At our facility, the interventional cardiologist routinely performs a diagnostic right heart catheterization with transplant heart biopsy. He documents cardiac output, wedge positioning, etc. What would constitute medically necessary for a diagnostic right heart catheterization when evaluating a transplanted heart and performing a heart biopsy?
Recently our cardiologists have started prophylactically inserting a "permatemp pacemaker" at the end of all TAVR procedures as part of a new guideline (I'm not sure whether this is an internal policy or a new guideline for standard of care on all TAVR). If no significant heart block develops, they are removed later. I feel that we should not bill for prophylactic care and that code 33216, and then the subsequent 33234, should only be billed when the patient is documented as having heart block necessitating the continued pacing after the removal of the pacing wire/balloon used during the TAVR. What are your thoughts?
A report for a UGI stated: "A normal swallowing mechanism was noted with free passage of barium through the esophagus and into stomach. There is a small hiatal hernia with trace gastroesophageal reflux. The stomach is distensible throughout. Visualized gas mucosal was unremarkable." Is this enough documentation to support code 74246 for a double contrast UGI? I was told the "visualized gas mucosal" indicates the air contrast.
What codes to apply for CT-guided 14 French pigtail placement in remnant stomach that is distended ten years post gastric bypass? Yes, we would report code 75989, but what other code(s) would be appropriate?
"Pre-procedural planning was discussed in detail with the patient prior to initiation of the localization and injection procedure. No pertinent allergies are reported. Lesion localization was performed following procedural timeout with CT scanning of the patient in the prone posistion. 1% lidocaine was infiltrated into the subcutaneous tissues following skin cleansing with Betadine x3. A 22 gauge spinal needle guiding needle was advanced into the left S1 neuroforamen. Extraluminal extra thecal placement was confirmed with a small amount of Isovue 200 A 1:1 solution of 0.75 percent Marcaine, and Celestone solution was then administered. No procedural complications were encountered." I was not sure if this would still be reported with code 27096...or possibly 62319/64483?
1. Dual AVN physiology with inducible AVNRT (very challenging anatomy with probable left-sided involvement successfully resolved after right-sided RF and cryoablation and left-sided RF ablation). 2. Inducible right atrial tachycardia arising from the proximal CS, also successfully mapped and ablated with cryoablation. Would this be reported with codes 93613, 93621, 93623, and 93653? Would I add code 93657 or 93655? Also, do I need to code for the left-sided mapping? ("Because this was so unusual, and in light of the prior failed ablations, we did perform left-sided mapping.")
"Patient with congenital VSD is brought to cath lab for transcatheter VSD closure. They are unable to properly place the device, and the device and catheters are removed. They then make a small thoracotomy incision and place a sheath through the RV and deploy the closure device from there. Sheath is removed, and the RV and thoracotomy incisions are closed." Would this be reported with code 33999 (unlisted cardiac surgery), or could it be reported using code 33681 (closure, VSD with/without patch)?
Congenital heart catheterization...."There was important pulmonary vein desaturation in the right and left pulmonary veins. I placed a wire into the left upper pulmonary vein. I test occluded the defect with a 10 mm x 2 mm Tyshak II balloon. I measured the arterial saturation, which was unchanged. There is no improvement in her pulse oximetry despite complete occlusion by TEE. Could not demonstrate that a reasonable benefit would be achieved with device closure."
Last year, I'm thinking we could have used 0078T/0079T for visceral extensions. But now they have changed to fenestrated graft CPT codes. What can we use now to show a Viabahn graft to repair the celiac during a TEVAR? Could you code this out for us? "Percutaneous endovascular repair of the 5.5 cm descending thoracic aortic aneurysm using a Gore TAG grafts (45 mm x 15 cm and 45 mm x 10 cm x2) placed from the level of the mid descending thoracic aorta to just above the superior mesenteric artery. Snorkel reconstruction/repair of the celiac axis using an 8 mm x 10 cm in length Gore Viabahn graft. Selective cannulation of the celiac axis with selective angiography before after placement of the Gore Viabahn graft. Percutaneous access left brachial artery. Application of the Aptus Endostaple X 4 at the distal attachment site to seal leak at this area."
In our pediatric electrophysiology studies, an assistant physician is always present. This physician helps with real-time interpretation of the intracardiac electrograms to help with mapping. They help with determining where to place the catheters for mapping, as well as localizing the accessory pathway for ablation. By having an attending physician assisting with the mapping, this helps reduce anesthesia time by more efficiently identifying subtle signals that determine where to perform the ablation. They also help to monitor for any possible complications during the ablation, such as complete heart block. In pediatric electrophysiology, since the hearts are smaller than adult patients, we are more careful with number of burns that are placed, because they can have more harmful consequences. The assisting physician uses his/her expertise to help determine the best site of ablation and, therefore, minimizes the number of burns needed for a successful ablation. It seems to me this is a dual surgeon case. How would this be coded?
With regards to Question ID #5330, we have a similar case with balloon inflation throughout the graft across the anastomosis to the right external iliac vein, with stent placement across the venous anastomosis into the venous limb. In #5330, you agreed with codes 36147, 37221, which is an arterial stent placement. I keep coming to code 37238, but it excludes lower extremity. What code will be used for iliac venous anastomosis stent placement?
My radiologist wants to report both codes 49406 and 49803 for this procedure. "The skin overlying a large collection of free fluid was marked and prepped and draped in the usual sterile fashion. A paracentesis needle was advanced into the collection with ultrasound guidance, and fluid return was obtained. Fluid was aspirated and sent for evaluation. The needle was removed. A 0.35 wire was advanced into the fluid. An 8.5 French pigtail drainage catheter was passed over the wire. The catheter was secured and connected to drainage bag. The patient tolerated the procedure well without immediate complication." Although they do not hit an NCCI edit, my gut is telling me that without documentation of a separate percutaneous puncture site I would not be justified in billing for both procedures. What are your thoughts? I feel uncomfortable coding both because the needle or catheter is removed at the completion of 49083, and the way this report is documented I do not see two separate procedures but just the placement of the drainage catheter with drainage of fluid.
This is a follow-up to your question ID# 5395. I thought I could report a primary stent code 37236 for each side (one was left renal and one was right renal)... thoughts?
I have something different to code that I have not come across before - a Methylergonovine injection into the RCA during a heart catheterization. Is this separately coded? And, if so, what would the code be? I have looked everywhere for this and the only thing that I found was that you should not report code 37202 or 93463 for injection of drugs into the coronary arteries. Note states: "Methergonovine challenge to the right coronary artery in view of the patient's persistent symptoms and unchanged anatomy decided to continue with a metahemoglobin challenge to the right coronary artery. Methergonovine was given in three-minute intervals, initially at 0.05 mg up to 0.15 mg with presence of angina, as well as diffuse coronary spasm of about 70% to 80% stenosis, especially distally in the posterior descending artery and posterior left ventricular branches."
Patient had a stent intervention in the right coronary and then aspiration thrombectomy in the PDA. Should the unlisted code be assigned for the aspiration thrombectomy, and if so, do we use a modifier for this?
Patient scheduled for a pocket revision, but the day of the procedure only two superficial skin lesions near the pacemaker incision were removed and placed in Formalin. What should the hospital code?
"Patient with malpositioned port cath here for repositioning. Access via right common femoral vein, pigtail cath advanced over Bentson wire into right internal jugular vein and manipulated around misdirected port cath. Common femoral vein accessed a second time with endovascular snare cath and advanced over a wire into right atrium. Bentson wire directed through pigtail and ensnared. Both snare and pigtail cath were withdrawn as a unit, successfully repositioning port cath into right atrium." We assigned code 36597 (repositioning of previously placed CVC under fluoroscopy guidance). Your book advised to also use code 76000 — why, when fluoroscopy is stated as part of code 36597? IR advised that code 36010 is specifically for this type of catheter placement. Dr Z’s coding book gives this example on page 178. "4) The port is checked (36598) showing fibrin sheath. Via separate femoral access, a snare is used to perform fibrin sheath stripping of the catheter tip in the superior vena cava (add 36010, 36595, 75901)." No fibrin sheath is documented. Please explain what codes are correct on this case.
How would you code a core biopsy of a sacroiliac joint lesion? MRI showed possible infection. Bone or joint aspirate maybe.
I received the following statement from a cath lab director: "What I saw about injections integral to a procedure is that for cardiac cath, the only injections integral to the procedure are the basic sedations, which we don’t charge for. Anything else such as NTG given intracoronary, metopralol IV, Integrillin bolus, and then infusion are not integral to every case. Those are very specific instances and in my mind it seems we should be able to charge for them." My feeling is that separate billing for the administration of these drugs with code 96374 or 96365 would not be appropriate when administered during the course of a cardiac cath or a coronary intervention due to well established NCCI bundling edits. The reason why I say that is that the cardiac cath/coronary intervention would not be considered complete or performed properly on a patient without the performance of these infusions, therefore integral to the main procedure. Is this take more conservative than it should be? Do you agree with it, or is there another code that should be considered?
I am working on a case where the patient has a history of an aortobifemoral bypass with graft. In this surgery the patient has bilateral femoral pseudoaneurysms at the aortofemoral groin anastomosis and the femoral anastomosis. The fem-fem graft is taken down, then the physician repairs the right pseudoaneurysm with an interposition graft and states he completes a similar procedure on the left side. After this there is poor blood flow on the left side. The physician then creates a fem-fem bypass one end, which is on the Darcon graft to repair one of the pseudoaneurysms. He also does multiple thrombectomies, as the patient has prothrombin gene mutation. I know the thrombectomy (34201-50) is bundled. And the aneurysm repair (35141-50) seems to bundle with the bypass (35661). Can I code for the aneurysm repair on the side that the bypass doesn’t terminate on, or is it still bundled?
"Procedures performed: Bilateral groin cutdown with common femoral vein exposure. Extensive left common femoral vein endovenectomy followed by patch angioplasty. Focal right common femoral vein endovenectomy with primary closure. Kissing stents from IVC into the iliac system... Left groin venotomy was made and extended. An extensive amount of scarring was saline(?) as typical of chronic thromboses with recanalization and anatomy was seen. Extensive endarterectomy of the common femoral into the profunda and also the femoral vein and distal external iliac vein was performed. A bovine pericardial patch angioplasty with 6-0 prolene running suture was performed." We were unsure if open thrombectomy code 34421 would be appropriate in this case without findings or removal of thrombus. Is the reference to the scarring typical of chronic thromboses sufficient? We were unable to locate a venous equivalent to an endarterectomy. Your guidance is greatly appreciated.
Please tell me which codes you recommend for this procedure that was performed in 2013. "PROCEDURE:Ultrasound and fluoroscopically-guided sclerosis of a venolymphatic malformation in the subcutaneous tissues of the right buttock. CLINICAL HISTORY: Female with painful subcutaneous venolymphatic malformation in the subcutaneous tissues of the right buttock. TECHNICAL DESCRIPTION: The patient was brought to interventional radiology and positioned prone on the fluoroscopy table. The right buttock was sterilely prepped and draped. Under ultrasound guidance, the venolymphatic malformation was accessed with a 25 gauge needle. Contrast was injected through the needle to verify positioning within the malformation. Approximately 3 mL of Sotradecol foam (four parts 3% Sotradecol, four parts air, one part lipiodol) was injected into the malformation under intermittent fluoroscopic visualization. This was repeated at two additional sites of the malformation. Needles were removed from the patient. Hemostasis was achieved with manual compression."
The 2014 version of your Diagnostic & Interventional Cardiovascular Coding Reference it says (page 526, #3): "There is no code at this time to report 3D echocardiography. When 3D echocardiography is performed for medically indicated reasons and requested by the treating physician, report code 76376 or 76377 in addition to the echocardiogram code depending on whether an independent workstation is utilized for the 3D rendering." Then page 557 indicates the following: "10. Do not report 3D reconstruction codes separately (76376 or 76377). 3D reconstruction is included in the basic procedure codes." I am billing for a diagnostic echo, and the above two statements seem to be contradictory. Is the second statement referring to surgical procedure vs. diagnostic procedures? Is code 76377 appropriate to bill with a diagnostic echo when medical necessity is documented?
How would you code a CT-guided breast biopsy? The patient was an inpatient and unable to go into MRI scanner, and this radiologist prefers CT guidance over ultrasound. I am at a loss.
I know I asked you previously about the Baylis Power Wire. The question of the use of code 36475 for these upper extremity (subclavian primarily) cases has come up. Is there any recent data that restricts the use of code 36475 to the greater saphenous vein or its branches (as this has been the most common site)? Would the use of the Baylis Power Wire qualify these cases as an RF ablation?