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AVF with interposition graft

I've seen quite a few cases where a basilic vein transposition or cephalic vein transposition AVF requires an interposition graft due to vein not being quite long enough. I tend to just report the main code 36818 or 36819 and not code for the interposition graft, but is that the right thing to do?

Reporting 34716 with 33363 (TAVR)

Can code 34716 be reported when performing a TAVR? STS guidance states graft conduit creation is included in TAVR codes, but our surgeons do not agree. No definitive coding guidance exists.

Per the surgeon: "Our primary approach is to surgically place a conduit onto the axillary artery. This is not covered by code 33363. That is covered by code 34716. Not used for just bypass but also for delivery of endovascular prostheses (a.k.a., a TAVR valve)."

OP report example: "Side biter was placed, followed by arteriotomy and placement of an 8 mm graft in an end-to-side fashion. Graft was flushed with heparin and distal clamp placed. This allowed placement of a 6 French sheath into the graft. An AL1 diagnostic catheter and straight TSF guidewire were then used to advance across the stenotic aortic valve and placed into the LV. The LV catheter was then placed. This allowed passage of the 14 French delivery sheath under fluoroscopy into the arch. No BAV was performed due to pre-existing AI. The Edwards S3 23mm TAVR delivery system was advanced over the wire and across the aortic valve."

robotic tri-segmentectomy of the left upper lobe

Would I use code 32669 whether robotic trisegmentectomy of the left upper lobe was one or three segments?

Intention of procedure was stenosis, after PTA there was dissection

Patient had stenosis in common femoral artery. MD performed angioplasty, and follow-up angiogram demonstrated dissection. Would you code for the intended procedure, which was angioplasty in the common femoral artery, or would you code for the stent placement for the non-occlusive dissection?

Percutaneous Needling (Tenotomy)

Please advise as to what CPT codes would be appropriate. Does the response in question ID 15139 apply to this case?

The patient's identity, planned procedure, and laterality were confirmed. The skin overlying the lateral right hip was prepped and draped in usual sterile fashion. The skin and subcutaneous tissues were anesthetized with 1% lidocaine solution. Under ultrasound guidance, a 20-gauge spinal needle was advanced near the greater trochanter and the deeper soft tissues were anesthetized using 0.25% bupivacaine solution. Subsequently, percutaneous needling (tenotomy) was performed by gently fenestrating the distal gluteus medius and minimus tendons using the 20-gauge spinal needle. Once the fibrosis/scar tissue was released and the tendons were adequately softened, the needle was removed.

IMPRESSION:

1. Right gluteus medius and minimus insertional tendinopathy.

2. Uncomplicated ultrasound-guided percutaneous needle tenotomy of the right gluteus minimus and medius tendon insertions.

93657 vs 93655 for CAFE

Indication was Afib and Aflutter. "PVI was completed and exit block confirmed for each vein. After PVI, isuprel was started and burst pacing was performed from the CS catheter. Patient was induced for Aflutter, and subsequently an activation map, Ripple map, and coherent map were performed that showed an area of slow zone conduction in the septum of the left atrium; areas were targeted with ablation. Aflutter organized with proximal to distal activation in the CS catheter. Multiple areas in the septum were targeted for complex fractionation. A few areas of complex fractionation noted in the posterior wall as well. These were targeted as well. The catheters were taken to the right atrium, and ablation of the CTI was performed. The flutter was terminated during the ablation in the CTI." One coder thinks this should be coded as 93656, 93655 x 2, and 93623, while the other coder thinks it is 93656, 93657 x 2, 93655, and 93623. What is the correct coding please? Second question, is CAFE always coded as 93657?

VATS with control of bleeding/evacuation hematoma

Can you please help with the coding for this procedure? We are trying to determine if 35820 would apply for this scenario or maybe 32999 (unlisted VATS procedure). Thank you. 

"Earlier this same day, the patient had a VATS with wedge resection. The patient came back to the OR for post-op bleeding. After general anesthesia, the previous port site was opened. A 10 mm port was placed into the chest, and a 30-degree scope was passed into the chest. There was a large hematoma that was present. This was irrigated copiously and completely evacuated. The second port site was opened. All port sites were then systemically examined. All three port sites were generally oozing. The posterior port site seemed to be the culprit; however, no arterial bleeding was identified. Two 36 French chest tubes were brought through the port sites and directed up anteriorly and posteriorly to the apex. The port site was closed." 

3D with Spectral Doppler during TEE

Can code 93319 be billed with 93320 when completed during a transesophageal echo? It does not conflict in my NCCI edit checks like 93325 does. What is the rationale behind this?

Modifiers 52/53 for 93356

Can we append modifiers -52 or -53 to code 93356? If so, what would be the best practice for documentation?

Can 33235 be billed if leads were only partially removed?

Due to infection, lead #1 went through the TV and cannot be resected any further than where it enters the subclavian vein. Lead #2 could not be resected further than where it enters the chest. Both leads were divided and capped. The note then describes that the pocket incision was opened, and dissection down to the leads occurred. The leads were pulled back into this pocket and then were dissected down underneath the subpectoralis area for complete resection, and once the leads were completely resected all the areas were inspected and closed. This sounds like only part of the leads were removed. Can code 33235 be billed in this situation?

EPS/Ablation pre-proc DX: paroxysmal atrial fib/paroxysmal atrial flutter

May we report codes 93656/93655 for the following?

"Cryoballoon ablation with PVAI, RF ablation CTI. Four femoral venipunctures/sheaths placed. ICE cath to right atrium, low normal EF/trace pericardial effusion noted. Ablation catheter to right atrium, 3D map created. CS cath advanced to CS. Baseline conduction taken. RF of CTI delivered. Bidirectional block confirmed. Ablation catheter removed. ICE-guided transseptal puncture, trace pericardial effusion noted. Cryoballoon advanced to left atrium. 3D map created. Pulmonary veins identified. Voltage mapping. Four pulmonary veins targeted with cryoablation. Entrance and exit block documented. Comprehensive EP study with R/L atrial pacing/recording and His bundle recording. AH and HV intervals noted to be 120 ms and 54 ms respectively. ICE noted baseline trace pericardial effusion. All catheters removed."

When can you bill 35700

In 2015 patient had a re-do right femoral endarterectomy and now is having fem-pop bypass with vein (35556). Can we also report code 35700 for the re-do groin for bypass now with prior right femoral endarterectomy from 2015?

Steroid Injection of the Breast

Steroid injection of the breast: Can 19030 be reported for this with US guidance? My inclination is to report 96372 or 19499 with 76942, but there is no clear direction in the CPT Codebook.

MD input provided of procedure:

"Assess sonographic area of granulomatous mastitis, draw up the steroid mixture smaller area: 2 mL steroid mixed with bupivacaine larger area: 4 mL steroid mixed with bupivacaine to fill 10 mL syringe skin and subcutaneous anesthesia with 1% lidocaine inject steroid/bupivacaine mixture into the area of GM."

This practice will be reporting primarily for pain in the breast/injection with US guidance. Any information you can provide is appreciated. I did see another response for a similar question so understand if this does not get a separate response.

Transvaginal fistulogram study

Our hospital IR department performed a contrast injection under fluoroscopy into the vaginal vault via a Foley catheter in a patient with Crohn's disease and a known rectovaginal fistula. Upon injection there was no gross evidence of fistulous communication to the rectum. The Foley catheter was removed. What should be reported?

Excision of infected AVG

What code would I use when an infected AVG is removed along with removal of a stent in the basilic vein during the same surgical session?

Exposure/mobilization of internal jugular, carotid artery and vagus nerve

Primary doctor planned an anterior cervical discectomy with decompression of spinal cord, arthrodesis, and structural allograft. Due to history of neck irradiation, for throat cancer, there was significant scarring. My vascular doctor was called in and asked to expose and mobilize the internal jugular, common carotid, and the vagus nerve. Numerous adhesions and scar tissue were found. Multiple vessel loops were utilized for mobilization. I'm not certain what codes would be appropriate.

unbundling edit with 33261 and 33268

I wanted to bring up the fact that nowhere in the CPT Codebook does it say that you can't bill 33268 with 33261. The new guidelines say: "(Do not report 33268 in conjunction with 33254, 33255, 33256, 33257, 33258, 33259, 33265, 33266, 33420, 33422, 33425, 33426, 33427, 33430)." I see nothing about 33261; however, I'm getting an edit when trying to code these together. Do you know if this is an error with Medicare NCCI guidelines? I also don't see that you can't bill them together per your 2022 books. It would make sense that these codes are unbundled due to 33261 being an ablation. Thoughts?

Temporary Pacemaker reposition

Is there a code for temporary wire reposition?

Ilio-mesenteric bypass using a harvested vein

How do you code an arterial bypass involving the anastomosis of the iliac artery and mesenteric artery? Code 35633 is for other than a vein; however, in our case a vein was used. Procedure described as being performed was "right common iliac artery to superior mesenteric artery bypass graft with a segment of the femoral vein harvested from the right lower extremity". Patient had a postoperative diagnosis of mesenteric arterial ischemia with occluded superior mesenteric artery bypass graft. Should this be an unlisted code?

pseudoaneurysm repair & endarterectomy

Provider performed pseudoaneurysm repair in the left SFA and also had endarterectomy in the common femoral for occlusive disease. Can we report both or just one?

CCI edit 32608 and 32609

When is it appropriate to append a -59 or -X modifier to 32609 when performed in conjunction with 32608? For example: "Patient is status post a lung transplant. He has nodules on his skin, and there is a concern for a post-transplant lymphoproliferative disorder. Endobronchial attempts failed, referred for surgical resections for definitive diagnosis. Two biopsies of the right lower lobe of the lung were taken via thoracoscopy and sent to path. There was a dark area on the pleural surface that appeared to be old blood, and this was biopsied."

Are the lung and pleura considered different structures, and are we able to append a -59/-X modifier? Or, since both biopsies are done on the right lower lobe, are they considered bundled?

Popliteal Artery Aneurysm Repair

For the stent graft of the popliteal to mid SFA with exclusion of popliteal, I use 37236-RT. How do you code open exposure right femoral 2/2 large antegraded femoral sheath? I am looking at 34812, but I do not have the primary code. I am wondering if 37236 is the correct code to use. Please help.

Atrial flutter ablation w/ PVI and multiple left atrial flutters

"Patient arrived in atrial flutter. An ablation line was created from the right sup PV to the antral mitral valve annulus with shift of a flutter at 330 msec. Ablation from the left sup PV and the anterior mitral valve annulus terminated the atrial flutter. We noted a different (concentric) atrial flutter. Ablation from the LSPV to the RSPV resulted in termination of this atrial flutter. Conclusion: Successful ablation of three different left atrial flutters." 

Would this only be reported as 93653 since the atrial flutter ablation was all in the PVs, or would we also report code 93655 for the "different (concentric)" atrial flutter ablation?

Correct coding for wedge resection of blebs 32655 or 32666, 32656

Correct coding for wedge resection of blebs 32655 or 32666, 32656? 

"Procedure details: the patient was brought to the operating room and placed supine on the table. General anesthesia was induced and patient intubated with double lumen tube. Perioperative antibiotics were given. Bilateral lower extremity sequential compression devices were placed before induction. He was then placed in left lateral decubitus position. He was prepped and draped in usual fashion. 3 thoracoscopic ports were placed and the chest explored. He had blebs visible in RUL apex. This area was resected with purple load stapler. The superior segment of the RLL also had irregularity of the edge, thus this area wedge resected as well with purple loads. Pleurectomy was then performed from the 6th rib cephalad, sparing the apex where the subclavian vessels lie. The remainder of the pleura was scratched with a bovey scratch pad. A 28F chest tube was placed apically, and a 24F blake placed at the base. Patient was awakened from anesthesia and taken to recovery in good condition. There were no apparent complications."

What would be the best cpt code for debridement of fibrinous exudate

I am not sure what code to use since debridement was done on the fibrinous exudate.

Procedure:

1. Washout of chest wall wound involving the right sternoclavicular joint

2. Debridement of fibrinous exudate overlying the clavicle and sternal notch

The patient was brought into the operating room and placed on the operating table. The old wound vac was removed and I started by copiously irrigating the wound with 3 liters of sterile saline using the pulse lavage. There were some areas of fibrinous exudate overlying the right clavicular head and sternal notch, which I sharply debrided with scissors back to healthy tissue. I then replaced the durable wound vac sponge measuring approximately 20 x 13 x 2cm.

ESWL of pancreas

What is the correct CPT for ESWL of pancreas? Our physicians are recommending 43265, but there is no support of the ERCP portion being done during the encounter. The procedure report states: "Extracorporeal shock-wave lithotripsy was performed using the Dornier Delta II. Began with a power of 1 at 60 shocks/minute with a total of 4000 shocks. There was successful partial fragmentation of the pancreatic duct stone."

VENOUS SAMPLING BY CATHETER

What is the correct CPT code for venous sampling by catheter?

Continuous electrogram recordings, infusion of isoproterenol....

How would you code this procedure? The provider reported 93660 and 93623, but 93623 is an add-on code, and 93660 is not a primary procedure for 93623.

"The patient was brought the lab in the fasting state after informed consent was obtained. The groins were prepped and draped in a sterile manner. Anesthesia was provided by anesthesia consult. Please see separate documentation report. Continuous twelve-lead electrocardiogram was employed. Continuous hemodynamic monitoring was also employed. Despite isuprel infusion to increase baseline HR >20%, isuprel washout, infusion of calclium gluconate, infusion of IV caffeine and >45minutes of observation awake and under anesthesia, NO PVCs WERE NOTED. Hemodynamics remained stable throughout the procedure."

Descending TAA repair and decompression of aneurysm sac via thoracotomy

Please help. I'm really hoping this isn't an unlisted code and that there is a CPT code that accurately represents the below procedure, but every one I come across involves graft stent placement. Code 33877 would be perfect, I think, except for the no graft placement issue. Is there a code I'm missing, or is this unlisted code 37799?

"Patient had percutaneous endovascular repair of dissecting descending thoracic aorta, which came off just below the pre-existing stent graft placed five years prior for descending thoracic aorta traumatic injury. They successfully excluded the aneurysm, but one week later CT scan showed persistence of large aneurysm, which was causing mass effect on esophagus and left heart. Patient was taken to OR for open exposure of the aneurysm and repair with decompression of aneurysm sac. Cardiologist performed left posterolateral thoracotomy. Vascular surgeon opened aneurysm sac and removed the thrombus. TEE showed sac was totally decompressed, and sac was closed over the previously placed stent graft and aortic wall repaired with suture."

Balloon Dilation of a Pre-Existing Stent

Would you report code 33745-52 or 37246 for balloon dilation of a pre-existing stent in the LPA for in-stent restenosis in a congenital heart cath patient?

His bundle lead

I was inquiring on how you would recommend billing for his bundle lead? It was billed as 33208. This is the first time I have seen this. 

"Procedure: An approximate 2-inch incision was made in the left chest wall, and using a combination of blunt and sharp dissection, the pacemaker pocket was fashioned down to the pre pectoral fascia. Using standard Seldinger technique, two guidewires were placed into the left axillary vein and confirmed by fluoroscopic imaging. Over these guidewires, standard peel-away sheaths were advanced into the left axillary vein. Through these peel-away sheaths, standard pacemaker leads were positioned (Table 1) under fluoroscopic guidance.

Table 1:

Location Company Model # Serial # Date of Implant

RA Medtronic XXX XXX October 7, 2022

His bundle Medtronic XXX XXX October 7, 2022"

His Lead placement in new CRTP device

A His lead was placed instead of a left ventricular lead in the coronary sinus (there was not a suitable vein). The His lead was attached to the interventricular septum, the RA lead was placed in the right atrial appendage, and the RV lead was placed in the RV low septum. All leads were cleaned and attached to the biventricular PPM generator. (The His lead was plugged into the LV port.) What should be coded for a His lead placed in this manner? I understand code 33225 would not be suitable, as it is not a coronary sinus lead placement.

saphenous vein harvest, open technique cxl procedure

Patient is in the OR for a CABG. Saphenous vein is harvested, open technique, but the vein is not usable. The doctor speaks with cardiologist and concludes that the patient is high risk and could easily have PCI to the occluded vessels, which is better for the patient and closes the thigh incisions. How would you bill for this to give the provider credit?

100% CALCIFIED OCCLUSION

If physician documents 100% occlusion calcified mid - left circ would you consider coding this as CTO (C9607)? No previous heart cath or any other non invasive procedure done before. Patient only diagnosis history of HTN and hyperlipidemia. Please advise.

Epidural block injection

"Reason for exam: CT fluoroscopy epidural block injection for right lumbar radiculopathy. CT was obtained, and images were used for localization of the right L4-5 neural foramen. Procedure: After infusion of subcutaneous xylocaine, a 22 gauge spinal needle was inserted into the patient's back at approximately the L4-5 level. Under CT fluoroscopy, the needle was then advanced so that the tip abuts against the exiting right L4 nerve root. With the needle tip in this location, a solution composing of 80 mg of Depo-Medrol and 4 cc of 0.25 % Sensorcaine was injected through the needle. The needle was then removed."

Code 62323 is charged by the rad department. It seems like a nerve block injection, and I would want to code it as 64479. Please advise.

75774 for additional selective venography

We have been following the instruction that 75774 only applies to subselective ARTERIAL studies; however, CPT Assistant (Septmeber 2022) states, “If venography is performed in a main vessel and then a selective venogram is performed, report code 75774 in addition to the venography code for the initial vessel.” Can you please clarify from the AMA that 75774 can be used for both arterial and venous studies?

aortobifemoral bypass with aortic and femoral thromboendarterectomies

My physician did an aorto-bi-femoral bypass with aortic thromboendarterectomy, left common femoral endarterectomy with eversion endarterectomy of the profunda femoris, and endarterectomy of the proximal superficial femoral with tacking of the intima of the SFA and patch angioplasty of the CFA and SFA. It is my understanding that the thromboendarterectomy (both aortic and femoral) would be included in the bypass coding. He disagrees and says he does more work than just establishing inflow/outflow. Also, he wants to code for the profunda and superficial endarterectomy in addition to the CFA endarterectomy. I was under the impression that if it was one arteriotomy and one patch angioplasty you would use only one code (CFA, 35371). From what I can tell from his op note, only one arteriotomy was made and one patch angioplasty used. I guess my question is, when would it be appropriate to code separately for the endarterectomy with bypass and when would it be appropriate to code for more than just the CFA endarterectomy when the profunda and SFA are done as well?

Penumbra Cat Rx

We have physicians dictating that a coronary mechanical thrombectomy was performed using a Penumbra Cat Rx catheter. The department wishes to charge 92973 for the procedure. Would this be an appropriate charge? Or is the Penumbra Cat Rx catheter considered an aspiration catheter and the procedure is inherent?

76098 with Localizations

Do radiologists need to wait for the path report results to dictate and bill code 76098 with an localization procedure?

35151 and 75710

Is the follow-up angiogram (75710) billable following PTFE graft aneurysm repair of the popliteal artery (35151)?

Bilateral Lung Transplant with co-surgeons

Our doctors are both billing for a bilateral lung transplant (32854-62), but the operative notes state that each did one lung, right and left. The specialties are the same. Is this sufficient to establish the medical necessity of a co-surgeon?

X ray radiographic guidance

We are not sure if we can use 77001 for x-ray spot radiographic guidance. MDs are performing insertions and removals of tunneled catheters, ports under spot film x-ray radiographic guidance. They are not documenting fluoroscopic guidance, and there is an image saved after such procedures. Same goes with lumbar punctures.

Peripheral Shockwave

Can we report code 37225 with the C9764 (Shockwave) in the ASC setting?

Breast Biopsy with Hologic Localizer System

"Tag was deployed with x-ray guidance in right breast. Patient taken to operating room, and the tag was identified using Hologic reader. Dissection proceeded deep to the capsule, to the fascia of the pectoralis musculature. A 2 cm area of breast was excised with the Hologic capsule and sent for mammogram. Mammography of the surgical specimen verified tag and calcifications were biopsied."

I am questioning the tag deployment with x-ray guidance. I am thinking of reporting 19301 for the lumpectomy and 76098 for radiological examination of specimen. What are your thoughts?

Non-CHD, post MI VSD closure. 93581 or 93799?

Old answers (ID:14602 & 3515) to this question state to use 93799. However, the 2022 Z ref book pg 176 says that since non-cong. heart cath codes are in the parentheticals as not reportable with 93581 that may indicate the use of 93581 for percutaneous VSD closure of a post MI VSD. in this case should we code the heart cath and unlisted for the closure or just the closure that bundles the heart cath? Case: H/O MI; treated with PCI (3 stents); noted to have a ventricular septal rupture the next day and went into CHF.S/P surgical patch closure of the VSR/VSD. Pre: Moderate to large residual VSR/VSD at the superior margin of the previously placed VSD patch, minimal diameter 13-16mm. Right and left heart cath performed, LV angio done. 18mm occluder device placed. Post:Small residual shunt through the VSD device, no additional VSR/VSD is noted.

Placement of thoracic spine marker in IR for surgery.

Coding to be used in IR for placement of a surgical marker in the thoracic spine. Patient is bariatric and needs the marker to be placed in IR prior to surgery. What would be the correct coding for this procedure in IR? It will be a separate encounter from the surgical procedure.

new cpt code 33268 clarification

During a CABG procedure the atrial appendage is cannulated and then oversewn/ligated at the end of the procedure. Can code 33268 be billed in this case, or is this considered closure and therefore included in procedure?

Peri-OP Device Eval.

"Tachy therapies were disabled before the surgery, and pacing was turned to VVI 40 mode. Parameters were returned to original values at the end of the procedure." This verbiage is often used in reports I'm reviewing, and I wanted to know if I am correct in not reporting 93286/93287. The CPT guidelines state there should be a report regarding certain elements of the device in addition to the adjustment that is done peri-operatively. There is usually some version of this in the reports I see. 

CSV during the RHC

Ablation SVT substrate incl comp EP study (93653); ablation of add’l arrhythmia substrate x4 (+93655); left atrial/coronary sinus recording w/ pacing (incl in 93653); Med infusion w/ prog stim (+93623); 3D map (incl in 93653); intracardiac echo (+93662). During the procedure, another MD performs/bills a congenital RHC – Abnormal native connections, which found dilated coronary sinus with venous anatomy demonstrated for potential future procedure (93594).

Question: EP wants to bill 36012 for coronary sinus venogram stating that “venogram is not related at all to the EP study or ablation; it is formal diagnostic imaging to evaluate options for future defibrillator upgrade and should be billable other than the fact there aren't great codes for it.” Based on the documentation, it appears he performed the CSV during the RHC. What is the appropriate code for the CSV, if any?

93571 for iFR, DFR

I am inquiring to see if there have been any updates in regards to coding for an iFR and DFR. Should we still be coding 93571-52?

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