Knowledge Base

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Aspiration Thrombectomy

Laser catheter SFA, popliteal, tibioperoneal trunk. Angioplasty of the left popliteal artery. Aspiration thrombectomy of the left popliteal and left peronal/left tibioperoneal trunk arteries was then performed using a Pronto LP aspiration catheter. Is it okay to code the thrombectomy with atherectomy?

Embolization of Vein Branches off FP/SVBPG

For the following example, which is the correct code to report? 37241 or 37242? "Patient has in place a right common femoral artery to below-knee tibioperoneal trunk insitu great saphenous vein bypass, which appears patent. Several areas of enlarged tributary veins emerge from within the proximal, mid, and distal thigh, providing rapid flow of contrast into the venous system. These appear to be filling antegrade from the bypass. The anterior tibial artery, beyond the anastamosis, was in need of revascularization; however, it could not be accessed. A prograde catheter was advanced down into the bypass and selective access into a tributary vein branch off the insitu conduit was obtained. Coil embolization x three coils was performed using 2 x 20, 2 x 40, and 2 x 40 coils into different vein branches. These coils are under arterial pressure and were accessed through the arterial system, but as an insitu vein, it is connected to the venous system."

Cone CT

Can code 76380 be added to the interventional coding for the following? "IVCgram with complex retrieval of IVC filter requiring dissection. Post retrieval cavagram and cone CT without contrast demonstrate a single fractured filter leg as seen on cone CT and with fluoroscopy."

Cerebral Angiogram with Embolization

"Cavernous carotid artery aneurysm was found on CTA. Therefore, selective catheter was placed on right internal carotid artery, and cerebral angiogram was confirmed aneurysm. Catheter was then navigated into the right middle cerebral artery, and Pipeline embolization device was placed across the neck of the aneurysm. Angiogram showed endoleak. So the second pipeline embolization device was placed." Can I report code 36224 along with 61624, 36217, and 75894? Or, should I use codes 36224 and 61624 only?

Epicardial Lead Removal Only

"In 2012, patient had left mini-thoracotomy and placement of epicardial pacing system; however, the place where these leads were attached to the pacemaker generator was infected. In view of this, in October 2014, the leads were truncated at the point where they were entering the pericardial space, removing the remaining part of the leads towards the pacemaker generator as well as the generator itself. This admission, patient was temporized with a transvenous pacemaker system from the neck and was sent to Cardiothoracic Surgery for placement of epicardial leads. Upon performing median sternotomy, we noted significant adhesions inside of the pericardial space from the previous opening of the pericardium. These adhesions were carefully taken down to the point where I was able to identify 3 epicardial leads that were placed before and were truncated at the level of the entry into the pericardial space. These were carefully released and removed and sent to the pathology." The only code I am coming up with is 33999 (in addition to 33202/33221-51, implant report not attached).

75625 vs. 75630

"Patient with aortic stent graft in to evaluate for endoleak. From right CFA, catheter was advanced over a wire into proximal abdominal aorta cephalad to patient’s graft. Carbon dioxide aortogram performed. Catheter was withdrawn into the graft and aortograms performed in different projections. Selective right internal iliac arteriogram was then performed. Left CFA was accessed and catheter advanced into the left internal iliac artery for selective arteriogram. These demonstrated small endoleak at base of aneurysm below the graft bifurcation." Codes 36245-50, 75736, 75736-XS, and 75625 were assigned. As patient already has a known aneurysm treated with stent graft, would the aortogram be reported with code 75625 or 75630?

Defibrillator RV lead replacement due to defect with repair of the RA lead

"Patient admitted due to multiple shock from defibrillator and deterioration of the insulation and exposed part of the RV conduction wire. After testing, the decision was made to implant a new RV lead and repair the old lead with silicone. A new RV lead was advanced to the right atrium transvenous and then positioned under fluoroscopic guidance with the tip in the mid right ventricular septum. Attention was then turned to repairing the exposed portion of the right ventricular lead. First all 3 pins were capped with silicone caps, which were tied in place. The exposed part of the lead was then covered with a silicone tube, the medical adhesive silicone was placed inside the tube, and the tube was closed with 2-0 silk ties at approximately 3 cm intervals. The right atrial lead was repaired in a similar fashion. The old atrial lead and the new RV lead were reattached to the old defibrillator. The leads were then checked through the device. The device with the capped RV lead was placed in the pocket and the wound was closed." Would you report codes 33216 and 33218?

V45.82

I am finding little reference for the use of this code. Would you use V45.82 if the provider documents history of stent or PCI? Can it only be reported if the exact word "angioplasty" is dictated and at no other time?

Vertebral Body Biopsy at Two Levels

The patient had breast cancer with multiple vertebral lesions. The physician biopsied the L1 and L2 vertebral bodies using two different access sites. Would you report code 20225 twice? One of the coders is saying that we should only code one biopsy since it is a contiguous site and it was probably done just to ensure a proper specimen. We would like your opinion.

LHC Documentation

If aortic pressure is documented, but not the ventricular pressure, can you still bill code 93458? We need to understand exactly what documentation is required to bill left heart catheterization code 93458.

Lead Fracture

We have a patient who presented with an existing dual chamber ICD for an upgrade to a biventricular ICD. The LV lead was inserted, but after the insertion this lead was accidentally damaged with the slitter catheter. This new LV lead was then removed, and a new LV lead was inserted. Do we code for a lead removal in this case or just stick with the code for the addition of the LV lead (33225) since it was all the same operative episode?

Cystoscopy with insertion of an occlusion balloon catheter for PCNL

I'm not sure what code would be appropriate for cystoscopy with insertion of an occlusion balloon catheter(52005 vs. 53899). "The urologist performs this prior to the patient going to IR for percutaneous nephrostomy tract dilation. The interventionalist manipulates the ureteral balloon cath, positioning it near the UPF, and the balloon is inflated. Contrast and air are injected, and the collecting system is opacified and distended. Tract is dilated (50395-59), and case goes back to urologist where he does the percutaneous endoscopic nephrolithotripsy and nephrolithotomy (50080, 50081). Then the interventionalist places a double-J ureteral stent and a nephrostomy tube (50393-59, 50392-59). The following day a percutaneous nephrostogram is done to evaluate integrity of right collecting system and ureteral stent function. No obstruction was noted, so removal of the neph tube was done (50394??, 50389)." The 70000 codes are picked up by the chargemaster.

Brachiocephalic Artery

I have a case in which the catheter was placed in the right brachiocephalic artery and documented as below. "Right brachiocephalic artery: Cervical view: The catheter was advanced into the right brachiocephalic artery, and angiography was performed over the cervical region. The cervical view of the right brachiocephalic artery shows tortuous origin of the right common carotid artery and tortuous origin of the right subclavian artery. The origin of the right vertebral artery is not well visualized. There is no significant steno-occlusive disease noted." If the left subclavian was also selected and the left vertebral was viewed and documented, would I only report code 36225 (unilateral)? Or would I also be able to report code 36221 for the right side? 

Contrast Echo

How would we bill for Definity administered as contrast during a non-stress echo? Code 93352 is defined as used during a stress echo, but they did not perform the stress portion and they used Definity instead of doing a bubble study. Would 93352 still be the correct code in addition to 93306?

Angiography with Laser, ICD-10

I came across ICD-10 code B210110, Fluoroscopy of single coronary artery using low osmolar contrast, laser, intraoperative. In which scenario is laser used for angiogram? If it is for atherectomy or thrombectomy, I would think it should be an additional code instead of angiogram with laser.

Branches of the LAD

In the left anterior descending (LAD), is the left posterior descending artery (LPDA) considered an additional branch in coding? Or are only the diagonals of the LAD considered additional branches?

Coding Both Bone Marrow Aspiration and Bone Marrow Core Biopsy

According to the CPT Assistant March 2015, when both bone marrow aspiration and bone marrow biopsy of the same site are performed we can report both codes 38221 and 38220. Since there is an NCCI edit, can we use a -59 modifier to override this? Please clarify.

Biventricular Pacemaker Gen C/Out

Our physician performed a biventricular pacemaker generator change. He also inserted a new right ventricular lead and capped the old one. I reported codes 33229 and 33216; however, code 33216 is being denied. Maybe I am not seeing what is a simple answer. Could you please assist?

Removal of Previously Placed Occluded Graft

We could use help on coding for the removal of the previous placed occluded graft. "Procedure: The common femoral, the superficial femoral, and profunda femoris arteries were dissected first on the right and then on the left. The femoral-femoral crossover bypass was dissected. The bypass was found occluded. The patient had an excellent pulse on the right side, but no palpable pulse on the left side. We cross-clamped first on the right side the distal external iliac artery, the profunda femoris, and the superficial femoral artery. We transected the femoral-femoral bypass that was occluded, and excised as much graft tissue as possible so that we had a good inflow through a wide opening in the right common femoral artery. On the left side, an identical procedure was performed of the occluded superficial femoral and profunda femoris artery. We transected the femoral-femoral crossover bypass. We almost completely excised the old graft that was well incorporated. It had no evidence of infection."

Midline Catheters

We are confused on what CPT and ICD-9 codes should be used for placement of a midline catheter. We were using code 36000, but our auditor recommends code 36569-74 (local anesthesia is used) based on CPT Assistant September 2014. The intent is to place a midline, not a PICC, so there is some confusion as to why code 36000 isn't appropriate. Also, wouldn't we change 38.97 to 38.99 as well, since these are not in the central circulation? Here is an example of our dictations: "An appropriate arm vein for line access in the upper arm was widely patent, and a hardcopy ultrasound image was recorded. 1% lidocaine was used for local anesthesia. Using ultrasound guidance, real-time visualization of midline needle entry was used to gain access to the patent right basilic vein above the antecubital fossa. The midline was deployed and was flushed with saline and fixed to the skin. Tip of the midline catheter lies in the peripheral venous circulation distal to the axillary vein. IMPRESSION: Successful right 18-gauge midline placement with use of real-time ultrasound."

Midline Catheter Placement

What is the appropriate CPT code for a midline catheter placement?

Stent for Dialysis

What is the appropriate code for non-coronary stent replacement performed on a dialysis patient?

Pericardial Window

What is the appropriate code for the creation of pericardial window with biopsy?

Fluoroscopic Guided Injection for CT Myelogram

Patient goes to X-ray department for fluoro-guided injection for myelogram, then to CT for spinal exam. Code 62284 bundles 77003 per hospital NCCI edits. Should X-ray only report code 62284 and not 77003?

Pecutaneous Gallbladder Aspiration

I have read the guidance for use of code 10160 when there is not site a specific code for aspiration of abscess, but with our Medicare carrier (NGS) they do not allow for coverage for the dx's that I usually receive for percutaneous aspiration of the gallbladder. I have therefore been using the unlisted biliary tract CPT code. What would you recommend for this scenario? Usually the dx is acute cholecystitis and the providers usually state that no catheter was to be placed.

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