Knowledge Base

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Angioplasty Subclavian Vein with Selective venogram

"Venogram was done by selective cannulation of right subclavian vein from right basilic approach. Apparent stenosis found. Left subclavian vein was then cannulated and contrast injected for left venogram. IVUS was done of both right and left subclavian veins. Provider proceeded to perform angioplasty of right subclavian vein stenosis." Is the venogram coded in addition to the angioplasty? If so, isn't this considered "non-selective" since it was from a basilic vein approach (36005, 36005-59) and not reported? Can the venogram of the left subclavian vein be reported since intervention was done on the right subclavian vein?

Test Occlusion of Fenestration

Would a test occlusion of a fenestration be reported with an unlisted code (93799)? "INTERVENTIONS: Test occlusion of the fenestration. A 014 Mailman guidewire was passed through the right Judkins, which was passed through the fenestration and advanced into the descending aorta. Over this guidewire, a pre-prepared 10 x 20 mm mini Tyshak balloon was advanced. This was then pulled back near to the atrial baffle. After partial inflation, the balloon was pulled across the fenestration and held straddling the fenestration. The balloon was left in situ for about 5 minutes, and saturations and hemodynamics were repeated. Following this, the balloon was deflated and removed. An angiogram was performed, and the balloon was inflated to confirm complete occlusion of the fenestration."

PCI on variant coronary artery

One of my cardiologists performed a PCI on variant coronary artery in a patient who had no prior interventions or grafts. He first placed a BMS in the LD, finding normal anatomy there. He then documented an anomalous LC that “originates from the right coronary artery”, and placed a BMS in the mid to distal anomalous LC to treat an 80% stenosis. Would the LC intervention be coded as a major vessel equivalent with 92928-LC? Or would it be coded as part of the RC distribution with 92928-RC since he had to separately select the ostia of the RC to reach the LC?

Swan-Ganz vs. Right Heart Catheterization Criteria

There is a discrepancy between the coders and techs regarding the use of codes 93503 and 93460 when a patient has a Swan placed for pressures during a LHC and it is left in after the procedure is complete for prolonged monitoring. Some believe thats if any right heart pressures are taken in the cath lab we cannot charge 93503 and that it is an automatic RHC in addition to the LHC. Some believe that if there aren’t RA/RV pressures it isn't a full diagnostic RHC and therefore 93503 should be charged. For example, a patient comes into the cath lab in cardiogenic shock and has a LHC performed, pulmonary artery pressures and wedge pressures (no RA or RV pressures), and the Swan is left in for prolonged monitoring. Is this 93458 and 93503? Or does this count as a right heart catheterization and therefore we should charge 93460 only? 

Complete Runoff

What is meant by a complete runoff? Does the imaging have to be to the toes in order to bill for the complete runoff? "Both groins were prepped right common and left common femoral arteries were accessed; a 5 French sheath was placed into each vessel. There was high grade stenosis in the left common iliac artery and multiple stenosis in the external iliac artery, common femoral artery, and beginning of the SFA. On the right there was high grade stenosis of the RCA and occlusion of the RSFA and CF . We performed angioplasty across these areas using a 5 mm balloon x 200 in length and then deployed 8 mm x 57 in length expandable stents across the CIAs. We then deployed a stent across the ext iliac, CF, and the beginning of the SFA on both left and right sides and post-dilated these areas. After this, repeat contrast study revealed a widely patent iliac arterial system as well as common femoral arteries, SFA, and profunda femoris." Would the correct codes be 37226-50, 37221-RT, 37223-RT, 37221-76-XU-LT, 37223-XU-LT, and 75716-26-XE? In this case would it support the runoff?

CT Guidance PERCUNAV CT/US

"The lesion was not directly visible under UL imaging. Therefore PERCUNAV CT-US imaging was used to help position the targeted lesion. A preprocedural low contrast dose exam was performed to delineate the lesion. Under CT-UL fusion guidance, a suitable site for access of the right liver dome lesion was localized. A small dermatotomy was made. Under intermittent CT and Perkin guidance, a 19 gauge needle was advanced to the targeted lesion in the right liver dome. Repeat low contrast dose CT was performed to confirm appropriate position. Multiple core biopsy samples were then obtained utilizing the supercore biopsy device. Following specimen collection, all needles were removed. Hemostasis was achieved with manual compression." Would we bill codes 47000 and 76499-26, or would we also add code 76942-26? 

Venogram LE with 37252

In follow-up to question ID #8381, there is an NCCI edit that says I can't bill 36005 and 37252. Does 75822 become my primary?

Percutaneous staining of pulmonary nodules with Methylene blue

Is there a CPT code for percutaneous injection of methylene blue into pulmonary nodules? Or do we use unlisted code 32999? This will be performed under CT guidance (77012).

Chemical Cardioversion

"Patient was brought to the cardiac cath lab. Ibutilide was administered in 250 mcg increments over 5 minutes. After roughly 30 minutes the patient was converted to NSR." I'm coding for the hospital, not the physician. Do we use code 96374 or 93799? Or something else?

Transposition or Direct Anastomosis

"We started procedure with a longitudinal incision of 3 cm at level of axilla. A subcutaneous tissue was dissected until we identified neurovascular plexus. Axillary vein was dissected free and encircled with vessel loop proximally and distally total 3 cm. We started to tunnelize the graft in the subcutaneous tissue. Through the tunneler we performed a loop of 20 cm from axilla to antecubital fossa. We started fashioning arterial anastomosis end-to-side and performed 6-0 prolene on a running suture. At the end we checked flow inside the graft, which was excellent. Should I code a transposition (36820) or direct anastomosis (36821)?

32557 or 32550

"After administration of local anesthesia and using ultrasound guidance, a 19 gauge needle was advanced via posterior approach into the previously demonstrated right pleural collection. A specimen of thin amber fluid was obtained for lab for studies. The tract was dilated to 8 French, and an 8 French pigtail catheter was inserted. The catheter was connected to a Pleur-evac. Follow-up chest radiograph was scheduled." Should we report code 32557 or 32550?

Angioplasty of Fontan Fenestration

What is the appropriate CPT code for angioplasty of the Fontan fenestration? The note states, "The wire was positioned into the right atrium. Through this wire, we advanced the balloon and inflated it on two occasions across the Fontan fenestration."

Coil Embolization

For coiling of right superior and inferior gluteal arteries, should we bill codes 37242 and 37242-59?

Upper Arm Dialysis AV Fistula

One of our doctors routinely accesses the brachial artery on upper arm AV fistulograms. With the 2017 changes, is there a way to charge for brachial artery access, either by CPT code or modifier?

Billing for 77001

In the 2017 edition of the Interventional Radiology Coding Reference, example 2 in the "Vascular Access Device Placement" section of chapter 7 states: "Patient presents for central catheter. Ultrasound is used to determine suitability of the jugular veins. The right jugular vein is determined to be too tortuous to use. The left jugular is suitable for the placement. Ultrasound is used as guidance for needle placement (76937). Hard copy images (permanent recording) and reporting are documented. The non-tunneled central venous catheter is placed without difficulty and secured with suture (36556). After catheter manipulation and injection of contrast, confirmation of tip placement in the superior vena cava (77001) is documented on a stored image." In this example, how do you know that tip placement was confirmed by fluoroscopy? In this same section you state, "Some catheters may be placed without any guidance. The use of these guidance codes requires specific documentation to support utilization of the access guidance codes." If they do not state fluoroscopy was used, how can you code 77001?

US Guidance with LE Revascularization

You have previously stated that the SIR confirmed that ultrasound guidance is allowed for arterial access. My question has to do with usage of ultrasound during lower extremity revascularization and the CPT definition of these codes. When I started coding vascular cases, I was told that ultrasound with codes 37221-37235 is not allowed because of CPT guidelines and descriptions. Per the CPT Codebook, codes 37221-37235 include the work of accessing the vessel. The CPT Codebook describes ultrasound code 76937 as "ultrasound guidance for vascular access". Since the ultrasound is used to access a vessel, and accessing of the vessel is included in codes 37221-37235, then you don't code it. This has come up again with a new practice, and the physicians feel they should be able to use code 76937. I only use the code with arterial access for non-occlusive procedures like 37236, which actually states in the CPT Codebook that ultrasound guidance can be used when performed. I would like your opinion on this. 

36593 Declot by Thrombolytic

Why can we not bill code 36593 on the professional side?

35883 or 35876

"#4 Fogarty was passed into the profunda, then passed easily and well into the profunda for a distance of at least 30 cm, and minimal thrombus was extracted. Clot was easily extracted from the femoral-femoral bypass graft; normal pulsatile arterial inflow was restored. At this point, this is thoroughly irrigated and inspected, and then bovine pericardial patch brought to the field and cut to the primary size and sewn in using two separate CV 7 Gore-Tex sutures. Excellent Doppler signals were noted outflow right profunda and at the right peroneal artery post procedure." I am thinking of reporting code 35876, while the doctor states it should be code 35883. What's your opinion?

Central Dialysis Segment vs. Peripheral Segment

"Doctor performed a thrombectomy via transverse incision. After thrombus was removed, a fistulogram was performed, which showed a moderate stenosis throughout most of the fistula up to the deltoid level where the vein became more normal appearing in caliber. The outflow was examined all the way through the subclavian level, and there was no evidence of central vein stenosis. Guidewire was advanced through the fistula, and a 6 mm balloon was used to iron out areas of narrowing readiness. Completion fistulogram showed improvement." Would we only report code 36831? I am confused about central vs. peripheral. I don't know when it would be appropriate to report code 36907.

Office Hysteroscopy

How would you code ultrasound guidance for a hysteroscopy that is done in an office? Would you use unlisted code 76999? This is a facility charge done by hospital US department staff.

IVUS of the Thoracic Aorta

I have a patient who had suspected thoracic aortic aneurysm due to spinal pedicle screw penetration. Patient underwent aortography, and, due to the potential nature of the screw threads catching the aorta (since they were touching), they performed IVUS, which showed the screw juxtaposing the aorta but no penetration. No intervention was decided this session. How do I report IVUS with no qualifying procedure? Or is this just a courtesy we performed? Also is the PCS code for aorta IVUS B240ZZ3, single coronary artery IVUS? We have to add both codes at our facility.

Occlusion of vessel appropriate for angioplasty?

Just seeking a clarification to make sure we are not barking up the wrong tree. If hemodynamically significant stenosis is documented, this is justification for angioplasty. If the physician documentation is "the superior vena cava is completely occluded", does that support that this vessel is essentially severely stenotic? Or would the physician truly have to document severity of stenosis as opposed to the vessel just being occluded?

Replaced Left Hepatic

As of this year, I've seen embolization procedures for liver mets that referenced a "replaced left hepatic artery". I only find references to replaced right hepatic. Is this similar to when it's the right?

Multiple Central Catheters via Separate Accesses, Separate MDs, Separate Times

Dr. A (different provider, different group) placed a tunneled cath in the RIGHT jugular vein. Later that day our provider Dr. B removed the RIGHT jugular central venous cath and placed a non-tunneled dialysis cath via LEFT jugular vein using ultrasound guidance. How would I bill for my doctor (Dr. B) so that the new cath does not bundle against the other (Dr. A) cath placement? Would it be like this for Dr. B: 36589, 36556-59, 76937-26-59?

Moderate Sedation

Very often the documentation for moderate sedation says that it was administered by an interventional nurse or nursing staff. We are billing for radiologists. In order to bill for moderate sedation, does it have to be administered by our physicians?

Neurovascular Intervention and Imaging 36224

Coil embolization was done for the known left internal carotid aneurysm at the intracranial segment. 3D reconstruction at the separate work station, angiogram during the intervention, and the follow-up angiogram were done at the same session. The description of code 61624 says any method and does not mention S&I. Can I add codes 75894, 75898, and 76377 with codes 61624 and 36217?

36246

Do we still report code 36246 if a catheter approaches from the radial artery instead of transfemoral artery to the internal iliac artery?

LP for Intrathecal Chemotherapy Administration

I have two providers performing one procedure. Dr. A does a lumbar puncture under fluoroscopic guidance and collects CSF per oncology. Chemotherapy was then injected by Dr. B. Dr. A flushes spinal needle, reinserts stylet into spinal needle, and then removes it (one puncture only). For Dr. A, should we report code 62270 or 62272 with 77003? Should Dr. B submit code 96450 for just the injection of the chemotherapy?

AAA Repair with renal artery stent

During a AAA repair, the provider used 9 endoanchors due to short aortic neck. Also, a stent was placed in the renal artery as a chimney for the graft through the brachial artery access. Bilateral femoral cutdown was performed for endograft placement. At the end of the procedure, femoral endarterectomy was performed on the right side. A stent was also placed in the left common iliac artery for atherosclerosis. My questions are: 1) Is the renal stent considered integral to the AAA repair since it was used as a chimney for the endograft? 2) Does the use of the endoanchors as well as placement of the stent quantify using a -22 modifier on 34802? 3) Can we report code 34834 for brachial access as well as code 34812 for left-sided femoral artery cutdown? 4) Does a modular bifurcated endoprosthesis include a short limb and a longer limb? Our provider used the word "extension" for the longer limb, and I wasn't sure if it is a true extension. I did not include the report, as it is quite long and would not fit.

Excision infected fem-pop graft,reconstruction using vein cadaver

"POSTOPERATIVE DIAGNOSES: Infected above-knee Propaten graft on the right femoral to distal SFA with possible stenosis of jump graft to tibioperoneal trunk. PROCEDURE PROPOSED: Excision of infected femoral popliteal Propaten graft, reconstitution with cadaver vein. PROCEDURE PERFORMED: Extirpation of infected right femoral popliteal graft, reconstruction of the common femoral artery using cadaver vein donor, femoral to below-knee tibeal/peroneal bypass using cadaver vein and thrombectomy." I'm not sure about the appropriate codes: 35700/35884/35903 or 35700/35566/35903 or 35700/35876?

Temporal Artery Pseudoaneurysm

"Temporal artery pseudoaneurysm. PROCEDURE PERFORMED: Open right temporal artery pseudoaneurysm resection. TECHNIQUE/PROCEDURE: After the patient was prepped and draped in a sterile manner, I made an elliptical incision encompassing the temporal artery pseudoaneurysm that I had just previously embolized its inflow. I made an incision in the middle of the wound and then tried to circumferentially remove the temporal artery pseudoaneurysm in this segment. Upon doing this, the skin edges were completely necrotic and friable. Therefore, I had to make a more elliptical incision encompassing all the dead tissues in which the pseudoaneurysm was found. After doing this, I then removed this entire segment." How would you code for the resection of the temporal pseudoaneurysm?

Insertion of Biventricular ICD with Removal of Subcutaneous ICD and Electrode

Patient is having a biventricular ICD inserted. A pocket is created; RA, RV, and LV leads are inserted; pocket closed. Then via another incision, the patient's current subcutaneous ICD generator and subcutaneous ICD electrode are removed and that incision is closed. Should we report codes 33249, 33225, 33241, and 33272? Or would this be considered an ICD exchange (33264, 33225, and 33272)? We are not sure if a subcutaneous ICD generator is the same type of generator as the one for a biventricular ICD and therefore a generator exchange code is appropriate, or if we just code the insert of biventricular ICD and removal of subcutaneous ICD generator and electrode as completely separate procedures. Regardless, all of the transvenous leads inserted would be "new", so I am leaning towards codes 33249, 33225, 33241, and 33272 being how this case should be coded. Can you please give us guidance on this?

Atherectomy at the Time of Aortic Valve Replacement

I am billing code 33405 with a -22 modifier appended. Here is the provider statement: "On the posterior wall of the aorta approximately 0.5 cm distal to the left main, there was a ruptured plaque that was debrided. There was a small intimal defect that was patched with a bovine pericardial patch with running 6-0 prolene suture."

Replacement of CRT-D generator with addition of new atrial lead

Patient had an existing CRT-D and a right atrial lead that was malfunctioning. The doctor inserted a new atrial lead, capped the old atrial lead and left it in place, and replaced the CRT-D generator with another of the same type. Would this be reported with codes 33264 and 33216? Or codes 33249 and 33241?

Temporary Pacemaker Replacement

"Patient is dependent on a transvenous pacemaker, which has lost capture with concern for lead migration out of position. Using the pre-existing transvenous pacemaker, under fluoroscopic guidance, we positioned the pacemaker to the desired location near the right ventricular free wall. We documented good capture... The pacemaker was secured." Would this be billed with code 33210?

Spinal Embolization

If T6, T7, and T8 are embolized on the right side, would code 61624 be reported one time or three times?

73501 vs 73521 unilat vs bilat hip xray pre unilat THR

Can you please clarify which imaging code is appropriate for the following scenario? Patient is about to undergo a total hip on the left side. Imaging is done in advance. Images of both hips are obtained. We are told that the left hip is imaged because it is diseased or injured, and the right hip is imaged solely for templating purposes (to measure, calculate angles, etc. to order the correct components for the other side). Is there appropriate medical necessity to be able to bill bilateral hip imaging, or is it not medically necessary to code for the other side because the other side isn't injured or being treated and would therefore be more appropriately billed as unilateral (just for the affected side)? We can see both sides: bilateral seems appropriate because they need that second side to be able to treat the first side, and unilateral seems appropriate because they have no medical necessity to bill for the second side since it is not being treated. Please let us know what you feel is appropriate and the rationale.

MRI of the Brain and MRI of the Orbit

We had a patient come in for an MRI of the brain and MRI of the orbits performed on the same encounter. Should I only report code 70551 for both the brain and orbit?

Perclose Device Failure

The entire EVAR procedure was completed percutaneously. AAA was repaired, and physician proceeded to perclose device to close percutaneous access. The perclose device failed, and decision was made to perform cutdown to suture the artery. Can we bill code 34812 for this cutdown after AAA was repaired?

35081 or 35091?

We have a patient who has a large perirenal abdominal aortic aneurysm right up to the level of the left renal. From the operative note it reads: "We clamped the common iliac vessels first, then the perirenal aorta using our aortic clamp. We opened up the aorta and removed an extensive amount of thrombus. There were several lumbar vessels, which we oversewed with 2-0 Mersilene. At this point, we had our lumbars oversewed, and we had our clamps in position. We chose a 16 mm Dacron graft and sewed our proximal anastomosis. The proximal anastomosis was sewn right into the left renal orifice. On completion of our anastomosis, we flushed it with saline and found there to be no leaks." Should we report code 35081 or 35091? 

Multiparametric MRI for Prostate

Our radiologists have been performing this post-processing for PIRADS 3 cases to assist the urologists when they perform the prostate biopsies. What would be your recommendation regarding capturing this in CPT? Would it be considered under 3D rendering with 76377? Or is an unlisted code our only option here? It is being used on MRI of the prostate. Here is an example of the documentation: "A multi-parametric MRI of the prostate was performed on a 3T system using a phased array pelvic coil. Sequences: High resolution small field-of-view axial, coronal and sagittal T2-weighted images, small field-of-view axial diffusion weighted images, large field-of-view axial fiesta, small field-of-view axial T2 gradient echo, and small field-of-view dynamic axial T1-weighted images. Images prior to and following the administration of 15 ml intravenous prohance. CAD software analysis was performed." The radiologists state this is a time-consuming process. 

Saphenous Vein Procurement

I am at a loss on how to code this particular case. "Patient had a resection of a radialocephalic aneurysm. The physician then took saphenous vein to revise the AV graft per interposition." I am unsure what code to use for the saphenous vein portion of the procedure. Does code 36832 include the removal of the patient vein? I can't seem to find any info on this.

Sedation - Physician Supervision

Would this sedation documentation be sufficient? Or should physician supervision or face-to-face time also be documented? "Moderate sedation was administered and monitored by radiology nursing staff for 30 minutes."

Removal of AngelMed Guardian device

How would you code the removal of an AngelMed Guardian generator (0412T)? "Patient was prepped and incision made under the original incision and carried down to pulse generator site. The pulse generator was removed along with its two sutures that were attached to the pectorals fascia. All bleeders were cauterized. The lead was detached from the device; the lead was capped with 0 silk. The pocket was then irrigated with bacitracin. The pocket was then closed with 2-0 Vicryl for fascial layer, 2-0 Vicryl for the drama layer, and 4-0 Vicryl for the cuticular. Stere-Strips dry dressing was placed." Is this considered a cardiac contractility modulation (CCM) system (0412T) Category III code?

Open graft thrombectomy and endovascular renal thrombectomy and stents

For the following example, should we report codes 35875, 37184, 37236, 37237, and 36245? "Patient has aorto-bi-femoral bypass graft. MD performs open thrombectomy of the graft and converts over to endovascular to perform thrombectomy of the right renal. Secondary to continued thrombus in the aorta and aorto-bi-femoral limbs, decision was made to place stents in the aorto-bi-femoral limbs to extend into the aorta. Viabahn stents were placed simultaneously in both limbs. Stents were introduced to line up below the level of the right renal artery. Stents were deployed simultaneously. On the right a balloon was introduced into the stent. On the left side, a balloon was introduced into the stent. Balloons were inflated simultaneously with good apposition noted distally. Follow-up angio demonstrated good flow in limbs; however, the patient had persistent aortic thrombus greater than 50% at the level of the right renal artery, but below the level of the left renal artery. Therefore, bilateral iCAST stents were introduced through each of the sheaths to the level below the left renal artery and stents deployed." 

Femoral lead extraction for fragment

In a cardiac device extraction, a surgeon moves to femorally remove the remaining lead fragments. What CPT code covers that segment of the procedure?

Modifier 51

After reviewing question ID 8094, I have a question. The scenario we have now is 36226 and 36223-50. The question is where to put modifier -51. Since we pay by RVUs, one coder suggested that we put modifier -51 on 36223-50, and the other coder wants to put it on 36226 because it has the lower RVU (36226 RVU = 6.25, 36223-50 RVU = 8.63). Can you explain and put this to rest for us? 

20600-20611

A patient had two joint injections performed during the same day. The patient presented with pain in the right wrist, and the attending injected Kenalog in the FCR and radioscaphoid joints. The FCR was done using ultrasound, and the radioscaphoid joint was performed using fluoroscopy. I understand there is an edit (category 2) in place for both 76942 and 77002, which hits against 20606. Would you suggest coding for the ultrasound-guided arthrocentesis one time with 20606? Or can we break out 20606, 20605-59 (XS), 77002-59 (XS)?

Bicuspid Aortic Valve//History of Repaired Coarctation

A 28-year-old patient who has a bicuspid aortic valve and a history of aortic coarctation repair, surgical repair at 10 days old, and angioplasty at 12 years old. She also has left ventricular diastolic dysfunction and pulmonary hypertension. She is having a right and retrograde left heart cath as well as lower extremity venography. She has no stenosis or gradient of the aorta at this time. Would you code this heart cath as congenital or non-congenital? And would you include the diagnosis of aortic coarctation or not?

REBOA Resuscitative Endovascular Balloon Occlusion Aorta

The trauma team is looking to start performing the REBOA (Resuscitative Endovascular Balloon Occlusion Aorta) in the emergency department. Vendor information suggests coding as 37244; however, my understanding is that code 37244 is for a permanent occlusion and this procedure appears to be a temporary occlusion to control bleeding until patient can be taken to the OR/IR lab. Is code 37244 or a UPC more appropriate? Also, would this include imaging to place the balloon?

3D separate workstation followed by coil embolization

Diagnostic cerebral right internal carotid angiogram was done for the known aneurysm. Then, 3D reconstruction at the separate work station was done to evaluate the aneurysm for the precise measurements of coil sizing. The coil embolization was followed. These are all done in one session by the same neurosurgeon. I have codes 61624, 75894, 75898, 36224-RT, and 76377. Are these the correct codes for this case?

Sheath Insertion for Dialysis

Can you please tell me if this would be reported with code 36901? "Recent malfunctioning of fistula right arm with two recent episodes of declotting and viabahn stent insertion. Venous access is recommended prior to dialysis for the next few weeks. APPROACH: Run-off vein right upper forearm ultrasound guidance. CATHETER: Two 6 French vascular sheaths. PROCEDURE: Following local anesthesia and utilizing maximal sterile barrier technique, the vein listed above was punctured with a micropuncture needle. Utilizing ultrasound guidance, a sonographic image was obtained for confirmation of needle position and vessel patency. A .018 wire was passed through this needle, followed by insertion of a 4 French dilator. The 018 wire was then exchanged for an 035 J-wire, followed by insertion of a 6 French vascular sheath. This was performed twice in the same vein, with insertion of two sheaths, both rectus cephalad. The hubs of the sheaths were then stabilized to the skin with a sterile opsite dressing. The patient was sent for dialysis. Status post successful venous sheath insertion for dialysis."

Arterial Line with Cerebral Angiogram

If the interventional radiologist puts in a left femoral vascular sheath with ultrasound guidance as an arterial line for the anesthesiologist during a cerebral angiogram, can we charge for arterial line placement? Would the correct codes be 76937 and 36140? The cerebral angiogram was done via the right-sided femoral sheath.

CT-Fluoroscopy

When the provider uses CT-fluoroscopy for a biopsy, do we bill for CT guidance or fluoroscopic guidance? I told the coders to bill for CT guidance per your instruction of: "Only one form of guidance may be coded. Use the most intensive guidance code if multiple guidances are used (e.g., MRI > CT > US > fluoroscopy)." Am I correct in my logic? 

Y90 Tumor Treatment

Patient had a selective catheterization and angiography with infusion of Y90 resin microspheres into the segment of 7 branches of the right hepatic artery. Nuclear Medicine assisted in the administration of the Y90 and also performed SPECT CT localization imaging after the embolization to confirm proper delivery of targeted region. Would it be appropriate to report code C2616 with 78803 and code 79445 with 78803? Both combinations are hitting an NCCI edit. Can modifier -59 be added?

A PCUI to OMB SVG anastomosis was done, PCI to mid OMB CTO occlusion and at

Would codes 99244-LC, 99243-52-LM, and 92937 be appropriate for PCI to the OMB SVG anastomosis, or would code 92937 not be reported since it is the same vessel?

37186

For the following, do you recommend reporting thrombectomy with code 37186 (in addition to 37224)? "Balloon angioplasty of right superficial femoral artery. Follow-up arteriogram revealed partial response of the SFA to the angioplasty especially in the proximal SFA; however, there was presence of significant amount of clot in the common femoral artery and profunda occluded and the collateral vessels into the popliteal artery. At this time given the absence of any mechanical thrombectomy devices in this hospital I proceeded to advance a 4 French sheath over the 6 French sheath and perform several passes aspirating the sheath as a thrombectomy device. She was advanced into the profunda femoral. Arteriogram revealed still remaining clot in the common femoral artery and 1 More Pass I was able to clean the common femoral artery; however, the SFA now was clotted. The branches were preserved as the initial arteriogram, and there was no evidence of any clot in the common femoral artery. At this point I was concerned that if I try to advance the sheath and aspirated the SFA I could deliver call back into the common femoral performed."

Paracentesis Procedure

Can we report code 49082 if the physician only inserts the catheter for drainage and doesn't stay for all of the drainage and to subsequently remove the catheter? Would a -52 modifier be required if the physician doesn't perform the insertion to removal of the catheter and/or doesn't remain in the room?

92960 for Ablation

Is cardioversion not included for billing if done during the procedure for ablation?

Percutaneous AAA repair

"Bilateral percutaneous accesses of common femoral artery were performed. EVAR procedure (34803) was performed. Perclose device on left femoral access was closed. Attempt to perclose the right femoral access failed. We then obtained proximal control using a 7 mm balloon in the right external iliac artery. We then made an oblique 4 cm incision in the right groin. This was taken down through the subcutaneous tissue with bovie electrocautery. The common femoral artery was then dissected free from the surrounding tissue using blunt and sharp dissection. We then closed the arteriotomy using 6-0 prolene in an interrupted mattress fashion." Can we charge code 34812 for right groin incision since percutaneous closure failed?

Modifier 50 and 37248/37249

For a Medicare patient, is it proper to use modifier -50 with both codes 37248 and 37249?

Radiofrequency Ablations of the Knee

We are doing radiofrequency ablations of the knees and are using CPT code 64640. Can we also charge for fluoroscopy (77002) with these procedures? I cannot find where they code against each other.

70496 and 70460

Can codes 70496 and 70460 be billed together with a -59 modifier appended? I'm getting an NCCI edit. If yes, please explain why.

Thoracentesis with Ultrasound Marking

If a thoracentesis is being performed by a pulmonologist in Outpatient Surgery, but requests for the ultrasound technologist to scan the chest and mark fluid, do we report code 32555? Or codes 76604 and 76942? 

34900 VS 37242 VS 37236

"Patient is status post aorta-bi-femoral bypass in 2014. Recent CTA showed retrograde flow via the right internal iliac artery into the right external iliac artery and filling a right common iliac artery aneurysm sac. Access was via the patient's right native common femoral artery below the anastomosis of the right side of the aortofemoral graft, but above the right superficial femoral artery with serial dilatations due to scar tissue. Catheter was advanced into both the native right external iliac and right internal iliac arteries with angiograms performed, confirming CTA findings in addition to tortuous and mild aneurysm dilation of the proximal right internal iliac artery. A 8 mm x 7.5xm Viabahn stent was deployed segmentally across the proximal right internal iliac artery into the right external iliac artery. Repeat angiogram showed exclusion of the right common ilia artery aneurysm." Is this procedure reported with codes 34900, 75954, and 36245? Or with codes 37242 and 36245? Or with codes 37236 and 36245? 

Bronchoscopy Done Post Decortication via Vats

A cardiothoracic surgeon sometimes doing post-bronchoscopy CPT 31622 after VATS. There is no NCCI edit, but bronchoscopy has a designation of "separate procedure"; should this be removed? "Example - male who presents with shortness of breath and cough and fevers for the past week. He received a chest x- ray which showed a large pleural effusion. A 1-cm incision was made over the 7th intercostal space. dissection was carried down to the chest wall and chest cavity was entered bluntly. Thoracoscope was then inserted. A second port site was made over the 5th intercostal space. The fluid was cleared out it was noted that the right lower lobe and right middle lobe were completely trapped. The right upper lobe was partially trapped. There was a rind on both the parietal and visceral pleura. The rind was then taken off completely off the parietal and visceral pleura (CPT 32652), the surfaces of all 3 lobes of the lung, completely freeing them, allowing them to completely expand. The patient then underwent a bronchoscopy. The bronchoscopy showed no abnormalities."

Thrombectomy with Axillobifemoral grafting

Would I code the thrombectomy with the bypass grafting? "The left groin had had open vascular surgey in the past, very possible for ECMO cannulation. There was a lot of scar tissue around the common femoral artery. With slow dissection with sharp and blunt techniqure, I dissected the left SFA upe to the bifurcation and then I dissected the PPFA then up onto the Common femoral artery to the le vel of the inguinal ligament and i dissected the external iliac artery above the circumflex iliacs while maintaining their patency. This was a difficult dissection on the left side due to the severe scaring and there was evidence of an old patching on the CFA. Next the vesseloops were applied and clamped on the femoral vessels. First the left femoral arteries were clamped. A longitudinal arteriotomy was fashioned in the common femoral artery across its bifurcation. I used 4-0 fogarty balloon for proximal thrombectomy of the external iliac and common femoral arteries and 3-0 fogarty balloon for the SFA and popliteal artery thrombectomy."

93965 Replacement Code

The 2017 coding updates have deleted code 93965 (Noninvasive physiologic studies of extremity veins, complete bilateral study) and does not offer a replacement code. Would code 93970 (Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study) be appropriate to now report? I have read the following information, and it seems to make sense. It reads: "93970 is defined as a Duplex scan of lower extremity veins including responses to compression and other maneuvers, complete bilateral study. This is both an imaging and non-imaging study. It includes the collection of BOTH physiologic in the form of Doppler analysis of bi-directional flow, the spectrum analysis, and B-mode imaging". Any help would be greatly appreciated. Thank you.

Resection of AV Fistula Aneurysm, Revision with graft, PTA cephalic arch

"Patient has 2 aneurysms in the prox aspect of his AV fistula. He had multiple venograms by an outside interventionalist & review of notes indicates a moderate stenosis just distal to aneurysm that has been ballooned multiple times...aneurysms were excluded using Ioban. A small transverse counter incision was made over the prox aspect of the arterialized cephalic vein & circumferentially dissected. Having achieved proximal control, we created another counter incision just approx 2cm distal to the distal fistula. This is to exclude both fistulae & area of stenosis. We then tunneled an Accuseal graft & created an end-to-end anastomosis with the graft & the prox arterialized cephalic vein. We then made an end-to-end anastomosis between the graft & the distal cephalic vein. Central venogram was performed with PTA of cephalic arch for 50% stenosis) We then turned to aneurysms. 2 elliptical incisions over the apices of the aneurysms are created & the aneurysms are circumferentially dissected & ligated at both ends & removed." What should I charge for this case?

Prostate Embolization

For prostate embolization, is code 37243 the only appropriate CPT code? Is it a bundled code

Re-read of TEE

Our providers are being asked to interpret a TEE that has been performed elsewhere and previously read by another physician. I'm hesitant as to how to code for this. Code 93314 includes the acquisition, which does not apply to this, so I was leaning towards a -52 modifier. However, the interpretation and report for this TEE has already been billed for. What do you suggest?

AV Dialysis graft angioplasty performed in Surgery

I have discovered a charging practice at a facility where a surgeon sometimes performs an AV dialysis graft angiogram and angioplasty (all well as other interventions) in surgery if the schedule is full in cath lab. I have been notified of charge edits occurring in surgery and was asked to help. The issue is Radiology has been charging code 36901 for their tech operating the c-arm (providing fluoroscopy). Surgery reports their procedures by time increments. Apparently HIM soft codes surgery procedures. Therefore in a scenario above they want to enter code 36902, which causes an edit with code 36901. I do not feel Radiology should be entering code 36901, as they are only preforming fluoroscopy. I feel there is duplicate charging occurring. Is there a recommended charge for Radiology to use when providing fluoroscopy in these cases? I do not think they have any chargeable procedure in this case. Any recommendation would be appreciated.

ICD-10 Congenital Echo Coding

In the situation where a patient has had a congenital heart defect repaired or it has corrected, do you code for a congenital echo (93303) or a regular echo (93306)? Does simple congenital heart disease versus a more complex congenital heart disease diagnosis come into play?

Intraoperative Navigational Head CT

I am wondering if the hospital (TC) can charge CT head wo for these scans done in the operating room. Scanner is AIRO by BrainLab. "The radiolucent reference frame was attached to the head holder, and the bed was rotated 90 degrees for the intraoperative stealth CT. The stealth CT was acquired for registration and was then merged with the pre-operative MRI. CT showed that the needle biopsy was a little lateral to the lesion. There was no hematoma on the new head CT. The new stealth head CT was merged with the pre-operative MRI, and a new plan was made. A third intraoperative CT was obtained that confirmed we were in within the lesion and there was no hematoma. We used the intraoperative AIRO CT system to register after fixing the Reference arc. This helped plan the surgical incision."

Moderate Sedation Provided by the Same MD Performing the Procedure

We have several MDs at our hospital based facility that are certified to order moderate sedation, which is administrated by a nurse. The same MD who orders the sedation is performing the procedure. Does this fit the description of CPT code 99152, moderate sedation provided by the same MD performing the service the sedation supports, as it is the same MD on both the order placed and the procedure? The independent trained observer would be the nurse. (Note that our patients are over age 5.) Or, would it be more appropriate to use CPT code 99155 for this situation?

36902 with 36833

The 2017 CPT guidelines indicate that if open dialysis circuit creation, revision, and/or thrombectomy (36818-36833) are performed, CPT codes 36901-36903 are not separately reportable. Am I understanding correctly that if an open revision with thrombectomy is performed in the AV graft body (36833), and an angioplasty is performed of a hemodynamically significant stenosis in the venous outflow through a separate puncture outside of the graft body and anastomoses, that code 36902 is still not separately reportable because it's still in the peripheral segment? My coding software shows that codes 36902 and 36833 are in a PTP edit, but the edit allows a modifier... Would the modifier allowance be for a separate practitioner or separate encounter only? Finally, code 36833 shows as the column 2 code and 36902 as column 1, even though 36833 has much higher RVUs and is more extensive, which is not adding up to me. I want to be sure we are coding hybrid procedures with combined open and percutaneous techniques appropriately, as the procedure seems to have taken a big revenue hit in 2017.

Moderate Sedation OP vs. IP

You answered a question on Jan 12, 2017 and stated that for OP hospital setting codes 99151, 99152, and/or 99153 are reported by the physician performing the procedure. The hospital would report the same codes. You have also provided information that the physician can only bill 99152 in the facility setting and the hospital would bill 99153. Can the physician bill codes 99152 and 99153 if in the POS of 22 but only 99152 if POS is 21? Please clarify this for us. 

Conscious Sedation

According to the Special Newsletter dated 1/20/17 it states that a facility can bill 99153, which is an add-on code for 99151-99152; however, in the MPFSDB under PCTC, the indicator 9 is listed. Since our interventional radiologists are billing codes 99151-99152, the hospital cannot bill 99153. Do you know of a solution for the hospital to capture the revenue and be able to add 99153 when appropriate?

Arterial Angioplasty

Is the lateral plantar artery considered an additional vessel when coding lower extremity endovascular revascularization? Can you separately for this?

Thrombosis of arteriovenous graft 36904 with open thrombectomy

"A fistulogram with thrombectomy and angioplasty was performed on a patient with thrombosis of left arm arteriovenous graft (36904). Unfortunately the clot from the graft had been pushed distally through the arterial anastomosis into the brachial artery above the bifurcation of the radial and ulnar arteries. Patient was taken to the operating room for an open thrombectomy of the brachial artery." Code 36831 cannot be used with 36904, even with a modifier. Would code 36833 be correct?

Debridement with pacemaker generator exchanges

Our physicians have recently started doing a lot of debridements where they are listing out under procedures performed: "Wound debridement, subcutaneous, area 12 cm2". Then in the body of the report they are stating, "Wound debridement was carefully performed with sharp dissection to free the leads from scar tissue in the subcutaneous layer. Area of dissection was 12 cm2." Is this enough documentation to report code 11042 with an -XU modifier along with the pacemaker generator exchange (in this particular case was a dual chamber generator exchange, 33228)? Do you recommend T82.897A for the diagnosis code of the scar tissue around the leads in the subcutaneous tissue that led to the debridement? We know that generally the cleansing of the pocket area is included, and there is not a documented infection or hematoma drainage, so we are unsure if it is okay to report code 11042 with the above verbiage.

Unlisted J-Tube Change without Fluoroscopy

To code a replacement of a jejunostomy without fluoroscopy, where the catheter tip location is confirmed with a post contrast KUB, is code 49451-52 appropriate (modifier to explain the difference in imaging)? Would an unlisted code be best? Code 43760 is for a gastrostomy replacement without fluoroscopy. Putting a -52 modifier on code 43760 would explain the difference in anatomy of the procedure, but I feel the anatomy (49451) is of more importance than the difference in imaging used (43760). 

Embolectomies Popliteal-Tibio-Peroneal Arteries

When only one incision is performed, but all three areas are done, then only code 34203 can be reported once, correct?

Joint Aspiration with No Fluid Obtained

How would I code a joint aspiration if fluid is not obtained? "Using sterile technique and fluoroscopic guidance, a 3.5 inch 20 gauge spinal needle was inserted percutaneously into the left hip joint adjacent to the femoral component of the left hip prosthesis. The needle was repositioned multiple times in attempt were made at aspiration. No fluid was aspirated."

Open Angioplasty of Peripheral Dialysis Segment

How would you code an open venoplasty of the brachial vein via an incision in the AV graft? Is this still reported with code 36902?

Bovine Graft Excision vs. Reexploration/Washout/Debridement

I'm hoping you can help point me in the right direction on this one. Header states "arm wound washout", though I feel this is much more in-depth than that. "Patient has previously placed bovine arterial graft after arterial pseudoaneurysm excision. Non-healing wound now with drainage/bleeding. There was a 3 x 2 cm area of erythema next to the open wound. Looks like possible cellulitic tissue. Upon further dissection, it was noted that the bovine graft was exposed at this area. Doppler was used on the graft, and there was no flow. The wound was exposed further longitudinally. The exposed graft was dissected out until well incorporated ends proximally and distally. The exposed/non-incorporated graft was excised and proximal and distal ends oversewn with 4-0 prolene suture. Luminal thrombus was removed and the lumen instilled with rifampin prior to oversewing. Wound was debrided with cautery. Skin excised to well perfused edges. Further rifampin was instilled into the wound. Approximated SQ tissue with 3-0 vicryl suture. Approximated skin with interrupted 3-0 nylon suture."

Resection of Gore Thoracic Endograft

I am lost with this, so I'm hoping you can help. "Patient had an infected endograft along with ulcer in the thoracic aorta. Patient was put on bypass. We saw the aorta and up to the arch, and then we removed the endograft without difficulty. We then resected the aorta all the way back to the undersurface of the arch. This included freeing up the left subclavian, separating it from the arch, so we had a good rim to sew to. We debrided all the material from the aortic wall. We sized a 26 Hemishield graft. The proximal anastomosis was constructed. The aorta was incised distally, and distal anastomosis was constructed. We proceeded to re-warm the patient. During this time a side-biting clamp was placed on the descending Hemishield graft. Eye cautery was used to make an opening, and an 8 mm interposition graft was placed between the left subclavian artery end-to-end and the hemishield downstream. A latissimus muscle flap was then split and brought through the thoracotomy and wrapped around the fulling enclosing the space with viable muscle."

AAA Screening Code for Female or Patient Younger than 65

We had female patient come for AAA screening. We billed code 76706, but it denied saying that this is for male 65 to 75 only. So, what is CPT code for female or for people younger than 65 years old? We used to bill code G0389, but it's deleted this year (2017).

Cardioversion

Patient comes to the ER with complaints of a racing heart and heart palpitations with a past medical history of paroxysmal atrial fibrillation. She has a surgical history of previous TEE and CV. EKG shows atrial fibrillation with RVR and incomplete RBBB. Patient is admitted under observation, and the physician performed cardioversion in the cath lab two days later. No other procedures are performed. Is this considered emergent or elective? Are we able to report code 92960?

ICD-10 Cerebral Infarction

Provider has documented the indication on the operative note as "cerebral infarction unspecified" (I63.9). After reading the operative note, documentation seems to support ICD-10 code I63.232. What would be the appropriate ICD-10 code to bill?

36558 vs. 36565

Should this be reported with code 36565, or would this be reported with codes 36558, 36558-59? "The right internal jugular vein was accessed with a 21-G needle. The catheter cuff was placed 1-2 cm inside the tunnel exit site. The micropuncture catheter and microguidewire were exchanged for a peel-away sheath and a 0.035 inch guidewire which was positioned into the IVC. Using fluoroscopic guidance, the catheter was advanced through the peel-away sheath and positioned with the tip in the mid-right atrium. The right internal jugular vein was accessed with a 21-G needle using ultrasound guidance. A 0.018 inch guidewire was advanced into the vein using fluoroscopic guidance. A site 1-2 cm below the inferior margin of the right clavicle was identified as the tunnel exit site. Using a #11 blade, a small incision was made and the catheter was tunneled through the chest incision to the lateral neck dermatotomy. . Using fluoroscopic guidance, the catheter was advanced through the peel-away sheath into an appropriate position. Cath in atrium."

77001 with 36901

I have a guidance question. The physician first places tunneled cuffed hemodialysis catheter with fluoroscopic guidance (36558/77001). In the same setting he then performs an AV fistulogram (36901). Is it appropriate to report code 77001 for the catheter placement once the fistulogram is performed?

Biventricular Pacemaker

When a biventricular pacemaker is initially inserted, and the atrial lead is not placed, would we code as if it were a multi-lead system or simply as a dual chamber?

Coronary Intervention Hierarchy

What would be the appropriate codes for the following coronary interventions? Rotoblade therapy followed by stent in the obtuse marginal branch followed by angioplasty and stent in the proximal circumflex coronary artery. 92928 and 92934, 92929 and 92933, or 92928 and 92933?

Com/Ext Iliac stents for access dissection during attempted kissing stents.

A 5 FRENCH KUMPE CATHETER AND GLIDEWIRE WERE USED TO TRAVERSE THROUGH THE LEFT COMMON ILIAC ARTERY. DESPITE MULTIPLE PROBING, THE GUIDEWIRE COULD NOT BE ADVANCED INTO THE DISTAL ABDOMINAL AORTA. DURING THE MANIPULATION, THERE WAS ANTEGRADE DISSECTION NOTED INVOLVING THE DISTAL COMMON ILIAC ARTERY, SPIRALLY DOWN TO THE EXTERNAL ILIAC ARTERY. GIVEN THE SPEED OF DISSECTION, WE HAD TO QUICKLY INTERVENE. AN 8 X 60 MM SELF-EXPANDABLE STENT (ABSOLUTE) WAS QUICKLY DEPLOYED IN THE LEFT DISTAL ILIAC ARTERY TO PREVENT FURTHER DISSECTION. SUBSEQUENTLY, ANOTHER 8 X 40 MM SELF-EXPANDABLE STENT WAS OVERLAPPED INTO THE COMMON ILIAC ARTERY TO TREAT THE INITIAL POINT OF DISSECTION. GENTLE ANGIOPLASTY WAS PERFORMED WITHIN THE STENTS, WITH AN 8 X 40 MM BALLOON CATHETER. POST INTERVENTION CONTRAST INJECTION SHOWED RESTORED WIDE PATENCY THROUGH THE LEFT ILIAC ARTERY. THE PATIENT HAS BEEN ON THE TABLE FOR 2 HOURS. IT WOULD NOT BE SAFE TO ATTEMPT CROSSING THE LEFT COMMON ILIAC ARTERY IN THIS SETTING. THEREFORE, WE DECIDED TO TERMINATE THE PROCEDURE. Code 34900 or 37236 1 time.

Dorsalis Pedis

Is the dorsalis pedis artery considered part of the tibial/peroneal treatment zone in lower extremity endovascular revascularization?

TEE Guided Cardioversion

Can a TEE and cardioversion be billed together, or should we just bill for the TEE?

Lariat Procedure in 2017

Would it be appropriate to report code 33340 for the Lariat procedure? Or is your advice to still use unlisted code 33999?

CardioMEMS

Is there a CPT code to report recalibration of a CardioMEMS device during a right heart catheterization?

93571 with C9600

I work for a hospital, and we are getting an edit when we report code 93571 with C9600 (diagnostic angiograms were done on a different visit). Code C9600 is not listed as a "base procedure" for add-on code 93571. I saw an old Q&A from 2014 addressing this issue as an NCCI edit oversight. Code C9600 was added as a base procedure for IVUS, but not for FFR. Have there been any updates since then? Or do we not code for the FFR in this situation?

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