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Units for CPT 64400

With the revision to CPT code 64400 this year, can we report up to three units unilaterally if all three branches (ophthalmic, maxillary, and mandibular) are injected? Or does the revision to the code only allow for one unit per side regardless of the number of branches injected? I read the code description as the former, but we are seeing some conflicting coding guidance published about this code, and we are looking to confirm. 

TAVR ECHO

Can you please advise on how to bill for profee services for an echo that is done during TAVR? The report has both pre and post TAVR findings. The echo is either read by the same cardiologist performing the TAVR or a different cardiologist from the same group. And then there is another echo done two hours after the TAVR procedure. Again, the echo is either read by the same cardiologist performing the TAVR or a different cardiologist from the same group.

34707 vs. 34718

If a physician placed an iliac branched endograft in the left common/external/internal iliac for an iliac aneurysm, but patient does NOT have aorto-iliac aneurysm nor exisiting aorto-iliac graft, is it 34707 or 34718? We think according to photos in CPT book and also instructions that we can't use 34718 because that is only if they already have an aorto-iliac endograft in place. We thought 34707 would be used for IBE in left iliac when there is no previous aortoiliac endograft. Is this correct? Or can 34718 be used as a stand-alone IBE without previous aorto-iliac endograft?

Mitral replacement with chordal sparing/subvalvular apparatus preservation

The provider wants to bill for the chordal sparing with the replacement code 33430. What CPT code would be used for setting a fee for the 33999 to bill the chordal sparing? "TITLE OF OPERATION: Mitral valve replacement with a 27 mm Carpentier-Edwards Magna Thermafix bovine pericardial bioprosthesis with preservation of the posterior mitral valve leaflet and cords. A left atrial vent was placed via the right superior pulmonary vein. Waterston's groove was developed, and a standard left atriotomy incision was made. Exposure of the mitral valve was good. A Frigitronics cryoprobe was used to perform a modified Maze procedure. The base of the left atrial appendage was oversewn internally with a 4-0 Prolene suture. The mitral valve was inspected and found to be structurally normal. The anterior leaflet and cords were excised. Pledgeted sutures of 2-0 Ethibond were placed around the mitral annulus in an everting fashion. The mitral annulus sized to 27 mm bovine PATHOLOGY SPECIMEN: Excised anterior mitral valve leaflet."

Corvia Trial

Right heart cath (93451) with bike exercise (93464) was performed, along with ICE (93662) and enrollment in Corvia trial. Since the intervention was randomized, and I do not know if an implant was placed or not, do I still report code 33999 with comp code 93580? If I can report code 33999, do I code separately for the exercise bike and ICE? 

STEMI and CTO Same Vessel

The physician dictated 100% 26 mm long thrombotic culprit lesion in the mid LC was successfully stented during acute MI. He also states 100% 38 mm long CTO lesion in the second OM was successfully stented. If I bill the STEMI code 92941-LC, what would be the appropriate code for the CTO in the branch?

Ultrasound with placement of nephrostomy tube

If a nephrostomy tube is placed using ultrasound guidance, does the report need to document that a permanent record was obtained?

Tricuspid valve repair

When is it appropriate to use 0570T (additional prosthesis)? My physician states that three Triclip XTRs were used. Is clip the same as prosthesis?

Endarterectomy and Intra-op Carotid Duplex Performed at Time of Procedure

Can intra-operative carotid duplex (93882-26) performed at time of carotid endarterectomy (35301) be billed together? "Details of procedure: Eversion endarterectomy of external carotid artery performed. Flow restored to external/internal carotid. Intraoperative carotid duplex was then performed, which revealed widely patent right internal carotid artery, proximal common carotid artery, and antegrade flow through the external carotid artery with no evidence of intravascular debris or mobile flap."

93356

What needs to be documented in the echo report in order to bill 93356?

Definity Contrast with TTE

Our cardiologists want to start charging for Definity contrast use with TTE in the office setting. Would codes 93306, Q9957, and A9700 be correct for billing these services?

Embolic Protection Device and CPT 0483T

During a TMVI (0483T) our physician uses a cerebral embolic protection device, and at the end of the procedure the cerebral embolic protection device is removed. He would like to bill for this, but we do not believe he can. Can we bill for the placement and removal of the cerebral embolic protection device?

NIPS, 93724 vs. 93624

What CPT code should I use for this procedure? 93724 or 93624? "Syncope with paroxysmal tachycardia; suspicion for ventricular tachycardia. Previously implanted dual chamber pacemaker. Persistent atrial fibrillation. Programmed ventricular stimulation utilizing the pacemaker. Transthoracic cardioversion of atrial fibrillation. Interrogation and reprogramming of previously implanted dual chamber pacemaker system. Program stimulation via the pacemaker system with ventricular lead in right apical region was performed, utilizing single, double, and triple extrastimuli, long-short sequencing, and burst pacing. Aggressive program stimulation port Foley was utilized to try to induce ventricular tachycardia. No ventricular tachycardia was inducible. Adhesive electrodes were placed anteriorly and posteriorly on the thorax. Shock was synchronized to the QRS complex. End expiratory biphasic technique was utilized. A single 360 joule shock was successful in reverting a-fib to atrial paced rhythm. Pacemaker system was interrogated after the cardioversion shock."

93650

Our physician stated that he performed an AV node ablation recently. I felt his documentation was lacking, so I queried him to ask him to update what he ablated. This is what the ablation portion of the procedure said: “A 4 mm tipped ablating electrode was advanced fluoroscopically to the His bundle electrogram. Catheter ablation at that site produced complete heart block and ventricular demand pacing at 40 beats per minute. She was convalesced for 20 minutes in the EP lab and remained in complete heart block." His response to the query was: “The His bundle electrogram identifies the AV node, which doesn’t produce an electrogram. So that verifies the AVN ablation.” Is this enough to justify 93650?

Pacing and Recording from Left Atrium

When a supraventricular tachycardia ablation (93653) is performed, and documentation states "left atrial pacing and recording", is that sufficient to report 93621? In your CV book, pg 503, #20, it says, "Report should clearly document that left atrial recording/pacing was performed from the coronary sinus catheter, as it cannot be assumed." Code verbiage states left atrial pacing and recording from coronary sinus OR left atrium.

Congenital echo

CPT Assistant, May 2015, states to use the non-congenital echo codes for "simple" congenital anomalies such as PFO or biscuspid aortic valve. Can you clarify if there are other "simple" anomalies? The article makes mention of complex congenital heart disease... are only those conditions, such as coarctation of the aorta/TOF/etc. supportive of the congenital echo codes?

78803 vs. 78830

I understand that 78306 is for a whole body scan and that 78315 is for a three-phase bone scan. However, what code, if any, can be added if the technician performed additional images using SPECT/CT with 78306 or 78315? CPT 78803 or 78830? CPT 78205 was deleted for 2020. CPT recommends using 78803.

Bilateral fistulogram and angioplasty on both sides for stenosis

Is it appropriate to code bilateral fistulogram and angioplasty on both sides for stenosis with 36902-RT and 36902-59LT? I know that this has an MUE of 1. Is there a more appropriate way to code this?

Assessment of Tricuspid Valve and Perivalvular Leak mapping

"A patient with Ebstein’s anomaly status post TV repair x3 with RV dilation and dysfunction in the setting of significant paravalvular leak with direct communication between the right atrium and right ventricle presents to cath lab for diagnostic RHC and assess of right-sided defect. The interventional cardiologist performs a RHC and turns the case over to an electrophysiologist to perform assessment of the TV and perivalvular leak under transesophageal guidance. The EP provider crosses the defect with a steerable octapolar mapping catheter and positions it in the area of His potentials, which was directly adjacent to the previously placed wire crossing the perivalvular leak. The cath was advanced through the perivalvular leak and both His potentials and R bundle potentials were recorded. Fluoroscopic imaging confirmed that the perivalvular leak was directly adjacent to the area of His potentials. This info was relayed to the team, and at this point the decision was made to not place a device in the perivalvular leak due to the concerns of causing AV node injury." How is this reported?

Stent and Debridement

Can you bill 37721 and 11042 on the same leg? I believe we should not; however, my physician thinks otherwise. "Yes it’s the same side, but the sites are totally distinct and separate. The iliac artery and fempop arteries are not the same site as the heel, nor are they contiguous with the heel. Moreover, these are completely different procedures on completely different structures – excisional surgical debridement of a foot wound and endovascular revascularization of iliac and fempop arteries."

Iliac Endarterectomy

Received a denial stating that code 35351 was documented in the record. Here is what was documented: "9 x 40 balloon angioplasty balloon was advanced into the common iliac artery and used to provide control. Distal external iliac artery was clamped distally. Longitudinal arteriotomy was made with a 12 blade and extended proximally distally with the Potts until adequate endpoints have been achieved. Thin endarterectomy plane was created and plaque was passed off. 5-0 Prolene and bovine pericardial patch was used to create left external iliac patch angioplasty. There was excellent distal external iliac pulse at this point after balloon control was withdrawn."

Pseduoaneursym with Bypass graft

"Patient comes in with an infected femoral pseudoaneurysm in the left groin. The provider first performs an iliofemoral bypass graft that does not involve the pseudoaneurysm. The physician then makes an incision in the left groin and expresses the clot and old blood. An old femoral/tibial graft is identified, and dissection takes place distally down to the medial thigh. The graft is clamped and transected. The graft is oversewn using prolene." The provider billed 35665 and 35661. Would 35141 not be more appropriate?

Patent Ductus Arteriosis Stent/Angioplasty

In review of question ID # 13757 dated 3/25/20 with response from Dr. Dunn, I am asking for clarification and an explanation for correct coding when placing a stent or providing an angioplasty to the PDA. Previously an unlisted procedure code was recommended for use. Is it now your consideration that CPT codes 37236 and 37246 better describes these procedures?

Billing for Tissue Adhesives

Is using floseal, aminofill, or surgical billable? I have a provider who wants to bill for using all three of these items when closing a thromboembolectomy and on other open procedures. Is this billable? Shouldn't it be bundled into the closure of the procedures? If they are billable, what CPT codes would you use?

What other codes can I bill besides 36838 and 36901?

What other codes can I bill besides 36838 and 36901? "In terms of the arm, I exposed the brachial artery a little bit more than 7 cm proximal to the anastomosis to the brachial artery of the graft. I then made a longitudinal incision to expose the anastomosis to the graft and exposed the brachial artery just beyond that. I went ahead and harvested right greater saphenous vein through a continuous thigh incision. The incison was closed in layers. The proximal anastomosis was done end to side with the vein to the brachial artery again about 8 cm proximal to where the graft comes off the artery. It was sewn end-to-side to the vein. After proximal suture line end-to-side, I distended the vein and tunneled it in the soft tissue. Ligated the native brachial artery just beyond the takeoff of graft and did an end-to-side anastomosis distal to that to the brachial artery. Suture line end-to-side. There was a good pulse in the graft and the radial pulse feels normal. Puncture sheath in graft, through distal incision, I did a subtraction angiogram, which showed the graft to be widely patent without any stenosis."

In-Person Programming and ICM Interrogation

Can in-person programming and ICM interrogation be billed together for same date of service (93284 and 93290 with a qualifying modifier)? I have not found an NCCI edit that states not allowed, but Medicare denies 93290 as inclusive to 93284. I do not feel like modifier -51 is appropriate to append to the ICM. What would you recommend?

Oral contrast

We had a patient come in through the ED, and the doctor ordered a CT and an ultrasound. The patient started drinking the contrast while having the ultrasound. The CT was then canceled. Can we charge for the oral contrast? 

33999 & Flouroscopy

Does code 33999 include fluoroscopy, or can 76000 or 76496 be reported in addition to 33999?

MS-DRG 23

What MCC drives the payment to MS-DRG 23 vs. 24?

CS Modifier

Should you apply the -CS modifier to diagnostic radiology CPT codes?

Cardiac Rehab Phase I

Could you tell me if it would be appropriate to report 93797 or 93798 on an inpatient claim for phase 1 cardiac rehab?

35703 vs. 35226

CPT code 35703 for release of right popliteal artery? Or 35226? "TITLE OF PROCEDURE: 1. Release of right popliteal artery. 2. Intraoperative duplex ultrasound, confirmation of appropriate release of the popliteal artery. A 19year old patient with R Popliteal artery entrapment. She had undergone prior fasciotomy with no relief from her symptoms. Preoperative workup with a duplex ultrasonography demonstrated obstruction of the popliteal artery with plantar flexion.A lazy-S shaped incision was made across the popliteal space. Subcutaneous tissue was divided. The fascia was divided. The overlying crossing veins were divided. The nerve was carefully preserved and the popliteal vein was retracted. Deep and lateral to the vein was the popliteal artery. The artery was then carefully freed up all the way from well above the knee joint to its bifurcation into the anterior tibial and tibioperoneal trunk."

HeRO Graft

My physician is wanting to bill codes 36830 and 36558 with C1750 for HeRO graft. Is this correct?

Contrast Supply Charges

If contrast is given through drainage tubes, G-tubes, arthrograms, can we charge for the supply of the contrast? I know that we can't charge for oral/rectal contrast given but not sure about through other routes.

Code 39545- Diaphragm Transthoracic Repair

I have an op note, and code 39545 is billed with 32663, 31622, and 32674. The diaphragm repair is denied by insurance. Op report states the diaphragm "is a little bit high riding" and also "a little bit in the way and was going to be a hindrance to take down the inferior pulmonary ligament. Due to this, a diaphragm plication stitich was placed and used to retract the diaphragm inferiorly." Does this phrasing support the code definition of 39545?

TAVR with through a large sheath access

Can you please advise on the correct billing of a transcatheter aortic valve replacement (33361)? "Through a 14 French sheath (34713)... was placed in the left groin." The parenthetical notes in CPT do not seem to allow this.

93970/93971

Is documentation of compression and/or other maneuvers required in the reporting for 93970/93971?

Ablation procedure

I am wondering how you would code this ablation procedure. 1. Pulmonary vein antral ablation was performed to isolate PV antral regions with bilateral PV isolation (PVI) confirmed on HDX mapping electrogram. 2. Additional linear ablation was performed at the left atrial (LA) roof to achieve bidirectional LA roof conduction block. 3. Additional linear ablation was performed at the left atrial (LA) lateral wall from the mitral annulus to the LPV anterior carine to achieve bidirectional LA anterior block. 93656 for the PVI then 93655 x 2 or 93655 & 93657.

Documentation for CABG

Provider documents a summary of his arteries/veins bypassed in the header section of his operative note and in an operative summary but does not always describe the details in the body of the operative note. Do you have any recommendations on submitting charges when documented like this? This has been reviewed with the provider, but he does not want to addend his notes.

Division of Myocardial Bridging with involvement of aorta documented

"The sternal incision was made and divided. Patient was placed on bypass. To begin, the mid distal LAD bridge was divided using a combination of sharp dissection and cautery. There was several bridging veins across the bridge that had to be ligated as well. Once this was completed, attention was then paid to the RCA. It was a 2 mm vessel and was isolated and opened. A segment of vein graft was anastomosed here. The remainder of the CABG procedure took place." Along with the appropriate CABG CPT codes, what CPT would you use with the myocardial bridging? Documentation does not support CPT 33507.

Physician billing 36245-50, 36245-50 separate lines vs Hospital billing

PB side is billing two separate lines 36245-50 for bilateral segmental artery angiograms at levels L3-L4. The hospital side is not accepting this CPT coding. HB edit that says: 36245 units of service greater than one is inappropriate for bilateral procedure reported with a modifier 50. Any advice?

Re-cannulation/Angioplasty of modified right Blalock Taussig Shunt

"Two-week-old infant with Tetralogy of Fallot with severe outflow tract obstruction and threatened discontinuity of pulmonaries. He is status post modified right Blalock Taussig shunt and pumonary artery arterioplasty. A pigtail catheter is inserted in the right femoral artery, advanced retrograde into the ascending aorta, and LHC performed. Selective cath was used for innominate angiography with findings of complete occlusion of BT shunt. Tyshak II angio cath was advanced across the shunt. Three inflations were performed to 6 ATM. Terumo catheter was advanced into pulmonary artery for pulmonary pressures. Selective angio of transverse aorta with findings; selective angio of pulmonary arteries, innominate artery, Blalock shunt all with findings. Successful angioplasty of BTS." For coding, I think 93452 for congenital LHC, 93568 for pulmonary angiography, and 37246 for BTS angioplasty, but I'm unsure about the codes for the transverse aortic and innominate artery angiography. I would appreciate your thoughts on this.

Congenital vs. Non-Congenital Echo After OHT; Aortic Coarctation repair

If a patient underwent an OHT but the aortic coarctation was repaired years ('05) before the transplant was performed ('20), would we use the congenital echo code, in this case a follow-up 93304 or 93308? Our pediatric docs still consider this to be a congenital condition. If the congenital heart is removed/transplanted with another heart, then the congenital condition no longer exists, correct? What is an example of a residual condition that remains in order for congenital echo codes/cath codes to be used ,and should the provider document the details of the residual congenital defect remaining?

64581 vs 64561

In question #13631 on Feb 24 you identified OUR method of placement of an InterStim electrode as percutaneous (64561). Cath lab supervisor insists that our method is open/incisional (64581) because she believes a layered closure is used. According to our documentation, the physician makes an incision “through the fascial layer” next to the directional guide, then inserts the lead introducer sheath with dilator over the directional guide. After the electrode (quadripolar lead) is placed, a second incision is made posterior to the iliac crest at the site where the tunnel and lead exit the body “into the subcutaneous tissue.” Closure is only described as “with 0 vicryl subcuticular sutures and 4-0 monocryl skin sutures.” I believe that “subcuticular suturing” normally involves suturing the dermis, the layer immediately below the epidermis, making this a simple, non-layered closure. Does the closure method described above, or any closure method, justify the use of 64581 when the electrode is placed percutaneously as described in question #13631?

Lap retro peritoneal bx

I have a surgeon who loves lap proc. He wants to do a biopsy of sacral mass laparoscopically. The only code we can find is 49010. I gave him 49321 but he says this is not retroperitoneal. Other than an unlisted code have I exhausted the options?

Axillary Balloon Pump Insertion

We have been seeing a few of these cases come through, where the patient has an IABP percutaneously inserted through the axillary artery and a PTA balloon inserted in case of rupture and/or to tamponade during catheter insertions/removals, and sometimes performed in order to help the IABP maneuver through the artery. My question is would this still be 33967 for percutaneous IABP insertion? Can you charge for any type of extremity angiogram (75710) when performed, or would that be mapping? If there was a narrowing that was seen (subclavian/axillary) and described 70%, can a PTA and extremity angiogram be charged? Lastly, can a removal of a femoral IABP be charged as 33968 at the time of the axillary artery IABP insertion if it was a different session than the initial femoral artery IABP insertion?

VATS pleurectomy, intercostal nerve block

What CPT codes would be appropriate for right upper lobe anterior segment wedge resection and right upper lobe apex wedge resection secondary to profound bullous emphysema? Surgeon is suggesting 32666 and 32667. This was done at the time of VATS parietal pleurectomy (32656). In addition, intercostal nerve block (64420?) with 0.5% marcaine with epinephrine was done. Is this billable?

36818 or 36821

Which code best fits this procedure, 36818 or 36821? Does a pocket creation count as tunneling? "Medial longitudinal incision was made above the antecubital fossa and deepened with electrocautery. The cephalic vein was identified and skeletonized with sharp dissection, with side branches tied with 4-0 Ethibond ties. The brachial artery was identified by pulsatile palpation medially and the overlying biceps fascia incised. The artery was carefully separated with sharp dissection. The brachial artery was dissected free along a 4 cm length. Vein was transected distally, and the end portion was longitudinally cut to create a foot plate. The vein was then dilated with serial dilations to 4.5 mm. Profunda clamps were then placed proximally and distally on the brachial artery. Arteriovenous fistula was then created as end of vein to side of artery anastomosis. Proceeded with closure of the arm incision. Vein was approximated under the subcutaneous pocket that was created."

COVID billing (ICD-10 code usage)

The group of cardiologists that I am employed with is now seeing COVID patients at our local hospitals. Most have issues with SOB/respiratory failure/cardiomyopathy and have tested positive for COVID. My question is would I need to append U07.1 on the CMS 1500 form to document the patient as having COVID? Basically, what would be the proper way to document COVID for cardiology? With all of the recent changes with COVID codes, I am quite concerned that I am not documenting properly.

Removing dual pacemaker and leads and insertion of leadless pacemaker

Patient had recurrent problems with lead dislodgement and was admitted for removal of displaced and dislodged pacemaker system with placement of a leadless ventricular pacing system. How would you code this?

CPT 71045 & 74018 charged together for single image/exposure

For what many may call a babygram or kiddiegram, NOT for foreign body. A single AP view of the chest and single AP view of the abdomen, one exposure and single image for infants. Can we charge 71045 and 74018?

Coronary Angiography, Aortic Root, and Right Subclavian

"A selective coronary angiography was performed for a patient with aortic stenosis. Catheterization was performed from the right radial artery and advanced into the aortic root from the right subclavian. Then a selective angiography was performed, and findings for the coronary angiography are read including LM, LAD, RI, LC, and RC." Is 93454 the appropriate code for this procedure? Does a code need to added for the aortic root? There are no findings for the aortic root.

Carotid stent w/Distal Protection Device and embolization

My provider treated a left carotid for stenosis. Once the provider had placed the stent (DPD) he performed balloon angioplasty within the stenotic portion of the stents. The angioplasty revealed wide patency of the distal common and proximal cervical left internal carotid artery without any residual stenosis. Can the office bill for 37215 and 61624 for the left carotid?

33508

We have some that are billing only for the assistant. Should 33508 be billed twice, once for the physician and once for the assistant? Which would be appropriate?

Laser-assisted Transgraft Embolization of Aortic Aneurysm Sac with Onyx

What is the CPT code for laser-assisted transgraft embolization of aortic aneurysm sac with ONYX? "Aortogram was obtained which confirmed type II endoleak. This appeared to originate from an upper pair of lumbar arteries at cephalad portion of the aneurysm sac. Decision was made to perform a laser-assisted transgraft embolization of the aneurysm sac. The 7.0 French Oscor twist conformable sheath was then directed against the wall of aortic endograft in the region of the paired lumbars and through the sheath a 0.8mm Spectranetics laser catheter advanced against the wall of the endograft and with multiple laser pulsations the laser catheter was able to be advanced through the wall of the endograft and into the aortic aneurysm sac. A mailman wire was then advanced through the Spectranetics laser catheter and into the aneurysm sac. Next Echelon microcatheter was advanced over the mailman wire into aneurysm sac. Next multiple vials of Onyx were injected into aneurysm sac. After completion of Onyx inj, Aortogram revealed no extravasation from transgraft defect...."

Observation visit- AICD misfire ruled out

I am considering using atrial fib I48.9 and adding additionally ACID status Z95.810. Or maybe I should use Z45.02 encounter AICD management as primary diagnosis? Please recommend primary diagnosis for observation visit. Patient came to ED due to having shock from his sub-q AICD. Cardiology consult gives final dx- Device interrogation showed ICD shock for atrial fibrillation with exceeded 200 BPM.

Bilateral sacroiliac nerve block of medial and lateral branches of lumbar

Would bilateral sacroiliac joint block including medial branches L4 and L5 and the lateral branches of S1 and S2 be coded as a sacroiliac joint block (64451) or as a lateral and medial branch block (64640-50, 64640-50, 64493-50)? "A 25 gauge Quincke needle was passed atraumatically to make contact with the periosteum just lateral to the junction of the superior irritating process in the L5 transverse process, superior reticulating process and sacral ala and the neuroforaminal opening at S1 and S2 using intermittent fluoroscopy on the right side. At this point a steroid solution consisting of 0.5% bupivacaine containing 5 mg of Kenalog per mL was slowly and incrementally injected after negative aspiration, through each needle. The procedure was needed on the opposite side."

PCS code for Basilica procedure done during TAVR

I see that an unlisted CPT code is recommended for the Basilica procedure. Is there any recommendation for the PCS code for the Basilica procedure?

Gastrojejunostomy Tube "Re- Placement" (vs. Exchange)

When a patient presents for a GJ tube replacement because the tube "fell out" and required gaining access into the established gastrostomy tract and then basically doing the work of a G to GJ conversion, how is this most appropriately coded? Should we use 49452 as a typical GJ tube exchange, or 49450 + 49446 to reflect the additional work performed compared to a GJ exchange over full wire access through an existing GJ tube?

Code 75630 & 36252

Can you report code 75630 for an abdominal aortic aneurysm and 36252 for selective bilateral renals for renal artery stenosis?

How do you bill for a DSA

How is intracranial DSA coded?

Catheter Placements and Leg Imaging

Would the following be correct codes for selective imaging? Right femoral artery access > left internal iliac artery (36248) -> left common femoral -> left profunda artery -> branch of left profunda artery (36247-furthest order) Imaging: 75736 for internal iliac, 75710 for basic leg, 75774 for profunda branch imaging

Congenital cardiac cath codes

Would congenital cardiac cath codes apply for the following? "24-year-old male with significant past history of congenital aortic stenosis and underwent valvotomy and ligation of small PDA as a newborn. He underwent aortic valve replacement with St. Jude prosthesis in 2003, repeat aortic valve replacement with prosthetic valve in March of 2007. The patient's most recent transthoracic echo showed an ejection fraction of 35-40%, increased gradient through the aortic prosthesis, and severe mitral regurgitation. The patient has been seen by cardiac surgery and currently undergoing workup for possible intervention. The patient was referred for cardiac catheterization as part of his preoperative workup."

Global Modifiers

Surgeon performs wedge resection on lung mass. Frozen section shows consistent with nonsmall cell carcinoma, and a lobectomy is performed in the same setting. One month later, patient is planned for chemo and port-a-cath has been requested for chemo access. Same surgeon places port-a-cath. Two weeks later, total decortication is performed on contralateral lung (in relation to lung mass resection) for pleural effusion. Which modifiers are correct for these situations? 58? 78? 79? Is the Port-a-cath related to the resection since the cancer was found during that service (use of 78 modifier)? Is the contralateral decortication unrelated because it is contralateral (use of 79 modifier)?

Catheter placement in the central shunt

I am unsure what CPT to use for the catheter placement in the central shunt. A congenital heart cath was performed, and a pigtail cath was placed within the central shunt with findings listed of the SVC, bilateral innominate veins, and bilateral pulmonary arteries. What code would I use for the cath placement in the central shunt? 

Therapeutic drug injection part of clinical trial

Our radiologist used a 22 gauge needle into the lymph node, and a total of 1 cc of STING agonist solution was injected throughout the lymph node using ultrasound guidance. What CPT codes can be used for the injection and the guidance portion of the procedure for a clinical trial study?

33361-33366 -Co-Surgeon Documentation Requirements

TAVR/TAVI requires two physician operators, and all components of the procedure are reported with modifier -62. When two physicians work together as primary physicians with distinct skill sets needed for TAVR/TAVI, each physician should report his or her distinct participation by appending modifier -62 to the appropriate procedure code (33361-33365). My question lies in the documentation requirements. We know what SHOULD be documented, but what is REQUIRED to be documented to support both providers? Is it REQUIRED for both to have separate operative reports or just by the nature and mandate that two surgeons must perform the TAVR/TAVI - that documentation in one operative report would be compliant even if the operative report didn't actually say which MD performed which part?

Venoplasty for DVT

Our physician used an Atlas PTA balloon to treat DVT in the common iliac vein. Would you code this scenario as unlisted or 37187 (thrombectomy) since that was the intent of the venoplasty to tx DVT? 

Clarification of Catheter Placement

If a diagnostic angiogram of bilateral lower extremities is performed with catheter placement in the distal aorta (36200 and 75716), then followed by a contralateral revascularization, do we get to keep the 36200 for the diagnostic angiogram?

Subclavian dual vortex port placement with vein cutdown and open exposure

"Left IJ vein accessed and venography performed. Occlusion found and unable to surpass occlusion. Subclavian vein was accessed instead. After multiple attempts, they switched to a cutdown and open exposure of the subclavian vein in order to place the dual vortex catheter. Catheter finally was placed in the atriocaval junction under fluoro. Subclavian vein sutured and repaired." How should this be coded? Is open exposure of the subclavian vein bundled with 36558? My codes are 37799 (catheter placement in IJ), 75860, 36558, and 77001.

Nasogastric feeding tube contrast injection

What CPT code do you suggest for contrast injection of a nasogastric or NJ feeding tube? Some suggest 74241, and I have seen some suggest 49424/76080.

ICD Gen Change with Azygos Vein Lead Placement

How would you recommend coding this? "The pocket was opened, and a new azygos vein lead was placed due to failed ICD therapy. The old generator was then removed and replaced with a new high energy generator, which was attached to the previously placed RV lead and the new azygos lead."

Congenital right heart cath and attempted transseptal puncture

If the physician performed a right heart cath, and then attempted a transseptal puncture but was unable to cross the atrial septum (after multiple attempts for more than one hour), can I report code 93532-52, or would I just report code 93530?

“Cephalo-subclavian junction” stenosis

Is code 36907 reportable for “cephalo-subclavian junction” stenosis? "AVF aneurysm: The left arm was isolated as a sterile field. After Marcaine Xylocaine infiltration the arterial side of the fistula was incised to dissect out the aneurysm and overlying thin skin with appropriate in flow and outflow vessel. There was enough redundancy in the fistula that the aneurysm could be resected with end to end closure of the inflow and outflow vein. 5000 units of heparin was given and the fistula was clamped proximally and distally. The aneurysm was resected. The marks needle was inserted into the cut venous side of the fistula. A central venogram was obtained. Outflow veins were followed into the atrium and there was evidence of 70% narrowing of the lumen at the level of the proximal stent of the cephalo-subclavian junction. A 7 french introducer was placed and a 10 mm 4 cm charger balloon dilatation catheter was passed and the lesion was dilated to profile. The two ends were sutured end to end with 4-0 prolene. When clamps were released there was a good thrill in the fistula and a hemostatic anastomosis."

Cerebral Aneurysm Embolization with Vasospasm

"Patient is status post Pipeline embolization. Patient clinicially, CTA and TCDs are consistent with vasospasm. Right vertebral angiogram showed vasospasm. Vasospasm was treated with 10 mg of intra-arterial verapamil over a 10-minute infusion. Left internal carotid angiogram showed vasospasm and filling of the left ophthalmaic aneurysm. The vasopasm was treated with 10 mg of intra-arterial verapamil over a 10-minute infusion. Given persistent filling of the aneursym, an additional Pipeline embolization was performed. A 4 x 12 Pipeline was successfully deployed. Two follow-up angiograms of the left internal carotid were performed." Can we charge for follow-up angiograms with a modifier for the embolization? Follow-ups are bundled with codes 61650 and 61651.

Reticular Vein and Telangiectasias Treatment

Would the appropriate code for this procedure be 36468-50? Should we code 36470-50 in addition for the reticular veins? "Procedure: The patient was prepped and draped in the usual fashion. Utilizing ultrasound as well as vein light, access was obtained into abnormal appearing venous structures. Polidocanol solution was instilled at each of these locations. Follow-up ultrasound at the conclusion was performed. Findings: Use of ultrasound and vein light systems allowed for access of reticular veins and telangiectasias. These sites were accessed, and polidocanol solution was instilled. There were no significant residual sites present bilaterally at the conclusion. Impression: Successful sclerotherapy performed bilaterally."

Lumbar Spinal Angio 36245

How would you code for bilateral L1-L4 angiogram? We have billed this as 36245 x 3 (due to MUE) and the remaining as 36245 x 5. Now we have some carriers wanting this billed with modifier -50 (DOS prior to 2020). So would I bill that as 36245 -50 x 4 since I have a total of 8 injections?

Pocket relocation w/new SC ICD & Lead

My physician removed a SC ICD on the right and capped the RV lead and closed the incision. A new SC ICD on the left was placed with new RV lead. Coding 33249, 33241, 33223?

Ultrasound guidance for congenital anomalies

Is there a specific NCCI edit in regards to billing 76937 with congenital cardiac procedures? If so can you direct me to where that can be located in NCCI? Medicare only references the adult non-congenital codes.

76937 Ultrasound guidance for vascular access

For real-time visualization of vascular needle entry with permanent recording, does the image have to be a video recording, or can it be just a picture of the needle entering the vessel?

Reporting Diagnostic Cerebral Angiogram Codes with Intervention Codes?

When performing an embolization (61624) it is my understanding if the patient has had a previous diagnostic angiogram, then we would report the treatment codes (36126-36218) with the embolization. Is there ever an instance in which diagnostic and treatment codes could be reported together with the embolization? For instance, 61624 for the left MCA, 36217 left MCA, and 36223 for right common carotid, with the rationale that once the coil has been placed a clinical change has occurred in the patient, and therefore a diagnostic code could be reported for the vessels of the side not treated?

AAA Repair with Endarterectomy

How would you code this op? Physicians want 37221-RT, 34705, 35371-50, 35372-RT, and 34812x2. “Incision over femorals, dissected out CFA, SFA, & PFA. On LT, needle access of CFA but wire wouldn’t pass dense calcific disease. Proceed w/endarterectomy on LT. Incision in CFA & 2 cm into SFA. Plaque taken from CFA, SFA & PFA. Closure began leaving 1 cm gap. 12 Fr sheath placed through gap. On RT, 18 Fr sheath was placed. Main body deployed. Contralateral LT iliac limb deployed through sheath on LT. Extension limbs were needed but not because of continued aneurysmal disease. The main body went down to the iliac bifurcation on the RT with a known occlusion of RT int iliac artery. Elected to extend stent down 5 cm into EXT iliac artery. Iliac stent deployed. Sheath removed. Closure completed. Then endarterectomy on RT. Incision in CFA & several cm into SFA. Endarterectomy done on CFA and proximal PFA but there remained significant disease beyond. Separate arteriotomy is made on PFA for distal endarterectomy. Endarterectomy done in distal PFA. Patch closure on CFA & PFA.”

NM VP Shunt Eval

We have a patient who has ventricular intracranial shunt displacement. Neurosurgery administered In-111 DTPA and our radiologist is interpreting images. In 2015 (Question ID: 6377) you recommended 75809. Would that still be your recommendation today? Would we bill 75809 with -52 mod if we interpreted images but did not supervise, or would we bill individual xrays? Report states: "EXAM: NM CSF SHUNT EVALUATION HISTORY: Ventricular intracranial shunt displacement TECHNIQUE: 1.1 mCi of In-111 DTPA was administered into the patient's right sided shunt reservoir by neurosurgery. Subsequent imaging of the head, neck, chest, abdomen, and pelvis were performed immediately after the radiopharmaceutical administration and at 4 hours. FINDINGS: Initial activity in the shunt reservoir and ventricles is identified. On immediate images, there is faint activity noted along the course of the shunt catheter with activity noted in the perioneal cavity and no evidence of localized collections. IMPRESSION: Findings consistent with patent ventriculo-peritoneal shunt."

Venous Arterialization

How would you code venous arterialization where an artery is anastomosed to a vein through an open approach, distal valve lysis is performed, and distal venous side branches are ligated via separate incision? Are the fistula creation codes only for dialysis, or would it be appropriate for venous arterialization procedures?

32666 vs. 32608 for RUL

"Diagnosis lung cancer, right lower lobe. Three ports were created in the chest wall. A 5 mm thoracoscope was inserted. The inferior pulmonary ligament was mobilized. An anterior hilar dissection was performed. The right inferior pulmonary vein was isolated and transected with an endoGIA stapler. Next, the bronchus to the lower lobe was isolated in the usual manner and transected. The fissure was completed, and pulmonary arterial branches were taken. The specimen was removed in an endocatch bag. A mediastinal lymph node dissection was performed, taking multiple level 4 and 7 nodes. N1 nodes were taken during the lobectomy as well.  The right upper lobe mass was readily palpated. It was wedged out using an endoGIA stapler. It was relatively small. Chest tubes were placed, and the lung was reinflated. Dressings were applied, and the patient was brought to the ICU in stable condition." Should I use code 32666 or 32608 for RUL?

Unilateral Ribs including PA Chest

In order to qualify for 71101 (unilateral ribs including PA chest), does the chest view have to be PA, or can it be stated as frontal, AP, or single-view chest?

AMPLATZER™ PI Muscular VSD device under a HDE

What is the professional CPT used to bill AMPLATZER™ PI Muscular VSD device under an HDE? Should we use unlisted code 93799?

Repair of penetrating abdominal ulcer w/ Gore graft

Ulcers that "looked like saccular aneurysms". Three Gore cuffs used, with 16 French sheath. Not sure what code to use? EVAR codes do not seem to describe. Is this considered a stent (37236) or EVAR? How many can be coded? Three used, help!

Left VATS & ligation of the left atrial appendage with articlip

Can you please tell me what CPT codes to use for a left VATS and ligation of the left atrial appendage with articlip procedure? Indication is for PAF and inability to anti-coagulate. I'm thinking unlisted code 33999, but I would appreciate your feedback.

SIRT Mapping 79445, 78830, 76380

Is it correct that 79445 should not be reported during SIRT mapping because the administration of radionuclide is not therapeutic and is included in the nuclear medicine portion of the exam that day? In addition, if during our mapping is it okay to report 76380-XE if diagnostic Spin CT was performed during the IR angiographic study and findings were given? Or is this Spin CT considered part of the same encounter as the nuclear medicine SPECT CT exam 78830?

33866 Hemiarch with DHCA Documentation

Does documentation alone of "Deep Hypothermic Circulatory Arrest" enough to imply no cross-clamp and open anastomosis was performed? Is documentation of "hemiarch reconstruction" alone describe how much of the ascending aortic aneursym was resected and where the distal anastomosis was done? I am being told that these statements alone are enough to bill hemiarch +33866 without documenting EACH of the specific CPT guidelines. (1. DHCA 2.incision into the transverse arch under the arch vessels and also 3. extension of the ascending aortic graft to the aortic arch by beveled anastomosis without a cross-clamp.

GJ Exchange or G Tube Conversion

If a patient has a GJ tube that has become dislodged/pulled out and a Foley catheter or G tube is placed in the stomach to keep the track open, the patient then goes to IR for replacement of the GJ and leaves IR with a new GJ in place. Is this considered a GJ replacement since the patient initially had a GJ tube, or is this a conversion from a G tube to GJ since the tube or catheter was in the stomach at time of replacement? 49452 vs. 49446

Angiogram after CT for hemorrhage prior to embo

When a CT is done that shows pelvic hemorrhage, but not the source, and the patient is sent to IR to have an embo but they do imaging to find the exact source, is this considered diagnostic and billable? Or would it be guiding shots since the hemorrhage was known?

Cancelled Ablation

After anesthesia was provided, but before the patient was prepped and draped, he began vomiting. Afib ablation was cancelled. Do we charge 93456-74 or 93619-74 or anesthesia bill only?

Functional MRI Liver

What is the appropriate CPT code for functional MRI of liver?

Endarterectomy with angio and post op stenting

Our surgeon routinely performs a common femoral through profunda and SFA endarterectomy (35371). A couple of questions regarding inflow/outflow and follow-up angiography. More often than not he will do a post endarterectomy angiogram with a contralateral stick (over the horn) approach with findings. Is this billable or considered bundled? Subsequently he will stent the external iliac into the common femoral (37221). This appears to be billable, as it’s considered a different vessel from the CF endarterectomy... is that correct? He then proceeds to stent the proximal SFA and profunda femoral origin. Now would this be considered bundled, as it’s included in the inflow/outflow coding rules? These can be confusing on what is actually codable and what is bundled. My codes are: 35371 and 37221 with the rest considered bundled. What is your opinion on this?

Fem-peroneal bypass with jump graft to distal peroneal artery

"Left fem-peroneal bypass using reversed ipsilateral greater saphenous vein. After patching the femoral artery with a portion of the greater saphenous vein the vein was then anastomosed and tunneled to the level of the peroneal artery. It was diseased in the more proximal segment, so a patch was placed with a segment of the GSV, and then the graft was anastomosed end-to-side into the patch. Angiography confirmed poor outflow fromt he peroneal segment. Provider then harvested a segment of the contralateral GSV and created an end-to-side anastomosis within the prior bypass and an end-to-side anastomosis between the jump graft and peroneal artery." We feel that code 35566 is supported for the initial bypass graft. We are not sure about the jump graft in this case. Is there a separately reportable code option for this additional work?

Exchange ICD gen with new lead/ cut yoke of old lead

Cardiologist exchanges the ICD generator due to end of life (single chamber RV) and also puts in new lead due to lead failure. The documentation states, "New lead was placed in the right ventricular septum and sutured. The yoke of the old lead was cut and removed, and the residual portion of the old lead was capped." I am thinking this should be reported with codes 33249 and 33241, but another coder says it is 33262 and 33244. Please explain how you would code this and what does it mean when they say, "Yoke of old lead was cut and removed but also capped"? Is this a removal or a capping of lead?

Anastomotic Blowout - Fibular Free Flap Reconstruction one week ago

Is 35231 the correct code for the following? "Procedure: 1) RT ext jugular vein harvest measuring 3 cm. 2) Anastomosis of the LT facial artery to the vein graft to the peroneal artery. Bulldog clamp used to achieve hemostasis while the rest of the hematoma was copiously irrigated. The external carotid artery stub was noted to be too short to reach the remaining peroneal artery and the right neck was evaluated for any suitable vein graft candidate. The right external jugular vein was found to be patent and of adequate length. Careful dissection along the superior aspect of the sternocleidomastoid muscle released the external jugular vein from the surrounding tissue. Approximately 2 to 3 cm of vein was harvested and was brought into the left neck. This was cleaned in preparation for microvascular anastomosis. Superior aspect of the external jugular vein was anastomosed in an end-to-end fashion to the left common carotid artery using interrupted 9-0 nylon suture. Distal aspect of the external jugular vein was then anastomosed to the peroneal in an end to end fashion."

CardioMems recalibration during RHC

Can code 93290 be used to report CardioMEMS recalibration during right heart catheterization?

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