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Ask Dr. Z Forum Q & A Examples
Below are four examples of Ask Dr Z Forum Coding Questions & Answers. Questions are all answered by Dr. David Zielske, MD.
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Q.For the removal of a thrombus in the cerebral or carotid arteries, would you suggest the new mechanical thrombectomy code of 37184? Or use the unlisted code 37799?
A. The code 37184 is for removal of arterial clot, and is not specific as to "non-neuro", so I would use the new percutaneous thrombectomy code in the intracranial circulation. Be sure that 37186, for secondary thrombectomy, wouldn't be more applicable in any specific case. Sometimes they will develop a "brain specific code" in the future, but for now these codes describe removal of clot from an artery. Posted June 26, 2006
Q. This was a particularly difficult procedure to code: Right groin access. Initially, abdominal aortogram was performed with a 4 french omniflush positioned at t12-L1. Next, catheter positioned into the celiac trunk for a brief celiac trunk arteriogram. Next, catheter positioned into SMA for SMA arteriogram. Then, catheter was utilized as a guide within the SMA proximal orifice and a high flow microcatheter and micro guide wire were used to selectively cannulate the middle colic artery branch of the SMA. Next, left branch of the middle colic artery was super selected and a catheter was positioned into the left branch for digital subtraction arteriography of this branch feeding the splenic artery. Next, catheter repositioned into IMA. IMA arteriographpy done. Then, super selection IMA arteriography was performed with placement of the catheter into the superior and inferior branches of the left colic branch of the IMA Again, digital subtraction arteriography was performed.
A. For this procedure we would code the ultimate catheter placements and the visceral angios that were done as well as the additional selective images beyond basics. The celiac angio would be 36245-59 and 75726 the SMA angio would be 36247 for the ultimate catheter placement into the third order selective left colic branch off the middle colic artery. The middle colic and SMA selections are bundled into this code. The imaging would be 75726-59 for the SMA and 75774 for the left colic. The middle colic artery cath placement did not document an angiogram, and so you cannot code for that. The IMA catheter placements would be 36247-59 and 36248 for the 2 separate third order selective catheter placements into the inferior and superior left colic branches off the IMA. The imaging codes would be 75726 for the initial IMA angiogram and 75774 twice for the individually selected and imaged superior and inferior branches of the left colic artery off the IMA. Modifiers have been placed. Posted August 5, 2004
Q. A patient has a pancreatic head mass and presents for a pre-operative visceral arteriogram. The ordering surgeon orders these if he believes that the operation could be altered/canceled by the results of the arteriogram, e.g. potential vasculature involvement. We are unsure if we should be using a pre-operative diagnosis code such as V72.83 as the primary dx or the cancer code. Which would you recommend?
A. I would code the neoplasm as the primary code. This doesn't sound like routine pre-op testing if they are looking for vascular involvement of the tumor. Posted June 24, 2004
Q. How specific does the radiologist need to dictate catheter placements? We have radiologists who will dictate "... selective catheterization and injection of the subclavian and common carotid arteries was performed." Is this enough to justify catheter placements in both the right and left common carotids, and right and left subclavian arteries, or do they have to dictate each time the catheter was moved? They will also state for renal selection "... selective catheterization of renal arteries..." and that is it. What are your thoughts? I would like to stress to them the importance of detailed dictation supporting the coding, therefore supporting the reimbursement, but I think they believe the above dictation is detailed enough. Am I being too picky? Thank you for your time!
A. In my opinion, and it is just that, an opinion, I would agree with the MD's that they have said enough to justify one carotid selection and one subclavian injection as they state arteries. I would recommend that if they combine two different type of arteries, that they state it with a minimum statement such as BOTH subclavian and BOTH carotid arteries. The renal arteries I would code for one on each side--the problem there being that some people have 3 or 4 renal arteries and I couldn't code for those. Having said all that, I would stress the importance of describing the procedure in as detailed a manner as possible, including stating the vascular access site, each vessel selectively catheterized and injected with contrast and all images obtained, as well as any intervention, complications and remedies utilized during the procedure. There are as many ways to dictate as there are physicians out there. Unfortunately the ones who have limited documentation may also have limited reimbursement at the end of the day. Posted June 24, 2004
Q. Hi again. Help again. The doctor enters thru the femoral artery to the femoral vein, then does right cath, then cath was used for left heart cath and left ventriculogram and angiography of the abdominal aorta. The catheter was used for angiography of the coronary arteries, and the cath was used for angiography of the subclavian vessels and left mammary artery and also selective angiogram of the saphenous vein bypass grafts. I not sure whether I should use 36200, or use a selective code 36245. Thank you.
A. In this example, it appears that all the angio for the subclavian is related to the internal mammary. In this case there is no cath placement code for the subclavians as they are bundled into the cardiac cath codes. The placement of the catheter into the aorta is bundled into the heart cath and is not separately billable (do not code 36200 with a heart cath. It is a zero CCI edit also--which will not allow you to bill them together anyways.) Posted August 20, 2004
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