Ask Dr. Z

1.  Bilateral pelvic lymphangiography performed, demonstrating multifocal extravasation of lipiodol from lymphatic ducts along the superolateral aspect of the right pelvic lymphocele, reflecting additional sites of lymphatic leak (separate from the

larger leak identified and embolized 2 weeks prior). No lymphatic leak identified on the left.

2.  Antegrade embolization of the right pelvic lymphatic leak (3:1 mixture of lipiodol: n-BCA).

3.  Abscessogram performed via the right pelvic lymphocele drain, demonstrating an approximately 10 mL opacity semilunar cavity, without communication to the bladder or any other structures.

4.  Sclerosis of the right pelvic lymphocele (Doxycycline with 1 hour dwell time). Drain left in place, connected to gravity bag. Please flush with 5 mL sterile saline twice daily and record output.

38790-50,75807,37241,20500,76080?

Can I bill for an empric ablation of slow pathway?

Ventricular pacing - VA conduction was present as baselinem midline, and decremetnal. Ventricular extrastimulus testing was performed with retograde AVNERP=500/300/290ms and VERP 500/240ms.

Atrial pacing - incremetnal atrial pacing show no pre-excitation. AV Wenchebach cycle length=410ms. With atrial extrastimuli dual AV notal physiology was persent, AVNERP=500/370ms. Patient started on Isuprel. With pacing Typical AVNRT could be induced but double echos were easily reproduced. Patient was not inducible for Atrial tachycardia or Atrial Fibrillation. Decision was made to perform empiric slow pathway modification.

Ablation: Slow pathway modification was performed by RF ablation.

Post Ablation: AH & HV intervals were unchanged. With isuprel and atrial pacing, AVNERP=500/350ms. AV nodal echos could not be induced.

Conclusion:

Dual AV nodal physiology was persent and double echos were noted. Patient likely has AVNRT.

Successful ablation for slow pathway for treatment of typical AVNRT.

Seeking clarification on your recommendations for saline fluid bolus challenge with repeat hemodynamics. Based on your reply on 7/6/23 to ID 19099, it appears you are now recommending billing the 93463 for a fluid challenge if there are pre-bolus hemo data, and post-bolus hemo data captured on the report. This goes against a previous recommendation on 10/6/16 for ID 8459 where you did not recommend billing 93463 (appears there was some debate/uncertainty if saline would qualify as a pharmacological agent per the code description). Clarification on your current recommendations is appreciated.

Would this be CPT 33216 or unlisted 33999? A 6 French sheath was placed in the right common femoral vein under ultrasound guidance. A 5 French BER II catheter was advanced under fluoroscopic guidance to the superior vena cava, and then to the stump of the occluded right internal jugular vein. The catheter was exchanged over a guidewire for an 8.5 French transseptal dilator. A BRK needle was then advanced to the level of the clavicle and oriented anteriorly. Inside-out puncture was performed using a sharpened 0.018 in guidewire. A peel-away sheath was placed. A Medtronic pacing lead was advanced to the RV apical septum and the fixation screw was extended. Sensing and pacing parameters were measured. The sheath was removed and the lead was anchored with silk suture. A pulse generator was connected and anchored. What is this was used for lead placement in a DC PPM insertion (33208)?

Confused about brachaxillary creation.

"Circumferential dissection of the brachial artery was performed. Vessel loops were placed in Potts fashion proximally and distally. second incision was created in the left axilla. Circumferential dissection of the axillary vein was performed. Using a Gore tunneling device, the graft was tunneled on the anterior aspect of the arm from the brachial artery to axillary vein, graft was tunneled subcutaneously. The axillary vein was occluded proximally and distally using profunda clamps. Longitudinal venotomy was created using #11 scalpel, extended using Potts scissors and end of graft side of vein anastomosis completed using 6-0 Prolene suture. Upon completion of anastomosis, vascular occlusion was taken down. Graft was occluded in the venous end using angled DeBakey clamp. The brachial artery was occluded proximally and distally using profunda clamps. Longitudinal arteriotomy was created using #11 scalpel and extended using Potts scissors. End of graft side of artery anastomosis completed using 6-0 Prolene suture."

Hoping you can clarify coding a super-selective catheterization of the left middle meningeal artery petro-squamosal branch.

Our surgeon performed an embolization of a left sided dural AV fistula. Patient had previous diagnostic angiogram a few days prior so I will be using the catheterization codes only. Would the following be coded as below?

Selective Cath LCC, Selective Cath LIC, Selective Cath LEC, Selective Cath Left Middle Meningeal Artery Petro-squamosal Branch

LCC not allowed

36216 LIC

Left External not allowed

36218 Left MMA Petro-squamosal

61624, 75894-26, and 75898-26 as completed (MUE 2)

When the external carotid is catheterized as non-diagnostic, I question how to bill additional sites on the way, and if additional 36218's would be allowed, or is it just the furthest point going forward and additional 36218 in the same vascular family only if you pull back the catheter?

Procedure performed was 0600T, but has been giving us issues with billing and the claims being denied since this is an experimental code. It was advised to use S9990 instead. The question would be for facility because health plan authorized the use of S9990 for PC.

According to many articles in order to bill 93970/93971 "both color flow and spectral Doppler are needed" to be performed. The report does not flat out state they were:

"A venous duplex exam was performed. This showed occlusion of the left great saphenous vein from the saphenofemoral junction to the distal thigh. At this point, the vein becomes very small and does not reflux. The saphenofemoral junction and common femoral vein are patent with no clot extension. No reflux is seen at the junction."

Does reflux count clinically to support color flow and spectral?

I am new to cardiology coding, and this one has me perplexed. I appreciate any direction.

"1. Severe native three-vessel disease involving the left main, LAD, intermedius ramus, LCx, and RCA.

2. Successful IVUS guided PCI of the intermedius ramus with Abbott Xience sky point 2.5 x 28 mm DES postdilated using a 2.75 NC balloon in T stenting fashion to LCx.

3. Successful IVUS guided PCI of the LCx into left main and LAD into left main using DK crush technique with placement of a Abbott Xience sky point 3.0 x 23 mm DES in the LCx followed by Abbott Xience sky point 3.0 mm x 28 DES in the mid LAD and Abbott Xience sky point 3.5 x 38 mm DES in overlapping fashion extending from the proximal LAD to ostial left main. The mid to proximal LAD stents were postdilated using a 3.5 mm NC balloon while the left main stents were postdilated using a 4.5 and 5.0 mm NC balloons. Lithotripsy was performed using a 3.0 mm shockwave balloon extending from the distal left main through the ostial, proximal, and mid LAD.

4. Right femoral artery access with Perclose closure."

Add-on code 0439T (myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability) may be used with codes 93306, 93307, 93308, 93350, and 93351. What documentation would be necessary in the report in order to capture 0439T?

Can you please offer guidance on this case?

The Pulmonary Veins were engaged with the Octaray and the pre-op CT scan along with ICE registered images were all used to merge with the Biosense mapping data obtained from the Octaray. The initial map demonstrated activity in all 4 veins as well as significant area of fractionation in the mid posterior wall.

Exit and Entry block were created and demonstrated in all of the major Pulmonary Veins (PVs) after the completion of the wide area circumferential ablation lesion sets.

At this point, after having isolated the veins are continued to be repetitive salvos of a left atrial tachycardia which mapped to a fractionated areas on the posterior wall and for this reason we isolated the posterior wall with a standard box lesion set. We then demonstrated block in the posterior wall and saw no more salvos of left atrial ectopy.

Would this be 93656 and 93657 or 93655 for the box set?

Thank you!

Would this be 27884 or 13160 or other recommendation? I’m thinking 27884. 

"After prepping and draping, the previous VAC dressing was removed and the wound was felt to be stable and healthy-appearing there is no purulence material or necrotic areas and no significant areas of focal bleeding. The deep soleus muscle was debrided to allow debulking of the muscular layer and the gastrocnemius was mobilized to allow my releases to the tibia. Two drill holes were placed in the anterior tibial crest and a FiberWire suture was then used to go through the tibial bone tunnels to capture the fascia and tendon of the gastrocnemius to pull it up anteriorly after extensive irrigation of the muscle bellies and wound. He my recess was able to be closed without significant tension. Once this was closed the fascial layers were then closed using a 2. Strata fix suture followed by 0 strata fix and subcutaneous layer and 2 0 nylon in the skin. A sterile Prevena VAC dressing was then placed across the closed wound."

Not sure of catheter placement codes and which embolization code to use for this report.

"Endovascular revascularization of the RT lower extremity requiring embolization of multiple vein branches of the right femoropopliteal vein graft to include a direct arteriovenous fistula. The Left common femoral artery was cannulation in retrograde fashion. The catheter was advanced into the proximal aorta for imaging. The catheter was advanced into the contralateral right common femoral artery for right selective angiography. The catheter was advanced into the fem-pop bypass graft for super selective imaging. Decision was made to embolize venous branches from the mid to lower fem-pop vein graft to optimize perfusion into the widely patent trifurcation vessels below the popliteal artery. A microcatheter was advanced into 4 vein branches from the mid to distal fem-pop vein graft and coil embolization was performed. One branch vessel from the vein graft directly communicates with the femoral artery representing a direct arteriovenous fistula."

What if a doctor performs an ultrasound guided biopsy of one breast lesion (CPT 19083) and via the same incision an adjacent breast cyst was aspirated via ultrasound guidance (CPT 19000 - guidance would not be charged as same guidance was used for the breast lesion biopsy)? May each be separately billed for? If it were incidental (not planned) to the primary procedure we would not bill separately; however, if it was planned, may we bill for both, as the lesion and the cyst are two separate and identifiable issues?

This appears to suggest that same group practice providers can bill under one provider. Is this accurate and would it apply to stress test 93016? Doc A orders/interprets-Doc B supervises. Can we bill 93015 under doc A? POS11

20.3.1 – A/B MAC (B) Payment Rules

(Rev. 1931, Issued: 03-12-10, Effective: 06-14-10, Implementation: 06-14-10)

If a diagnostic test (other than a clinical diagnostic laboratory test) is personally performed or is supervised by a physician, such physician may bill under the normal physician fee schedule rules. This includes situations in which the test is performed or supervised by another physician with whom the billing physician shares a practice (see Pub. 100-04, chapter 1, §30.2.9). Section 80, chapter 15, of Pub. 100-02, Medicare Benefit Policy, sets forth the various levels of physician supervision required for diagnostic tests. The supervision requirement for physician billing is not met when the test is administered by supplier personnel regardless of whether the test is performed at the physician's office or at another location.

Hope you can help since we cant figure out what codes to use. Patient has abdominal aneurysm and iliac aneurysms. Vascular surgeon performed aorto-bi-femoral Dacron graft, bilateral common femoral and profunda endareterectomies and 6 mm Goretex common femoral to profunda jump graft and ligation of bilateral iliac arteries.

Should we go with 35102 for the Dacron graft? I am assuming that endarterectomies are not reported. Qhat about the jump graft? What code can we use and ligation of bilateral iliac arteries? Thanks!

I have an unusual case and need your help. Patient presented with NSTEMI in the middle of the night. He was responsive to nitro, and it was decided to defer consult until the morning. Throughout the night the pain waxed and waned, and he was responsive to increased nitro each time. When the cardiologist consulted in the morning, the patient stated he was having difficulty breathing.

"Impression: NSTEMI: Patient is having post-infarction angina and is developing heart failure. Emergent heart catherization recommended."

Stent was placed in the circumflex with resolution of symptoms. I'm having difficulty deciding whether to bill 92941 vs. 92928. It is documented the patient had an acute MI of the circumflex; however, with the initial deferral and the mention of POST- infarction angina, does the emergent status still allow for the stent to be reported using 92941?

Patient presents for RHC (93451-26) & EMB (93505-26) s/p heart transplant w/possible re-intervention on pulmonary veins. Both right/left PA wedge angiography performed to eval pulmonary venous return on levophase. Hand injection done with catheters placed in left lower branch of LPA, main LPA to evaluate the LLPV, RLPV, RMPV, Left lingular pulmonary vein. Findings: right sided pressures were reasonable, PA wedge angiography showed mild-moderate stenosis in left lower and right lower pulmonary veins on levophase with PCWP being 16-17 mmHg. Stenosis appeared to be stable compared to post-angioplasty angiography at the last cath. Therefore, we decided to leave those alone.

I don't feel that billing 93568/93569 is appropriate since not looking at the pulmonary arteries. Can we bill for selective placement 36014 for placement in LPA and 75746 for the S&I to look at the veins? Thank you.

A patient had a CTA. The finding showed subarachnoid hemorrhage. Patient brought to IR where the provider performed a diagnostic angiography prior to embolization. Provider indicates gold standard for a subarachnoid hemorrhage is not a CTA or MRA but rather an angiography. The angiogram is needed to confirm diagnosis and to confirm the suitable nature of the disease for treatment. He agreed in cases where they are just intervening that the diagnostic angiogram cannot be coded. However, a CTA or MRA is not adequate to diagnose the source of the subarachnoid hemorrhage and the catheter angiogram is needed.

Do you agree, in cases of hemorrhage, we can code for a diagnostic angiogram even though a CTA or MRA was performed? What about this same scenario for a non-ruptured aneurysm?

I have abbreviated the report to submit... Right heart catheterization was performed. Left heart catheterization was performed. Conduit angiography was performed. A super-stiff wire was navigated into the innominate vein. The 8-French venous sheath was exchanged for a 14-French x 65 cm Gore Dry Seal Flex sheath. A 5-French MultiTrack catheter was advanced into the conduit. Using the Medrad Power Injector, angiography was performed. Again, the conduit was seen to be diffusely small with a focal narrowing in the middle (possibly at the site of a previous fenestration). I proceeded to conduit stenting. The following stents were placed in the conduit: P4010 x 2 P5010 x 2 These stents were post-dilated with 18, 20, 22, and eventually a 24 mm high-pressure balloon up to rated burst pressure. The conduit appeared significantly larger. Final angiography showed patent stents with no extravasation. Report states this as an Extra-cardiac Fontan with 18 mm Gore-Tex conduit performed 20+ years ago. Recommended codes? 33745? 37236 and RHC/LHC?

I am billing unlisted code 37799 for vena cava resection and reconstruction. What code(s) do you recommend comparing this to in order to send description to carrier and to help calculate the fee?

"We began to resect the medial aspect of the IVC using a combination of Potts and Metzenbaum scissors. The tumor did extend cephalad and encroached upon the Rummel tourniquet and thus we replaced the cephalad Rummel tourniquet with a Satinsky clamp. We completed the caval resection with the assistance of our urologic colleagues, and when we are both in agreement that all gross tumor was resected we evaluated our options regarding primary caval closure versus patch venoplasty. Given the amount of medial caval wall that was resected, we elected to pursue patch venoplasty with a bovine pericardial patch. We performed a patch venoplasty in a running fashion using 4-0 Prolene."

Can you please clarify if in the femoral/popliteal territory a primary mechanical thrombectomy 37184 (diagnosis of thrombus was established prior to intervention) and an atherectomy with stent 37227 (different device used to perform) are performed if BOTH procedures can be coded (37227, 37184). There are no CCI edits with this code combination.

Our understanding is both procedures would not be coded if both are performed with the same device, but believe if separate devices are used and the mechanical thrombectomy was a “primary” thrombectomy these can both be coded. We are interpreting the NCCI Policy Manual Chapter 5 guidance to state that a SECONDARY mechanical thrombectomy (37186) CANNOT be coded with an atherectomy procedure in the same vessel, but wanted clarification as to whether this also applies to a PRIMARY mechanical thrombectomy? There is an NCCI edit with 37186 and the lower extremity atherectomy codes, but not with 37184.

Is a coiling embolization for middle meningeal artery intracranial or extracranial?

Can you recommend any helpful illustrations that tell you which arteries are intracranial and extracranial?

I need your expertise on this case where the provider did IVUS with automatic pullback from LAD to LM. Per operative report "Then the Opticross IVUS catheter was advanced over the wire and IVUS was performed with 66.0 mm automatic pullback at 1 mm/sec from mid LAD to distal LM.

Left main: very large and short segment, no significant CAV observed.

Proximal LAD: Eccentric I.T> 0.81 mm located proximal to D1 branch (MLA 12.07 mm2, lumen 3.58 x 4.28mm, EEL 4.66 x 5.15.mm).

Proximal mid LAD: Focal spot of plaque-like I.T> 1.10 mm located between D1 and D2 branches (MLA 6.97 mm2, lumen 2.75 x 3.31mm, EEL 3.36 x 4.27mm.).

Mid LAD: Eccentric I.T> 0.45 mm located distal to D2 branch (MLA 7.67 mm2, lumen 2.73 x 3.59 mm, EEL 3.29 x 4.04mm).

Do we code for 92978, 92979 in this case since there is a measurement indicated in the both LAD and LM? Or just code only 92978 since this is an automatic pullback?

I code OP accounts for hospital cath labs, and we have a couple of doctors who want to use acute CVA code I63.9 as the only indication for placement an implantable loop recorder, like LINQ 33285. I keep saying that this primary DX is not acceptable because the acute CVA occurred several weeks prior to the OP LINQ placement visit, and in most cases the patient has fully recovered. I find no other DX in the patient record that can be used, such as those suggested in your cardiology desk reference (syncope, arrhythmia, anti-arrhythmic drug monitoring, dizziness). But, when I use Z86.73 history of CVA as a primary diagnosis, I get an error from the encoder saying, "The current primary DX is listed by CMS as and unacceptable primary diagnosis." I believe the doctors want to use the LINQ to look for a latent arrhythmia, but these patients have no documented evidence of any arrhythmia or history of syncope. What can I use as an acceptable primary diagnosis?

How would you code repositioning of a GJ tube? I saw your answer to a previous question where you recommended 49465 because the catheter was only pulled back slightly and "nothing like trying to advance a catheter from the stomach into the jejunum". In my case, they had to advance the catheter into the distal duodenum.

"The retention balloon on the existing catheter was deflated, with a total of 2.5 mL of water removed from the balloon. The existing GJ tube was then advanced through the stoma and the retention balloon was injected with 4 mL of water without resistance. 10 mL of contrast was then injected through the gastrostomy port and lateral fluoroscopic image was obtained, which showed retention balloon within the stomach and no leakage of contrast outside of the stomach. 5 mL of contrast was then injected through the jejunostomy port to confirm appropriate catheter position. Both the jejunostomy and gastrostomy ports were then flushed with water. The patient tolerated the procedure well and there were no immediate complications."

Our physician placed a right ventricle leadless pacemaker and an CRT-P device with left ventricle lead only. How would the CRT-P device be coded if the only lead is the LV?

Indication: Polyclonal gammopathy, thrombocytopenia, and macrocytosis. Clinical concern for bone marrow disorder.

During fluoroscopic and cone beam CT guidance, right posterior iliac crest bone marrow aspiration and core biopsy was performed. "Cone beam CT was performed throughout this procedure and 3D advanced post-processing was performed using an independent workstation with active physician participation and supervision."

Is 76377 separately billable during CT-guided biopsy?

What is the appropriate code for lateral epicondyle injection? Diagnosis documented lateral epicondylitis, tennis elbow. Can we code 20550/20551 or 20605/20606?

"Patient has failed AVG in the forearm and presents for new AVF. The cephalic vein was identified, which had been part of the previous graft. The graft was dissected, and the segment connected to the cephalic vein was excised. The lateral branch of the cephalic vein through which the graft was connected was remodeled and oversewn with stitches. Brachial artery and cephalic vein were used to create the new AVF. Only the cephalic end of the AVG was removed."

Would this be considered a revision or removal with modifier -52 and new AVF code? (Brachial artery not used in the original AVG)

If the procedure being done is a left to right fem-fem bypass graft, would we use the RT modifier?

Summary

1. The left ventricular systolic function is normal, LVEF is visually estimated at 60-65%.

2. The left atrium is dilated in size.

3. The right ventricle is normal in size, with normal systolic function.

4. There is a small, circumferential pericardial effusion.

5. The pericardial effusion is smaller compared to study of 7/31/23.

IVC/SVC

IVC Diameter (Insp 2D) 0.5 cm

IVC Diameter (Exp 2D) 1.3 cm <=2.1

IVC Diameter Percent Change

(2D) 57 % >=50

LV Dimensions 2D/MM

LVID Diastole (2D) 4.4 cm 3.8-5.2

LVID Systole (2D) 2.7 cm 2.2-3.5

Pericardium 2D/MM

Pericardial Effusion

Diastole (2D) 0.5 cm

Assessment states "calcification of coronary artery". Does this support I25.10 with I25.84 as secondary?

Patient with grade 2-3 aortic injury at the level of the left subclavian, consistent with dissection.

PROCEDURE: Thoracic endovascular aortic repair with thoracic branch

endoprosthesis 37 x 15 Gore Tag with left subclavian branch of 12 x 6 via bilateral common femoral artery and left brachial accesses.

Would this be billed using unlisted CPT code?

How to code RFA of LV basal antero-septal segment for purpose of reducing myocardial thickness using saline vs. alcohol. AV nodal ablation was also performed same setting. What would be the best code to use 93583 vs. unlisted? If unlisted, would the comparable code be 93583, 93653, 93654?

"RADIOFREQUENCY ABLATION OF THE BASAL ANTERO-SEPTAL SEGMENT OF THE LV. Radiofrequency ablation was performed guided by intracardiac echo and fluoro. Extensive ablation was carried out utilizing a power of 40 Watts, with contact force of 10-30 grams, half normal saline as an irrigant, and each lesion 60-90 seconds application. Steam pops were frequently noted, as expected.  Half normal saline was used to create larger and deeper myocardial scar. Procedure was long and complicated (5 hrs), but the patient tolerated it well."

What should be documented to support the use of 93615, 93616? What does the numbers for the recording of atrial electrograms should look like on the documentation. Can you provide an example?

Patient with aneurysmal dialysis access:

After evaluating, I decided to repair with a stent graft, and I deployed a 9 x 60 mm Covera stent graft.

Following the stent graft deployment, it was dilated with a 9 mm balloon, and the pseudoaneurysm had no further pulsations after deployment of the stent graft. At this point, I decided to repair the aneurysm sac, and I performed a transverse incision over the aneurysmatic sac, dissected the sac from the subcutaneous tissues and excised the excess of sac. Then I closed with interrupted 4-0 PDS suture. Skin was approximated with interrupted 3-0 Prolene suture and skin staples.

Would you code with 36903, or 36832?

Physician evacuated a hemothorax following a stab wound using VATS. He placed a Tachosil hemostatic topical coverage on to the parietal plural exit site from the track of the knife. There was 1200ML of liquified hematoma evacuated. There was slight dark oozing from the site but no active red bleeding. I think this should be coded as 32653. But I was not sure if the placement of the patch should be coded separately. Is there a separate code for that or would it be included with the 32653?

"Patient with hepatocellular carcinoma in for Y90 mapping. Microcatheter was advanced into right hepatic artery, arteriogram performed demonstrated a hyperenhancing mass in the inferior right hepatic lobe. A Dyna CT was then performed demonstrating a small branch of the right hepatic artery supplying the mass in addition to a major branch of the right hepatic artery supplying the majority of the mass. Microcatheter was used to select the small right hepatic artery branch and particle embolization using 100 to 300 um Embospheres was performed to near stasis. Post embolization arteriography demonstrated markedly decreased flow into the target. At this point, the microcatheter was retracted and a total of 2 mL of MAA were slowly injected into the right hepatic artery."

Is 37242 appropriate for the embolization since this was prior to Y90, or is 37243 more appropriate since he states this was a feeding vessel? I'm confused if this is to be interpreted as prophylactic embolization.

Provider orders a CTA of the cardiac structure to evaluate the pulmonary vein anatomy/LAA for a planned ablation. When the CTA is read, the reading physician documents findings of the coronary arteries. Would you code this as 75572 based off of the indication for the exam and the order, or would you code as 75574 since it includes coronary angiography?

"Redo coronary artery bypass grafting times 3 with reverse autologous saphenous vein graft to the LAD, reverse autologous saphenous vein graft from the aorta to obtuse marginal coronary artery, reverse autologous saphenous vein graft from the aorta to LC.

There were extensive adhesions between all surfaces. Extensive lysis of adhesions was required. A saphenous vein graft was harvested using an endoscopic vein harvest. Patient heparinize. pericardial sac retracted. The patient cannulated, and cardiopulmonary bypass was begun. The aorta crossclamped and pt. received cardioplegia and systemic cooling.

Distal anastomoses were done with 7-0 Prolene in a running technique, Proximal anastomoses were done with 5-0 Prolene. The aortic cross-clamp was removed and the patient underwent complete de-airing of all grafts. The patient was weaned from cardiopulmonary bypass."

Would you use 33512 only? If not what CPT code(s) would you use for this re-do procedure?

Upgrade of left-sided dual chamber PPM to dual chamber biventricular ICD, US-guided vascular access, left upper extremity and coronary sinus venography, implantation of LV lead, pocket revision. Mixed cardiomyopathy EF 30-35%, NYHA class III heart failure, AVN ablation with DC PPM in-situ. Per the op report- the RA lead was re-used. The old RV was capped and a new RV lead placed in addition to the LV. 

Would this be coded as 33233, 33249, and 33225? Or 33231 and 33233?

During EP studies, our provider documents "Hemostatic introducer sheaths were placed percutaneously in the left and right femoral veins using the modified Seldinger technique. Multipolar recording electrodes were advanced from the femoral veins to the right heart and into the coronary sinus for comprehensive study. Once the comprehensive study was done, atrial flutter and atrial fibrillation were induced with low-risk findings." Should pacing and recording in the RA, RV, and bundle of His be specified or is "right heart" sufficient documentation to support billing 93620 and 93621? Placement in RA, RV, and bundle of His are documented in the cath lab event log but this information is entered and signed by nursing staff.

Patient presents for planned embolization of splenic arteries. Goal is to treat splenomegaly, as it is causing thrombocytopenia, which is complicating treatment for metastatic rectal cancer. Facility wants to charge celiac and splenic angios, as there is no documentation of previous catheter-based angio or CT. However, the decision to embolize a specific organ for a known pathology was made prior to the procedure, so my thinking is that any angiography performed during the embolization is necessary to perform the procedure and thus should not be considered as diagnostic. Any guidance provided is very much appreciated.

It is my understanding that for the physician side I use CPT code series 37220-37235 when Shockwave/intravascular lithotripsy is done in the lower extremities. How would I code for Shockwave/intravascular lithotripsy done in the perirenal aorta? Would I use 37246? Or an unlisted code? Could I still use IVUS 37252 with the perirenal aorta procedure?

Please explain when you would use 35876 over 35656. I have a provider that tunneled in a new graft PTFE into the old graft and did partial thrombectomy of distal old graft to make sure there is outflow. He did remove part of the old thrombosed PTFE graft also. Would this be 35656 since whole new PTFE tunneled graft inserted?

Patient with nephroureteral stent and clamped nephrostomy tube came and had conversion from nephroureteral stent to nephrostomy tube. How should this be coded? what is the difference between nephroureteral stent and nephroureteral catheter?

Study description: Patient was prepped and draped in the usual sterile fashion. Versed and fentanyl used for conscious sedation. Access was obtained to right popliteal vein using ultrasound guidance with micropuncture needle and a 8 French sheath was placed using modified Seldinger technique. 0.35 support catheter was advanced into the right common femoral vein perform selective venography and subsequently Glidewire was a advanced into the subclavian which was exchanged for Supra core wire. Following this with dilated popliteal venous access site for 13 French clot retriever. Two passes were made with retrieval of significant thrombus predominantly in the mid to distal and popliteal vein. Completion angiography showed no significant residual clot. Figure of eight suture was placed for achieving hemostasis no immediate periprocedural complications.

Would it ever be appropriate for a PICC line placement done by an RN in an outpatient clinic setting to be reported with CPT 36573 rather than CPT 36569 if the RN uses ultrasound? In order to consider the procedure to have been performed with US guidance, does there need to be a report of the US guidance documented by a radiologist? Would a copy of an image of the US guidance added to the medical record support the documentation required for CPT 36573? Would a narrative note by the RN of the use of US guidance be sufficient? The current documentation is done electronically, and the only indication of the use of the ultrasound device is one line that shows as “Ultrasound guidance used = Y.”

The facility PICC team is trying to determine if the outpatient PICC line placement procedures would qualify for reporting of CPT 36573 instead of CPT 36569, and if so, what specific documentation must be in the medical record for the coder to be able to assign the correct CPT code.

Please assist with suggestion for CPT code(s) :

ACCESS ANEURYSM RESECTION

Pre/Post-Operative Dx: Infected thrombosed aneurysmal AVF- Complete resection all infected tissue

Indications for surgery:

Longstanding right AVF, aneurysmal. Now thrombosed with infected open wound. Catheter in place.

Procedure:

The procedure had been discussed with patient (and family when present) all questions answered. The patientconsented to the procedure including intraoperative decision-making and alteration of plan as needed. After site marking thepatient was brought to the OR and sedation and block were administered by the anesthesia team. The right arm was preppedand draped per routine and a time out verified correct patient procedure and side.

We fashioned two incisions to resect all compromised skin and infection. The aneurysm was entered and subtotally resected,removing all abnormal tissue.

The wound was irrigated and closed using 2-0 Nylon mattress sutures and the arm wrapped. Sponge needle and instrument counts were correct.