907

"Micropuncture technique was used to cannulate the fistula above the antecubital level. Fistulogram was performed, which showed a patent fistula of the cephalic arch where there were two tandem stenoses. The one at the very top of the cephalic vein was nearly occlusive. There was a second approximately 80% stenosis a few centimeters peripheral to this. The micropuncture was exchanged for a 7 French sheath. A 0.035 guidewire was advanced easily through both stenoses and into the central veins. Adorado balloon was then across more central of the two stenoses and inflated. The balloon fully inflated at 18 atmospheres. The second stenosis was then addressed and the balloon fully inflated. Fistulogram showed no residual stenosis. Partial central venogram was performed through the innominate level, which showed no stenosis. Fistula was clamped and was entered through third incision right between venous and arterial cannulation site. Kelly clamp was used to milk out thrombosis. The fistulotomy was closed and flow restored. Cannulation site was closed." Should this be reported with codes 36831 and 36907? If not, what codes are appropriate?

Coarctation of aorta and bicuspid aorta valve

I have a provider that is trying to tell us that if a patient has a coarctation of the aorta and a bicuspid valve then we need to bill the congenital CPT codes. I noticed that you answered a similar question in March, but I was wondering where you got your information so I can provide that information to my provider.

Excision of AV Fistula

"Our patient had an infected chronic thrombus and aneurysm in her left upper extremity AV fistula. She was taken to the OR for excision. A duplex Doppler was used to measure the brachial artery flow and to check the outflow vein to decide on the area of disconnection and division. Images were retained. The fistula was excised by disconnecting it from the brachial artery, followed by anastomosis and repair of the brachial artery. The aneurysm, chronic thrombus, and overlying skin were excised in the needle access segment of the fistula. The cut end of the outflow vein was repaired at the level of the shoulder. The 6 x 4 cm skin defect was closed with flaps." Can any imaging be billed? How do we code for the excision of the fistula?

Tunneled cvc with port insertion using same pocket

Can I charge for a removal and an insertion on the following dictation?? Do I need a modifier for the use of existing pocket? "A single incision was made over the reservoir with a 15 blade. The port was removed in its entirety. The pocket was flushed thoroughly. No drainage was noted from the pocket. Under ultrasound guidance, access into the left internal jugular vein was obtained using a 5 French micropuncture system. A permanent sonographic image of the vein was obtained to document patency. An Amplatz wire was then advanced into the inferior vena cava under fluoroscopic guidance with the utilization of a Kumpe catheter. A tunneling device was utilized to bring the catheter from the port site utilizing existing pocket to the jugular vein. CONCLUSION: Successful placement of left internal jugular Bard single lumen PowerPort catheter and removal of left subclavian Infuse-a-Port."

75625 and 75716 with no findings

The physician would like to have 36246, 75625, and 75716 billed. However, the report states the wire was advanced from radial, after left and right femoral would not allow wire to cross, and into the aorta. Abdominal aorta performed, showing severe occlusion with no collateral flow on long leg runoff bilaterally. Would it be more appropriate to report codes 36200 and 75625 only?

FFR performed with Medicare drug-eluting stent

If patient has FFR only, then a drug-eluting stent is inserted, would we report code 93799 for the FFR where C9600 is not listed under the codes that you would apply for the add-on 93571 FFR code? I see 92928, but not C9600, and we have had denials when charged with C9600. In this case, would we treat it like the FFR is performed alone and charge the unlisted as well as C9600?

Non-tunneled cath placement for CT contrast administration

Our IR department places a non-tunneled cath for CT or MRI exams on patients who no longer have access available. These lines are placed in the internal jugular vein as described here: "Under real-time ultrasound guidance, the IJV vein was accessed with a micropuncture kit, and an image documenting patency was recorded to PACS. The 5 French microcatheter was left in the right IJV. It was capped and covered with a tegaderm." We have reported codes 36556 and 77001. From other questions listed, we should be adding modifier -52 to 36556. Another suggestion is to use code 36011. What is/are the correct CPT(s) for this exam?

75630 vs. 75716

"Catheter placed just above the renals. An aortorenal angiogram was obtained, showing patency of the renal arteries and infrarental aorta with excellent flow through the iliacs on either side." Would you go with 75630 or 75716?

Aortogram with lower extremity studies

I still get quite confused with coding abdominal aortogram and lower extremity angiograms. Here is my current scenario. Abdominal aortogram and bilateral lower extremity study from one cath position; findings are of infrarenal AA, BCIA, BEIA, and BCFA. Then the physician moves the cath to the left popliteal artery and completes the left leg run-off with further detailed imaging down to the foot. Should I report code 75630? Or codes 75625 and 75710-LT? Or codes 75630 and 75774?

93655

Patient is scheduled for an ablation for PVI, but was in atrial flutter when he arrived in the lab, so the atrial flutter was ablated before the PVI. Can we bill for code 93655 when it is performed before the primary PVI? The physician's documentation is as follows: "The patient arrived at the clinical electrophysiology laboratory in atrial flutter with a ventricular rate of 85 beats per minute. The QRS width was measured at 90 milliseconds, and a QT interval was measured at 320 milliseconds. The HV interval was measured at 52 milliseconds. The attrial flutter showed concentric left atrial activation and counterclockwise rotation of the right atrium, negative sawtooth waves in leads II and III, and a VF and positive in lead V1. Utilizing Carto 3-dimensional mapping as a guide, energy was then targeted in a linear fashion from the tricuspid, mid isthmus to the inferior vena cava. This resulted in termination of the tachycardia. We then turned our attention to the primary arrhythmia, which was the atrial fibrillation and proceeded with the pulmonary vein ablation."

33210 with AICD generator replacement

Can a temporary pacemaker (33210) be reported with an AICD generator replacement (33263) if done during the same encounter?

Pacemaker moved from the left to right side

My physician moved a patient's entire pacemaker implant from the left side to the right for chemotherapy purposes. He wants me to bill the removal of the leads (33234) and insertion of a device (33207). Would this be the correct coding for what he did? Since he moved the entire implant to the other side of the body, I am tempted to use the repositioning code (33215) and not the new and replaced pacemaker code, but I am still unsure. 

Generator Evaluation

When a patient has electrodes changed for a pacemaker, but the generator is not changed, would it be appropriate to charge for a generator evaluation since only the leads were changed (33216 and 33235, RV lead replaced and removed)? Or would code 93280 or 93288 (evaluation) be included in the CPT codes for RV lead removal and replacement?

Attempt type I endoleak repair

"PT presents to undergo repair of type I endoleak. Bilateral femoral access with left subclavian cutdown was performed to accommodate large french sheath. From subclavian access with great effort 12 french catheter advanced into descending aorta. Noticed was significant bleeding at the left subclavian cutdown site. Conduit separated from the artery tearing the artery. Covered stent from right femoral approach encountered difficulty advancing across arterial tear due to kinked wire. Stent was pulled back, however unable to remove from right femoral decision was made to deploy in external iliac. Once again through the wire access of the subclavian a stent was successfully deployed across the area of arterial damage in the mid left subclavian. A complete thoracic & abdominal aortogram was performed confirming large type I endoleak. Decision to reexplore alternative treatment option for type I endoleak." Code selection 36200 left subclavian, 36215 right femoral, 36140 left femoral approach, and 37236 stent placement of arterial tear. Recommendations?

Modifier for C2616 for Y-90 Case

For Y-90 treatment cases, we are noticing that a modifier needs to be added to code C2616 when billed with 78205 (liver spect scan). Is -XU the correct modifier to add and why?

Sternoclavicular joint Injection

Can you tell me how to code a sternoclavicular joint injection? I am unable to find any documentation to guide me to the correct code.

Endomyocardial Biopsy

I need help coding the following procedure. Is it coded the same as 93505? "TIA PROCEDURE: She was brought to the lab and prepped in the usual sterile fashion. Vascular access was obtained with ultrasound-guided punctures of the right femoral vein with 14 French and 10 French sheaths. Intracardiac echo was used to guide the procedure. Images of the RV, septal masses were incorporated to the 3D CARTO map. A robotic Hansen catheter was used to guide an ablation catheter and create a CARTO 3D map of the RV and direct the robot into the septal mass. Then, the ablation catheter was removed and a bioptome was inserted. The robot was used to direct the bioptome to the masses in the distal septum. Multiple specimens were collected of the mass and the inside cystic core. The patient tolerated the procedure well. ICE showed no effusions. The sheaths were pulled, and Proglide sutures were deployed to achieve hemostasis and allow rapid ambulation. CONCLUSION: Successful robotically guided biopsies."

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."

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