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Code 93356

I am confused if code 93356 or 93356-26 can be billed on a professional claim? I work for Cardiologist that is owned by hospital. Is this a facility charge?

Central line placement for moderate sedation

Can we code placement of a central line separately to 36556 in addition to 99152 when the physician is using the line for administration of sedation meds in a patient with no IV access? The physician is performing lower extremity arterial interventions.

Intraoperative Bleed with treatment by Gelfoam with Thrombin

Male w/infected LT knee was in operative suite when I was called. Had exposure on anterior surface of LT knee & incision in below-knee area on medial aspect of proximal LT calf. Ortho surgeon had been evacuating the area of infection when he noticed bleeding behind the tibia. When I arrived patient had a tourniquet insufflated to 300 mmHg. We let this down & noticed bleeding posterior to proximal LT tibia. I extended incision about a half a CM proximally. Upon doing this, was noted patient had significant venous pressure. By extending incision I was able to see into the depth of the wound better. All bleeding appeared venous in nature. I took Gelfoam soaked in thrombin & packed the area. Tourniquet reinsufflated to 300 mmHg. We left this in position for 10 minutes. Tourniquet released, no evidence of active arterial bleed. Good Doppler signal over DP, no signal over PT. No active pulsatile bleed from knee incision. Gelfoam & thrombin left in position. Ortho surgeon closed incision. Should I code only an E/M for my vascular surgeon's work?

Is "crossed the aorta" sufficient?

Hello,

Is stating "aortic valve was crossed" or "LVEDP was measured" adequate documentation for billing 93452 or does the provider need to give the numeric value of the LVEDP?

Thank you!

0715T coding with C1761 and 92920

(For percutaneous transluminal coronary lithotripsy, use 0715T). (Use 0715T in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975)

Patient had a 92920 along with 0715T. Which requires c1761 for the0715T. We are being told not to report code 92920 with c1761. But 0715T requires the c1761. Would we change the supply code c1761 to possibly c1725?

Aortoplasty

What is the CPT code for aortic root aortoplasty with Aortic valve repair with free margin plication of all 3 cusps and placement of 23 mm rigid annuloplasty ring

lithotripsy by Shockwave balloon

Our physician performed Shock Wave balloon lithotripsy of the Lt SFA (6x60 mm) along with Drug coated balloon angioplasty LT SFA (6X40mm). We are trying to determine if this is 37224 angioplasty or 37225 atherectomy which includes angioplasty and not billing both CPT codes. Our department feels we are not coding this correctly. Does Shockwave balloon lithotripsy mean an atherectomy was performed? If you need any additional information, please let me know. Please advise since Dr. Z is the Expert to clear this up. Just waiting for an answer.

Question 18154

Intraatrial Septum documentation for complete TEE

TEE with no specific documentation of Right Atria (All other required elements are documented -LV, MV, TV, AV, PV all were imaged and findings documented)

My question is they documented:

Intraatrial septum:

The left atrial appendage is normal in appearance with no evidence of thrombus

Pulsed wave doppler of the left atrial appendage demonstrates normal emptying velocity

No interatrial septum shunt visualized by color doppler.

Is that sufficient to show that they are viewing both the left and right atria to report a complete study?

New 2023 pulmonary angiogram codes

This pertains to the new pulmonary artery angiogram 93569 and 93573 codes during congenital cardiac catherization. If the MAIN pulmonary artery is selected with bilateral pulmonary angiograms is this a "selected" 93573 or does the selection need to be of the left and right pulmonary arteries?

Limited vs complete echocardiogram

If the MD orders a limited echo and the report states a limited echo was performed using colorflow and doppler AND all elements of a complete study were resulted (LV and LA, RV and RA, mitral, tricuspid and aortic valves, pericardium and portion of the aorta adjacent to the heart.....should a 93306 be billed instead? Does the order need to match the code and is it appropriate to bill a complete study when the intent is to perform a limited?

Accessory Renal Artery Stent

Can we code an additional stent when both the right main renal artery and right superior accessory renal artery are stented? 37236 and 37237

AV Fistula Ligation/Repair of Brachial Artery for immature AV Fistula

Percutaneous access via outflow vein close to the antecubital fossa with fistulogram + central venogram.Angioplasty along entire length of the peripheral outflow vein, however, vein was still clearly somewhat diseased.Separate percutaneous access via outflow vein closer to the shoulder with fistulogram and angioplasty of the anastomosis. Repeat fistulogram showed extravasation. Balloon was reinflated, no change on repeat fistulogram which told me that the rupture was at the anastomosis directly. Longitudinal incision was made overlying the AV anastomosis w/blunt dissection of brachial artery. No backbleeding from the outflow vein. Brachial artery was fully mobilized w/creation of end-to-end anastomosis resulting in excellent pulse in the brachial artery. I then ligated the open end of the outflow vein using medium clips. There was a seroma at the basilic vein harvest site with was drained w/needle (100ml). Provider wants to bill 36902,35206,37607. Would this be a revision, 36832-22 (for conversion to open)? Your guidance is apprecicated. Thank you.

35881 Lt fem tib revision w lt arm vein & angiography lt lower extremity

35881 for revision w seg vein interposition (portion not shown). What code would be used for the angiography (prior noninvasive testing done)? Access was achieved by a longitudinal incision over the palpable graft pulse at the level of the knee. Sharp dissection was used to expose roughly 2 cm of the bypass graft, which at this level appeared to be of good caliber and quality and had a strong pulse. It was encircled with a vessel loop. The graft was then accessed antegrade with a 21-gauge butterfly and angiography confirmed patency of the distal graft with a focal area of critical stenosis in the graft several centimeters below the knee, but several centimeters proximal to the anastomosis. The area of diseased vein was roughly 4 to 5 cm, but the distal anastomosis appeared patent and the posterior tibial artery ran off uninterrupted into the foot. With the area of graft revision now marked after angiography. 75710-26-59?

Successful partial reconnection of PV's

Would this be coded 93656 vs. 93653 due to successful reconnection/re-isolation of PV's?

Presenting rhythm was atypical left atrial flutter that was LA roof dependent

The atrial flutter terminated with mechanical effect of the catheter in the LA roof (near the left PV). Repeated attempts to re-induce the atrial flutter were unsuccessful, so we decided to perform LA roof ablation with a line of ablation from the left common PV to the right superior PV along the roof. The target power was set at 40 Watts. The target flow was set at 30 mL/min. Chronic partial reconnection noted of the right superior & left common PV's - successfully re-isolated. Re-do pulmonary vein antral isolation (PVAI) was performed using RF ablation. Ablation was performed in atrial pacing. During ablation along the posterior wall and anywhere close to the esophagus power was limited to 30-35 watts. Esophageal temperature was monitored throughout ablation. Maximal esophageal temperature = 37.1 deg C. After RF ablation entrance and exit block were noted in all pulmonary veins

Payer not reimbursing 37228 d/t "significant residual stenosis"

A provider performed angioplasty of the tibioperoneal trunk. Pre-treatment stenosis was 100%, post-treatment stenosis is documented as 50%, and is documented as follows in the report:

"We balloon dilated the right tibioperoneal trunk to 6 Atm for 2 min with a 2.5 mm by 100 mm Coyote balloon from Boston Scientific. Pre-treatment stenosis was 100%. Post-treatment stenosis was 50%. The distal most peroneal artery could not be traversed but there appeared to be improvement of flow into collaterals."

The payer is denying payment with these remarks:

"Per CPT, the clinical documentation provided in the narrative operative report does not sufficiently describe or support the requisite criteria for approval of the requested CPT code. As such, CPT 37228 is denied as "not documented." A significant residual stenosis is documented."

So, basically, they're denying payment of revascularization because he could only open this completely occluded vessel to 50%. Is there some definition of technical success that must be met in order to bill a revascularization?

RHC With Pulmonary Angio 93569?

Patient with repaired Tetralogy of Fallot and has a pulmonary valve implant. Noninvasive imaging demonstrated notable pulmonary insufficiency, so patient is brought to cath lab for diagnostic cath. They do a right heart cath and angiography of the main pulmonary artery. Would you agree with 93451 and 93569? Just want to verify since there are new pulmonary angio codes for 2023

AVM embolization of leg 37242

Three (3) 4F micropuncture catheters were placed under real-time ultrasound guidance into the right greater saphenous vein and proximal and mid tributaries of the RT greater saphenous vein via direct puncture x2 followed by subselective catheterizatiom of the right'genicular artery to achieve the most comprehensive coverage of the lesions.

A thorough assessment of flow dynamics and deep venous connections as well as the potential for nontarget embolization due to anomalous anatomy was performed. Embolization x3 was then performed using an embolic slurry with continuous reassessment of anatomy in between doses using both color flow duplex and angiography.

I believe 37242 for one separately identifiable area with 36245. Dr. wants 3 (MUE 2). Are there multiple separately identifiable surgical areas in the leg? Groin? thigh ankle?

Thank you so much for your help and education.

0075T CMS Denials

We are receiving denials from CMS indicating modifier incapability when billing for Vertebral Artery Stenting (0075T). We’ve tried using various modifiers without success. You referenced this same issue previously in a Q&A for September of 2014. Do you know which modifier we should be using for this procedure? Thanks in advance for your help.

Multiple Dog Bite Wounds Radial-Radial bypass & Ulnar-Ulnar bypass

Patient had emergency bypass due to Multiple Dog Bite wounds. 2 bypass procedures were required radial-radial & ulnar-ulnar. Would we code 35523 X’s 2 or 37799 & compare to 35525? Cut down onto the radial artery. Radial artery was dissected free from structures proximally there was obvious injury to the radial artery. Complete disruption was a through and through puncture injury on the radial artery at the antecubital fossa. No brachial artery at the antecubital fossa. Total bypass length 4 and half centimeters onto. It was a functional end-to-end anastomosis. Ulnar artery lot of tissue injury muscle tearing from the dog injury and the ulnar artery was below the biceps muscle. Dissected it free from surrounding structures. There is a crush injury I then used reverse greater saphenous vein and did end-to-end anastomosis on both the proximal ulnar artery and the distal ulnar artery for total bypass length approximately 2-1/2 cm.

1. AV node ablation , Left bundle-branch pacing

.Using fluoroscopic guidance via 9 French sheath a left bundle branch guide sheath and lead were placed into the left bundle branch position. Prior to placing the lead the his bundle was identified in order to guide positioning. Using electrocardiogram and fluoroscopic guidance the appropriate position was found and the lead was screwed into position. Once the appropriate numbers verified left bundle branch specific pacing the sheath was removed and the lead was fixated to the muscular fascia. Using fluoroscopic guidance via a 9 French sheath a Tacticath SE ablation catheter was advanced into the right atrium. A 3D electro anatomical map was created of the right atrium and the right ventricle noting the atrial signal, ventricular signal, his signal and the coronary sinus. An appropriate his signal was identified this was ablated. The doctor is wanting to bill 93619, 33208, is that proper billing? Shouldn't the 5 catheters be mentioned. I'm very confused about the LBB pacing implant. Does the 22 modifier up RVUs? HELP!!!

IVUS AND FFR WITH CARDIAC CATH IN ASC

Dr. Z with new 2023 C codes, if a physician performs LHC (93458) WITH IVUS there is C7523. If LHC with FFR is performed there is C7524. What if BOTH FFR and IVUS are performed? It seems disingenuous to code both C7523 and C7524 and receive double payment for 93458. Do we just pick one C code? Code one C code and the other with 52? Any help is greatly appreciated? Thank you!

Open AAA Repair with Graft Limb to CFA

Open repair AAA w/right CIA attachment and left CFA as follows: Attention was then directed to the left common` femoral artery. The left limb of the graft was positioned within the previously described retroperitoneal tunnel. The left superficial femoral and profunda femoris arteries were controlled using elastic vascular loops. Using a #11 scalpel blade a longitudinal arteriotomy was made in the common femoral artery and extended using Potts scissors into the proximal profunda femoris artery. The plane between the plaque and the common femoral artery was developed circumferentially using a surgical elevator, and the plane was developed proximally and distally. The plaque was removed, and great care taken to remove all debris from the endarterectomized vessels. No tacking sutures were placed. The graft was spatulated and the femoral arteriotomy repaired in an end of graft to side of artery anastomosis using 5-0 Prolene suture in a running fashion. Would this be coded with 35081 and 35371? The left CIA, EIA and IIA were found to be occluded same session.

VATs/Aborted Chest Wall Resection

Approximately the sixth interspace anterior to the anterior axillary line the trocar sites was injected with local anesthetic. A port was placed intercostal space under direct visualization. Nerve blocks performed from that level through the 11th level. Tumor was then identified. Using the local needle the superior inferior lateral margins were identified. The medial margin appeared to be beyond the costal margin. Incision was then made over the mass. Skin flaps were then created superiorly inferiorly medially and laterally. We then entered the chest 1 interspace above the mass. The finger then sweep medially to identify the medial margin it was then noted that there were deposits on the diaphragm that were not previously visible. These were removed and sent to pathology for frozen section as above after an additional 5 mm incision was made laterally. The cryoprobe was then used to treat the intercostal nerve bundles from level 8 through 11. Once frozen section returned intra-op consult completed and decision to abort. How would this be coded?

Diagnostic EP study w/attempted induction without His bundle recording

My provider did a Diagnostic EP study including right atrial recording/pacing, right ventricular recording/pacing, and attempted induction of arrhythmia without the His bundle electrogram as it was "not readily identifiable from the superior approach and had been evaluated at a prior EP study". Would you still bill the 93620 or bill each component separately? If billing each component separately what CPT codes would I bill for this case?

C7516

Hi Dr. Z when using the code C7516 with a Coronary Angiogram and IVUS of say the LAD, if you also did an IVUS of the CX at the same time of the procedure, would you use 93454, C7516LD, 92979LC?

Repair or not?

Our doctors inserted a Perclose device and are charging 35226. Is this correct? Here is the note for this portion: At the right groin level, we then removed the previous sheath after rewiring it. There was an existing Perclose, and this provided some hemostasis. We added a 2nd Perclose, this gave excellent hemostasis with a good distal pulse. We applied pressure on the right groin for several minutes to obtain good hemostasis.

This seems odd to me (of note, we also billed 32551, 33990 and 34716). Thank you.

Abdominal Debranching

Midline incision - trans-peritoneal exposure of R external iliac artery, SMA, common hepatic artery and Left renal artery and inferior branch of R renal artery distal to bifurcation.

 

2 limb Dacron graft anastomosed to R external iliac (diseased native vessel) with 1 limb anastomosed to SMA and 2nd limb anastomosed to common hepatic artery (extremely diseased native vessel) I'm leaning towards 35633 and 35632,52. Thoughts?

 

PTFE graft sewn from SMA limb of Dacron graft to L renal artery

 Separate PTFE graft sewn from common hepatic artery limb of Dacron graft to R renal artery inferior branch

I'm thinking unlisted for the SMA to L renal and hepatic to R renal. Maybe compared to 35636,50. Thoughts?

Patient is having debranching done prior to EVAR scheduled in the future.

Any help would be greatly appreciated.

Neck Stab Wound Exploration with Ligation of External Jugular Vein

Should I report 20100, or 37799 for Ligation of Ext Jugular Vein?

"Patient had a 6 cm oblique laceration just lateral to the sternocleidomastoid with obvious muscle belly visible in the wound. We extended this incision 1 cm superiorly and laterally for better exposure. After further inspection of this injury, there was a clear through-and-through injury to the external jugular vein, and as such, was not amenable to repair. We ligated the proximal and distal vessel using 2-0 silk ties. In similar fashion, we ligated the facial main tributary with a 2-0 silk tie. We transected the vessel to gain better exposure to the underlying structures and we palpated for a carotid pulse which was immediately adjacent to where we ligated the external jugular vein, so we decided to explore the carotid sheath and the sheath was opened utilizing blunt dissection and we were able to dissect out the distal common carotid artery. There was no evidence of laceration or contusion to the artery. Carotid sheath was intact and injured, and no violation to trachea or esophagus."

Doppler imaging done as part of standard protocol

Pt sent to our facility for pelvis and transvag US. Our standard protocol is to do US with color Doppler & obtain spectral waveform ovarian arterial and venous flow. Is 93976 appropriate in addition to the ultrasounds? We did not have a provider order but it is our standard

Indication menorrhagia

Technique Routine pelvic ultrasound protocol. Transabdominal eval of general pelvic anatomy and uterine size. Transvaginal eval of the endometrium, myometrial detail and eval of ovaries and adnexa w/ doppler

FINDINGS: bladder is not adequately prepped for proper transabdominal examination of the pelvis

UTERUS: measures 7.8 x 3.6 x 5.4 cm. The endometrium measures 0.7 cm. No focal myometrial abnormality

RIGHT OVARY:measures 2.8 x 2.0 x 2.1 cm. No right adnexal or right ovarian mass. No abnormal or non physiologic cyst. Blood flow is demonstrated by Doppler

LEFT OVARY:measures 2.9 x 2.2 x 2.9 cm. No left adnexal or left ovarian mass. No abnormal or non physiologic cyst. Blood flow is demonstrated by Doppler

PERITONEUM:No ascites or mass

IMPRESSION: Normal pelvis

71275 3D supervision requirement

Good morning. We are coding for a professional client and came across a CTA report that clearly states the 3D reconstruction was NOT supervised by the radiologist. Can you please clarify whether supervision of the 3D reconstruction is a required element of CPT 71275? Sample section of the report below. Thank you so much!

Report Sample:

Imaging Protocol: Computed tomographic angiography of the chest with contrast.

3D rendering (not supervised by radiologist): MIP and/or 3D reconstructed images were created by the technologist.

Radiation Optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction.

Contrast material: Isovue 370

Contrast volume: 100 ml

Contrast route: Intravenous

TAVR complication requires patch repair of RCFA by CV Surgeon

Question ID:17880 from 10/17/22 addresses TAVR complication repaired by PV surgeon. We have similar issue but repair was done by the CV surgeon present for the case. "A linear incision was made above the insertion point of the DrySeal sheath. The artery was quite deep. Bridging veins were clipped and divided. The tissues were quite woody and indurated, but ultimately circumferential control was obtained around the right common femoral artery proximally and distally. The sheath was removed, the old proglide sutures were removed. Potts scissors were used to debride torn intima/adventitia. The residual hole was inspected, and appeared to me to be large to repair primarily. A 0.8cm x 8 cm patch was obtained, and a 1 cm circular patch of bovine pericardium was fashioned. This was sewn to the artery using a running 5-0 prolene suture. The vessels were back bled to get out any debris from under the patch, and the patch was tied down.

33361 + repair (which cpt do you suggest?) or 33362 because it was the same surgeon to do TAVR and repair?

Many thanks!

36820-53, 36821

LT wrist Radiobasilic transpo fully created due to concerns that the fistula would not develop it was taken down and revised to a non-transposed brachiobasilic AVF. Since the second attempt was successful and created through a separate incision would we be able to bill 36820-53 with the 36821?

Incision basilic vein to wrist. Basilic vein dissected & branches ligated/divided distally & proximately. RA was dissected. Vein was tunneled medial - lateral aspect of forearm bringing vein to RA. The vein was spatulated. Flow was established then through the fistula. The basilic vein harvest site was then closed. Noted to be no flow in the fistula. The anastomosis was then taken down and revised. Incision was made over the distal upper arm over the basilic vein made arteriotomy which was stented with Potts scissors. The vein was then spatulated using a running suture was sewn in there is a strong thrill in the fistula due to the larger size of the vein & artery. Hemostasis was confirmed. The radial artery incision and the upper arm incision were closed.

Exploratory laparotomy; exploration of AAA sac with evacuation of contents

"Pt has distant history of open retroperitoneal AAA repair. Aneurysm sac has gotten larger over the years and now presents with abdominal, back, and groin pain. Surgeon is concerned the aneurysm sac enlargement is related to these symptoms. Exploratory laparotomy with exploration of the AAA sac and evacuation of contents and control of bleeding performed.

Midline laparotomy incision was made. The aneurysm sac was evident, intestines retracted appropriately, posterior peritoneum was incised and aneurysm sac dissected free. Aneurysm incised, fluid came out under pressure with blood clot component, cultures taken. Contents of aneurysm evacuated and retractors placed. Evidence of arterial bleeding from lumbar vessels, these were suture ligated. Hemostasis assured. Aneurysm sac reclosed with running Vicryl along with posterior peritoneum."

What CPT codes would you use to code this case? I was thinking 49000 (exploratory laparotomy) and 35221 (repair blood vessel), or would an unlisted procedure code be best? 

documentation for FFR

We have interventional cardiologists at our facility who are stating that the term "FFR" automatically means that pharmacologically induced stress was part of the procedure. They are using the term "FFR" in their cath reports, but are not actually documenting that a drug (such as adenosine) was administered. Is using the term "FFR" alone enough to support coding 93571 without modifier -52? Or is it still necessary for the physicians to document the drug administration?

Hybrid VSD device closure

Plan was to provide perventricular access for device closure of muscular ventricular septal defect by cardiac catheterization team. Pericardium was opened by CTS. An 18-gauge needle advanced through pursestring suture into RV. Wire from a 9 Fr sheath advanced through the needle & under echo guidance across VSD into LV. Wire was in LV, needle was removed & 9 Fr sheath was advanced over the wire across the VSD into LV. Wire & dilator were removed & sheath flushed. Tip of the loader was then cut off once the device 14 mm Amplatzer muscular VSD was fully pulled into the loader. The loader was advanced into the 9 Fr sheath. VSD device advanced through the 9 Fr sheath into VSD under TEE guidance. Device was manipulated & placed straddling ventricular septum under TEE guidance & release the device which was done by unscrewing it from the delivery cable. At this point the device appeared to be quite stable and the sheath was removed & pursestring suture was secured.

Would you code 33681-52 since no CPB used or unlisted code 33999 vs 93799?

Brush biopsy of distal left ureteral anastomosis

"Left genitourinary catheter conversion. Local anesthesia was administered. The existing PCN was severed and a KMP loaded with Glidewire was advanced into the small bowel across the stricture. The KMP and wire were placed with a superstiff Amplatz and the 8 French sheath was advanced into the distal ureter. A fusion cytology brush was coaxially introduced through the sheath to obtain the specimen which was sent in a sterile cup. The brush and the sheath were then exchanged for PCNU tube. Contrast injection was performed. Genitourinary catheter placed: Boston scientific 10 French by 24 cm. Findings: Ureteral stricture at the distal anastomosis. External catheter securement: Non-absorbable suture."

I'm aware I'll be using 50434 for the conversion of the tubes, but are we still using unlisted code 53899 for the brush biopsy of the ureteral? 

CTO C9607 WHEN NO STENT PLACED

Can the hospital bill C9607 for the revascularization of CTO when no DES is placed? Only a cutting balloon was used. Physician billing 92943.

Extracorporeal circulation and CABG

Pt is 56 yo with 3V CAD recent NSTEMI & severe ischemic cardiomyopathy. I am having trouble coding the Extracorporeal circulation code. The report states midline sternotomy was performed the LIMA was harvested from L sternal border endoscopic fashion (33533 & 33508) . Pt placed on extracorporeal circulation with aortic annula, 2 venous cannula and ascending aortic root vent. (33954 or 33956) Pt was placed on cardiopulmonary bypass, at the end of the procedure the patient was weaned off cardiopulmonary bypass. Everything I find on ECMO says it is performed after the CABG to give the heart and lung a rest to assist in healing or is ECMO also used during the CABG? Thank you for your assistance and time.

Convergent A fib ablation--33254 vs 33265

"An incision was made over the xiphoid process and dissection was carried down to the level of the xiphoid, which was dissected free and excised. The inferior aspect of the sternum was then elevated, and the pericardium was opened under direct visualization. The pericardiotomy was extended medially and laterally to allow for placement of the convergent cannula. A 5 mm scope was passed thru the cannula and the heart was examined. There was a moderate amt of epicardial fat present in the left atrium. There were some moderate adhesions over by the pulmonary veins. The ablations were begun. A total of 16 were completed, which appeared to cover the majority of the posterior wall of the left atrium. Some adhesions were taken down. A 24 French Blake drain was placed and fascia, subQ, skin was closed."

We are having a hard time determining if this would be 33254 since he excised the xiphoid and visualized the pericardium or if 33265 is more appropriate since a scope was utilized. Thank you.

C1900 Lead for LV Pacing in Bundle of HIS

Patient presents for cardiac resynchronization therapy due to severe LV dysfunction with EP 15-20% , chronic ischemic cardiomyopathy and left bundle branch block. A Medtronicquadripolar lead (C1900) was delivered into the proximal posterior lateral vein through the coronary sinus guide sheath, however given the small caliber of the vessel the lead could not be extended sufficiently into the branch. Multiple attempts were made but due to the unsuitable coronary sinus anatomy this attempt had to be abandoned. Lead was advanced to the region of the HIS bundle until adequate sensing and thresholds were confirmed. ICD was attached to leads.

Since the physician used C1900 lead in bundle of HIS to obtain LV pacing can we charge 33249 and 33225?

Holter Monitor Question (CPT 93225)

When a patient comes in for the hookup of their holter monitor, we bill CPT 93225 (connection, recording, and disconnect). The holter monitors are programmed to auto-disconnect. The patient typically returns the monitor to the office so the recording can be uploaded, reviewed, and interpreted. At that point, the professional component is billed.

Our question is: If the patient does not return the monitor, is it still appropriate to bill the CPT 93225 (even though we did not receive the actual recording) since the monitor was hooked up, recorded, and auto disconnected?

Left Bundle-Branch Pacing Question 18029 Clarification

Recommendation to my question 18029 was to code 33264, for:

A biventricular device was attached to the existing leads. The left ventricular port was capped. The pocket was flushed and the device was then placed into the pocket. It was closed in a three-layer technique and the dermal layer was sealed with dermal adhesive.however:

Question ID 17177

A biventricular ICD replacement was performed with existing RV, RA, LV leads. The existing LVL was capped, and there were no appropriate branches for LV pacing, so a left bundle lead was placed. Is 33264 the appropriate code for this procedure?

Answer

Since a new lead and new generator were placed, report codes 33241 and 33249. -Dr. Dunn

Will you please advise on why there were different recommendations for these two scenarios?

Removal of IVC Filter Fragments

Patient presents with fractured retained IVC filter fragments in IVC, pulmonary artery and right atrium. According to Question ID: 4176 all fragments removed from vessels would be covered with 37193. Would this apply to the removal of fragments from the atrium as well or would removal of foreign body 37197 be appropriate?

median arcuate ligament release

What is the CPT code for median arcuate ligament by laparoscopic approach?

Eagle Syndrome-Decompression

My vascular surgeon performed a diagastric muscle resection, C1 transverse process resection, and stylohyoid process excision in order to accomplish a decompression of the right internal jugular vein. I am torn as to where to begin with a CPT code since all of these procedures were performed to accomplish one problem. I thought about using 35701-22, but this does not seem to capture all of the work involved. I don't want to code multiple CPTs, as that may seem like up-coding. What are your thoughts on how to approach this coding scenario?

Cholangiography without contrast

Patient had CT abdomen and pelvis with contrast. Next day, cholangiostomy tube check was done through existing access without contrast. How do we code cholangiography without contrast? The result was normal function of internal and external catheter.

Breast Biopsy using Contrast Enhanced Mammo

Our providers are sometimes performing stereotactic breast biopsies using contrast enhanced mammography to visualize the lesion within the same setting. In addition to 19081, should we also capture 76499 for that contrast enhanced imaging?

PERCUTANEOUS US GUIDED SYNOVIAL BIOPSY OF HIP

AFTER OBTAINING CONSENT, AN US CORE BIOPSY OF THE RT HIP SYNOVIUM WAS PERFORMED. PREPROCEDURAL IMAGING OF THE RT HIP DEMONSTRATED A TOTAL RT HIP ARTHROPATHY WITH EXTENSIVE SYNOVIAL THICKENING ALONG THE ANTERIOR MARGIN OF THE FEMORAL STEM. THE RT HIP WAS SCANNED AND THE REGION OF INTEREST WAS LOCALIZED, UNDER US GUIDANCE, 5 PASES WERE MADE AND BIOPSY SPECIMENS WERE OBTAINED USING AN 18 GAUGE BIOSY GUN. WOULD THIS BE CODED AS 76942 AND 20206?

37244 hemarthrosis

Can you please provide the documentation to support that 37244 must be for acute active hemorrhage? We have an outpatient report for embolization of hemarthrosis. Is a planned outpatient embolization for this indication coded as 37242 or 37244? We have a dispute over documentation that it must be acute bleed indication, which we do not see supported in the CPT Codebook.

SAVR after TAVR

Patient presented with severe stenosis and regurgitation of bioprosthetic valve (previous TAVR). The patient also has a history of CABG. The bioprosthetic valve was found to be adhered to the ascending aorta and the ascending aorta needed to be replaced from the distal to the sinotubular junction. The bio valve and the native valve were excised, and a new valve was placed. 33405-22 for this portion. The surgeon then had to reimplant the previous coronary bypass grafts into the newly grafted ascending aorta. I am certain we need to go with an unlisted code for the ascending aorta replacement and thinking that we'll utilize 33859 as the comparable code after confirming with the surgeon. Also, adding 33530 for the re-operation. Is there anything additional that you would recommend?

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