Knowledge Base

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Coding ASD/PFO after is has been repaired

After the ASD/PFO has been repaired and there is no residual left, should I code the echo as congenital (93303) or non-congenital (93306)?

Repair RT femoral artery & drainage of abdominal wall hematoma

"Patient had enlarging hematoma in the right groin post angio. Incision was made in the right groin, and dissection was carried down to expose and gain control of the femoral artery, which was bleeding actively. Interrupted prolene sutures were utilized to control the bleeding. It was noted the patient did not have retroperitoneal hematoma. After further dissection on to the external iliac artery, patient was noted to have a large abdominal wall hematoma. The external oblique muscle was opened up, and a large hematoma was evacuated. There was old clotted and non-clotted blood. Patient appeared to have had a small tract from the active bleeding area of the artery posterior to the muscle into the abdominal wall. Upon completion of the drainage, the area was irrigated thoroughly with irrigator solution and antibiotics. Wound was then closed in a double-layer fashion with absorbable sutures." I have 35226 for the femoral repair, but I am stumped on how to report the hematoma drainage. Any guidance would be greatly appreciated.

Extensive Resection of AV Fistula and repair of brachial artery

The physician removed a massive 5 cm wide fistula that was not infected. He also repaired the brachial artery. Code 35903 is for removal of an infected fistula. Is there a more appropriate code for this? We are trying to avoid using an unlisted code.

How do we use the new multiple contrast codes 74220 and 74221

One of the changes made this year is to break CPT 74220 into two codes, to distinguish between single contrast exams and double contrast exams. Code 74220 has been retained, but redefined as "single contrast". Code 74221 has been added as a new code for "double contrast" exams. The example given for 74221 is an exam in which both barium and a solution of sodium bicarbonate crystals in water are administered. Scenario 1: Does the definition of 74221 apply only to studies in which both barium and an effervescent agent are administered, or does it also apply to studies in which any two contrast agents are used? Scenario 2: How would we code the occasional study in which water-soluble contrast, barium, and an effervescent agent all are administered? The definition of 74221 is specifically "double contrast". Would we have to report such a study with unlisted code 76499?

Congenital vs. non-congenital echo

I review coding for a pediatric cardiology group. The cardiologists frequently bill complete congenital echoes even when there is no congenital finding (for example, syncope or a functional murmur). Is there a difference between the two "complete" echoes with regard to the structures viewed and measurements? In one conversation, one of the doctors did seem to feel the complete congenital echo was more work than a complete non-congenital echo and wished to bill the 93303/93320/93325 instead of 93306.

Endocardial EP Ablation

Patient had a PVC ablation performed from the endocardial regions instead of epicardial. Is there a difference in reporting?

Radiofrequency Ablation Sacral Ala & Lateral Branches

For the following dictation, what can be coded? Would it be coded as 64640 x 4 (for the levels) or 64640 x 12 (for the 12 sites)? “Procedure: Fluoroscopically-guided radiofrequency ablation at right sacral ala and lateral branches at S1, S2, and S3 (12 sites). Detail: Following informed consent, and with the patient under general anesthesia, she was prepped and draped in usual sterile fashion. The skin and subcutaneous tissue were anesthetized. Following this I used a 22 gauge angulated 150 mm exposed tip needle at each level, correctly placing them under fluoroscopic guidance at right sacral ala and lateral branches at S1, S2, S3. After stimulating at each level without evidence of motor signs, I performed radiofrequency ablation at each site, heating the affected nerves to 80 degrees centigrade for 90 seconds. A total of 12 sites were heated and treated. I removed the needles and applied sterile dressings.”

ICE Catheter Used During TIPS

How would you code for an ICE catheter used for guidance during a TIPS procedure?

Cutdowns

How to code cutdowns. What does the word cutdown mean? Femoral artery cutdown? Carotid artery cutdown? Brachial artery cutdown? Is the repair included in the cutdown?

BASILICA During TAVR - Comparison Code

We are reporting unlisted code 93799 for a BASILICA procedure performed during TAVR in addition to 33361; however, we're unable to come up with a comparison. What CPT code might be used a reasonable comparison for the BASILICA procedure?

New coverage information for Vertebral/Kyphoplasty

Can you please help me understand the new LCD for vertebral/kyphoplasty? Am I understanding correctly that the patient has to be seen by a neurologist prior to the procedure being done? And did they remove all the previous ICD-10-CM codes? The new policy I'm looking at only shows: M80.08XA - Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture; M80.08XS - Age-related osteoporosis with current pathological fracture, vertebra(e), sequela; M80.88XA - Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture; M80.88XS - Other osteoporosis with current pathological fracture, vertebra(e), sequela I'm really confused by this. I need to understand it better before I let my IR know about these changes. I think they took place.

Watchman and A-line Monitoring

Can code 36620 be billed with 33340?

50684

When is it appropriate to bill code 50684?

Cerebral angio

Would it be possible to code diagnostic and catheter selection during the same study? Example: The doc knows that he is performing an embolization for a known aneurysm in the right internal carotid artery. Before he starts this, he says he is doing a left diagnostic angio (left carotid artery and left vertebral). So, would this be coded 36224/36226-LT and 36217 (for right internal) and 61624 for embo? Or would these qualify for all cath placements (36217/36216 x 2)?

Clarification 33208/33233 vs. 33214 (Re ID:13287)

In follow-up to our previous question (Question ID: 13287) titled “Single chamber tv PM replaced w/dual chamber PM generator and L atrial lead,” can you clarify why CPT code 33214 would not be appropriate in this scenario? Is it related to the anomalous patient anatomy (arterial switch) and the new lead being placed in the LA instead of the RA? Code 33214 seems to describe exactly what was executed in our procedure. "Procedure: Patient with single chamber (LV lead) pacemaker, pacemaker generator removed, insertion of new lead to L atrium, and new dual lead pacemaker generator inserted. Existing ventricular lead retained and hooked up to new generator."

Thrombin Injection into superficial tumor bleeding site

Would unlisted code 37799 be appropriate for the following? "Patient referred for removal of tunneled central line. The catheter exit site involvement with tumor was prepped, and during the sterile prep the tumor started to be bleed superficially. Direct pressure did not ablate the bleeding, nor did cautery, nor injection with lido with epinephrine. 2000 units of thrombin was injected into the superficial tumor bleeding site, which resulted in cessation of bleeding. The catheter was not removed on this encounter."

37246 vs. 61630

Please explain the difference between codes 37246 and 61630 for intracranial angioplasty.

Collateral Stenting

Pediatric patient with dextrocardia, double inlet left ventricle, pulmonary atresia, and MAPCAs receives two stents, one in left and one in right aortopulmonary collateral. Do you agree with unlisted code 37799, or are cardiovascular system unlisted codes 39999/93799 more appropriate?

TPA challenge

Repeat mesenteric exam. No bleeding source identified again. tPA challenge done. What code is used for the tPA injection, if any?

BI VENTRICULAR AICD POCKET REVISION

I know that there is no longer a CPT for revision, so I was wondering what would be the best way to code this procedure. "Incision made over device and device removed. Leads disconnected from device, and pocket revision performed to free the previously placed leads. Leads were then reconnected to generator, irrigation of pocket performed, and generator placed back in pocket. Pocket closed and patient sent to recovery in good condition." Would this be billed as 33215 or unlisted CPT?

Percutaneous Drainage and Occlusion of Postop Atrial Hematoma

Patient had a post-operative coronary sinus dissection that propagated to the posterior LA and IAS causing a large hematoma that was obstructing flow. The procedure performed was percutaneous drainage of a coronary sinus/left atrial hematoma and placement of a 35 mm Amplatzer Cribriform Occluder device in the left atrium, through the hematoma, and into the right atrium. I’m going to use unlisted code 93799 comparable to 93580 for the acquired ASD occlusion repair. However, would the percutaneous drainage of the atrial hematoma be inherent to the placement of the atrial occlude device, or can I bill it separately? If I can bill for the hematoma drainage separately, would it be an unlisted code?

0205T vs. 93799

How and why would code 0205T be used? The description states intravascular catheter-based coronary vessel or graft spectroscopy during diagnostic evaluation &/or therapeutic intervention.

RHC with Heart Biopsy

When is it appropriate to report/code a right heart cath with heart biopsy when performed in the same setting for a patient post heart transplant? Is having any additional diagnosis, like pulmonary hypertension, sufficient to support coding the RHC? Is an additional diagnosis sufficient, or is there additional language required in the body of the note to support coding both RHC and biopsy?

How to bill IP procedure on OP

We had a STEMI come thru ER and emergently taken to cath lab. Patient was appropriately statused as IP by hospitalist and received a drug-eluting stent for a 100% occluded RC. Six hous post stent a different MD came behind and downgraded to OP status. How can we bill the case? Can we bill C9606 with -CA modifier?

Art line insertion with general anesthesia

Can art line insertion be charged with any procedure that uses anesthesia? EP, TAVR, cath lab? It seems it was mentioned in your most recent seminar; however, I cannot find notes regarding the comment. 

27590 vs. 27592

We're looking to find out when it is appropriate to bill 27592 vs. 27590 for an AKA, first operation. "Standard anterior-posterior fishmouth type incision was made justt above the knee. This was carried through skin, sub-q tissue, and through crural fascia muscle layer. All muscular tissue was transected using electorocautery surround the femur. We then identified the popliteal arter and ven and ligated artery and vein with silk sutures. We then ligated distally as well and transected them. Next, we completed our posterior circumferential transection of muscles and tendons around the femur. Finally the sciatic nerve was ligated high in the field and then cut high in the filed and allowed to retract back. I then made another cut anteriorly on the femur with the oscillating saw to create a bevel to avoid any compression. A rasp was used to file down the edge of the femur so it was not sharp. I then irrigated and achieved full hemostatis. I buried the popliteal artery and vein stumps. We then closed in layers."

Technical portion of remote device check

Since 93299 has been deleted from CPT, if the patient does not have Medicare so G2066 does not apply, what CPT code should be reported on a claim?

2020 pericardiocentesis code guidance

With the pericardiocentesis code updates for 2020, could you please provide guidance regarding the use of 33016 and 33017? What is the difference between a drainage tube that we may see with 33016 and an indwelling catheter we see with 33017? What should we look for when trying to determine the difference? The old code, 33010, was used when drainage access was done percutaneously. Code 33016 doesn't use specific language to that effect, but is that still the same? Similarly for 33017, with the old code there needed to be an incision made, but now the code description states that this is done percutaneously; does that mean an incision is no longer required?

EPS with ?RHC?

Patient with wide complex tachycardia has a diagnostic EPS with 3D mapping, programmed stimulation of the left ventricle, and ICE revealing a right to left shunt. A Swan-Ganz is placed and O2 saturations and QP/QS are calculated, but no pressures reported. Swan is removed at end of procedure. Reporting 93620, 93613, 93622, 93623, 93662, but ????? the O2 sats and QP/QS as this is not 93451?

Carotid Arteriogram and Intervention

"A right brachiocephalic stent was placed via a right femoral approach. A selective catheter was placed in the right brachiocephalic with images. The catheter was then advanced through the right bracheocephalic, subclavian, and axillary in the right brachial artery. Images of the right brachiocephalic were obtained. The bilateral common carotids, bilateral subclavian, bilateral vertebral, and the right axillary were all read." Are 37218, 32222-59, and 36226-59 the codes to use for this procedure?

93657 for CFAE ablation post PVI ablation

Would it be appropriate to report code 93657 for CFAE ablation in absence of atrial fibrillation after PVI ablation (per CPT Assistant 9/1/2019 Frequently Asked Question: Surgery: Cardiovascular)? CPT Assistant's answer would be in contradiction with the description of the code, which states the code is for the treatment of atrial fibrillation remaining.

When to code percutaneous vs open ECMO procedure

Encounter 1: the surgeon did percutaneous insertion (over 6 years in age) into the common femoral artery and femoral vein. The next day (Encounter 2) they do groin cutdown and expose both artery and vein. They decannulate both vessels and perform patch repair on both vessels. Do I code 33952 (percutaneous) for the first encounter and 33984 (open) for the removal and repair of the femoral blood vessels? 

37241-37243 VS 20615 FOR ANEURYSMAL BONE CYST

I've seen both 37241 and 20615 as answers for sclero of an ABC. How would you code these?....#1Care taken to avoid inferior epigastric and femora vessels. direct injxn. doxycycline foam sclero into rt. pubic rami and acetabulum ABC w/guidance-3 sites....#2 - Prev.angiog.com.iliac art. showed no abnl.tumor vascularity. Image guided sclero of lg. aneurysmal bone cyst rt. ilium-4 sites. Which code? How many sites coded?

38222 Bone marrow biopsy(ies) and aspiration(s) Documentation example

One of the physicians I code for only states a bone marrow biopsy and aspiration was done, but doesn't provide a description of how the procedure was performed. Could you please provide an example of the documentation needed to support the assignment of 38222? 

Interstim Confusion

Could you please clarify the changes in how codes 64561 and 64581 are used since the stipulation of temporary vs. permanent has been removed? Code 64561 is now described as including guidance and is percutaneous, and can be either temporary or permanent placement of electrode. Code 64581 is described as using an open approach, and it also can be temporary or permanent. My surgeons normally use a percutaneous approach to place a permanent tined lead through the S3 foramen, create a pocket and tunnel, attach an extension to the lead, and send the patient home for a trial period before they call the patient back for placement of the InterStim generator (64590). This sounds like 64561 to me because of the percutaneous approach and use of fluoro guidance. The type of lead and the fact that it is permanent seem irrelevant. They want to code 64581 because they are placing a permanent tined lead, and they have always used 64581 for stage 1.

Open repair of right radial artery pseudoaneurysm with primary r

How would you code this procedure? Would you use 35045 or unlisted code 37799 where no graft or patch graft performed? "Patient was brought to the operating theater and placed in a supine position. The patient's right arm was prepped and draped in the usual sterile fashion. Once timeout was completed, we created a longitudinal skin incision overlying the pseudoaneurysm with a 15 blade. We dissected through subcutaneous tissue with electrocautery. We identified the pseudoaneurysm and dissected it out circumferentially. We dissected out proximal and distal radial artery and applied vessel loops for proximal and distal control. We then systemically heparinized the patient. We obtained proximal and distal control and then created a vertical arteriotomy with an 11 blade. Carried this cephalad and caudal with potts scissors. We retrieved some old thrombus from the sac and were able to identify small bleed from the artery where the sheath had been placed. We oversewed this with several 6-0 prolene sutures and a pledgete suture."

Modifier 62

I have three providers who think that they can bill out modifier -62 for each on a TAVR procedure. PLEASE, correct me if I am wrong, but a -62 modifier is only for two providers of different specialties. Only two providers can bill out for the procedure with a -62 modifier with supporting documentation. Not 3 or 4 providers. Is this right?

Single Chamber Pacemaker update to Bi-V pacemaker

The patient has a right ventricular lead, which was retained. The old generator was replaced with a Quadra Allure MP™ CRT-P, and the left ventricular lead was inserted. Would code 33229 be reported, or is 33214 more appropriate since only the right and left ventricular leads were utilized?

Cooling Cath

For 2020, is unlisted code 37799 the correct code to use for cooling cath?

Nipride challenge via existing Swan

A patient has a nipride challenge via existing Swan who also has critical care billed. Is this challenge bundled with the critical care, or how is this billed?

MSK Injection

Do you agree with codes 20550/76942 for this procedure? Instillation of steroids/local anesthetic mixture into laminectomy defect at L4 and L5 with ultrasonographic guidance.

Reporting Additional Codes with CPT 37215

For physician billing, are any additional codes appropriate when a carotid stent is placed using flow reversal? My understanding is that code 37215 includes the work of establishing flow reversal and closure, but some physicians want to bill codes 36556 and 35201 in addition to 37215. Here's an example of the documentation: "Right femoral vein access was gained using micropuncture under ultrasound guidance. An 8 French venous sheath was placed. Next a supraclavicular incision was made over the area of sternocleidomastoid muscle. Common carotid was dissected. Micropuncture was used to access common carotid artery. Silk road sheath was then inserted and secured with 2.0 silk suture. Flow reversal then connected. A 7 x 30 mm silk road carotid stent was then deployed. Postprocedure angiogram showed no residual stenosis. Wires and sheath were removed, and arteriotomy was repaired primarily with 6.0 Prolene stitches. Common carotid was unclamped. Total of 8.5 mins of flow reversal. Wound was irrigated, and hemostasis was controlled. Platysma was closed with 3 0 Vicryl in running fashion."

Second Epicardial LV Lead Used

I could use your help with this case ICD case. The first epicardial LV has failed, and the pocket was open to utilize the second LV lead. The generator was not changed; only the second epicardial lead was accessed/connected and the previous lead was capped. Here is part of the actual report: "The previously capped second epicardial LV lead was seen on the floor of the pocket, dissected out from the chronic scar tissue. The cap was then removed from the lead. The currently used LV lead was then disconnected from the chronic header, and the previously capped LV lead was connected to the header. Adequate sensing, impedance, and capture thresholds were confirmed through the second epicardial LV lead. The previously utilized but fractured epicardial lead was then capped and placed in the pocket. The device and leads were inserted in the pocket with care to ensure that the leads were beneath the device. The pocket was irrigated with antibiotic-containing solution." Would I report code 33999 for this scenario?

Medtronic Unibody Graft

I reported code 34703, but I'm not sure if that's correct. The note lists "unibody graft" for AAA. "An oblique incision was made on the right side, dissecting down to the site of the fem-fem graft through the previous scar. Once the external iliac arteries encircled with a loop, a micropuncture was used to access the vessel, and catheters were placed up into the aorta. There was noted to be plaque at the aortic bifurcation and the aorta. An angiogram was performed that showed where the renals were with a good neck. The patient was then heparinized. A 32 x 14 x 102 graft was deployed and brought up from the right side with some degree of difficulty. The device was released at the level of the renal arteries, which are approximately at the same level, and the top caps were released with good apposition here. Next, an angiogram was performed for the distal portion, and a 16 x 16 x 124 limb extension point was brought down to the hypogastric artery."

90 day PM or ICD remote monitoring

The rep is performing the interrogation, sending the information the provider, and the provider holds the claim until the 91st day. These codes are per 90 days, so can the patient have the remote services performed prior to the 90 days, and is it appropriate to hold them until the 91st day to bill? This would seem to be a stretch of the rules for these codes. Please provide clarification on remote coding and the correct dates for both the 93295 and 96.

ICD gen change with fluoro

I have a physician who did an ICD generator change and is wanting to bill 76000 for fluoro of lead. Report says: "Fluoroscopy of the ICD pocket, entire lead length from pocket to RA and RV was performed in AP, RAO and LAO. No externalization of the leads was noted." He then went on to exchange the generator, doing nothing to the leads. His indication is: "Fluoroscopy of leads to assess for conductor externalization." Would this be billable? He is a new EP to the practice and none of our other EPs have done this before, so we just want to be sure.

35011

Excision of left brachial artery pseudoaneurysm/reverse saphenous vein interposition graft left brachial artery with excision of excess skin. I was thinking 35011/15839. Despite no edit being in place for 35525, it does not look right being billed as 35011/35525/15839. May I please have your advice?

Watchman denials for dx I48.19

The Watchman procedures that we have billed since 10/01/19 for diagnosis I48.19 are not on the NCD 20.34. They are requesting that we change it to I48.1. As you know an additional 5th digit is now required for this code due to coding update 10/01/19. The NCD has not been updated to reflect this change according to our MAC, which is CGS. Is the only way to get this paid is do an appeal? Do you have any information or suggestions on how to handle this issue? At this time we have 6 claims that are not paying.

Synthetic graft & saphenous vein used for bypass

Our vascular surgeon documented fem to posterior tibial bypass done with synthetic graft and saphenous vein graft. This was due to saphenous vein not being sufficient length to accomplish the bypass, so he elected to perform a composite Gore-Tex and saphenous vein graft. End-to-side anastomosis done with the synthetic graft to the femoral, posterior tibial anastamosis was accomplished by means of an end-to-side anastomosis with the saphenous vein and end-to-end anastomosis was accomplished from the saphenous vein to the distal Gore-Tex graft. Would I use an unlisted for this procedure?

Additional 3rd order with 36224.

The patient had a diagnostic angiogram of the ICA followed by neuroembolization of the anterior and middle cerebral arteries. I wanted to code for the catheter placement into the anterior and middle cerebrals with 36218 x 2. However, 36224 is not a base code for 36218. Please advise what to charge, if anything, for the catheter placements after 36224.

332498 & 33225

How would I code a CRT placement with capped atrial port? "An RV single-coil ICD lead was delivered and deployed, as well as LV lead, both leads anchored to the floor of the pocket. Pulse generator was brought to the field and the atrial port was plugged." Code 33249 is correct for dual leads. How do we account for LV lead, 33225?

93299 vs. G2066

Can you explain if the G2066 is to be reported in addition to the 93297 / 93298 codes - wouldn't this be double-dipping on the technical portion if 93299 was deleted and CPT Changes is saying this was deleted and the 93297/93298 will reflect the practice expenses? Is this new HCPCS code a "tracking" code and no reimbursement is expected?

Two docs, same group for cath and intervention

Quite often, one of our cardiologists will do the diagnostic cath, and then the interventional cardiologist will step in right after to do the angioplasty/stent. For years, I have been applying the -59 modifier to the diagnostic cath, and I am now being told that this is incorrect since two separate docs are involved. Since they are from the same group, isn't this recognized as one and the same doctor and a -59 modifier will be needed on the diagnostic cath?

Ablation of SI

How would you code the following? It has been suggested to use codes 64640 and 77013, as these are not true paravertebral facet joints. Looking for clarification or suggestions. "The region of the medial branches at the L5/S1, S1, S2, and S3 levels were identified under CT. The overlying skin was then numbed using 1% lidocaine. Under CT guidance needles were advanced adjacent to these nerve sites. The ablation needles were placed, and motor testing was performed at four sites. No motor activity was appreciated. The sites were then numbed with Marcaine, and ablation of the L5/S1 facet as well as the S1-S2 and S3 sites along the SI joint was performed. Needles were removed, and sterile dressings were applied. IMPRESSION: Successful SI joint ablation."

Does documentation support 93657?

Does this documentation support 93657? "Isolation of all four pulmonary veins was performed. While isolating the right pulmonary vein, phrenic nerve integrity was verified via pacing, the phrenic nerve utilizing the quadripolar catheter above the pulmonary veins. Following the last cryo-application, the cryo-balloon was removed, and a post-ablation voltage map was then created. There was evidence of a gap in the right superior pulmonary vein. The balloon was then prepped again and advanced in the right superior pulmonary vein. An additional application of cryotherapy was made. Following this, the balloon was exchanged for the PentaRay catheter again. Post-ablation voltage mapping showed all veins were isolated."

93880 MUE

We billed out 93880 but received a denial because the patient had one at another physician office. The MUE lists 1 and 3. Is there only 1 per day, or can we appeal with report? Could possible modifier -XP and/or -77 be used in this case?

C9754, 64415

I have a physician who is doing the Ellipsys placement. Prior to the procedure he is performing a supraclavicular nerve block. Is this a separately billable procedure, or is it considered part of the per fistula placement?

37184 - 37188 and TPA

Is the use of tPA a requirement when performing percutaneous transluminal mechanical thrombectomies? 

How to obtain proper reimbursement for unlisted procedures 37799?

I verify with the surgeon a comparison code and we send letters to the insurance companies. I have also suggested management involvement on a contracting level. However there are payers out there that deny unlisted procedures as investigational. I don't understand that, as some of the procedures have been performed for years. Some examples of unlisted procedures that come to mind are stab phlebectomy of varicose veins less than 10 incisions, median arcuate ligament release, and bypass revisions that don't have a code in CPT like revision of arterial bypass that are not lower extremity or hemodialysis grafts. What do you suggest?

Multiple attempted, unsuccessful line placements

My provider attempted to place a central line in four different vessels with US/fluoro, but was unsuccessful. The op note states, in summary, "Inability to thread wire through vein once vein accessed. Attempted at right subclavian, right IJ, left subclavian, and left IJ." Ultimately, the provider was unable to place a central line and abandoned the procedure. Do I code each attempt with a -53 modifier?

CPT code for Innominate to left common carotid artery bypass with 8 mm dagr

CPT code for innominate to left common carotid artery bypass with 8 mm Dacron graft and 8 mm Dacron graft cannulation of innominate artery. These two procedures were done with aortic valve replacement (David procedure): 33864. Can't find codes. 

ICD pocket debridement

Patient with CRT-P came in with pocket infection. Opened pocket and just did debridement of pocket with tissue cultures sent to lab. Placed original device back in pocket and closed. What would be the correct billing code for this procedure?

Aortic root replacement, cut down and LAA

If the following procedures listed below were performed during the same operative session, would the LAA be considered bundled with the aortic root replacement? Also, how would you code this scenario? 1) Aortic root replacement with 27 mm freestyle with ascending aortic aneurysm repair with 26 mm tube graft. 2) Right femoral artery cutdown for arterial cannulation. 3) Ligation of left atrial appendage with Atriclip. 

49325

In question ID 8519 (answered in 2016) regarding a delayed extension of an intraperitoneal catheter extension, the example states that the exit site is the left upper quadrant, but the CPT description is for remote Chest exit site. I can't find any resource the clarifies the remote chest exit site can include an upper abominal quadrant. To be fair, our cases perform the extension at the time of initial placement (49324) but for future coding and auditing purposes, can you let us know where this clarification comes from and why we can code 49325 for an extension into the abdominal area?

KX modifier on device codes

I am getting a denial back from our billing office stating that the required modifier on C1785 is missing. The primary diagnosis was I48.1, and CPT 33208 was coded with a -KX modifier appended. Is the -KX or -SC modifier also required on the device codes?

When is it ok to bill for non-pv triggers post PVI ablation?

"We isolated all pulmonary veins using wide area circumferential ablation. The right carina was ablated. External cardioversion was not performed. Pulmonary venous conduction block was demonstrated using entrance block (adenosine) and exit blocked (pacing). Posterior wall isolation was not performed, but an anterior roofline was ablated." Are codes 93656 and 93657 correct?

Correct coding for a "Florida sleeve " for aortic root dilation & AV insuff

Our doctor's short description of what was done is: "Transesophageal echocardiography; total cardiopulmonary bypass; Florida sleeve aortic root reconstruction using 30 mm Dacron Hemashield graft and reduction aortoplasty of aortic root above the midportion of the noncoronary cusp." We are back and forth between 33864 and 33860-22. Since the Florida Sleeve procedure is new to our facility, I'm asking what the most appropriate code would be. Since the surgery was similar yet a different procedure with the root than the "David Procedure".

Modifiers LT/RT on Dialysis circuit codes

Is it correct to add -LT/-RT site modifiers on dialysis circuit codes 36901-36909 or creation/revision of the graft/shunt codes 36800-36861?

Thoracotomy drainage lung parenchymal&pleural abscess

What is the code for the procedure above? and here is the note. Thank you in advance, I performed a standard posterolateral left thoracotomy, shingling the rib in about the fifth intercostal space. The lower lobe was very inflamed and matted down and the upper lobe was relatively adherent as well. With difficulty, I was able to mobilize the lower and upper lobes. There appeared to be 2 abscesses of the lower lobe that are perforated into the pleural space and there were multiple collections of thick yellow pus. There was approximately 1200 mL or more of purulence in a rather small hemithorax. I was able to mobilize the lung and wash the entire space out. The chest wall was rather raw as anticipated and oozy, so we did give him DDAVP. We irrigated with multiple liters of saline. I did obtain cultures. I placed a posterior right angled 28 at the base of the thorax and a more anterior access tube to the apex of 28.

Thrombectomy at time of AVF creation

"A patient underwent creation of a brachiocephalic AVF. After construction, thrill in the fistula was noted to be weak. The anastomosis was taken down and fresh thrombus was seen at the anastomotic site. This was removed and flushed away with heparinized saline. Then thrombectomy of the brachial artery was performed with a Fogarty catheter. The artery was flushed. A Fogarty catheter was passed into the cephalic vein and a small amount of thrombus was extracted. The vein was flushed. The anastomosis was redone." How would this procedure be coded? Would the thrombectomy be considered part of the AVF creation, or is it separately reportable?

DFR during heart cath

We have been seeing some of our heart doctors say they are doing a DFR during heart cath. I have seen the FFR but have not been able to find enough information to get a code for the DFR procedure. Physician says EX: "We then did Comet wire interrogation of the LAD and left main Distal to the LAD lesion the DFR was 0.85, significant. Next EX: Diagnostic cath was done then a DFR determination RCA with Mach1 6 French FR4, unfractured heparin weight adjusted." Some coders are using the 93571 FFR, but Im not sure there is enough documentation for this. Do you have any information on the DFR procedure? 

Large French cath placement with Impella joint case

The vascular surgeon was called into the cardiology case for a placement of the Impella (33990), requiring placement of a 14 French for the cardiologist to be able to place the Impella in a high risk patient. Code 34713 is only allowable with TAVR, EVAR, FEVAR, and TEVAR procedures. It would not be an allowable separately reportable service for the vascular surgeon, or as an add-on to the Impella. Would they both share code 33990 with either an -81 or -82 modifier for the vascular surgeon for the placement of the 14 French sheath, or would the vascular surgeon not be able to bill for the Impella at all?

93623 Post Ablation

I believe 93653, 93655, and 93609 are documented here, but I wonder about 93621 and 93623? Is the coronary sinus location for 93621 and key word 'induced' enough to support 93623? "We first mapped and ablated the left slow pathway, mapping the retrograde sequence during atypical AVNRT with retrograde left slow pathway. After ablating this pathway, the sequence in the coronary sinus showed only retrograde right slow pathway activation. The right slow pathway was then ablated. Junctional beats were seen both with left and right slow pathway ablation. After this, no sustained tachycardias were inducible with and without the use of isoproterenol. After waiting period of about 30 minutes, repeat testing was done, and no tachycardia was inducible. The patient was recovered from sedation. Catheters were removed. There were no recognized complications."

Update on convergent or hybrid cardiac ablation?

A question about how to code for hybrid approach EP ablations was asked back in 2017 (question ID 8968). Recommendation was to use an unlisted code for this investigational procedure, and to check with specific payers. Also, use 93656 for A-fib ablation if done at separate encounters. Are there any more current recommendations on how to code these procedures now (2019/2020) from Dr. Z?

Coding for 93623

Is the following documentation sufficient to report code 93623? Would you please explain why or why not? "Bidirectional block was demonstrated in and out of all four pulmonary veins post ablation. Adenosine was administered in 9 mg boluses to check for dormant pulmonary vein reconnections, and additional ablation was administered as needed to eradicate these connections."

93463

Is CPT code 93463 billable for the physician side? A doctor had performed a dobutamine challenge for aortic stenosis assessment during a heart cath. In his documentation, he stated the resting peak and mean gradients along with his findings. Hospital/facility side is saying it's only a technical charge whether he administered it or not. Please advise.

Follow up on Holter question ID: 8872

Code 93225 is a code that does not have a physician component. Can this code be billed without the device being returned for scanning and analysis?

Septostomy

Can a blade method septostomy (92993) be coded with a transvenous balloon septostomy (92992) performed in the same session, or is one bundled into the other?

Biventricular ICD Changed to a Biventricular Pacemaker

Patient presents with biventricular ICD …. Due to her current condition(s), the physician decides to change to a biventricular pacemaker and uses the existing leads. When you gave an example in January 2018 transposing the type of generator change, your printout states to code the PM generator removal (33233) and the ICD generator attached to existing leads as 33240, 33320, or 33231, as appropriate. This would imply the opposite coding would be 33221 and 33241. Can you provide any insight?

Joint injection?

"Using fluoroscopic guidance, a 25 gauge needle was advanced to the location where the gluteus medius and minimus tendons attach to the greater trochanter. A small amount of contrast was injected to confirm position of the needle tip. Subsequently, a mixture of Depo-Medrol 80 mg and lidocaine was injected at each site." Is this a hip joint injection?

36831 vs. 36833

Regarding the previous Q&As about billing open thrombectomy with open angioplasty or open stent placement, the advice was to bill 36833 for revision. We have been using 36833 instead of 36831 for open thrombectomy with open stent or angioplasty in the dialysis circuit. We have received several denials from Humana and Healthsprings after they have requested and reviewed the procedure notes. They are stating that all angioplasty and or stent placement in the dialysis circuit is bundled and we are billing 36833 in error. The only guideline we can find in CPT states open dialysis circuit creation, revision, and or thrombectomy (36818-36833) bundles peripheral segment angioplasty and or stent placement (36901 36902 36903) However dialysis circuit central segment angioplasty or stent placement may be reported separately (36907 36908). Is there any CPT guidelines or any other references that we can use for the appeals to show that we are correct in using 36833 for open thrombectomy with open stent or open angioplasty in the dialysis circuit? 

Appropriate Use Criteria Modifiers

I was hoping you could expand on two of the HCPCS modifiers that relate to Appropriate Use Criteria (AUC). 1) Modifier QQ - ordering professional consulted a qualified clinical decision support mechanism. Considering that there are more specific modifiers that will be available for CY 2020 (MA through MH), will this modifier have any relevance next year? 2) Modifier MG - the order for this service does not have appropriate use criteria in the clinical support mechanism consulted by the ordering professional. Can you explain when this modifier might be appropriate?

FFRs and IVUS codes

How is everyone billing for FFRs and IVUS codes? We get a lot of denials for FFRs and IVUS codes. Are we applying a -59 modifier or not? Or just a -26 and branch modifier or not? These codes have me so confused.

62264 or 62321

Is the appropriate code for this procedure 62264 or 62321? "The patient was brought to the fluoroscopy suite, and monitors were applied. The patient was placed in the prone position on a carbon fiber fluoroscopy table. The skin was prepped, wiped, and draped in the usual sterile fashion. Lidocaine 1% was used for skin and subcutaneous anesthesia. A Coude needle under fluoroscopy in PA/lateral position was used to enter the caudal epidural space. No CSF, blood, or paresthesia was noted. Epidurography: 5 ml of Omnipaque 240 was injected to confirm the epidural placement of the needle with real time fluoroscopy. No intervenous or intrathecal diffusion was noted. Poor lumbar and sacral diffusion and filling defects corresponding with patient’s pain distribution were noticed. A catheter was advanced towards the L4-5 level. Following multiple gentle mechanical manipulations contrast was injected, which showed some improvement in the lumbar and sacral diffusion. Then a solution containing lidocaine mixed with betamethasone was injected without problem, needle removed."

LD and LM separate vessels for IVUS/IFR/FFR

There are times whe our cardiology docs will pull back into the LM to verify the adequacy of the test when there is a lesion in the LD. In this case, we would just charge for the LD study. However, if they need to look at the LM for stenoses or a lesion as well, can both the LM and LD or LC be coded in that instance? My thought was yes, but one of our physicians told me he was told not to bill separately. Could you please advise?

92997 for PTA of embolus?

A patient presents to IR with bilateral main pulmonary artery emboli. The provider performs PTA of both arteries in an effort to create a channel for perfusion, and then initiates TPA bilaterally. There is no underlying, chronic cause for the PE; this was an emergent event. Is the PTA billable with 92997/92998? I am getting hung up on if its a true stenosis or not, and if the PTA was only a means to place to TPA catheters.

37226 or 37236?

Can we please pick your brain? Would the below procedure qualify as occlusive, or should it be used with 37236? "The left external iliac artery is patent with minimal atherosclerotic disease. The SFA is patent for about a centimeter, and there is a total occlusion of the SFA along about 8 cm length and appeared there is reconstitution via collaterals. There is some filling defect in the proximal aspect of the reconstituted SFA, which is now about mid femoral level consistent with thrombus and probably the cause of embolic debris. The popliteal artery is patent with minor irregularities, but no evidence of aneurysm or stenosis." Physician "felt that recannulization of the SFA was indicated because of the concern of embolization and thrombus that a stent was indicated". Stent was placed in this area.

Coding for 93566 vs. 93566, 93567, 93568

"HX: 1-day-old with HLHS on prosteaglandins. Cath and placement of flow restrictors in bilateral PAs, stent PDA, atrial septostomy in order to allow growth before Norwood proc. PROC: antegrade RHC using 5 French end-hole wedge catheter was performed & DSAO & RV pressures obtained & baseline oximetry. Power injection performed in RV. Measurements were made in RPA & LPA. ANGIO: Power injection performed in RV w/berman catheter and contrast shows no catheter related TR. The RV is moderately hypertrophied w/adequate systolic function. There is no angiographic obstruction of main PA. There is a large duct which is opacified & the descending aorta. There is retrograde faint opacification of ascending aorta. Both branch PA's appear of normal caliber. There is normal distal arborization." Would you code 93566 since injecting RV, or 93556, 93567, and 93568 based on angio description?

Diagnosis for cardiac monitors

My educators and I are having a discussion. Maybe you can help us on this. "Event monitor was placed. There were 7 events including baseline. Events showed sinus rhythm, sinus bradycardia, and sinus tachycardia. Symptoms includes shortness of breath, dizziness, and racing heart. Conclusion reads: Event monitor with 6 events recorded, symptoms were reported for sinus rhythm, sinus tachycardia." Would R00.0 be an appropriate diagnosis, or would the indications be a better choice since there really isn't an abnormal finding? My thought is that the sinus "rhythms" are just the rhythm the patient was in at the time they had their "symptoms." Sinus tachycardia isn't an abnormality to code here is it?

Code 76376

Is the following documentation sufficient to report code 76376, or does it need to state acquisition scanner? "With a 5 French vertebral catheter, the right internal carotid artery, left internal carotid artery, and left vertebral artery were selected in turn. Standard angiographic runs were performed from each location; rotational acquisitions with 3D reconstructions were performed from the left vertebral artery. The images were reviewed."

Fluoroscopic guided bilateral pedicle marker using Hilal marking coils

Could you tell me if C9728 would be the appropriate charge for the scenario below? Due to the fact they are placing coils, the attending feels 76000 would be the correct charge. "Using fluoroscopic guidance, a 20 gauge spinal needle was advanced toward the left T12 pedicle. Three 3 mm Hilal marking coils were placed overlying the pedicle. Placement was confirmed with fluoroscopy. The procedure was repeated at the right T12 pedicle, and again coils were placed overlying, then confirmed with fluoroscopy."

His Bundle Recording

I'm confused about what exactly is needed to bill 93600. Is just notating an HV interval enough?

DORV - TOF Type

The physician documents "double outlet right ventricle - Tetralogy of Fallot" type. Would you recommend coding both Q20.1 and Q21.3 to accurately capture the condition/diagnosis? Our CDI department recommends capturing both, but I would like to have your input. 

Code 0296T - External electrocardiographic recording

We receive many denials on code 0296T. Can you provide any guidance or suggestion for resources on required documentation and billing guidelines for this procedure both alone and in conjunction with other codes such as 93458, 92928, stress test codes, and ECG with pacemaker interrogation?

Percutaneous Fem-Fem Bypass for femoral occlusions.

Is code 35661 for open proc or can it be used for percutaneous bypass? "The interventional radiologist performs percutaneous accesses in RT internal jugular and LT SFV then performs small suprapubic incision and performs a needle access in each femoral vein through the incision. He places Ensnares through each percutaneous access (RT IJV/LT SFV) then performs through and through access from the lright internal jugular to the left femoral vein through the subcutaneous tissues in the suprapubic area. That area is dilated with balloons, the distance is measured with marking catheter. Long sheath placed the RT IJV through suprapubic soft tissues into the LT femoral vein. Through this sheath, percutaneous bypass was created using 8mmx15cm Viabahn stent. Two additional 8mmx10cm Viabahn stents were deployed to cover the complete segment between the two femoral veins with balloon dilitation. Successful percutaneous LT fem vein-RT fem vein bypass creation." Should this be an unlisted code (37799)?

93619 or 93620?

Is this reported with code 93619 or 93620? "Indication: Persistent atrial flutter with symptoms of congestive heart failure and slow ventricular response. An octapolar catheters and placed in the coronary sinus and quadripolar catheters were placed in the RV and His bundle region. A 20 pole catheter was then placed around the tricuspid annulus and baseline measurements were made revealing an AA interval of 280 ms, and R-R interval 950 ms and HV of 52. Pacing was performed from the coronary sinus and demonstrated a PPI minus TCL interval of approximately 55 ms. Pacing from the right atrium however demonstrated PPI minus TCL of over 200 ms suggesting this was not typical CTI flutter. The cardioversion was then performed to restore sinus rhythm and with further pacing maneuvers, we were able to demonstrate the continued presence of both clockwise and counterclockwise block. Significantly, the patient developed AV Wenkebach at cycle length 710 ms in sinus node recovery times were performed at 500 ms resulting in an SNRT of 3090 ms with a corrected CNS RT of over 1700 ms which was blatantly abnormal."

Geniculate nerve ablation with Coolief system

We have a physician using the Coolief system to perform geniculate nerve ablation. Procedure: Ultrasound-guided nerve ablation of the following nerves: Superior lateral geniculate branch from the vastus lateralis, Superior medial geniculate branch from the vastus medialis, Inferior medial geniculate branch from the saphenous nerve Ultrasound confirmed that needles were 50% depth of the femur and tibia and at the correct anatomic locations for all 3 needles. Motor stimulation was tested at 2.0 V with no leg movement. An additional 2 mL of 1% lidocaine without epinephrine was slowly injected at each of the 3 previously mentioned locations. Then a thermo-radiofrequency ablation of each of the geniculate nerves was done at 80°C for 2 minutes and 30 seconds each. The needles were then withdrawn. Is it appropriate to report 64640 or should it be an unlisted 64999? In addition, can we report our code per nerve or is each knee 1 treatment area, so 1 CPT?

Can you code 92997/92998 and 37236/37237 same session/same vessel?

Can you please clarify whether it would appropriate to code both pulmonary angioplasty codes (92997, 92998) and arterial vascular stent placement codes 37236, 37237 for pulmonary artery stent placement at the same session and in the same vessel? MD performed right heart catheterization, pulmonary artery angiography, LPA/RPA angioplasty – due to LPA,RPA narrowing bilateral stents were deployed. Of note the intent was not initially for stent placement but to determine why there was pulmonary stenosis. Please see reference below from Dr Z’s Medical Coding Series -Interventional Radiology coding Reference. Pg 278 #17. Separate cardiac codes for pulmonary artery angioplasty (92997,92998). Use established arterial vascular stent placement codes 37236/37237 for pulmonary artery stent placement(s). These procedures included catheter placements at the time of cardiac catherization.

What code would you use for the palcement of an Alfapump?

Would you use 49419 for the following? Sequana Medical’s alfapump is a fully-implanted, programmable, wireless, CE-marked system that automatically pumps ascites from the peritoneal cavity into the bladder, where the body eliminates the ascites naturally through urination. The potential of the alfapump to address the unmet medical need in patients with recurrent or refractory ascites has been demonstrated in multiple clinical studies showing a significant reduction in the need for large volume paracentesis, which is paracentesis where at least 5 litres of fluid is removed (i.e., the current standard of care), and a significant improvement in patients’ quality of life."

CTO 92943 Clarification use Mod 52 or 53

For physician billing, if the intent of procedure is CTO but only angioplasty is performed, is a modifier -52/53 required? Or since 1 of the 3 components is performed would no modifier be required?

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