Ask Dr. Z

How many times can I report 37204 when treating coiling of collaterals(thyrocervical, two separate small branches, the right internal mammary and left internal mammary). Patient is 3yrs of age status-post Norwood with Sano procedure in the newborn period. In June of the same year had bidirectional Glenn with pulmonary arterioplasty. He returns today for pre-Glenn hemodynamics and likely coiling of collaterals. A diagnostic right/left retrograde heart cath with pulmonary angiography was done prior to coiling. Thank you.

Dr.Z, Patient came for declot of the stent placement from the distal right subclavian vein to the proximal SVC for dialysis. Fistulogram peformed and there is no stenosis other than the previously placed stent which is occluded. The stent was recanalized using a guidewire combination which was then advanced through the right into the IVC. The occluded stent was then sequentially dilated up to 12 mm. There was dissolution of the thrombus from the distal aspect of the stent but there was residual thrombus in the proximal stent. After failed angioplasty of these residual thrombuses the decision was made to insert a new 12x16 mm stent. My question is since there is no stenosis but only thrombus can we code PTA? Please explain. Thanks

Dear Dr. Z, we've got a case that's challenging my understanding of the new dialysis graft/fistula codes. Your comments & advice would be welcome. CLINICAL DATA: PT W/HX OF RT.FOREARM LOOP GRAFT AND RT. UPPER ARM AV GRAFT, REFERRED FOR EMBOLIZATION OF RT.FOREARM LOOP GRAFT AS WELL AS DIAGNOSTIC FISTULOGRAPHY OF RT.UPPER ARM AV GRAFT. Procedures performed: 1. Retrograde access of rt.forearm loop graft. 2. Diagnostic fistulogram. 3. Selection of axillary artery & performance of a rt. upper extremity arteriogram for eval. of brachial artery. 4. Amplatz embolization of arterial limb of rt. forearm loop graft. 5. Antegrade access of right upper arm AV graft. 6. Diagnostic fistulogram of rt. upper arm AV graft 7. PTA of venous anastomosis with an 8mm balloon. 8. Removal of sheath & catheters and hemostasis obtained w/manual compression. (Note:I have not typed out the body of the report because physician did such a good job in this procedure heading list, but if you need, will be glad to provide) I've arrived at these CPT codes: 37204 + 75894; 36147, 75658-59 for study/work on forearm graft. 36147(?-59) and 35476 + 75978 for study/work on upper arm graft. My question: 36147 did not edit out in our Encoder when coded x2; do you think it will be correct to submit x2 since pt has 2 different grafts in one arm? Also do you agree with 75658-59 for studying brachial artery? Did not code 36120 since brachial artery not directly punctured; axillary artery selected after retrograde access in rt forearm loop graft. Any suggestions you have would be appreciated. THANKS SO MUCH FOR YOUR HELP! :D

Dr. Z, Could you please tell me how you would code this; CT guided aspirations of 7 renal cysts followed by sclerosis with 95% alcohol. I currently have this coded 50390x7, 77012, and 96379 for the sclerosis. Can I code for each cyst and would you code the sclerosis? THANKS

I have a couple cases where the dr is placing a filter in the IVC through femoral access but the filter doesnt deploy correctly so they have to place another filter above the first through the jugular vein. How would this be coded? Would you use 37620 twice? Would you add a 52 modifer on one of them if you do use it twice? Would you show both accesses 36010 twice, with or without a modifer? thanks for the help.

Dr Z, First, let me start by apologizing for having so many questions. Who would think I was a certified coder. Recently we had an inservice on nephrostomy coding. With catheter placements 74475 would always be used as CPT states "introduction of catheter for drainage". Question is when would anyone use the parenthical codes with 50392 besides the (74475, 76942 or 77012) Judy

Patients presents for R/L Heart cath and a "Constriction Study" is documented in the report findings. It is measuring: Kussmaul, RVSP, RVEDP, LVEDP and LVRFW. Is there a CPT code to report for this study or is it inclusive to the diagnostic catheterization. Thank you.

Good afternoon, Dr. Z and Dr. Dunn. I just wanted a little clarification on the usage of 37250, 37251, 75945, and 75946. How do you know when to use 37250 and 37251 vs. 75945 and 75946, or do you always use them together? Also, what type of documentation should I look for to justify the use of either set or both sets of codes? Please, let me know. Thanks, in advance.

Dr Z, My patient has a non healing ulcer of his foot and our doctor is doing abdominal and extremity angiography. Along with the angiography he is also doing "renal sparing" catheter placements in both renal atreries for targeted renal therapy. This infusion was performed for 2 hours and 26 minutes. Can I code for this "renal sparing" and if so would be an unlisted procedure 53899? Appreciate your help.

Thank you for the time you undoubtedly spent reading through and analyzing this report. I see we were pretty close on the coding, except for the use of the additional 75710,26 and the use of 75774,26, RT. We did have 36246,RT coded, I just neglected to include it when I submitted the initial question. The reason I used the additional 75710,26 was because the initial one was retrograde and the one performed near the end of the session was antegrade, although from the same location. The reason I used 75774,26,RT was, because, after the initial bilateral lower extremity angiograms from the aortoiliac bifurcation (75716,26), another angiogram was performed after the catheter was advanced to the external iliac artery, and prior to what I thought were the supervision and interpretation related studies, for further, more detailed, diagnostic study of the leg. Could you, please, explain to me why you chose not to code those? I also noticed that you considered all of the additional views and projections a part of the other radiological procedure codes, which is the direction I was leaning in, and chose not to include ultrasonographic codes, which is what I was really stuck on. Could you walk me through your decision making process, as it pertains to those codes? My thinking is that the duplex wouldn't be coded, because the doctor just mentioned reference to it, as opposed to actually performing it. Even if she did perform it, it wasn't clear in the op report. On the other hand, although it's not flagged by NCCI edits, would you consider a duplex inclusive to the other procedures, even if it was clearly stated that it was performed intraoperatively? If you would code it separately, would you code it as a duplex (93925/93926) or as intraoperative ultrasound (76998/76937)? I imagine intravascular ultrasound (37250/37251) would only be used if ultrasonography was performed through an intravascular catheter, but I'm not sure. As you can see, I appreciate the guidance you've already provided, but I still have a lot of questions about these kinds of cases. I have a hard time differentiating between the different codes and when it's appropriate to use (or not use) each code. I want to fully understand the reasoning and logic behind your decisions so I can apply them to future cases. Thanks, again.
 

Good afternoon, Dr. Z. I'm having a warm time with this op report. The surgeon makes mention of a duplex, several different angiograms, and several different views and projections. I'm not sure if I should bill an ultrasound service for the duplex, any additional radiological services for the views and projections, or how many angiograms I should bill for. On top of that, she mentions angioplasties and stents in the heading, but according to the narrative of the body, I feel as if the coding of the stents is all that's appropriate. Please, help. Thanks, in advance. So far, I've coded 37205,RT, 37206,LT, 75960,26,RT, 75960,26,LT, 75716,26, 75625,26, 75710,26,59,LT, and 75774,26,RT. The dxs are 440.22 (I upgraded from 440.21 because of the surgeon's mention of possible rest pain in the body of the report), 996.74 (I'm not sure if 996.1 fits better to describe the fact that the distal anastomosis of the previous fem-pop bypass can't be demonstrated, due to the knee replacement), 709.2, and v43.65. Here's the op report: DATE OF OPERATION: 03/25/2010 ANESTHESIA: Conscious sedation and local anesthesia. PREOPERATIVE DIAGNOSIS: Atherosclerosis with claudication right le POSTOPERATIVE DIAGNOSIS: Atherosclerosis with claudication PROCEDURES: Via Left common femoral artery approach: 1. Aortogram. 2. Aortoiliofemoral angiogram. 3. Selective right lower extremity angiogram. 4. Nonselective left lower extremity angiogram via the left common femoral artery sheath. INTERVENTIONS: 1. Angioplasty, of severe greater than 90% focal stenosis at the junction of the distal left common iliac and external iliac artery, angioplasty with 8 mm x 40 mm angioplasty balloon. 2. Angioplasty/stent placement of proximal right external iliac artery, severe greater than 90% focal stenosis with 8 mm x 36 mm Valeo balloon expandable stent. 3. Placement in the distal left common/proximal left external iliac artery, a 10 mm x 40 mm nitinol self-expanding stent and finally completion lower extremity angiograms. PROCEDURE: The patient was identified and brought to the catheterization suite. She was placed on supine position on the table. Bilateral groins were prepped and draped in the usual surgical sterile fashion. The left common femoral artery was accessed with the micropuncture needle. There was evidence of some dense scar tissue at the site of the previous groin incision. Micropuncture sheath was placed followed by a short 5-French sheath over the introducer wire. There was some resistance of the wire at the level of the left common iliac, so this was not traversed further. Retrograde angio was performed thru the sheath demonstrated severe focal iliac stenosis. Once the 5-French sheath was in place, we were able to negotiate through a left common iliac stenosis with a glidewire in conjunction with a Glidecath. Omniflush catheter was then placed at L1. Aortograms were performed. The Omniflush catheter was pulled down to distal aorta and the aortoiliofemoral angiograms were performed. This demonstrated a severe greater than 90% stenosisl, focal, at the junction of the distal common iliac/ left external iliac artery. This was pre-dilated with an 8 mm x 40 mm angioplasty balloon. Oblique projections were performed. This was done as attention was to be directed first to completing angiograms of the symptomatic right leg with possible intervention. There was evidence of known bypass graft coming off the mid-external iliac artery. Below the level of the bypass, there was severe disease of the distal left external iliac artery and severe disease of the common femoral artery with sheath nearly occlusive. The aorta was patent without significant disease. In the right iliac system, the proximal common iliac artery was patent as was the external iliac artery. There was question of stenosis also at the level about at the right distal common and external iliac artery with the internal iliac artery at that site, oblique projections needed to be done for further evaluation. There was moderately severe disease at the distal external with severe stenosis right crossing the inguinal ligament and moderate disease of the proximal right common femoral artery. Oblique projections of the right iliac system demonstrated a severe stenosis, focal greater than 90% of the proximal external iliac artery. This was able to be traversed with an 0.018 Whisper wire in conjunction with a Glidecath, which was positioned on the distal right external iliac artery. Right lower extremity angiograms were performed. The profunda femoris was open and the proximal superficial femoral artery was open and then occluded in its proximal portion. Via collaterals, the popliteal artery reconstituted at the level of tibial plateau. The patient had bilateral knee replacement, and so there was difficulty in completely demonstrating the popliteal artery. The popliteal arteries were evaluated with 2 views with maximal obliquity, demonstrating the majority of the vessel. This was correlated with duplex therefore and the flow was brisk to the popliteal artery and visualized the portions were without irregularity with good diameter to the below-knee popliteal artery. There was severe tibial vessel disease in the right leg. Tibioperoneal trunk was patent. The posterior tibial and peroneal arteries were occluded at approximately 5 cm and 10 cm. The anterior tibial artery was patent with mild-to-moderate disease in its proximal portion. The popliteal artery via collaterals was recanalized at the level of the mid tibial plateau of the femur. There was good luminal caliber to the popliteal artery where it reconstituted to the infrapopliteal segment and the flow was brisk, but a small portion of the midportion was not able to be demonstrated. This is correlated with the duplex which does not suggest any mid-popliteal stenosis. There was mild-mod irregularity of the terminal popliteal artery. Tibioperoneal trunk is patent. There is severe tibial vessel disease. The peroneal artery and posterior tibial arteries were then occluded after the first proximal 5-cm. The anterior tibial artery is patent with mild-to-moderate disease origin and then demonstrates mild disease and is patent where it becomes more diminutive as the dorsalis pedis artery onto the foot with very diminutive and incomplete plantar arch. The plan for the right leg done in this patient with claudication symptoms and question of developing some rest pain was some discomfort now in her toes which is new, is to treat the greater than 90% right external iliac artery stenosis and then based on re-evaluation of her sx to perform right common femoral artery endarterectomy with endarterectomy/angioplasty of the distal external iliac and possible right common femoral artery to ATA artery bypass with better views of the popliteal artery in the OR. The 0.018 Whisper wire was tracked back through the Glidecath and positioned on the distal right external iliac artery. The Glidecath was pulled back to the proximal right common iliac artery. A copilot was attached to the Glidecath and a hand injection was performed and the proximal right external iliac artery stenosis was located. Stiff glidewire was placed in the CFA. Right severe EIA stenosis was then treated with an 8 mm x 40 mm balloon expandable Valeo stent. Completion angiograms demonstrated very good results. Following this, the guidewire was tracked back into the aorta and this was exchanged for a SupraCore wire. A SuperCore wire was then placed in the aorta via the left iliac system. Angiogram was performed and the left iliaclesion was marked. The severe stenosis of the distal left common iliac, junction of the external iliac artery was then treated with a 10 mm x 4 mm nitinol self-expanding stent. Completion angiogram demonstrated excellent result. after the stent was postdilated with a 10 mm x 40 mm balloon. Following this, the Omniflush catheter was tracked over the wire and the completion angiograms were done through the Omniflush catheter in the distal aorta, both iliacs with excellent results and 0-10% residual stenosis of the proximal right external iliac and the left distal common/proximal left external iliac artery lesion. Following this, guidewire was tracked back to the Omniflush catheter and both were removed via the left common femoral artery sheath. I should mention that 5000 units of intravenous heparin was given under my direction and an additional dose was given and ACT monitored throughout the procedure. Now via the left common femoral sheath, left lower extremity angiograms were performed. This demonstrated the distal common femoral artery to be either occluded or the sheath occluding the artery so that the common femoral and profunda were not demonstrated. The bypass graft was demonstrated and was patent. There was one area of some mild narrowing, which did not appear significant in the proximal third of the thigh, which may be from some mild compression of the muscle. This appeared to be less than 30%. The bypass graft was patent and was anastomosed to the popliteal artery. The distal anastomosis of the fem-pop bypass graft is not demonstrated with the knee prosthesis despite the maximal oblique projection. Runoff is via the anterior tibial with moderately severe disease approximately 5-cm in the proximal anterior tib and then severe greater than 99%, functional occlusion of the anterior tibial in its mid section. The distal anterior tibial artery was of better caliber and patent onto the foot and the dorsalis pedis artery is extremely diminutive on the foot. The patient tolerated the procedure. At the completion of the procedure, she was taken to the recovery room in stable condition and the sheath is to be pulled when the ACT is less than 180.

Dr. Z, We have a question pertaining to charging of supplies. During an EP case a lead was implanted, and due patient's anatomy did not fit well and the lead was explanted. Can we charge for the lead? We were always told that if the went into the patient's body, we are supposed to charge, but since we extracted the lead, I am not sure. Thanks for sharing your knowledge.

Our radiologist did a CT guided biopsy/aspiration of a mass posterior and medial to the right acetabulum (soft tissue of the acetabulum). Could you please tell me how you would code this.
 

HELP!!! Dr. Z - I am looking for a code for open removal of a left groin introducer. This patient was in the CATH Lab and attempts were made to open a long segment occlusion of SFA that was unsuccessful. The patient was then taken to the OR for open removal of the introducer because of the occlusive nature of the device in his left groin. Thank you for your help!!!

Hi Dr Z, Could you please clarify the use of the 59 modifier with moderate sedation codes 99144 and 99145. We have a case where the pt had a stent 37205 and 2 PTA's done 35474 and 35470. The 35474 and 35470 CPT codes have the bullet beside them talking about moderate sedation being integral to the procedure. The 37205 code does not. If two of these have a bullet and the one code doesn't do we still pick up the moderate sedation charges and add the 59 modifier? We ran everything through code correct and the edits are coming up for the 35474 and 35470 but not the 37205. We're not sure if we should append the 59 modifier since there was a procudre done without the bullet or if you have one with a bullet it overrides all other codes. Thanks for your help in clarifying this, Lisa C.

Hello Dr. Z, I'm having trouble coming up with a catheter placement code for this AAA repair, can you please give me your thoughts on this procedure? Appreciate your help. Judy, CPC 1. AAA Repair Due to the patient's underlying medical condition, informed consent was obtained from the patient's daughter. The patient was placed supine on the CT scanner and axial images were obtained to localize an access to the abdominal aortic aneurysm sac. It was elected to access the aneurysm sac from an anterior approach just to the right of midline, ultimately to access the flow lumen of the endoleak which was just ventral to the iliac limb portion of the Excluder endograft. CT-GUIDED ANTERIOR ACCESS TO THE ABDOMINAL AORTIC ANEURYSM SAC

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.