I have never coded for the epicardial access for EP ablation and have not been able to find information. Would you give your insight on what the following procedure coding would look like? The patient was brought to the EP lab. The ICD was reprogrammed and interrogated. Both groins were prepped in the usual fashion. Local anesthetic was applied to the skin. Following a modified Seldinger technique, one 8 French sheath and one 11 French sheath were placed in the left femoral vein. A 4 French sheath was placed in the right femoral artery. Via the subxiphoid approach, epicardial access was obtained with an epidural needle and an 8 French flexible steel Arrow sheath. Mapping and ablation catheters were placed in the 9 French sheath and 9 French Arrow sheath. A 3D map of the epicardium was created. The 4 French arterial sheath was exchanged for an 8 French Arrow sheath due to the torturous nature of the aorta. During epicardial mapping an IBI HIS catheter was placed in the right and left ventricles for pacing. There was a patent foramen ovale present. The mapping and ablation catheter was advanced through the aorta to the left ventricle via the retrograde approach. Left ventricular pacing and recording were performed, a 3D map of the endocardium was created. Ventricular stimulation was performed and programmed ventricular stimulation was performed. Several different VT morphologies were induced by ventricular pacing. All of the VTs were mapped to an area posterior to the mitral valve. RF energy was delivered with termination of the VTs from within the left ventricle, epicardially, and from the anterior cardiac vein. Aspiration of the pericardial space was performed throughout the case. At the end of the procedure, protamine was given, Solumedrol 125mg was given via the epicardial sheath, the sheaths and catheters were removed, and good hemostasis was achieved with direct manual pressure.
A documented pacemaker dependent patient was brought in for end-of-life pacemaker generator replacement. A temporary pacemaker single chamber was inserted, and the dual pacemaker was replaced. The patient was placed in observation where it was noticed that there was a sudden loss of ventricular capture due to the chronic ventricular lead being displaced. The patient was taken to the special radiology suite emergently and had a temporary pacemaker wire placed and then was taken to the cardiology suite where the chronic ventricular lead was replaced. This was originally billed as two sessions (33228 with 33210-59, and 33234 with 33216 and 33210-59). Code 33228 is not allowed with 33216 even with an appropriate modifier. Can we bill codes 33207, 33234, and 33210-59 x 2?
The physician performs embolization of an AVM by catheter-directed insertion of coils, glue, etc. He then performs additional embolization using a direct stick technique under ultrasound and fluoroscopic guidance on the same AVM. Should we be coding this with both codes 37204 and 37799? Or would the direct stick embolization be included in code 37204? Are the fluoroscopy and US guidance codes both assigned either with or without code 37799?
My physician completed a right fem-pop bypass using saphenous vein. As the right external iliac was not clampable for an endarterectomy, he instead balloon angioplastied the stenotic segment and placed a stent through a micropuncture needle in the common femoral artery. I would only code for the bypass, as I would consider this part of localized inflow and outflow. My provider disagrees and thinks this should be billed in addition to the bypass. Can you please provide your thoughts?
Which ablation CPT code would we report for the following? Vascular clinic is saying liver code 47382 and HIM is saying unlisted biliary tract code 47999. "RF device was placed through the biliary catheter into the bile duct for ablation of malignant biliary strictures and stents."
CPT codes C9608 (CTO) and 92944 read "each additional coronary artery or coronary artery branch". The other add-on codes for PTCA, stent ect read just "each additional branch". So, if two CTO primary vessels are intervened upon, do we report code C9607 twice? Or codes C9607 and C9608?
We have multiple opinions flying around on this one, so I wanted to run it by you. Patient has/had DVT of the lower extremities and had a filter placed. She is seen now to have a lower extremity venous ultrasound done prior to removing the filter to check the status of the DVT. On the left it looks to have resolved, but on the right it's undeterminable if it has completely resolved. Would you use the DVT diagnosis (453.41/453.42), a follow-up (V58.81/V58.89), or a pre-op (V72.83) diagnosis code? I'm leaning towards the DVT, but a few do not agree, so I was hoping to get your opinion on it.
What are the supervision requirements for stress and nuclear stress tests? Does it require "direct" supervision? General supervision? And does it have to be a physician or can it be an NP?
I am new to IR coding. I have an operative note for a fistula to the radiocephalic for dialysis. It looks like they did an anastomosis. Please help with the correct CPT and ICD-9 procedure codes.
We have not been able to find specific information as to when it is appropriate to use radiology S&I code 74235 with code 43247 when performing removal of foreign body. Is there something specific we need to be looking for in order to report code 74235?
One of our doctors will soon begin doing fetal cardiac interventions (aortic valvuloplasty, pulmonary valvuloplasty, ASD creation, pacing) in conjunction with doctor from Maternal Fetal Medicine for the access to the fetus. Any idea how both doctors would bill for these procedures? Please help.
I'm coding a fluoroscopically-guided lumbar puncture and epidural blood patch. I understand the CPT codes for the epidural blood patch are 62273/77003, but I'm a bit confused as to whether I need to also report codes 62270/77003 for the lumbar puncture. "TECHNIQUE: Under fluoroscopy the L2-L3 interlaminar space was identified, and a 22 gauge spinal needle was advanced into the thecal sac. A total of 8 ml of clear fluid was obtained in four tubes and sent to the lab. At the L4-L5 level a 20 gauge spinal needle was advanced into the epidural space under fluoroscopy. Subsequently, 9 ml of autologous blood was injected into the epidural space w/o complication. The needle was then removed." Please advise regarding the correct codes to use for this procedure.
This question was brought up, and I would like to have your opinion. Prior to 2013 there were only three coronary arteries recognized by CMS. Therefore, prior to 2013, you could bill 92978 x 1 and 92979 x 2 for IVUS during PCI, if performed. Now that 2013 AMA and CMA both recognize five coronary arteries (LM, LD, LC, RI (if applicable), and RC) could it be possible to bill IVUS more than a total of three times?
Do you know if the Crosser Catheter system has been approved for use other than atherectomy? An issue has come up with the product being used for "recanalization of an occluded vessel" prior to proceeding with angioplasty. Product has a C-code of C1714, which is going to edit since documentation only supports the angioplasty procedure. Is "recanalization of occluded vessel" enough to justify changing this procedure to an atherectomy? I don't feel that it is.
Can you please explain why when fibrin sheath PTA is done via the same access in a hospital facility modifier -52 is not utilized only on the physician side? This modifier is used in other outpatient hospital coding and is approved per the CPT Manual (where modifiers are listed). I know this is in your literature but not the explanation behind it.
We bill for the radiologists who are employed by a hospital system. They are required to provide the interpretation for all imaging procedures performed and have decision-making authority for protocols, as well as provide supervision to the technologists. When they are performing the final written interpretation for radiology procedures that include an S&I component (particularly, e.g., angiography and aortography) we are billing with only a -26 modifier. I have seen recommendations that we should also append a -52 modifier, which I am challenging based on our organization structure and protocol. Also during some IR procedures (e.g., cholangiograms) I see recommendations that the interpreting radiologist can only bill for the intraoperative spot films performed instead of the cholangiography initial and additional sets (74300-74301). We have been billing the cholangiography. Should we only be billing the abdominal films (74000)?
I was wondering if you have had anyone ask about a bundling edit we keep running into. We are a hospital facility and are reporting the new DES codes (specifically C9602-LD, 92921-LD, and 92978). We are getting an "add-on" edit and need to report the primary procedure. The new DES "C" codes are not on the list. If we were to report code 95933-LD, we would not get an edit, but we would get a denial on the CPT code. Were there any changes/edits there were missed that were similar to the EPS codes?
I need advice with the following case please. "Intra-op direct exposure of superior opthalmic vein with angiocath access was secured. Patient then brought to IR department for embolization of carotid-cavernous fistula. In IR, angiocath sticking out of opthalmic vein accessed with microcath and moved to cavernous sinus with coil placement. After embolization, patient went back to operating room for decannulation and ligation of opthalmic vein." Would you do anything for the catheterization into cavernous sinus from superior opthalmic (36211)? Unlisted (36299)? Or just stick with embolization codes and follow-up angio from RCCA? There is no mention of imaging findings through opthalmic vein, just advancement of microcath and coil embolization into cavernous sinus.
Good afternoon. How would you code the following scenario? Would modifier -73 or -74 be appropriate to report in this instance since this is a radiology procedure? Would the modifier be applied to the RS&I or surgical component or both? "An attempt was made to perform a stereotactic biopsy. The calcifications could not be localized with stereotactic technique. The biopsy could not be performed. The patient understood the explanation. The microcalcifications may have to be biopsied with needle localization technique."
For the following procedure, is code 0281T appropriate for the scenario? PROCEDURAL DETAILS: 1. Accesses: Arterial access was established in the right femoral artery with difficulty. He has a history of right total hip replacement, which appears to have been a complete reconstruction, with femoral head way above the corresponding left femoral head. As such, the usual vasculature anatomy appears to be completely mal aligned. Nevertheless, after some maneuvering, a 5 French short sheath was inserted into the femoral artery. This sheath was sutured at the conclusion of the case, and there was no hematoma. An attempt was made to obtain venous access on the right, again with difficulty, and ultimately, the left femoral approach was used. The left femoral vein was accessed easily, single puncture, allowing the passage of initially an 8 French short sheath. 2. Left heart catheterization was performed through the Mullins sheath. 3. Left atrial appendage angiography was undertaken through a 5 French pigtail catheter, placed in the mid body of the left atrial appendage, hand injection undertaken on multiple occasions. 4. A transseptal puncture: A Toray wire was advanced through the left femoral venous access, sheath removed, and a Mullens sheath advanced up into the SVC then retracted back to the fossa. This was all under fluoroscopic and echocardiographic guidance. The BRK 1 needle advanced into the Mullins sheath, and with hemodynamic monitoring, as well as echocardiographic guidance, a single transseptal puncture was attained yielding a satisfactory position, and left atrial pressure immediately. Throughout the procedure, ACT was maintained at a satisfactory level. 5. Transseptal delivery of Watchman 27 mm device: The initial TEE measurement under general anesthesia condition yielded 21-22 mm diameter for the LAA, suggesting at 24 mm device. The assessment on the previous day was a maximum of 24 mm. Nevertheless, the 24 mm device was delivered, however, not in a satisfactory position, and was retrieved. Given the suggestion that the 24 mm was not yielding a satisfactory compressions ratio, a 27 mm occluder was then used, and on deployment, it appeared that the delivery system was not intubated enough, most likely to do with the left femoral approach, biasing it superiorly. Nevertheless, a third 27 mm occluder was then used (second device fully deployed). This was after advancement of the pigtail catheter deep into the apex of the left atrial appendage, allowing the delivery sheath to be advanced three quarters into the left atrial appendage. On delivery of this 27 mm occluder, it was deployed satisfactorily, occluding the appendage with minimal/trivial Doppler flow, and a tug test demonstrated satisfactory deployment. At this point, the Watchman device was deployed, and the delivery sheath removed en bloc, and a figure-of-eight suture was placed satisfactorily, attaining hemostasis immediately. PROCEDURAL FINDINGS: 1. Opening aortic pressure 96/61. 2. Left heart catheterization: Mean LA 17 mmHg at the commencement of procedure. 3. TEE: See separate report. RESULTS OF INTERVENTION: Successful closure of left atrial appendage ostium with a 27 mm device with excellent position, anchorage, ceiling, and sizing parameters. CONCLUSION: Successful closure of left atrial appendage with a 27 mm Watchman device with no complications.
Can you please indicate the correct coding for vertebroplasty done on T12, L1, and L2? I recall in your lecture that now you would report that with codes 22520, 22522, and 22522, as well as three imaging charges (72291). Is that correct?
I have an interventional radiologist who performed a right internal jugular hickman catheter exchange (36581) with fluoroscopic guidance (77001) and then accessed a dialysis graft to obtain a blood culture. Can the blood culture be reported with code 36500? The report reads as follows: "The patient's left arm HeRO dialysis graft was accessed with a micropuncture kit. Over a stiff Glidewire, a Berenstein catheter was advanced through the graft to the right atrium. Blood culture was acquired through the catheter as it was slowly withdrawn through the dialysis access. The catheter was removed, and hemostasis was achieved with manual compression. Fluoroscopy was used intermittently during the case." This question is for professional billing. What would you code in this situation?
I have a question in reference to Question ID 4429. There the question is posed: "I have a question for you from the webcast on Tuesday regarding the acute MI code. There is much confusion on whether or not a non-STEMI is an acute MI. Are we to assume that a non-STEMI is an acute MI? If so, what clinical indications (documentation) would need to be present?" Your response was: "We have asked the societies that created the code and left out their definition of MI. I know this is an issue with MDs. We will let you know when that definition is published." Could you tell me if this has been clarified, and if so, what is the definition?
Would a laser thrombectomy qualify for a 92973 thrombectomy add-on code?
I received this memo from CAHABA regarding new changes to -59 modifier effective July 1, 2013 CHANGES WITH MODIFIER -59, Effective July 1, 2013, Modifier -59 can only be used, when medically necessary, to unbundle a procedure code that has been bundled related to the National Correct Coding Initiative (NCCI). Claims billed with the same procedure code two or more times for the same date of service should be submitted with the appropriate repeat procedure modifier rather than using modifier -59. Multiple Procedure Modifiers -76 and -91, Modifier -76 is used to report a service or procedure that was repeated by the same practitioner subsequent to the original service or procedure. Modifier -91 is used to report repeat laboratory tests or studies performed on the same day on the same patient. Modifiers -76 and -91 do not replace modifiers such as -RT, -LT, -50, -E1-E4, -FA, -F1-F9, -TA, and -T1-T9. If billing a procedure code two or more times for the same date of service, the claim should be submitted with the procedure code listed on one line without the -76/-91 modifier and each subsequent procedure listed on a separate line with the -76/-91 modifier. My question is... does this apply to same procedure codes done on different vessels in the same setting (which is so common in IR)? For example, a superior mesenteric artery was selected and imaged, and at the same setting the inferior mesenteric artery was selected and imaged, resulting in two procedure codes of 75726. Would I append a -59 or a -76 modifier now?