Knowledge Base

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Set Ascending Direction

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?

Scab Removal off the AV Fistula

"Patient has a scab over the AV fistula, and the physician is concerned the patient might start bleeding. An eliptical incision was made over the area of the scab and carried down through the skin and subcutaneous layers. The scab was lifted off the fistula; the underlying fistula, however, was intact and did not need any intervention. He then simply freshened up the edges of the fistula. He went ahead and undermined both the medial and lateral flaps of skin and then began closing the wound using layers. Deep layer was closed using 3-0 vicryl; skin was closed using a 4-0 monocryl." I'm not sure of the proceudure and diagnosis coding. In his pre- and post-op dx, the physician mentioned arteriovenous fistula malfunction. I'm not sure if this is considered a fistula malfunction. Please advise.

Omental pedicle flap/gastroepiploic pedicle closing Aortobifemoral bypass

"After the bypass was in place, anastomosis was completed and groins were closed (35646). We were unable to close the retroperitoneal structures over our graft with sufficient coverage to separate the duodenum from our aortic suture line. We subsequently mobilized a large omental pedicle flap utilizing the left gastroepiploic artery as our inflow. This was then tunneled through a retrocolic hole in mid transverse colon mesentery into the retroperitoneum. This was secured over our aortobifemoral bypass graft using interrupted Vicryl sutures. Our intra-abdominal contents were then returned to their normal anatomic positions." Would this be 49905 or 49906? If so, do you know of a published list of approved codes for these add-ons?

Atrial clip placed at time of a CABG or MVR

Case: 1) Provider performed multi-vessel CABG with endovein harvest. After completing, the left atrial appendage was measured, and a 35 mm atrial clip was applied. Case 2) Once heart was well rested, the heart was initially rolled up and the left appendage inspected. After measuring the base, a 40 mm atrial clip was selected, and the tip was than excised to vent the remaining appendage. The heart was repositioned, and a left atriotomy was completed after further defining the pulmonary vein and pulmonary artery anatomy. Once this was done, adequate exposure to the mitral valve was achieved. The provider continued to perform a replacement of the valve. Is the atrial clip considered included in the types of surgeries I have outline, as well as when a MAZE procedure is performed? I am receiving conflicting information. One source suggests it is part of the work already being performed. Another source suggests using an unlisted code. Since the introduction of our new percutaneous code for this procedure, it has become more grey.

Laser Lead Extraction

I read that when coding for biventricular ICD removal (33244 and 33241) you would append a -22 modifier to 33244 since you are removing three leads and not two. Is this correct? Of note, this was a laser removal as well.

Hysterosalpingogram 74740 and 58340

In our hospital, the gynecologist comes in to do the injection, and the radiologist does the imaging. The hospital reports both codes 74740 and 58340. Should a -TC modifier be attached to either of these codes?

Complete echo with spectral doppler but no color flow

If the physician dictates a complete echo with spectral Doppler, but no color flow, do I report code 93306 with a -52 modifier? Or codes 93308 and 93321?

Remote Heart Monitoring

While performing an internal audit of remote heart failure, I noticed several services not billed dating back to 2016. Can I bill these services now, as I can download reporting for the specific DOS? Would the tech service 93299 reflect the actual date of service? What DOS would be used for 93297, the professional component? 

KX Modifier

Is the -KX modifier still in effect to report for billing on the physician coding side?

Left Dorsalis Pedis an additional artery on Left Anterior Tibial?

A PTA was performed on the left dorsalis pedis. A PTA with atherectomy was done on the left anterior distal tibial. Is the left dorsalis pedis PTA an add-on to the 37229? Or part of the 37229? 37229, 37232 or 37229?

List of tunneled and non tunneled catheters

Do you have a list of names of types of tunneled catheters and non-tunneled catheters? I used to have a great list to refer to, and in an office move I cannot find it.

POP TO POP BYPASS FOR TRANSECTED ARTERY D/T TRAUMA

Saphenous vein was harvested to bypass the transected portion of the popliteal artery (above knee to below knee bypass). The damaged section of artery was ligated distal to the proximal anastomosis and proximal to the distal anastomosis. Would you use code 35571 or an unlisted procedure code?

Moderate Sedation

When the providers are performing a procedure that now has the moderate sedation billed separately, does the moderate sedation documentation have to be in the body of the report or can we use the nurse notes to bill it?

Aortic Repair

Can/should the procedure to repair intraoperative dissection be coded? "Mitralplasty with cardiopulmonary bypass was performed. Left atrium was closed with 3-0 Prolene running suture. Patient was cardioverted to sinus rhythm and came off bypass. Blood pressure was allowed to rise, venous line was removed, and ascending aorta was found to have bluish discoloration. Patient had an intraoperative aortic dissection. Right femoral artery cutdown was performed and Fem-Flex cannula inserted. Patient cooled to 20 degrees centigrade. Ascending aorta was transected proximally, and tube graft was sewn, two layers for posterior wall and one layer for anterior wall. Adentitia was preserved. Clamp was removed from ascending aorta. Aorta was transected distal to cannulation site. There was 2 cm linear cut in the aorta at the cannulation site from an extension of the cannulation orifice. We then did distal anastomosis with two layers posteriorly and one layer anteriorly. Patient was rewarmed. There was bleeding from proximal anastomosis and tear found in the intima. We redid suture line with pledgets and biological glue." 

Repair of Two Arteriovenous Aneurysms

"A curvilinear incision was made over the aneurysm, and proximal and distal control were obtained without much difficulty. The aneurysm was rather eccentric. Skin flaps were elevated. The fistula was clamped, and the anterior wall was resected off of the aneurysm. Some of the lateral wall was then resected as well. There was a lot of laminated thrombus in the anterior saline, and then fistulotomy was closed longitudinally using 5-0 prolene. Flow was restored to the fistula, which obtained a good thrill. Additional sutures were applied to achieve good skin approximation. Light pressure dressing was applied." The physician called this an aneurysm repair (36832); however, I see thrombus was removed. Would we code this as 36831? I don't see that the fistula was revised.

3D Echocardiogram with CPT Code 76376

We have a question regarding CPT code 76376, In the CPT code description it states "under concurrent supervision". Does that mean the MD needs to be physically present at the time the post-processing takes place? Usually the echo tech will complete the post processing back in the echo lab and then send the study to the MD to be read. So in this instance can you bill code 76376?

CTO Intervention 92943

What are the documentation requirements to use the CTO code 92943? Is 100% occlusion enough to use code 92943, or does the physician have to state chronic total occlusion to use this code?

IVUS 92978

Can code 92978 be reported if the IVUS was done post intervention on the lesion? The RCA stent was well apposed and expanded by IVUS. In the summary, severe 80% mRCA lesion status-post successful PCI with DES x 1 Moderate 50% ostial RCA lesion status-post IVUS showed MLA of 5.6 mm2.

Endarterectomy of ICA and ECA with separate incisions

"An extensive endarterectomy was performed on the proximal ICA with heavily calcified plaque. There was plaque in the ECA as well, so a separate incision was made in the ECA and plaque was removed. The arteriotomy was then closed with suture." Can this be billed with codes 35301 and 35301-59 since two separate arteries were endarterectomized and a separate incision was made in the ECA?

NCCI edit between 37227 and 37186

Is there a new NCCI edit between codes 37227 and 37186? I never noticed it before.

Follow-up ultrasound following biopsy of liver

Can we bill a follow-up ultrasound of the liver the following day after the biopsy to check for any bleeding?

Guidelines for Peripheral Intervention

Could you provide a link or point me in the right direction to locate CMS guidance on what percentage of a blockage in the peripheral vein or artery is considered too small in order for a PTA or stenting to be medically necessary?

Appropriate fluoro CPT for Destruction by neurolytic agent 64640

We are seeing that your 2017 charge sheet maps 64640 to the spinal fluoro 77003. I'm wondering if that is already an errata on your site. Just confirming the peripheral/other goes to the more general 77002.

MRI Orbit 70551

An MRI of the brain was completed along with a complete MRI study of the orbit. There are complete clinical indications for the necessity for an MRI of the orbit from the referring physician. Would it be correct then to bill codes 70551 and 70551-XS?

Mitral Line after PVI

I see this pretty often and am unsure every time. For this particular case the physician completed a PVI. After this the patient's afib converted to left-sided atrial flutter (in other cases flutter is induced after PVI). Mapping was performed that showed mitral reentry, therefore a mitral line was performed. In this case that terminated the arrhythmia to afib. The impression states: "Left-sided mitral flutter was ablated with the mitral line joining the left inferior pulmonary vein." Is the mitral line just an extension of the PVI, or is it a separate ablation (93655)? I often see a similar account with a roof line joining the pulmonary veins. I've seen some direction that says the mitral line and roof lines are included in the PVI since they are done so often, and I would like your opinion please. 

Regarding Coronary CTA

If patient has had a coronary CTA and is now in the cath lab, can we still do the coronary angio? I know with CTA legs it is a prior diagnostic procedure.

Can we bill 76881 with 20610, 77002?

I am seeing charges for 76881 come in with 20610, 77002. I don't feel we should be able to charge for this because I'm not sure if its medically necessary. They do aspiration/injection frequently without knowing/checking how much fluid is actually there. Can you give me your thoughts? Provider note states: "Survey view of the right hip was performed using real time grayscale ultrasound to determine if sufficient joint effusion was present for ultrasound-guided aspiration. No significant joint effusion was seen and the procedure was then performed fluoroscopically. The right hip was sterilely prepped in the usual fashion and anesthetized with approximately 4 mL locally infused 1% lidocaine solution. Under direct fluoroscopic guidance, a 22 gauge spinal needle was advanced into the right hip joint. A small amount of Omnipaque solution was injected to confirm intra-articular needle position. A combination of 2 mL Kenalog (40 mg/mL) diluted in 5 mL 1% lidocaine solution was injected." I would code this as 20610 and 77002. What are your thoughts?

Gastrostomy Button Exchange

"The balloon of the MIC-KEY gastrostomy button was deflated. The button was removed, and a new 14 French low-profile MIC-KEY gastrostomy button with a 1.2 cm stomal length was placed. The balloon was inflated with 2 mL saline. Gauze was placed between the tube and the skin." Would we use code 49450 for the g-tube exchange? Or do we add a -52 modifier to 49450 or use an unlisted code?

Closure Device G0269 and C1760

When a closure device is used during a uterine fibroid embolization, when would it be appropriate to assign G0269 and/or C1760 in the following locations: 1. Global - office (POS 11), 2. ASC (POS 24), and 3. Outpatient (POS 22)? When does the facility get to code, and when does the physician get to code for it?

Right Gastric and Left Hepatic

Based on previous responses it has been noted that the right gastric is commonly a branch of the left hepatic, which I can see in the "Celiac Arterial" anatomy chart in your publications. My question is about coding when both of these vessels are catheterized in the same case. If the left hepatic is catheterized distal to the origination of the right gastric, would you consider it to be a separate placement (36247, 36248)? I would have this same question about a scenario involving the right hepatic and cystic.

Venous Lower Extremity Intervention

For venous lower extremity angioplasty and stents, do they follow the same territory rules as lower extremity arteries (iliac, femoral/popliteal, and tibial/peroneal territories)?

Billing drugs and supplies for IR group in office setting

Can you provide us with guidelines or resources in regards to what supplies (if any) and/or drugs can be billed for an IR group within an office setting? What drugs or supplies would be inherent to the reimbursement within the procedure code, and/or what drugs can we additionally bill for?

Fluoroscopy with Pacemaker

Can I use code 76000 with codes 33217 and 33225? "Using a 0.014 whisper wire, through an inner and outer sheath, the appropriate branch was cannulated, and the wire was advanced distally. The lead was then delivered to this branch. Satisfactory sensing and pacing were confirmed, without diaphragmatic stimulation at 10 V on the proximal poles of the quad lead. No diaphragmatic stimulation was seen on the minimal vectors tested during implant. The proximal poles unfortunately had limited capture, but the distal pole actually had the latest activation. Next, using the splitter, the inner and then the outer sheath were successfully split. Next, the short introducer sheath was split. The lead was tied down with 0 Ethibond suture. Attention was next turned to the atrial lead. Another 7 French sheath peel way introducer was inserted over the second wire. This was used to position the atrial lead. The atrial lead was positioned into the appendage were was screwed in place. Satisfactory thresholds were measured. The sheath was split. The lead was tied down with 0 Ethibond suture."

Spinal Cord Neurostimulator

According to the new Pain Management boo,k fluoroscopic guidance for the initial electrode array placement (63650 and 77003) may be reported separately, but there is an NCCI edit in place. Should these be billed together?

76642 vs. 76882

Can you use code 76642 when ultrasound is performed on the axillary tail only? Is this considered a compliant use of this code?

Moderate Sedation Facility

I work for a hospital (IVR), and I am looking for guidance on how to bill the new moderate sedation codes. When we have a case, a nurse administers the meds and monitors the patient. The doctor does not. He is performing the procedure only. Would codes 99155 and 99156 be the correct codes to use?

93623

My provider is performing an SVT ablation (93653). Drug infusion is inducted (93623), patient goes into a different arrhythmia, and an ablation is performed after adding the infusion. Can we bill for the drug infusion (93623)?

Left Atrial Appendage Exclusion

Atrial clip inserted during sternotomy for repair of cardiac injury to right ventricular outflow tract. Would I use code 33340 or 33999 for atrial clip? With good exposure of the left atrial appendage, the left atrial appendage was excluded with a 35 mm atrial clip and then vented.

Midline Catheter Insertion

Your Diagnostic Radiology books says: "A 'midline' catheter (placed in the arm and advanced with the tip in the subclavian vein) is a central catheter (PICC) for coding purposes. Use code 36569 to describe this procedure." The other note says we can capture 36569-52 if the PICC cannot be advanced from the extremity centrally due to subclavian occlusion. If this occurs, and the tip is in the axillary vein, we would report the lesser service. Our radiology staff have said that the midline catheters are too short to reach the subclavian vein, so they would never qualify a midline catheter as a central catheter. Can you comment on this for us? I need to clear it up for us. It is as clear as mud to us right now.

Endo-Anchors

From previous Q&As it appears that the endo-anchors placed during the initial stent graft deployment cannot be coded. Since there is significantly more work/risk/time involved in placement of the anchors, do you have an opinion on justification for a -22 modifier? Also are you aware of any movement to create a CPT code for this procedure that is becoming ever more common?

Preservice Work, Interservice Work, and Postservice Work

I was wondering if you need to have the documentation of preservice, interservice, and postservice in the operative notes, or is it okay to have this documentation listed in other parts of the record?

Infected port catheter site follow-up wound care code

Patient had infected port catheter removed and will be coming weekly for wound check, irrigation, and repacking of wound with Iodoform gauze. No anesthesia is involved. Is there a CPT code for this, or is it just E&M?

Cuff shave of peritoneal dialysis catheter cuff

I'm unsure of the appropriate code for this procedure. Operative report reads: "A small ellipse of skin was created around the exit site and dissection taken down around the cuff. The entire cuff was exposed, and a rim of soft tissue was created around the exit site where skin had heaped up and grown onto the cuff. I removed 1-2 mm rim of epithelium as well as the cuff. I shaved the cuff from the catheter, taking great care to remove only the cuff and not to injure the catheter."

Pelvic Doppler Studies

What has to be mentioned when coding 93975?

Recurrent pelvic congestion syndrome

"The previous supraumbilical transverse incision was created with a #10 blade. The muscle layers were divided with a bovie cautery. The abdominal cavity was explored and no abnormalities were appreciated on exam. The Omni tract retractor was placed in position. The small bowel was eviscerated to the right side. The aorta, vena cava, left renal vein and superior mesenteric artery were dissected. All lymphatic tissue encountered were ligated with hemoclips and divided. It was noted that the juncture of the left renal vein previously transposed to the vena cava was examined and found to be patent. The ovarian vein was still patent and very large. It had a common trunk proximally but quickly bifurcated into two smaller branches which then came together to form a common trunk in the pelvis. The ovarian vein was clamped in the pelvis and then transposed to a partially occluded vena cava above its bifurcation. The anastomosis was constructed with 7-0 prolene. The anastomosis was hemostatic." The doc has dropped the code 34510, but I don't think this is correct. What are your thoughts?

Thyrocervical Trunk Angiography

I'm wondering how to report catheterization of the subclavian artery followed by catheterization of the thyrocervical trunk, as well as angiography of both. I'm thinking of code 36225-52. Thoughts?

Define Complete Doppler

I am faced with a group of doctors who want to charge for a complete Doppler study for every transesophageal echo that they perform. I know that when Doppler measurements are documented for one or two valves, that is a limited Doppler study (93321). However, the doctors are wanting me to define a list of the sites measured in a complete Doppler TEE (93320). I believe a complete Doppler should include measurements at all four valves and the left ventricular outflow tract. Is there anything else that needs to be documented? What measurements do you personally look for before you apply 93320 to a TEE?

PVI for patient not in atrial fibrillation

Our patient has a history of atrial fibrillation, for which PVI was scheduled. When the patient presented for the procedure, he was found to have a supraventricular tachycardia at the start of the case. The arrhythmia did not appear to be A-fib. After mapping, the focus of the tachycardia was suspected to be at the right pulmonary vein. The EP physician performed PVI. Entrance and exit block were confirmed. Attention was turned to the initial tachycardia, which could not be re-induced. Is code 93656 appropriate for this PVI since the patient was not in atrial fibrillation at the time of the procedure? Or would it be more appropriate to report code 93653 for ablation of the SVT at the right pulmonary vein?

Open Thrombectomy

Patient was in for open thrombectomy of AV fistula followed by angioplasty and stent insertion. Is there an additional code for the stent placement if it was done via open approach? Would code 36903 in addition to 36831 be appropriate? If not, what code do we report, if any? “An incision was made in the medial side of the arm where the patient had an arterial revision in the last week, and then a graftotomy was made in this position and a #4 Fogarty was used to thrombectomize both the arterial and venous limbs. Once this was done, a 7 French introducer sheath was placed into the graft in the venous limb, and a fistulogram was performed. There was a very tight stenosis at the AV graft AV fistula anastomosis and at the venous anastomosis. So, an 8 x 5 cm Viabahn stent was then deployed at both locations. Then, an 8 x 4 balloon was placed over the wire in this position and angioplastied several times to 26 atmospheres."

Lexiscan- rest and stress portions done on different days

Occasionally the rest and stress portions of the Lexiscan (nuclear stress test) are performed on two different days, usually in patients who have a larger body mass. Would it be appropriate to bill codes 78451 and A9500 for the DOS that the rest portion was done and codes 78451, A9500, 93015, and J2785 (if the patient is unable to walk on the treadmill) for the stress portion and bill with the DOS this was done? Would we bill the same for Medicare and commercial? Or for commercial plans would we bill codes 78452 and A9500 on the rest day and then codes A9500, 93015, and J2785 (if applicable) on the day the stress portion was performed? Also, to confirm, should the DOS each portion was done be the DOS used as the billing date? And would you suggest two reports (each dated accordingly), or would one report documenting the date each portion was performed be sufficient?

Intercostobrachial Supplemental Nerve Block

What would be the correct nerve injection code for a intercostobrachial supplemental nerve block? The physicians are performing this in conjunction with a brachial plexus/interscalene single-shot block (64415) for post-op pain management. Would 64420 be appropriate for the supplemental intercostobrachial block? Or would 64450 be more appropriate since the intercostobrachial nerve is a cutaneous nerve off of the T-2 intercostal nerve?

ONYX to Treat EVAR Endoleak

In researching the product ONYX liquid embolic system LES, the FDA has it listed with a classification name of "Agent, Injectable, Embolic". However, in the approval statement, this is noted: "Device is indicated for presurgical embolization of brain AVM." That being said, if an embolization is performed with the ONYX system to treat an EVAR endoleak, is this considered "off label" and therefore should be coded with a UPC? Or, would it be appropriate to utilize code 37242?

Radial Approach

When radial approach fails and LHC is ultimately performed via femoral approach, should we code radial access 36215-59, followed by LHC 93458 (of course, without femoral access since it included in the LHC code)? If so, are specific diagnosis codes required for radial access to be reimbursed?

93452 and 93462 during EP Ablation

"Transseptal puncture was done using Baylis needle at central fossa under ICE and hemodynamic guidance. Entry to left atrium was verified, and left heart catheterization was performed. Mean LAP was 30 mmHg. Agilis sheath was then inserted to the left atrium and tip deflected into the mid-MV. Pentary cath was deployed to the left ventricle, whose geometry was acquired. The other EP catheters were inserted into the CS, right ventricle, and left ventricle. 3D maps of right atrium and left ventricle were created with CARTO. HIS bundle was located and labeled. EP study was performed to assess AV and VA conduction and sinus node recovery time. Clinical PVCs were seen with infusion of Isuprel. The ablation cath was then positioned to the respective cardiac chambers, and activation and pace mapping was performed using PASO software. Ablation was performed targeting the respective sites, and complete disappearance of PVCs was seen following ablation." Can we report codes 93452 and 93462 during this EP ablation? Encoder specifies that code 93452 is allowed but with modifier -59. Are these two typically coded/billed together for EP ablations?

US Liver Ablation with US and CT Guidance

Please advise on proper coding of the following procedure. "TECHNIQUE: Informed consent was obtained. The patient was placed in supine position and placed under general anesthesia by the anesthesiology service. Utilizing ultrasound and CT guidance, a 17 gauge RF needle was advanced right hepatic lobe masses. RF ablation of the liver masses was performed. Tract ablation was performed. The needle was removed. A sterile dressing was applied. The patient was taken to recovery in stable condition. INTRA-PROCEDURE MEDICATION: Contrast agent Omnipaque 300 50 ml 100 milliliter. INTRAVENOUS IMPRESSION: Successful ultrasound and CT-guided ablation of right hepatic lobe hepatocellular carcinoma." Both US guidance and CT guidance were utilized for the liver ablation. Should this be coded as 47382, 77013-26, and 76940-2659 OR 47382, 76940, and 74160?

Ablation

"Patient presents for hydrodissection followed by ablation. A small incision was made in the RUQ. Under ultrasound guidance, a Hawkins needle with a blunt tip was advanced into the peritoneum from a subcostal approach. A Benson wire was advanced into the peritoneum under CT fluoro guidance. Then, a 6 French pigtail catheter was placed over the wire toward the dome of the liver, and 2L of 5% Dextrose was infused into the peritoneal cavity. Periodic CT fluoro was used. As fluid was infusing, the lesion began to separate from the liver. A non-contrast scan of the liver was performed, which confirmed that the lesion was, in fact, a diaphragmatic implant, not an exophytic liver lesion. Given the risk of diaphragmatic paralysis and other complications if we were to ablate the lesion, the decision was made to terminate the procedure. The intraperitoneal fluid was drained and the catheter was removed." Had liver ablation been performed, would we code both the ablation 47382 and 49084??

Mild regurgitation ICD-10

If the provider states "there is/was mild aortic regurgitation" in the report, can that be coded or does it need to be moderate? In our office we have had a difference of opinion on this. If it can be used, would you use I35.0 as the dx code?

ICD-10 f/u after pacemaker

If a patient is coming into the office one year post pacemaker for CHB, would you still code the CHB with status post PPM as the diagnosis code?

ICD Changeout for FDA Advisory

Patient presented for an ICD generator and lead that are under advisory from the FDA. There is no supporting information to state that the generator was showing an ERI status now or that there were any lead failures noticed in the device checks. Device was placed for secondary prevention and patient is solely reliant on the ICD, so decision was made for a complete removal/replacement. The provider is coding the procedure as a mechanical breakdown of ICD generator and ICD electrode (T82.111A and T82.110A). Is this appropriate without evidence to support any actual complication? Is there another ICD-10 code that is more appropriate to report when changing out due to an FDA advisory or recall, or do we simply revert to the Z45.02? Is there anything else we should be doing on facility or physician side to make sure the claim is processed smoothly when there is an FDA advisory/recall?

Iliac Stent

We are seeing several denials for iliac stenting with diagnosis of iliac arteriosclerosis. We are using I70.8 for iliac stenosis. We have WPS Medicare, and this is not a covered diagnosis. Is there a different diagnosis code we should be using?

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