Knowledge Base

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Intracardiac Echocardiography - w/out a primary procedure

A patient who previously had a Zenker procedure and Watchman implant is now scheduled for an intracardiac echocardiography (93662). I do not have a primary procedure, so would 93662 be the correct code? The physician is indicating he cannot do a TEE, and he therefore wants to bill code 93662.

Physician reuses an ICD generator

My physician explanted the RV lead and implanted a new one. He reused the RA and LV leads. The old generator was removed and reimplanted. I only coded the new lead (33216) and removal of a lead (33244), but he wants to code the removal of the generator (33241). Is the removal of the generator billable?

49185

"Patient has a pelvic lymphocele status post pigtail drainage. Patient came to IR suite. 30 ml of fluid was aspirated from cyst through the catheter. Contrast was instilled to visualize cavity. Contrast was aspirated out. 50 ml dehydrated ethanol was instilled. Patient was advised to turn every 15 min for 2 hours. The catheter was then put to gravity bag." Can I report codes 49185 (sclerotherapy of cyst) and 10160 for aspiration? Or just 49185?

ICD-10 AV Node Ablation

I have a case in which an AV node ablation was performed along with a pacemaker placement, and the pre-op and post-op diagnosis were dictated the same to reflect permanent a-fib. During the AV node ablation, the doctor dictated as achieving a complete heart block during the procedure. Is it okay to use the complete heart block as a diagnosis code since a complete heart block was created?

Aortogram with Heart Cath 75625

Our physician did an abdominal aortogram with a heart cath for an indication of "difficulty mounting catheter". Would this be considered a guiding shot? Or is this an indication justifying a separate code for a diagnostic aortogram?

BATO of Gastric Varices

Would the following be reported with codes 37241, 36011, and 36012? "Right portal vein punctured with ultrasound. Wire and catheter were passed into superior mesenteric vein. Contrast injection demonstrated a dilated left gastric vein feeding fundal varicosities and a gastrorenal shunt. Catheter was placed into gastric vein. Contrast was reinjected, confirming the presence of gastric varices. The right common femoral was punctured. A catheter was placed into the left renal vein. A directional catheter was placed at the origin of the gastrorenal shunt. Multiple attempts at placing an occlusion balloon into the origin were unsuccessful. A directional catheter was placed deep within the gastric vein. A balloon occlusion catheter was placed through directional catheter into the gastro vein. Onyx18 was injected, filling the varices in the fundus of the stomach. The Onyx was injected until a small amount was seen to opacify the large varices near the distal end of the gastrorenal shunt. The balloon was removed and contrast reinjected through directional catheter, confirming occlusion of gastric vein."

TAVR Percutaneous vs. Open

Patient had a TAVR procedure, and the valve was delivered percutaneously (33361). The large bore sheath was removed at the end of the case, and there was leaking around the femoral artery. Therefore, a femoral cutdown was done and the vessel repaired with suture. Should this be billed as open (33362)? Or should codes 33361, 34812, and 35226 be reported?

Subclavian Embolization

Would the following be reported with code 37242? "Patient has Kommerell diverticulum and is being prepped for thoracic endograft. Status post carotid subclavian bypass for treatment of dysphagia lusorm with aberrant subclavian artery. Here now for plug occlusion of the right subclavian. The pigtail catheter was exchanged for a vertebral catheter, which was used to selectively cannulate the aberrant right subclavian artery in its midportion. This catheter was exchanged for a 6 French flexor sheath, which was positioned in the mid right subclavian artery proximally to the vertebral artery. We then placed an 8 x 7 mm and 10 x 7 mm Amplatzer plug occluders in the proximal subclavian artery proximal to the vertebral artery."

Reduction Atrioplasty

Can we get coding assistance with the following? "During the time of reperfusion, a large swath of right atrium was then resected on the posterior aspect of the incision keeping this short of the crista terminalis. The right atrium was closed with a running double-layer 4-0 Prolene suture. We rewarmed to normothermia and then came off bypass."

76377

ER patient had CT head, CT cervical, CT chest, and CT abdomen and pelvis. Code 76377 was used for lumbar and thoracic findings, so there are 2 charges for 76377. If we can only report one 76377,  what can be billed for both the lumbar and thoracic regions documented findings? The radiologists feel the scanners are very good to detect the needed information on the CT of chest and abdomen, for the lumbar and thoracic region. What are your thoughts? We reported codes 76377 x 2, 71260, 72125, 74177, and 70450.

Clarification on 33210 vs. 33216

I need clarification on a previously answered question regarding 33210 vs. 33216. "Patient presents to ER with CHB and ventricular escape 25 beats a min. He’s temporized on IV dopamine, which was started emergently. A permanent screw-in pacemaker lead was placed temporarily in a patient who did not have a previous implanted device (no infection). The lead was temporarily attached to an external device, after which the lead was removed 4 days later, and a brand new device and leads were implanted (same setting)." Coding suggestions? I was thinking of coding 33216 for permanent screw in PM lead for first procedure and then 33249 and 33234 for second procedure. Is code 33216 only appropriate to report when a patient already has a device placed and the sole purpose for the lead placement was for infection?

Verbal Orders

Could we accept verbal orders while following CMS guidelines? For example, we have an order for a CT of the abdomen from the ordering physician. CT is performed, and now our physician says we need to do a MRI of the abdomen, so we call the ordering physician and get a verbal order. Is that acceptable? What is the protocol for verbal orders?

Multilevel Blood Patch

"Successful multilevel high volume autologous epidural blood patching. Using fluoroscopic guidance, three 20 gauge x 3.5 inch Touhy needles were localized to the dorsal epidural space at the L2/3, T9/10, and T3/4 levels. Positioning of the needles was documented radiographically and with injection of contrast material. Subsequently, a total of 22 cc of autologous blood obtained. A sterile fashion was injected into the dorsal epidural space. 6 cc at the T3/4 level, 6 cc at the T9/10 level and 10 cc at the L2/3 level. At each level, injection of blood was stopped when the patient felt discomfort. The needles were removed, and hemostasis was achieved with manual compression." Should code 62273 be reported x 3 or only once? 

G0463

What are the requirements for billing code G0463 in a facility setting?

2017 Moderate Sedation

If a procedure is being done with anesthesia, the moderate sedation codes would not also be used, would they?

Embolization of LV Pseudoaneurysm

Patient with prior cardiac trauma has developed a left ventricular pseudoaneurysm, which is treated by coil embolization. Would this be reported with code 33999 or 37242?

Billing for Fluoroscopic Guidance by Surgeon

There seems to be some confusion in our practice for billing code 77001-26 for port-a-cath insertion. If the surgeon uses fluoroscopic guidance stated in his note, can he bill for it without dictating a report? Our radiologist also bills for fluoroscopic guidance with a report. Can they both bill for it?

ClariVein vs. VenaSeal

What code do you use for a VenaSeal procedure? I have used unlisted code 37799 in the past for this. However, with the introduction of the new mechanochemical ablation codes in 2017, I believe that we could use code 36473-52 instead of the unlisted code. VenaSeal is similar to ClariVein with the exception of the mechanical component, therefore a reduced service would make sense, but I have not found any recommendations as of yet.

Pacemaker Laser Lead Removal

Our hospital recently started performing laser lead removal in the cath lab. With the use of laser, I understand there are no additional codes required, correct? We also use surgery standby and perfusion standby. Are additional charges allowed for those? Also, does code 33249 cover all of the following procedures? 1) Laser lead extraction of right ventricular pacemaker lead. 2) Laser lead extraction of right atrial pacemaker lead. 3) Pacemaker generator removal. 4) New right atrial pacemaker lead placement. 5) New right ventricular ICD lead placement. 6) New biventricular ICD generator to existing CS lead. 

Correct Modifiers for 61645 and 75710

Our patient had a cerebral arteriogram and thrombectomy of the left internal artery and middle cerebral artery. We coded as follows: 61645-LT, 36224-59RT, 36225-59LT, and 75710-26/59/76. Codes 61645 and 75710 were denied because the modifiers were inconsistent or missing. Please help us understand what we are missing.

JP Blake Drain

Which code do we use for the insertion of the drain, and which code for the removal?

Biventricular ICD Removal

What codes would you bill for a complete biventricular ICD removal? Patient was having complications, so the physician removed the generator, RV ICD lead, RA ICD lead, and LV ICD lead without replacement of anything. Is the LV lead removal billable? If so, what code would you suggest?

CT Guided Percutaneous Gastrostomy Tube Placement

While code 49440 is for fluoroscopically-guided G-tube placement, how would we code this if only CT guidance is used?

Reporting Pro & Tech

If a service is performed on one day, but the physician reads it on the following day, do we need to bill the pro and tech portions with different dates of service?

Coding Use of Bone Marrow Aspirate to Aid Wound Healing

I need help coding the injection of bone marrow aspirate into a non-healing wound. I've searched the Knowledge Base and couldn't find the answer. Here is an excerpt from the operative report. "Through two punctures in the anterior superior iliac spine area, harvest needles were applied to the bone marrow, and 120 mL of aspirate was removed from each iliac crest. This was spun down to clotted autograft material. After the autograft was formulated in syringes, we implanted the autograft proximal to the wound about the right heel into healthy tissue to effect late closure or delayed primary closure by secondary intention of the wound. In addition, we injected several areas along the anterior tibial and posterior tibial artery at 1 inch depth, 1 mL each injection to stimulate neovascularization in a patient with severe peripheral arterial occlusive disease." What would be the appropriate code for this?

93015

For our doctors' office, if one physician is supervising and another does the report, are we to split up the codes? Where one will charge supervision, one for the tracing and one for the interpretation? Or since they are from the same practice, can we bill code 93015?

Stab Phlebectomy

My physician did a stab phlebectomy, bilateral, with 5 incisions on the right and 6 on the left. I know it would be coded with 37799 since it is less than 10. But, it is appropriate to use modifier -50 since there were 5 on one side and 6 on the other? Or should I use -LT and -RT modifiers?

Additional Imaging in Visceral Arteries

I know in many of the examples from your publications that after the initial basic celiac (or other visceral artery) exam the suggested coding reflects 75774 for each new more selective vessel, but what is included in that initial basic exam? In other areas of imaging (i.e., extremity), staging the imaging by shooting small sections at a time likely wouldn't be coded with 75774, so I was just wondering what makes the visceral vasculature different. Here's a hypothetical report: "Celiac axis was catheterized, followed by selective arteriogram. Next the catheter was advanced to the common hepatic, proper hepatic, left hepatic, right hepatic, and right hepatic superior segment arteries for selective arteriograms."

2017 Conscious Sedation

The CPT Codebook contains a chart to assist with coding physician time. For example, 68-82 minutes you would code 99152 + 99153 x 4 (for 5 years or older), then 83 minutes or longer it states, "Add 99153." The "or longer" sounds like the timing ended. Does this mean you can only charge each additional 15 minutes 5 times maximum?

Renal Alcohol Ablation

Patient has metastatic transitional renal cell carcinoma. Can code 49185 be used for main renal alcohol ablation?

33210 versus 33216

Recently our physicians have started placing a C1898 lead as a temporary pacing lead, attached to an external single-chamber pacemaker. Can you advise us which code is more accurate? Code 33210 or 33216? Also, in what circumstance specifically would you use code 33216 instead of 33210?

Sacral Catheter Placement

I have a question on the new code for 2017. In-house patient needed to have infusion, so the interventional radiologist placed a catheter in the sacral epidural space with fluoroscopy guidance. Catheter was left for future infusion, but radiologist did not give drug. Local anesthesia was given by needle injection to the same space prior to the catheter placement. Can I report code 62327?

AV Fistula of Leg

When the physician has no other option to place a fistula in the arms, and he decides to do a direct in the leg from the common femoral vein to common femoral artery, should an unlisted code be used? If so, should we have the code mirrored to 36821?

35476

Can a venous angioplasty be coded when the report only indicates that the patient has thrombus or occlusion of the extremity vein(s)? I am seeing a lot of reports where they are doing extremity venous angioplasties, but they are not dictating that the patient has a stenosis. Should I return the reports to the doctor to clarify? My understanding is that angioplasty can only be billed when done for stenosis.

Deep Femoral Endarterectomy

My surgeon performed an endarterectomy of TWO branches of the deep femoral artery. An incision was made on a lateral deep femoral branch and extended onto the common femoral. A second incision was made on a medial deep femoral branch. Would you code this twice with 35372 x 2?

76881 once per extremity

With code 76881, can you bill this code per each joint on each extremity (more than once per extremity)? A Physician is insisting that you can bill code 76881 once for the shoulder and then again for the elbow at the same encounter. The LCD states, "More than one complete ultrasound per joint, per extremity, in a 12-month period will be considered not medically necessary." The physician is interpreting this to mean that they can bill per joint rather than per extremity (i.e., more than one 76881 on the same extremity). Can you please help clear this up and provide an official source other than this LCD that I can refer to. I could not find an NCCI policy on this. 

IVC Filter Removal

I have always coded an encounter for removal of an IVC filter with Z46.89. Now my auditor is telling me that I should be using Z45.89. I code a lot of these, and I would really appreciate an answer. Who is right?

Fem-pop In-situ Bypass with Iliac Angioplasties

Patient has in-situ bypass (fem-pop). Patient also has angioplasty of the ipsilateral common, internal, and external iliacs. The common femoral was exposed, and dissection was carried down to the inguinal ligament. The LCFA was then dissected and controlled, then the physician exposed the distal popliteal and prepared for bypass. The physician then dissects the in-situ vein. He prepared the in-situ vein for bypass, then turned his attention to performing the endovascular part of the case. Through the exposed common femoral artery, a micropuncture needle is inserted…” and he performs angioplasty of the LCIA, LIIA, LEIA. He clamps the LCFA distally with clamp and proximally with clamp, then turns his attention back to the actually in-situ bypass. Can I bill out the in-situ bypass with the iliac angioplasties? I am saying NO, they can’t be billed. I need someone else’s opinion.

Pacemaker insertion, transvenous and epicardial

The patient has one transvenous atrial lead and two epicardial right ventricle (open subxiphoid approach) leads placed with pacemaker insertion in the same initial placement session. How would this be coded?

Popliteal Aneurysm and Revascularization

Patient has large popliteal aneurysm treated with stent graft, but also has other disease treated with atherectomy and angioplasty in the fem/pop territory. If it was just popliteal aneurysm, I would follow advice to use code 37236. However, in the setting of other interventions, how would you approach? Do you suggest reporting codes 37236 and 37225? Or would you combine all of it into code 37227?

93979 vs. 93926

I was given direction many years ago to bill code 93979 for groin duplex for pain after angiogram being veins and arteries are addressed, and it's been brought to my attention that code 93926 would be more appropriate. I attached an example of a report. "Interpretation Summary: This is a normal groin arterial duplex of the right lower extremity. Right Leg Findings CFA: 79 cm/s, triphasic. CFV: Normal exam duplex groin right. Right Leg Findings DFA: 85 cm/s, triphasic Rt. DFV: Normal SFA Prox: 139 cm/s, triphasic SFV: Normal."

Arterial Injury With Shunt and Vein Graft Repair

Patient had a gunshot wound to the thigh. Through and through injury to the femoral artery. The patient was in shock, so we only did a shunt temporarily until the patient was hemodynamically stable. Later that day we returned to the OR and did a saphenous vein harvest and interposition graft repair. I’m thinking that the initial shunt is going to be bundled with the second surgery. Due to it being an injury, I was thinking of reporting code 35256 for the second surgery. How would we decide to code from the repair of blood vessel section (35256) vs. using a bypass graft code (in this case 35556)?

Celiac Block and Neurolysis

If a celiac block (64530) is performed and the patient is observed for a period of time, then the physician proceeds with celiac neurolysis (64680), would we only bill code 64680? If the procedures occurred on two separate dates for whatever reason, would they both be billable?

33263 vs. 33264 -- CPT book and Ask Dr. Z clarification

Page 195 of the 2016 Professional Edition CPT Codebook (page 197 in 2017 book) contains a grid listing some common ICD procedures and how to code them. The last scenario listed is the conversion of an existing ICD system to a biventricular system. The codes recommended are 33225+33263 or 33264. It is my understanding that a biventricular device is always considered a multi-lead device, even if only two leads are present. This was stated in Ask Dr. Z. question #8202 of July 29th. Under what circumstances would we report code 33225 with 33263 (instead of 33264) for a biventricular upgrade per the CPT book guidance?

Lower Extremity tPA with Thrombectomy

"Venogram was performed, demonstrating segmental thrombus throughout the right SFV, as well as popliteal vein. This was followed by placement of 4 mg of tPA infused with a mechanical device within the right lower extremity venous structures from the proximal SFV to the popliteal vein. Angiogram was performed, confirming some segmental thrombus in the right SFV and popliteal vein. This was followed by placement of a thrombectomy extraction 6 French catheter. Thrombectomy was performed within the right lower extremity from the SFV to the popliteal vein." Based on this documentation, can code 37212-59 be reported with thrombectomy code 37187? Via phone discussion, the physician states that after tPA the patient is sent to post-op for an hour and then brought back for the thrombectomy. Does the "mechanical device" used for the tPA support reporting the infusion service?

L subclavian angiogram during cardiac cath

Patient presents for cardiac cath and subclavian angiogram. Indications are positive stress test, angina, vertigo, memory issues, carotid US with suspicion of subclavian stenosis. Procedure performed via right radial artery access. Catheter placed in right subclavian artery and contrast injected, revealing diffuse atherosclerotic stenosis in proximal left subclavian artery. (Cardiac cath and intervention performed without issue.) How would the left subclavian angiogram be coded? Would this be reported with code 75710-LT?

Stent placed in Lower Exteremity Vein Graft to tibal artery

A patient with a LE vein graft to tibial artery was seen in office by surgeon. US revealed an impending stenosis. Patient brought to cath lab for angiogram and possible intervention. OP report states a 99% stenosis was seen proximal to a stent in the distal vein graft. More proximal vein graft lesions and the proximal posterior tibial artery were treated with a 5 x 40 and a 5 x 20 mm balloon respectively. Pre-occlusive stenosis in the distal tibial vein graft which was successfully stented. The proximal posterior tibial artery was also angioplastied1. Procedure was coded as 75710 37230. However, WPS Indiana has denied this due to non-covered diagnosis code T82.858A stenosis of prosthetic graft entered by coding. If believe dx code is incorrect since this is not a prosthetic graft. Is it appropriate to use 37230 for stent placed within vein graft? Or should a different CPT code be used. Recommendation of dx code. HP does not mentioned claudication.

Fractional Flow Reserve Without Catheterization

The physician performs a left heart catheterization at NCP cath lab and then transfers the patient to cath lab at hospital to do 93571. Since this is an add-on code and can't be billed alone, would you bill this with unlisted code 93799? The physician thinks that 93571-26-XE will get us paid for Medicare, and for commerical insurance to bill CORS only with 93571 to get paid. What are your thoughts?

Codes for Spinal Angio

I have findings for all the selective cath's. I'm really confused on the thyrocervical, T5's, and the LT supreme intercoastal. I find myself confused with the families when they are done with other 3622x codes. 

Cavo-tricuspid isthmus ablation

Can I report code 93655 with 93656 for cavo-tricuspid isthmus ablation? "Conclusions: 1) Apparently successful wide area circumferential ablation of the left atrium and pulmonary vein isolation. 2) Successful cavo-tricuspid isthmus ablation. Next attention was directed to the left antral region with wide area circumferential ablation, following which repeat voltage mapping again demonstrated elimination of all electrical activity. The Penta Ray catheter was then exchanged out for a Lasso catheter, and DC cardioversion was required to restore sinus rhythm. Entrance and exit block was demonstrated in each of the four pulmonary veins. Following completion of the WACA and PVI, adenosine was administered to evaluate for recurrent PV potentials and none were appreciated. Small electrograms appreciated on the posterior superior aspect of the right superior pulmonary vein were determined to be far field from the SVC. A complete EP study was performed, and no inducible tachycardia was appreciated. Given a previous history of isthmus ablation, trans-isthmus conduction time was measured and found to be over 190 ms in both directions."

Failed or billable access

I really need your help. Patient with iliac stenosis. Doctor states access is gained on the right side, and catheter is crossed over bifurcation and into the common iliac, but occlusion prevents access into the external iliac. So the doctor opens access from the left side (34812) and places a stent. Can we code the failed attempt catheter (36245) with the successful stent (37221)? I would normally code this contralateral access if diagnostic test was performed also, but in this case no angiography was documented. Could you please advise?

Upper Extremity Venous Angioplasty 35476

I have a case where they accessed the AV fistula via two access sites, completed a fistulogram, then performed angioplasty on the subclavian vein as well as the basolic vein. Would you report codes 35476/75978, 35476/75978 (for the 2nd intervention), 36147, and 36148? 

2017 Moderate Sedation Calculation with TEE and Cardioversion

My physicians are trying to determine how to calculate intraservice time when performing TEE followed by external cardioversion. I notice that internal cardioversion is on the list of codes to bill moderate sedation with, but not external cardioversion. Any guidance on how to determine start and stop time for moderate sedation for TEE and cardioversion?

Iliac Extension 34825

When placing a AAA graft, and the doctor documents iliac extension placed to the internal iliac take off, is this considered an extension? Or does it have to cross into the external iliac? I know with the FEVAR it has to extend to the external, but I didn't know about regular AAA single docking limb placements with extension if it was billable if it stopped in the common iliac.

CRT-P upgrade to CRT-D

Patient with ischemic cardiomyopathy, EF less than 35%, wide QRS (chronic right ventricular pacing), and NY Heart Assoc. class 2 to 3 symptoms who currently has CRT-P (RA and RV dual chamber). During the procedure, the physician upgraded to CRT-D and implanted LV lead. During the procedure it was also determined that the existing RV lead would be capped and a new RV lead implanted. The existing RA lead would be used with new defibrillator. We coded this as 33264 and 33225, but how would we code the insertion of the new RV lead?

Where does it end?

I am trying to figure out if the CPT definition of the anatomical extent of a dialysis shunt matches any ICD-10 definition of where the shunt begins and ends. In an earlier question (#8222) I asked if conditions relative to a dialysis shunt occurring between the arterial anastomosis and the right atrium should be coded with complication codes from the T82 series of ICD-10-CM. Sara’s answer was in the affirmative. Now I see that in the November Case of the Month, a stenosis of the Brachial vein (between the arterial anastomosis and the right atrium) in not coded with a complication code from T82, but rather with a disorder of vein code, I87.1. I would have thought that T82.858A was appropriate. I was further confused by your use of T82.898A for the venous collateral, which I have always coded with I87.8. Why is it that the second stenosis, on a direct path to the right atrium and in the same zone, is NOT considered related to the presence of the fistula? Yet, the venous collateral IS considered related to the presence of the fistula?

Transcatether Mitral Valve Replacement via Transapical Approach

What would be the proper coding for the following procedure? "The patient was then prepped and draped for transapical transcatheter mitral valve replacement. The physician will dictate all surgical aspects of the left ventricular transapical approach and closure. With the sheaths in place, we moved forward with the transcatheter mitral valve replacement via a transapical approach. The physician gained access to the left ventricular cavity with a Cook needle. A Rosen wire was then extended into the left atrium across the bioprosthetic mitral valve. We then advanced a long 7 French sheath into the left atrium. We exchanged an extra stiff Amplatz J-wire to the left atrium. An Edwards Sapien 29 mm XT bioprosthesis was malleted onto its transapical delivery system and advanced over the stiff wire. Under coaxial fluoroscopic guidance, we placed the XT transcatheter valve within the previously placed mitral valve prosthesis. Under rapid right ventricular pacing, we deployed the XT valve inside of the previously placed mitral valve prosthesis."

Abdominal Aortogram

I need some clarification on medical necessity for abdominal aortograms. Is peripheral vascular disease enough to justify an aortogram? I have been looking for aneurysm, pseudoaneurysm, abdominal bruit, aortic stenosis, and such. Please clarify what is sufficient.

ECMO

If a surgeon inserts one ECMO cannula percutaneously in the RFV and a second ECMO cannula through open cutdown in the LFA, would it be appropriate to report codes 33954 and 33952-59 during the same encounter? I see that the edit between the two codes allows for a -59 modifier, but I'm looking for clarity on whether the separate anatomic sites for insertion is sufficient to unbundle or if the cannulae would actually have to be performed by a different provider or during a different encounter to unbundle.

Staple Removal

I enter charges for a cath lab in a hospital. A lot of the cases are done on an outpatient basis. I can't come up with an appropriate charge for this, so I would appreciate your input. "The patient is an 85-year-old male who had a dual chamber pacemaker done at an outside institution who presented to my office for staple removal. However, the staple at the medial superior edge of the incision did not affix correctly, and it seemed to fold in on itself. I was unable to remove it given the tools I had in the office, so I brought him to the lab for removal. LOCAL ANESTHESIA:  Lidocaine 2% 5 ml without epinephrine. The staple was removed using two Kelly clamps to straighten out the staple to allow for removal. Octyl liquid bandage was applied over the incision afterwards. No complications." Even though the patient was brought here to do this, it still seems like something we cannot separately charge for. What are your thoughts?

Endarterectomy with fem-pop bypass

If a patient is undergoing a femoral-popliteal bypass, and the surgeon documents performing an endarterectomy of the profunda femoral artery on the ipsilateral leg, can we unbundle the endarterectomy if the intent of that endarterectomy is not to facilitate graft placement? For example, an arteriotomy is created in the common femoral artery, and endarterectomy is performed in the CFA, which is the inflow vessel (bundled), carried into the origin of the SFA, and then carried into the profunda, but in the profunda, the endarterectomy is not just at the origin into the vessel; it extends 15 cm into the profunda due to extensive underlying disease. The surgeon has dictated that the intent of the profunda endarterectomy is not to establish inflow to the graft but to remove significant disease from the profunda itself and improve the patient's long-term outcome. Would we be able to report code 35372 for the PFA endarterectomy along with the bypass graft in this scenario? Would the scenario change if a second arteriotomy was made on the PFA itself?

Denver shunt inserted by a radiologist

What documentation supports the assignment of code 49425 vs. 49418?

Code with 33881 ,33883 3884 X4?

1. endovascular repair Type II thoracoabdominal aortic aneurysm using the multi-branched stent-graft technique, with placement of branches into the left renal artery, right renal artery, celiac axis and superior mesenteric artery

Open IVC Filter Removal

I have a patient who had a failed attempt at endovascular removal of the IVC filter. One month later the patient has developed abdominal and back pain and is deemed an appropriate candidate for exploratory laparotomy and open removal of the IVC filter. Would you code the open removal as 34502 or 35221? The filter penetrated through the IVC and duodenum, which another physician stepped in to repair (44602). Does 34502 or 35221 include removal of the filter with vessel repair, or should I look to using an unlisted code?

Denver Shunt Placement and Paracentesis

A patient presented for a Denver shunt placement and had ascites removed from the peritoneal space. Is paracentesis included with the shunt placement, or can this be billed additionally? We are reporting codes 49425 and 76000 for this procedure.

CRT-P at ERI and LV macrodislodgement

Patient presents with CRT-P gen at ERI and macrodislodgement of LV lead. LV lead is removed and replaced with new LV lead. Generator is exchanged. Can you confirm the correct coding of this case?

Ventricular program stimulation was performed

Can I still charge for 93641 when the MD states: "Induction of arrhythmias for testing of defibrillator and lead system. Ventricular program stimulation was performed. There was non-sustained ventricular ectopy induced, which was sensed normally by the device." Even though he did not do DFT shock testing.If I cannot charge for this, is there another charge I can use?

Removal Central Line with Percutaneous Stitch Repair of Carotid Artery

How would you code percutaneous stitch closure repair of the left common carotid artery? "Clinical: Iatrogenic left carotid artery injury with central line insertion. Procedure: Fluoroscopy reviews the tip of the central line in the descending thoracic aorta. A wire was placed through the line, and the line was removed. Percutaneous closure of the left common carotid artery injury was carried out. Hemostasis was achieved. The suture was cute and sterile dressing was applied."

Left atrial appendage resection during MVR or Maze

I’ve advised my providers that left atrial appendage resection is not separately billable with open mitral valve procedures, per STS guidance. They feel resection of the LAA is different than ligation/plication/clipping, and should therefore be billable with mitral valve procedures. 1) Is LAA resection/amputation also inclusive in mitral valve procedures? 2) Why is LAA included in both mitral valve and Maze procedures?

Open exposure fem artery

Can you report code 34812 with lower extremity bypass? Or only when AAA is performed?

Redo thoracotomy recurrent pleural effusion

"A 4 cm skin incision was the performed. The fascia and subcutaneous tissue were entered with electrocautery obtaining hemostasis simultaneously. The pleural cavity was entered, and immediately we recognized the large pleural effusion approximately 2 L of fluid were removed from the pleural cavity. The previously created pericardial window had remained patent, and it is possible that some of the fluid was coming from that area. The lung was stuck to the chest wall. Pneumolysis wasperformed with some degree of oozing around it from the pleural cavity. Once all the fluid was evacuated, the pericardium was drained with a pigtail catheter inside the pericardial cavity, anchored to the skin with a statlock. Intercostal nerve cryolysis was performed at the level of incision manner. 2 chest tubes were then placed through the incision anchored to the skin with heavy silk and connected to a pleural evac." Pt had a pericardial window 3 days prior to this service not sure what to code. 32551? what about the pneumolysis 32124?

Cpt code 93458 and 75756 be billed together

Physician performs a left heart cath and left internal mammary angiogram. Documentation states patient has severe 3 vessel disease including the LAD,LC, and RC. The patient needs to undergo bypass surgery with LIMA to LAD,SVG to OM1,SVG to OM2 and also PDA and posterolateral. He performed a left subclavian internal mammary angiogram. Could you bill cpt code 75756 for the angiography of the internal mammary along with the heart cath 93458?

Angioplasy of Existing Stent

Patient has previous femoral artery stents that are now occluded. The physician does an angioplasty of the stent. Is that coded as a new angioplasty (37224)?

MRI Scapula

What is the correct CPT code for MRI scapula?

KX vs. SC Modifier

In instances where a biventricular pacemaker is being implanted, and the CPT codes are 33208, 33225, would a -KX or -SC modifier be appended or omitted considering the CMS article specifically states that that the information in the NCD only applies to single or dual chamber pacemakers? Or is this an instance where the we would look to the “Other” category/group list that is mentioned to not be all-inclusive? I would think that this may give us license to use the -SC modifier.

Epicardial Ablation

Is pericardial access billable when performed by a physician from a separate specialty during an ablation procedure? The physician has documented his own report for this procedure. If it is billable, what code would be used?

AV Loop Graft

Patient with lower extremity traumatic wound with need for free flap underwent popliteal artery to popliteal vein AV loop graft using the greater saphenous vein for the later creation of the free flap at a later date. Would this be reported with code 36821?

Aortic innominate/carotid bypass through sternotomy hemashield graft

I need help with this case. I'm looking at codes 33881, 33884, 75957-26, 75958-26, and 37799 for the sternotomy: aortic dissection distal to left subclavian. "Procedure: Standard sternotomy was performed, and pericardial cradle was created. Ascending aorta and arch were dissected from surrounding tissue, and the innominate and carotid were encircled with vessel loops. Proximal and distal control was established. 14 x 7 mm hemashield bifurcated graft was brought to the field. Partial occlusion clamp was placed on the aorta, and the proximal was complete in a side fashion using 5-0 prolene. We then brought the limbs under the innominate vein, and sequentially the right common carotid and innominate anastomoses were created in a end-to-end manner using 6-0 prolene."

Mediastinal bleeding, status post orthotopic heart transplantation

Which CPT code is more appropriate for the following example: 32120 or 39010? "The previous sternotomy incision was reopened. Sternal retractor was placed. There was a moderate amount of clot that was removed. Irrigation with warm saline was then performed. I identified multiple spots on both right and left pericardium that were oozing, which were controlled with cautery. There was also significant periosteal bleeding that was controlled on either side. Patient was previously packed with lap pads, which were all removed. I then directed my attention to the LVAD pocket area, which also had an area of bleeding that was controlled with cautery. I then packed the mediastinum for a period of 15 minutes to assure hemostasis, removed the packing, and was satisfied with the amount of hemostasis. I made a decision to leave one lap pad in the LVAD pocket area, which was hard to control. The sternum was then closed temporarily with three sternal wires. Skin was closed."

Right leg wound debridement with excision of skin and wound VAC placement.

I would like to know how to code this procedure and the wound VAC placement please. "Right leg wound debridement with excision of skin, subcutaneous tissue, muscle, and tendon. Wound measures 24 cm long, 7 mm wide, and 4 cm deep upon completion. Wound VAC placement. Bland devitalized anterior compartment muscle underlying the entire volume of the open wound and extending proximally about 2.5 cm under intact skin. This is debrided down to moderately viable tissue at the base of the anterior compartment. The neurovascular bundle was preserved. There was moderate bleeding at the base of the wound with subsequent hemostasis acquired and a VAC dressing is applied with excellent seal. Evaluation of flexion contraction under anesthesia reveals a distinct contracture with a 'rock' of posterior compartment scar likely resulting in the contracture. Once hemostasis was acquired, the wound was irrigated with antibiotic saline and then a VAC negative pressure dressing was brought into the field. This was applied in a 2-layer technique. This was connected to a vacuum pump."

Cutting Angioplasty with Perforation

"Under fluoroscopic guidance, the upper arm dialysis access fistula was catheterized and fistulogram was obtained. There was a greater than 50% stenosis within the mid cephalic vein that was dilated with an 8 mm angioplasty balloon and high pressure angioplasty balloon with no effect. The lesion was then dilated with a cutting balloon. Following angioplasty with a cutting balloon there was a leak identified from the cephalic vein. Multiple attempts at balloon tamponade were performed, and these were unsuccessful at controlling the leak. An 8 mm x 6 cm fluency stent graft was then placed across the leak and dilated to 8 mm. Follow-up fistulogram was obtained and showed free flow of contrast through the stent. Cephalic arch and central veins are patent. The arterial anastomosis is widely patent. There is a small pseudoaneurysm in the cephalic vein near the arterial anastomosis." I am assigning codes 36147 and 37238. Should something be stated about the perforation? If so, how should this be coded?

Exploration and Attempted Thrombectomy of AVF

Can we bill code 36831 for the attempted thrombectomy? We did pull thrombus out, it just wasn't all of it. I would love to know how you would code this. "Patient has a history of pseudoaneurysms, multiple interventions, and stents in the cephalic arch and the proximal AVF. Presents with it completely thrombosed. Incision was made, and embolectomy catheter was used to perform thrombectomy of the AVF. Fair amount of thrombus was retrieved from the mid portion as well as the pseudoaneurysms. However, unable to enclose the embolectomy catheter down towards the arterial anastomosis with the presence of a stent in the proximal segment of the AVF. Was able to direct the catheter in a retrograde fashion through the stent and was quite close to the arterial anastomosis. Stent was compressed, which made thrombectomy difficult. Thrombectomy was performed in the distal aspect of the AVF, and a small amount of backbleeding obtained. Due to difficulties advancing any further, the incision was closed. Will plan for AV graft insertion in a few weeks."

Iliopsoas Muscle Drainage

I'm having difficulty coding the following: "1% lidocaine was infiltrated into the subcutaneous tissues at the site marked for local anesthetic. Utilizing direct sonographic guidance, an 18 gauge needle was advanced into several small hypoechoic collections within the right iliopsoas muscle with approximately 1 to 2 cc of serosanguineous return."

C2623 with 37225

I have a patient that had atherectomy performed on a diseased segment in the SFA, followed by angioplasty with a drug coated balloon. This portion of the case was coded with CPT 37225 (atherectomy with or without angioplasty). Ucare has denied the claim citing MM9100 which indicates drug coated balloons C2623 should always be paired with either 37224 or 37226. They don't include 37225 as an allowable procedure code with C2623. Does this omission of 37225 from the transmittal make sense, or do you think this is a misapplication of logic? I have very clear sequence of events in the op note being atherectomy first, followed by angioplasty.

Baker Cyst Aspiration

Would you code an ultrasound-guided Baker's cyst aspiration as 20611 or 10160/76942? "Diagnosis: Right Baker's cyst. Ultrasound was used to examine the area within the right popliteal fossa area. Following infiltration with local anesthetic, a 21 gauge needle was advanced into the right Baker's cyst. Approximately 4 cc's of synovial fluid were removed with ultrasound guidance. There was no evidence of remaining fluid collection after aspiration. Images were stored for documentation."

Kissing Stents in Iliac

How are kissing stents in the iliac coded?

Toe Amputation

Is CPT 28820 correct for the procedure? Can we also bill for debridement? "Patient had a LT 1st & 2nd toe amputation on 8/15,complicated by delayed wound healing. The patient had several debridements on 8/21, 8/29, and 9/2 and 10/13/16.He was admitted on 10/13 with fever, chills, and necrotic, foul-smelling drainage from his left foot wound. He presents for planned 3rd toe amputation and further debridement of his wound. Using a 15 blade a circumferential incision was made to include left 3rd toe. Necrotic tissue was debrided from the wound edges as well as the wound bed. The incision was then carried down to the 3rd metatarsal bone using sharp dissection. The metatarsopharyngeal joint was then identified and the toe was disarticulated. Using a bone rongeur the head of the 3rd metatarsal was removed. The bone was soft and fell apart with debridement. Bone tissue samples were sent for culture. Further debridement was performed until healthy bone tissue was reached. The wound was then irrigated using normal saline. Wound measured approximately 12.0 cm x 7.5 cm by the end of the debridement."

Left Atrial Appendage Ablation for Atrial Fibrillation

What code(s) would you use for the ablations? "Physician performed TEE. Using ICE, transseptal puncture was done. Ablation catheter was placed in the left atrium, and 3D mapping of the left atrium was performed. It was identified that the pulmonary veins were silent. Assessment of the conduction via pacing of the pulmonary veins was done. It was identified that there was signal in the left atrial appendage. RF ablation and isolation of the left atrial appendage were done. Then it was identified that there was signal at the base of the right superior pulmonary vein, which was ablated as well. Conclusion: Treated atrial fibrillation with ablation without immediate complications. Isolation of the left atrial appendage." 

Lymphatic Malformation

Is it appropriate to code 49185 or 37241? "PROCEDURE: Lymphatic malformation sclerotherapy. Ultrasound mapping confirmed the presence of lymphatic malformation within area of concern, comprised of 3 dominant large macrocysts and multiple smaller macrocysts. The largest macrocyst was accessed using ultrasound guidance and a 20 gauge Angiocath needle. The cyst was aspirated to completion and injected with a dilute solution of Sotradecol 3%. The Sotradecol was left to dwell for approximately 5 minutes and then aspirated. The cyst was then injected with a smaller volume of the contrast-opacified doxycycline solution than was initially aspirated. The two remaining dominant macrocysts were each treated in a similar fashion. The remaining smaller macrocysts were accessed under ultrasound guidance, aspirated, and then injected with a slightly smaller volume of doxycycline solution. Post procedure ultrasound and radiograph confirmed the presence of contrast opacified doxycycline solution within the region of concern."

CT-guided embolization of the thoracic duct

What code should I use for CT-guided embolization of the thoracic duct? "Technique: Informed consent was obtained. The patient was placed on the CT scanner table. Right lateral chest wall was prepped and draped. Skin was anesthetized with lidocaine. Under CT guidance, two 20 gauge needles were advanced into the cisterna chyli/thoracic duct. The appropriate location of the needles was confirmed with repeat CT. 10 mL mixture of NBCA with Lipiodol was administered through the needles. The needles were removed. Post procedure imaging did not demonstrate any complication. Sterile dressing was applied."

Correct use of 93655

The patient has PAF and atrial flutter confirmed on an event monitor. He is referred for PVI and atrial flutter ablation. The PVI is completed successfully. Afterwards, the following is documented: "Burst atrial pacing and single/double atrial extrastimuli failed to induce atrial flutter, A-fib, and SVT. RF ablation was performed linearly across the CTI. Differential pacing confirmed bidirectional CTI block." Since the atrial flutter does not appear to have been "spontaneous or induced", as stated in the description of code 93655, would code 93655 still be appropriate here? Does a distinct arrhythmia need to be seen DURING the procedure in order to warrant the use of code 93655?

CTO vs. CAD

Provider did a coronary cath. For diagnosis I used CAD I25.10. However my auditor stated I needed to also use I25.82 (CTO) based on the fact of 100% stenosis with collaterals. Is she correct? CORONARY CIRCULATION: --  Distal left main: There was a 50 % stenosis. --  Mid LAD: There was a 100 % stenosis. --  1st obtuse marginal: There was a 100 % stenosis. --  2nd obtuse marginal: There was a 100 % stenosis. --  Proximal RCA: There was a 100 % stenosis. CORONARY CIRCULATION: The coronary circulation is right dominant. Distal left main: There was a 50 % stenosis. Mid LAD: There was a 100% stenosis. Circumflex: Normal. 1st obtuse marginal: There was a 100% stenosis. 2nd obtuse marginal: There was a 100 % stenosis. Proximal RCA: The distal vessel was supplied by extensive collaterals from the LAD. There was a 100 % stenosis.

G0288 for Pre-TAVR Pre-VSD planning

Can you bill code G0288 (recon CTA of aorta surgical planning) after a CTA was done at an earlier date of service for TAVR or VDS planning? Is the intent of G0288 only for the aorta? The physician is doing measurements several weeks/months later, and I want to use code G0288 for global office billing for this work (owns the independent workstation). 

Bilateral Iliac Stents

Abdominal angiography, bilateral lower extremity angiography, self-expanding stent placement to the right external iliac artery, and also self-expanding stent placement to the left external iliac artery. Would I submit code 37221-50, or are these considered separate families? What would the correct coding be for this procedure?

Co-Surgery EVAR - Two Vascular Surgeons

I am auditing claims for two vascular surgeons in the same group practice who are documenting co-surgery for EVARs. Surgeon A works on the left groin performing a cutdown and inserting a catheter into the aorta, and Surgeon B does the same on the right. They continue to work together simultaneously throughout the procedure to deploy the main body graft and any extenders. Since they are in the same specialty, can we bill a co-surgery on the main body and extenders where modifier -62 is permitted? CMS defines co-surgery as two surgeons (each in a different specialty) working together to perform part of a procedure reported with the same CPT code(s), but they also state that "co-surgery is also defined as two surgeons working simultaneously to complete a portion of the same procedure, e.g., bilateral knee replacements". Some MACs appear to indicate that co-surgeons can be of the same specialty in that latter definition of working simultaneously: http://www.wpsmedicare.com/j5macpartb/resources/modifiers/modifier62.shtml. 

Conduit Angiography

The patient had a Norwood/Sano/modified right BT shunt. What codes should we use for angiography of a Blalock-Taussig shunt from the RIMA to the pulmonary artery, angiography in the Sano conduit, and separate pulmonary angiography during a congenital heart cath? We submit code 93568 for the pulmonary arteries, but how do we code the angiography in the shunts?

Pubic Rami Fracture with Kyphoplasty Method

What code can be used for pubic rami fractures treated percutaneously with kyphoplasty balloons and filled with cement? Will 2017 CPT codes have anything to use for this procedure? It seems the only code now is an unlisted code. 

Echo

In order to bill a complete echo, the following structures have to be examined unless technically impossible: left/right atria; left/right ventricles; aortic, mitral, and tricuspid valves; the pericardium; and adjacent portions of the aorta. What exactly does "adjacent portions of the aorta" entail? Is it parts of the aorta itself or structures surrounding the aorta?

61640-61642

Do codes 61640-61642 include diagnostic angiography? Can they be used with codes 36221-36226?

Coding for discontinued CT-guided adrenal biopsy

Please advise on the proper coding of the below procedure (hospital and professional charges). "PROCEDURE: The patient was placed in the prone position. A time-out was performed, and the patient's skin was marked using imaging guidance. The patient's skin was then sterilely prepped and draped in the usual fashion. Local anesthesia was provided with injection of 10 cc of buffered 1% lidocaine. Using CT guidance, a 17 gauge outer needle was advanced towards the left adrenal gland. At this time, it was determined that there would be no safe window to approach from this location. The patient was then repositioned in the right lateral decubitus position, and again no safe window was visualized. After discussion with the patient it was decided to abort the procedure. The patient tolerated the procedure well, and there were no immediate complications. FINDINGS: CT images demonstrate initial placement of a 17 gauge needle without a safe window for left adrenal biopsy."

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