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Cardiac Ultrasound

One of my cardiologists desires to bill handheld echo exams as a "limited exam". After research, I have discovered this exam is included in the E&M. My physician states, "We will have to find out eventually what it takes to bill for handheld echo exams appropriately since the new devices: A) now allow storage of the images, and B) can perform all measurements needed for a limited echo exam documentation. Hence, I would see no reason why that is not possible. I'm anxious to hear what you find out." Please advise.

Medically Unlikely Edit Review

Our cardiologist performs EKGs in office, and our office bills code 93000 along with A4556 x 5 units. But currently a message appears for NCCI MUE... should this procedure (A4556) be billed along with the EKG if the provider owns the equipment? Or will it be inclusive? Also, under what circumstance can these two codes be billed as such?

Perisciatic space and scatic nerve injection CPT 64445

Is perisciatic space injecion the same code as sciatic nerve injection? "Right perisciatic steroid injection. We injected 40 mg kenalog 3 cc lidocaine into the right perisciatic space utilizing a 25 gauge needle in the posterior approach."

CPT 93286

When is it appropriate to report code 93286 or 93287? "This patient was brought to the facility for elective DC cardioversion for the diagnosis of persistent atrial fibrillation. After the patient was adequately sedated, transthoracic, synchronized, biphasic shock was used to successfully convert the patient to sinus rhythm (please refer to the Procedure Grid for details). The patient tolerated the procedure well with no complications. In summary, pre-op and post-op diagnoses were persistent atrial fibrillation with unsuccessful cardioversion of the above. This was attempted three times, without conversion. She did appear to organize to an atypical atrial flutter, which I tried to pace terminate with the pacemaker, which also was ineffective. I interrogated and reprogrammed the pacemaker with a more aggressive sensor setting (low threshold)." Would it be appropriate to report code 93286 with the cardioversion in this scenario?

Percutaneous paraspinal mass biopsy

CT-guided percutaneous biopsy of right paraspinal mass... Would I code as soft tissue biopsy (20206) or lung (32405)?

99211 with 93284

I'm wondering about appropriate usage of 99211 here. MA did brief HPI, no blood pressure taken, and a statement that a 93284 was performed. No report or interpretation. Can code 99211 be billed with 93284? It doesn't seem appropriate, even with the -25 modifier. 

Embolization of Segmental Left Hepatic Artery

I don't understand how to report catheterization of multiple segmental arteries of the left hepatic artery. Here is an example... The patient has HCC and presents for embolization. The OP report states: "Catheterization and arteriogram of segmental branch of the LHA and additional segmental branch. Also catheterization and arteriogram of segmental branch of replaced RHA. Embolization of both arteries was then performed." Am I correct to report 36247-LT, 36248-LT, 36247-RT, 37243? 

Transjugular Liver Biopsy

"The doctor was not able to biopsy liver, gained access in jugular vein, US done, access into IVC, access to right hepatic lobe. Wedge pressures obtained. Attempts made to biopsy, but could not because of a sharp 90 degree turn." I cannot report code 37200... I have 36011, because biopsy was not done. Or should I code 37200 with a -52 modifier?

Peripheral Selective 2nd Order Catheter Placement Clarification

I am in need of coding clarification in regards to peripheral coding from a right femoral artery access site. "Access placed in right femoral artery, and a catheter is advanced to the right common iliac artery for selective angiogram. Catheter is then withdrawn to the right external iliac for selective angiogram." Would it be appropriate to code for the 2nd order catheter placement in the right external iliac even though the access was from the right femoral artery?

ERCP with clearance of blood clots from bile duct

Patient had an ERCP with balloon sweep of the main bile duct, which removed air bubbles and old blood clots. Would air bubbles and blood clots be considered debris? Would 43264 be the correct code for this procedure? If not, what would?

Left Colic Branches

I have a report that says the IMA and its distal branches were selected. Then he gives findings of left colic and a branch for catheter placements. I get confused he went into the left colic and then a branch. Would it be 36246 and 36248, .r would it just be 36247?

Angioplasty in a failed AV fistula

What is the appropriate ICD-10-PCS coding for an angioplasty in a failed AV fistula?

Discharge or E/M visit code next day after Routine Afib ablation?

Patient has elective ablation and is kept overnight. Patient is stable and no complications. The physician wants to bill code 99214 for his follow-up visit the next day after ablation. The note reads like a discharge next day after routine ablation. The provider insists that because the procedure is a 000 global period he should be able to bill either a discharge or E/M follow-up code for the next day visit. My understanding is patient in bed after routine surgery with no complications means the provider cannot bill for an outpatient discharge the following day. I don't think it would be correct to bill an outpatient E/M the next day either, but I cannot find anything that supports this. Now I am confused! Please help! Patient is POS 22, and there was no order to admit to observation or inpatient.

Harvested Saphenous Vein Graft

If a physician harvests both saphenous vein and an artery graft and only ends up using the artery graft in the CABG, can you code/bill separately for the harvested saphenous vein graft that was not used? Or is this still considered bundled?

Closure Device (G0269)

For 2017 when is it appropriate to charge G0269 (placement of occlusive device)? Specifically, is it appropriate to charge G0269 when doing an aortogram with run-off (75625, 75716, 36245)? Also, do you know if there will be changes regarding G0269 in 2018?

Does a small bowel series equal 4 abdominal AP xrays?

Our surgeons want to order a small bowel series. Our radiologists would prefer that each KUB that is in the series be ordered individually, as the same radiologist is not always available to read. Is it appropriate/compliant to change 74000 x 4 into 74250??? If not, why not???

SI joint DJD/arthritis ICD 10 code

Can you tell us the proper ICD-10-CM diagnosis code for "DJD sacroiliac joint"? We aren't sure if this should code out to spondylosis sacral/sacrococcygeal or if we should go totally out of the spine to code this.

Downgrade of Single Chamber ICD to CRT-P

"Patient had a single chamber ICD that was at ERI. Instead of replacing the ICD generator, the decision was made to replace it with a CRT-P generator. A left ventricular lead was inserted, and the original right ventricular lead was re-used and attached to the new CRT-P generator." Would the correct CPT codes for this be 33241, 33221, and 33225?

O-arm billing

When an O-arm is used in a spinal procedure, how is it coded? Is it still fluoroscopy (76000) plus the spine code? With the number of images obtained it just seems like there should be a better code.

EKG and device check same day

When is it appropriate to report an EKG (93000) the same day and same encounter as a device check (pacemaker, ICD)?

TAVR 33362 and 34812

TAVR with TF open access done. The IC and CS bill 33362-62. A vascular surgeon does the cutdown. It is my understanding that he/she cannot bill for the cutdown, as it would be included in 33362. My CS is asking if he should be billing differently since he is not doing the cutdown. I don't think he would bill for a reduced service. I don't think the vascular surgeon should bill for 34812 -59, although it does say allowed in the NCCI edits. Any confirmation or guidance appreciated. 

Open Thrombectomy and Open Angioplasty Peripheral Segment

When an open thrombectomy of AVF (36831) along with an open angioplasty or open stent placement for a stenosis in the peripheral segment is performed, is it correct to code this as thrombectomy with revision (36833)? If not how would this be coded? 

Peripheral and central circuit AV angioplasty?

"Open thrombectomy of AV fistula. Thrombus was extracted, but no good back bleeding. Fogarty passed at shoulder level but could not be passed into the central circulation. Performed fistulogram. Shows occlusion of cephalic vein before it entered the subclavian. Brought up a catheter & could get through the obstruction to the superior vena cava. Passed catheter beyond that, pulled the wire & performed imaging which confirmed patency of the proximal left brachiocephalic vein and the superior vena cava. Angioplastied along the length of the area that appeared abnormally narrowed, several inflations were performed, followup imaging revealed recanalization of the cephalic vein arch, resolution of the stenosis, good flow through the left brachiocephalic vein & the superior vena cava. There was now reflux into axillary vein distal to the cephalic arch." 36831 open, 36902-XU cephalic-peripheral. Do you feel the brachiocephalic was also angioplastied? (Procedure header states angioplasty of the left cephalic vein arch and of the left brachiocephalic vein)

How often can you report diagnostic imaging

Patient was seen three months ago for initial chemoembolization for hepatoma where diagnostic imaging was performed. Patient returns for second treatment with doctor's notation of partial response to therapy on the H&P. Patient has chemoembolization performed again with diagnostic arteriograms. Is there a timeframe where diagnostic imaging would be medically necessary and reportable during subsequent chemoembolization procedures?

LSVC Venography during Heart Cath

"Patient presents to the cath lab for a complete right and transseptal left heart catheterization with multiple congenital anomalies including oculo-auriculo-vertebral syndrome and left lung aplasia, as well as a hypoplastic aortic arch with coarctation, PDA, VSD, and ASD. His pulmonary flow is all managed by his single right lung, and he has continued to struggle with hypercarbia and is currently on 35% FiO2 with saturations in the low 90s. He is also currently on sildenafil secondary to concerns for pulmonary hypertension in the setting of the single lung. He comes to the catheterization lab today for a diagnostic cardiac catheterization to assess His hemodynamics and pulmonary vascular resistance. Cineangiography was performed in the IVC, RUPV, LSVC, RPA, left ventricle, right femoral vein angiogram (related to difficulty with access)." We plan to report: 93533, 93565, 93568, 75827, 75825, and 75820. Is it appropriate here to also report code 36011 for the “selective” catheter placement/imaging into the patient's left superior vena cava?

Hepatic arteries catheterization

Vessels studied: Common hepatic artery segment 4, hepatic artery, right posterior hepatic artery, right hepatic artery. How would you code the catheterization of the above arteries?

FFR

We receive patients who have heart caths done at outpatient centers, but then may require further treatment; however, when FFR and/or IVUS is done because the coronary lesion is borderline, but the FFR is negative not requiring intervention, would we charge for the FFR (93571)? Or would we charge 93799? What if FFR is done the day after heart cath/coronary angiogram because it was late in the day and patient had to be held overnight?

36251 or 75625

If a patient has a renal angiogram performed, would the following be considered a selective renal angiogram, or would it be charge it as an aortogram?: "Using a 3DRC catheter, the ostium of the left renal artery was engaged, and selective angiogram revealed normal renal artery and no evidence of a stenosis." The catheter going no further than the ostium is what has us questioning whether or not it is a true selective angio, or if it is considered to still be in the aorta. 

Replacement or Conversion

Do I code a displaced gastro-jejunostomy tube to a conversion because it coiled into the stomach?

Fisulogram VS Angiogram

How would you code this procedure? "Left AV dialysis fistula was accessed with the help of ultrasound guidance, and a picture was saved to PACS. A fistulogram was performed. Attempts to cross the arterial anastomosis were unsuccessful. The left CFA was cathed with the help of ultrasound guidance, and a picture was saved to PACS. Catheter was manipulated into left radial artery and angiogram performed. Severe stenosis of arterial anastomosis was seen. This was angioplasied with good results. Both the groin catheter and arm catheter were removed and sites closed." Would you report code 36902 only, or do you code for both acesses? And, can you code for 76937 with new dialysis intervention codes? Would you consider this just a fistulogram or an arm angiogram to look at the artery?

Critical Limb Ischemia

What would be the most appropriate ICD-10-CM for the diagnosis "critical limb ischemia"? My physician always wants to use I99.8, and it is questionable in support of some procedures. I typically make the change to arteriosclerosis of arteries of extremities, etc... but I am wondering if there is a better code to describe the ischemia of the limb.

Discontinued Open AV Fistulogram with angioplasty/thrombectomy

The surgeon was attempting to perform a fistulogram with appropriate intervention (i.e., angioplasty and/or thrombectomy as required) on a direct AV fistula. He was able to insert the wire, but not the catheter. As a result, he opened, dissected out the arterialized vein, incised the vein, and once again attempted to perform the procedure. Again, he was unable to pass the wire completely or the catheter at all. He then discontinued the procedure and closed. Please help. I have no idea how to code this. 

INFRARENAL AAA

My provider did infrarenal AAA. Using ultrasound guidance, he accessed both femoral arteries. He deployed Gore endovascular stent with careful attention not to encroached the left renal artery. Then, Gore limb was placed into the right common iliac. An extender device was placed from the main body limb just above the left hypogastric. My question is: it is appropriate to report code 34825 since he used another limb extension?

Heart Biopsy for Surveillance of Rejection

Heart transplant patient’s last biopsy result was rejection 6 months ago. The patient came back for surveillance of rejection. Heart biopsy with right heart catheterization was done by Dr. A, and coronary angiogram was done by Dr. B. These procedures were done in one setting. What are the correct codes for hospital in this case? I get an NCCI edit when I report codes 93456 and 93505. 

76942 vs. 76965

We are providing US guidance for the placement of the Ovoid and tandems used in brachytherapy for CA of the cervix. Since the actual treatment source is not being placed, is it appropriate to use 76965 for this procedure?

TAVR & Endarterectomy

For a TAVR procedure (i.e., CPT 33362), it requires an IC and CS to perform the procedure jointly. Each bill with a -62 modifier. If a vascular surgeon does the cutdown, she/he cannot bill separately for the cutdown. However, if the vascular surgeon does the cutdown, the TAVR procedure is performed (IC & CS), upon completion of the procedure, stenosis in the femoral artery is noted and vascular surgeon does the endarterectomy? Can the vascular surgeon bill for the endarterectomy? All based on medical necessity. Thank you!

Pocket Revision Without Relocation

When a pacemaker or ICD pocket is revised but NOT relocated, is the advice still to report an unlisted code, or would reporting the "relocation" code with a reduced services modifier be appropriate for the hospital billing?

Ultrasound-guided Foley catheter balloon decompression w/ catheter removal

How would you code a guided Foley catheter balloon decompression with catheter removal? "The patient was prepped and draped in a sterile technique. 1% lidocaine without epinephrine. Under ultrasound guidance, a 25 gauge needle was advanced from a ventral approach into the proximal penile urethra where there is an inflated Foley catheter balloon. The needle was advanced into the balloon causing immediate decompression of the balloon. The Foley catheter was removed. Four ultrasound images were sent to PACS for documentation. Ultrasound-guided Foley catheter balloon decompression with 25 gauge needle for Foley catheter removal."

Bilateral IVUS

The patient had bilateral femoral access to the vena cava, and IVUS interrogation was performed through both access sites with two pullbacks being performed on both sides (vena cava and external iliac). In coding the IVUS, would we use codes 37252 and 37253 x 3? Or, because there were separate access sites, should we use codes 37252, 37252-59, and 37253 x 2?

Renal Artery Intervention

Patient had stenting on both the right and left renal arteries. Per MUEs, code 37236 can only be charged once per day. Code 37237 is an add-on code for additional arteries, but is code 37237 for additional on the same renal? Or would it be applicable to bill code 37237 for the other renal?

Pre-Procedure Pacemaker

Turning pacemaker on and off during pre and post procedure I would code 93286 x 2 with a modifier -76. We are constantly receiving denials, so I have decided to add this modifier. Is it okay to bill this procedure times two with this modifier?

GI bleed intermittent - angiography with embolization

"Prograde microcatheter was then advanced over a wire into the gastroduodenal artery (third order). A second digital hand injection was performed to confirm good positioning within the descending portion of the gastroduodenal artery. An initial pod 5 mm coil was deployed within the artery in good position. Follow-up injection demonstrated some flow through the coil. A second 4 mm x 15 cm Ruby coil was deployed. Follow-up injection demonstrated near cessation of flow. A 6 French sheath was placed. Through this, a 5 French SOS Omni catheter was advanced over a Glidewire under fluoroscopy. The celiac artery was selectively catheterized, and a digital hand injection was performed. Successful embolization with coils of the gastroduodenal artery centered at the duodenal branches, which are suspected to be the source of the patient's acute intermittent upper GI bleed." Please indicate the ICD-10-PCS codes for this visit. I have 04V33DZ and B4121ZZ. Would that be correct?

Can we bill for TEE ProShield Storage tube?

I have this question from one of my sonographers. Could you please let me know if I can bill patients for a TEE ProShield storage tube? I am told they use this tube on every patient whenever a TEE is done. I have not found any information about it. 

Diagnosis Code for Aftercare of Carotid Stenting

When a patient comes back in for aftercare during the global, following a stent placement in the carotid artery, is Z48.812 the appropriate diagnosis code for the encounter?

Can we code thoracic aortogram w/ right internal carotid stent

It sounds like the surgeon feels the thoracic aortogram is supported for coding as diagnostic separately. CPT code 37215 includes diagnostic imaging of the carotids, but what about the other findings he had from the thoracic aortogram? This patient was transferred from another hospital to this hospital for a stent procedure. The following is from the operative note: "Microsheath was placed, followed by a Magic Torque wire followed by a 6 French 11 cm sheath. The patient was then systemically heparinized to a goal ACT of 300. A pigtail catheter was placed in the patient's thoracic aorta for a thoracic aortogram, which demonstrated patent right innominate artery and right subclavian artery, the right carotid system, with what appeared to be greater than 80% stenosis of the right internal carotid artery. The left subclavian artery was widely patent, the bilateral vertebrals were patentm and the left internal carotid artery appeared occluded. Given these findings, we elected to intervene." Can we code separately for the thoracic aortogram (36221)?

Biopsy Neck Mass

"Ultrasound scanning demonstrated right neck mass. The overlaying skin was prepped and draped in sterile fashion. Using local anesthesia, a total of four 23 gauge FNAs and two 20 gauge core biopsies were obtained. Pathology quick-reading was deferred. Hemostatis was achieved with manual compression. Successful ultrasound-guided right neck biopsy. Full pathology results to follow." Would this qualify for code 21550 or codes 20206 and 76942? 

LHC & Coronary angio with RHC & biopsy s/p transplant

Our physicians have started doing a left heart catheterization and coronary angio on all status-post heart transplant patients at one year out from transplant and then after every two years for graft vasculopathy surveillance as a standard routine. I saw Q&A #9772. Would surveillance for graft vasculopathy support medical necessity to bill the coronary angio? I am assuming the left heart catheterization is not billable, correct?

Bleomycin Sclerotherapy of Submandibular S.T. Ranula

The physician wants to use code 49185 for Bleomycin sclerotherapy of submandibular S.T. ranula, which also included a core biopsy due to solid contents. Does code 49185 only pertain to intra-abdominal procedures, or could you use it for subcutaneous areas? Other options might be 21899 for unlisted with 20206 for biopsy or 20206 with 96401 for non-hormonal anti-neoplastic subcutaneous injection. Any suggestions?

Open and VATS pulmonary wedge resection at same time

What would you code for three pulmonary wedge resections performed: two wedge resections performed on the right lower lobe via thoracotomy and one wedge resection performed on the right upper lobe via VATS. Per the procedure report (abridged): “Posterolateral thoracotomy incision was created… We initially proceeded with wedge resection of the right lower lobe… Two wedge resections were performed in the lower lobe. Once we completed wedge resections of the right lower lobe, we proceeded with the right upper lobe. The thoracoscope was inserted through a chest tube site incision… Once adequate mobilization was confirmed, we were able to identify the lesion that was noted on chest CT. That lesion was easily palpable. It was elevated, and wedge resection was performed with adequate margins using multiple staple loads." Is it appropriate to report codes 32666, 32505-XS, and 32506 to capture different access for one of the wedges? Code 32667 can't be reported with 32505 primary per CPT, otherwise codes 32505, 32506, and 32667 would appear to be the most accurate coding.

HeRO dialysis graft intervention

My physician performed a PTA on 80% stenosis of the venous outflow portion of a HeRO dialysis graft. With the new dialysis codes, would this be considered part of the central segment 36907? Can I get some insight into coding percutaneous interventions for a HeRO graft?

Billing 93455 and 93568 together

I am getting an edit when I try to bill codes 93455 and 93568 together. Can you explain why?

TAVR converted to SAVR

We have a patient who presented for TAVR. The valve was in the body, but was not deployed. A complication arose, and the patient was converted to an open valve replacement. The original valve for the TAVR was removed, and surgical valve was implanted. We are trying to figure out what to code and what to charge for both hospital and physicians. Hospital side we were thinking we would only charge for the surgical repair and code for the surgical repair. Can we charge for the valve that was in the body and then removed as a supply? Does the interventional cardiologist bill for the TAVR with a modifier and the surgeon bill for the SAVR?

Exteriorization of peritoneal dialysis catheter

Would I use unlisted code 49999 for this? If so, what code is it comparable to since there is no repositioning code? "The patient underwent placement of a tunneled and buried peritoneal dialysis catheter about 6 months ago. He now requires dialysis, so I was asked to exteriorize the catheter. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. Only local anesthesia was used. The abdomen was prepped with antiseptic and draped. Xylocaine was infiltrated over the catheter, which was palpable through the skin. The site selected was about 1 cm lateral to the palpable cuff. A small incision was made. The catheter was carefully dissected out and exteriorized. It was not damaged. It flushed and aspirated well. It was connected to tubing with a valve. It flushed and capped. I placed two sutures of 4-0 Monocryl at the exit site to snug it around the catheter. Sterile dressing was placed." 

Right Heart Cath (93451-59) with Biopsy (93505)

Can a right heart catheterization (93451-59) be coded with biopsy (93505) in this case? "A patient with history of orthotopic cardiac transplant, now with mildly reduced ejection fraction and complaining of easy fatigue. Based on patient's mildly reduced EF and fatigue, she was brought to the cardiac catheterization laboratory to evaluate for possible entiology with endomyocardial biopsy and right heart catheterization (RHC). Five endomyocardial biopsies were taken from the right ventricle and intraventricular septum and sent to pathology. Right heart cath was performed with a 7 French Swan-Ganz catheter. The usual pressures were measured along the way. Thermodilution technique was used to obtain cardiac output. HEMODYNAMICS: 1) RA: 11/13, with mean of 10.; 2) RV: 28.5, with EDP of 1-.; 3) PCWP: 16/5, with mean of 13.; 4) PA: 30/16 with mean of 21.; 5. Thermodilution cardiac output: 3.4 L/min with cardiac index of 1.91 L/min per m2. Summary: Normal right and left filling pressures with decreased cardiac index at rest. Result of endomyocardial biopsy pending."

Transvaginal drainage of pelvic fluid coll & Transvaginal bx of pelvic mass

Transvaginal drainage of pelvic fluid collection and transvaginal biopsy of pelvic mass were done transvaginally. Should I use unlisted code(s) for the pelvic drainage and mass (27299) or (20999)? I'm not sure what to use. Please advise, because I don't think I can use 10160 or 20206 or possibly 49180. 

Diagnosis Code for Lead Repaired

Is there a diagnosis code for a lead already repaired (after care)?

49465-GASTROSTOMY TUBE INJECTION

Does the following documentation meet CPT criteria to code 49465, or does contrast injection under fluoroscopy have to be dictated in order to code? "EXAM: G/J TUBE CHECK CLINICAL HISTORY: GASTROSTOMY TUBE INJECTION COMPARISON: NO RELEVANT COMPARISONS. FINDINGS: GJ TUBE OVERLIES THE LEFT UPPER QUADRANT. SMALL AMOUNT OF CONTRAST NOTED WITHIN THE COLON PRE-INJECTION IMAGE. FOLLOWING ISOVUE CONTRAST INJECTION, OPACIFICATION OF THE STOMACH. MAJORITY OF THE STOMACH NOTED WITHIN THE CHEST CONSISTENT WITH LARGE HIATAL HERNIA. MODERATE GASTROESOPHAGEAL REFLUX NOTED. SMALL AMOUNT ANTEGRADE PROGRESSION WITH INTO PROXIMAL SMALL BOWEL. IMPRESSION: GASTROSTOMY TUBE IN SATISFACTORY POSITION WITHOUT EVIDENCE OF LEAK. FLUORO TIME 0.2 MINUTES. THIS PROCEDURE WAS PERFORMED BY PHYSICIAN ASSISTANT SHELLEY OMER, PA-C UNDER MY SUPERVISION."

33270-Q0

With the new technology of subcutaneous ICD implants, would it be recommend to append modifier -Q0 to 33270 when a primary prevention subcutaneous defibrillator is inserted? The NCD 20.4 is not very specific as to what CPT codes require the -Q0 modifier for primary prevention ICD implants, only the diagnosis codes.

4b Branch of Hepatic

I have a case where the left hepatic is coming DIRECTLY off the aorta and not the celiac. "They selected the right hepatic and left hepatic, and then, through the Chung catheter, a microcatheter was used to select the segment 4B branch of the left hepatic artery supplying the tumor. Chemoembolization was then performed of this artery." I cannot find a diagram that shows catheter selection for variant anatomy of hepatics. I have a 36247 for the right hepatic selection, but I'm not sure if 4B is a 36246 or 36247.

CABG with Endovascular Harvest

Could you clarify the guidelines of the CABG section that indicate if the assistant performed the procurement of the graft to assign the codes with an -80 modifier? Isn't modifier -80 only for a physician as an assistant? If the provider indicates the harvest was performed endoscopically, is the add-on code also to be appended with an -80 modifier?

Coding for CAVC when only the common AV valve is repaired

CPT code 33670 for a complete AV canal repair includes the closure of the VSD, closure of the ASD, and the common AV repair. What would you recommend for coding when the ASD and the VSDs are left alone and only the common valve is repaired? There is no CPT code for just a common AV valvuloplasty. What would you recommend: 33670 with modifier -52 because the entire procedure was not completed, or would you choose 33425 or 33463 based on the side of the valve that the MD repaired?

AV graft thrombectomy cutdown then pta percutaneous 36905?

When a thrombectomy through a cutdown using a Fogarty balloon is followed by fistulogram and a separate stick for a percutaneous PTA or PTA/stent for stenosis at the venous anastomosis, is this all covered by CPT code 36905?

Axillo-fem-fem bypass thrombectomy with ligation of fem-fem bypass graft

"Patient noted to have bifurcation at the site with one limb going towards right femoral artery and 2nd medial limb going towards fem-fem graft portion. The medial portion of limb was then ligated and divided and the graft then was repaired using 6-0 Prolene sutures. Next transverse arteriotomy was made with the right limb of graft. Initially Fogerty cath was passed distally and could not go beyond the 30 cm. An angiogram was done through the open portion of fem artery anastomosis. Using glidewire and glide cath, the right SFA was entered and over-the-wire Fogarty used for thrombectomy of SFA. Repeat angio revealed stenosis at right SFA at level of anastomosis. At second attempt at thrombectomy patient noted to have dissection with SFA also. Decision was made to perform angio and stenting SFA extending into bypass graft. Second stent was deployed at anastamosis. Next, thrombectomy was done of proximal graft. #6 Fogarty cath was used to remove the clot from proximal graft. Graft arteriotomy performed and repaired." Should CPT codes be: 35875, 37226, and 75710? Or 35876 and 37226?

Pseudoarticulation Joint Injection

The service is described as a fluoroscopically-guided injection of pseudoarticulation of lateral L5 transverse process on the left and the sacrum. How would you recommend this be coded? 

Billing for Kissing Iliac Stents

I recently entered charges for kissing iliac stents with a modifier -50 appended to code 37221 per your text and the CPT Codebook. We have facility CDMs that are assigned to a CPT code, and in this case code 37221 is built for a unilateral stent placement. Should I attach the -50 modifier to unilateral code 37221 or request a bilateral CDM with the -50 modifier? We don't want to just get paid for a unilateral placement, but I don't want them to bill it twice either.

Tunneled rt sided Aspira Cstheter Placement using US & Fluoroscopic guidan

"Indication: Recurrent right side pleural effusions with history of pneumonia. Physician performed a skin incision four fingerbreadths away from pleural access site and tunneled the catheter to the pleural access site from the anterior abdominal wall. Over a 035 wire under fluoroscopic guidance, a series of skin dilators were utilized followed by a large peel-away sheath. The physician then tunneled a 14.5 French Aspira catheter from the anterior abdominal site to the pleural site and placed it through the peel-away sheath into the pleural space using guidance. This was then closed, and the catheter was affixed to skin. The physician then performed a thoracentesis; fluid was dark amber and was discarded." I'm been told by an old coder to use code 49418, but the coder who replaced her said you code where the catheter stops (i.e., pleural space), so she thinks it should be reported with code 32557. The more I look at it the more confused I become.

TCAR and US assessment

Can you bill for ultrasound assessment prior to TCAR? Note states: "Ultrasound assessment was performed, and skin was marked. Distance from CCA at the clavicle to the bifurcation (lesion) was measured at 5 cm, and this was documented in a hard copy by ultrasound performed by me. The patient was prepped and draped in the usual sterile fashion."

REPROGRAMMING VS INTERROGATION

I suggested to one of my physicians that code 93284 be changed to 93289 because there was no documentation of reprogramming or iterative adjustments. He replied that they are reprogramming the device when they "clear the counters" (which was documented in the report) and thinks 93284 should stand. Do you agree? 

CORONARY AV FISTULA CLOSURE

How would I code the below scenario? Please help!! "Initially, we had trouble negotiating the right coronary artery into the fistula due to the 180-degree turn; however, once we were able to accomplish the AV loop, we were able to take the Neuro catheter all the way into the mid segment of the fistula. Once we had accomplished this, we removed the AV loop and then advanced the 9 mm microvascular plug. We then deployed the 9 mm microvascular plug successfully and performed an additional angiography conforming that the microvascular plug was in position prior to its release."

CPT 20206 and 20611

"Patient had a left hip arthrocentesis and also aspiration of complex fluid collection along the lateral proximal femur. Spinal needle was inserted into the hip joint and fluid aspirated. There was also fluid collection adjacent to the prosthesis along the lateral aspect of the proximal femur near the hip." Can both codes 20206 and 20611 be reported?

Is this 93923?

The following patient was evaluated bilaterally in digits only for steal syndrome. The physician notes, "Bilateral upper extremity PPG waveforms were obtained of the bilateral upper extremity digits at rest. PPG waveforms are symmetrical. The left upper extremity AVF was than manually compressed with simultaneous PPG waveform of the 1st digit. Upon compression of the arteriovenous fistula, there was no significant increase in the waveforms amplitude." Does this meet 93923 since waveforms were evaluated, or does it still also have to be multiple levels (forearm, wrist, digits, etc.)?

Intraoperative Echo 93355 with 33340

Any word on the NCCI edit change between codes 93355 and 33340 that was supposed to be implemented on October 1st?

Venous Angioplasty

"Patient presents for hemodialysis catheter exchange due to catheter not functioning properly. Catheter was removed, venous angioplasty was performed along tract to disrupt possible fibrin sheath, and a new catheter was placed." In addition to the replacement code, is it appropriate to bill code 37248 for the angioplasty due to this being the tract and not the dialysis circuit itself?

Fibrin sheath through CVC with replacement

If the physician uses CVC to access and clear fibrin sheath and then replaces the CVC, is code 36595 or 36596 bundled into code 36581 for facility coding? "The pre-existing dialysis catheter was dissected free of the underlying soft tissues and partially removed over a 0.035 inch glide wire. Contrast was injected into each lumen, which demonstrated a fibrin sheath surrounding the catheter within the superior vena cava. The catheter was then removed. The sheath was disrupted with inflation of a 14 mm angioplasty balloon. A follow-up superior cavagram was performed. The new catheter was then placed over the guidewire into the superior vena cava such that the tip was at the SVC/right atrial junction."

Medicare Split/Shared Evaluation Services

For Medicare patients seen in outpatient hospital/inpatient hospital place of service, are we allowed to combine the documentation of the same day, face-to-face EM services of a hospital employed NPP and our private practice MD as a split-shared service under our MD provider number? Our coding compliance department has always interpreted the Medicare rules to mean the NPP and MD must be employed by the same practice. Are we correct in our interpretation? 

Iliac aneurysm closed using coils

I am hoping to get help on how to code a specific peripheral procedure. The patient presented with a large right iliac artery aneurysm. My physician accessed the right common femoral artery and was able to successfully close the iliac aneurysm with coils. I am unfamiliar with the use of coils, and I'm not sure which CPT code would be the most accurate to use. Any help with this scenario would be appreciated.

MRI Arthrogram Supply Q9967

Can we bill for the supply of Optiray (Q9967) when used for localization prior to Dotarem injection for MRI arthrogram? "Under CT guidance, a 27 gauge needle was directed into the radiocarpal joint space. 1 cc of Optiray 300 was used to verify intracapsular location. Next, 2.5 cc of 1:200 Dotarem was injected into the left wrist joint. Needle system was removed. There were no immediate complications. Patient was transferred to MRI for further imaging."

Gore Excluder iliac branch endograft 0254T

We are not getting reimbursed for code 0254T in Florida or Michigan by Medicare carriers (considered experimental). Can we recoup and charge 34825 for the external iliac and 34826 for the internal portion? Plus the catheter? These are being performed quite often with AAA repair and Excluder 34802, so code 34900 is not an option. But the iliac branch device is being performed to repair iliac aneurysm. 

Stents in LAD

Can you report code 92928 for stent to the diagonal branch of the LAD and then 92929 for stent to the mid LAD? Or would this only be 92928?

37252-37253

My provider did IVUS of aorta, right femoral artery, right popliteal artery, right tibial artery, and left peroneal artery during revascularization procedure. Can I report 37253 x 4 (right femoral, right popliteal, right tibial, and left peroneal)?

TEE during structural intervention by both interventionalist and anesthesia

This question is in regards to code 93355 for facility billing, when the anesthesiologist places the probe and the interventional physician does the rest. For facility coding, can we charge anything for this TEE since the physician who did the intervention was involved? Just verifying, but we cannot charge a regular diagnostic TEE, correct? 

Brachial artery median cubital vein AVF creation

"A transverse incision 2 cm below the antecubital crease was made. I dissected out the median cubital vein and cephalic and basilic inflow and outflow. I divided the distal basilic and cephalic veins as well as the proximal basilic vein. This created a pedicle out of the median cubital vein. Next we incised the fascia adjacent to the biceps tendon in the cruciate manner. The brachial, radial, and ulnar intercosseous arteries were dissected out and prepared for control. I elected to use a 3-4 mm proximal radial artery as my inflow in hope of preventing ischemia distally. After control of the radial artery and longitudinal incision, I used the basilic vein as a Carrel patch and sewed the median cubital vein to the right radial artery with running 6-0 Prolene. There was excellent thrill in the AVF. The subcutaneous fat was reapproximated with 3-0 Vicryl. Skin was closed with subcuticular 3-0 Monocryl." Should I report code 36821 for this?

CRT-D Downgrade to CRT-P

Would it be appropriate to use code 33229 for downgrade of a CRT-D to a CRT-P? "Procedure: Blunt dissection was used to access the device. The CRT-D device was explanted. The leads were physically and visibly inspected and appeared free of defect. The right atrial, right ventricular, and coronary sinus leads were disconnected from the explanted device and affixed to the new biventricular permanent pacemaker. Conclusion: Successful generator change from a CRT-D to CRT-P."

77012 billed with 20552 Trigger Point injection

I have multiple accounts that hit for a modifier -59 edit for the 77012 against the trigger point injection. Should the -59 modifier be applied to the charge if performed under CT? I cannot find any material on this stating it cannot, and nothing says it is bundled into the charge. Please advise if this can be performed together and reported together appropriately with modifier -59. 

Heart Failure and HTN combination codes I11.0 and I11.9

Please clarify the necessity of using a heart disease code sequenced after I11.9 when the heart disease falls within I51.4-I51.9. I understand that with I11.0 I am to specify the heart failure code following the I11.0... but if I submit code I11.9 for heart disease in the I51.4-I51.9 category, should I code the specific heart disease code following the I11.9 or is it not necessary? Code I11.9 does not have a "use additional code" note following it the way code I11.0 has "use additional code to identify the HF" following it. 

Gallbladder Fossa

How would you code CT-guided placement of an 8 French drainage catheter within the gallbladder fossa biloma? We know the gallbladder fossa is not part of the gallbladder. However, we are having a debate between codes 47533, 49406, and 49405.

FFR 93571--new trend without Adenosine if baseline not below 0.92

It has come to our attention that a new trend has started to not use adenosine on FFRs if the baseline is not below 0.92. I would assume the recommendation is to still bill these as 93571-74 for facility and 93571-52 for the physician coding. Is this correct? 

CPT 33860 and 33870

Can we report codes 33870 and 33860-33864 when total arch replacement is performed? The physician replaced the ascending aorta as well as the transverse arch with re-implantation of the head vessels.

Jump graft from a bypass

Patient had a left brachial artery pseudoaneurysm. A resection was done, and then a left brachial to radial bypass with basilic vein was performed. (I have this coded as 35523.) Then a jump graft was performed from the brachial/radial bypass to the ulnar artery. Can I bill for the resection? I am also unsure if I should code the jump graft as 35523 with a -59 modifier or submit an unlisted code instead.

Midline Catheter Insertion

Is it appropriate to bill code 36568 or 36569 for a midline insertion with a modifier -52?

75825

What information should be documented in an IVC venography report when performed alone or in conjunction with lower extremity venograms? Many times catheter placement is in the iliac vessels, and the reports state, "IVC patent." Is this sufficient to bill 75825? Is it necessary for the IVC venograms to be documented as a full and complete study?

PCI for under-deployed stent

Patient presents with chest pain, status-post stent in the LAD several months ago. Coronary angiogram was done, and IVUS shows under-deployed stent in LD; angioplasty was done to expand the stent. Can we show an angioplasty here? There was no documented stenosis in the report, only the under-deployed stent. 

EKOS Procedure and Pulmonary Angiography

Can I use code 75743 when the physician dictates EKOS done under fluoroscopy (no injection)? "INDICATION: Dyspnea, saddle pulmonary embolism with right heart strain. RECENT HISTORY: ECHO and CT scan show significant PE burden and right heart strain. PROCEDURE: Placement of ultrasound-accelerated catheter-directed thrombolysis to bilateral pulmonary arteries via right femoral approach. TECHNIQUE: Right femoral vein was cannulated using micropuncture, followed by insertion of 6 French sheath. With similar technique, another 6 French sheath was introduced just distal to first sheath, then pigtail cath was advanced into the pulmonary artery with pressures recorded (32/11 with mean 20 mmHg). Following this, two EKOS catheters were placed in each pulmonary artery bilaterally under fluoroscopy and secured in position. The patient was then given 1 mg of tPA through each EKOS catheter for a total of 2 mg. At the end of the procedure, the sheath was then sutured in place, and the patient was transferred to the ICU for 12-hour tPA continuous infusion via sheath." I plan to report codes 37211-50, 36014-50, and possibly 75743. Is that correct?

Diagnostic arteriography during angioplasty or stent.

"The patient is a 74-year-old woman. Approximately 6 months earlier patient underwent treatment of left lower extremity femoral popliteal artery occlusive disease and disabling claudication with placement of covered stents in her left superficial femoral artery. She has developed recurrent disabling claudication symptoms. A recent ultrasound study revealed a new stenosis near the distal end of the stent in the popliteal artery. The decision was made to proceed with further evaluation with diagnostic arteriography and possible percutaneous reintervention. There was no CT scan done." Can I bill 75710-2659 as diagnostic study during the intervention, or would that be considered run-off angiography and bundled with stent placement? We are performing selective left lower extremity arteriography and left lower fem-pop balloon angioplasty.

93976/93975

The CPT descriptions for both codes 93975 and 93976 contain the wording: "Duplex scan of arterial inflow and venous outflow of abdominal....organs" limited or complete. Do both codes require documentation of arterial inflow and venous outflow? If either one of those components is missing, do we code the limited exam, or do we not code the duplex exam at all for lack of documentation?

Vascular Study Question/Technician vs. Reading Physician

For vascular study readings, our workflow is as follows: A vascular test is done. The technician enters the information into the report. The report has his/her name and time listed directly below the impression on the report. Then the reading physician signs each report electronically after he/she reviews the report and the attached images. The physician may or may not make changes to the documentation. If changes are made, the original person (technician) who added the documentation will be removed at that time; however, if no changes are made, the technician’s name will remain on the report. My question is, since the impression was already originally entered by the technician, can we bill for the reading physician since he/she is reviewing the findings? Example: "Conclusion: Negative study for deep vein thrombosis within the left lower extremity [10/6/2017 7:17:25 AM - Doe, John]."

Failed Watchman

Patient arrived for Watchman. Transseptal puncture was done along with left atrial angio and left atrial appendage angio. After reviewing the angios and intra-op TEE, it was determined there was not enough depth to place the Watchman. The hospital updated the patient's status to outpatient and billed 93452. I'm not sure the coding is correct for this failed Watchman. I was thinking of 33340-Q053; however, this must be billed as inpatient. Please advise.

Procainamide Study

What is the appropriate coding for procainamide challenge to rule out Brugada syndrome?

Treatment for in-stent restenosis

Situation: 64-yr-old female with left lower extremity claudication (lifestyle limiting), status post SFA recanalization and stenting. On follow-up, U/S velocities were 600 cm/sec, suggesting high grade stenosis. Patient was asymptomatic at the moment. We performed an angiogram showing 80% stent restenosis, treated with angioplasty/re-stenting. How would you code this?

Stent in RC and then angioplasty in 2 branches of the RC

Physician placed a stent in the RC (92928-RC), followed by angioplasty in the RPDA (92921-RC). Then, he did kissing balloon angioplasty in the RPDA and RPLV (92921-59RC). Can I bill for the third procedure in the right coronary?

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