Knowledge Base

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Chronic Total Occlusion 92943

Can I report CPT codes 92941 and 92943 in an "elective status" scenario? Or only in "emergency status" situations? If the patient has a CTO and goes in for an elective PCI, is it okay to report code 92943?

Aspiration and Contrast Study of the Left Thigh Fluid Collection

How would you recommend coding the following? I am thinking 20501 and 76080. Is the aspiration separately codable? "Under real-time imaging guidance, a 5 French access catheter was inserted into the lateral thigh fluid collection. 50 mL of thick nonpurulent fluid was aspirated. Specimen was sent to microbiology for further analysis. 10 cc of Omnipaque 300 was then injected into this cavity under fluoroscopy. No communication to the joint space was seen to joint space side. Permanent images saved in the patient's medical record. 1) Technically successful aspiration of left proximal, lateral thigh fluid collection. Specimen sent to biology for further analysis. 2) Contrast study of the left proximal lateral thigh fluid collection revealed no communication with the left hip."

Ref Question ID: 11615-Angiovac intracardiac

We have just begun to do these cases in our Hybrid Suite. The advisement by the company rep is to use code 33315. We are currently using 33999. I want to be sure that we are coding these cases appropriately. Has the way these procedures are coded remained the same or changed for 2019?

Disruption of Fibrin Sheath During Tunneled Cath Exchange

Would CPTs 36581, 36595-5952, 75901 or 36581, 77001 be appropriate for the following procedure? "The right neck was prepared and draped in sterile fashion. The patient's existing catheter was prepared and draped. A wire was passed through the catheter into the inferior vena cava under fluoroscopic guidance. The catheter was removed through the existing tunnel. A 10 mm x 4 cm balloon was placed through the existing tunnel into the lower superior vena cava and right atrium. Balloon angioplasty was performed with the intention to remove any residual fibrin sheath in the lower superior vena cava and right atrium. The balloon was removed. The patient's catheter was replaced with an identical line. The catheter was flushed and sutured into place. There were no immediate complications. A final spot radiograph shows the tip of the catheter to be in the right atrium."

Echo 93307 vs. 93308/93321

I know if all the components are there and Doppler/color flow are noted, we bill 93306. I also know when to be a 93308 and 93307. What I am unclear on is: all components are there and there is only mention of 2D/MMode and spectral Doppler. Can you then bill 93307? Or is this 93308/93321?

R&L Heart Cath (93460) with Biopsy 93505

Patient is seen for his post transplant surveillance. He had an echo that showed mildly dilated RV with mildly reduced systolic function. He has moderate tricuspid regurgitation. The physician performs a right and left heart catheterization with biopsy. I know we do not code 93451 with the 93505; however, would it be appropriate to code right and left heart catheterization with angiography (93460) or left heart catheterization with angiography (93458) along with 93505 in this case? We are starting to see more cases like this, and I want to make sure we understand correctly.

LE Revascularizations

When lower extremity revascularizations are performed in office setting (pos 11) under moderate sedation, are we allowed to bill for Q9967, J3010, and J2250 as well? Example: 37225-LT, 37252, 37253, 75625-59, 75710-59, 76937, 99152, 99153 x 3, Q9967, J3010, and J2250. Of course appropriate documentation for the moderate sedation and amounts of the drugs would be listed in report... I'm just not sure on the rules for billing the drugs themselves, and I can't seem to find any information from Palmetto GBA (AL). Thanks so much for any guidance.

Facility Reporting for Ultrasound Guidance

Our organization allows departments to report G0269 closure device; HOWEVER, our coders do NOT append a modifier to bypass the edit for additional reimbursement, as we understand this is a packaged service. We report all procedures performed under the OPPS, as long as coding guidelines permit. To our understanding, reporting all procedures performed within guidelines support CMS with future decision making regarding MUEs and packaging status for example. Regarding 76937 ultrasound guidance, currently, you do not receive an edit with 93458 and 76937 for HOPD billing. The current 2019 NCCI Policy is only addressing physician billing. Should the facility continue to report ultrasound guidance when performed with cardiac, coronary, EP, PPM/ICD procedures? Please advise on facility reporting to ensure our healthcare organization is reporting services appropriately.

36818 or 36821?

"I made a transverse incision at the arm crease, identifying the cephalic vein. I skeletonized the cephalic vein down to the forearm and up on the arm to allow for a tension-free transposition. I then began dissection of the brachial artery. We then identified that the brachial artery was a little more deep and lateral, and we began mobilizing the brachial artery. We got vessel loop control of the brachial artery. I divided the cephalic vein down on the forearm. I then beveled the end of the cephalic vein with appropriate length for tension-free transposition. We applied clamps to brachial artery and made an arteriotomy. We then transposed the cephalic vein onto the brachial artery, end-to-side anastomosis with 7-0 Prolene." Provider is saying this is 36818, but I don't think the documentation supports 36818. Please help.

Percutaneous stent in AVG and removal of overlying ulcerated skin

"Diagnosis: Left arm AV graft pseudoaneurysm with very thin overlying skin. Procedure: Loopogram with stent placement and revision of left arm AVG. A 5 French micropuncture needle was used to access the AV graft at the apex, and the micropuncture sheath was inserted. A loopogram was performed, revealing the large pseudoaneurysm at the arterial limb. An 8 French sheath was then inserted and exchanged over a J-wire, then a Bentson wire was inserted across the lesion. A 7 mm x 10 cm Viabahn covered stent was deployed across the area of the pseudoaneurysm, and balloon angioplasty was performed. Repeat imaging revealed resolution of the pseudoaneurysm. Wire/sheath were removed. A 4-0 Prolene U stitch on an RB needle was performed. Next, the area of the thin overlying skin was removed in elliptical fashion, and then the healthy skin was closed with 3-0 nylon vertical mattress sutures in an interrupted fashion." Should we code separately for removal of skin, as the stent was placed percutaneously? What code(s) should be used?

Repair of a false aneurysm in AV graft

"Needle entry into AV graft, diagnostic angiogram of graft revealed large false aneurysm, which compresses the true lumen by 60%, as well as stenosis in mid portion of the graft. Stent deployed to repair stenosis and simultaneously exclude false aneurysm. Skin was anesthetized over false aneurysm and needle placed directly into false aneurysm to fully drain. Seal was not complete, so balloon was inflated in stent to exclude false aneurysm. Second time, a Yueh catheter was placed to drain. 0.7 cc thrombin was injected directly into false aneurysm to dwell. No further leakage to aneurysm - successfully thrombosed. With incision and drainage, clot was removed from false aneurysm. Incision was closed with suture. Next, angioplasty was performed to treat stenosis in mid portion graft." What CPT codes can be assigned for this case?

Vein Occlusion

My doc did an angioplasty for a chronic occlusion of the left innominate vein before placing a CVC. "Occlusion/Vein" in the ICD book brings me to thrombosis, I82.B21. Do I code for CPT 37248 for stenosis (he doesn't use the word "stenosis," only "occlusion"), or do I code 37187 because of the DX occlusion says? The doctor says this is not a clot/thrombus. Can I code 37248 with I87.1 since an occlusion is 100% stenosis??

DFR

Recently our physicians have been performing dFR instead of FFR. For facility coding we have been using 93571 with a -74 modifier for outpatient procedures. What would you advise we use to report this procedure?

Percutaneous Fistula Graft Creation (Ellipsys)

Can you give me the correct Facility Coding guide for the creation of the Ellipsys AVF graft? Please include ICD-10-PCS codes as well.

One pseudocyst 2 catheters 49405

I have a patient with a pseudocyst of the pancreas, and the attending placed two indwelling drainage catheters. Would that be 1 or 2 units of 40405?

Cor Triatriatum

What is the correct code for transcatheter RF septotomy of the congenital cor triatriatum sinistrum?

Impella

"Patient came in for redo MVR, TVR, and insertion of Impella LD. A 10 mm Gelweave graft was then anastomosed to the distal ascending aorta using running 5-0 Prolene suture. The graft was brought out the left neck near the sternal notch. The Impella LD was then inserted and positioned in the ascending aorta. The aortic cross clamp was removed. The patient was deaired, rewarmed, and weaned from bypass in the usual manner without difficulty. The Impella was appropriately positioned across the aortic valve with excellent hemodynamics. All cannulae were removed and all sites oversewn." Do you recommend an unlisted CPT code?

20206 vs. 20220

Our physician performed a CT-guided core biopsy of the right S1 pedicle soft tissue mass. The soft tissue mass eroded the right S1 pedicle yielding fragmented cores. Would this be coded 20206 instead of 20220?

Modified Barium Swallow (CPT 74230)

Does the physician have to be in the room for the hospital to bill a barium swallow (74230)? If they are not, what can they bill? What about the professional component?

Percutaneous Removal AV Graft Stent

What CPT code we would use for the removal of the AV graft stent? "1) Antegrade and retrograde ultrasound-guided access to the right forearm AV graft (image stored x2) with fistulogram and left brachial arteriogram. 2) Foreign body retrieval, arteriovenous graft covered stent removal. 3) Pharmaco-mechanical thrombolysis of AV graft. 4) Percutaneous transluminal angioplasty of arterial and venous anastomosis with completion fistulogram. PROCEDURE: Through the antegrade sheath, wire access was obtained through the arterial limb stent graft and into the venous limb of the graft. A 10 mm Gooseneck snare was advanced over the wire. The stent was constrained with manual compression on the skin and captured with the snare. The snare and sheath were removed as a unit over the wire. Covered stent graft was removed in its entirety. Successful retrieval of the constrained indwelling covered stent in the arterial limb of the graft. The previously noted iatrogenic graft-venous fistula is no longer present. Successful arteriovenous graft thrombolysis."

AV fistula angioplasty and thrombus removal via two separate access sites

"We started the procedure by locating the left arm cephalic vein fistula. Access was achieved, and a 5 French was advanced without difficulty. Left brachiocephalic AV fistula angiogram and central venogram done, and a recurrent stenosis at left cephalic arch was noted and crossed with torque wire. Balloon angioplasty of cephalic arch with 8 x 40 mm Charger balloon (36902). Completion angio shows excellent flow via cephalic arch without residual stenosis. We then noticed presence of chronic clot adherent to proximal cephalic vein at aneurysmal segment without complete occlusion. Another access was done with micro puncture kit and proximal location and upsized to 8 French. We utilized an 8 French LIMA guide for suction thrombectomy and were able to remove some clot from cephalic vein. Completion angio shows some residual clot at cephalic vein without any flow compromise. Repeat duplex US shows residual clot, which was not able to be removed with suction catheter." For the thombectomy, since it is being done via a separate access site, would this be 36905-59 or 37187-59?

Amplatzter Duct Occluder Closure of Main Pulmonary Artery

"The patient is a two-year-old with tricuspid atresia, status-post bidirectional Glenn procedure with continued antegrade flow from the right ventricle. A recent catheterization showed high systolic pressures in the LPA with a high Glenn pressure noted. Pulsatile flow noted in the LPA with systolic pressures up to 18-20 mmHg with a mean gradient of 16 mmHg. There was loss of pulsatility with a mean pressure of 13 mmHg within the SVC. Angiography demonstrated a narrowing in the MPA from a band that was placed. The narrowing was approximately 4 mm. A 6 French delivery system was advanced into the RV retrograde from the pulmonary artery. An ADO 6/4 device was positioned within the MPA and adjusted following angiography. The device was felt to be in appropriate position and released. The pulsatile was no longer noted in the LPA. Pulmonary pressures were elevated at 15 mmHg with no gradient in the SVC." Would you code this with unlisted code 93799?

Loop Recorder Pocket Revision

"The anterior chest was prepped and draped in the usual sterile fashion. An incision was made over the generator. The capsule was incised, and the generator was removed from the pocket. A device pocket was fashioned. The pocket was flushed with Gentamicin irrigation solution. The generator was implanted in the pocket. The pocket was closed in layers using 2-0, 3-0, and 4-0 absorbable suture. The skin was closed with a subcuticular technique. Successful loop recorder implant pocket relocation." Would this be 33285 or 33999 or 17999 [33285-applicable for reporting implant and explant services associated with older implantable/insertable loop recorder (ILR) devices where medically appropriate]??

Anastomosis only

"Patient undergoes rotationplasty, and vascular surgeon performs anastomosis of SFA to popliteal artery and femoral vein to popliteal vein." How would you report this case? Should we use repair code of blood vessel?

Disc space and end-plate biopsy

"Utilizing fluoroscopic guidance, three passes into the lesion were made using an 11 gauge OnControl biopsy needle system at the T8-9 disc space via the posterior right paramedian approach. Passes were made into the disc as well as into the inferior end-plate of T8. Aspirated tissue was sent for microbiology, including gram stain, aerobic and anaerobic cultures, smears and cultures for AFB and fungi, as well as cytology and pathology. IMPRESSION: Uneventful fluoroscopically-guided biopsy of the T8-9 intervertebral disc space via the posterior right median approach." Should I report code 20225 since end-plate mentioned, or should I report unlisted code 64999 since it is disc space between T8-T9?

Ellipsys Fistulas

Since these are created for dialysis, would you use the dialysis intervention codes? "U/S guidance was used to access a patent and compressible right radial artery at the wrist using a 5 French slip-cath micropuncture needle and dilator. An image was stored. Through the dilator, a mixture of heparin, verapamil, and nitroglycerin was diluted with blood and gently infused into the radial artery. Next, through the cath, a glidewire was advanced up to the radial artery to the level of the wrist, followed by a 4 French Kumpe cath. An arteriogram of the upper extremity was performed, which included the perforator and veins feeding the cephalic and brachial veins. Next, the Kumpe cath was used to negotiate from the radial artery directly into the perforator vein, and a venogram of the upper extremity was performed into the central venous system. This confirmed a stenosis of the radial artery at the cephalic vein with the cephalic vein stenosis as well. Then cath was exchanged for a balloon, which was used to dilate the radial artery and perforator vein for 90 secs."

Percutaneous Tracheostomy with Dilator

I'm sort of on the fence on how to code these. In the ICU the neck was prepped and draped in the usual fashion. The patient was given sedatives and paralytics. Bronchcoscopy was performed by Dr. X and dictated in a separate note. "The neck was anesthesised with lidocaine solution. Tranverse incision was made at the level of the cricoid, and under direct visualization a large bore needle was advanced into the trachea at the second to third tracheal ring. A wire was advanced. The tract was dilated to 38 French, and an 8.0 cuffed tracheostomy was advanced under direct visualization. The cuff was inflated. The patient was ventilated. The bronchoscopy was introduced through the tracheostomy. Bloody secretions were evaluated." I am interpreting this to 31730... is this appropriate? The pulmonologist coded to the brochoscopy... or is it going to be an unlisted type category?

Resection of aneurysm of right femoral popliteal bypass

What CPT code is reported for resection of aneurysm of right femoral popliteal bypass? "Procedure name: resection right femoral popliteal artery aneurysmal degeneration with interposition Dacron graft. Patient had previous fem-pop bypass with great saphenous vein. The pseudoanerusym was arising off the mid superficial artery graft. Incision was made in the thigh and aneursym resected, then Dacron graft sewed end-to-end to the distal portion of the femoral-popliteal bypass. Arteriotomy made in the popliteal artery and embolectomy catheter passed down the peroneal artery, tibial artery, and anterior tibial artery with thrombus removed."

Does this support 34812?

Does this following technique support the assignment of 34812 for placement of Impella (33990) via cutdown? "Cath was inserted in the LFA. The performance level equalled P9. Cardiac output equalled 3.6 L/min. Comments: Left common femoral artery was punctured under ultrasound guidance. A 6 French sheath was placed, and the arteriotomy was subsequently pre-closed with one perclose device. The arteriotomy was then upsized with serial dilations to the 14 French short impella sheath. The aortic valve was crossed with an Al-1 catheter, and the Impella was advanced through the catheter into the LV with subsequent uncomplicated Impella insertion. At the end of the case the Impella was slowly weaned to P2, and, after 5 minutes of hemodynamic stability consisent with pre-PCI values, the Impella was removed and the arteriotomy closed with the single perclose and an angioseal device without significant bleeding."

Angiograms 75710 & 75716

Is there a simple statement that tells me when an angiogram (other than a completion angiogram) and/or an aortogram can be billed with LE revascularization due to occlusion?

93228 Mobile Cardiac Telemetry

I am being told this monitor can be programmed to be used up to 7 days. However, the CPT description states: "...remote attended surveillance center for up to 30 days." If this monitor is used up to 7 days and not 30, do I need to add modifier -52 when only 7 days were monitored?

Disc Space Core Biopsies

"Under CT guidance a 17 gauge introducer needle was advanced to L3/L4, and aspiration was done, but there was no fluid return. Four core biopsies were obtained with an 18 gauge SuperCore system. Samples were placed in sterile jar and sent for microbiology." Would this be 62267 or an unlisted code?

Global Period Question

We are having some debate regarding what it means when a "new post operative period" begins. If a doctor does a 90-day procedure on 07/01 and then an unrelated 90-day procedure on 7/15, according to CMS global surgery booklet, a new global period begins. Does this mean the original 90-day procedure global has stopped and the clock is completely reset? Or does this just mean a "new global period starts" for the new unrelated procedure and the previous procedure is still in its 90 day period? (The new global period does not affect the previous surgery but allows for 100% payment for the newest procedure.)

His Bundle recording with PM implant.

Patient had a His bundle lead and an RV lead placed with His recording. Would this be considered "mapping," or can we bill 93600?

Injection of Intercostal Arteries for Pelvic Angiogram

Left femory puncture. Right common iliac angiogram performed for trauma. No extravasation found. Right internal iliac angiogram performed without extravasation. Right L3 and right L4 lumbar arteries injected without extravasation. Would the correct coding be 75710, 75736, and 36246, and for right L3 and right L4, 75726 x 2 and 36245 x 2?

Clarification on catheter access/placement

Probably a pretty basic question regarding cath placement, but for some reason I find it a bit confusing. When accessing a branch vessel (i.e. greater saphenous or gastrocnemius vein), and we advance into a larger vessel (i.e., ipsilateral femoral vein), does that cath placement in the fem become 36011, as opposed to the 36005 that it would be had we accessed it directly?

Left Masticator Space Core Biopsy

What is the code for left masticator space core biopsy? "The patient was placed in a supine position on the CT table. Limited images were performed to select a trajectory into the left masticator space. CT images confirmed the Spencer lesion. The skin was prepped and draped in sterile fashion. Skin anesthetization was achieved with local anesthetic. Axial images were obtained with a needle in place confirming trajectory planning. Using intermittent axial imaging, a guiding needle was advanced to the masticator space. The inner stylette was removed and the matched biopsy device advanced through the guiding needle. Biopsy was performed. The needle was removed. Post biopsy images were performed. Biopsy Device: Bard Mission, 20 gauge. Specimens: Three cores were performed yielding Linear non-fragmenting specimens, which were placed in formalin and delivered to the pathology department. IMPRESSION: CT-guided core left masticator space biopsy."

ICD-10 Sequencing

I'm looking for guidance for diagnosis sequencing for inpatient cardiology visits. In particular, principal diagnosis [i.e., reason for admission (non-cardiac) vs cardiac diagnosis]. Auditor has told us that the reason for admission should be the primary diagnosis, not the reason for cardiology consult/treatment.

Sclerotherapy for lower extremity AVM

"We then advanced a balloon occlusion catheter (Scepter) into the anterior tibial artery, and arteriogram was performed. The Scepter catheter was advanced into an inferiorly oriented division. From this location we performed three separate injections of 2 mL of EtOH with the occlusion balloon insufflated and an ankle tourniquet applied over 10 minutes followed by 10 minutes of non-injection. We performed arteriograms from this location in between injections. We then redirected the Scepter into the superior branch and 2 mL of EtOH were again injected over 10 minutes, in the same fashion." Procedure is for lower extremity AVM. Is embolization coded to 37241 or 37242?

Abandoned Access

I had an auditor tell me we can bill for abandoned access in certain cases for cardiac caths. Is this true? Example: "The area of the right wrist was anesthetized with 1% lidocaine injection. Using a micropuncture needle, the right radial artery was attempted to be accessed; however, on ultrasound it was noted to be occluded. The left wrist was then anesthetized, and using a micropuncture needle the left radial artery was accessed and a 6 french Terumo slender glidesheath was inserted using a modified Seldinger technique. Radial cocktail was then given interarterially." They then performed a LHC. Can we bill 36140 for the abandoned access in this case and the LHC? In any case? 

Can 93724 be reported if procedure was unsuccessful?

My provider performed dual chamber pacemaker interrogation in order to attempt pace termination of patient's atrial flutter. Pace termination was unsuccessful in converting him to normal rhythm. Is 93724 still reportable? It seems like this would be similar to cardioversion, which is reported even if it's not successful. My nurses are wanting to change the 93724 to a regular interrogation charge when the termination isn't successful. Can you please advise? 

Ruptured carotid artery stent placement

A patient had a ruptured internal carotid artery secondary to radiation and malignancy of the right neck. A carotid stent is placed to repair the rupture via femoral exposure. The physician stated it was more in the cervical carotid area than intracranial, so my question is would this be stent placement 37236 or carotid stent 37216 (no flow device was used) since it was treating hemorrhage?

Thrombolysis with carotid stenting with DEP

I'm wondering if I can bill together 61650 and 37215. I checked NCCI edits and it didn't hit for any edits. This is what the provider did: "Placement of a Infinity 088 guide catheter within the left common carotid artery. Follow-up angiogram of the neck via left CCA contrast injection showed severe 85% focal stenosis involving the proximal to mid cervical left internal carotid artery. There is a meniscus sign indicative of clot/soft plaque. Additionally, there was severe tortuosity of the cervical mid to distal left ICA leading to this surgery to be extremely difficult. Navigation of a 035 Glidewire past the stenosis within the cervical left ICA. Follow-up angiogram of the neck via left CCA contrast injection showed severe spasm involving the cervical left ICA. Intra-arterial infusion of 5 mg of verapamil into the cervical left ICA over 10 minutes time. Then navigation and deployment of a 3 mm spider distal embolic protection device to the petrous left ICA. Then the 035 Glidewire was subsequently removed."

Stenting iliac artery for extravasation

What stent code would you use for stenting of the external iliac artery for bleeding (not atherosclerosis)? The physician is calling it "active extravasation," which was resolved by placing the stent.

Tricuspid Valve Repair using MitraClip prosthesis

Can we report codes 33418 and 33419 for tricuspid valve repair using MitraClip prosthesis? Also, can I charge for the supplies considering it's "off label"?

Attempted Angioplasty

Attempted to stent the 3rd diagonal from the graft but unable to pass the wire into the diagonal branch due to torturous branch. Can I bill for an attempted angioplasty?

Cerebral Angiography

Can 36228 be coded after the decision was made to embolize a cerebral artery, or would it be considered roadmapping? The physician performs a bilateral internal carotid angiogram, then states, "After obtaining above diagnostic angiogram, the decision was made to perform endovascular treatment of the right A1 A2 junction aneurysm with stent-assist technique. The right A1 segment is small, therefore the decision was made to perform the stenting of the right A1 to A2 segment, then coil embolization of the aneurysm will be performed from the left A1 segment through the anterior commuting artery." The physician then moved the catheter up and performed a right anterior cerebral arteriogram prior to performing the embolization... is this reported with 36228, or is this included in 75894? The report also documents that there was one intermittent contralateral cerebral angiogram with findings documented (75774), and then two post-procedural angiograms, one of the right internal carotid and one of the left (both with findings documented)... is this reported with 75774 x 2? Would the two post-procedurals be coded as well?

Octopus endograft leak, stenting of LT renal artery component

Would this be coded as a delayed graft extension 33886/75959/36247, or 37236/36247 for the IR physician? "History of thoracic aneurysm with Octopus graft, graft balloon component is outside LT renal artery causing type III leak. 3rd order arteriogram through LT renal artery Octopus graft in the type III endograft leak, stent LT renal artery with reapposition of thoracic octopus graft component into the LT renal artery. Stenting performed by IR physician and vascular surgeon. Vascular surgeon performed cutdown LT axillary artery. Access made into the LT axillary artery w/direct puncture. Negotiation into LT subclavian artery, descending thoracic aorta first using Omni Flush catheter within a RT lateral component of graft, ultimately into LT renal artery limb. Placement of a ViaBahn stent. Stent & LT renal graft component then lined with a self-expanding stent. The LT renal artery Octopus graft component is dislocated out of LT renal artery, causing type III leak. Stenting LT renal artery w/re-apposition of LT renal Octopus component into LT renal artery."

Charge for balloon tamponade post Impella removal?

"Patient had an access from the left groin previously. We advanced an Omni Flush catheter and crossed over to the right common femoral artery, advanced a Supra Core wire beyond the level of the sheath into the right SFA, and advanced a 7 French sheath into the right external iliac artery. We then advanced a wire through the side port of the 14 French sheath, through which Impella device had been placed, and we removed the Impella CP device successfully out of the body. We placed a 12 French sheath into this access site, and continued bleeding around the sheath was noted. We advanced an 8.0 x 40 mm balloon into the right external iliac artery and inflated it to 10 atmospheres to achieve balloon tamponade. Following that, through the wire that has been placed in the right CFA, we performed the Perclose using a ProGlide device. We then advanced the balloon into the common femoral artery access site and performed balloon tamponade for 20 minutes." After Impella removal 33992, I'm not sure what else we can code. Thoughts?

37241 with 37242

Can I bill 37242 x 2 along with 37241 for occlusion of LIMA, RIMA, and veno-venous collateral that drained to the coronary sinus? Or would I use just 37242 x 2?

Disc Biopsy Clarification

We've been charging/coding our disc biopsies with unlisted code 64999 per your previous recommendation. However, I now see in your most recent publication it states to "use code 62267 if disc biopsy is performed instead of aspiration". Can you please clarify which is the correct code to report for a core sample of disc for diagnostic purposes?

Preoperative Localization Intervertebral Disc space

Embolization coils were placed in the interlaminar space to serve as pre-operative localization devices. Would this be considered soft tissue 10035 or unlisted 64999? If unlisted, is the fluoroscopy separately reportable? Procedure note as follows: "INDICATION: Preoperative localization of T10-T11 intervertebral disc space. Local anesthesia (lidocaine) was administered at the site of entry. Under fluoroscopic guidance, a 6 inch 20 gauge Chiba needle was advanced into the interlaminar space between T10 and T11 in the midline. Stylet was removed, and tumor embolization coils (4 and 8 mm) were gradually pushed into the interlaminar space inferior to the lamina of T10. After the placement of the coils, the needle was removed. Sterile dressing was applied. The patient was then taken to computed tomography scan for confirmation of the position of the coils. Successful placement of embolization coils in the interlaminar space at the level of intervertebral disc at T10 and T11."

Revision of external iliac to popliteal dacron graft thrombectomy.

Patient has an external iliac to popliteal graft using Dacron. Procedure includes Fogarty catheter thrombectomies and multiple graftotomies. The only revision synthetic bypass graft code I'm finding is 35883 for a femoral anastomosis. This patient does not have a femoral anastomosis. Another option 35875/35876 is for arterial or venous graft, which doesn't apply to this patient. What code would I use for an iliac Dacron graft thrombectomy?

Thrombolysis started by physician A, repeat eval by physician B same day.

Patient had a thrombolysis (37211) by Physician A, and repeat evaluation by physician B below. "The groin and existing catheters were prepped in usual fashion. The 4 French cath was then aspirated and flushed, and a right upper extremity angio was done from the brachial artery to the hand. This showed no flow in either the radial or ulnar artery beyond the mid forearm. The patient was prone, and repeat angio was performed, which demonstrated similar findings. I then proceeded to administer aliquots of nitroglycerin and ultimately heparin, tPA, and verapamil through the catheter into the distal forearm. A total of 1000 mcg of nitroglycerin, 5000 units of heparin, 4 mg of tPA, and 5 mg of verapamil were administered. Periodic angiography was performed in between aliquots of medication. Ultimately the final angiogram was performed, which demonstrated significant improvement in flow into the radial and digital arteries and filling of the palmar arch." Would Physician B not get any codes for the repeat evaluation above?

In-stent restenosis

Are you aware of any specific guidelines for coding diagnoses of restenosis in a stent that was placed greater than a year ago vs. a newer stent? Should the coder use the atherosclerosis diagnosis as PDX followed by the stent restenosis code if the stent is over a year old?

20611

Can you confirm that 20611 is just like 76937 where ultrasound guidance evaluation of potential access site, vessel patency, and real-time visualization of needle entry have to be documented in physician report to code?

Balloon tamponade to common femoral

"A patient had Impella removed, which created a hemorrhage. The patient was brought back emergently to the lab. Access was obtained, and the physician went directly to the hemorrhage and performed balloon tamponade for 5 minutes and then another 3 minutes. Angiogram was then performed and homeostasis was achieved." Do you recommend using 37246? Then, same physician, same day, different patient. Planned insert/removal of VAD in the same session. Physician did prophylactic balloon tamponade with removal of VAD. Is this balloon tamponade included with the removal?

CT or Fluoro Guided SI Joint Injection and PSIS Trigger Point Injecti

Is it appropriate to bill 27096 and 20552-XU if the provider injects the SI joint using CT or fluoro and performs a sacral PSIS trigger point injection? Since they are treating the same area, I question whether both can be billed.

Venous access via PPM/ICD pocket

I have a case where an ESRD patient (AV shunt in left arm) presented to cath lab for upgrade of a dual PPM to CRT-D (primary prevention). The left UE venogram could not be performed due to the presence of the shunt, so the cardiologist opened the PPM pocket, accessed the vein (via the pocket), and performed a venogram, which revealed an occluded innominate-SVC junction. What CPT code would I use for the venous access on this case?

Vasospasm infusion in bilateral vertebral arteries

I have a question from one of my NIR physicians regarding vasospasm treatment in both vertebral arteries: "I've read about the 3 territories for vasospasm infusions, but in reality there are 4. If there is vasospasm of both vertebral arteries proximal to the point where they merge to form the basilar, infusion of verapamil into one of them won't treat the other. Since I performed therapeutic infusion over 10 minutes each into bilateral vertebral arteries could we justify 61651 as well?"

Ablation coding, new EP physician

Is this sufficient documentation for ablation coding (new EP physician)? "The patient arrived in AF/AFL, and underwent successful double transseptal puncture utilizing intracardiac ultrasound guidance and then completed 3D map of left atrium and pulmonary veins. Patient was cardioverted initially with 200J x 1 with successful conversion to NSR for initial voltage mapping of the left atria Wide area circumferential ablation was performed successfully and without complications, with confirmation of PV isolation with the circular mapping catheter for management of atrial fibrillation.. RF linear lesions outside the PVs were completed at the roof and inferiorly creating a posterior box which terminated an atypical flutter when creating the inferior line. Atrial flutter from the right atria was also ablated. Successful completion of bidirectional conduction block with RF ablation between TV and IVC in cavo-tricuspid isthmus to manage right atrial flutter. Post ablation, there was abnormal SA (cSNRT > 900ms) and AV function, VAD and normal HV function (43ms) and no inducible SVT without isuprel."

Remove and replace pacemaker with same generator?

If the physician attempts to remove the generator due to possible infection but then changes his mind and puts it right back, can we use the remove/replace code (33228) even though there was no new generator placed, or would this be unlisted? "Given the extremely poor wound healing of this incision I suspected that the pocket was potentially infected as well and considered removing the pacemaker generator and packing the pacemaker pocket. Upon disconnecting the pacemaker the patient became profoundly bradycardic, and I immediately reconnected the pacemaker. Given his dependence on the pacemaker and lack of overt infection I elected to irrigate the pacemaker pocket with warm Clorpactin and placed the pacemaker in an antimicrobial absorbable patch."

Fontan Stenting for Stenosis

There is a similar question already asked by fellow subscribers about dilating a Fontan fenenstration, but I want to run the question by you... do you agree with unlisted code 93799 for stenting a Fontan for stenosis? This patient is in early 20s, and Fontan procedure was done year 2000. There is no fenestration in this patient's Fontan.

Does a MRCP require documentation of 3D?

Does an MRCP require documentation of 3D in the report, or does the exam itself (being documented as a MRCP) imply 3D?

IFR Without Result

Would you code an additional IFR for the RCA in this situation? "The wire was advanced across the left circumflex OM lesion and the iFR was 0.93, consistent with non-hemodynamically significant lesion. We then decided to do IFR assessment of the right coronary artery lesion. We used the same guide and advanced a wire across the right coronary artery lesion; however, the iFR wire malfunctioned and would not give us an accurate iFR result. However, because the lesion did not appear to be significant, we decided not to proceed with any further intervention."

CT Cisternogram

Should this be coded 62323 and 77015 or with 62323 only? +70470/CT? "Procedure: The patient was placed in the prone position on the fluoroscopic table. The L3-4 interspace was localized fluoroscopically. The skin overlying the L3-4 region was prepped in the usual aseptic manner. Generous quantities of one percent lidocaine was used for local anesthesia. The L3-4 space was then accessed with a 22 gauge spinal needle. A fluoroscopic spot image was obtained. 10 cc of Omnipaque 300 were injected into the epidural space with confirmation by fluoroscopy. The patient was then placed in the Trendelenburg position in both the prone and supine positions. Confirmation of cranial transit of contrast by fluoroscopy was performed. The needle was removed. The site was dressed with an adhesive bandage. The patient tolerated the procedure well. There was no immediate complication. The patient was then transferred to the CT scanner. FINDINGS: Fluoroscopic spot image demonstrates the needle tip projecting over the L3-4 spinal canal. Technically successful lumbar puncture for CT cisternogram."

Surgical Package with a device insertion

Patient with chronic afib. Patient went into cardiac arrest and had a biventricular ICD inserted. EP physician wanted to initially do ablation for the afib with insertion of device prior to cardiac arrest as part of a previous plan of care. Next day EP physiscian sees patient - wound check, interrogation, chest x-ray, and EKG performed. Per operative note on this visit: "Patient did well with biventricular ICD implantation yesterday. I reviewed her chest x-ray, ECG, and device interrogation. These are all stable from my perspective. I have left her at VVIR 75 to 120 beats per minute. Atrial lead is in place in case we elect to pursue a rhythm control strategy after she improves clinically. No AV node ablation performed, as her rate control was good and I felt this was not urgently necessary. Her CHF appears to be much improved, though she continues to have some rales. I agree with ongoing diuresis. From my perspective she can be discharged whenever Dr. X and the team feels this safe. I will follow-up with patient in the office in 1-2 weeks as an outpatient for her afib." The physician believes this isn't a post op visit. Please confirm.

20501 vs. 49424

Would you please help me with the distinction between 20501 and 49424? Is it just the difference between whether or not a catheter is used to inject the contrast into the fistula?

Previous Fontan, embolization of collateral 37241, 93531, 93568, 36012X2

"Percutaneous entry with a 6 French sheath placed in right femoral vein and 6 French sheath in right femoral artery. A 6 French wedge catheter was advanced to right heart, and a pressure and saturation sweep was performed. Angled Glidecaths were used to complete the right heart cath. A careful pullback from the LV to descending aorta was performed using a pigtail. The Glidecath was advanced to the innominate vein with hand injection performed, demonstrating the veno-venous collateral. Over a wire the Glidecath was exchanged for a 5 French JR guiding catheter and advanced into the veno-venous collateral, and a 4 mm AVP II was selected and advanced to the venous collateral and device was released. Hemodynamics list: Hep Vwedge, SVC, IVC,RPA, LPA, LV , AAO, DAO, Fontan pressures, transhepatic gradient of 2 mmHg. Cineangiograms lists Hemi-azygous and collateral 1 hand injections." Does 36012 x 2 describe the further selections? Was hepatic wedge pressure performed? Do we need angiography codes 75889, 75605?

Ligation with phlebectomy

"The greater saphenous vein was identified on the right. It was previously ablated; however, it was ligated. Secondary varicosities off of the saphenofemoral junction were also identified and ligated, including a large redundant secondary vein near the saphenofemoral junction. They were ligated proximally and distally and oversewn with 2-0 Vicryl stick tie. Once this was accomplished, a multilayered closure was performed. Dermabond was placed in the groin. Previously marked varicosities on the right lower extremity were removed with a stab incision. Stab phlebectomy was performed, removing the vein proximally and distally by clamping proximally and distally, transecting, and gently removing the vein. This was repeated down the medial aspect of the leg posterior to knee and the popliteal fossa, calf, and along the shin. 17 more incisions were made, for a total of 18. Once all the varicosities that were marked were removed, copious irrigation and hemostasis was obtained." Would this just be 37765? Provider wants to use 37700 and 37785 also, but the bundle?

Vein Mapping

What is the code for upper extremity vein mapping prior to the creation of a AV fistula? No Spectral was done. Does the code selection change if it's not done on the same day as the fistula creation and/or by a different physician?

Cone Beam CT

I understand that the physician has to state that he/she is the treating physician (this is for Y-90 mapping). For the cone beam CT coding, this is taken from software that creates CT like volumetric images (not a CT machine) and reconstructs and evaluates at a separate 3D workstation. Can we report code 76380 if CT arteriography of hepatic is performed along with 76377 (providing all documentation is documented for the 3D images)?

77001

Would the statement below be sufficient to code 77001? It doesn't mention that the removal itself of the port was guided, just the phrase below, in what appears to be a spot film. "A fluoroscopic view the chest was obtained saved and archived a single-lumen left subclavian port to be present with the tip at the cavoatrial."

Order Timeframe

How long is a physician's order good for? Our radiology department has always used one year as a rule. Is there definitive guidance from Medicare or the ACR on the acceptable timeframe? 

Microvascular Disease

Could you suggest a diagnosis code for "microvascular disease" or "small vessel disease"? Many patients with chest pain, but fairly clear coronaries, are being diagnosed with this issue.

Bilateral Pulmonary Artery Thrombolysis

Our physicians are performing left and right pulmonary artery thrombolysis using two EKOS catheters, but using only a single access site. Must they use two different access sites (sheaths) to apply the bilateral modifier -50? Or since two catheters were used, one for the left and one for the right, is it appropriate to use the -50 modifier?

Radial vasospasm during a cerebral angiogram

We have a provider that is doing cerebral angiograms with the approach being via radial artery. The provider states vasospasm was present in radial artery and treated before completing angiogram. What code would we use for the treatment of the radial vasospasm?

AVF-Remote access

"The right internal jugular vein was accessed under real-time ultrasound guidance. The needle tip was visualized accessing the vessel. Permanent imaging was archived in a picture archiving and communications system. A 5 French sheath was placed. A 4 French flush catheter was used to catheterize the left upper arm fistula through the right internal jugular vein access. A fistulogram was performed, demonstrating patent arterial anastmosis. A 4 French angle glide catheter was used to select the left brachial artery followed by angiogram with fistulogram and central runoff. Angioplasty of the 50% pre-existing venous outflow stent stenosis was performed using a 7 mm x 8 cm drug-coated balloon catheter. Angioplasty of the 50% stenoses in both left subclavian and left brachycephalic was performed using a 12 mm x 4 cm balloon." Are the codes 36902-52, 36907, and 36012 for the jugular access?

20611 and Fluoro Guidance

Can we bill 77002 with 20611 when both US and fluoro guidance are used? I know 77002 is bundled into 76942, but a -59 is allowed.... when fluoro guidance is used in addition to the US guidance, do we bill 20611 alone?

Valvuloplasty of a Melody Wave

"12-year-old male with congenital heart disease of double outlet right ventricle, ventricle septal defect, interrupted aortic arch, sub aortic stenosis, and hypoplastic ascending aorta. He is status post arch reconstruction, aortic balloon angioplasty, and balloon angioplasty of the RV-PA, pulmonary valve replacement, and pulmonary valve conduit homograft and a 2018 Melody Wave implant. A selective PA demonstrates moderate insufficiency of the Melody Wave; angiography provides severe distal Melody Wave stenosis secondary to moderate sized vegetation. Now - status post successful balloon valvuloplasty of Melody Wave." I am not finding a listed CPT code for a Melody Wave valvuloplasty. Would this be unlisted code 377999? Can I charge 93533, 93566, 93568, 93567 for this patient's cath procedures?

MRI BREAST BIOPSY DYNA CAD

I have a question on MRI-guided breast biopsies. Our rads use DynaCAD when performing an MRI-guided breast biopsy procedure. They specifically state the images were reviewed and the procedure was performed using a computer-aided detection system (DynaCAD). Can an unlisted MRI code be used to capture this?

Coding of bicuspid aortic valve with aortic stenosis

Our cardiologists perform a lot of echo interpretations on patients they have never seen (hospital patients, referred by other providers, etc.). We will frequently see "bicuspid aortic valve" on an echo interpretation in addition to "aortic stenosis." There is an Excludes1 note under I35.0 aortic stenosis that prevents Q23.1 from being reported with it (Excludes1: Aortic valve disorder specified as congenital, Q23.0, Q23.1). How are we to report "bicuspid aortic valve, aortic stenosis"? Going one step further, if patient has bicuspid aortic valve with a mitral and tricuspid valve condition, this same Excludes1 note prevents us from assigning the I08 code with the bicuspid Q23.1. Would these fall under the "exception to the Excludes1 definition as the circumstance when the two conditions are unrelated to each other"? I understand that a provider query is preferred, but our providers are reading these studies only and have no knowledge of the patient for us to query.

Iliac aneurysm repair with non-covered stent

Our physician treated a common iliac aneurysm using a non-covered stent; he used just a plain peripheral stent. Would this be reported with the endograft iliac aneurysm repair code (34707), or would we report a stent placement code (37236) and the cath placement code?

Assistant Surgeon for CTO 92943

What would justify medical necessity in documentation to have an assistant-at-surgery for CTO procedure? I have a doctor who is stating he was assistant, but the documentation does not show why or what he did to help in the procedure as to why an assistant was needed. My doctor is stating two or more physicians are often recommended for CTO procedures. How do we determine medical necessity to support appending an -80 modifier?

Embolization post trauma

Multiple blunt injuries with hepatic and splenic lacerations. Patient presents for embolization of the splenic artery and the right and left hepatic arteries. Would you consider this to be two separate organs and code 37244 x 2, or one surgical field and code 37244 one time only?

Ultrasound guidance used but image not saved

If a provider uses ultrasound guidance for an FNA biopsy but fails to retain image, and this is stated in the report that FNA was done under ultrasound but no image retained, which CPT code should be used? 10005 with mod -74 or 10021?

Graft/CFA thrombectomy & SFA/PFA dissection flap removal patch angioplasty

"Occluded right CFA limb of a right axillary-bifemoral bypass. Previous right groin incision reopened. Fresh inflammatory tissue surrounded the graft and femoral dissection. Dissection carried down to SFA and 2nd order branch of PFA. Graft removed from CFA and found with semi organized murky thrombus. Thrombectomy of the right limb of bypass graft with a forgarty to establish inflow, then from CFA, SFA, and PFA. Arteriotomy extended onto the SFA and PFA where occlusive dissection flaps were found, removed, and tacked down with prolene stitches. Arteriotomy was patched with bovine pericardium with extension of the patch onto both the SFA and PFA. Arteriotomy was made into the patch at the CFA, and the bypass was reanastomosed to the patch in an end to side manner." Is this coded with 35876 only? Or with 35302 and 35876?

ICD-10-CM Question on Dialysis Catheter Exchange Encounters

I see a lot of patients come in for routine dialysis catheter exchange with ESRD, and I code this as Z49.01, N18.6. My reviewer recommended to me that I should add Z99.2 as well. My view is that Z49.01 includes the fact that the patient is on dialysis, and there is an "excludes 1" between these two codes stating they should not be reported together. Her view, which I can see as well, is that there is a "code also" notation under N18.6 stating to add the Z99.2. She also pointed out that Z49.01 doesn’t give the full picture because it doesn’t state if the patient is on temporary or chronic dialysis. For example, if patient had a temporary dialysis catheter and was coming in to have it replaced with a permanent catheter, Z99.2 would help explain that the patient needed chronic dialysis. What are your thoughts on this?

Is this enough to code 93657?

Is this enough to code 93657? "There was evidence of recovery into the upper PVs and the posterior LA wall.PV potentials were blunted. A 4-pole irrigated contact force tip ablation catheter was advanced into the LA. 3-D mapping with the NAVX system was used to create a model of the LA and PV's. The left PV's isolated with relative ease (wide posterior ablation).The RIPV posteriorly directed was very challenging. To isolate the RSPV, Ablation was extended onto the roof and septal aspect. Ablation was necessary on the posterior carina. Isolation was confirmed with bidirectional block into each PV.Burst pacing was performed in attempt to induce atrial flutter. This induced an atrial flutter (CL 300 ms - earliest activation on CS1,2). Entrainment from CS1 ,2 -- yielded a PPI 70 ms. Thereafter the flutter degraded into AFIb with variable LC and activation.This was cardioverted.Attempt to reinduce AFL continuous yielded AFib. Additional ablation was done along the roof."

Additional Ablation Code

"Linear wide area circumferential ablation was done in the pulmonary vein antra of both the right and left pulmonary veins. Complete encirclement was done with power controlled up to 40 W in the anterior aspect of the LA and 30 W in the posterior aspects of the LA. Subsequently, a Lasso catheter was placed in the LSPV, and pacing from the CS was done to identify PV potentials. Ablation at the earliest site of the PV potential terminates conduction to the PV. This process was repeated for the LIPV, RIPV." Please note during the ablation in some areas of the antra, there was significant bradycardia, suggesting ganglionic plexi were also ablated. Does this documentation support 93657 or 93655 in addition to the A-fib ablation?

Stenting for Coronary Artery Dissection

"A patient undergoes drug-eluting stenting of the LAD for stenosis (CAD). Non-flow limiting dissection is noted post-procedure, and this is treated with placement of an additional stent." How would this procedure be coded? Would it be appropriate to report 93799 in addition to C9600?

Heart Cath with IMA Coil Embolization

Please see following medical record: Right and left heart catheterization, congenital, Angiography - SVC, left PA , RIMA and LIMA, then coil embolization both of RIMA and LIMA. Can we report 37242 and 37242-59? Or only report 37242 once? We report 93564 for angiography for IMA; is right? Also, should we report the cath replacement for 37242 and 37242-59 (I mean 36216 and 36217)?

US ABD Complete and US Elastography

Can these two (US ABD complete and US elastography) be billed together if they were done at the same time?

RFR and FFR During Cardiac Cath

"Proximal RCA RFR was 0.94, and FFR was 0.93 with IV adenosine, which are both non-significant." Since the RFR is approved in 2019, and I am not finding coding rules on this topic, would this be reported as 93571-RC (for FFR) and 93571-52-RC-XU (for RFR)? Or should I report 93571-RC (FFR) and 93572-52-RC? Or only 93571-RC (FFR) assuming that the RFR would be bundled into the FFR?

PICC Placement

If a nurse places a PICC line using US guidance (but does not keep a permanent image), and then a chest x-ray is done to confirm tip location (with permanent image), is this enough to report the "with imaging guidance" code? Or would this be coded as 36569?

How is access common femoral artery with stenting of carotid artery coded?

How is access common femoral artery with stenting of carotid artery coded? "OPERATIVE PROCEDURE: Patient prepped and draped in the usual sterile fashion. Ultrasound was used for right common femoral arterial access and placement confirmed with fluoroscopy. A wire was advanced into the aorta and catheter advanced into the arch. Using an angled glide wire and glide cath, the right innominate and then subclavian was selected. A stiff wire was advanced down the subclavian and into the brachial artery under direct visualization and a 7 French x 90 cm Ansel sheath was advanced into the innominate. We had been giving heparin since the start of the procedure in compliance with neurology stipulations. With the sheath in the innominate, angiograms were obtained and the exact location of the port entrance was identified. An 8L x 29 mm VBX stent was advanced with some difficulty through the sheath and positioned across the area of injury. Cutdown and angiogram was taken through the port for confirmation of positioning. The stent was deployed and the port removed. Angiogram demonstrated a small leak, so the stent was post-dilated with a 9 mm balloon."

Diagnostic TEE vs. TEE Monitoring

Can you provide some tips/guidance on how to distinguish a diagnostic TEE from TEE monitoring when a surgeon provides TEE findings during a cardiac procedure such as a CABG/valve replacement? I will often see surgeons provide baseline TEE findings (e.g., after opening the chest, they note that a TEE probe was inserted either by themselves or the anesthesiologist, and the TEE reveals normal left ventricular function, no pericardial effusion, and severe mitral regurgitation). In this example, if the patient came to the OR for a planned mitral valve replacement due to mitral regurgitation, and all I had were those findings, I would think this is just a baseline/confirmatory study that is part of TEE monitoring (they will use the TEE again after valve replacement to ensure resolution of the regurgitation and preserved LV function). Am I correct in my assessment? In contrast, would a diagnostic TEE require a decision to intervene or a change to the plan based on the findings of the TEE (similar to an angiogram/venogram during intervention)?

Iliac - Pop Bypass via Obturator Bypass

I'm not sure how to code this. Is this an unlisted code for bypass? Does the obturator portion have its own code, or is that included in procedure? "An oblique incision was made in the right lower quadrant and deepened through the subcutaneous tissue. The fascia was divided and the anterior sheath out laterally. After this was performed, the transversalis muscle was divided. Access was then gained to the retroperitoneal space here, and the Omni retractor was inserted. The bowel contents were retracted to the midline without entering the abdominal cavity. The common iliac artery on the right side was isolated with vessel loops, just after the origin from the aorta. The external iliac artery was diseased, although it did have a pulse in it. The obturator canal was then dissected out, and then a medial incision was made in the thigh distal to the groin and deepened down to the sartorius. Once this was performed, the dissection continued superiorly from here, and then a clamp was passed from the groin incision through the obturator canal into the abdomen under direct..."

Drug thrombin during embolization?

"In an office, type 2 endoleak communicates with lumbar artery located at right posterolateral aspect of the sac. I attempted to catheterize the lumbar artery but could not get the catheter to advance over the wire into it. I aborted further attempts and placed coils immediately adjacent to the origin of the lumbar artery. Entire endoleak was coil embolized. While coils were deployed I periodically injected small amounts of thrombin." Can I code for the drug - thrombin?

Diagnostic or not? 61635, 61645, 36226

Patient comes in with aphasia and has CTA, which shows occlusive thrombus distally within the M1 branch of the right middle cerebral artery, with reconstitution of M2 branches and non-occlusive thrombus within the basilar tip. Patient is taken to IR suite, and a thrombectomy and stent placement are performed of MCA. He also states, "I did look of the left vertebral of the demonstrated nonflow-limiting basilar embolus, which I decided not to treat." I coded 61645 and 61635, and I need to know if the vertebral angiography should be coded as diagnostic. I don't think we would code it because it was know,n but others say it should be coded because he looked at it and decided not to treat. Please advise.

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