Ask Dr. Z

MD performs open thrombectomy AV graft,does fistulagram,does angiplasty and stent to the axillary vein and finally does open thrombectomy of brachial artery. At one point in time I read that establishing inflow and outflow was considered part of the procedure. Is that correct? Or could we bill 34101,37207,35460,75790,75960 and 75978? I know 36831 is included in 37207. Thank you

IVC venography injected from ipsilateral common iliac for placement of caval filter. Venography showed patient already had a filter in place. 36005 states extremity. What cath code would be appropriate?

Dr Z, I have a physcian who always dictates in his report aortogram with subselection of the renal artery during a cardiac cath. I have coded 76525 for the aortogram and have not use anything for the subselection of the renal artery since that is all that he states in his dictated report. I know G0275 is for non-selective renal artery but I am unsure what to do with the terminoloy subselection. Thanks

Dr Z., our cardiologists are now placing a catheter in the femoral vein in order to cool down an acute cardiac patient. These are STEMI patients admitted from the ED. Our cardiologist would like to know if they can charge for that, and if so what would be the CPT code for it? Thank you Jane Mateski, RHIT, CCS

When using the new fistulogram code, 36147, and an intervention is done, is any modifier, either 51 or 59 needed for the 36147?

Is CPT code 93351 only to be used in a non-facility setting?

Briefly--For over 6 months this patient has had a persistant enterocutaneous fistula communicating with the duodenum & hepatic flexure of the colon. After multiple catheter changes & down sizings, the drainage catheter was pulled approximately 3 weeks ago. Patient was brought in yesterday, fistulogram was performed. The tract was dilated slightly with biopsy brushes before a catheter was inserted &he tract back filled with Tisseel glue as the catheter was withdrawn. MY question is does this qualify as an embolization? Appreciate your opinion. Thanks from KC, MO.

Dr. Z, I am confused about the use of CPT code 49081 for "subsequent" paracentesis. I have read multiple questions/answers that are posted in the database, and my understanding is that the code may be used for separate access, on same date and case, yet the CIRCC study guide says the paracentesis must be performed at a different time. Could you please clarify?
 

Pt had a pta with stent insertion of the left internal carotid artery. What would the approptiate cpt and Icd-9 codes for this procedure. I was told that if they are in the internal/external carotid artery this is cerebral artery (intracranial). Please verify
Thanks

Dr. Z During pacemaker or AICD generator changes or lead replacements the physicians are stating under venography guidance the procedure performed and no mention of fluoroscopy either in the log or report? Can we charge 71090 here? Thanks

Please advise when to report temporary pacemaker with modifier -59. The Q & A's that I reviewed (#325 & 1554) do not match my billing scenario. Patient is admitted for complex percutaneous coronary intervention on three vessels (third redo). LVAD is inserted into the left ventricle which caused a complete heart block. Temporary pacemaker was then inserted. At the completion of the complex procedure, the LVAD was removed along with the pacemaker. Can 33210 be reported with modifier -59? Thank you

Dr.Z, Should we report 36831 open thrombectomy of AV fistula for dialysis and 35460 open angioplasty when they remove thrombus and find a stenosis at the venous outlet. I get message suggesting I append modifier 59 to 36831. Thank you Jane

Dear Dr. Z. I have a case where the port has rolled in the mediport pocket. The interventional radiologist opened the pocket, removed the port, repositioned the same port within the same pocket, and closed up the pocket. We are debating the use of two CPT codes: 36576 (repair of central venous access device, with subcutaneous port) and 36597 (repositioning of previousy placed central venous catheter under fluoro guidance). Would you recommend either of these for this procedure? Or is there another CPT code that would be more appropriate?

This is an outpatient acct where the patient was brought in for coronary angiogram. They found two lesions in the LC. One was intervened on with a DES. The second one was found to be only 60% occluded so the physician decided to treat that one medically. The procedure was concluded and the patient was brought to recovery. An hour later, the patient complained of chest pain. EKG revealed no acute changes (patient did become bradycardic and hypotensive) and the physician decided to repeat the coronary angiography where it was found that the lesion not intervened on turned out to be really 80% occluded so a stent was placed in that portion of the LC. Because the patient's medical condition had changed, can a second stent be captured? We understand that the repeat angio can be charged; we're just not sure about the second stent. Thank you so much!

Is a renal angiogram included in billed with 75630? Thanks

We have a vascular surgeon that performs AV shuntograms and PTA's of the shunt in a surgical suite. A radiology tech will typically provide the fluoroscopy. The radiology department wants to charge 76000, on the facility side only, for the work/time provided by the tech. Is this allowable? There are no CCI edits, on the facility side, when both 36147 and 76000 are used together even though 36147 includes fluoroscopy. There is a CCI edit when both 76000 and 75978 are charged. We instructed the radiology dept not to charge 76000 with 75978. However, we were uncertain when only an AV shuntogram was done and the tech provided the fluoro. Thank you for your help.
 

A physician emobolized the left cavernous sinus. He performed a direct puncture of the venous varix in the left cavernous sinus. How would the access be coded? Thank you

Hi Dr Z. Quick Question A "Bard Biopsy device" used for Breast Biopsies. Is this device a Percutaneous Vacuum assisted/rotating device 19103 or a percutaneous Needle core biopsy 19102 ? I am seeing cases where it is documented solely as "a Bard Biopsy Device" and other cases documented as a "10-gauge Vacuum assisted BARD biopsy needle" Please advice

Hi, Dr. Z! My question is in regards to cases where the physician does an atherectomy first - it is suboptimal and he then does an angioplasty. From what I have read, we are only allowed to bill for the successful procedure which would be the angioplasty in this case. Is it appropriate to bill the radiology S&I for the atherectomy (75992/26), since the physician did that reading as well? Thank you!

We are asking for further clarification when coding an Atherectomy of the Common Femoral artery. As advised by our Cath Lab staff the procedure documented below should code to 35492 Atherectomy iliac. We agree in Coding that the external iliac and the common femoral are the same vessel. But, CPT 2010 does not include in the index or in the Transluminal Atherectomy section any direction to code documentation specified to common femoral to the iliac. I have provided the case as documented below. ENDOVASCULAR INTERVENTION: SUCCESSFUL ENDOVASCULAR ATHERECTOMY OF THE LEFT COMMON FEMORAL 99% TO 20% AN ATHERECTOMY DEVICE WAS PLACE (MS-M FOX HOLLOW) IN THE LEFT COMMON FEMORAL ARTERY AND CUTS WERE PERFORMED. THE GLIDEWIRE WAS PLACED AND THE DEVICE WAS REMOVED. A BALLOON WAS THEN PLACED IN THE LEFT COMMON FEMORAL (6X4X130 EV3 EVERCROSS) AND INFLATIONS WERE PERFORMED. THE BALLOON WAS REMOVED. ENDOVASCULAR FINDINGS: LEFT COMMON ILIAC -- 50% (NO GRADIENT) LEFT COMMON FEMORAL -- 99% STENOSIS

Patient with a traumatic CCF had a diagnostic angiogram and treatment. Physician selects bilateral CCA, ECA, ICA and bilateral Vertebral with imaging.Giant The common carotid arteries are normal bilaterally. The right CC fistula is seen with poor flow intracranially. The left intracranial circulation is unremarkable. Both vertebral imaging procedures and external carotid imaging demonstrate lack of supply to the fistula and normal anatomy. RICA was selected and sacrificed with detachable coils. A follow up angiogram was performed in the RICA demonstrating complete occlusion and no further connection with the CCF. The LICA was selected again and an angiogram was performed demonstrating ACA and MCA arterial distributions. The ACOM appears robust and the right A1 and the right MCA artery show good flow. The right vertebral artery was selected again and an angiogram was performed demonstrating a patent right PCOM with flow seen in the MCA and ICA terminus. There is slow flow seen beyond the supraclinoid portion of the RICA in retrograde fashion to the coil mass. Can I code for the second catheter placement in the LICA and Right Vertebral. Can I also charge for 75898 x3?

Could you help me? Would this be coded 36247,35475 and 75962 or 36247,35475, 75978(angioplasty for the arterial side of the fistula)AND 36247 59,7507859 (angioplasty of the brachial artery)? The radiologist refuses to say native brachial artery. He also does not say how far above the anastomosis. I was audited a few weeks ago and now I am second guessing myself(I work for the hospital).I have your coding book and love it. Thank you. Frances () AVS(FISTULOGRAM) PROCEDURE - INDICATIONS: Poor blood flow at dialysis and pulling clots. RESULT: ARTERIAL VENOUS FISTULA: Technique: Informed consent was obtained from the patient. Access was gained into both the arterial venous side of the patient's arterial venous fistula. Contrast was then injected. This was then followed by angioplasty at the arterial side of the fistula with a 5 mm. balloon. The brachial artery was also angioplastied with a 5 mm. balloon. The catheters and sutures were then removed. Hemostasis was obtained. Complications: No immediate complications were encountered. Medications: 1% local Lidocaine to the skin, Versed and Fentanyl for conscious sedation. Approach: Fluoroscopy. Physical status: ASA-4 Findings: The patient demonstrates a brachiobasilic fistula. There is narrowing involving the arterial side of the fistula in the range of 80% to 90% with some mild aneurysmal formation. This was successfully treated with angioplasty with improved patency. There was an area of irregularity involving the brachial artery above the anastomosis which was angioplastied. This resolved after this. There is an indwelling stent involving the outflow venous structure. Just some minimal narrowing in this was identified but this was not treated because this was in the range of 20% to 30%. There is also an indwelling stent within the right brachiocephalic vein into the superior vena cava. This appears patent. IMPRESSION: Successful arterial venous fistulogram with arterial side angioplasty and brachial artery angioplasty for abnormalities.
 

One of our vascular surgeons is following a new protocal for looking for a discection in the ascending aorta using CT with the goal of using a minimal amount of contrast. He is placing a pigtail catheter in the ascending aorta in the Cath Lab and then we are immediately sending the patient to CT for a CT which is enhanced with the contrast infusion during the CT. We are not certain how to bill for the catheter placement in the Cath Lab. Can anything be billed other than supplies for the pigtail catheter placement only (no exam). Also, can they only bill for the standard CT angio of the chest (71275)for the CT exam? Thanks for any help
 

My question is regarding clarification of peripheral and central vessels in regards to A/V 2010 fistula/graft procedures. Is the cephalic vein and the brachial vein considered to be in the "peripheral" zone? (reasoning...I have some physicians who are documenting the cephalic and the brachial veins as being located in the "central" zone. Would a venoplasty in either of these sites be considered "central" or "peripheral"? Thank you Dr. Z!
 

If a physician punctures the dorsal pedalis and goes retrograde into the SFA....what would be the selection code?? Thanks for the help!

Please advise on coding and using 36147 in declot of severe stenosis with access obtained in cephalic vein in the mid foremarm, after attempt to access cephalic vein from basilic vein without success therefore the entry into cephalic via antecubital space was obtained and then angioplastied. A fistulogram was taken prior to procedure.Our endovascular lab coded using 36147; 75978; 35476; & 75791, but coding staff said that we should not be charging 75791 nor 36147 just the 35476 & 75978. Your expertise to clarify would be greatly appreciated as to the appropriateness of our original charges.

Hi Dr Z, This is for HOPPS. Can we code/charge for supplies related to an attempted embolization? We appended modifier -52 to the embolization code. The radiologist's dictation states: Following the diagnostic arteriogram, and through a left internal carotid artery approach, a single lumen occlusion balloon catheter was introduced in the inferior division of the left middle cerebral artery across the neck of the aneurysm. A microcatheter was then maneuvered in the fundus of the aneurysm. Multiple attempts to embolize aneurysm with platinum coils using the balloon-assisted technique proved to be unsuccessful due to the shallow nature of the aneurysm and to the tortuosity of the cervical segments of the left internal carotid artery. The endovascular procedure was then aborted without any complications. The post-treatment left internal carotid arteriogram showed no branch occlusion or other intraluminal filling defects. Thank you for your help!

How do you recommend coding a CT post discogram? CT with contrast or CT without contrast? Thank you!

Dr. Z, when performing Complete EP study, sometimes we see an arterial access catheter placed to measure and monitor pressures. They are not using this access other than monitoring the pressures. Can we charge 36620 with '59' along with 93620? Please explain. Thank you.

I am confused about code 47801 for choledochal stent. In one of your questions in 2006 a case was provided where code 47556 was recommended whether dilation occured or not prior to stent placement. I have a case where the physician placed a 10mmx6mm stent across the common bile duct with post angioplasty with 10mm balloon. Contrast injection to confirm patency. Since the intent of the balloon was for post dilitation would code 47801 be correct? I am confused about this code and when to use vs 47556 when stent is implanted. Thank you.

Dr. Z I have a Neuro-IR physician that performed at CT-guided transforaminal epidural and nerve root injections with fibrin glue. Levels were bi-lat T8/9; T9/10; T10/11 with contrast for needle verification. Would the correct code be 77012/ 64490-50/64491-50, 64492-50? A blood patch would not be the correct code or would it? In his dictation, he did not state any type of patch other than the fibrin glue. Thoughts? Thank you

Patient with a traumatic CCF had a diagnostic angiogram and treatment. Physician selects bilateral CCA, ECA, ICA and bilateral Vertebral with imaging. The RICA was selected and sacrificed with detachable coils. A follow up angiogram was performed in the RICA demonstrating complete occlusion and no further connection with the CCF. The LICA was selected again and an angiogram was performed demonstrating ACA and MCA arterial distributions. The ACOM appears robust and the right A1 and the right MCA artery show good flow. The right vertebral artery was selected again and an angiogram was performed demonstrating a patent right PCOM with flow seen in the MCA and ICA terminus. There is slow flow seen beyond the supraclinoid portion of the RICA in retrograde fashion to the coil mass. Can I code for the second catheter placement in the LICA and Right Vertebral. Can I also charge for 75898 x3?

Hi, have dictation for injection of a peritoneal dialysis catheter. What codes are used? Thank you.

Percutaneous Lymphocele Drainage (bilateral) Hi Dr Z how would I report CT guided catheter drainage of bilateral pelvic lymphoceles for a male patient? Do I report the Unlisted code once or twice (49999) with SI code 75989 x 2 please advise.

Dr. Z, I need a code for a localization done on a patient under CT guidance. The patient previously had a kidney removed due to renal CA. CT showed recurrent tumor in the kidney fossa. The radiologist placed two Kopan hook needles in the area and the patient went to the OR. I charged the CT guidance 77012, but I am unsure what surgical code to put with it. 19290--specifically for breast localization 49411--specifically for radiation therapy What would you charge with this code? Thank you!

Hello Dr. Z, please read below: Cone beam CT acquisition was performed during contrast injection into the right hepatic artery with two dimensional CT reconstruction demonstrating the dominance of supply to the tumor mass by posterior branches of the right hepatic artery. Post embolization cone beam CT acquisition which was also transferred to a separate workstation demonstrated retention of the oily contrast only within the tumor mass and not within the remainder of the liver. >From what I am told by the dept., a 3D image is produced but what is being questioned is the CONE BEAM CT...is there a separate CPT code for this procedure or is this just part of the 3D process?  I know what's missing is the 3D documentation, right. Can you please explain?

If a bilateral arthrogram is done on the shoulders can 77002 be coded twice with a modifier?

I have a question regarding a percutaneous valvuloplasty procedure. The patient arrived from another hospital. A heart cath was recently done and the referring physician stated the patient had normal anatomy with an ejection fraction of 45 percent. The patient was referred to our facility for aortic stenosis repair. The op report for the valve repair includes: Hemodynamics-pressures and cardiac output measurements documented for the right heart. The left ventricular end-diastolic pressure severly elevated. The description for the percutaneous valvuloplasty. Final hemodynamics reported. aortic root angiogram indicates no aortic insufficiency. Since there was a previous heart cath, I didn't think a second one could be coded. Is that correct? Is the only procedure that should be coded in this example 92986 for the valve repair? We have just started doing these and any guidance would be appreciated. Thank you.

I have a question regarding Fractional Flow Reserve performed in multiple vessels. Following angiography, an FFR is performed in the LAD, and then an FFR is performed in the 1st Diagonal Branch of the LAD. Can this be reported with 93571 and 93572? or does this procedure have the same rules as PTCA/Stents and is considered just one vessel for CPT coding purposes?

Hello! I am unsure if I can bill more than 1 set of 37204 & 75894-26 for the embolization part of this procedure. Also, an Amplatzer plug was used in internal iliac. I am OK with the cath placements. Dx: Growing AAA with a type II endoleak from multiple inferior lumbar arteries from different sources. 1. Coil embolization of a lateral lumbar and pelvic artery with the source coming from the internal iliac artery branch with a shared vascular supply from the contralateral internal iliac and coil embolization of 3mm Tornado and 5mm Tornado coils for a total of 5 coils. 2. Selective cath of an ascending lumbar artery and insertion of 0.75cc of NBCA embolization glue. 3. Selection of the origin of the right internal iliac artery and deployment of a 16mm Amplatzer plug to the right common internal iliac origin. Thank you,

My question is in regards to charging for the PICC line insertion on the hospital side when the line is placed by a RN. This is both for inpatient and outpatient. On the inpatient unit the lines are placed bedside. Outpatient lines are placed in the infusion center, emergency room and recovery room. The PICC line insertion charge is a treatment room charge, but is performed bedside on the inpatient unit, recovery room or emergency room. Is it ever appropriate to charge the PICC line insertion in addition to the room charge? What about if the nurse is declotting the PICC line bedside, is this billable or bundled into the room charge? Thank you for your help,

Dear Dr. Z, This is a procedure we've been unable to locate any coding advice on thus far: CLINICAL INFO: ESRD w/left upper arm fistula that is difficult to cannulate PROCEDURE: Skin overlying the Left Upper Arm fistula was prepped/draped...Ultrasound was used to mark the course of the fistula on the skin. Multiple sterile OR markers were used. Then, 22 gauge needle was used to abraid the skin through the ink. This resulted in small tattoo dots along the course of both sides of the fistula. IMPRESSION: Successful marking of he course of a left upper arm fistula. We have considered Unlisted Skin 17999 (APC 12, SI "T") with 76942 (SI "N"), but also wonder about Unlistd Vasc. 37999 and/or Unlisted Ultrasound 76999. Your opinion and advice would be much appreciated! Thank you in advance. It was great meeting you at our facility in November!

Dr. Z, Please give me your insight on this case. I'm just not sure which codes to use - patient with a CSF fluid leak has a lumbar puncture and contrast injected. The patient is tilted head down for 20 minutes then transported to CT for a maxillofacial and cerebral scan. Would the lumbar puncture be coded -- 62311, 77003 or 62284, 77003? We are coding the CTs separately. Thanks for your help.

Dr. Z- What is the correct code for this report? The radiologist indicates 78195 but I am leaning towards 38792 because he doesn't describe any lymph node imaging: Utilizing aseptic technique, a total of 600uC of Tc99 Sulfur Colloid was injected intradermally into the right breast. Scintigraphy confirmed uptake of the radiotracer. The patient was then transferred to the operating room for intraoperative localization. Please correlate wtih the operative report. Thank you.

A physician accesses both common carotid arteries and performed both bilateral cerebral as well as bilateral cervical angiograms. He then went back (same session) and accessed the right internal carotid and performed a second cerebral angiogram. Is the 2nd angiogram (75665) billable with the 75671 (bilateral cerebral angio) w/ modifier 59? The patient has moyamoya so he only accessed the commons before deciding to go into the right internal.

Pt had a PTA with stent insertion of the left internal carotid artery. What would the approptiate CPT and ICD-9 codes for this procedure. I was told that if they are in the internal/external carotid artery this is cerebral artery (intracranial). Please verify. Thanks
 

The H&P says the patient has a Fem-Tib bypass graph. The Preoperative diagnosis on the Op report says Stenosis of the left leg anterior tibial bypass. If this is an open procedure, do I code to the vessel that was bypassed or as a vein angioplasty 35460? The operative report reads as follows:

"A 1cm transverse incision was made over the vein bypass on the lateral aspect of the patient's left knee. A pursestring sture of 6-0 Prolene was placed and the patient was heparinized with 5000 units. Seldinger technique ws used with a micropuncture set and a 5 French sheath was placed. Catheter was advanced up to the area of stenosis near the proximal anastomosis and an angiogram revealed a 90% stenosis proximally. It was crossed with a 014 wire, dilated with a 3 mm balloon and it was improved to about 30% stenosis. No stent was felt optimal in this locatin in the groin and the heparin was not reversed. The flow in the bypass was much better and the pulse distally was palpable. The sheath was removed, pursestring tied. Wound was closed with 4-0 vicryl subcuticularly. Benzoin, Steri-Strips, and Opsite dressing were applied. "

Thank you again for your help.
 

When a vascular surgeon performs an angioplasty of a femoral vein graph and documents he made a 1 cm incision above the graph prior to utilizing seldinger technique, would the incision make this an open procedure? Does any incision make a procedure open even if the vessel is entered by seldinger technique?
 

Dr. Z. Do the imaging guidance rules of one per encounter apply to 75989?