Knowledge Base

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Stenosis vs. Clotted AV Fistula

Coding guidelines state that when an intervention is performed on an AV Fistula, the arterial and venous sides are considered one vessel. It's understandable when a stenosis exists and requires just one wire to be placed, but I was wondering if there is an exception when a clot is encountered since two wires are placed and two sides are ballooned/stented?

Theraspheres Documentation

One of our IR physicians is listed as an "authorized user" on Therasphere embolization reports and is asking to have codes 77263, 77300, and 77790 billed. Can you tell us what documentation must be included in the reports to bill for them? We aren't seeing anything other than, e.g 98% of the prescribed dose was delivered.

Mammogram

Is it appropriate to report a diagnostic CAD and diagnostic mammogram for spot magnification and/or compression views for patients returning following a screening mammogram with CAD?

74176 with 74174

CT of abdomen/pelvis performed at 10:42 am for acute abdominal pain. Results: The infrarenal abdominal aorta is mildly aneurysmal with atherosclerotic calcification the wall. There is only very slight interval change from previous study. At 12:44 pm a CTA abdomen/pelvis was performed. Results: 3.5 cm aortic aneurysm, slightly increased. Since these were performed two hours apart in different sessions, can I add modifier -59 to 74176? Or should I combine them?

Kyphoplasty 22524

We discovered that the RVUs for code 22524 jumped from 16.61 in 2011 to 223.41 in 2012. Approximately $1463.00 to $22,109.00 in 2013. Is there a specific reason for this high increase? I would appreciate any information you have for us to pass on to our concerned patients and physicians.

Code 33240

We have a patient who had an LV lead implant during aortic valve surgery. Four days later patient comes to the EP Lab for implant of dual chamber ICD (RA and RV leads added). I think codes 33240, 33217, and 93641 would be the correct codes to use, but everything I read on code 33240 says implant of generator only, nothing about using code 33217 for placement of additional the leads. Should I just count this as initial insertion of ICD and use 33249? I know I can't code for the lead placed in surgery, but I didn't know if this falls under the description for 33240.

Cutting Balloon Angioplasty

If a cutting balloon is used to do an angioplasty, do we report an atherectomy?

CT Guided Nonvascular Alcohol Ablation Lymph Node

Would code 20500 be appropriate for this non-vascular alcohol ablation? What about code 77013? Thanks for your feedback. "Percutaneous ethanol injection into the portal enlarged metastatic lymph node PET positive lymph node. Under CT guidance, Chiba needle advanced into the target lymph node. Anhydrous ethanol was injected in small aliquots with intermittent scanning to observe the distribution and position of the needle. We injected approximately 17 mL of absolute ethanol intralesionally. Particular care was used to avoid needle entry and injection into the biliary and vascular structures."

Catheter Placement with Thrombectomy

We performed a thrombectomy on a patient's POP, ATA, PTA, and peroneal. We also performed a PTA to the posterior tibial artery. I think I have code 37184 for the POP, code 37184-59 for the ATA, code 37185 for the peroneal, and code 37228 for the PTA. My question is, can I bill catheter placements too?

Coronary Sinus Venogram with Embolization of Fistula from LAD to Left Ventricle

A coronary sinus catheter is placed via left subclavian vein for a CS venogram to locate site of a fistula from distal LAD artery to what appeared to be CS, found to actually be the left ventricle. Catheter was placed into the distal LAD, traversing the fistula to deploy coils and close off the fistula. Verified results with final angiography. We reported codes 37204, 93454, 75894, and 75898. How would the coronary sinus venogram be coded?

Code 37226 vs. 36246

Once again I find that I am second guessing myself, and I need to ask for clarification of what is the main difference between codes 37226 and 36246.  When are you supposed to use one set vs. the other? Can you please explain?

Periaortic Fistulous Tract Occlusion with Deployment of Amplatzer PDA Occlusion Device

Per the physician's dictation, aTEE was done, which demonstrated a jet of eccentric severe periprosthetic aortic valve insufficiency. The fistulous tract was crossed with a slip-tip catheter. Through this catheter an AGA patent ductus occluder was deployed through the fistulous tract. Upon release of the occlusion device significant reduction in the periprosthetic valve regurgitation was seen on the TEE and was confirmed by left aortography. The procedure was then concluded without complication. This is not a procedure that we have done in the past and therefore need your advice on how this should be coded/billed.

Integrilin Infusion

"Patient comes in and has an embolization of an ACA aneurysm, and a follow-up angiogram shows nonopacification of the majority of the A2 segment of the ACA. Subsequent angio demonstrates thrombosis of the portion of the A1 segment of the ACA and ciling was halted. An internal carotid angio was performed, and the occlusion of the distal aspect of the A1 segment was identified. 7.5 mg of Integrelin was infused into the A1 segment of the ACA. After 10 minutes a repeat angiogram was performed . The A1 segment remained occluded. It was decided not to further pursue thrombolytic therapy and clot retrieval at the current time." Is this a true infusion? Can we report code 37211 for the Integrilin that was given, or is this documentation not enough to support an infusion?

Medi-Port Question (36561)

For a Medi-Port insertion (36561), does the name of the device alone (right IJ 8 French power injectable AngioDynamics Smart port) suffice to support the reporting of code 36561, or is it necessary to document the pocket creation? Dictation documents the ultrasound used- with permanent image kept, the fluroscopic guidance for final placement, tunnel creation, just not the actual port pocket.

Code 93531

My docs did a catheterization, and our cath lab charged code 93460. Should this be reported with codes 93531 and 93563?  "Right and left catheterization with selective coronary angiography. Patient has sinus venous ASD and anomalous pulmonary venous return to the right side. Impression large left to right shunt due to shunting at the atrial level. The patient has dilated right-sided chambers, repair of the congenital anomaly as described above is indicated CVT will follow."

Platelet Rich Plasma Injection 0232T

We are going to be doing a platelet rich plasma injection with ultrasound guidance. Code 0232T includes guidance, harvesting, and preparation. The harvesting and preparation are going to be done in a physician's office and then the patient will be sent to our outpatient radiology department for the injection with ultrasound guidance. Any suggestions on how to make sure we get paid for the guidance portion of this procedure?

Failed/Unsuccessful CTO Crossing Lower Leg

How does one properly code for a failed/unsuccessful procedure to recanalize (cross a CTO) an obstructed peripheral artery (e.g., lower leg)?

Documentation for Right Heart Catheterization

The cardiologist has reported a right heart catheterization (93451) for this procedure, and I'm not sure if his documentation is adequate. The report reads: "The right femoral vein was accessed using the modifier Seldinger technique. I then attempted to use the Edwards pulmonary catheter, but it would not cross into the pulmonary vein. I then switched to the 7 French Arrow catheter. After manipulating for about 5 minutes, I was able to cross into the pulmonary artery. At this point, this was placed in the pulmonary artery, but it would not wedge. I was able to get pulmonary artery pressures with this and then subsequently able to get PA and RV as well as SVC, IVC, and right atrial pressures." Can I assume he went through the tricuspid valve since he went from the pulmonary vein into the pulmonary artery?

Dynamic CT Myelogram of the Cervical and Thoracic Spine

The study performed was a myelogram, but instead of using conventional fluoroscopy, they did it under CT (62284, 72270, 72126, 72129).  Please advise us on coding and documentation.  "Patient in CT room, L2-L3 level was localized using CT scouts.  Needle was placed into the thecal sac under intermittent CT/scout guidance. Then underwent multiple CT scans using dynamic CT myelographic method. (1-5) acquisitions were performed using a cranial to caudal technique.  After injection of the full amount of intrathecal contrast to include the cervical and thoracic spine. Cervical: Ventral epidural extravasation of CSF is observed at the C4-5 level where there is also anterior cervical fusion with ventral plate. No other area of CSF leak is identified.  Anterior fusion hardware is also seen at C6-7.  Hardware is intact and unremarkable.  One of the C5 screws extends to the posterior cortical margin of the C5 vertebral body.  Vertebral body heights and alignment are maintained.  No fracture is seen.  Th: Vertebral body heights and alignment are preserved. No CSF leak is evident."

Mechanical Thrombectomy - Mechanical Curretage of a Thrombus Embolization

Is code 92973 reserved for AngioJet only? Patient with MI had thrombus burden (100% occlusion) in the RCA, where PCI was done with a DES. This led to thrombus embolization into the posterolateral branch(es), which was treated with adenosine and nicardipine. "The mechanical curettage was also performed with guidewire manipulation and passing the previously inflated stent balloon down into the proximal portions of the branches of the posterolateral branch." We were wondering if the intervention here to the posterolateral branches would be considered a mechancial thrombectomy.

Jetstream

I am encountering an issue with the use of the Jetstream atherectomy device. As you know, this device is indicated for both atherectomy and thrombectomy from the same catheter. The physician dictated that he performed an atherectomy/thrombectomy within a lower extremity vessel. There is no mention of the presence of thrombus within the vessel during the procedure. Is it appropriate to charge/code for atherectomy and thrombectomy for this procedure, as the physician only mentioned a calcified lesion in the vessel?

LHC + IMA + Subclavian + Vertebral

Patient presents with history of coronary artery disease, peripheral vascular disease of the extremities, and carotid artery stenosis, status post PCI and PTA of subclavian artery. Recent stress test and Doppler ultrasound of great vessels had abnormal results. Procedures performed include left heart catheterization plus selective injections of coronary arteries, (native) right/left internal mammary arteries, right/left subclavian arteries, right/left vertebral arteries (from subclavian catheter placement), and right/left carotid arteries. Interpretations include coronary artery stenosis (414.01), subclavian artery stenosis (440.20), normal internal mammary arteries, normal vertebral arteries, and carotid artery stenosis (433.10). Are the following codes appropriate for the combination of coronary and peripheral vascular procedures performed in the same setting: 93459-TC, 36225-50, 36222-50, 36216-59RT, 36215-59LT, and 75716-59TC?

Medial Branch Blocks/RF Spinal Ablations/Facet Joint Injections

Our pain management physicians are doing facet joint injections, medial branch blocks, and RF ablation of the facet joints. We are having them dictate the joint levels for the RF ablations, as I get that they need to inject multiple levels for one joint, but I’m confused on how we should be coding the facet joint injections and the medial branch blocks. I thought these would still be per injected level. This is what we have been doing for the three areas… what do you think?? L2, L3, and L4 would be three facet injections (64493, 64494, 64495). L2, L3, and L4 would be three medial branch blocks (64493, 64494, 64495). L2, L3, and L4 would be two RF ablations for two facet joints (64635, 64636).

PICC Insertion with Sherlock ECG Tip Confirmation System

Can you give me your opinion on this type of situation? Our facility is starting to use the Sherlock ECG monitoring device with our PICC lines. Do you know the appropriate codes that we are supposed to use for the ECG? So far I have the PICC line code 36569, then they are doing an ultrasound with hard copy 76937... and what would we code for the ECG?? Would any of these be appropriate: 93000, 93005, or 93010? Or something else? 

Reimplantation of Left Verterbral Artery to Left Common Carotid

Any suggestions on coding the catheterization and imaging of the left subclavian artery if the vertebral artery has been anastomosed to the left common carotid artery and no longer arises from it? This angiogram was done due to post op TIA symptoms the same day as the vertebral reimplantation surgery. Can I bill codes 36225 and 36223 for the following? "Catheter advanced under hemodynamic and fluoroscopic control, positioned selectively into the left subclavian artery, single view cervical zone accomplished. No gradient at catheter tip. Catheter then selectively placed into the left common carotid artery multiple views cervical and intracerebral accomplished. Left vertebral artery anastomosis to the left common carotid artery defined in multiple projections. Complete and diagnostic angiograms were done of both the left subclavian and the left common carotid including extrancranial and intracranial circulation plus the vertebral." (I just did not have room to include the findings in the question.)

Items 276 to 300 of 1953 total

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