Knowledge Base

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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?

Quadratus Lumborum and Lateral Femoral Cutaneous post op nerve blocks

Surgeon requested quadratus lumborum and lateral femoral cutaneous blocks for post operative pain management for a hip replacement. Both blocks were single-shot. The quadratus lumborum approaches use a fascial plane through which the abdominal branches of the lumbar arteries course. The lateral femoral cutaneous nerve originates directly from the lumbar plexus and is not a branch of the femoral nerve. Is 64450 the appropriate code?

C9600 with 92921

Code C9600 is not listed as a primary code in the OCE editor for 92921. Is your recommendation still to use 92921 with C9600?

"catheter-based" studies and angoigrams

We have a question regarding diagnostic angiographies performed after a "catheter-based" study was done, taking into account the CPT guidelines indicating when it is appropriate to bill for this angoigraphic study performed, etc., which we understand. At a recent seminar, the guest speaker indicated that a CTA was not a "catheter-based" study, so I guess we're looking for some clarification then as to exactly what's considered a "catheter-based" study.

Minimally Invasive 33405 or 33406 and Modifier 22

I have surgeons who want to use modifier -22 on codes 33405 and 33406 because they document a minimally invasive approach. At the STS 2020 Conference, they stated that these codes include the approach (open, minimally invasive, or robotic) and no modifier should be used. What is your recommendation on the use of modifier -22 for minimally invasive procedures? Example: -22 modifier for non-sternotomy case. "Right mini anterior thoracotomy incision was made over the 3rd rib. This incision was taken down to the 3rd rib. The right internal mammary artery and vein were identified and clipped and transected. A segment of cartilage was then removed, and the Alexis soft tissue retractor was then inserted to expose the upper mediastinum. Pericardial fat was excised and pericardium was opened and pericardial stitches were placed to expose the aorta."

Open removal of stent in poplteal artery

Code 37197 is for percutaneous removal of foreign body. What code do we use for open procedures? Patient had a stent due to aneurysm and the stent thrombosed. Removed stent and did a bypass.

Moderate sedation codes and times

2019 instructions were clear, nothing for less than 10 minutes, then 10-22 minutes, then each additional 15 minutes or fraction thereof. I'm not so clear on the 2020 rules. Code 99152 is for the first 15 minutes. Is that to say 99152 can be used for 1 to 15 minutes? So if the monitoring is 7 minutes it would be appropriate to report 99152?

Tunneled Catheter Removal

We're having a disagreement. Is the mention of a Hickman or Trifusion cath removal with blunt dissection of cuff enough to charge tunneled cath removal 36589? I am being told it must say "tunneled", and while I agree that would be great if it did, I am thinking that if you use blunt dissection to release the cuff, it has to have been tunneled. The order to remove stated "removal of tunneled Hickman catheter" by the way.

76377 ICD-10 Possible codes

We are consistently getting denied for CPT code 76377 when performing a diagnostic angiogram or aneurysm embolization procedure. When CPT codes 36221 through 36228 were first introduced in 2013 according to CPT Changes issued by the AMA, code 76377 was an approved reportable code when used during catheterization CPT codes 36221-36228, and it was a necessary and essential component of the endovascular management and of diagnosis complex lesions and management and diagnosis of cerebral aneurysms. We recently noticed that Medicare is no longer paying for 76377 when we code the usual ICD-10 codes, which we had in the past year for justification of these procedures. We also noticed when searching that there are no longer ICD-10 codes matched for 76377 that begin with an "I" besides I05.0-I05.9, I08.0-I08.9, I23.1-I23.5, I33.0, I34.0-I34.9, I36.1-I36.9, I39, I48.0, I48.11-I48.21, I48.3-I48.4, I48.91-I48.92, I51.0-I51.2, I97.110-I97.19. None of these codes can be used for our procedures. What is the reason for the reduction of ICD-10 codes and what can we do?

Multi-day MRI

What is the correct coding/charging/billing for a patient where it took three consecutive days to complete the ordered procedure of MRI w/wo contrast (72158) because the patient could not tolerate the scan for longer than 15 minutes at a time. There is one order, and one written report. The written report documents that the exam had to be done on three different days because of the patient’s condition. The first two days were the without contrast component of the scan and the third day had the contrast administered.

Ductus Arteriosus Stent Open Chest

I'm not sure how to capture the stent insertion by the interventional cardiologist below. "The chest was open by the surgical team. Pulmonary artery band were placed by the surgery team. A 6 French sheath was positioned in the proximal main pulmonary artery. An angiogram was performed for aorta/Pulm arteries. Measurements were made of the ductus arteriosus. The ductus was crossed with an angled glide catheter and a 0.035 rosen wire was positioned in the descending thoracic aorta. Over this wire a 7 mm x 2 cm protege self expanding stent was positioned across the ductus arteriosus. It was deployed in the standard fashion. Flwup angiography demonstrated good positioning of the stent with retrograde flow in the arch. The entire ductus appeared to be covered with good flow into the left pulmonary artery. The surgery team removed the sheath and proceeded with chest closure." Is this unlisted CPT 93799?

AVF/AVG Declotting Procedures in Global Period

Many of our dialysis patients have angioplasties or thrombectomies or stents performed in AVF/AVG. These procedures fall in the global period of the same AVF/AVG placement or revision. What modifier should be used for the physician charges for the procedure performed in the global period? The fistula repair is usually related to the patient's underlying illness (renal disease) not directly related to the fistula's creation or revision and is not strictly a complication of the earlier procedure. 

Endarterectomies

For this OP report, would you report codes 35371 and 35302 for both sides? "Attention is then turned to the right femoral artery. An arteriotomy is made with 11 blade and extended with Potts scissors in the CFA and carried down onto the first 2-3 cm of the SFA. An endarterectomy was then performed. The Penfield elevator was used to create a plane. The proximal endpoint was cut flush with tenotomy scissors, and proximal plaque was then removed with a hemostat. This was in the proximal CFA. An eversion endarterectomy was then performed for the first 2 cm of the PFA with a nice feathered endpoint seen. The distal endpoint of the SFA endarterectomy was created with gentle traction, and the distal endpoint was not initially clear of plaque. The plaque down the SFA on the right was fairly extensive, and we extended our arteriotomy another couple of centimeters down the SFA to be able to get a nice feathered distal endpoint, which we were able to achieve. The same was done on the left except there was a stent in the SFA that they had to partially transect."

Lead Revision Same Session as Initial Implant

Patient comes in for an ICD implant. They extubate the patient, and patient becomes violent and dislodges a lead. Patient consents to immediate lead revision. Patient is then re-prepped, placed back under anesthesia, and they fix the dislodged lead. They never left the OR. Do we capture the lead revision, or is it included in the initial implant since they did not leave the OR?

Percutaneous electrosurgical technique for innominate vein occlusion

The interventional radiologist and cardiologist performed a procedure to open an occlusion of the innominate vein. The IR doctor tried but was unable to cross the occlusion. He exchanged the catheter for a Termo catheter, and a piggyback guidewire was advanced to the point of occlusion. Next, an Astato guidewire was advanced to the point of occlusion. By separate access, the cardiologist placed a catheter into the SVC to be used as a target. A Bovie was attached to the back end of the Astato guidewire, and electrocautery was performed under fluoro guidance. After multiple passes without success, the decision was made to forego further attempts at recannulization. I coded the cath placements, but wasn’t sure about the electrocautery... 37187, 37799? 

Lumbar Epidural Steroid Injection performed in an office

When a lumbar epidural steroid injection is performed in an office (62323), can you also bill for the Kenelog (J3301) and the bupivacaine (J3490) that was injected into the epidural space as well as the Omnipaque 240 (Q9966) for contrast?

37224/75716

I was hoping you could help me with some updated information. What I have been reading is 2011 and 2016. Based on the below language, is it enough to bill codes 37224/75716 with modifier -59? " Please note, secondary to the findings on angiography, it was decided to proceed with an intervention, as there was no previous imaging. Angiogram was performed, showing proximal occlusion of the left SFA with reconstitution of the above-knee popliteal artery." I'm trying to make sure that they are clearly showing medical necessity. I am still new at this and want to make sure I am doing these right.

Kidney Cyst

Physician performed aspiration on two renal cysts under ultrasound guidance. Can we code each cyst separately with 50390 with US once?

Diagnostic venography and intervention

"Access site was right posterior tibial vein. Venography was performed at right posterior tibial vein, popliteal vein, femoral vein, common femoral vein, right iliac vein, and IVC. Venography demonstrated total occlusion of femoral, popliteal, and right posterior tibial vein. From same access site, venoplasty was performed at right posterior tibial vein, popliteal vein, and femoral vein using different venoplasty balloons." Should it be coded with 34248 and 37249 x 2 for venoplasties done at three levels, 36012 for catheter placement only as all lesser vein are in route to IVC, 75825 for IVC venography, and 75820 for extremity venography? I'm confused how to exactly code this scenario because there is very limited info regarding venous studies and interventions and also code set variate as compared to arterial system.

Sclerotherapy without imaging guidance, diagnostic study, contrast,

Can we report code 49185 even though imaging guidance wasn't performed, and contrast wasn't administered? Can we also report code 49185 when sclerosants aren't used? "Provider injected 30 mL of desiccated ethanol into the abdominal wall seroma via previously placed drain. Patient was turned every 15 minutes to allow the alcohol to bathe all sides of the seroma cavity. The alcohol was then aspirated completely with 30 mL removed. Patient tolerated procedure well."

Replacement of 40 cm biliary catheter as NUS. 50382 versus 50387

We are debating whether this would be a stent or a catheter replacement. One of us has coded 50382, and someone else coded 50387. "Small amount of contrast was injected through the left pre-existing NUS, confirming appropriate location and occlusion of the distal aspect of the tube. The catheter was transected and removed over wire. The wire could not be passed into the distal pigtail and submitted a proximal side hole. A Balkan sheath was advanced over the wire and used to advance a wire across the occluded ureter. This was ultimately successful in recovery of the pathway into the bladder. Over wire, the system was exchanged for a new 8.5 French 40 cm biliary catheter used as NUS. Catheter tip pigtailed in the bladder." Is there a good way to tell the difference between a stent and catheter? Our physicians use the words interchangeably, sometimes even in the same OP note.

Nephrostomy- dilatation to accomadate larger tube exchanged

Would 50435 be used for following? "Patient has existing nephrostomy tube for two weeks, but now has leaking. OR procedure: Patient in the prone position. The nephrostomy was to release the suture that is holding the nephrostomy in the loop in the renal pelvis. The nephrostomy was then intubated using a 0.35 Glidewire. The nephrostomy was removed. Using the nephrostomy dilator we then maneuvered the Glidewire so that it would go all the way down to the ureter into the bladder. At this point then we were able to dilate the nephrostomy tract to 14 French. After dilating the nephrostomy tract an 14 French were then introduced the 12 French nephrostomy tube together with its obturator through the Glidewire and then maneuvered the nephrostomy so that the loop will be made right at the renal pelvis. Having looked into the renal pelvis then the procedure was basically terminated the the suture was locked that holds the loop of the nephrostomy."

Trying to understand 93561 and 93562

If a patient has a right heart cath and is found to be in cardiogenic shock and admitted to transplant ICU for Swan-directed therapy, does that qualify for billing 93561/93562, and what type of documentation shall I look for? I know you would bill 93561 the first day after the cath and 93562 each subsequent day until removed.

Subclavian Venoplasty for Swan Access

Patient presented for a right heart cath for LVAD workup. "We then attempted to advance a Swan-Ganz catheter into the RA; however, it would not pass the mid portion of the subclavian vein due to likely stenosis from multiple pacing wires. We then advanced a Grandslam wire into the RA and performed venoplasty using a 2.0 x 25 mm balloon. However, the Swan would still not pass. We then advanced a 5 French MP through the stenotic segment using balloon-assisted tracking. Through the 5 French MP catheter we then advanced a wedge catheter into the PA, which was then used to perform right heart catheterization." The rest of the right heart cath with angiography went fine and was documented appropriately. Can I submit code 37248 for the venoplasty performed in addition to 93456? Or is there a better code?

27592 vs. 27596

We have a patient who had an above-knee amputation (27590) one month ago, but then came back due to infection and had a revision, although they are doing a guillotine type revision being left open at the end of the case. The patient went back to the operating room five days later and had another revision with more bone, but this time it was closed. Would we code both revisions as 27596-78, or the first revision as 27592 and second revision as 27596?

Pacing and 'recording' of left atrium

What documentation do I look for to validate that 'recording' was done in the left atrium? I send queries on this every day. Today my response from an EP physician was: "CS pacing and recording was performed. This sentence, "Decremental pacing from the proximal CS showed AVWBCL at 520ms ms with no persistent crossover,' indicates that. This sentence shows CS pacing and recording. There is nothing further that is needed to document that." Dr. Z, can I 'assume' that recoding was done when documentation states,"AVWBCL at 520ms with no persistent crossover"?

Is it appropriate to add modifier 51 to radiology codes?

Would it be appropriate to add modifier -51 to code 75710 when performed with other services on a given date?

BCBS deny claims for CPT 36200 due to "missing modifier"

When billing 36200 for abdominal aortogram with bilateral lower extremity runoff, BCBS is the only payer that is denying 36200 due to "missing modifier". It appears they are requesting an anatomical modifier. When resubmitted with a "50" or "RT" modifier the claims are processed. All other payers are processing the claim without any modifier on the 36200. I cannot find anything that states this code requires a modifier. Do you have any suggestions? The following is the provider's description of the catheter placement: "Both groins were prepped and draped in the usual sterile fashion. After local anesthesia with 1% xylocaine, the right common femoral artery was entered percutaneously, and a 4 French sheath was inserted with guidewire. A 4 French UF catheter was then inserted and placed in the descending aorta, and aortic angiography was performed under digital subtraction."

CABG with endarterectomy

We coded a CABG and endarterectomy (codes of 33533, 33517, 33508, and 33572-LD). Insurance denied 33572 for modifier. Modifier -LD was removed and insurance denied again. Are there other factors in coding a CABG and endarterectomy together that we should be aware of? Is there a scenario where coding a CABG and coding the endarterectomy of 33572 at the same surgical session would be inappropriate or bundled?

Z codes for MRI

Is it appropriate to place Z95.0 in the primary position when coding for a patient with a cardiac device having an MRI? Or is it more appropriate to code the diagnosis first and then the Z code?

Open femoral artery retrieval of long catheter

Physician performed an open right femoral artery exposure, opened the femoral artery, and retrieved a long catheter that a cardiologist had broken off inside the artery. At first, I had thought of using code 35703; however, more was involved than exploration of artery. Would I use unlisted procedure code 37799 in this case? I would appreciate any thoughts on an appropriate CPT code to use.

Exploration: is repair of the artery included?

Can you report codes 35703 and 35226 together?

Corrected Transposition of Great Vessels

If a patient is status post correction of transposition of great vessels, would the cardiac cath code be from the congenital or non-congenital section?

LINQ removal & placement

If a LINQ recorder was removed from the left parasternal border and a new LINQ was placed along the left sternal border 4th intercostal space, would this be considered a new location? And therefore the removal and placement of the LINQ recorder can be coded with 33286-XU and 33285? If the LINQ was placed in the same pocket only the insertion would be coded. Report details: "Old LINQ was removed, 3-0 polysorb suture was placed and dermabond applied (33286). New LINQ was placed along the LSB 4th ICS, and dermabond and steristrips applied (33285)."

Pelvic Vein Ablation for Pelvic Congestion Syndrome

We have a physician wanting to start using Sotradecol 3% for pelvic vein ablation/sclerotherapy to treat pelvic congestion syndrome. Would this be coded with 37241 as a venous embolization, or would you go with an unlisted vascular (37799) code for this procedure?

2nd and or 3rd degree AV block diagnosis

We have a provider who documented the indication for a pacemaker as non-reversible symptomatic bradycardia due to 2nd and/or 3rd degree AV block. There is no further documentation to support 2nd or 3rd degree block in the record. Would you code anything for this documentation or consider it 'working uncertain diagnosis' and only code the bradycardia? I realize this was taken verbatim off Noridian's nationally covered indications; however, I'm having trouble justifying dx coding with the AND/OR verbiage.

Criteria for 36820

In order to qualify for 36820, does the physician documentation need to indicate the vein was mobilized or tunneled? If the physician indicates the vein was "transposed", does that meet the criteria? We have a physician who documents forearm fistula as "vein was transposed", and I just want to make sure this is sufficient.

PICC vs. Venoplasty

Do you recommend codes 36573 and 37248 for the following? "The left arm was prepared and draped in sterile fashion. The brachial vein was shown to be patent by ultrasound. A spot image was stored. The vein was punctured under direct sonographic guidance and local anesthesia. A wire was advanced to the SVC. The tract was dilated. The wire did not pass centrally. Contrast was injected to confirm a stenosis at the level of the thoracic outlet. Ultimately, a catheter wire was associated across the stenosis. 4 mm balloon angioplasty was performed to facilitate passage of the PICC line. The catheter was measured and cut to length. A dual lumen PICC line was placed through a peel-away sheath. The final tip was confirmed to be in the lower superior vena cava with a spot fluoroscopic image. The catheter was secured, flushed with Heparin, and a sterile dressing was applied. FINDINGS: Central venous stenosis at the level of thoracic outlet protruding wire passage. Area treated with 4 mm balloon angioplasty to facilitate PICC line placement."

Percutaneous closure of pseudoaneurysms in the ascending aorta

Two years after having an aortic valve replacement and replacement of the ascending aorta with a Hemashield graft, the patient developed two small pseudoaneurysms adjacent to the ascending aortic graft. The doctor closed them both percutaneously using ASD and VSD occluder devices. What CPT code would you recommend for these closures?

Catheter Selectivity

When coding catheter placements, does the dictation/radiologist have to say selectively catheterized or have the verbiage "select" to code it? Example: "The Mikaelsson catheter was used to select the celiac artery. The microcatheter was advanced into the right hepatic artery." Can "advanced in" be counted as a "select?" Does that meet the rules and guidelines? Any idea where I can find more information on this subject? 

61645?

"Left subclavian was selected, and angiogram here revealed complete occlusion of the origin of the left vertebral artery. There was a somewhat prominent posterior deep cervical artery noted with origin stenosis and some reconstitution of the vertebral artery, as well as retrograde opacification of the occipital artery with filling of facial lingual and maxillary trunks. Wire was carefully manipulated through the origin, and catheter was advanced to slightly open the origin. Left common carotid: Wire was carefully manipulated through this plaque and preocclusive lesion to at least slightly improve the antegrade flow. This was now judged to be barely but adequate flow. OP Note: Mild mechanical clot/stenosis disruption by wire/catheter tip manipulation." FROM DR. Z BOOK: Is this 61645? This code is for revascularization by any method to treat thrombus/embolus/occlusion of cerebral arteries. 

Chest pain with CAD

The physician documents that the patient has chest pain, and the angiogram shows stenosis in the coronary arteries. I would code diagnoses I25.10 and R07.9, but I am being told that it should be I25.119 since angina is chest pain caused by ischemic heart disease. Should the connection be made that the chest pain is angina due to the reduced blood flow to the heart, or does the provider have to make the connection by documenting angina to code I25.119?

Fem/pop bypass and Peroneal Thromboembolectomy

Left femoral access, superficial femoral artery endarterectomy, then performed proximal vein anastomosis, brought the vein graft through the tunnel, then performed arteriotomy in the below the knee popliteal artery and performed endarterectomy of that as well. We also performed balloon thrombolectomy in the peroneal artery, and there was no clot noted. We then performed end vein graft to side popliteal artery anastomosis, again spatulating it and making the anastomosis approximately 15 mm. My question is, with this documentation can we bill codes 35556 and 34203? Is there enough information to support the embolectomy?

IRE of Renal Tumor with Biopsy

After placing Nano knife probes "bracketing" a renal tumor, FNA and core biopsy of the tumor are done, then the IRE completed. Is the biopsy also reported?

Pacemaker Lead Port Swapp, Provider Error

Patient received an ICD upgrade from single to dual. Next day, they reopened the pocket and swapped the lead ports due to provider error. Facility side: can this be charged to patient, and if so would you say 33215? What would this procedure be considered? I don't think the patient should be billed for an provider/device rep error. Patient is outpatient as well, which would matter as far as charges.

Fem-Pop VENOUS Revascularization

Should we follow the revascularization guidelines for lower extremity arteries when coding venous stent or angioplasties? Would an angioplasty in the femoral and popliteal veins be coded as a single angioplasty? Do you have any official guidelines supporting either way?

Infected fem-fem and LT fem-pop graft

"Our physician did excision of infected femoral to femoral graft, excision of left femoral-popliteal infected graft, patch angioplasty of the right femoral artery, and embolectomy of the left popliteal artery. On the left side the femoral anastomosis was isolated and the graft subsequently divided. We were able to clear the origin of the previous deep femoral artery endarterectomy and had sufficient artery for primary closure without impingement on the deep femoral artery. The graft was completely excised. Adjacent saphenous vein was harvested for a length sufficient enough to create a patch for the femoral artery once the graft was removed. The vein was then sewn as a generous patch onto the artery taking generous bites both on the vein and artery." Would I report codes 35903 and 35903-59LT for the excision of the two grafts? Would I report code 35256-RT for the patch angioplasty of the right femoral artery? Would I be able to code for the embolectomy of the left popliteal artery?

Moderate Sedation

Is it appropriate to use a cath log for moderate sedation times? The cath log has a list of all participants on the procedure such as monitor and an RN's name and then scrub and RN name. Then times are used from start time of Versed and Fentanyl, and end time is the procedure complete time. Is this acceptable?

MRI-guided laser ablation prostate lesion

When a patient gets an MRI-guided laser ablation of a prostate lesion, would you use 53899 or 55899 for the unlisted?

LV Lead Removal/Multiple Lead Removal

We are seeking clarification on the correct coding of two scenarios: LV lead removal and multiple lead removal. After extensive research, we are finding conflicting guidelines from multiple reputable coding resources. For LV lead removal, some say the LV lead removal is included in the appropriate removal code, whereas others say report unlisted for LV lead removal. For multiple lead removal (more than two leads), we found three different coding suggestions: 1) append modifier -22 when more than two leads are removed to capture the additional work; 2) report unlisted for multiple lead removal, as the current CPT codes do not capture multiple lead removal; and 3) report the appropriate removal code even if more than two leads are removed, as these codes cover all leads. These two scenarios overlap in some cases, which adds an extra layer of confusion (e.g. RA, RV, and LV lead removal). Please provide your expert opinion and rationale.

Pacemaker pocket pain with removal of lead collar wing

Patient indicating pacemaker pocket pain returned to the procedure room in the hospital during 90-day global period. The provider documentation states pocket incision was opened and pacemaker removed from the pocket. The provider then states: "It was noted that one of the lead collar's wings was pointing up, and this wing was removed." The pacemaker was reinserted in pocket. The pacemaker was not detached from the leads, and the leads were not removed or revised per the report. I have been unable to find a CPT code to bill this. Should unlisted code 33999 be billed, and can this be billed in the global period?

G89 - Pain, not elsewhere classified

We have a pain management group that says that they were told never to use chronic pain diagnoses for the follow-up visits for chronic pain medication management. They did not provide a source, and we have failed to find any guidance that confirms what they have been saying. Is there an guidance when we should or should not use the Dx codes from G89 category for the purpose of the follow-up visits for medication management for chronic pain?

Dual PM replaced with replacement of LV lead addition of bundle of HIS lea

The left V lead was advanced and positioned into a previously selected coronary vein. A second sheath was advanced over the remaining wire through which the His catheter was advanced to the His cloud. A new generator was brought into the field and connected to the leads. Device(s) Explanted: LV Lead: Pulse Generator: Device Information: Generator: His Lead: RV Lead: CS Lead: The RV lead was not replaced. Should this be charged to 33234 or 33229 for the LV lead and unlisted for the bundle of his lead?

3D ICE

Can 3D ICE be billed using codes 93662 and 76376 to indicate the 3D portion of the work?

Bilateral Procedures in 2020

I am a little confused on the use of a -50 modifier or -RT/LT modifiers for spine injections and cerebral angio add-on codes. Is it appropriate to code 64493-50, 64494-RT, 64494-LT, 64495-RT, 64495-LT for 3-level bilateral lumbar facet injections? How would you code bilateral external carotids: 36227-50 or 36227-RT, 36227-LT?

Pre OP Thyroid nodule localization with MAA

"FULL RESULT: Transverse, longitudinal and oblique ultrasonic sections of right neck was performed. Color Doppler evaluation also was performed. 1. Under antiseptic precaution and ultrasound guidance, 0.47 mCi of technician MAA particle in 0.2 cc was injected into the right mid thyroid nodules including 1.0 size size and 0.6 cm size. No complications were observed. Postbiopsy images show no evidence of bleeding. 2. Under antiseptic precaution and ultrasound guidance, 0.49 mCi of technician MAA particles also was injected into the right mid lateral neck level III 0.4 cm size nodule. Patient tolerated the procedure well. No complications were observed. Postbiopsy images reveal no evidence of bleeding.IMPRESSION: 1. Ultrasound-guided technician 99 MAA particles were injected into the RT mid thyroid bed two nodules. 2. 2. Ul-guided dictation 99 MAA particles was also injected in RT mid neck level III 6 mm nodule." Would you code 60699 & 76942-26? Would you code 60699x2?

Open removal of fractured catheter from line placement

"While radial artery line was being placed by the anesthesia team, the catheter broke off at its hub and was retained in the left radial artery. The left arm was prepped and drapped. A longitudinal incision was made and the radial artery exposed. Vascular tapes were placed proximally and distally. The arterial puncture site was closed with a 7-0 prolene. The retained catheter was palpable. A transverse arteriotomy was performed and the catheter removed. Tapes were secured and the radial artery repaired with interrupted 7-0 prolene sutures." I could not find an open code for fractured cath removal, only the percutaneous code 37197. He also closed the puncture site in addition to closure of the open procedure. I'm not sure exploration code 35860 would be appropriate either. Would it be unlisted 37799 (possibly based off of 37197 and an arterial repair code, and if valid arterial repair of the puncture site or would that be inclusive?), or is there a more appropriate code?

Transabdominal/Transvaginal ultrasound exam

We had a consult tell us that we should be coding 76856 and 76830 for this exam. The docs are coding 76857/76830. They are using both Transab and Transvag. Can you clarify how both of these can be coded but neither are documented separately? This looks like 1 exam. "Indication: Post-Menopausal bleeding Method: Transabdominal and transvaginal ultrasound examinations. Uterus: Normal. Position: anteverted. Endometrium: fluid noted within with a focal echogenicity Endometrial thickness: 1.4mm Cervix: Normal Polyp (size/mean documented) Right Ovary: Normal, No adnexal masses (Size/Mean documented) Left Ovary: Normal, No adnexal masses (Size/Mean documented Cul de Sac Normal, no fluid within Impression: Endometrial polyp outlined by fluid."

75716 requirements

Does a provider have to perform imaging on the entirety of both legs (to toes) to be able to bill 75716? For instance, the right leg is imaged from common iliac all the way to dorsalis pedis. The left leg is imaged from common iliac to common femoral. The provider wants to bill 75710, but I believe 75716 is more appropriate.

61626 vs. 61624

Would you report code 61626 or 61624 for embolization of a ”high cervical skull base right internal carotid artery aneurysm with a wide neck”? We were leaning towards 61626 since it’s skull based but were wondering since it affects cerebral circulation if we should go towards a cerebral embolization. "A pipeline flow diverting stent was deployed through the phenom microcatheter across the neck of the aneurysm. Completion angiograms were performed demonstrating no vascular pruning or parenchymal deficit intracranially."

Endarterectomy of the distal iliac artery

Is endarterectomy of the distal iliac artery reportable with code 35566? "Incision was made on the left leg, the distal popliteal and TP Trunk that were dissected free. The saphenous vein had caliber 3 mm, dissected it below the popliteal and also incision was made from the knee toward the groin and the vein was removed. Next inguinal ligament was identified and the iliac artery, common femoral, superficial and profunda were isolated and dissected. Then the tibioperoneal trunk was crossclamped, thromboendarterectomy was done at the takeoff of the posterior tibial. The saphenous vein was reversed and cut to match the opening in the artery and end-to-side anastomosis was performed. The vein was brought via subfascial fashion towards the left groin where the common femoral, profunda superficial were fully exposed and crossclamped opened with a knife and Potts scissors. We did an endarterectomy of the area involving the distal iliac artery and also in the profunda and superficial, there was a big branch of the profunda that was open, the vein was divided and an end-to-side anastomosis was done between the artery and vein.

Jugular Vein Aneurysm Excision

How would you code an excision of right external jugular vein aneurysm? Would you use unlisted code 37799?

Tricuspid valve repair using Pascal clasp device

For tricuspid valve repair using the Pascal device, CLASP TR Trial, would unlisted code 33999 be used, or 0569T and 0570T?

Shockwave

Does the shockwave device have a HCPCS code, and is it still considered like angioplasty?

Charging 76380 with an US guided biopsy

If a radiologist gets a CT pre biopsy and then does the biopsy with ultrasound, but also does a CT after the biopsy, can we charge for 76380?

92941 Multiple Times?

Is it ever okay to bill 92941 twice in one day? Examples: If the MD states co-culprit lesions for the STEMI? Or if the patient has two different STEMIs noted on the same day with different culprit lesions and different MDs intervening (different practices)?

Thrombolysis (61645)

Right M1 occlusion following four attempts at the mechanical thrombolysis. No reperfusion is obtained. Can we still bill 61645 with a modifier -52 or only the guidance?

93613 & 93650

In reading some reports I noticed that 3D mapping was performed during an AV node ablation. The mapping wasn't billed separately, but there are no NCCI edits indicating this is bundled. Is there a specific reason this could not be billed separately?

Follow-up after TAVR procedure

I have a cardiac clinic patient coming in 7 day TAVR procedure follow-up. In the clinic note, MD states in assessment/plan as first listed diagnosis is "severe aortic value stenosis". Would we use Z48.812 for first listed diagnosis? In your answer for question 10857 it was stated to use Z09, but we are thinking Z48.812 is more specific to a cardiac procedure. Can you please elaborate on your answer "Do not report code I35.0, Nonrheumatic aortic (valve) stenosis, as this condition is no longer present"? Is aortic stenosis with the new aortic valve only coded as a complication because the new value completely resolves this condition?

TEE 93312

If a baseline TEE is performed on the same day but before a TAVR or Watchman procedure, is this a billable service for the physician who is involved with the intervention?

ECG 93000 Technical & Pro Done Different Days What Date of Service

For 93000, many times the "official" interpretation is not done on the same date of service. If that reading is done on a different date from the technical component, can we still bill the global 93000? This is for services performed in place of service 11; we own the equipment, we employ all providers.

Breast abscess

"Under US guidance using an 18 gauge needle, 5 cc of pus was aspirated. The aerobic culture showed isolated Eschericha Coli susceptible to all antibiotics." Is this coded with 10005 or 10160?

Attempted TCAR with Complication Requiring Standard Endarterectomy

I have an attempted TCAR procedure in which after insertion of flow reversal and CCA exposure the attempted wire crossing dissected the plaque causing an obstruction. The physician thought it was a thrombus and attempted aspiration with no thrombus return. He ended up doing a standard endarterectomy using the flow reversal system and a separate incision. My question is, since he did a separate incision would I be able to code the TCAR with a -53 modifier since he still utilized the flow reversal? I would think since this is part of a clinical study it would need to be reviewed. Also, would the intraoperative arteriography be codable? The sheath was able to be advanced to the ECA. I would greatly appreciate your coding advice for this scenario.

93356 for Facility Coding

Is new add-on code 93356 appropriate for facility coding?

Midline edit

When a midline cath insertion is done with ultrasound guidance, we code 36410/76937. We keep getting an edit stating that 36410 is for "incidental only" procedures. Any recommendations?

Scout x-ray view - Gastrostomy Injection

Would the following be coded with 74018 or 74019? Is the scout billable? "A single AP abdomen scout was performed. Gastrostomy tube was injected with contrast. A second AP abdomen was obtained. No fluoroscopy was used."

Ultrasound guidance w/PFO Closure

For physician services, is ultrasound guidance (76937) billable in addition to PFO closure (93580) by the same MD when used only as guidance?

92970 versus 33990

My cardiologists frequently will place a temporary Impella at the time of a cath procedure and remove it at the end of the procedure. Can you tell me if this should be coded with 33990 or 92970? Can you also let me know what the difference is between these codes and when we would use one or the other? 

Cervical Carotid Stent for Stroke

Our patient was brought to the cath lab for stroke management after an attempted carotid endarterectomy that resulted in a post-op complete occlusion of the cervical carotid. We placed a cervical carotid stent without distal protection and restored full flow to the distal vessels. No thrombectomy was required. Would you use code 37216 for this procedure?

36005 bundles into 75820 & 75822

We are having issues while trying to bill the new 2020 codes for vascular mapping. We've been billing 93986 (unilateral) or 93985 (bilateral). There is no issue here. -- The code book tells you that you can code 75820 (unilateral) or 75822 (bilateral) along with code 36005. There is no bundling issue in our software, but the claims keep getting rejected, because it states that 36005 bundles into 75820 and 75822. We've even tried to append modifier -59 (as well as the laterality modifiers) to code 36005, but nothing seems to be working. Can you provide guidance on how to bill successfully, as a physician, for vascular mapping?

Osteoplasty

What code can I use for billing percutaneous cement osteoplasty of pelvic bone?

ISR, again

Patient recurrent in-stent restenosis, treated multiple times. Restenosis has returned; patient now presents for brachytherapy. Is this T82855A or T82855D?

CT-guided lung nodule microcoil localization & indocyaninegreen (ICG) inje

How should we code a CT-guided lung nodule microcoil localization and indocyaninegreen (ICG) injection?

Fibrin Stripping

How should fibrin stripping be coded when done via the same access as central line replacement?

Abdominal aortic contained ruptured aneurysm

Should a contained ruptured aneurysm be coded as a ruptured aneurysm (i.e., use 34702 instead of 34701)? 

PVI for Atrial Fib followed by PVI for induced Atrial Flutter

"Diagnostic catheters placed in the crista terminalis and CS. Sheaths placed in right and left femoral veins. 3D map of the left atrium. ICE provided. During RF ablation of left pulmonary veins, atypical atrial flutter was initiated, which was mapped extensively. This was found to be re-entry in the left PV. This terminated with LPV ablation. Post ablation both exit and entrance of confirmed in all veins. Re-confirmed at 30 minutes post isolation." Can I charge 93656 and 93655 for the different arrhythmia? Or because of the PVI is this considered part of 93656?

Documentation for 20551

When the documentation does not specifically state "origin" or "insertion", may we still use code 20551? "The patient was placed in the supine position, and the skin over the right anterior iliopsoas tendon area was prepped and draped in usual sterile fashion using chlorhexidine. Non-buffered 1% lidocaine was infused in the superficial and deep soft tissues for local anesthetic. A 22-guage 3.5" needle was advanced deep to the psoas tendon under direct ultrasound guidance. A total of  5 ml of a mixture containing 4 ml of 0.5% ropivacaine and 40 mg Kenalog was then injected. The needle was removed and the skin was bandaged. Ultrasound images were archived. There were no immediate complications."

35883 vs. 35876

Is 35883 or 35876 be more appropriate? Maybe 35883, 34203, 35371 for this case? "We began by opening up the left groin incision and removing the previous sutures. We then gained control of the CFA, profunda, SFA, and the bypass graft. We opened up the proximal portion of the graft. We identified acute thrombus within the lumen of the bypass graft. We also ID what appeared to be an obstructing flap in the LT CFA. We, at this point, decided to make an incision over the entire CFA and performed revision bypass angioplasty. We extended it proximally towards the inguinal ligament. We then confirmed there was a large flap within the lumen itself that was causing the obstruction. Endarterectomy of the entire CFA was performed. When then took a 0.8 x 8 mm bovine pericardial patch graft and performed patch angioplasty. We then reopened the distal incision above the knee, ID the distal graft, and gained control of the pop. A graftotomy was made and using a Fogarty catheter thrombus was removed from the entire graft and the SFA and then distally to the tibial vessels."

SCLEROTHERAPY W/LARYNGOSCOPIC VISUALIZATION

Please help with code for laryngoscopic visualization, Medicare guidelines notwithstanding... "FINDINGS: Using a 25g butterfly and Alligator 170mls of Doxycycline (17mls) placed in multiple sites in the posterior pharynx and peri epiglottis under laryngoscopic visualization until distension was achieved. At no site was blood aspirated prior to Doxycycline injection. Images were obtained under laryngoscopy only.   IMPRESSION: Successful laryngoscopically guided injection of Doxycycline into the peripharyngeal vallecula and tongue base LM."

Angioplasty of iliac arteries with endovascular repair of aneurysm

Patient has AAA and has stenosis of femoral and iliac arteries. Documentation states the patient had bilateral external iliac artery angioplasty to facilitate advancement of aortic main body. Would that be included in the aneurysm repair, or can I bill the angioplasty separately? There is documentation that the patient could need femoral endarterectomy in the attending note prior to surgery.

93990

Without specific documentation, like "color Doppler", does the below documentation of the measurements meet duplex criteria for CPT 93990? "LT ARM AVF  ** FINDINGS **: Inflow Artery: 1.66 M/s Anastomosis: 2.26 M/s Prox Fistula: Depth/Diameter: 4.7/5.6 Mm Velocity: 3.70 M/s Mid Fistula: Depth/Diameter: 8.3/6.6mm Velocity: 221 Distal Fistula: Depth/Diameter: 10.0/5.9 Mm Velocity: 1.95 M/s Anastomosis: not a graft outflow Vein: 1.65 M/s  ** IMPRESSION **: Upper Extremity Hemodialysis fistula imaged for Vascular Surgeon.   Patent LEFT upper extremity first stage brachiobasilic AV fistula without stenosis."

32555 or 32557

The patient with pleural effusion had left-sided thoracentesis done. Impression: Successful US-guided diagnostic and therapeutic left pleural drainage catheter placement. My question is that the drainage catheter was removed after two hours before the patient was discharged. Should this be 32555 or 32557?

Impella Device

There was a VT ablation done on a patient by one of our EP providers. This provider had one of our interventionalists place an Impella device during this ablation for ventricular support. Upon completion of the ablation the Impella was turned off and removed, and patient was sent to ICU. I have not see this device used for this purpose before. I am wondering what your thoughts were on this.

SIJ RFA

Since CPT 2020 added 64625 with note not to report in conjunction with 64635, we are not sure how to code sacroiliac joint denervation with radiofrequency lesioning of the L5 dorsal ramus and lateral branches of S1, S2, S3, S4 (using Simplicity III). Dx: bilateral sacrococcygeal spondylosis w/o myelopathy. "Procedure:...C-arm visualizing lateral inferior boarder of sacrum just lateral to S4 foramen... The needle contact the scrum bone the advanced lateral to S4 & other foremen but medial to the sij in cephalad direction. .. Simplicity III electrode inserted at entry point where spinal needle was placed...probe advanced maintaining contact with sacrum...Lesioning was carried out in the Simplicity III Program protocol at 80 degrees centigrade for 5 min. L5 Dorsal ramus RF: C-arm repositions... L5-S1 vertebra body squared. S1 superior articular process ID-ed. two 10 rf needle advanced to border of superior articular process and sacral ala. Motor stim done to 2 hz w/no motor recruitment...steroid injected. site lesioned 90 sec at 80 degree centigrade."

64561 vs. 64581

The people I work for will only listen to you. Would you code this as 64561 or 64581 for placement of an InterStim quadripolar lead? "Needle introduced 2 cm above sciatic notch and 2 cm lateral to sacral midline, feeling for foramenal margins. S3 foramen identified and penetrated. Depth of needle confirmed, adjusted with fluoro. Needle position confirmed by observation of bellows and plantar flexion. Needle stylet removed and directional guide placed, confirmed with fluoro. Needle removed. Incision made peripheral to directional guide thru fascia. Lead introducer sheath with dilator placed over directional guide into foramen ensuring radiopaque marker of introducer did not extend beyond anterior edge of sacrum. Dilator unlocked and removed with directional guide. Lead placed through introducer sheath to first white line. Position checked with fluoro. Lead further introduced until 3 electrodes visible below sacrum. Electrodes tested by observation of bellows and plantar flexion. Introducer sheath retracted under fluoro, deploying tines into perisacral tissue."

TAVR and Embolic Protection

I'm wondering if there have been any up dates this year to whether or not it is allowable to bill an unlisted code (33999 or 93799) with TAVR for Sentinel embolic protection device.

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