Knowledge Base

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Radiofrequency Ablation to Third Occipital Nerve

Would you use code 64640 for a radiofrequency ablation to a third occipital nerve (TON)?

3D Performed in Conjunction with Mammogram

I am looking for info on if you use an additional code (unlisted or whatever) to report 3D tomosynthesis for a mammogram. Medicare just gave their opinion about a month ago, that said they cover 3D mammogram, but there is not a separate code, so hospitals should report it just like a 2D mammogram. I am hoping that Dr. Z has commented on that ruling by Medicare. 

Stent Placement in a Dialysis Graft

I may be overthinking this, but I need your expertise. Patient presented for intervention for a pseudoaneurysm within the arterial end of an upper extremity dialysis AVG. In addition, he had 70% stenosis in the venous outflow. Balloon angioplasty of the venous outflow and stent of the arterial pseudoaneurysm were performed, two distinct locations but within one graft. My inclination is to only code the stent, as PTA is bundled into stent placement and the AVG is considered one vessel. Is this correct, or may I separately code for the PTA?

WADA

I noticed in your 2014 Interventional Radiology Coding Reference, page 261, coding instructions #8, it says, "Selective catheter placement and imaging are separately billable."  The cervicocerbral angiography codes include the catheter placement, so the catheter placement would not be reported, correct?

Endologix AFX Device

The IRs are recently using the Endologix AFX device, but dictation is very poor, making it difficult to decide if I should be using codes 34804/34825 or 34845. I am leaning towards code 34845 because, in their reports, they state they are placing the main body device and then placing a proximal device in the infrarenal location without comprising the renal arteries.

Lymphatic Malformation Embolization, 2014 Codes

Code 38999 (unlisted CPT due to direct approach) vs. 2014 transcather codes... Code 37244 does not seem to fit lymphatic malformation direct approach embolizations. "Ultrasound-guided needle placement: Ultrasound evaluation showed numerous predominantly microcystic changes in a thicken soft tissues in the submandibular and right facial region and in the tongue base. A few macrocystic changes are present. Under ultrasound guidance, 18 gauge catheters were carefully inserted into multiple areas of the macro and microcystic areas. Percutaneous embolization: 6 ml of 3% sodium tetradecyl sulphate mixed with 10 ml of room air and a foamed emulsion was made. The sclerosant was slowly injected with ultrasound guidance at 6 lymphatic micro and macrocystic malformation sites. Firm manual compression was applied after needle withdrawal for 3 minutes. A small amount of fluid was aspirated prior to the cyst injections."

Transnephric Venous Fistula Embolization with Gelfoam, 37241

What can we code for the following?  "A nephrostogram was performed on the left through the existing nephrostomy tube. The left nephrostomy tube was then exchanged over a stiff angle glide wire for a new nephrostomy tube and anchored in place. An antegrade nephrostogram was then performed on the right through the existing nephrostomy tube. The nephrostomy tube was exchanged over a stiff angle glide wire for a new nephrostomy tube. A follow-up nephrostogram shows fistulization from the lower pole calix of the right kidney to small branch of the right renal vein with rapid opacification of the main right renal vein and inferior vena cava. The nephrostomy tube was exchanged over stiff angle glide wire, which was passed down the right ureter. A peel-away sheath was then placed over the wire into the right renal pelvis, and a C1 gliding catheter was advanced into the lower pole calix and in the fistula to the vein. The fistula was then embolized with multiple gelfoam torpedos. A follow-up nephrostogram shows occlusion of the fistula without oppacification of the renal vein. A new nephrostomy tube then placed."

Use of Code 93503 vs. 93451

Coding guidelines state, "Do not use 93503 in conjunction with other diagnostic cardiac catheterization codes." 1) If a Swan is inserted in the cath lab with other diagnostic procedures, but no pressures are taken, am I correct in thinking that we would have to charge code 93451 because of the coding guidelines? 2) If a right heart catheterization is scheduled with a pericardiocentesis, but pericardiocentsis is not completed and the physician dictates the "catheter was sutured in place for subsequent bedside monitoring", should we charge code 93451 based on the fact that a right heart catheterization was done? Or, does the specific dictation for monitoring make it a Swan insertion?

92960 Cardioversion with Cardiac Catheterization

In your book you state that an elective cardioversion can be billed separately when done before an EP study. Does this hold true for coronaries too? The CPT Codebook does not have any guidelines to go with a cardioversion. We have a physician who is starting to schedule cardioversion with his cardiac catheterization as routine cases.

Code 49083 vs. 49406

Under what circumstances would you use abdominal paracentesis (49083) vs. new drainage code 49406? I know code 49406 is for catheter-based, but I was always under the assumption that code 49083 was appropriate for needle or catheter drainage.

Myelogram with Injection into Existing Lumbar Drainage

CT myelogram was performed with contrast was injected via an already existing lumbar drainage. Would we code this by using code 62284 with a -52 modifier? "Using the patient's existing lumbar drain, the side port was accessed. 15 cc of Omnipaque 180 mg contrast was administered intrathecally through the spinal needle. There was no fluoroscopically noted extravasation during the contrast injection, and the needle was removed. Multiple fluoroscopic radiographic images were obtained, after the table was tilted with the patient's head moving up and the feet down, to keep the contrast in the lumbar spine and define the inferior margin of the thecal sac."

Radial and Femoral Access

I have had two situations with procedure (93458) where the MD has gotten radial access, advanced to the coronaries, and was unable to select them. The other case he was able to select the left, but not the right, coronary artery. Both changed their approach to femoral and were able to complete the procedure. Are these coded differently with the second access site? Since both times the catheter was advance beyond the access site?

Code 33222, Pocket Relocation

"Patient with chronic complete heart block, whose generator has reached end of service status. In addition, the patient has a subcutaneous pocket with mild protrusion of the device and expressed a desire to have a better cosmetic result. After administration of local anesthetic, pocket was opened and generator explanted. Additional anesthetic infiltrated to the pocket floor, cautery performed for bleeding, and submuscular pocket created. New generator connected to existing leads (RA and RV) and buried into the submuscular pocket. Closure was completed, and device was programmed." In this situation, where they only extended the device pocket to a submuscular position but not a new location, would you report code 33222-59 (pocket revision) in addition to code 33228 (generator change), or would it be considered a component of the generator replacement?

PICC Replacement Same Access with Venography

Can you take a look at this one for me? Do codes 77001 and 36584 fit this case? Anything else? "Superior venacavography and right upper extremity venography via the existing PICC site.  Exchange of existing 6 French PowerPICC line for same. The existing catheter was cut over a wire, and a sheath was placed. A 5 French diagnostic catheter was placed to the level of the axillary vein, and venography was performed. The right internal jugular vein was catheterized as well, and venography was performed. This revealed a widely patent central venous circulation. A new 6 French PowerPICC line was placed over a wire  with its tip residing at the cavoatrial junction. The line was sewn to the skin with 2-0 Ethilon, sterilely dressed, and flushed with sterile saline. Spot and digital subtraction angiography was sent to PACS archive. Total fluoroscopy was 7.4 minutes.  Findings: Normal central venography. No evidence of hemodynamic significant stenosis or thrombus. The right internal jugular venin is patent. No evidence of thrombus in the right upper extremity venography."

Revision of PCN Tubes

This is the description of what was performed. "The Revolution fixation devices were removed. The external portions of the tubes were then relocated to a more lateral position and new fixation devices applied. This was done due to the patient having pain when supine." I am unsure what to code for this. Fluoroscopy images were taken at the beginning of the procedure to assess the internal portion of the tubes, and everything was fine. Would unlisted be the best option?

Thrombosed Dialysis Leg Graft

"Thirty minutes prior to the procedure, I placed 2 mg of tissue plasminogen activator into the graft. This was allowed to dell. We then accessed the graft initially near the arterial limb, but I could not be sure if I was in. Therefore, I went further distally and accessed antegrade towards the venous limb. We were able to successfully place a 6 French sheath. I was able to aspirate thrombus. Imaging revealed a high grade stenosis at the saphenofemoral junction and the previously stented area. We then treated the outflow with a 7 x 40 mm balloon. An arterial sheath was placed in the opposite direction near the same area, and a wire was able to be advanced up into the left external iliac artery through the common femoral artery. We then treated the first segment of the arterial limb of the graft with a 7 x 40 mm Dorado balloon. Finding stenosis at saphenofemeral junction, proximal portion of venous outflow and first segment of the AV graft near the arterial anastomosis." I reported this with codes 36870, 372220, 35476, 75978, 36147, and 36148.  Am I correct?

Pulmonary Embolus, Thrombolysis, Right Heart Cath

Are codes 93451, 37211-50, and 36014-50 correct for the following procedure? (Patient had diagnostic CT priot to this procedure.) "A balloon-tipped Swan-Ganz catheter was advanced serially through the right heart chambers (pressures were measured) and was then advanced up into the right main pulmonary artery into the wedge position where pulmonary wedge pressure was measured. Another wire was advanced through the catheter lumen and advanced into the mid lobe of the right pulmonary artery. Another wire was able to be selectively directed into the left main pulmonary artery and the left mid branch. It was used to perform selective angiogram of the main pulmonary artery. This catheter was removed. The 12 cm long EKOS catheters were then advanced along each of the two V-18 wires and positioned carefully with their proximal infusion edge being above the level of the pulmonic valve. Following positioning, the V-18 wires were removed and replaced with the inner core wires of the EKOS catheters to provide ultrasonic drug delivery. The catheters were then sutured in place and connected appropriately to the infusion devices. Thrombolytic infusion was initiated per protocol."

Right Heart Catheterization with Biopsy

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?

Permatemp Pacemaker Placed Post TAVR

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?

Documentation for Double Contrast UGI

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.

Code 49440, Drainage of Gastric Remnant

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?

S1 NeuroforamenIinjection CT Guided

"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?

Ablations

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.")

Hybrid Congenital VSD Repair

"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)?

Test Occlusion of ASD

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."

Items 276 to 300 of 2045 total

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