Knowledge Base

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Acute Marginal Branch

Please clarify intervention on the acute marginal branch. Is the acute marginal considered a branch of the right coronary? Should we report codes 92928-RC and 92929-RC for the following intervention? "We successfully advanced a 2.5 x 22 mm Resolute drug-eluting stent over the ATW Marker wire and positioned it across the mid RCA stenosis where it was deployed using up to 16 ATM. We then advanced a 2.25 x 12 mm Resolute drug-eluting stent across the proximal acute marginal branch stenosis where it was deployed using up to 15 ATM. The stent balloon was pulled back slightly and used to post-dilate the area of overlap between the deployed stents."

SINGLE LEAD PACEMAKER GENERATOR CHANGE

1) Pacemaker generator change. 2) Placement of a new lead in the right ventricle. 3) Capping and abandonment of old lead.... When the existing right ventricular lead has been capped and abandoned and new lead is advanced into the right ventricular apex using a combination of straight and custom-formed stylettes onto new pacemaker generator (pulse generator was also changed), should this procedure be coded as 33212, 33216, and 33233? Or 33227 with 33212 and 33216? And is fluoroscopy always included in pacemaker procedure?

37785 "Varicose Vein Cluster(s)"

37785, Ligation, division, and/or excision of varicose vein clusters. Does the documentation need to state "varicose vein clusters"? Our physician is removing large varicose veins through separate incisions and then suturing those incisions.

33216 vs. 33210

I was reviewing a question from 2013 in regards to insertion of single transvenous electrode connected to external pacemaker. Is 33216 still accurate, because the description states permanent pacemaker or implantable defibrillator?

Revision vs unlisted procedure for pacemaker pocket procedure

We are questioning if we should bill a revision or an unlisted code for the following pacemaker procedure. "A 4 cm incision was made on the skin overlying the infraclavicular fossa with a #15 blade. Dissection was carried down with electrocautery to the pre-pectoral fascia until his chronic DCPM was identified. Further dissection was performed and the device extracted from the body. Hemostasis was obtained as needed with electrocautery. The generator was seen in a vertical position. The generator was then removed, and a deeper caudal pocket was made using blunt dissection. Hemostasis was obtained with electrocautery. The lead and device were then placed in the pocket and sutures with 1-0 silk suture."

Definity and 93352

Is it appropriate to bill code 93352 if in the physician's interpretation he does not mention the use of Definity? It is listed in the report as a medication administered and signed off by the physician, but he does not personally refer to it at all in his interpretation.

Removal of ENDOcardial Left Ventricular Lead

Patient had a biventricular pacemaker with a malfunctioning left ventricular ENDOcardial pacing lead. Physician performed, by thoracotomy: 1) Placement of EPIcardial lead left ventricle, 2) Removal of ENDOcardial lead left ventricle, 3) Removal of current pacemaker generator with replacement of new pacemaker generator and reattachment of the existing right atrial and right ventricular leads. I know the placement of epicardial lead is 33202, but I can't locate a code for removal of an endocardial lead. I would assume the generator exchange is 33229. Would CPT code 33238 be appropriate for the endocardial lead removal?

Ultrasound guidance for vascular access

I code for neuroendovascular physicians, and I recently attended a coding seminar and was told that we cannot bill for ultrasound guidance for vascular access. Could you please clarify this statement for me since all the research I have done does not confirm this?

36620 Intraop arterial BP monitoring during EP case

The EP physician wants to bill code 36620-59 with every EP procedure since he documents the following in his report, "5 French SideArm vascular sheath was placed in the artery and was used for intraoperative arterial blood pressure monitoring." He doesn't document any more information after that as to why, etc. Is this sufficient to bill in addition to an EP procedure?

Interrogation of Pacemaker

For this case we are not sure how much needs to be documented to code for interrogation of pacemaker and what code would be best with this documentation. "Right femoral region was prepped and draped. See cardiac cath log sheet for sedation. The patient's device was interrogated and programmed to a lower rate of 30 BPM. An 8 French sheath was placed in the right femoral vein using modified Seldinger technique. Radiofrequency energy was applied to the AV node with an 8 mm tip ablation cath, resulting in complete heart block. Sheath was removed, and the device was then programmed to a lower rate of 80 BPM." I am thinking of code 93650, but I'm not sure what to code for interrogation of pacemaker. Is there enough documentation to report codes 93286 and 93286-59? Or is code 93288 or 93279 best? We are confused on when to use the interrogation device codes and what is supposed to be documented for each code. Can the cardiology nurses report code 93279 the day after a pacemaker is put in? 

UroNav Prostate Biopsy

I found a question from 2015, but I'm looking for current information regarding the coding of this procedure. For our procedures the patient has the prostate MRI done at another location and then we import that data into the UroNav unit the day of the procedure. At the time of the procedure the live ultrasound of the prostate is performed, and that exam is fused with the prior MRI to create a 3D rendering on screen that is used for the prostate biopsy. Multiple core biopsies of the prostate are then done with the guidance of the image appearing on the UroNav unit. Currently for this procedure we are using the codes 55700, 76942, and 76377. We are being told that we cannot use code 76377 because "there is no separate reimbursement for that code, as it is considered a packaged service". What is the correct billing for this entire procedure? 

CPT 76885 with 76886 and CPT 73562 or 73564 with 77073

Under what circumstances can codes 76885 and 76886 be billed during the same encounter (e.g., can they be billed separately when both static and dynamic tests are performed, and findings for static test and dynamic test are reported in separate paragraphs)? Under what circumstances can code 73562 or 73564 be billed with 77073 during the same encounter? Would it be appropriate to report three views of the knee if three views of the knee are taken and one additional view is reported for “scanogram”? Diagnoses are knee pain and/or arthroplasty follow-up.

Heart Catheterization with LV Pressures

Prior to the McKesson reports, cath reports would describe the catheter crossing the aortic value, which meant you were in the left ventricle and performing a left heart catheterization. Reports no longer have this verbiage however. So my question is, if the report indicates LV pressures were taken, does this constitute a left heart catheterization? LV gram would constitute a left heart catheterization, but this is not always performed. Any help in determining if a left heart cath is done is very much appreciated.

23350 and 20610 reportable together?

We have scenario in which a patient had a therapeutic injection of Depo-Medrol for shoulder pain (20610) at the same time that Omnipaque, Omniscan, lidocaine, and ropivacaine were injected via a 22 gauge needle inserted into the glenohumeral articulation to perform a diagnostic arthrogram and post arthrogram MRI. Is it appropriate to report code 20610 along with 23350? All meds were injected via one needle. 

Chemo injection into liver percutaneously

The patient has hepatocellular carcinoma (HCC). The procedure performed is a Pexa-Vec (oncolytic immunotherapy drug) ct-guided injection into the liver. What is the CPT code for the injection procedure?

100% Subtotal Occlusion of RCA

We are trying to code a case where the physician states he stented a 100% subtotal occlusion of the RCA. No thrombus is mentioned. Would this be coded as a CTO?

Placement of a tunneled port via the hepatic vein

How would you code placement of a tunneled port via the hepatic vein? Would the same port placement codes (36561, 77001, 76937) be correct? 

EVAR with 2 docking limbs and four extensions

"Patient presents with AAA as well as bilateral common iliac artery aneurysms that involve bilateral common iliac artery bifurcations. The patient's bilateral common iliac aneurysms are not amenable to standard endo-grafting and will require the use of a Gore iliac branched endoprosthesis to obtain a seal, as well as to maintain preservation of flow into the internal iliac arteries. Our physician did EVAR with an aortic endoprosthesis with two docking limbs, distal extension into external iliac artery of endoprosthesis on right side, distal extension of endoprosthesis, internal iliac on right side, distal extension into external iliac of endoprosthesis on left side, and distal extension into internal iliac with distal endoprosthesis extension on left side." This is the first time we have done this with four extensions. What is the best way to code these?

Open thrombectomy fem/pop with perc thrombectomy of TP trunk

Would the following example be reported with codes 34201 and 37186? "We made a transverse incision in the distal common femoral artery. We inserted an 11 French sheath. Angiogram demonstrated thrombus in the popliteal artery and distal superficial femoral artery. There was single vessel peroneal run-off with chronically diseased and occluded anterior tibial and posterior tibial arteries. We brought a NAV6 filter into the tibioperoneal trunk. We performed over-the-wire thrombectomy of the superficial femoral artery and popliteal artery. We removed a lot of thrombus. Repeat angiogram demonstrated patency of flow in the popliteal artery with irregularity and debris in the tibioperoneal trunk. We performed mechanical thrombectomy with a Penumbra CAT8 catheter of the popliteal artery and the tibioperoneal trunk."

Intra arterial injections during cardiac cath

When a patient has a cardiac cath performed via radial access, I've been told intra arterial injections are being administered to "prevent" vasospasm while the catheter is being manipulated and moved throughout the cardiac cath procedure. These injections are not given when access is gained via the groin. These claims are hitting a CCI edit with the cardiac cath codes and CPT 96373. In my opinion, this would be included as part of the cardiac cath procedure and adding a 59 modifier would not be appropriate. What are your thoughts? Thank you.

Embolization with CT Imaging

I know the embolization codes include guidance, but I wanted to make sure that means CT guidance as well. I am wondering if a limited CT could be separately reported if CT is used to identify a specific area of endograft leak prior to embolization (same patient encounter).

G0288

For G0288 surgical planning for vascular surgery of aorta, can the code also be billed for post-op follow-up treatment? My understanding is that the code is for surgical planning only, but the facility where I work is using it for follow-ups to TAVRs and AAA repairs where no surgery is planned. Is that allowed?

Cardiology - revision lead VS complete pacer replacement

I have a case where the cardiologist put in a dual chamber pacemaker (33208-KX). The following day the patient had chest pain and palpitations, so the note says the patient will have revision of pacemaker and leads. I am not sure how to code this revision. Here is the revision report: "An incision was made inferior to clavicle. Dissection was carried down to myofascial plane and then continued caudally to form a pocket for the generator. The atrial lead was placed in the atrial appendage. Ventricular lead was placed in right ventricular septum. Suture was used to secure the new leads. The leads were pushed in about another 2-3 cm to provide more slack. Thresholds and impedance were excellent. New generator was securely attached to the leads and placed in pocket." Would this be just a revision (33215), or would you code this as removal and replacement of the entire system?

Perforated Temporary RV Lead - Need comparable code for unlisted procedure

We are requesting your opinion on an accurate comparable code. We suggested code 33215; however, the provider prefers 33300 (at 10% work effort) due to prepping in case things didn’t go as planned. "Operative Note: Patient had a temporary lead perforate the RV. A permanent system was placed before the patient was transferred here. The patient was taken to the OR and placed under general anesthesia. I was prepared to perform placement of a percutaneous drain, moving to a subxiphoid pericardial window, moving to a full sternotomy to repair the defect directly if complications occurred. We began with exam of the heart under fluoro, then, with a good eye on the lead, we carefully pulled it back through the perforated site, into the heart, then into the SVC. Echo confirmed there was no effusion or evidence of bleeding, indicating that allowing the pericardial space to seal functioned successfully and there's no need to open the patient. I removed the lead back into the sheath, and the procedure was concluded. The lead was successfully removed without complications from the perforated RV."

33249, 33241

Patient has a dual chamber ICD with a right ventricular lead fracture. Procedure performed was right ventricular lead replacement, fractured right ventricular lead capping, and replacement of dual chamber ICD with testing of ICD. What are your coding recommendations? 

Transposition of AV Fistula

A new AV fistula (brachial/cephalic) is created, and the cephalic is brought over and sewn end-to-side into brachial (I know this is 36821), but they then elevate the cephalic with sutures underneath to superficialize it during closing... would the procedure then become a transposition (36818)? 

CPT code 75572

We need clarification after a TAVR is performed due to a disease. After which the surgery is performed, our team bill status post codes for the CT cardiac morphology instead of the disease that warranted the TAVR. Of course Medicare is denying the status post code TAVR. I would think if the physician has  "Severe Aortic Stenosis" under the impression/assessment that this ICD-10 code can be used. Please advise.

NSTEMI vs I21.A9 and sequencing of I21.A9 vs T82.867A

The new MI codes are throwing us off a little. If our doctor admits the patient with a NSTEMI (I21.4), but after taking the pt to the cath lab an in-stent thrombosis is found, should we code the I21.4, I21.A9 and the T82.867A or leave the NSTEMI code off since by definition the stent thrombosis meets the definition of the new MI code I21.A9? Also, if we know an MI is due to an in-stent thrombosis, would you recommend sequencing the I21.A9 or the T82.867A first? Thank you.

New EVAR codes 2018

Are assistant surgeons and co- surgeons allowed for the new EVAR codes?

Transforminal ESI or Midline

"Utilizing fluoroscopic guidance, a 20 gauge Touhy needle was placed into the left paracentral posterior epidural region at the L4-5 level. Needle localization was confirmed with contrast injection in multiple views and negative aspiration. 4 mg of dexamethasone and 1.5 mL 0.75% Sensorcaine were injected into the epidural region." Is this transforaminal approach or midline? Please advise. 

Impella and ICD Removal with Heart Transplant

"Sternotomy were performed. ICD was excised from left deltopectoral pocket and placed outside the body. ICD leads were cut at the level of the innominate vein in the deltopectoral pocket. Right subclavicular incision was reopened and Hemashield graft exposed. As soon as cardiopulmonary bypass was initiated, the Impella 5.0 was pulled out, and Hemashield graft was stapled off. The donor heart came to the field. The interatrial septum was inspected; there was no PFO. The LAA of the donor heart had been opened on procurement and had been closed. The heart was then implanted in the usual fashion." Are codes 33945, 33944, 33241, 33243, and 33992 correct? Impella was inserted two days prior via Hemashield conduit. If code 33992 is not correct, how would this be coded? I'm not sure of the documentation requirements for 33944.

Pocket Relocation vs. Revision

During EOL generator change, a pocket revision procedure is noted in the operative report to reduce perioperative infection risk. Is debridement code 11042 for 14 sq cm appropriate to report? "A 10 blade was used to make an incision approximately 3 inches in length over the pre-existing scar. Blunt and sharp surgical dissection was carried down to the endothelialized capsule, which was incised. The pulse generator was removed from the capsule. Leads were removed from the head of the device. Chronic threshold testing and lead evaluation demonstrated all three leads to be adequate for utilization. A complete capsulectomy with excision of all devitalized tissue was performed at this time, with removal of approximately 14 cm tissue at this time. Hemostasis was assured with electrocoagulation. The pocket was copiously irrigated with Bacitracin solution. A new CRT-D pulse generator was brought on the field."

36593 or 36596?

For the following case, should code 36596 or 36593 be reported? The physician is defining as catheter declot, but the "explosive irrigation" is throwing us. "Pre-Op Diagnosis: Catheter dysfunction. Procedure: The risks and benefits of catheter thrombolysis were discussed with the patient in detail. The patient understood, and informed consent was obtained. The ports were prepped and draped in usual sterile fashion. The ports were aspirated and then explosively irrigated using normal saline. 2 milligrams of tPA was then slowly infused into both ports."

Central Shunt Stent

Looking for codes for a stent and angioplasty to the central shunt as follows: "Using a 5 French long flexor sheath into the right femoral artery, stent was inserted in the right-sided shunt. The stent was deployed in the junction of the right BT shunt and the right pericardial tube. The stented region was ballooned again. Post stenting, angiography demonstrated patency of the shunts and the LLPA. Left lower branch of the LPA was ballooned as well. Shuntogram of the left BT shunt and right-sided shunt were performed prior to the revascularization." Struggling to find codes applicable to the shunt work. 

Temporary Arterial Shunt for Vascular Injury

We have a stab wound case where our surgeon placed a temporary vascular shunt in the femoral artery to allow flow to the distal leg. Once flow was reinstituted into the patient's leg, our surgeon then called a vascular surgeon (not associated with our practice), who then repaired the artery with a vein graft. Are we allowed to code for the temporary arterial shunt, and, if so, what code would we use for that? The vascular surgeon billed code 35256.

Additional Selective Venogram

In the "Case of the Month" for December, you state that no code should be reported for the imaging of the left ovarian vein done after the left renal venogram. But your previous advice has been to use code 76496 for additional selective venograms in the same family (renal, pelvic, and internal iliac branch veins). Why is code 76496 not appropriate in this instance?

CODING FOR SHOCKWAVE LITHOTRIPSY & ANGIOPLASTY OF SFA

What is the code for this new procedure? "The patient had a severely calcified SFA and was going to be treated with lithotripsy at this intervention. Patient was given 10,000 units bolus of heparin, and then shockwave lithotripsy was performed with a 5mm balloon at the SFA. There were two tandem lesions separated by 6 mm. These were treated first with inflations of 4 atmospheres and then 6 atmospheres with shockwave therapy at each inflation. Then the balloon was carried more proximally and was treated in a similar fashion. There was a mildly resistant area in the SFA, which was treated with two more cycles. There was a nice angiographic result. I obtained a 5.5 shockwave balloon and treated the proximal SFA lesion and the common femoral artery. I treated the proximal lesion at 4 atmospheres, retrieving the balloon into the common femoral and inflating this to 6 and then 8 atmospheres, and treated with 2 more cycles. Follow-up angio revealed persistent disease, which was successfully treated once at 4 atmospheres." Would this new technology be reported with an unlisted code, or would I use current codes?

Cartoid Stents

Can we have more than one stent coded in the cervical carotid, for two distinctive lesions, in common and internal? Would there be times when multiple stents can be coded individually?

Manipulation of Existing Tunneled PleurX Drainage Catheter

"A patient with pleural effusion and an existing tunneled PleurX drainage catheter is taken for a tunneled pleural catheter check. Subsequently found to have PleurX catheter malfunction. A Bentson wire and subsequently an angled glidewire were advanced into the catheter. These could not be advanced through the entire length of the catheter. Subsequently, a Roadrunner catheter was successfully advanced through the entirety of the catheter length. The catheter was slightly manipulated with the guidewire." Would unlisted code 32999 be the proper coding of the guidewire manipulation of the existing tunneled PleurX drainage catheter of the right pleural space?

Selective right and left iliac angiography

I have a physician who is doing selective right and left iliac angiography during a left heart catheterization. "We gained access from the right brachial artery. The left main coronary ostium was selectively engaged with the JL3.5 catheter, and angiograms were taken in multiple projections. The right coronary ostium was selectively engaged with the JR4 catheter, and angiograms were taken in multiple projections. The JR4 catheter was introduced in a retrograde fashion across the aortic valve into the LV, and pressure measurements were made. Selective right and left iliac angiography was performed by injecting the 4 French JR4 catheter. Selective right and left iliac angiography: Both of these angiograms demonstrated a probable proximal total occlusion of the iliac arteries. There was diffuse disease of the distal vasculature. There were prominent abdominal collateral vessels noted on angiography." Would we bill code 93458-26 with 36245-50? I am also finding that code 75716 might be appropriate too. What would be the best way to bill for the angiography?

33880 with 34848

Can I bill EVAR with FEVAR if they are done at the same operative session? Usually these two are done as staged procedures, but in this case they were done concurrently. FEVAR includes proximal extensions, but I do not think that applies to axillary delivery of the thoracic endograft placed before FEVAR device. NCCI does not bundle the two, but I am hesitant to bill them together. Can it be done?

Left Atrial Appendage Closure; incomplete procedure

The patient was admitted inpatient and had TEE done. No intracardiac thrombus was seen. ICE catheter was inserted and revealed thrombi on right atrial and ventricular pacing leads. Transseptal puncture was not performed. Since ICE is an add-on code only, what would be most appropriate to bill? 33340-Q0,53?

Coding for multiple vascular embolizations/occlusions (37242 / 37241)

How would you code this vascular embolization/occlusion scenario? Coil occlusions were done of five collateral vessels: 1) Collateral from left hepatic vein to systemic pulmonary vein; 2) Collateral from innominate vein to the area around the left mainstem bronchus/carina; 3) Collateral from left lateral thoracic artery to left lung; 4) Collateral from right bronchial artery to the right lung; 5) Collateral from right thyrocervical artery to the right apex of the heart. For surgical fields, I see right lung, left lung, heart apex, systemic pulmonary vein, and vein in area of mainstem bronchus/carina. We often report code 37242 twice for coiling of APCs on the right and left sides, but this is way past that. I can't believe we could be billing that many separate occlusion codes. What would you suggest?

New CRT-D with His lead

Patient receives a new CRT-D with the third lead placed at the bundle of His (as opposed to the LV). For the lead charges we are using HCPCS codes C1777, C1898, and C1898 (instead of C1900). For procedure codes we are still unsure. We have 33249 for the device; what additional procedure code would be best for the His bundle lead placement? 

Left AVG with Plication

This provider did a left AVG with plication. "He did an arterial anastomosis, first applying vascular clamps using a blade and Potts scissors arteriotomy was done. An end-to-side anastomosis was done and noted to have good flow in the graft. Then an end-to-side anastomosis was done on the high brachial vein. Prior to completion all vessels were flushed and hemostasis was noted. Doppler signals above and below the venous anastomosis were noted to be very strong. However there were faint Doppler tones in the radial and ulnar arteries, so two separate areas of plication of the AVG were sutured. Doppler tones on the radial and ulnar arteries were then back at baseline." This was done on a patient with ESRD on hemodialysis needing permanent access. Should they have used the new codes for dialysis circuit (36901-36909)? Or should codes 36830 and 37607 be used instead?

Pleural Tunneled Catheter Exchange

Would unlisted code 49999 be used for a pleural tunneled catheter exchange? "A 0.035 stiff guidewire was inserted through the existing tunneled catheter to secure access. The cuff of the existing catheter was dissected away from the surrounding skin and mobilized. The old Aspira catheter was retrieved over the stiff Glidewire. A new Aspira catheter was then advanced over the Glidewire into the loculated pleural collection. The new catheter was sutured to the skin."

Bilateral Pulmonary AVM Embolization

Bilateral pulmonary AVM embolization with 10 catheterization sites of the lobes. Would you report codes 37242 (x 2) and 36015 (x 10)?

Diagnostic and Therapeutic same session

Patient had a peritoneal abscess. The doctor did a diagnostic aspiration first (10022), then placed a catheter for continued drainage (therapeutic 49406). I do not see an NCCI edit on these two codes, but I'm not sure if I can bill both same day/same session/same abscess. Please advise. 

34712

Our providers on occasion dictate the following for AAA repair: "Amplatz device was used to place surgical staples around the neck, which went quite nicely with excellent seal." For 2018 we have 34712, fixation device (e.g., anchor, screw, tack). Does the staple fall into this category?

36833

I am auditing a case where a physician performed thrombectomy of an AV graft through an open incision and graftotomy. He then shoots a diagnostic fistulogram (bundled) and identifies a hemodynamically significant stenosis in the venous outflow. He treats this stenosis through a percutaneous stent placement. Can I report code 36833 for the combined procedures in this case since there was an open incision and thrombectomy to start the case and edits prevent coding 36831 and 36903 together?

2018 Guidelines for Sphenopalatine Block

What are the current 2018 CPT codes for sphenopalatine block? Is fluoroscopy included?

POPLITEAL INTRAPMENT

For the following example, would code 35741 be correct? "Patient had subtotaled popliteal artery just above his knee, about the place it looked like for entrapment. Skin incision made posteriorly across the fossa. We angled the skin incision. We opened across the fascia, went down, and found the artery. There was a lot of inflammation around the artery, and it looked like the artery was not going to be viable for an endarterectomy with patch angioplasty, so we closed the incision, flipped him over, and took the greater saphenous vein from his right groin. We oversewed the branches and cut the valves out so we were able to use this for the interposition. Incision was closed and stapled. We then turned him back over, prepped and draped, and opened the posterior incision behind his right knee. We gave 10000 units of heparin. ACT was just was 225. We gave another 10000. We then clamped the artery and did the proximal anastomosis. We had good flow through it. We cut it to appropriate length. We did the distal anastomosis, both with 6-0 Prolene, and closed." 

93792 and 93793

I need some clarification on how to use the new INR related codes for 2018 (93792, 93793). Are these codes used in conjunction with 85610 or would these codes replace 85610. Also, are these to be used for both office and in home INR monitoring? Any insight or information on these new codes would be greatly appreciated.

Medicare Complexity Adjustments

We just received the information about the complexity adjustments codes for 2018. Is this for providers or hospitals? The term "complexity adjustment" is new for us at the hospital. What does it mean for the hospital?

Echo with DEFINITY

We do echos with DEFINITY. Please tell me the correct code grouping: 93306, 96374, Q9957 or 93306, 96409, Q9557?

2 Interventions Same Day Different Time

If a stent was placed in the diagonal branch, and after this was done it was found that the occlusion was in the main LD and so the provider goes back 3 hours later and places a stent in the main LD and also performs a kissing balloon angioplasty in the main LD and the diagonal branch, would we be able to bill for both stents plus the angioplasty on the second attempt?

Soft tissue T9 pedicle marker placement

What would be the correct code for fiducial marker placement in this case? "Patient has metastasis from hepatocellular carcinoma, replacing the T9 vertebrae. He accesses the T9 pedicle, and a gold marker was deposited within the soft tissue just dorsal to the right T9 pedicle and another to the left T9 pedicle." Is this soft tissue or bone or thoracic?

Iliac Venography with Heart Cath

"A Swan-Ganz catheter was advanced into the common iliac vein however it met resistance. The Swan-Ganz catheter was pulled back into the introducer sheath, and the right common iliac venography was performed. No lesions were identified." Is this considered bundled with the procedure?

Vertebral Artery Stent Billing

Can the vertebral artery stent (0075T) be billed with the basilar artery thrombectomy (61645) during the same session? Would this also be the case for 0075T and 37215 since they are in different territories?

Retrograde approach catheter placement

For the following example, we are not sure about the correct CPT code for retrograde catheter placement? 36246? "The right groin and right foot were prepped and draped in the usual fashion. Under ultrasound guidance the distal anterior tibial artery at the level of the ankle was accessed with a micropuncture needle. Images were saved for further review of the medical records. A 2.9 French sheath was advanced into the artery and arteriogram was obtained to confirm the intraluminal placement of the sheath. Next 200 mcg of nitroglycerin were administered through the sheath. Next a Cook wire was advanced with the help of the 0.18 CXI catheter to the level of the occluded SFA. Next different wires were utilized including a 0.018 wire, then a 25 g CTO Cook wire and all these wires were unable to cross the lesion despite the support catheter. Next I tried a 0.018 Glidewire to try to obtain a subintimal plane and that also was not possible. We proceeded to pull wires and catheters the micro sheath and manual pressure was held for 10 minutes at the level of the ankle." 

IVC filter removal involving laser assistance

Patient had filter in place for 13 years. It had fractured into four pieces, all in close proximity to the original placement site. The largest piece of the filter was embedded in fibrous tissue, and a laser was used to free the filter. Should I only report code 37193?

TPA into Abdominal Abscess

We have a patient who has an abdominal abscess catheter in place. They were found to have complex debris within the abscess cavity. TPA 2 mg in 10 ml of saline was injected and left for 2 hours prior to opening JP suction. Should the administration of the TPA be billed with 49185 or unlisted code 49999?

Venous stenting

My provider is doing placement of a vascular reconstruction device in the right transverse sigmoid sinus junction with cerebral angiogram and venous sinus manometry for pseudotumor cerebri syndrom. The following are the codes that we are billing: 61635, 36224, 36012, 75898, 75894, and 75870. I'm trying to verify if this coding is correct.

CODA balloon insertion for emergent AAA rupture patient transfer

A 90-year-old patient presented with abdominal pain in the ER. CT was performed, which showed a rupture AAA. The Cath Lab call team was requested. Once the team arrived, the patient was sent to the cath lab. Ultrasound vascular guidance fluoroscopy was used, then the physician inserted a CODA balloon to stop the bleeding and stabilize the patient for transfer to another facility, with the surgery team awaiting the patient's arrival." I am not aware of a CPT code specific for a CODA balloon insertion. Would it be acceptable for the cath lab to code catheter (balloon) placement (36200) and unlisted procedure? Or perhaps balloon embolization to stop a hemorrhage?

CT guided cryoablation and microwave ablation of lung

Would you code CT-guided cryoablation and microwave ablation of right lung 0340T, 32998-RT, and 77013 same session?

GJ Tube Placement

What is the proper coding for the initial GJ tube placement under fluoroscopy?

3D 76376

Can you tell what statement would be good documentation for a radiologist to state if using 3D? I cannot find documentation that states what specifically needs to be documented. I have some providers that state 3D MIP images, MIP reformations, 3D postprocessing including MIP images, MIP reconstructions, 3D reconstructions. Do any these qualify for documentation for the 76376?

Fat pad biopsy

Our physicians are doing fat pad biopsies of the abdominal wall to rule out amyloidosis. Sometimes they use a core needle, and other times they make a small incision for this. There is a lot of debate regarding the correct CPT for this. Some think it should be 22900 for the incisional biopsy and 20206 for the core. Others have said it should be 22999. Can you help with this? I have looked all over the internet for help and can't find any consistent guidance.

Venography through plasmapheresis fistula

Patient has a created upper extremity AV fistula for plasmapheresis (not dialysis). They are performing venography through the fistula. Do we use dialysis circuit code 36901 or stay with 36005/75820? You answered a similar question in 2011 instructing to use the non-dialysis codes, but with new CPT codes, have there been any changes in how to view this?

PAs and myelograms

We currently use codes 62302-62305 to bill for myelograms performed by the radiologists. They would like to utilize the PAs for the myelogram injections. Would it be appropriate to have the PAs perform the injection and bill under their NPI for code 62284, and also bill under the radiologist NPI for codes 72240-72270?

ReDS Wearable System

What CPT code would you recommend for ReDS Wearable System? The ReDS™ Wearable System is a non-invasive, portable, wearable vest cleared by FDA that uses impedance plethysmography technology to accurately quantify lung fluid volume through a brief, 90-second reading. Measurements of lung fluid volume with the ReDS™ Wearable System, which clinicians use to guide treatment of heart failure patients, have been demonstrated by clinical evidence to reduce the rate of re-hospitalization of heart failure patients by 87%.1 The ReDS™ Wearable System is appropriate for use in multiple settings of care, including hospital inpatient, hospital outpatient, physician office, and home monitoring. 

Mammography

I have coded an US-guided lymph node clip placement with 10035, but they also did a post digital mammogram. It does not seem correct to code mammography when only axilla is imaged? Should code 77065 be reported?

75625 vs. 75630

For the example that follows, which fits best: 75630 or 75625? "Aortogram was obtained in multiple views. There was a high-grade lesion of the proximal right common iliac artery. The right internal and external iliac arteries were patent. The external iliac artery was a little large than the 6 French sheath. The left common iliac artery stent was patent. The stent originated 2 cm distal to the aortic bifurcation. The left external and iliac arteries were patent. The catheter, wire, and sheath were removed. A figure of eight 6-0 prolene was used to close the access site."

Aspiration of Fluid Collection

I work for a hospital. Our physician performed a CT-guided aspiration of a midline paraspinal collection for diagnostic purposes. The physician describes the collection as a postprocedural hematoma of the subcutaneous tissue. The physician manually aspirated 15 cc of yellow material with a 5 French Yueh centesis catheter needle, which was submitted for culture and sensitivity. Would the appropriate code for this procedure be 10022 or 10160 (both with 77012 for CT guidance)?

93286 and 93287 performed by reps

Our physicians are documenting in their op reports that pre and post reprogramming of the PM/ICDs is being performed before and after certain procedures such as ablations/cardioversions, so we assumed this was being done by the physician. However, we have found out that these reprogrammings are being performed by the Medtronic reps even though our physician is signing the device reprogramming form showing what changes were made to the device. I assume we cannot bill this under the physician or on our facility claim, as this is being done by an outside rep...is that correct?

Aneurysmal Bone Cyst

What would be the correct CPT code for sclerotherapy of aneurysmal bone cyst?

Cerebral Angio with Intercostals

Indication for case was an abnormal CTA. Right femoral access used. We have the following CPTs charged. Are they correct? "Procedure Summary: Spinal dural arteriovenous fistula with venous hypertension. Fistula appears to be present at T12/L1 levels: internal carotid left and right (36224 x 2), vertebral left and right (36226 x 2), external carotid left and right (36227 x 2), subclavian bilateral (75716), right thyrocervical trunk (36218, 75774), left thyrocervical trunk (36217, 75774), left supreme intercostal (36218, 75705), intercostals bilaterally T4-T12 (36215 x 18, 75705 x 18), lumbars bilaterally L1-L4 (36245 x 8, 75705 x 8)." Are we close?

Embolectomy vs. Atherectomy

"The left external iliac artery lesion was stented with a 6 mm x 6 cm self-expanding stent, which was dilated to 6 mm. Catheter positioned in the SFA. A 6 mm x 6 cm self-expanding stent was then placed across the area of occlusion. The catheter was then positioned in the above-knee popliteal artery, and an outflow arteriogram was performed below the level of the knee. Using a straight Glidewire, the peroneal artery was accessed. The occlusion in the mid peroneal artery was crossed and suction embolectomy performed. A 0.018 wire was then placed. A 2 mm x 15 cm balloon was then used to dilate the peroneal artery. Repeat arteriogram was performed. An attempt was made to recanalize the left anterior tibial artery using multiple different wires; however, the chronic occlusion could not be crossed." Would you report code 37186 for the embolectomy with 37228, or 37229 atherectomy peroneal? In addition to 37221 (iliac) and 37226 (SFA)?

Intra-arterial chemoinfusion

"Renovo Rx catheter was positioned along the splenic artery adjacent to the adenocarcinoma. The infusion port was injected with contrast to ensure distal and proximal occlustion. Once occlusion confirmed, the infusion of 2000 mg gemcitabine in 132 mL was performed over a 20-minute interval using the power injector. Post infusion splenic artery angiogram was performed, demonstrating no evidence of vessel injury or extravastion." Can I bill anything for the chemoinfusion? I know I can bill for the catheter placements and diagnostic angios. I am billing for the professional side, and the patient is an inpatient at the hospital. Can I report code 96422? Or something else?

CT marking with methylene blue

Is there a CPT code(s) for CT localization with methylene blue at T9-T10? A neurosurgeon is to perform a T9-T10 laminectomy with decompression and requested my provider do a CT marking with methylene blue. The report states: "Using intermittent CT fluoroscopy for guidance, a 22 gauge, 3.5 inch spinal needle was introduced into the soft tissue of the back and progressively advanced up to the posterior aspect of the T9-T10 posterior elements. Repeat CT imaging of thoracic and lumbosacral spine was obtained to verify correct needle position at the T9-T10 level. I then injected approximately 1 mL of methylene blue through the spinal needle at the T9-T10 level. The needle was removed." 

One Stent Covering Two Lesions

I have a case where there are two separate lesions, one in the mid left circumflex and the other in the obtuse marginal. One stent was able to cover both lesions. With these two lesions being separate and in the main artery and branch, should I code this as one intervention? Or as two interventions with 92928-LC and 92929-LC?

Congenital Cath and 92990

Can a congenital catheterization code (e.g., 93533) and 92990 be reported together?

Bone marrow bx & asp with fluoro

Code 38222 is not listed as an appropriate code to report with 77002, but codes 38220 and 38221 are. Is this an oversight, or should fluoroscopy not be reported with 38222?

Sniff Test

Since code 71023 was deleted for 2018, what code do you suggest to report a sniff test?

Venography with Thrombolysis?

Patient had a DVT diagnosed in the PVL prior to initiating thrombolysis. Can we charge for the "confirmatory" venogram done during the thrombolysis encounter?

Renal Duplex

Does a statement of patency (i.e., "right renal vein, left renal vein are patent") constitute as "venous outflow" and support billing a complete study (93976)? The arterial inflow is equally documented ("no significant stenosis of bilateral renal arteries").

38220, 38221, 38222

Is code 38222 to be used when both bone marrow aspiration and biopsy are performed through the same incision? If aspiration and biopsy are performed though two separate incisions, do we use codes 38220 and 38221?

CPT code 35883 used alone or with other codes?

I am having trouble deciding when it's appropriate to use code 35883 alone or with other codes. What all does this code include? One case - previous iliofemoral bypass, which was aneurysmal. "After dissection and mobilization it avulsed off the proximal anastomosis. The entire graft was removed from operative field, and a new 8 mm graft was placed in the same location, distal external iliac to distal common femoral." Is this reported with code 35883 alone or just removal of graft (37799) and 35665? The other case was similar, ax-fem-fem bypass with aneursym on left femoral artery. "Patent ax-fem on the right, occluded fem/fem. Thrombectomy of right to left fem/fem. Aneursym of left femoral artery resected and interposition graft was placed left femoral artery to left profunda artery after it was thrombectomized." Is this codes 35883 and 35875-59 (for fem/fem thrombectomy)??? Also considered 35876. Can you please advise on these cases and how to determine when to use 35883 alone or with other codes.

Atrial Flutter

Would the following be coded as an unlisted procedure? "Patient scheduled for atrial flutter ablation. Patient presented to EP lab in AFL. Due to patient comorbidity, (coincident AF, recent Watchman implant) physician decided (prior to procedure) he would not pursue AFL ablation if circuit was left-sided. J-wire was advanced to IVC. Repeat access, repeat to 1 cm above the last, and 3rd access to 1 cm above, and J-wire advanced to level of right atrium. Sheath was introduced. SRO sheath was advanced into right atrium. Halo cath was advanced and draped across the tricuspid valve. SC cath was advanced into body of coronary sinus. Baseline findings recorded. Physician decided not to ablate. Conclusion: left-side AFL. Unable to pace terminate."

FEVAR with scallop

Dr states 34847. Cath advanced into bilateral renals through the renal fenestrations. Then, soft cath, the SMA scallop was cannulated, a wire was advanced down SMA. Balloons inflated for release of constrainment of fenestrated body. Does the scallop count as the third opening? Or is this just a two opening (34846)?

MODIFIER KX ON PACER IMPLANT

I'm having a disagreement with my auditor. Per MLN Matters, I think I should only append modifier -KX to a pacemaker code if I see the blurb "non-reversible symptomatic bradycardia" somewhere in the chart. She doesn't think that is needed and believes you can add the -KX as long as the claim contains one of the following diagnosis codes: I44.2, I44.1, I49.5, or Q24.6. What is your interpretation please?

Arterial Patency

The long description for code 76937 describes US assistance for vascular access. CPT Assistant, December 2004, describes assessment of venous patency and needle passage to the venous lumen. My question is whether this code can be reported for assessment of arterial patency and arterial passage to the arterial lumen. Or, is this code limited to venous line placements?

Modifier SC

Can we append modifier -SC to pacemaker implantation claims when we are doing the implantation prior to an AV node ablation?

PTEG venting tube

How would I code PTEG tube check, and how would I code placement of a PTEG tube? Should the placement be an unlisted code? Should the check to go code 49465?

27590 vs. 27596

"Periosteal elevator was used to dissect the femur to a position higher than the soft tissue amputation. This level was at the upper third of the femur. We then used the pneumatic saw to divide the femur. We then trimmed the anterior aspect of the femur so that it was beveled and had a smooth edge. We then divided the posterior flap of soft tissue. As he has become more cachectic, the soft tissue around his prior left above-knee amputation has atrophied. In addition to this problem, he has developed hyperostosis of the distal aspect of his femur. This has caused severe ulceration with exposed bone of the distal aspect of the left above-knee amputation site." The provider used code 27590, and the coder used 27596... can you tell us when it is appropriate to report code 27596? This was done two years after original amputation.

Fistulogram with AVF or AVG revision

With the new 2017 dialysis circuit codes, when a revision or thrombectomy/revision is performed, can you code an extremity arteriogram or extremity venogram with the open procedures?

93621

Can add-on code 93621 be reported for catheter advanced from the LFV to the CS for mapping of mitral valve annulus? (CPT 93653 is my primary code). "A Bard dynamic decapolar 6 French catheter was advanced from the LFV to the CS for mapping of the mitral valve annulus. A St Jude 6 French Daig quadripolar catheter was advanced to the right ventricle from the RFV. A St. Jude duo-decapolar BDB Livewire catheter was advanced via a 7 French LFV sheath, and the entirety of the right atrium while in the flutter was mapped. The TCL was 220 msec."

Thoracic Duct Stent

I'm looking for some assistance regarding thoracic duct stenting. "Viabahn covered stent deployed across cranial aspect of thoracic duct in area of lymphatic leak." I'm wondering if this would follow the same logic as a lymphatic embolization and be coded as a venous stent, or are we looking at unlisted code 38999?

Selective or non-selective

My doc places the catheter in the posterior tibial vein (this is where he starts procedure), goes up to CF, does a venogram of leg, and then goes into the IVC and images the IVC. This is all ipsilateral. Is the catheter placement 36011?

Can 37215 be coded more than once ipsalaterally?

MD placed a stent in the right common carotid with EPD, then performed angioplasty and placed two more overlapping stents all the way to the distal cervical right ICA. Patient had "near occlusive stenosis". All three stents overlap each other, so we are inclined to report code 37215 once, but I wanted to verify that we aren't missing any codes. EPD was used in all three stent placements.

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