Knowledge Base

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Dialysis Access

Can you please explain the difference between codes 36818, 36819, 36820, 36821, and 36825? Perhaps with examples of each? I've been reading through my new book, Dr. Z's Vascular & Endovascular Surgery Coding Reference, but I am still as confused as ever.

Modifier for Same Day Stent and Cardioversion

My cardiologist did a cardioversion and a stent on the same day. Do I use modifier -59 on both the stent and cardioversion since they are in the same CPT code set?

Echo Documentation

I would appreciate your guidance on documentation. It has been proposed that the CPT guidelines before a section are technical requirements that need to be performed, but are not necessary to be documented in the professional report unless they are “clinically relevant”. For instance, for a complete echocardiogram (93306), the guidelines state the structures that need to be evaluated or the reason that they can’t be visualized needs to be stated. If, for instance, the right atrium was not referenced in the report because it was not deemed to be clinically relevant, could a complete echocardiogram be billed if all of the other elements were on the professional report? In your opinion, have we met the requirements for documenting a full echo (without including all the elements in the professional report) because we have the supporting tape to show that the service was rendered completely? Secondly, would a statement indicating that “the structures were visualized” suffice? In other words, must it be an interpretation of what is seen?

Temporary Device Interrogation/Programming

A critically ill neonate with coarctation of the aorta with multiple ventricular septal defects s/p CoA repair, patch closures of membranous and mid-muscular VSD, and PAB placement, who is in complete heart block with temporary pacemaker. A plan is in place by a cardiothoracic surgeon to place permanent pacemaker when patient stabilizes. In the meantime, our EP doctors do temporary device interrogations. Can we bill for temporary device interrogations? If so what codes can we use?

ICD-9 Coding, Sick Sinus Syndrome

We have been audited by an insurance carrier and told we can not use the diagnosis of sick sinus syndrome if the patient has had a pacemaker placed and it is working properly. They have instructed us to only use the dx code for status post pacemaker placement. Do you agree with the above information? If not can you please provide me with sources that I can use to back up that information?

Follow-Up Angiogram with Aneurysm Clipping and Diagnostic

Our physician recently attended a conference where he was told that you can now bill all of the following: 4-vessel diagnostic angio done (36226-50 & 36224-50), emergent crani done for aneurysm clipping (61697), and follow-up angio done in internal carotid (36224) to make sure the clipping was complete. This is done all in one operative session. MUEs previously had 36224 as one, so we have only been billing code 36224-50 in these cases. But I see the MUE table for April 1, 2015 now is showing three per day for code 36224. (Looking at the January 1, 2015 MUE table on your site the MUE for code 36224 is still at 1.) So with that in mind, is it acceptable after April 1, 2015 to then bill codes 36226-50, 36224-50, 61697, and an additional 36224?

Conversion of Inferior Vena Cava Filter to Stent

I was wondering if you have ever seen this before? And what you would code to? An IVC filter, stent? "Utilizing the gooseneck snare and sheath, the hook of the filter was engaged with the snare. Gentle traction was then placed on the gooseneck snare and sheath to allow the hook to be disengaged from the filter and removed in its entirety under fluoroscopy onto the table. A fluoroscopic image was taken, demonstrating that the struts of the inner portion of the filter did not fully deploy. A 5 French Sos catheter was advanced over the wire into the inferior vena cava under fluoroscopy. Several passes were made with the catheter in order to remove any fibrous bands. Repeat images demonstrated that several of the struts were not fully deployed. Further maneuvers were performed with a Rim and Cobra catheter. Despite these additional maneuvers with these catheters, there were two struts that were not fully deployed. At this time, a balloon was used to assist deployment of the struts fully. Following the use of a balloon, the structures were fully deployed."

Lower extremity catheter placement and angiogram

"Right common femoral artery was accessed, and a 5 French sheath was placed. Omni flush catheter was advanced to the abdominal aorta using the support of a Glidewire. A flush catheter was placed in the abdominal aorta, and angiogram was performed. Next, the Glidewire was advanced to the common femoral artery on the left. Next, Omni flush catheter was exchanged for straight flush, which was advanced to the proximal left common iliac artery. Next, run-off was performed. Next, the catheter was removed and right groin sheath was used to perform right lower extremity angiogram." I reported codes 36245-LT, 75625, and 75716. Are those the correct codes for this scenario? Glidewire was up to left common femoral artery, but catheter was placed at left common iliac artery.

Mitral Valve Prosthesis Repair

Would code 33418 be appropriate for repair of regurgitation of an existing mitral valve prosthesis? The physician used an Amplatzer device.

Ultrasound for Inguinal Hernia

What is the best CPT code to use for an ultrasound of the abdomen/lower extremity for ingunal hernia? 76705 or 78881/78882?

Atherectomy of Left Arm

Could you please clarify the uses of code 0234T. The CPT description states "transluminal peripheral atherectomy". Since there is a separate code for the brachiocephalic trunk and branches (0237T) on the right side of the body, does this mean that code 0234T may be used for atherectomies in the left arm, as well as renal atherectomies?

Venography and PICC Line

Please let me know if I can code venography and PICC line together on this type of case. "Clinical History: Needs improved central venous access, poor peripheral access. A small amount of contrast was injected, confirming chronic occlusion of the right upper extremity central venous system. Therefore, right internal jugular central venous catheter placement was pursued. Access to the right internal jugular vein was gained by sonographically-guided puncture. A permanent sonographic image was obtained. The vein was confirmed to be patent. Under fluoroscopic guidance, a dual lumen peripherally-introduced central venous catheter was placed with the tip at the junction of the superior vena cava and right atrium at completion. A permanent radiographic image was obtained. Fluoroscopy time was 3.1 minutes. Successful placement of right internal jugular central venous catheter." Please let me know if I can report codes 75820 (not sure), 77001, 76937, and 36556 for this case.

Mofidifer for 93287

When a patient with a biventricular defibrillator comes in for an EPS study (93620, 93621, 93623), and his/her defibrillator is turned off before the EPS procedure, then turned back on and reprogrammed after the procedure, we have been placing a -59 modifier on the second instance of 93287. Will that still be the most specific/appropriate modifier in this scenario, or will modifier -XU or -XS be more appropriate?

19083-50, no longer

I took a webinar for the CIRCC exam by Dr. Z, and I think Dr. Z mentioned that we no longer would apply modifier -50 if -LT and -RT breast lesions are biopsied. Instead we would use add-on code. Could you let me know where I can find the AMA article about it. I was just reviewing 3M Encoder Pro, and they still recommend using modifier -50 for a bilateral procedure. Could you clarify?

62311 with CT Guidance

I know fluoroscopic guidance is included with code 62311, but our IR people almost always use CT guidance for this procedure. Would you use code 77012 with this procedure, or are all types of guidance included?

Modifier 52 on Nuclear Medicine Study

I have a question on using a -52 modifier. Patient comes in for a nuclear medicine stress test (78542). The rest portion is performed with images, and for various reasons the stress portion is not completed. Should this be reported with code 78452-52 or 78451 for what was actually performed? The interpreting physician does not want the code to be changed, but to code what was originally ordered. Documentation is there to describe that the test was not completed. I have some advice that says to code the original order with a -52 modifiier, with the example that the patient could not cooperate for the complete study. My thought is if there is a code for what was performed that is what should be coded. Any help would be appreciated.

Aspiration Thrombectomy of Lower Extremity

Can aspiration thrombectomy of the lower extremity be considered a mechanical thrombectomy and reported with codes 37184-37186? Or does an AngioJet need to be used to report for these codes? The patient had tPA for 18 hours (second and final day) and was brought back for a re-look. Infusion catheter was removed. The thrombus was still present in the popliteal artery. Aspiration thrombectomy was performed, still not sufficiently removing the thrombus. The physician then performed balloon angioplasty. I am thinking of reporting code 37214 for the final day of tPA infusion, code 37184 for a primary thrombectomy of the popliteal, and code 37224 for the PTA of the popliteal. Am I reporting the correct codes?

Post-op EKG

The patient had an external cardioversion for atrial fibrillation. Case end was called and patient was transferred to "holding". An EKG was performed at this point. Is this EKG (93005) considered included/during the procedure and not separately chargeable? Or is this chargeable, as it was performed after procedure ended and patient was transferred to a different area?

Inflow, Outflow Procedures

I would like to know if the physician does a fem-pop bypass with reversed transposed gsv, iliofemoral thromboendarterectomy, and profundoplasty, can I bill codes 35556, 35572, and 35355?

Foreign Body Retrieval

We have physicians who have been given the direction, by company reps, to use code 37197 when snaring a wire advanced from an access site in the foot and exteriorizing it though a sheath placed in the common femoral artery. Is that an appropriate use of code 37197? I code for the facility and have never reported code 37197 in that scenario. I don't believe it is an appropriate use for code 37197, and I am being questioned by the physicians. If you could clear that up for me, I sure would appreciate it!

Attempt Upgrade Single ICD to Biventricular ICD

Patient has single ICD at end-of-life and RV lead. Plan is to upgrade generator to biventricular ICD and place LV lead. Multiple attempts made to place LV lead are unsuccessful, so in the end only a single ICD is replaced. How would you code this scenario?

Onyx 34 (1cc)

Is there a HCPCS code specifically for Onyx/embospheres for the hospital charge related to embolization procedure for nosebleed?

CTO with Dual Injections

At our facility we have started a new CTO program. These cases are, as expected, more complex. The technique that has been adapted here is bilateral access with dual injections of both the LMCA and RCA to assess the collateral flow for a potential retrograde approach. The physician who has been doing these procedures feels that we should be able to charge something in addition to code 92943 or C9607. I have been expressing my disagreement with him. I feel that the CTO charge already encompasses the additional access and greater procedure involvement. Please advise.

Prior Duplex Sonography of graft prior to angiogram and intervention. Performs limited angio of tibal artery. Do you code for angio even thought is a limited area of study with prior knowledge of stenosis based on Duplex Sonography?

Indications: Significant stenosis of posterior tibial artery (by duplex sonography) Procedure Report: The skin overlying the graft was infiltrated with 1% Lidocaine without epinephrine, and the graft punctured with a micropuncture needle. An .035 glide wire was inserted into the graft and the needle exchanged for a 4F sheath. Multiple AP and oblique views of the distal femoral to posterior tibial artery, and tibial artery were obtained. A diffuse stenosis was seen distal to the graft. In fact, approximately 15 cm of vessel was very narrowed. A 014 Choice PT wire was passed across the anastomosis followed by a 2x120 Fox SV balloon. The vessel was angioplastied, stent placed. This case is a sample of a phyisian that uses Duplex sonography on graft patients in office then brings them in for an angiogram of the portion of interest. This is not a full extremity angio. Can you still code a diagnostic angio. Prior to intervention. We are reluctant due to the limited area being studied and prior duplex sonography. In this case we coded Stent placement.

93352 Stress Echo Billing

Are there any physician supervision requirements (direct vs. general) for billing the contrast code 93352 with a stress echo? Code Correct indicates that the physician gives the patient the contrast, but our locations have general supervision, and the tech usually gives the contrast.

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