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Dr.Z, question regarding pacemaker debridement. A week before Patient had pacemaker infection so pocket moved to the other side and prescribed antibiotics. A week later came back for the closure, and has lot of scar tissue. What can we charge for the closure? Thanks

Dr. Z, Please explain the rationale for new code 36148 additional access for therapeutic intervention. Sometimes our physicians access graft in 2 locations and criss cross catheters were placed, in 2009 we can code this with 36145 twice with or without intervention. With new codes can we charge 36147 and 36148 (for the second access) when they perform only diagnositic study no intervention performed or only 36147 since no intervention performed with the additional access. And also even when they perform intervention we can't tell from the report whether they used the second access to perform intervention, please explain. Thanks
 

With the new 2010 AV fistula codes I am not sure how to code a cath placement. Fistula was accessed with a needle, contrast imaging done (36147). Tapered narrowing approaching the arterial anastomosis. The arterial anastomosis itself is moderately narrowed. The entire juxtaanastomotic segment was irregular in contour with two discrete moderate foci of stenosis. Balloon cath was advanced over the wire. Angioplastied the inflow segment down to the radial artery in an overlapping fashion (35475 & 75962). Can I also charge for catheter placement in the radial artery 36140? Thanks for your help.
 

Greetings,

This site has been my life line. Here I go with another AV fistula creation.
Local anesthetic was infiltrated along the previous surgical scar in the antecubital fossa. The skin incision was made overlying the previous incision and cautery was used to dissect down to the aneurysmal portion of the fistula. This segment of the fistula was mobilized circumferentially and the arteriovenous anastomosis was identified and dissected free. The fistula was doubly clamped and divided. The stump of the fistula, which was still attached to the vein, was oversewn with a GoreTex suture. This allowed the very small stump to act as a vein patch angioplasty to the brachial artery. The remaining segment of the aneurysmal portion of the vein was excised. The wound was then closed in layers with interrupted Vicryl in the deep tissue and a running Vicryl suture for the skin. Is this a revision of a fistula or ligation?

Will there be new codes for G0393 and G0392? If so, what are they being replaced with?  (Asked 11/9/09)

When performing a Thoracentesis and Paracentesis at a single outpatient encounter can you charge for the US guided needle placement once for each procedure or a single guidance for both procedures.  thank you.

Hi Dr. Z, When the MD documents in his/her procedure report a crossed catheter technique to access an AV fistula/graft, would this always be reported with 36145, 36145-59?  Does this terminology always indicate two access sites? Thanks. (Submitted 11/09/09)

Hi Dr Z.one of our interventionalists does this procedure frequently for Liver Ca and I'm having trouble getting it coded correctly. I hope you will be able to help. I use your book when I code these but I would like some validation that I'm using the right codes. PROCEDURE: 1. Superior mesenteric artery angiogram. 2. Accessory right hepatic artery angiogram arising from the superior mesenteric artery. 3. Celiac artery angiogram. 4. Selective left gastric artery angiogram. 5. Selective gastropancreatic common trunk angiogram. 6. Coil embolization of this common pancreatic gastric trunk. 7. Selective left hepatic artery angiogram of two segmental left hepatic arteries. 8. Selective right hepatic artery angiogram. 9. Gastroduodenal artery angiogram. 10. Coil embolization of the gastroduodenal artery. 11. MAA infusion of approximately 2.5 mCi Tc 99m MAA into the accessory right hepatic artery arising from the superior mesenteric artery. 12. MAA infusion of approximately 2.5 mCi Tc 99m MAA into the right hepatic artery arising from the celiac artery. DESCRIPTION OF PROCEDURE: The patient was laid supine. The right groin was prepped and draped in the usual sterile fashion. Skin and deep subcutaneous soft tissues were anesthetized with 1% Lidocaine. A small skin nick was made with a #11 blade, and then using micropuncture technique, the right common femoral artery was accessed and a microwire advanced. Over the microwire a #5-French microsheath was placed. Through the microsheath an 0.035 3-J wire was advanced into the abdominal aorta, and over the wire a #5-French working sheath was placed. Over the wire and through the sheath, a #5-French Sos Selective catheter was placed over the wire and formed in the abdominal aorta. It was then used to select the superior mesenteric artery and a digital subtraction superior mesenteric artery angiogram was performed, and using a Progreat microwire and microcatheter, the microwire and microcatheter were used to select the accessory right hepatic artery arising from the superior mesenteric artery proximally. A digital subtraction right accessory hepatic artery angiogram was performed, which showed dominant supply to a hypervascular complex right-lobe-of-liver mass along with several satellite lesions. The accessory right hepatic artery supplies a moderate amount of the right lobe of liver, likely greater than half of it. Next, the microcatheter was removed and the Sos selective catheter was used to select the celiac artery. Digital subtraction celiac artery angiogram was then performed. This reveals a complex configuration of celiac artery with two left gastric arteries arising from the bifurcation of the common hepatic and splenic as well as a very large pancreatic gastric trunk. Using Progreat microwire and microcatheter, the wire was used to select the left gastric artery, and a digital subtraction left gastric artery angiogram was performed. Then using Progreat microwire and microcatheter, the gastric pancreatic trunk was selected. This comes off in a trifurcation fashion with gastroduodenal right and left hepatic branches. This pancreatic gastric trunk was selected and then back- coiled with 0.018 Vortex microcoils to complete stasis. Hand-injected arteriogram was performed documenting the adequacy of embolization. Next the left hepatic artery was selected. There are two left hepatic arteries, the segment two branch first was selected and digital subtraction angiogram performed. Next the segment three branch was selected and digital subtraction angiogram performed. Next right hepatic artery was selected and right hepatic artery angiogram was performed, which showed a branch vessels supply to part of the hypervascular dominant right-lobe-of-liver hepatocellular carcinoma. Next the gastroduodenal artery was selected and a digital subtraction gastroduodenal artery angiogram was performed. This was then coiled to complete stasis using Nestor microcoil as well as Azure detachable coil. The gastroduodenal artery was coiled to complete stasis and a post-coiling angiogram was performed documenting adequacy of embolization. Next the catheter was brought into the proper hepatic artery upstream to the trifurcation of vessels. 2.5 mCi Tc 99m MAA was then infused at this site. Delivery materials were then safely disposed of by the nuclear medicine technologist. A new Progreat microwire and microcatheter were placed after the Sos Selective catheter was used to select the superior mesenteric artery. Microcatheter was then used to select the accessory right hepatic artery, and the remaining dose of MAA was injected. 2.5 mCi Tc 99m MAA were injected into the right accessory hepatic artery. Infusion materials were then removed and safely disposed of by nuclear medicine technologist. The right groin sheath was then removed and excellent hemostasis achieved using manual compression for about 15 minutes. My codes are 37204 and 37204-59, 75894, 75894-59, 36245, 36246, 36247-59x3, 36248 x's3.

Thanks for your help in advance

We did a diskogram at three different lumbar levels, so I have coded 62290x3 and 72295x3 with modifiers. Our Radiologist is also wanting us to code CPT 64999 additionally for what he is calling a functional anesthetic diskography. He placed these tiny little, what he is calling functional micro balloon catheters at each level. After the conventional diskogram he left the catheters in place and stood the patient up and injected lidocaine at each level waiting 20 minutes between levels and had the patient bend forward and back and from side to side as well. All of this is documented in his dictation with pain levels from the patient. Would you suggest additional coding for this? Your help is greatly appreciated! Thank you!

Dr. Z I have a question regarding standards or benchmarks for coding of interventional radiology, cardiology &/or endovascular procedures. I am trying to gather information on the average number of cases that are coded in a day or week. I realize that each case is different and it might be too difficult to put something like that together, but I figured you would have the information if any was available. Thank you for any information you can give me

Hello guys- I have a physician who is going to perform intracranial procedures at another hospital, mostly elective coilings. We have done this at other hospitals and they coded the procedures, the entire procedure. This time, could we code for the professional services only, by adding the 26 modifier on the 70,000 series codes? Is this wrong to do or is it mandatory? Thank you

During cardiac cath on a medicare pt. the phy. documents below with one cath position. Findings are both renal and iliacs, would you code both G0275 and G0278 from just one contrast shot from the renal area? "DESCENDING AORTOGRAPHY: The descending abdominal aorta has at least moderate atherosclerotic plaquing with some aneurysmal dilation distal to the renals. The left renal artery has a cleft-like 60 to 70% stenosis. The right renal artery was not well visualized, is overlapped with the inferior mesenteric. There is mild plaquing of the left iliac artery. The left internal iliac is not well visualized. Right iliac artery is aneurysmal with mild plaquing. There is moderate plaquing seen in the right external iliac artery." Thanks! Jim H.

With the new codes for AV grafts 36147 and 75791 how do you code if via one access into the graft the farthest catheter placement is the SVC. Example is declots where via only one access into the graft a fistulogram is performed and declot of graft and SVC is performed. Code 36147 includes fistulogram and cath into graft. Code 36010 includes cath to SVC. Thanks in advance.

Dr. Z, Our interventional radiologist did a biopsy of the largest nodules in the left and right lobe of the thyroid gland (two seperate stab incisions). Do we code 60100 twice with only one guidance code 76942? Thanks for your help

If a radiologist does aspiration of 3 cysts in the left breast by ultrasound guidance, do you code 19000, 19001, 19001, 76942, 76942-59, 76942-59.  I just want to make sure I am understanding this correctly.

I love your site! thanks for all your help. Could you help me code this case.
Fluoroscopically Guided Transvenous FB retrieval Using US guidance we acessed the rt common femoral vein. I advanced the guidewire to the level of the inf vena cava and then inserted a 6 fr sheath.
The sheath was flushed. I advanced the guidewire to the level of the SVC over a guidewire I inserted a 6 fr long sheath the guidewire was removed through the sheath and under fluoro I advanced a multiloop snare with maxium transverse diameter of 1.5 cm LOOP snare was positioned adjacent to the venous catheter fragment in the right atrium. Multiple attempts were made with the snare that were unsuccessful. I then exchanged for a separate multiloop snare with max transverse diameter of 3cm. Again attempts made were unsuccessful. the catheter fragment is felt to be lodged against the wall of the rt atrium. I then removed the long sheath and inserted a 5 french pigtail in the rt atrium. I then placed a Ampltz guidewire through the pigtail catheter to open the catheter loop. The loop was then gently placed across the waist of the catheter fragment. Counterclockwise traction was applied to the catheter and guidewire which allowed the catheter to entangle the waist of the catheter. Under Fluo I gently pulled the catheter away from the right atrium and into the vena cava. The catheter was then pulled lower to the level of the rt common iliac vein. I removed the catheter and guidewire and replaced the loop snare. The loop snare was then used to grasp the end of the catheter fragment. I then removed the intact catheter fragment, loop snare and sheath from the right common femoral vein.
The fractured catheter fragment measures 11 cm in length. During the procedure the patient had a prolonged episode of atrial tach which did not resolve the following repositioning of the cath Cardiology was asked to evaluate the patient. The patients heartrate did return to baseline and no cardioversion or addl cardiac intervention were required. Successful Fluoroscopically guided retrieval of Venous catheter fragment from the rt
atrium. Thanks for your help

Dr. Z can CPT Code 76937 be reported with 75791, if the criteria to report the u/s guidance is met.

Our EP physicians would like to begin using AIGISRx anti-bacterial envelope when inserting PMs and ICDs.

I am responsible for the facility billing. AIGISRx is an anti-bacterial envelope made from knitted polypropylene mesh substrate, coated with a polyarylate bioresorbable polymer containing two antimicrobial antibiotics, minocycline and rifampin. AIGISRx is a dual component (resorbable and non-resorbable), sterile prosthesis designed to reduce infection and to stabilize the implantable PM or ICD when implanted in the body.

I have been notified by the manufacturer that they have "confirmed that using the CMS A4649-surgical supplies & devices-other implants, will allow for full reimbursement of the AIGIS anti-bacterial envelope ... this is a great first step toward CMS issuing a CPT code specifically for this type of device ... now we can say that this will not increase the cost of the procedure."

1. Do you agree, per OPPS 2009 Final Rule, there are no devices eligible for pass-through payment for 2009, and therefore, there would be no additional reimbursement, and the device would be unconditionally packaged into the reimbursement of the Insertion of the PM or ICD, whichever is performed.
2. Do you agree using this device will increase the cost of the procedure.
3. Would A4649 be the most appropriate HCPCS code to use with Revenue Code 0278?

Thank you.

Hello Dr. Z,
We are getting a denial for 77002 when added to 27093 for a Pre-MRI injection hip. According to encoder these are bundled. A modifier is allowed but 59 is not one of the choices.

I NEED HELP IN TRYING TO DETERMINE WHEN IT IS APPROPRIATE TO USE THE 58 MODIFIER. I HAVE BEEN USING THIS MODIFIER ON A RELATED SERVICE (99222) DURING THE POST OP PERIOD AND THEY ARE BEING DENIED. PLEASE ADVISE ON WHEN THE 58 MODIFIER CAN BE USED.

I would like to expand on a question you answered 10-14-08 regarding facility charging of fluoroscopy performed in the OR by a radiology tech.

I understand from your answer that the charge for the fluoroscopy should be generated by the radiology department if that is the department that has incurred the expense, ie. the tech whose salary is paid by radiology, which is the case in my situation. My question is, although the fluoroscopy (72291) is charged by the radiology dept, would the OR physician's documentation in his report of the fluoroscopy used to perform the OR procedure (22524) be sufficient. Or, does the radiology dept need to document anything?

Are the new codes for AV fistula angioplasty only for hospitals and out-patients facilities. We bill for radiologist on hospital base. Do we need to use these new codes or the oldest ones.