If you were to approach this physician on his documentation of the below generator changeout, what would be your exact verbiage? There is no documentation of work done, nor info on implanted device (only intraprocedural measurements). "PROCEDURE PERFORMED: Generator replacement of a dual chamber biventricular cardiac defibrillators, fluoroscopy of device and lead, and capsulectomy pocket revision. Explanted device is a Guidant CRT-D model D224TRK. Existing leads: Atrial lead is Medtronic model 5076, length 45 cm in the right atrial appendage. The ICD lead is a Medtronic model 6947, length 58 cm in the right ventricular apex, and the CS lead is Medtronic 4196, 78 cm long in the lateral branch. Tachy detection at 300 millisecond. Tachy interval for ventricular fibrillation, first therapy 35 joules then 35 joules x 5. Bed rest for 4 hours. Antibiotics used."
how do we code replacement of ICD generator with attachememt to existing right atrial and right ventricular lead and insertion of new CS lead using 2012 codes. Doesn't 33249 still include insertion or replacement of one or more right leads? Currently 33225 can't be used with 33262, 33263 or 33264. Medtronic and Boston Scientific and 3M all tell me that they are waiting for clarification from AMA on this particular coding scenario. I'm hoping you have more insight because we seem to be doing a flurry of these at the moment. Thanks
Dr, Z. Pt's loop recorder was not sensing R waves so pt was brought in and the recorder was removed from the original pocket which was sutured closed and then the same device was placed into a newly created pocket and device was ubterrigated. Is it appropriate to code 33282 and 33284 or is there something better?
I am unsure about how to code a TAVR procedure where subclavian artery access was used (cutdown). Do I need to use an unlisted code, or would I be able to use code 33363 (TAVR open axillary approach)?
Please do NOT include any actual patient medical records with your question. I have a surgery that I have never coded before and I am lost on this area. patient has Subclavian Steel syndrome with significant stenosis of left common carotid and innominate artery. Surgery performed was Resection of the aortic arch and head vessels with debrancing of the head vessels. resection of left subclavian artery with graft, resection of left common carotid artery origin with graft, innominate resection of origin with graft. Patient was cooled and circulartory arrested, placed on bypass. carotid and subclavian endarterectomized. Resected aortic arch in a patch fashion and resected the head vessels. we selected out a trifurcated 30 mm branch graft and created a nice patch with the head vessel branch grafts intact. 30 mm and 10 mm innominate, and 8 mm left cartoid and left subclavian branch graft. With the arch anastomosis completed we placed bioglue around to seal all suture lines. I think the 35301 for carotid endartectomy would be correct and 35311 for the subclavian and 35311-59 for the inominate. I am totally at loss for the Aortic resection and the debranching. Can you guide me. I may be totally off on this one. Thank you.
Dr. Z, How is an attempted interventional cardiac procedure coded when no device such as balloon or stent was used in the attempt and no repeat dx coronary study was performed. I can't use an interventional code because I don't have a device C-code to enter with the cpt code. Can the cpt code go through with a -74 on the cpt code because it was aborted after the attempt? Or just go with unlisted code 33999. If there was a dx study done with the atempted intervention, is it just the heart cath code billed or can we add the intervention code on with a modifier? This is when we attempt and have no device code open. Also, I've read that 33999 is used when an impella is inserted. When do you use 33999 (cardiac surg) and 93733 (cardio interv)? Thank you!
CAN YOU PLEASE TELL ME WHAT IS THE CODE FOR THE PLACEMENT OF IMPELLA DEVICE. THANK YOU.
Dr Z, Could you please take a look at the below case and tell me how you would code it. Would 33215 be appropriate? Thanks, Terri Derrick INDICATION FOR PROCEDURE: Increased shock impedance on a newly implanted ICD. PROCEDURE: ICD lead revision. ANESTHESIA: IV Versed and fentanyl. DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory in a fasting state. The patient's left shoulder was prepped and draped in the usual sterile fashion. 1% lidocaine was infiltrated into the skin surrounding the patient's fresh but closed ICD generator pocket incision. Three layers of sutures were ligated and removed, opening the pocket. The generator and leads were removed from the pocket. Noninvasive interrogation device confirmed a high shock impedance of greater than 125 ohms. Gentle traction on the proximal shocking coil plug freed the plug from header. The plug was reinserted into header and re-secured with set screws. The leads and generator were repositioned in the pocket. Noninvasive testing documented excellent impedances and pacing thresholds. The pocket was re-irrigated with antibiotic solution. The skin was closed in three layers. MEASURED DATA: Again, prior to the procedure, the patientâ€™s shock impedance was greater 125 ohms. At the end of the procedure the patientâ€™s shock impedance was 44 ohms. ESTIMATED BLOOD LOSS: 5 mL. COMPLICATIONS: None. CONCLUSIONS: 1. Loose plug/header connection. 2. Successful revision.
Need to find where it says that only one method of thrombus removal is to be used. I had a doctor, do an open thrombectomy of the brachial, then the axillary/subclavian, then the radial and ulnar, used a spider filter, then did angioplasty and stent of axillary/subclavian no stenosis documented. He wants to bill 36215 75710 75650 37203 75961 35475 75962 37205 75960 34101 34111x 2. I am trying to find documentation to show him that only one method of thrombus removal is to be used. The codes 36215 75650 and 75710 were from rt common femoral access, all others were done through the open brachial access.
Hi Dr. Z, If our doctor is performing an open emrbolectomy of the Brachial artery, Radial artery and the Ulna artery can i use 34111 twice with 34101 or do i just use 34101? Thanks for your help... Please see an example below ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A linear incision was made of the patients right medial aspect of the elbow and carried down with dissection. the patients bracial artery, radial artery,and ulna artery was identified, respectevily controlled with vessel loop. Than a transverse arteriotomy was made of the brachial artery. A #2 Forgaty catheter was passing through to the proximal brachial artey. There is organized embolus was expressed. Brisk flow was achieved and irrigated with saline and then embolectomy catheter was passing through the radial artery . the radial artery had minimal clots and passing through the ulna artery, the ulnar artery has an organized embolus as well. Both achieved brisk back flow and were flushed with heparinized saline. After satisfaction the transversed arterectomy was closed with interrupted 7-0 prolene stitch and restored right upper arm blood supply, palpable radial and ulnar pulse.
Hi, My Dr. performed open cutdown of left common femoral artery and left over the wire popliteal thrombectomy. How do I code the over wire thrombectomy. Should I use 34812 for cut down and 34203-22 for over wire thrombectoy? Please advise. Thanks, Renata
Dr. Z I need help coding Innominate vein to right Atrium bypass with a spiral vein conduit
In your book Vascular & Endovascular Surgery Coding Reference on page 240 example # 4 you use 35286 along with 34802 but when I put all the codes in I come up with that code as bundled. I thought you could not do anything else with the AAA repair. Can you help me to understand? Also can you do and endarterectomy of the common femoral when doing a AAA?
Hello Dr Z, Is a percutaneous endovascular repair of the abdominal aortic dissection coded the same as open AAA repair (34800 & 75952)? We did a percutaneous mid abdominal aorta repair using 3 Gore Excluder as an outpatient procedure. CPT 34800 and 75952 require inpatient stay. How would I code this? Thank you in advance and see you in Nashville Melissa Russo
Dr. Z..Please help. Endovascular repair. States caths, angios already in there then: following this, the device, 30 x 18 x 170 device was then placed via the right groin. It was advanced up to approximately the first lumbar vertebra, as well as the pigtail catheter. Then using a series of injections using 10 cc I was able to deploy the proximal portion of this endovascular prosthesis. It was deployed to the point that the figure of eight markers were seen on the gate. This was ballooned and inflated and pulled down into the prosthesis which appeared to be in good position. Next the retrograde injection was performed. The markers were counted out. It was felt that we could complete this procedure with a 14 x 16 x 105 prosthesis. This was deployed without difficulty. Next, the deployment on the right side was then completed. At this point the entire graft and distal fixation point were then angioplastied. Is this a 34802 or a 34803 or 34802 with a 34825 with the 75952 and/or 75953.
Could I get your opinion on this one please? I just wanted to see how many extensions you come up with for this one...here's what i'm thinking 34802 34812-50 36200-59-51-rt. fem punc. 75952 75953 x3 34825-51 34826 x2 36246-51-int. iliac cath (I was thinking maybe 1st order?) Embo (75894/37204/75898) was done by cvir phys. do you agree with 3 extensions? thanks! OPERATIONS PERFORMED: 1. Endovascular repair of abdominal aortic aneurysm using a Gore excluder device. 2. Left side ipsilateral 28.5 x 14.5 x 180 mm main body device. 20 x 95 mm distal extension into left common iliac artery. 14.5 x 120 mm distal extension into left external iliac artery. 3. Right side contralateral 20 x 115 mm contralateral limb. 26 x 33 mm aortic cuff (distal extension into right common iliac artery). 28.5 x 33 mm aortic cuff (distal extension into right common iliac artery). 4. Bilateral femoral artery cutdowns for exposure. 5. Second order catheterization of branches of left internal iliac artery from left femoral approach. 6. Transcatheter embolization and occlusion of left internal iliac artery (performed by Dr. Peter Waybill). ANESTHESIA: General endotracheal with supplemental local. DRAINS: None. TOTAL CONTRAST USED: 144 mL. INDICATIONS: Mr. Kettering is a 79-year-old gentleman with a 6.1-cm abdominal aortic aneurysm, which has been growing. He is brought to the operating room for endovascular repair. The risks, goals, and alternatives were discussed with the patient who understood and gave consent to proceed. OPERATION: A time-out was performed, the patient identified and procedure verified. General endotracheal anesthesia was induced without incident. The abdomen and both groins were prepped and draped in the usual sterile fashion. The patient received preoperative antibiotics within 1 hour of incision time and preoperative steroid and Benadryl administration was performed given the patient's known history of intravenous contrast. The common femoral arteries were then exposed through bilateral oblique groin incisions. These were performed a little bit higher than usual because of the heavy calcification of the femoral bifurcations. The inguinal ligament was identified and elevated cephalad. The distal external iliac artery was prepared. The crossing circumflex iliac veins were divided bilaterally. Soft spots were identified bilaterally for use. Single wall puncture technique was used on both sides, and a Bentson wire was inserted up into the abdominal aorta. 7-French sheaths were placed on either side. On the right, a marker pigtail catheter was inserted up in the perirenal aorta. On the left, a Lunderquist wire was inserted and over this the 7-French sheath was up sized to an 18-French DrySeal sheath. An aortogram was then performed, demonstrating the location of the renal arteries with approximately 150 mm of distance from the renal arteries to the aortic bifurcation. Based on this, a 180 mm length device was chosen with the left side used as the ipsilateral side. It was oriented such that the contralateral gate would be anterior. The device was then passed up through the sheath and was deployed just below the renal arteries without any complication. The C3 deployment system was used and only the proximal portion of the device was deployed. With a series of wires and catheters eventually requiring a C2 catheter and an angled glide wire, the contralateral limb gate was engaged and a pigtail catheter inserted and spun within the graft to confirm intragraft positioning. The pigtail was then advanced up and given that the device had been in position but not anchored for quite some time while the contralateral gate was engaged, I shot another aortogram demonstrating that the graft is still in good position. The remainder of the graft was then deployed and via the left side a 32-mm Coda balloon was inserted and the proximal attachment site ballooned to profile. The pigtail catheter had been exchanged at this point for a Lunderquist wire on the right. This side was also up sized to an 18-French sheath. Prior to this, a sheathogram was performed locating the right iliac bifurcation. We knew we are going to have to place a larger cuff on this side and so a 20 x 115 mm device was chosen to land us just into the right common iliac artery and allow room for distal cuff. This was placed via the left-sided 18-French access and deployed uneventfully. Another injection via the right sheath was done to locate the iliac bifurcation and a 26 x 33 mm aortic cuff was used as a distal extension on this side to obtain seal. The Coda balloon was then inserted, and all junction points and the distal attachment site were ballooned to profile. Injection via the left sheath was then performed to identify the iliac bifurcation. Based on preoperative measurements, it appeared that a 20-mm device would obtain seal and so a 20 x 95 mm device was inserted up the left side access and deployed uneventfully. The Coda balloon was inserted here as well, and all junction and distal attachment sites were ballooned to profile. An aortogram at this point was obtained, which showed a fairly extensive type 1B endoleak from the left side. It did not appear that a further ballooning of the limb would achieve seal, and so I chose to extend. At this point, I had a choice of either extending into the external iliac artery or placing a larger cuff. There was not a lot of room here between the end of the extension piece and the iliac bifurcation and so I reviewed the films with Dr. Waybill from Interventional Radiology, and we agreed that embolization of left internal iliac would be appropriate. The left internal iliac artery was then accessed by inserting an angled glide wire and the C2 catheter up the left-sided 18 French sheath as a buddy wire type system, so that we did not lose access across the device. The left internal iliac artery was cannulated successfully and the wire was inserted into the distal branches of the internal iliac artery. The catheter was able to follow and a Rosen wire was inserted to achieve a little bit more stiffness of the wire into the internal iliac artery branches. The catheter was then removed and a 7-French sheath placed into the distal internal iliac artery branches. The embolization of the left internal iliac artery was performed by Dr. Waybill and is dictated separately by him. Briefly, an 18-mm Amplatzer device had been chosen and was placed under fluoroscopic guidance with additional injections of contrast to confirm placement at the left internal iliac artery origin. This was deployed uneventfully, and the 7-French sheath was then removed. A 14.5 x 120 mm length extension was then chosen and placed up the left side and deployed about 3 cm into the left external iliac artery uneventfully. The Coda balloon was used to balloon this to profile as well. Another completion arteriogram was performed revealing a type 1A and type 1B leak from the right iliac attachment site. The proximal endoleak was addressed by reinserting the Coda balloon and ballooning the proximal attachment site to profile. Several additional images were performed with various obliquities on the right side, and I chose to extend a little bit farther with a 28.5 x 33 mm cuff on the right. This was inserted uneventfully and ballooned to profile. A completion arteriogram at this point revealed resolution of the type 1A endoleak a much slower flow into what was thought to be a type 1B endoleak but on further review, it appeared that it may have been a type 2 endoleak causing this puddle of contrast at about the midportion of the infrarenal aorta on the right. At this point, I did not feel that further extension along the right would be appropriate given that I had already sacrificed the left internal iliac artery, and I chose to terminate the procedure. All wires and catheters were removed with a good pulsatile blood flow noted, and both arteriotomies were repaired with interrupted 5-0 Prolene suture. Backbleeding, forebleeding, and flushing maneuvers were performed prior to closure, and all wounds were checked and made hemostatic. The wounds were then closed with interrupted Vicryl with Monocryl for the skin. Dry sterile dressings were applied. The patient was awakened and extubated and taken to recovery room in stable condition and tolerated the procedure well without immediate complication. Intraoperative autotransfusion was not used.
Please tell me how you would code this case? Is there a code for the contralateral limb? or is it included in the 34802. we placed 2 Perclose devices after accessing the right common femoral artery. We then placed a 7 French sheath in each common femoral artery and then advanced an angled guidewire into the right common femoral artery, up into the distal abdominal aorta. With this in place, we then used a 5 French pigtail to perform our first aortogram and runoff. With the first aortogram and runoff, we identified the takeoff of the right and left renals. We did have some overlapping on the left side with the inferior mesenteric artery. It required 2 extra aortograms with 1x magnification to fully delineate the takeoff of the left renal. Once we had this in place, we at this time changed our II to a craniocaudal angle of 15 degrees. With this positioning, we fixed the bed, fixed the II, and then introduced the main body device on the left side over a stiff Amplatz wire. With the main body device introduced, we selected out a 36 x 20 x 166 bifurcated main body device. We advanced this into the distal abdominal aorta just above the renal arteries. Once we were satisfied with this placement, we began the deployment. We deployed the device down to expose the contralateral limb and held it in place. We then took one more selective aortogram at the level of the renal arteries and noted that the device was in good position. We then removed our pigtail from behind the bifurcated device using an angled wire and then exchanged out the pigtail for an FR4 catheter. The FR4 catheter, however, with the angled glide could not be used to cannulate the contralateral gate. We therefore switched the FR4 to an MPA and with the MPA 5 French catheter, we were able to cannulate the contralateral gate with the stiff-angled glide. With this done, we then exchanged out the MPA for a 5 French pigtail. This was brought into what was seen to be the graft body. We were then able to spin the pigtail nicely and then injected approximately 10 cc of contrast. We could see very selective filling of the graft and then down the contralateral limb and then back up into the closed left iliac limb. Satisfied with the placement, we then brought in the contralateral limb. We selected out a 16 x 20 x 124 Endurant contralateral limb. This was positioned nicely over a stiff Amplatz wire and deployed. Once this was completed, we then released the proximal renal fixation and then withdrew our graft on the left side so as to complete the deployment. We then removed our MPA device and brought in a Reliant balloon from the right side. We ballooned proximally. We ballooned the gate and then we ballooned the distal iliac components on the right to obtain a good seal. We then brought the balloon to the left side and again ballooned proximally and distally on the left iliac limb. Once this was completed, we performed our aortogram with runoff. We noted that we had a good proximal seal initially but then had either late, Type 1-A endoleak or a Type 2 endoleak proximally. We had good sealing at the gate and good sealing at the distal iliac limbs. We then brought the balloon back in and inflated once more just above the graft sitting at the renals and then just below it so as to get a much better seal proximally. We felt that with this aggressive ballooning, we optimized our seal and then we repeated our aortogram. We noted a much better control and had a very tiny, Type 2 endoleak from the lumbar artery. With this completed, we then removed our devices, deployed our Perclose sutures, and got good hemostasis. We gave the patient a total of 80 mg of protamine. Of note, during the course of the procedure, we gave him a total of 14,000 units of heparin and had the ACT above 250 at all times. With the completion of the procedure and the administration of the protamine, we checked for pulses. We had good distal pulses. We had no bleeding at our access site.
Do we use code 34802 or 34203 for an Endurant 2 stent graft for AAA?
Would surgeon get any credit for placement of Palmaz stent placement during a AAA repair see dictation below AAA repair proceedure, Unibody graft placed along with proximal aortic cuff. "Angiogram was performed and demonstrated small type I endoleak with the rest of the graft widely patent with good flow into both iliac arteries. Therefore the 10 mm x 40 mm Palmaz stent was placed onto the CODA balloon and advanced back up into the proximal portion of graft" Using cpt 37204, 34825 for graft placement, code 37205 bundles according to coding rules. I have not been giving credit for 37205 Palmaz stent placement. Is this correct? Surgeon would like confirmation.. Thanks for any insight... Julie Breedlove Surgical Care Associates 502-638-5115
"Example: Standard Seldinger technique under US bilateral CFA were accessed with different sheaths. Perclose suture mediated devices were deployed in both CFA and additional 3rd device also deployed in right CFA due to dense calcification even though vessels of decent size. 18 French sheaths placed bilaterally. Abdominal aortogram was obtained. Following review Gore excluded graft is deployed; this is a modular bifurcated graft. Following deployment in the infrarenal location, tapered catheter & Glidewire used to cannulate the gate. Bell bottom device used from the left side, which was placed through the cannulated gate with 3 cm iliac overlap. The proximal end of graft anchored with 30 mm compliant balloon. Right iliac limb is fully eployed with 14 mm balloon. Overlapping left iliaclimb and gate were anchored in place with compliant 30 mm balloon that slowly inflated. Same balloon used to anchor the left iliac vein. Hemostasis was obtained using percutaneous suture mediated device. Hemostasis obtained with no evidence for bleeding with no immediate complications." Is this reported with codes 34803, 36140-RT, and 75952-26LT?
This patient was brought in for repair of iliac aneurysm and AAA. A bifurcated graft was placed and in addition, a stent was placed inside of the iliac limb of the graft due to vessel tortuosity. CPT book indicates that 37221 iliac stent is for occlusive disease. We have 34803, 75952, 36200 x2. Main body stent graft 32 x 96 was advanced from a right approach into the abdominal aorta. The contralateral limb was oriented anterolaterally. Proximal 2 stents were deployed and position adjusted to just below the level of the renal arteries. Contralateral limb was deployed. The suprarenal stent was deployed and catheter was pulled back to the distal abdominal aorta. Catheter was exchanged to a Kumpe catheter and later a Vanshee catheter. Contralateral gate was cannulated using the Vanshee catheter. Intraluminal position was confirmed by injecting a small amount of contrast within the graft. Lunderquist wire was advanced to the upper descending thoracic aorta. The catheter was removed. Left iliac arteriogram was performed to evaluate the common iliac bifurcation. A left limb 14 x 90 was advanced from a left approach to about 1-1/2 stent overlap. The stent was deployed proximal to the common iliac bifurcation. Due to tortuosity of the common iliac artery, it was decided to place a self expanding stent to increase radial force. A 14 mm x 60 mm SMART stent was deployed within the left iliac limb. The remaining 2 stents from the main body were deployed and nose cone was retrieved. Right iliac arteriogram was performed. Right limb 12 x 107 was advanced from a right approach to the right iliac limb. 2 stents overlap proximally and distally. The stent was deployed in the proximal right external iliac artery covering the origin of the right hypogastric. The infrarenal neck areas overlap and distal limbs were dilated using compliant balloons. The stent on the left was dilated using a 12 mm angioplasty balloon. Completion arteriogram was performed through a pigtail catheter from a left approach.
Dr. Z. I need help...incision was made at the proximal thigh to expose the proximal sfa. After exposure needle was used to puncture the vessel and a quidewire was inserted. This was then followed sheath and dilator. An angiogram was then obtained with a hand injection of contrast through the side arm of the right sfa sheath. This redemonstrated the popliteal artery aneurysm. The measurements were taken and sheath changed to allow passage of the stent graft device. An 8 mm wide x 10 cm long graft was selected and was placed under fluoroscopic control. This was then postdilated using an 8 and 9 mm balloon. A completion angio was performed demonstrated a leak at the distal aspect of the stent graft. Therefore and additional endovascular stent graft was placed with a greater than 1 cm overlap. This stent graft was then ballooned with a 9 mm balloon. The stent graft extension was an 8 mm wide x 5t cm long device. After this was done a completion angio was obtained of the stent graft areas and of the entire right lower extremity. This anggio demonstrates resolution of the leak in the popliteal area. ....the rest is results of the angio and closure. I know there isn't an endo for popliteal but could we use 34805-22; 34825-51; 34812-51, 75952-26; 75953-26 and 36140? One coder thought 37207/37208 which isn't supported by 442.3 popliteal aneurysm. Can you please help??
When billing code 34803, would I also report code 34812 if that is done? In our Encoder pro software it says that code 34812 is included in code 34803. "34803 - INCLUDES: Balloon angioplasty/stent deployment within the target treatment zone; introduction, manipulation, placement, and deployment of the device; open exposure of femoral or iliac artery/subsequent closure (34812)." Not sure if I should be billing code 34812 with a -59 (-XS) modifier or just not using it at all.
We have a case were the vascular surgeon placed a TAA and AAA graft with iliac coil embolization and also placed a renal stent. Are we allowed to bill an open femoral exposure (34812) and/or a brachial exposure (34834)? Or are they considered bundled due to the other procedures done during the case?
I am not sure how to code for the removal of an endograft (AAA, due to Type 2 endoleak). An aortobifemoral bypass was done, but I am not sure how to code the explant. 37799?? 22 modifier on the 35646? Something else? Since it was not infected, I hesitate using 35907.