Knowledge Base

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61624 CNS Embolization Rt ICA

I'm looking for clarification on the catheter placement for CNS embolization of right ICA. I understand a true diagnostic angio is separately billable, but somewhere along the line I thought that when there is no diagnostic angio that the catheter placement is separately billable with 32617 for the artery being embolized, so in this case 61624, 36217, 75894, 75898. Is that correct, or is the catheter placement inclusive?

Cervicocerebral Angiogram - Bovine Arch Anatomy

Your help with correct coding is greatly appreciated: "Indication: Stroke. Access: Right CFA. Initially right CCA was selected. Angiogram demonstrates no significant stenosis of bifurcation. Contrast advanced gently into proximal right ICA. Angiogram demonstrates patent right ICA. Angiogram over the head demonstrates occlusion of very distal small posterior division right MCA branch. The right ACA is patent. Right subclavian artery was selected demonstrating stenosis at the origin of the right vertebral artery." - 36225/RT "Catheter repositioned into brachiocephalic artery. Patient noted to have an bovine arch. Simmons 2 catheter was used to select the left CCA. Angiogram demonstrates no significant stenosis at left carotid bifurcation. Left ICA imaging demonstrates patent vessel, without significant stenosis at cervical level. Angiogram over the head demonstrates chronic occlusion of the MCA with multiple collaterals to distal MCA branches." 36223/LT (CCA) (Left ICA selective cath not documented.) Please advise if I am missing anything. 

Fluorescence angiography

We have a new physician who is using SPY Elite fluorescence imaging machine. Is there a specific CPT code for fluorescence angiography, if no prior imaging of this extremity was performed prior to this exam? Below is an example of his dictation. "U/S guided antegrade puncture of RCFA. Selective arteriography of the right SFA, popliteal and trifurcation Superselective angiography of the right AT Fluoroangiography pre-PTA of the right foot with Green Indocyanine. PTA of the right AT with 3x200 balloon at 14 atm. Repeat fluoroangiography with indocyanine green after PTA. Findings: Large ulceration, deep, of the dorsum of the right foot. Non healing for several months. Fluoroangio showed reduced perfusion of right 1st toe and R dorsum of foot. Angiography showed multiple critical stenoses of the right AT. 3mm PTA of R AT. Fluoro post PTA showed improved perfusion to 1st toe and dorsum of foot."

61624 and 61645

After left ACA aneurysm was embolized with Woven Endobridge device, clot was found at left ICA on subsequent angiogram. Thrombectomy was done with Soliaire. Can I code 61624 and 61645 together?

Knickerbocker Technique

What would be an appropriate code for TEVAR with use of Knickerbocker technique?

Facet Nerve Destruction

When coding 64635 and 64636, and the physician is only injecting one side (left or right), do you use modifiers -LT or -RT? Or do you only use modifier -50 when it is bilateral and no modifier when it is not?

Branch PA flow restrictors

Would it be appropriate to bill 37242 for placement of a microvascular plug in bilateral branch PAs for flow restriction in a patient with cardiac history significant for small left-sided structures and hypoplastic aortic arch? Basically, achieving the same effect as pulmonary banding.

Modifier QQ

How do we handle a case where a CT lung biopsy was ordered, but during the CT localization process the lesion is no longer present. We have been charging for 76380, but this requires a -QQ modifier in order to be paid by CMS. The decision to do the CT limited was not decided until the exam was done, so how do we bill this out? Should we bill 77012 and 32405 (-73 vs. -74 depending before or after sedation was given)?

CTA preop TAVR - CPT 75574

Code 75574 is for CTA of heart with coronary arteries; however, we have a physician who is documenting that the coronary arteries are "not well visualized, please refer to coronary angiogram," or only stating to "refer to a coronary angiogram for exam of coronary arteries." Would we use 75574 in this case, or is it more appropriate to use code 75572, which is a CT scan with contrast, not CTA code? The radiologist is coding 74174 for their portion of exam. 

Exc of AVF pseudoaneurysm and infected stent

Patient has a brachiocephalic AVF with a pseudoaneurysm and infected stent. The pseudoaneurysm is opened, hematoma expressed, and sac debrided. The remaining cuff of vein is ligated. Another incision is made, and cephalic vein/stent is freed up proximally and distally and removed in entirety. Would this be a revision of an AVF since it all occurs in the AVF? How would I code for the excision of the stent/cephalic vein in the AVF?

Really need an answer!!

Doctor performed mechanical thrombectomy and angioplasty of left subclavian and axillary veins. I asked if this was one long lesion of the subclavian/axillary OR was it separate lesions in both vessels. He responded it was one long lesion. I billed only 37248 because it was one lesion crossing two vessels. "A 14 x 40 balloon was inflated in the subclavian, deflated, and pulled back into axillary vein." Should I have billed 37249 also?

C9600RC and 93938RC or C9600RC and 92937RC

If the native RC is stented with a drug-eluting stent, and the right PDA is angioplastied via the graft, would we be at C9600-RC and 92938-RC? Or is C9600 not a primary code for 92938 (and we need to use 92937 instead)?

Attempted fistula

The patient came in for removal of a malfunctioning peritoneal dialysis catheter and creation of a fistula. The catheter was removed. Then creation of a fistula was attempted. From the op report: "We made a transverse incision over the antecubital fossa and dissected down. The cephalic vein was dissected free and ligated at the perforators. Attempts to flush the vein noted is to be under high pressure. I passed a vessel dilator without success and attempted to pass a 4 mm balloon which caused injury to the vein requiring ligation. We attempted to dilate the vein towards the wrist without success. At this point there was no possibility of fistula and the wound was closed with a 3-0 and then 4-0 Monocryl. We will need to reassess his venous system and possibly perform an upper arm graft. I need to discuss this with the patient prior to proceeding." How should the attempted fistula be coded?

Consultation with Planned Device Implant

I have a two-part question regarding the use of the -25 or -57 modifier. We have cardiologists, interventional cardiologists, and electrophysiologists in our group. It is not uncommon for a patient to have an appointment with one of the cardiologists, and end up getting scheduled for a procedure by either the IC or EP doctors. Typically, the cardiologist and the IC or EP physician will discuss the case, and then schedule the patient for the procedure, without a separate appointment with the IC or EP. Question 1: If the procedure is planned, can the IC or EP bill for a visit on the date of the procedure/surgery? Technically, this will be the first time the patient is seen and examined by the IC or EP, and the final decision to proceed with surgery is made. Question 2: If so, can they bill a consultation (non-Medicare), or are they required to bill as the admitting/attending provider?

Pulmonary Insufficiency with Mitral, Tricuspid and Aortic Insufficiency

When coding a diagnostic test, such as an echocardiogram, and the patient has mitral, tricuspid, and aortic insufficiency, we are to use the combination code I08.3. However, what code should we use when a patient has all of the above PLUS pulmonary insufficiency? Since pulmonary insufficiency defaults to nonrheumatic, we would ordinarily choose I37.1, but the "excludes" note under the I08 codes tells us we cannot code both an I08 code with an I37 code. What would be the proper code(s) to use if all four valves are involved?

Multiple Endarterectomies

Would it be appropriate to bill multiple endarterectomies in this case through one incision? "Anterior common femoral arteriotomy was made and carried proximally. Endarterectomy with freer elevator of common femoral artery was performed with patch angioplasy. Profunda did not back bleed. Profunda was opened and endarterectomy performed of anterior branch into ostium of posterior branch with patch angioplasty. SFA was explored in the first portion. Foreign body Angioseal was removed from SFA. Endarterectomy of first portion of SFA with patch angioplasty was done on SFA as well." Could we code 35302, 35372, 35371 with separate arteriotomies and patch angioplasties? Would foreign body removal be bundled into the endarterectomies?

Arterial pressure measurements

Is there a code for pressure measurements of the celiac artery obtained during an angiography? "Pressure measurements in the celiac artery showed pressure of 107/62 mmHg with a mean pressure of 81 compared to a pressure of 170-70 mmHg with a mean pressure of 103 in the aorta."

US-76937 Coding Guidelines

The IR physician performed a bilateral mechanical thrombectomy in the lower lobe of the pulmonary arteries and also placed an IVC filter during the same encounter. Can we bill for the US guidance used for selectively catheterizing the pulmonary arteries, or would is this inherent to the IVC filter placement since it was performed at the same time?

Intraperitoneal port evaluation with dye

What code(s) would you suggest for a failed intraperitoneal port evaluation using dye and fluoroscopy?

92960 Documentation

If the documentation for the pro-fee report does not state the joules used but only indicates pre/post diagnosis, post condition stable in sinus rhythm, and an Impression that states "successful direct current cardioversion," would that be enough information to support the code? 


I am billing for a physician who's doing a WaveLinq in the hospital. I am billing only his pro fee. I was told to use 37241, 36215, 76937, 75820, 36901, and 75710, but I remember reading an article from you that the physician should bill 37799. I could use some guidance here.


I work for a group of vascular surgeons who have started using AmnioFix bio-cellular matrix. This is how it is documented in the report: "The AmnioFix was then injected into the subcutaneous tissues along the length of the incision." Is this something they can be paid for, or would it bundle with the procedure? What code would you recommend?

Can we bill for the brachial artery exposure? What is the code?

Can we bill for the brachial artery exposure? What is the code? "Brachial artery was identified, dissected free, and then controlled proximally and distally with vessel loops. The artery was then accessed using micropuncture kit, which was subsequently upsized over the wire to a 5 French sheath. Then an Omniflush cath and guidewire were used to enter into the subclavian artery and down to the descending thoracic aorta. A Benson wire and a 90 cm 6 French sheath were then advanced over the wire and positioned just into the right limb of a previous aorto-bi-femoral bypass. Of note, the original bypass did have separate limbs that went to the external iliacs as well as right internal iliac artery aneurysm sac and into its main branch. I advanced 4 French catheter through the primary aneurysm sac and into this first branch vessel. I then advanced Lantern cath for coil deployment into the main branch, and I began to deploy coils up to the point that there were multiple branching points, which would also be occluded. I then packed the main aneurysm sac with multiple coils. Deployment of eight separate coils, which consisted of packing and POD coils."

Laparoscopic diaphragmatic hernia repair

I have a laparoscopic repair of a traumatic diaphragmatic hernia. "The omentum involved was retracted back into the peritoneal cavity and hernia sack dissected and removed. Sutures were used to close the defect." Entire procedure was laparoscopic. Should this be coded as 43281 or unlisted 49659? Hernia was not para esophageal.

Pelvic x-ray vs. hip x-ray

I work for a children's hospital, and there is some confusion about when to bill a pelvic x-ray vs. a hip x-ray. Here is an example of one I see all the time. "Examination: XR Pelvis 1 - 2 views. Imaging Technique: 2 views of the hip/pelvis are submitted. Findings: The bony mineralization is normal. The joint spaces are symetric. The acetabula appears normally formed. Hips are normally located. No fracture or intrinsic bone lesion is seen. The visualized soft tissues are normal." Should this be billed as a pelvis or a hip x-ray?

Can we code this as 36832 and 36907

Our coders are struggling to agree on how to code this procedure. We cannot come to an agreement of the best suited codes to use. "Patient has left brachiocephalic fistula that has two aneurysms that developed two ulcerations. Physician performed incisions in vertical fashion, excising the aneurysm and excessive skin on two aneurysmatic area, one above the antecubital area and the other in the distal upper arm. Incision taken down to the dilated aneurysmatic vein. Vein entered, skin and ulcer were excised in both lesions. Aneurysmatic vein wall then excised so about 1 cm of conduit on each incision. Closed venotomies on each incision. Clamp released for flow thru fistula. Then punctured access in mid upper arm, placed sheath, obtained shuntogram which showed the cephalic arch had a stent and vein was present. Superior vena cava was patent but innominate vein 80% stenosed. Angioplasty performed; sheath removed site closed."

Breast biopsy multiple lesions

If a patient has biopsies done on multiple breast lesions via the same puncture site, would this be one code, or would we be able to use the add-on codes for the additional lesions?

Certified in Nuclear Medicine

We have a new general cardiologist who will be sitting for his Nuclear Medicine Certification within the next month. He has started reading nuclear scans and is having them over read by one of our certified cardiologists. Can this be billed under the general cardiologist, or would it need to be billed under the Nuclear Certified providing the over read? Does the documentation need to include information about both providers?


DEXA BONE MINERAL DENSITY WHOLE BODY COMPOSITION. 32-year-old male. The calculated total body bone mineral density is 1.244 gm/cm2. The calculated percent fat is 15.1%. Please let us know how we can code it.

Open removal of infected stents with resulting pelvic abscess

Not sure how to code this: 35226 & 35860? "Evidence of infected stents. Pt opened and after dissection and lysis of adhesions Vascular clamps were placed in the proximal external iliac artery just distal to the origin of the internal iliac artery. The external iliac artery was transected at this level. The proximal end of the patent external iliac artery was then oversewn with suture in initial horizontal mattress fashion & subsequently the artery was folded over onto itself & secured with a running suture. This gave excellent hemostasis to the proximal end of the external iliac artery. Likewise, the distal external iliac artery was clamped & transected. The distal end was also oversewn with suture in a horizontal mattress & then folded over onto itself & secured for complete hemostasis. The intervening segment of the external iliac artery was then opened longitudinally to a very large phlegmon & thickened eschar tissue. Both of the intervening infected external iliac stents were removed."

Subclavian TAVR

Would we use unlisted code 33999 for subclavian TAVR? And since percutaneous would you use the comp code of 33361, or use 33363 as comp code? Patient underwent successful transcatheter aortic valve replacement via left subclavian approach (percutaneous).

Fem-Fem Venous Bypass for Venous Occlusion

What CPT code(s) would be best for a left femoral vein to right femoral vein PTFE crossover bypass graft with construction of left SFA to saphenous branch AV fistula?


Can an angiogram to access AV fistula with poss RLE covered stent or placement of coils be done in an office setting or hospital only?

Skin Perfusion Pressure Testing

What would the CPT code be for skin perfusion pressure testing? Report states "Skin perfusion pressure testing was performed of the left lateral foot to assess tissue perfusion at the location of the patient's wound. The contralateral right lateral foot was evaluated for comparison. Impression: Skin perfusion at the lateral plantar surface of the right foot is 75 mmHg, and at the lateral plantar surface of the left foot it is 67 mmHg. These values indicate adequate perfusion for healing." I have considered 93998, but since it wasn't a true vascular study I am wondering if a low level EM would be more appropriate?

Scheduled Biopsy-Mammogram

We have a patient who presented for an ultrasound-guided breast biopsy. This was based on prior mammogram and ultrasound showing breast asymmetry. The prescan for the biopsy showed no discrete finding for biopsy. We would normally charge/code for the intended procedure and attach either -73 or -74 modifier; however, the physician then ordered additional mammographic images to further evaluate. Would you recommend charging for the US-guided breast biopsy with the -73 modifier based on the reason the patient presented and original order? Would you also charge the patient for the mammogram unilateral? Or would you only charge the patient for the complete unilateral mammogram?

Transpedicular approach

What is the appropriate CPT code for a thoracic epidural steroid injection using a transpedicular approach?

BT Shunt Evaluation No Documentation of Heart Cath

Patient with TOF and pulmonary atresia s/p BT shunt comes in for evaluation of shunt and pulmonary arteries as well as embolization of collaterals. The embolizations are straightforward, but it does not seem that there was any heart cath performed. No documentation of catheter placement in any heart chamber and no pressures recorded. The only reference is in the title of the report, which says, "Left heart catheterization." Catheter travel documented is from left femoral artery access to aorta, innominate, subclavian, BT shunt, and ultimately pulmonary arteries as well as collaterals branching from aorta. Since the coding is very dependent on whether or not a heart cath was performed, what would you recommend if it turns out that it was not performed?

Left common carotid artery repair

I’m new to vascular coding. I need help with CPT code for left common carotid exploration with primary repair (35301 vs. 35701). "Neck was prepped. Physician made incision as followed the sheath down through the sternocleidomastoid divided by bovie technique. Vein was transected then suture-ligated with problem suture. Common carotid was identified and sheath entering through it was exposed. A pursestring suture was placed. The sheath was removed. Prolene was tied successfully, closing the arteriotomy."

Lead replacement with pacemaker generator relocation

I am reviewing a case where the physician needs to relocate the patient's pacemaker from the right to the left due to radiation treatment. In the process the physician removed the RV lead and inserted a new RV lead, but attached the lead to the existing generator. Is it appropriate to report 33222-XU for the generator relocation, with 33234 for lead extraction and 33216 for new lead insertion?

Coronary Artery Bypass Graft with Vein Interposition

"The segment of reverse saphenous vein was anastomosed to the obtuse marginal #1 with a 7-0 Prolene suture in end-to-side fashion. This was followed by a side-to-side anastomosis to the ramus. The proximal anastomosis was created with a 6-0 Prolene suture in end-to-side fashion. There was only a short remaining segment of saphenous vein. A proximal end was anastomosed to the diagonal with a 7-0 Prolene suture in end-to-side fashion, and the distal end was sewn to the mid LAD with a 7-0 Prolene suture in end-to-side fashion. The left internal mammary artery was then anastomosed side-to-side to the saphenous vein and the diagonal anastomosis with a 7-0 Prolene suture in a side-to-side manner. There was no valve to consider in this segment. Finally an end-to-side anastomosis was performed between the left internal mammary artery and the distal LAD with a 7-0 Prolene suture in end-to-side fashion." Surgeon says she did a CABG x 5 (3 mammary to artery and 2 saphenous vein grafts, 33535 and 33518). Does the vein interposition affect these codes, and if so, how?


Our coding department wants to use 50561 for this procedure. I'm questioning this since the procedure was not done through an endoscope. Can you please advise? "Contrast is injected via the existing nephrostomy tube. Via the nephrostomy tube, a 10 mm vertebral basket is advanced into the collecting system of the kidney. Manipulation of the basket was utilized to successfully catheter and removed a 6 mm x 5 mm urinary tract stone. Further injection of contrast via a 9 French sheath shows no further filling defects within the collecting system. Contrast is seen to pass into urinary bladder without obstruction. The sheath is removed and sterile dressing applied along with Steri-Strips."

35800 or 35301?

"Patient had carotid endarterectomy (35301) and three weeks later returned due to infection. Saphenous vein is harvested, neck opened, and Dacron patch removed. Area was washed, phlegmon was removed, and vein was sewed as patch angioplasty." How do we code this: as exploration for post of infection (35800) or as endarterectomy (35301)? Neither feels right to me.

PICC line exchange vs midline insertion

"The patient's right arm PICC was removed over a .018 wire. A new PICC was placed; however, it was not able to enter SVC. This was exchanged for a midline; however, there was no blood return. Subsequently the left arm was prepped, an image with ultrasound was obtained, and an attempt at PICC line insertion was unsuccessful. In turn a 3" midline was placed with good blood return." My question is, should we charge PICC exchange with a modifier (36584-52) or mIdline placement (36140)?

Interatrial Shunt Device

We had our first RELIEVE HF study patient using the V-Wave Interatrial Shunt (for advanced HF patients with preserved or reduced left ventricular ejection fraction who remain symptomatic despite the use of guideline directed medical and device therapies). It involves an RHC, transseptal puncture, and placement of a left to right shunting system. I am thinking the creation is similar to a atrial septostomy 92992, and the device would be charged similar to a stent in the chamber, which would be 93799. I'm curious to hear your thoughts.

Vessel Embolization

Can you assist with this difficult case? "We selectively engaged the RIMA, LIMA, lateral thoracic artery, bronchial arteries, and thyrocervical branches and performed selective angiography as well as vessel embolization in each of those vessels (to shut down collaterals)."

Repositioning of Peritoneal Dialysis Catheter

Can you please advise correct coding? 49400, 74190 and 49999? The patient reports the catheter has been functioning well up until last week, at which time there began difficulty at withdrawing fluid. He presents today to Interventional Radiology for evaluation and repositioning, if indicated. Under fluoroscopy, the catheter was seen to loop upon itself in the left lower quadrant, with its tip projecting over the sacrum. Contrast injection with the catheter in this position outlined bowel loops in the left lower abdomen, and although contrast could be freely injected, none was able to be aspirated. Following this, a 0.035 glide advantage guidewire was introduced through the catheter, exiting the catheter tip, and with gentle advancement of the guidewire, the catheter tip was able to be repositioned such that it eventually projected over the iliac crest. Additional contrast injections comfirmed proper tip location and function." Please advise best coding for this case.

3D Rotational Angiography w/33477 IMPLANT TCAT PULM VLV PERQ

Per prior education on CPT code 33477, caths, fluoro, imaging guidance, etc. are included in this CPT code. This question is regarding “3D Rotational Angiography of the conduit/PA branches w/Rendering and Post Processing w/simultaneous RV pacing at 190 bpm.” Can 3D rotational angiography be billed with 33477? Can anything be billed for the RV pacing?

PTEG / PTEJ tube replacements - repost #12956

I'm looking to verify tube replacement codes. My understanding is that the initial placements of both PTEG and PTEJ tubes would be an unlisted code (43999), and tube checks would be coded 49465 (question ID #10351). What about tube changes? Can I code 49450 and 49451, or are these unlisted as well?

36561 Insertion of CVA device, with subq port, age 5 or older

We are receiving denials for billing 36561 and 77001-26, 76937-26 together. I have not noticed this happening before; it seems to be recent. Our NCCI edit program is saying 77001, 76937 require a primary code, and it does not recognize 36561 as a primary code. Is this a correct denial? Did something recently change? I can't seem to find any recent information on it.

EOS imaging for a bone alignment study

We have purchased an EOS imaging machine for our bone length studies (77073). With this new imaging system our ortho docs are wanting to bill left and right knee 73560, pelvis 73521, and left and right tib/fib 73590 in addtion to 76377 3D when performed. Total of 6 CPT codes. Does this sound okay as far as billing is concerned?

93454 vs. 93458

Should you report 93454 if there are only pressures taken of the aorta?

Spinraza Injection

I am seeing two opinions how to bill for Spinraza injection. First way is to bill as 62323 (injection of diagnostic or therapeutic substance) vs. billing as 96450 (chemo administration into CNS, includes lumbar puncture). I understand 96450 includes the lumbar puncture, but if billed as 62323 can the LP be bill separately?

Pre-Bypass Mapping by Non-operating Surgeon

How would this be coded? "Lower extremity vein mapping shows the thigh veins, the greater saphenous to be of good quality on the right leg down to just below the knee where the minimum diameter is 2.8 mm. In the calf, it falls to 2.8 to 2.4 mm. On the left side, diameter is good to the distal thigh and then at the knee, it drops to 2.3 mm and is as low as 1.9 mm in the calf. IMPRESSION: This study shows adequate diameter of greater saphenous veins in the thighs with the right proximal calf saphenous vein usable as well."

33863 vs. 33864

What is the difference between codes 33863 and 33864? From what I understand they both replace the aortic root and both replace the proximal ascending aorta with a tube graft. Both require the coronary arteries to be connected to graft.

Left Phrenic Nerve Block Prior to Lung Biopsy

I believe this is not separately reportable for both provider and facility but I wanted to confirm. Patient with a low left lower lobe lung nodule presents for a CT-guided biopsy. The left phrenic nerve block to be performed immediately prior to the biopsy to decrease diaphragm motion.

Follow up to Question ID: 13106 re: CPT 36556

Our surgery coders are instructed to use the chest x-ray report to confirm the final catheter tip location when it's not documented in the op report. Is this enough documentation to support code 36556 as it pertains to the final tip position? Or do we still need our surgeons to document that they actually reviewed the x-ray report themselves to confirm that the tip is in the correct central vasculature in order to report 36556 per CPT guidelines? Your previous response talks about documentation requirements for billing the imaging guidance and PICC lines, which is not what we're asking here.

MRI of Brachial Plexus

What do you charge for MRI/MRA of the brachial plexus?

93286/93287 with VT and PVI Ablations

Is it appropriate to report codes  93286/93287 (peri-procedural device evaluation pre/post procedure for pacemaker/ICD) with VT (93654) or PVI (93656) ablations? I just noticed a parenthetical statement in CPT that states do not report in conjunction with each other. I was not aware of this and wanted to get your opinion.

If EP ablation is done for all 3 which is primary?

If patient comes in with atrial tachycardia, atrial flutter, and atrial fibrillation, and all three mechanisms were ablated, what determines which should be the primary CPT code? Supraventricular tachycardia ablation (Atrial tachycardia), Atrial Fibrillation Ablation (pulmonary vein isolation), Additional ablation of discrete arrhythmia (atrial flutter ablation), Electrophysiology Study, Electroanatomical 3D mapping, CS/LA pace and record, intracardiac echo, transseptal left heart catheterization, programmed stimulation after IV drug infusion.

Mynx device

For facility charging is the Mynx device separately billable in addition to the procedure?

Ganglion impar block

I was wondering if we can charge fluoro guidance 77003 with 64999 for the following procedure. "Image Guidance: Fluoroscopy. Following needle placement at midline, placed through the coccygeal ligament andadvanced into the presacral space; contrast dye 1 cc injected here spreads B, to retroperitoneal structures without vascular uptake. Images saved."

Lingual and Facial Artery

What is the CPT code for embolization of the lingual artery and the facial artery?

Documentation Requirements for 93650

In your opinion, is this op note complete and acceptable? It appears to be truncated, and we are seeking your advice on how to educate the physician to improve his documentation that he states is complete. "OPERATIVE PROCEDURE: AV node ablation. PREOPERATIVE DIAGNOSIS: Atrial fibrillation, which is difficult to rate control. INDICATION FOR PROCEDURE: Briefly, the patient is a pleasant 66-year-old gentleman with persistent atrial fibrillation, which is difficult to rate control. The patient is undergoing AV node ablation along with pacemaker placement. PROCEDURAL DETAILS: After informed consent obtained, the patient was sedated and the right groin was prepped and draped in the usual fashion. An 8 French sheath was put in the right femoral vein, 8 French sheath was upgraded to a long Agilis sheath, and ThermoCool catheter was placed by this sheath into the AV node location. AV node ablation was performed at 35 w. Successful AV node ablation noted presence of paced beats. After ten minutes of observation, the AV node did not recover, so sheaths and caths were pulled. Successful ABL."

Conventional cholangiogram vs near infrared fluorescent cholangiography

If a provider does the near infrared fluorescent cholangiography with cholecystectomy can you bill 47563? My thought is no because the radiologist is only injecting the dye. Your thoughts?

ICA thrombectomy and cervical ICA PTA with embolic protection

Patient has ICA occlusion. It was treated with thrombectomy and angioplasty of cervical portion of the same vessel. Distal embolic protection was used for angioplasty. Can we code both procedures, or only thrombectomy?

Bilateral VBX stent in the distal aorta extending into both iliac limbs

I have a procedure where patient has 80% stenosis just at the origin of an aorto-bi-fem bypass. The stents are placed half in the aorta and half in the aorto-bi-femoral graft. I am not sure what CPT codes to report for this procedure.

Partial Removal of AVG

Patient has an infected AVG. This required a partial explantation of the medial limb of the graft. Are we allowed to bill 35903 with or without a modifier for the first partial removal since the entire graft was not removed? The patient returned two weeks later, and the remainder of the AVG was removed.

Embolization 61624 and 61650 verapamil infusion

Regarding vasospasm during intracerebral intervention, does the provider have to mention that it's not "iatrogenically-induced vasospasm" in order to bill codes 61624 and 61650? "Case background: Ruptured right posterior inferior cerebellar artery. Under roadmapping technique, catheter was advanced over 5 French inner and Bentson guidewire into the right VA. The inner catheter and guidewire were removed and the guide catheter double-flushed with heparinized saline solution and connected to continuous heparinized saline flush. 3 mg of verapamil was slowly infused for ten mins into the right VA for treatment of vasospasm. Endovascular coil embolization of right posterior inferior cerebellar artery aneurysm was then performed." The vasospasm part is where I'm confused to code or not (didn't hit NCCI edits). Is it normal to have vasospasm before any intervention done? Or everytime there's vasospam prior to intervention we can't code the vasospasm? What if the intervention is on left ICA and the vasospasm treated is on left VA... can I code it in this scenario?


Please advise if I am able to bill for removal of suture material for this case: "TECHNIQUE: Suture material noted in the lateral aspect of the port incision site acting as nidus of infection. Region of redness/cellulitis was centered at the site of the suture, with the medial aspect of the incision appearing well-healed and without evidence of infection. The decision was made not to remove the port given there was no evidence that the port itself was infected including no fevers, elevated WBC count, or positive blood cultures, but to remove the suture material causing the infection and continue antibiotics to treat the cellulitis. The chest was prepped and draped in sterile fashion. The indwelling suture material was removed, and a sterile dressing was applied. IMPRESSION: Successful removal of suture material from the lateral aspect of the port incision site. This is likely acting as a nidus for cellulitis, and the cellulitis is expected to clear with a continued use of antibiotics."

Cardiac arrest in route to hosp, VA ECMO placement, diagnostic cath

Need help with this portion of case, wondering what your suggestions would be? "Upon arrival to the Cath Lab, the patient was noted to have very low flows on the ECMO circuit. Despite aggressive volume resuscitation and vasopressor administration, the patient remained in refractory shock. Her abdomen was distended upon arrival to the Cath Lab and this progressed throughout the case. Aspiration of the left arterial sheath demonstrated that the blood return appeared very dilated, and we fear that the patient had suffered a severe bleeding event. We really turned our attention to interrogation of the ECMO cannulae. A rim catheter was used to selectively engage the right iliofemoral anatomy and an angiogram was performed which demonstrated a well-placed and positioned arterial ECMO cannula. Using the modified Seldinger technique, a 6 French sheath was then placed in the left common femoral vein alongside the venous ECMO cannula. A venogram was performed which showed contrast extravasation outside of the vascular space at the level of the cavoatrial junction."

Open antegrade elephant trunk

My cardiac surgeon places an antegrade elephant trunk descending thoracic endograft by deploying the graft via an open aortic incision during a concurrent open ascending/arch replacement. Approach is sternotomy with transection of the ascending aorta. The vascular co-surgeon then gains access via femoral artery and threads a guidewire up to the area of transection, where it is exteriorized. The elephant trunk endograft is deployed antegrade by direct visualization, followed by completion of the ascending/arch graft replacement. There is confusion over whether the descending thoracic graft should be billed with 33880/33881 because it is an endograft (regardless of approach or direction of deployment) or if it should be billed with 33875 because it is an open approach for graft placement. Can you advise?

76377 with lymphangiogram?

Are 75807/38790 considered base codes for 76377?

Bilat Middle Meningeal artery embolization for chronic subdural

With the middle meningeal artery on opposite sides of the head, are these two separate surgical areas? Is 61624, 61624-59 appropriate? We recently had the same procedure done bilateral for acute subarachnoid bleed.

Embolization Code with EverlinQ AV Fistula Creation

I know I will be using unlisted code 37799 for the AV fistula creation, but what embolization code if any would I code? Or should that be part of the unlisted code? Also do I bill separate for the catheter placements for the fistula creation or should that be part of the unlisted code? "A 5 French catheter was then introduced through the venous sheath and into the brachial vein. Transcatheter embolization of the brachial vein was performed with a single 8 mm coil in order to encourage fistula flow through the perforator vein and into the superficial access sites. Post embolization angiogram demonstrates successful embolization with diminished flow through the brachial vein."

Fat pad biopsy

I was instructed to use CPT codes 20206, 76942 for the fat pad biopsy. This is a sample of the documentation from a radiology report we get: "An image was saved and sent to PACS. 2% lidocaine was used for anesthesia and a dermatotomy incision was made. Multiple fat globules were removed using forceps and placed in formalin and sent to surgical pathology for analysis." Could you please verify the correct coding for this procedure? 

Hybrid Transapical Transcatheter Pulmonary Valve Replacement

"Patient with a history of pulmonary stenosis, prior balloon valvuloplasty x2, and failed transcatheter valve placement. PROCEDURES: 1) RHC. 2) Angiography: RVOT and branch pulmonary arteries. 3) Hybrid, transapical, transcatheter pulmonary valve replacement. Subxiphoid midline incision performed, exposing the RV apex, pursestring suture placed. 18 gauge needle advanced through the suture and through the RV free wall into the RV cavity. Guidewire positioned in the ventricle and needle exchanged for a short sheath. Positioned a guidewire in the distal LPA. Transaortic Edwards delivery sheath positioned in mid RV. Sizing balloon used and then an S3 valve advanced over the guidewire and through the sheath and across the RVOT. Valve deployed. The guidewire and sheath were removed and the pursestring suture tightened, repairing the RV free wall access site. A mediastinal drain was placed." Should we use 33477 or 93799 because of the hybrid transapical approach? Any other recommendations?

Documentation requirement to use CPT 36556

This is a profee coding question in a teaching facility setting. Physician A (general surgeon) places a CVC at bedside without imaging guidance. We assume that the tip cannot be confirmed at bedside because the final position is not documented, although CXR is ordered by Physician A. Physician B (radiologist) then reads the CXR and confirms that the tip is in the correct central vasculature. Is this enough documentation to support 36556 (the op note without tip confirmation and CXR confirming tip position, that is)? Or do we still need Physician A to document that he/she reviewed the CXR to confirm final placement in order to report cpt 36556 in full (without modifier 52)?

Billing cpt 37252 and cpt cpt 93458

How do you bill IVUS with left heart catherization, and what are the CPT codes?

Gore Excluder Endograft

The physician is using a Gore Excluder endograft and lists a 14 mm x 7 cm bridge on right along with a contralateral limb on the right. Would the bridge be included with the Gore endograft or some type of an extender?

Balloon redilation of aortic coarctation stent

What CPT code should be reported for a balloon redilation of a previously placed stent for aortic coarctation? The patient is a 13-year-old who has had multiple procedures for aortic coarctation, including most recently a P3110 stent placed four years prior. The procedures documented on this visit included R/L heart cath, ascending aorta angio, descending aorta angio, RV angio, pulmonary artery angio, and balloon dilation of the existing stent. (The coarctation stent was redilated first with a 15 mm ZMED balloon and then with a 16 mm ATLAS balloon, inflated to 10 atmospheres.) Is there a specific CPT code for the balloon redilation of the stent, or would this be an unspecified code?

Atrial Thrombectomy

Three vessels for access, then: "The AngioVac device was prepared and advanced through the dry seal sheath into the upper IVC. The device was cycled. Under direct ultrasound guidance, numerous passes through the right atrium were performed to engage the clot. These attempts were ultimately unsuccessful. The AngioVac device was removed." What's the code going to be when it's not a coronary artery?

Reposition Dobbhoff

Please advise on how to code a Dobbhoff advancement. "Contrast material was instilled through the existing Dobbhoff tube. The existing Dobbhoff tube is in position within the distal duodenum. The tube is then advanced (under fluoro) to the distal second portion of the duodenum, but fails to advance any further distally." Can I code for a reposition, or should I just code the fluoro?

Right prostate artery embolization

How do you code the catheterization on this case? "Left radial access was obtained. The left anterior division of internal iliac was catheterized. Multiple attempts were made to gain access to left prostatic artery including Sniper microcatheter and Fathom microwire; however, the left prostatic artery was not cannulated or embolized at this time. Subsequently the right anterior division of internal iliac was cannulated. The prostatic artery was subselectively cannulated. The balloon on the Sniper microcatheter was inflated, and embolization of the right prostatic artery was performed to stasis with 300-500 micron embolic microparticles." Will this case be reported with codes 36247 and 36248? Or 36246 and 36247?

Paracentesis with US guidance

Per Ask Dr. Z #7655, US guidance for paracentesis & thoracentesis, there is no requirement that the doctor state that imaging was performed of the needle entering the fluid collection. But your IR book, pages 517-519, #8 advises that imaging modality is used to guide placement of needle/cath into area to be drained, must be performed in tandem with the drainage procedure. Please clarify, which is correct? Also, would a statement of "US: Yes" in a paracentesis report support a paracentesis with US guidance?

76937 Dispute

Our provider contacted the SCAI, The Society for Cardiovascular Angiography and Interventions, to dispute our recommendation that CPT 76937 is NOT billable with any cardiac (congenital or non-congenital) cath or ep procedures per ZHealth recommendations. The SCAI stated, "There is nothing preventing billing congenital cath w/ 76937 and the RUC database description of work does not address any issue with using this code for vascular access during a cardiac cath. All of the CPT guidelines clearly state the catheterization codes ARE NOT excluded. The congenital cardiac cath codes 93530-93533 DO NOT include imaging guidance for vascular access in the DOW(?) and are therefore allowed." With this information and explaining the NCCI Policy Manual instructions, how do I further justify, not billing CPT 76937 with cath/ep procedures if the provider documents properly?

Conversion of Biliary Catheter to Cholecystomy Tube

Would this be coded with 47490-52? "Injection into the biliary catheter was done for a cholangiogram. Then over a guidewire the internal/external biliary catheter was converted to a cholecystostomy tube under fluoroscopy. F/U cholangiogram was performed."

3D imaging codes 76376 & 76377

Due to Palmetto & CMS retiring their LCD on 8-23-19, with no new guidance given currently, what is your stance on how this will be handled in the future due to new technology? I am specifically interested in it being done in conjunction with echocardiograms.

Open broken femoral wire retrieval

What is the most appropriate CPT and diagnosis code for the following scenario? "Indications: Transfer patient from outside facility after a piece of wire broke off in the left femoral artery during cath lab procedure. Post-op diagnosis: Retained wire left common femoral artery Procedure: The patient was taken to the operating room where the left common femoral artery was explored through an extension of the previous surgical access site. The subcutaneous tissue appeared to have some hematoma formation. The section of the wire was identified and easily retrieved. A 5-0 Prolene repair the entry into the common femoral artery. There was no attempt at exploring the common femoral further. Furthermore, the arterial signals at the left ankle remained a hyperemic and biphasic in nature, indicating that there was no evidence of distal embolization. The wire was submitted for gross inspection. The subcutaneous tissue was closed with 3-0 Vicryl. The skin was brought together using 4-0 Monocryl. Blood loss was less than 50 mL."

RVOT stent extending across pulmonary valve

"Prograde right and left heart cath was done. Diagnostic catheter was positioned in the RV apex, and a right ventriculogram was done. Using this image as a guide, 5 French JR 2.5 catheter was positioned in the right ventricular outflow tract and selective angiogram done here. 018 roadrunner wire was advanced through the catheter and across the pulmonary valve in the pulmonary artery. The 018 guidewire was advanced to the right lower lobe pulmonary artery and a 5 French sheath advanced over the guidewire, and the main pulmonary ateriogram was done. After careful assessment of the anatomy 12 mm long Palmaz blue stent pre-mounted on a 6 mm balloon was advanced over the guidewire into the sheath. The balloon was inflated across the pulmonary valve, and the stent was implanted extending from the RV outflow tract and across the pulmonary valve and into the main pulmonary artery." What code best describes placement of the stent? 33999 or 93799?

RHC with Biventricular ICD Implant

The patient had a biventricular ICD implanted, but prior to placement the physician did a RHC with O2 SATS because of class III CHF U stage III renal insufficiency to adequately manage pressors and diuretics perioperatively. Can we charge 93451 for the RHC?

Endarterectomy and thrombectomy

"Diagnosis: Thrombosis common femoral artery and separate thrombosis of superficial femoral artery with dissection. Procedure performed: Thrombectomy of common femoral artery and endarterectomy of superficial femoral artery, which was oversewn with Prolene suture and encompassed the origin of the profundus femoris artery. Xenograft patch was performed in diamond-shaped fashion with running sutures." Would this be billed with 35302 (superficial femoral artery code) or another thromboenderectomy code, since this appears to encompass the profunda artery? And would you report code 34201 for thrombectomy of common femoral artery separately? (All performed from same incision.)

Documentation of Activation and Pacing

We sometimes see documentation that reads that catheter was advanced into CS "for assessment of LA activation and LA pacing." Physician never mentions recording. Is this documentation enough to support 93621?

Post Procedure Chest X-rays

So many times we get post procedure chest x-rays and it is unclear as to why it was ordered. Therefore, we do not know if it a confirmation of PICC placement or CVC.... Our physicians do check placement usually with fluoro or spot imaging in the angio suite. This is noted in the procedure report. If a CXR is performed (for example) 30 minutes post procedure. It is not clear as to why it was ordered and it is ordered by a different treating physician. Can we bill it, or is that still considered inclusive of the PICC or CVC? Yes, the radiologist will notate the line placement because it is the elephant in the room so to speak.

Dialysis Conduit Prolonged Bleeding

Patient referred due to bouts of prolonged bleeding after dialysis. Would the most appropriate ICD-10-CM code be T82.838 for hemorrhage/bleeding or T82.898 for specified complication?

Using 93971 and G0365

Can we bill 93971 for upper extremity dialysis access mapping for Medicaid instead of using the G0365 vein mapping code? I am aware that we should use the G0365 for the initial mapping. Also, if a patient has an AVG or AVF creation and it has failed, can we bill the G0365 a second time for vein mapping?

3D 93662

I'm hoping you can help clarify. My cardiologist is positive that we can bill for 3D ICE vs. 2D. I've told him that 93662 is not specific to 3D vs. 2D but he states the 3D is more expensive and time consuming, so we should be able to bill for it. He recommends using 93662-22 but I disagree. Is there a way to bill for 93662? Should we submit a CPT application for use of 3D?

What procedures must be done to support 93620?

What procedures must be done to support 93620? "Ex: The patient was brought to the electrophysiology lab in the fasting state. The patient was then prepped and draped in sterile fashion. 1% local lidocaine was infiltrated into the subcutaneous tissues in the right inguinal crease overlying the right femoral vein. Venous access was then obtained using modified Seldinger technique, on the right, with placement of a 4 French sheath. A quadripolar catheter was inserted via the 5 French sheath and positioned in the RV apex. A EP study was performed with attempted arrhythmia induction. Programmed electrical stimulation was delivered from the right ventricle with up to quadruple extra stimuli from the RV apex only. Also ventricular burst pacing was performed. No sustained ventricular tachycardia was induced." Should this be coded as 93603 and 93612, or is there enough to support 93620?

Anterior and posterior same mass breast biopsy

Our doctor performed the stereotactic core needle biopsy of anterior left breast cluster of calcification at 1 o'clock and on posterior left breast cluster of calcification at 1 o'clock. We would bill 19081 and 19082, or just 19081?

VATS procedure with a mini thoracotomy

What code would I use for a VATS procedure with a mini thoracotomy? "A thoracoscopic port was placed in the eighth intercostal space in the anterior axillary line. Initial surveillance was made and extensive adhesions noted. An additional port was placed in the fifth intercostal space in the anterior axillary line. The visualization was difficult given the adhesions. Therefore, this port site was enlarged to a mini thoracotomy in a muscle-sparing fashion. Sufficient adhesions were taken down to the upper lobe and some to the lower lobe leaving the lungs at the diaphragmatic level untouched. This allowed sufficient mobilization to realize that the fissure was totally incomplete except for a rudimentary line on the surface of the lung. The mass was palpable and was spanning the fissure. It was resected as a wedge specimen using an Echelon flex 45-mm stapler with thick tissue loads. Mediastinal lymph nodes were harvested from paraaortic position as well as levels 2 and 4. There were no hilar or subcarinal lymph nodes encountered. ProGEL was applied."

HCPCS Codes for Revenue Code 278

For hospital billing, does revenue code 278 require a HCPCS for each line item? Or is it okay to bill an implant under revenue code 278 without a HCPCS?

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