Knowledge Base

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AV fistula intervention with selective catheterization and angiogram of radial artery

I'm not sure if this is reported with codes 36147, 35475, and 75962, or if there is more to code for the radial artery cath and imaging. What are your thoughts? "Percutaneous retrograde puncture of the left forearm arteriovenous fistula was then performed at the level of the upper forearm with a single wall arterial entry needle. A fistulogram was then obtained. There was a focal stenosis at the arteriovenous anastomosis. This was crossed with a Glidewire. A Bernstein catheter was advanced selectively into the radial artery, and a selective radial artery angiogram was obtained. A 3 x 30 mm eV3 EverCross balloon was advanced over the wire and positioned across the arteriovenous anastomosis. The balloon was inflated to its nominal pressure, and the inflation was maintained for 2 minutes and repeated twice. Completion angiogram showed an excellent result with a widely patent arteriovenous anastomosis."

76937 Documentation

Our physicians use a variety of wording when it comes to the permanent recording and reporting of code 76937. Evaluating the access site, documenting patency, and real-time needle entry is usually not an issue; however, they will document things like "a permanent still image of wire position was archived", "ultrasound documented wire position", or "I advanced wire and documented wire position". Wire placement/position?? "Documented" doesn't necessarily mean saved and stored in my opinion. Are these acceptable examples of permanent recording and reporting?

Frequency Guidelines for Cardiac Rhythm Evaluation

We have been told by the pacemaker rep that, if we see the patient in the office and provide a pacemaker or AICD check and make changes, we can still bill the remote check every 91 days. However, we are receiving denials for one of the checks for frequency issues. Can you clarify if we can bill the mix of device checks in person with remote device checks, or will each check bump out a new time frame that the next check can be done?

Pacemakers/ICD's, Bi-Vent, and Venography

I have some physicians who insist on billing code 33224 along with codes 36005, 75820, and 75860. My understanding is that you have to use venography to see the proper placement, so it would be inappropriate to code additionally. I have also explained that code 75860 is not intended for the "coronary sinus", but I still hear arguments. Can you clarify please?

Hypogastric Coil Embolization and Stenting

Please advise if codes 37242, 34900, 75954, and 36200-50 are appropriate for the following: "Sheath was inserted into the right SFA and left SFA. Pre-operative imaging demonstrated two primary outflow branches from the right hypogastric aneurysm. We were able to advance a wire from the ipsilateral groin into the right hypogastric artery aneurysm, and, fortunately, this wire passed easily into the primary outflow branch. Nine 8 mm x 4 cm Tornado coils were deployed into the branch. Completion angiogram showed small type II endoleak. Left hypogastric aneurysm was stented into primary outflow branch. There was another small endoleak, so we chose a Gore Excluder limb stent from right common iliac to the external iliac, past the origin of hypogastric artery. Second stent was placed slightly above aortic bifurcation to complete perfect seal."

His Bundle Lead in CRT-D Devices

I have a physician who is wanting to know how to report His bundle lead in CRT-D therapy cases. He is placing three leads: 1) RA in RA port, 2) RV in RV port, and 3) His Bundle lead in the LV port. Codes 33225 and 33224 both describe insertion of pacing leads for left ventricular pacing, but these codes do not seem to fit our physician's situation, as he is inserting leads into the His bundle. What are your thoughts?

Separate reporting of external iliac stent with endovascular AAA

If the physician places a stent in a 50% external iliac artery narrowing because the narrowing is causing difficulty passing the AAA endograft, can the stent placement in the external iliac be reported?

Mechanical Thrombectomy, Intracranial

We've noticed that on the 2016 APC file, new code 61645 for intracranial mechanical thrombectomy/infusion for thrombolysis is assigned status indicator E (non-covered for Medicare). It is on the 2016 physician fee schedule, so it seems like an error on the APC file. Also, would 03CG3ZZ be the correct ICD-10-PCS code for intracranial thrombectomy?

2016 CPT Codes 61650 and 61651

How do you report the new codes for a nitroglycerin spasmolytic procedure? The description is for prolonged service and does not fit what we are doing.

CPT 93050

What can you tell us about code 93050?

MR Lymphangiography

Is there a separate code for billing an MRI lymphangiogram? The radiologist performed an MRI with and without contrast, along with MIPS. Exam is being performed for pre-surgical planning (patient has left leg lymphedema).

Excision of Forearm Venous Aneurysm

I'm having a hard time locating an exact CPT code for this procedure, and I am wondering if I should use unlisted code 37799. "The patient's venous aneurysm was marked in the erect position. The skin overlying the venous aneurysm was infiltrated with 1% lidocaine with epinephrine. It was incised with a #15 blade. The aneurysm was dissected from the surrounding soft tissue. The branch of the basilica vein, from which the aneurysm emenated, was ligated with 2-0 silk ties proximal and distal to the aneurysm. The skin was closed with 3-0 vicryl suture in a subcuticular fashion. The incision was reinforced with steri strips, and the wound was dressed." If the unlisted code should be used, what procedure is it comparable to? For pricing purposes?

E&M for Purse-string Suture

Consultation was requested regarding patient with prolonged bleeding from AV fistula after dialysis. Patient was seen in the ED – persistent bleeding from fistula’s single puncture site. There was no ulceration or infection. Physician placed a single purse-string suture to control bleeding. Is there enough here to code a simple wound repair, or would you code an E&M visit?

Right Lower Extremity Angiogram and 3rd Order Catheterization Right SFA

What codes would l use for a right lower extremity angiogram and a third order catheterization right SFA? Patient also had an angioplasty of right lower extremity vascular graft with a follow-up angiography.

Endovenotomy

Please advise on the proper codes for this procedure. "Operation performed: Open exploration, left common femoral vein, femoral profunda, femoris vein with endovenectomy of femoral vein. Construction of arteriovenous fistula between the left SFA and femoral vein with reversed anterior accessory saphenous vein. Bilateral lower extremity venogram and inferior vena cavogram. Open angioplasty of the left common femoral vein, external and common iliac veins, and inferior vena cava. Double-barrel stent placement of the para renal inferior vena cava with Palmaz open stent placement from the left and percutaneous stent placement from the right." So far I'm thinking I will need to use an unlisted code for the endovenectomy. I'm not sure about the AVF since there was no bypass performed. Any advise and help would be greatly appreciated.

3D Mammography

Will you please review the documentation below and advise on appropriate coding? "Patient is positioned in Selenia Dimensions Affirm stereotactic biopsy system (this is an attachment that goes on our Selenia Dimensions Tomosynthesis Mammography system). A tomosynthesis image is taken and target confirmed. Biopsy needle put into position in the patient’s breast. Stereotactic 2D pre-fire images acquired. Biopsy device is advanced further into the breast (fired). Stereotactic post-fire images acquired to confirm position of biopsy needle. Tissue specimen was obtained. Specimen imaging was performed (as indicated) on separate mammography unit. Biopsy clip was deployed. Post biopsy image was taken to confirm clip has deployed. This is done either 2D or 3D. Two-view tomosynthesis combo (2D + 3D) mammogram (full field image) performed to confirm clip placement, and area of target was biopsied."

Excision of AVF

We have a patient who had an ulcerated left AVF. We ligated the fistula, and she had further issues with the wound healing after the ligation surgery. She came in for her new access in the right arm and had foul smelling drainage from the open wound in the left arm. Decision was made to debride the wound and excise the portion of the AVF that contained the infected hematoma and to create the new AVF in the right arm. We did the AVF creation in the right upper extremity. My concern is how to code the excision/debridement. This was an AVF, not graft, so I don’t feel as though code 35903 would be accurate. I also don’t feel as though a debridement code or 10180 would cover the amount of work actually done. I don’t think I like a revision code either, because they don’t intend on using the AVF. I would appreciate your input!

Can I bill a femoral cutdown , aortogram w/ bilateral iliofemoral arteriogram with the placement of stent femoral artery?

I believe I can only bill code 37226 with 75630 if decision to perform intervention after iliofemoral arteriogram. No other codes. Is this correct?

50390 with 74425 in 2016

I just completed your 2016 updates webinar, and I understand that there are new nephrostogram and pyelogram codes that bundle diagnostic imaging. However, I noticed that in the 2016 codebook, under code 50390, it still directs the coder to add code 74425 (urography) to the 50390 injection code. I assume this is not for a diagnostic study. Under what circumstances or in what scenario in 2016 would you use code 50390 with 74425?

Aspiration Thrombectomy

"The physician performs a diagnostic angiography of the left lower extremity (75710-59) and then decides to place stents in the mid, distal, and proximal SFA (37226-LT). After this he performs a confirmatory angio and determines there is thrombus material in the posterior tibial and peroneal arteries. He then performs a suction thrombectomy, which removes the thrombus." I am unsure how to code the thrombectomy, as it was not mechanical and it is in a different vessel territory than the SFA stents. Is unlisted code 37799 my only option here, or is this not even billable?

Leg Shunt Angioplasty

Please advise on the CPT codes applicable to this procedure. "Operation: Patient has had problems with dialyzing on the right groin graft and is undergoing AV fistulogram. Procedure performed is right groin fistulogram, PTA, stenosis of arterial and venous anastomoses. Patient heparinized. A 6 mm x 4 cm balloon was used to dilate arterial anastomosis. Second sheath in venous limb and performed angioplasty of venous anastamosis with 6 mm balloon and then with 7 mm ballooon. After completing, fistula appeared widely patent. Sheaths were removed and direct pressure applied." 

Coronary Artery Bypass Grafts

Our surgeon assisted on a CABG, and primary surgeon coded CABG (3+1) 33533 and LIMA 33519. Our surgeon thought it would be CABG (x4) 33536 and Lima 33522. "Procedure: Coronary artery bypass grafting x 4 with LIMA to LAD, vein graft to the diagonal artery, vein graft to the second obtuse marginal artery and vein graft to the LV branch of the right coronary artery. Saphenous vein graft harvested in L leg. Simultaneously, sternotomy was performed..Bypass was initiated. Target vessels identified and marked. Aorta was cross-clamped...The LV branch was nice target over 1.5mm in diameter. Vein graft was anastomosed end-to-end; R coronary artery and posterior descending aorta was severely and diffusely calcified. The vein graft to LV branch of R coronary artery anastomosed to aorta..Marginal vessel was exposed. Vein graft was anastomosed to this vessel which on small side, 1.5cm. Vein graft was then anastomosed over diagonal vessel, also small, 1.5cm LIMA was anastomosed to LAD beyond its midportion. LAD was again quite small, 1.5 cm...anastomosis sewn, etc..."

Infrarenal aortic resection with graft reconstruction

Physican performs infrarenal aortic resection with aortic reconstruction with homograft (end-to-end anastomosis) and IMA reimplantation for indication of infrarenal aortitis due to Clostridium septicum infection. Since the indication is infection, rather than aneurysm, pseudoaneurysm, or other occlusive disease, I'm thinking of using code 33330 for the reconstruction (insertion of graft), along with add-on code 35697 for the IMA reimplantation, but I'm having trouble locating a code for the resection. Procedure: "Aorta was clamped just below the renal arteries and at the common iliac vessels. Aorta was divided 3 cm from the left renal artery and 2 cm from the aortic bifurcation distally. The homograft was cut to length just below the renals and an end-to-end anastomosis created. Distally the left and right iliac anastomoses were completed. 4 mm punch used to create an opening in the ant wall of the aorta. 6-0 Prolene used to create an anastomosis between the IMA and the side of the aortic homograft." 

IVUS Study

Two interventionists performed separate interventions during the same case; one did 92941-RC and the other 92928-LD. Each performed IVUS on the artery they intervened on. Can each bill for an initial vessel IVUS for professional billing? 

Wire Localization of Neck Mass

Would codes 21899 (unlisted procedure, neck or thorax) and 76942 be correct to bill for a wire localization of a neck mass? The payer (UHC) has denied twice, even with the operative notes were sent, for reason "CPT code inconsistent with provider". They paid on code 76942, but not 21899. Do you know if there is instruction somewhere saying these are the appropriate codes that could be sent to insurance company that might get them to consider paying on code 21899? 

Intracranial Thrombectomy, 61645

When looking at reimbursement for 2016 codes we are finding that code 61645 (intracranial thrombectomy/thrombolysis) is showing no reimbursement for outpatient. This code is not listed on the inpatient-only list (that we could find). Is there a different CPT code we should be using for this procedure, or are we missing something?

CABG with Incomplete Documentation

"CVT SURGERY OP note Dx ASHD Angina pectoris, CAD, NSTEMI Diabetes Hypertension Hyperlipidemia Morbid Obesity Sleep apnea OP CABG x 5 Vein graft to diagonal to OM to PDA IMA to diagonal to IMA Endoscopic vein harvest right thigh Findings Good LV, vein and IMA Morbidly obese Aorta OK Moderate distal disease thin walled vessels Tolerated well Off bypass easily No inotropes very bloody counts correct. This is all my surgeon has documented can i code based on this documentation." How can I explain to my manager that I need more documentation to correctly code? Where can I find the minimum documentation requirements for procedures in CMS? Your expertise will be a great help in this.

Stent in PA Conduit

How do you code stent repair of distal artery to pulmonary artery conduit (5 mm x 15 mm Genesis bare metal stent)?

Bilateral Outflow Venograms

This one is confusing me. How should I code the following? "PROCEDURE: Outflow venograms of the upper extremities. TECHNIQUE: Using ultrasound guidance, superficial veins in the wrists bilaterally were accessed with 22 gauge Angiocath cannulas bilaterally. Segmental venograms were performed of each arm bilaterally, including forearm venograms with and without tourniquet placement cephalad to the elbow joints bilaterally. Additionally venograms were performed of the thoracic inlet during bilateral contrast injections for evaluation of the subclavian and brachiocephalic veins. On the left there is a mild to moderate small segmental narrowing underlying the left clavicle, most likely related to extrinsic compression by the overlying bone. No collateral vein formation is seen; however, minimal reflux into the left axillary veins is identified."

TIPS Insertion with Thrombectomy

Our physician did a TIPS insertion followed by venous thrombectomies in the inferior, superior, and splenic veins. Can these thrombectomy procedures be reported in addition to the TIPS procedure? I'm looking at codes 37187, 36011, and 36012 in addition to 37182. 

Single ICD Upgrade to Biventricular System

Indications CSHF, NYHA Class III, EF 10%, Chronic RV Pacing, Sustained VT. Existing single chamber ICD, placed in 2013, is replaced/upgraded with CRT-D. From your Q&A and book I understand that I should code this with 33262 and 33225, but how do we code for the added right artrial lead? 

Angiography Left Ophthalmic Artery

What is correct code for this angiography? "After informed consent the patient was brought into the angiography suite and placed supine on the angiographic table. The right groin was prepped and draped using sterile technique. Ultrasound guidance was used to evaluate the right groin site, and patency of the right femoral artery was noted. Using a 5 French micropuncture kit with ultrasound guidance under real-time visualization, the micro-puncture needle was advanced into the right femoral artery, and intravascular location of the needle tip was confirmed on ultrasound and documented in PACS. Then the provided micropuncture dilator was placed, the inner stylet removed, and the outer dilator was connected to an RHV. Multiple attempts using a 0.008" Mirage microwire and Standard Magic Microcatheter to catheterize the left ophthalmic artery were unsuccessful. The left ophthalmic artery was successfully catheterized utilizing a Synchro 10 microwire and Marathon microcatheter."

Sheath Insertion into Atrium

Is there a code for insertion of a sheath into the atrium? The surgeon performed this in preparation for the interventional folks to place a stent in the pulmonary venous confluence. "...We introduced a vascular sheath into the right atrium (open chest). The vascular sheath was secured, and the patient was transferred to the cath lab for placement of the stent in the pulmonary venous confluence. Following the placement of the stent, the chest was closed..." The reasoning was due to lack of alternative access to this area after Fontan procedure. 

Removal of FFBPG at Same Time as ABF

A patient has a fem-fem bypass graft that keeps clotting. Doctor wants to “take down” the fem-fem graft and put in an aorto-bi-femoral graft. I cannot find a code for the take-down of the graft other than removal of infected graft. This fem-fem graft is not infected. Is the take-down included in the aorto-bi-femoral graft, or would a -22 modifier be appropriate? Any suggestions?

Repair of Ventricular Perforation, S/P TAVR

How would you code the following? "A small subxiphoid incision was made and carried down in the chest. The pericardium was opened and the tamponade released with several hundred mL of red blood in the pericardium. I tried to see where this bleeding was from, but I could not see it. Therefore I opened and did a median sternotomy and explored the chest. The main perforation appeared to be on the posterior wall of the left ventricle near the second obtuse marginal artery. It was repaired with 5-0 pledgeted prolene suture. Two mediastinal chest tubes were placed. I then closed the chest with interrupted sternal wires. She was stable and taken back to ICU."

ICD-10 Status Diagnosis Z-code Z76.82

When doing a cardiac cath for pre-evaluation for organ transplant, would it be appropriate to report code Z76.82 (awaiting organ transplant) as the primary diagnosis? There is conflicting information that shows it should not be used as a PDX, but on the professional side there is nothing concrete to back that up. Understanding that patients over 40 with history of heart disease or significant smoking history are required to have this done. For example, a patient awaiting lung transplant for J60 (Coalworker's pneumoconiosis) and pulmonary fibrosis. Would you report code Z76.82 primary, or use the reason for lung transplant?

ICD-10-CM, Gunshot Wound

Our coders are trying to decide which ICD-10-CM code(s) would be best to describe a gunshot wound, and the x-ray shows the bullet or bullet fragments. If we use "open wound" there is no option for "with foreign body". Some coders are thinking "puncture" or "laceration" because they both give the option of "with foreign body". I can't find any written guidance (other than external causes). Can you please advise?

37238

Physician stents the bilateral common and external iliac and removes IVC filter using US guidance. I'm reporting codes 37238-50, 37239 x 2, 37193, and 76937. Codes 37238 and 37239 have MUEs attached. Code 37239 can only be reported twice and code 37238 can only be reported once, so I'm appending modifier -50 to code 37238. Am I doing this correctly?

Billing Chemotherapy with Fluoroscopy 96450/77003

Since we have the chemotherapy nurse administer the chemotherapy, I have not billed the chemotherapy charge on physician billing side. Is this incorrect, and I should bill the chemotherapy administration?

Tumor Imaging

We have patients who come in for tumor imaging spanning 3-4 days. Day 1 is the injection, day 2 is the first image, day 3 is the second image, and day 4 is possible third image. We are currently reporting code 78802 per image and 78803 for the SPECT. Should this be billed with code 78804?

Lariat Procedure

Is there a CPT code for left atrial appendage closure (not with implant) – Lariat procedure? Is this reported with unlisted code 33999?

Mitral Valve Replacement

Is there any new direction that has been identified regarding Q&A #6584? The physician used Sapien XT 29 valve to repair aortic valve and another to repair mitral valve. Found two more dehiscience sites after mitral valve procedure and placed two Amplatzer ductal occluders. He describes "off label utilization of valve for ting placement with possibility of pugging dehisced 2 areas around mitral valve". What is the correct coding for this case?

Uterine Artery Embolization for Placenta Accreta

If a pregnant woman has a bilateral uterine artery embolization immediately prior to a C-section/hysterectomy due to placenta accreta or placenta percreta and high risk for hemorrhage during surgery, would this be coded with 37244 or 37242?

Removal of Graft

"Patient has thrombosis of aortofemoral bypass graft. Physician performed excision of PTFE femoral-femoral bypass graft with vein patch angioplasty and repair of right common femoral artery. Then he redid right to left femoral bypass graft using cryopreserved femoral vein. The patient does have some persistent drainage from the resent surgical wound in her right thigh, therefore a decision has been made to use cryopreserved femoral vein." Can I bill code 35903 for removal of infected graft with code 35661? Please advise.

Failed CTO Crossing

In a lower extremity endovascular revascularization of a chronic total occlusion, does a device like the Crosser™ Catheter fulfill the requirements as an atherectomy device? Also, in a procedure where a Crosser™ Catheter was utilized and the occlusion could not be crossed, does the physician report the procedure with code 37225 with a -52 modifier appended, or should it be reported with code 37224?

CPT Code 35721

Can you report codes 35721 and 27364 together? Another coder thinks that because the description of code 35721 says if you do a more comprehensive procedure through the same incision site to code the more comprehensive procedure that this means the original surgical incision site. I think this means the same incision site of the femoral artery. To me, if it was the surgical incision, all codes would bundle with it and only vascular codes bundle with. Plus everything I have read says you can code them together and CPT guidelines are for more comprehensive VASCULAR procedures, not any procedure. 

Selective Catheter Placement of the T4-L3

My doctor did a selective catheter placement on the left for T4-T7 and L4. He then did a selective catheter placement on the right for T8-T12 and L1-L3. How should I code this?

Drug-Eluting Stent to RCA, OM1, and OM2

The RCA, OM1, and OM2 were all stented. Would it be appropriate (because the CIRC was not treated) to report code C9600 x 3? The descriptor states "main vessel OR branch of".

Subclavian Stent with Thoracic Aortogram

Does the documentation that follows support the following codes: 75600, 36140, 75710, and 37236? "Sheath left radial artery, retrograde catheter left brachial, left axillary, left subclavian point of high-grade stenosis. Hand injection was performed, demonstrating the 99% left subclavian stenosis. Combination angled glidewire/glide catheter traversed the stenosis and was able to get into the descending thoracic aorta. Injection performed thoracic aortogram. Passed magic torque wire through angled glide catheter then removed angled glide catheter, passing ansel sheath across the obstruction. Then advanced a balloon expandable stent into position extending out into the thoracic aorta."

77012 vs. 77013

Based on the below operative note, could 77012 and 77013 be coded together using an unbundling modifier? "The patient was placed on the CT table in the prone position. After obtaining general anesthesia, local anesthesia was obtained with 1% lidocaine. CT guidance was utilized for placement of an 18 gauge needle guide into the 2.5 cm heterogeneous mass within the upper pole of the left kidney. Once confirming satisfactory placement, multiple 18 gauge core biopsies were obtained and placed in the proper container for disposition. The needle guide was removed. Utilizing CT guidance, a radiofrequency ablation probe was advanced into the left renal mass. After confirming satisfactory placement, ablation was initiated. Radiofrequency ablation was performed, 2 separate burns for 8 minutes each. The probe was removed, and hemostasis was obtained with direct manual pressure. Post ablation CT was performed to document hemostasis."

Spinal Angiogram

How do you code for a patient who has received spinal angiograms on 10 levels (T8-L4) for a total of 20 units?

Pacemaker Lead Replacement and New Generator

Patient had a dual chamber pacemaker placed in 2009. He has had noise in his RV lead, as well as ERI of his generator. His generator was removed and a new generator inserted, and his current RV lead was capped and a new RV lead inserted. His existing RA lead was reused and attached to his new generator, as was his new RV lead. There is confusion as to whether 33207 should be coded vs. 33208, 33233. It is my understanding that 33207 should be coded based on the lead that was replaced, not on the generator (single vs. dual) system. Others feel 33208 should be coded because the patient has both an RA and an RV lead system implanted. In addition, can you please clarify if the -KX modifier should be appended to both the CPT code and the HCPCS supply code?

Upgrading a Pacemaker to a Biventricular Pacemaker

When upgrading to a biventricular pacemaker, do I charge for a new pacemaker with LV lead insertion and put a -59 modifier on the code for removal of the old pacemaker? Or do I charge for removal and replacement with biventricular pacemaker with a -59 modifier on the code for LV lead insertion? And with the second option, can I charge for the removal of the device?

Coils Looped Around Pacemaker

The doctor states he did a pocket revision, but technically he had to go in and un-wrap coils around the pacemaker. Would you consider this a lead reposition? As code 33222 has changed in definition to pocket relocation. 

Cooling Catheter

Should a cooling catheter be billed with code 36556 or an unlisted code?

Carotid endarterectomy with diagnostic carotid angiogram

"Patient came in for a right carotid endarterectomy with patch angioplasty. After completion, closure, and arousal from anesthesia, the patient was noted not to be able to move her upper extremities and had significant weakness in the left leg. Decision was made to re-explore the carotid artery. Wound was reopened and vessel examined. There was a pulse in the common, internal, and external carotid arteries, and decision was made to perform an angiogram. Contrast was injected through a butterfly needle placed in the CCA just below the patch to obtain a carotid angiogram. The CCA and ICA, as well as anterior and middle cerebral arteries, were patent. Decision was made not to reopen the patch. Incision was closed." I know to report the endarterectomy with code 35301. I am uncertain about the diagnostic carotid angiogram since it is open and there was no catheter selectively placed – just a needle directly placed in the CCA. What are your thoughts?

Peri-splenic and peri-renal abscess drainage

The patient has a peri-splenic abscess located around the spleen beneath the left hemidiaphragm. Would code 49406 be correct, as the abscess is not located within the splenic organ itself? Also, some consultants are recommending that a peri-renal abscess drainage be reported with code 49405. Since the abscess is not within the organ, wouldn't 49406 be correct? Are there any AMA references that address "peri" conditions for drainages?

WPS and Popliteal Aneurysm

With the new LCD for ICD-10, popliteal aneurysm I72.4 is not covered for 37236. It also is not covered for 37226. What do you recommend if a patient has a popliteal aneurysm and is MCR or MCR replacement in our area? The particular patient I have now is having thrombosis due to the aneurysm, but by coding guidelines it would be covered for intent, which is the aneurysm. The thrombosis is covered under 37226 if it is ok to code for thrombosis and not aneurysm. We do these all the time, this is just the first one that came up since ICD-10 and I need to be able to educate my physicians on coverage. 

Dual chamber pacemaker extraction and implantation

How would you code a dual chamber pacemaker extraction, including the leads from the left subclavian site, and reimplantation of new dual chamber pacemaker to the right subclavian site?

Stress Echo and Full Routine Echo Same Day

Can you bill a full echo (93306) and a stress echo (93351) done on the same day? We are doing a full echo, then we are stressing the patient and doing a stress echo. NCCI states a modifier is allowed. Do you have any documentation requirements for doing both on the same day? Also, would you have to have separate unique diagnosis codes for each? 

Coding for Penile Angioplasty

One of our new physicians has scheduled a case in the cath lab for penile angioplasty for erectile dysfunction. How would we code that procedure? He plans to do angiography first, then the plasty.

Two Stent Placements, Iliac Territory

I'm trying to sort out when I can charge for two stent placements in the iliac territory. Scenario 1: Patient has bridging lesions in the common and external iliac arteries. Two overlapping stents are placed. Scenario 2: patient has two non-bridging lesions in the same vessels. Two non-overlapping stents are placed. Can I report codes 37221 and 37223 for both of these scenarios?

93456 vs. 93460

This patient has CM and facility wants to bill RHC & LHC. I do not see they did an LV or crossed the Aortic Valve. Do you see something that indicates this was done? "Under ultrasound guidance a #5 French sheath was placed in the right radial artery, a #6 French sheath in the right brachial vein. Right heart catheterization was undertaken utilizing a 5 French Berman catheter. Oximetry performed. Coronary arteriography was then undertaken with multiple angulated views utilizing #5 French L 3.5 and R 4 Judkins catheters. After reviewing the films to ensure an adequate study, the catheter and sheath were removed. RESULTS: HEMODYNAMICS: Normal sinus rhythm, rate of 82. RA mean of 11. RV 41/14. Pulmonary complete wedge pressure 22. PA 41/19, mean of 30. Aorta 132/68, mean of 90. SvO2 75.1%. SaO2 92.8%. Cardiac output 6.85 L/minute. Cardiac index 3.75 L/minute/m sq. CORONARIES: He states - no atherosclerosis. Patient has Mild biventricular elevation of filling pressures with mild pulmonary HTN & preserved cardiac output."

IVUS with Two Access Points

Could you please clarify the use of 37250/75945 and 37251/75946 when two accesses are used? In the case where right and left femorals were punctured and IVUS performed of both left and right femoral veins, would both accesses allow the use of 37250/75945? Or should we use 37250/75945 for the first puncture and 37251/75946 for the additional? We do understand that in 2016 these codes are deleted and combined to a bundled code. 

CPT Codes for Insertion of Cardiohelp VAD

What would be the correct CPT code for this procedure? "Decision was made to place Cardiohelp device. Patient was undergoing CPR intermittently during this part of the procedure. Left subclavicular incision was made, and left subclavian and axillary artery was identified. This was dissected free from soft tissue attachments. Needle was inserted into the artery, and a wire was placed under fluoroscopic guidance. Wire was placed in descending aorta. Axillary artery was then dilated, and arterial cannula was placed over wire. This was positioned in the thoracic aorta. Tip was positioned in thoracic aorta under fluoro. Separately, a venous cannula was placed in the right femoral vein. This was placed percutaneously over the guidewire and placed in the right atrium under fluoro. The cannulas were then hooked up to the Cardiohelp device, and the device was turned on. Cannulas were then secured to the skin." From my research this seems more like an ECMO than a VAD. What are your thoughts?

Right Subclavian Atherosclerosis ICD-10

I am unable to locate a good ICD-10 code for right subclavian atherosclerosis. I have looked under atherosclerosis, but I'm unable to find a code that truly fits.

93458 vs. 93454

Is documentation of "no gradient across the aortic valve on pullback" sufficient to support coding a left heart catheterization? The only other documentation is "catheter placement in LV" and "LVgram deferred". No systolic, ventricular, atrial, or end-diastolic pressures are documented. Are we to assume that pressures were performed since he was able to evaluate there is no gradient? The physician documented coronary angiography as well, so the question relates to whether this should be coded as 93454 for coronaries only or 93458 coronaries with left heart cath. 

MRV and MRA

Can you report code 70544 twice if you perform an MRA and MRV of the head on the same date of service, if they are performed at two different times?

Bilateral Ureteral Obstruction

After prepped, draped, skin anesthetized w/ 1% lido w/o epi, placed in prone position under gen’l anesthesia. Using fluoro guidance a 21-g needle was advanced into RT kidney collecting system in single pass. Contrast inj 74425-RT showed hydronephrosis & hydroureter to level of bladder. 4 Fr cath was placed, 8 Fr sheath placed, 4 Fr angled cath used to gain access into bladder. 8 Fr x 24 cm ureteral stent was deployed w/ distal pigtail in bladder, proximal pigtail in RT renal pelvis, noted to function. Using fluoro guidance a 21-g needle was placed into LT kidney collecting system in single pass. Contrast inj 50390-50-XU, 74425-LT showed hydronephrosis & hydroureter to level of bladder. 4 Fr cath was placed, 8 Fr sheath placed, 4 Fr angled cath used to gain access into bladder. A long 10 Fr peel-away sheath was placed, 8 Fr x 24 cm ureteral stent placed through sheath, sheath removed w/distal pigtail in bladder, proximal in LT renal pelvis, noted to function. 50393-50, Bilateral percutaneous accesses were removed. Any other codes or modifiers needed?

Coronary CTA

I have had two cases now where one physician has performed a complete cardiac CT angio showing non-cardiac and cardiac findings including coronaries and LVEF. The next day, a complete LHC with LV angio is performed by another physician. There are similar findings on both reports, but of course the LHC has the pressures and % of blockage in each vessel. I raised the question to the department, and they said it was because they needed views that can only be obtained with the cath. Will you please advise on the indications required to perform both procedures in the same visit and confirm that we are not "double billing"? What am I missing? Why do the CT first? I have never seen this done until just recently. As always, I appreciate your guidance and expertise.

73530

When 73530 is done at time of hip surgery with films and interpretation by radiologist, would code 73530 be billed as views or as diagnostic?

Upgrade from Dual Pacemaker to Biventricular AICD

The upgrade to a biventricular AICD from a dual pacemaker leads me to codes 33230, 33233, and 33225. But this scenario is very confusing because the descriptor for 33230 says "with existing dual leads", so should I use code 33231 instead because now with the addition of the LV lead that was implanted along with the biventricular generator I have 3 total leads?

May-Thurner Syndrome in ICD-10

Would you agree that May-Thurner syndrome would be coded as I87.1 in ICD-10? Also, would other acute conditions that result from the compression be considered integral to MTS?

Coding for CAD

My physician saw a patient with atherosclerotic heart disease of native coronary artery without angina pectoris, as well as atherosclerosis of coronary artery bypass graft(s) without angina pectoris. In the ICD-9 world we were instructed to code 414.00 for this scenario. With the increased specificity in ICD-10 would it be appropriate to code both conditions, I25.10 and I25.810, when known? Another scenario: Patient has known atherosclerotic heart disease of native coronary artery without angina pectoris with a history of CABG. Patient has not undergone a heart cath since the CABG procedure, so the cardiologist does not know if the atherosclerosis has advanced into the bypass grafts or not. Would the correct codes for this scenario be I25.10 and Z95.5?

AARO with Lower Extremity Revascularization

3M Nosology is stating S&I is inclusive to lower extremity revascularization per 2015 AMA CPT Codebook, page 238, so even if a true diagnostic procedure is performed prior to intervention it is not separately coded. What would the codes be for this AARO with intervention? "The right femoral artery was entered with US guidance and permanent recording was made. An Omni flush catheter was placed in the abdominal aorta and aortography performed with runoff. The catheter was placed into the left external iliac artery and additional angiography performed, showing occlusion of the left common femoral artery. The catheter was placed into the distal SFA, and atherectomy device was utilized. Multiple runs were made of the vessel. Next, the sheath was retracted, and runoff of the RLE was performed." Would the correct code assignment be 76937, 75625, 75716, 75774, and 37225?

50390 and 50392

What is considered a confirmatory antegrade pyleogram vs. diagnostic? "The patient is pregnant with pylelonephritis and hydronephrosis by ultrasound. Using real-time ultrasound guidance, right mid pole calyx was punctured with a 21 gauge needle. Antegrade pyelogram was performed. Access was obtained into the kidney using an AccuStick system. Guidewire advanced into the ureter. 8 French nephrostomy tube was positioned with in the renal pelvis. The nephrostomy tube was sutured in place using 2-0 Ethilon. FINDINGS: ANTEGRADE PYELOGRAM: Moderate right hydronephrosis with drainage of contrast into the ureter. The distal ureter could not be visualized due to abdominal shielding. Nephrostomy Tube Placement: 8 French pigtail catheter positioned within the renal pelvis. Impression: 1. Moderate right hydronephrosis. 2. Placement of 8 French nephrostomy tube." I was thinking of reporting codes 76942, 50390, 74425, 50392, and 74475. Do you agree with coding both 50390 and 50392?

Coil Localization

How would you code coil localization? "Indication: 1.1 cm nodule rt lung (near the fissure rt middle lobe) preop coil localization requested. A pleural catheter is placed and secured (this was coded with CPT 32557). From a separate antral lateral approach site for coil localization was sterilely prepped all the way down to the pleura at the intercostal space. Unfortunately the lesion is deep to the patient's breast tissue requiring an approach through the breast . A 20 gauge Chiba needle was inserted and advanced to the periphery of the lesion. The localization coil was then partially deployed with the central aspect immediately adjacent to the lesion at the ant/sup/medial margin of the sm nodule. Needle Cobb off including the remainder of the long coil, was then withdrawn, pneumothorax enlarged with pleural air injection, and the remainder of the coil was deposited within the pleural space. Ndl removed. Pneumothorax aspirated and final CT images performed. Pleural cath left in place in case pt develops visceral pleural leak before entering OR."

Ultrasound for Vascular Access

When is it appropriate to code for ultrasound guidance (76937) when getting access to the artery or vein for either an angiography procedure or a cardiac catheterization?

33249 NCD Edit

With ICD-10 becoming effective Oct 1st, we began receiving edits that procedure code 33249 was not meeting medical necessity regardless of the fact that the -Q0 modifier was attached to the code. "938 NCD Edit: Medical necessity has not been met, as there is not a covered diagnosis present on the claim." I'm wondering if this is happening at any other facilities or if there is an error with the edit. We use the NCT# 0199140 for the ICD Registry 470.7 as a secondary diagnosis, condition code 30, and DX code Z0.06. Hope you can help us!! 

Breast Fiducial Markers

The outpatient centers want to start doing breast fiducial markers under mammography and want to use HCPCS code C9728. Would this procedure fall under the breast code 19281? 

G0364

Is code G0364 used in conjunction with 38221 billable to all insurances?

20604 vs 20600 follow up for question ID #6415

JOINT PROCEDURES (Arthrocentesis) 20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting Question: JOINT PROCEDURES (Arthrocentesis): 20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting; but what code would you use if the documentation only states under US guidance but does not mention permanent recording and reporting, do you still use the same code or can i use the code 20604-52 for reduced services or 20600 as if US was not used for this particular example. pls advise.

ICD-10-PCS Code for Temporary Balloon Occlusion of Right Interal Carotid Artery

What ICD-10-PCS code would you use for temporary balloon occlusion (TBO) of the right ICA? "Diagnostic cerebral angiogram showed right ICA aneurysm. During 40 minutes of ICA balloon test occlusion, no neurological deficits were observed."

36200, 75710-26, 36221, 36216

"Patient has known subclavian stenosis and was brought to the cath lab for an angiogram. Procedures performed: Left radial access, right common femoral artery access, thoracic aortogram, left subclavian angiogram. Multipurpose catheter imaged the left subclavian artery. Vertebral artery was also imaged. Sheath inserted into right common femoral artery. A pigtail was used to perform a thoracic aortogram concurrent with an injection on the left subclavian artery to map the entire subclavian stenosis." The report then goes into details of the findings of the left subclavian artery (which is occluded) and also the left vertebral artery (found to be enlarged). There is diffuse atheromatous disease of the aortic arch. The right common femoral artery has no significant stenosis. There was no more information on catheter placement, and the physician wants to bill codes 36200, 75710-26, 36221, and 36216 for this. I do not agree. What do you think?

Coronary Embolization

Physician performed coiling and placement of 18 mm cribiform occlude device in the large bilobed aneurysmal SVG to diagonal artery. LIMA graft and root angiography performed in conjunction. Would you use codes 37242 and 93455? For the root angiography there's nothing specifically documented other than catheter was placed and root injected. Would you add 93567?

Snare Capture Lead Fragment

Patient presents for biventricular ICD system extraction. During extraction of leads, a piece of one of the leads fractures and lodges in the innominate vein. After leads are fully extracted, physician performed snare capture of fractured lead segment. Would you consider the snare capture a separately reportable procedure with CPT 37197, or would you consider it a part of the lead extraction code 33244?

Multiple Atherectomy Procedures

How should this scenario be coded? "TAMI solution was infused intra-arterial through the sheath. Right peroneal artery was successfully catheterized, 5000 units heparin administered IV, and laser atherectomy performed within the proximal right SFA, mid popliteal artery, tibial/peroneal trunk, and peroneal artery using a 1.4 mm spectranetics laser catheter. The right anterior tibial artery was selectively catheterized, and laser atherectomy was also performed across origin and into proximal aspect of the vessel. Angioplasty was performed in the proximal right superficial femoral artery and proximal and mid right popliteal artery using a 5 mm Ultraverse balloon catheter. Follow-up arteriography was performed. Angioplasty was performed across proximal right anterior tibial artery and tibial/peroneal trunk and proximal peroneal artery using a 3 mm Ultraverse balloon catheter. Follow-up arteriography was performed." 

Thrombolytic infustion 36593 vs Port -a-cath stripping 36595

I just started coding for our IR lab, and I'm trying to understand why you can't report codes 36593 and 36595 toegther. The patient was brought to the rRadiology depart and 5mg tPA was infused over an hour. Patient was then taken to vascular lab for stripping of the tip of the port cath. Is code 36593 included in 36595 when done on the same date? I understand the CPT Codebook says they cannot be report together; I'm just trying understand why.

CHD and Melody Valve

How would we code the following? "OPERATION: 1. Right and retrograde left heart cardiac catheterization. 2. Angiography: Left internal mammary artery/left coronary artery, main pulmonary artery, aorta. 3. Balloon angioplasty of right ventricle to pulmonary artery conduit with 20 mm BIB balloon and 22 mm Vida balloon. 4. Endovascular stent placement, right ventricle - to - pulmonary artery conduit (4010 Palmaz stent on 22 mm BIB balloon). 5. Percutaneous pulmonary valve placement (Melody transcatheter valve, 24 mm Ensemble delivery system)."

Thrombectomy 37184 and angioplasty 61630

Patient with right MCA occlusion with stroke. CT with contrast demonstrates evidence of RT MCA occlusion with a large area penumbra on the perfusion imaging. Now for attempted thrombectomy and revascularization of the right middle cerebral artery. Selective right ICA and cerebral angiogram, catheter advanced up to the edge of the clot and aspirated for 60 seconds, after removing catheter there was no evidence of clot within the tube. Following mechanical thrombectomy with direct aspiration technique and stent retriever x2,we were unable to obtain revascularization(37184), most likely due to the high-grade stenosis from an atherosclerotic plaque of the distal M1 segment. There appeared to be a very firm lesion at the distal MCA consistent with possible atheroma, and at this point we advanced a balloon across the stenosis and performed transluminal balloon angioplasty (61630). This resulted in partial revascularization. Can we report both codes since thrombectomy attempted but results were not to his satisfaction then he proceeded to angioplasty of stenosis?

AP Collateral Embolization

Would I use code 37242 only once for the embolization of the RIMA and the three aortopulomonary collateral arteries that were embolized, or do I use code 37242 once for the RIMA and then again for the aortopulmonary collaterals that were embolized since it was two different sites? Do I also code for the angio that was performed during the embolization (i.e., RIMA, right subclavian artery, and right vertebral artery), or just the right vertebral artery since this is the highest branch order? Also, do I use code 93564 for the aortopulomonary angio that the physician did during the procedure? Can I code the LIMA that was performed during this procedure?

Mesocaval Shunt

Do you code a percutaneous mesocaval shunt like a TIPS? Code 37160 looks like it is for an open procedure. Is code 37182 for any percutaneous method used for a portal decompression regardless of the vessels used to do so? 

TAVR with GZ 33361

I had a provider that did a TAVR on a patient for non-FDA approved indications. I was wondering how we bill this to show the carrier that we did this procedure? Would I just bill the TAVR code with modifier -GZ?

Sclerotherapy Stomal Varices

I'm completely lost on this one. How would you code the following procedure? "The left abdomen colostomy stoma site was cleaned with Chloraprep and draped in sterile fashion. Ultrasound showed prominent varices adjacent and deep to the stoma. Local lidocaine was given and a micropuncture needle was used to access the varices. The 3 French sheath was placed and venogram was done, showing the stoma varices that subsequently drain through the inferior epigastric veins into the external iliac vein. The volume to fill the varices was about 4 cc. 2 cc of 3% sodium Sotradecol was mixed with 1 cc of contrast and 2 cc of air to make a foam mixture. While direct compression was held in bilateral groin near the epigastric veins, 4cc of the foam sclerosant was injected. Pressure was held for 5 minutes. Ultrasound showed echogenic sclerosant througout the stoma. The sheath was removed and hemostasis was achieved with direct pressure."

Balloon Test Occlusion of Septal Perforator for Septal Hypertrophy

What code/s would be appropriate for the balloon occlusion of the septal perforator in the followng case? "LHC with Dobutamine infusion for assessment of gradient performed & results documented. All vessels were patent. Next we advanced a JL4 guiding catheter and manipulated it into the left coronary artery. It was injected for an angiographic guiding projection. The angioplasty apparatus was loaded into the guiding catheter and successfully negotiated into the septal perforator. The septal perforator was occluded with a 2.25 x 12 mm balloon. Of note, heparin was given as 9000 unit bolus prior to the balloon occlusion. Performed bedside echocardiography, which revealed a larger LV outflow tract, proximal septum hypokinesis and marked lessening of the intracavitary gradient. The balloon was up for approximately 3 minutes. The procedure was then discontinued."

Billing 61624 More Than Once

Can we bill for more than one unit of 61624 when embolizing with the Pipeline device?

76937, US Guidance for Vascular Access

Can we use code 76937 if the needles we use for vascular access don't show up on the ultrasound? We are able to locate the vessel by watching its movement. 

Appropriate use of 7th character A, D and S when coding thrombosis of AV access

Does the initial encounter character "A" mean physician/patient encounter or first time patient's access has thrombosed? Does "D" mean subsequent thrombosis or subsequent physician/patient interaction? Please give example of when to use 7th character "S".

Synechiae/Disobliteration/Endophlebectomy

Per the Journal of Vascular Surgery, May 2004, "Partial obstruction of post-thrombotic veins caused by endovenous scar tissue, which creates synechiae and septae that narrow and sometimes block the lumen of a vein." We did a venous disobliteration and PTA of the iliofemoral segment of vein, with a CorMatrix patch angioplasty of the left common femoral vein, followed by construction of a left femoral vein to left common femoral artery arteriovenous fistula. This fistula was to preserve blood flow, not a dialysis fistula. How would you code this?

Acute Thrombosis ICD-10

When assigning the ICD-10 codes for occlusion of the bilateral brachiocephalic veins, right internal jugular vein, right external vein, and right subclavian vein, would they be considered acute or chronic? I'm thinking acute, as it doesn't state chronic. Please clarify.

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