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Coding a second read of 19083

We have a radiologist who is performing a second read of procedures 19083, 77065, and 76641 that were performed at an outside facility. Codes 77065-26, 77 and 76641-26, 77 were coded, but we are unsure how to code the second read by the radiologist for 19083 since the -26 modifier isn't allowed for the code and the 77 modifier also would not be completely applicable. Can you please help?

Dual Chamber PM replacement and pocket revsion

We noticed you no longer get an edit with 33222 and 33228, so we were wondering in this scenario if we could charge for both. "The device was removed from the pocket, and the leads disconnected from the device. The pocket was enlarged inferiorly to relocate the PM lower to accommodate radiation therapy. The leads were tested and reconnected to the new generator."

Aspiration arterial thrombectomy in lower extremity vessel

Is it appropriate to report code 37184 for an arterial aspiration thrombectomy performed in a lower extremity vessel? Code 37184 specifically states "mechanical" thrombectomy. I'm wondering if this follows the same guidance for the coronary thrombectomy (CPT 92973).

failed balloon mechanical thrombectomy

"A 5 x 40 mm Bard conquest balloon was then positioned across the arterial anastomosis and the proximal fistulous inflow and a prolonged and insufflation performed with balloon achieving profile. Kumpe catheters repositioned in the brachial artery angiography performed. 1.5 cm cleaner device was passed from the distal sheath and attempt to break up thrombus within the aneurysmal segment of the cannulation zones fistula without success. This appeared to be very mature thrombus. Despite further attempts at balloon angioplasty and balloon maceration never achieved beyond temporary patency with residual thrombus occlusive in nature unable to be removed. Selective left upper extremity angiography was performed via the fistula using Kumpe catheter positioned in the brachial artery proximal to the anastomosis. Serial dynamic imaging obtained from this location distally to the fingertips."

They want to bill 36905, but I would like your opinion of the failed thrombectomy.

4D Parathyroid CT of Neck with Contrast

What is your recommendation on coding the following study for hyperparathyroidism with after study no CT evidence of parathyroid adenoma? Technique: 4D parathyroid protocol axial CT images of the neck were performed after the intravenous administration of 80 mL of Isovue 300. Coronal and sagittal reformations were provided. An adaptive iterative reconstruction technique was utilized for dose reduction.

Should this be coded as a CT soft tissue neck w/contrast 70491 or does the "4D" technique indicate at least 3D imaging was performed and this should be coded as 70491 & 76376? We cannot find any information on how to code "4D" technique CT exams, and this technique does not seem to meet the 3D code requirements so would seem to only be coded as 70491. Any guidance you can provide on coding "4D" CT exams would be very appreciated.

pseudoaneurysm and stenoses separate vessels, same leg

I understand if there is a pseudoaneurysm of the femoral artery and stenoses of another femoral artery, we report either 37236 or 37226, but not both. But what about the case where say the popliteal artery has a pseudoaneurysm and a stent is placed, and one of the femoral arteries has a hemodynamically significant stenosis and a stent is placed? Can we report both codes or just one?

Documentation for clip placement post biopsy

This is a two-part question. First we are hoping to get clarification on what documentation is needed in order to code out a post biopsy mammo for clip placement. Some of our rads only dictate: "POST BIOPSY FILMS CONFIRM CLIP PLACEMENT" or "AS A SEPARATE PROCEDURE IN A SEPARATE ROOM WITH A DEDICATED MACHINE, POST PROCEDURE DIGITAL MAMMOGRAPHIC IMAGING DEMONSTRATES THE LOCATION DEVICE AT THE TARGETED AREA". Is this enough to code out 77065? The second part is, if they just say post biopsy FILMS (along with proper documentation of clip) and they don't specifically say post bx MAMMOGRAM, can we still code out 77065? We were told that films are the same as x-rays which is what mammography is, therefor based on that verbiage it's ok to code out, but we want to be sure.

Brachiocephalic AV Fistula PTA via Native Radial Artery

How would you code a wrist radial artery access with catheter navigated into brachiocephalic AV fistula and PTA of fistula peripheral segment?

Limited color and spectral doppler

If you perform a limited color and spectral Doppler during a thyroid ultrasound to check for vascularity of nodules, would it be appropriate to bill 93998 for those services?

Lung aspiration Bx

Should the following scenario be coded as a CT-guided lung biopsy (32408) or as a CT aspiration biopsy (10009)?

"Limited computed tomography again demonstrated the fluid collection centered on the left lung. The preliminary scan is otherwise unremarkable. After the administration of local anesthesia, a 5 French one-step needle was advanced into the larger fluid collection within posterior left lung. A total of 27 cc of purulent fluid was aspirated and sent for testing. CT guidance confirmed successful placement of a biopsy needle. Completion images demonstrate expected post procedural change. Technically successful CT-guided aspiration of a probable abscess within the posterior left lung."

INARI FlowTriever II

INARI Medical has a new device called the FlowTriever II and it is intended for peripheral vasculature only.

Key Features:

-Laser cut element with proximal open cell design for optimized clot clearance.

-New disk shape designed to disrupt clot, improving effectiveness for aspiration.

- Increased usable length (120 cm) for more distal treatment.

- 52% shorter deployment length.

- Versatile sizing to treat vessels 6-16 mm in diameter.

Will you please clarify if this an aspiration thrombectomy catheter or mechanical?

RESCUE PCI

As soon as the patient arrived to our facility, he had a "rescue PCI".  He was a transfer from another facility after thrombolytics were given. Would this be considered "emergent?" They never say "emergent", and some time had passed from when he was at Urgent Care, then to the ER, and then transferred to our facility for PCI. The cath lab knew that he was coming so he presented straight to the cath lab.

Stent due to hemorrhage

What is the appropriate code for SFA stent due to hemorrhage? No occlusive disease. Right groin bleeding into a hematoma/pseudoaneurysm. 37226 or 37236?

Cardiac Cath w/ US guided Vascular entry

"Ultrasound-guided vascular entry in conjunction with manual palpation, fluoroscopy-guided vascular entry in conjunction with manual palpation, and vascular entry accomplished utilizing manual palpation. Left heart catheterization with selective coronary angiography, left ventriculogram. The risks, benefits, and details of the procedure were explained to the patient. The patient verbalized understanding and wanted to proceed. Informed written consent was obtained. Right femoral artery was accessed in a retrograde approach utilizing sterile technique."

Can 76937 or 76942 be billed with 93458?

Repair of fem-tib bypass aneurysm

"PROCEDURES:

1. Repair of left femoral to tibial bypass aneurysm with Gore-Tex interposition using hybrid graft.

2. Intraoperative arteriogram.

3. Balloon angioplasty to left femoral-tibial bypass.

INDICATIONS: The patient has a 7 cm aneurysmal dilatation to a left femoral to posterior tibial bypass that was felt to be in need of repair.

FINDINGS: The area of the aneurysm had significant inflammation that did not allow for good end point dissection. Because of this, the aneurysm was punctured for wire and balloon control and then an interposition graft was placed using hybrid grafts on the proximal and distal ends for control."

I'm confused with this one. I was thinking 35884, but they also placed a graft on the distal end of the bypass as well as the proximal end. Would we then code this with LE repair codes?

CT Venogram = Diagnostic Study

CTA and MRA = diagnostic study. Is a CT venogram diagnostic quality? Does a CTV mean we cannot charge diagnostic venogram when an intervention is performed?

Iliac node biopsy- Core and FNA

Biopsies of two different iliac nodes in the right lower quadrant were done. One was core and another was FNA.

1. Successful uncomplicated CT-guided core needle biopsy of larger and more inferior mildly PSMA avid right common iliac node.

2. Successful uncomplicated CT-guided FNA biopsy of smaller more cephalad and more PSMA avid right common iliac node.

Would you code 49180 and 10009 only, or would you code 49180, 10009, and 77012-XS?

MRI Sacrum and Pelvis

Is there any guidance on how to code an MRI pelvis and MRI sacrum? If ordered separately and medical necessity provided, would they be coded separately, or are they only considered a single exam since they are performed in the same session? If they can be coded separately, would a -59 or -76/77 modifier be appropriate? The only guidance I have found is that if the sacrum is imaged alone, it's coded as an MRI pelvis, and if it's imaged with the spine, it's included in the spine, but nothing on coding both when ordered separately as pelvis and sacrum exams. We have a provider that is stating that they have different protocols on the machine and they cannot just add a few images for the sacrum. Any information you have on this topic would be fantastic.

Stage 2 BASILIC VEIN TRANSPOSITION 36832 58 or 36819 58?

Stage 2: The coder believes this is 36832-58, and the doctor thinks it is 36819-58. Who is correct and why?

"A second oblique incision was made distally, near the area of previous arteriovenous fistula. This was taken down to the level of the basilic vein using electrocautery. The brachial artery was also identified. Branch points were identified and ligated using clips and 4-0 silk ties. Two additional incisions were made proximal to the first incision in sequential fashion. These incisions were taken down to the level of the basilic vein and a branch points were ligated using 4-0 silk ties. A curved tunneling device was then used to tunnel and transpose the freely mobile basilic vein through the subcutaneous tissue laterally, bringing it near the surface of the skin. incision at the distal end of the basilic vein. The brachial artery was then identified and vessel loops were applied proximally and distally. A #11 blade was used to make a small incision in the brachial artery. The arteriovenous end to side anastomosis was then created."

Multiple Embolectomy Same Incision

If a Fogarty is used to remove clots from the left external iliac, common femoral, popliteal, and left anterior tibial through the same incision, and then a separate incision was made to complete the left posterior tibial clot with Fogarty, could we report 34201 and 34203 for the first incision and then 34203 for the second incision? Or would we report only the most comprehensive code 34203 for each incision? 

Nasogastric tube Placement and Removal

Please help. This seems like quite a simple case, but I just cannot decide on the correct code(s) to use. The IR physician states that he placed a nasogastric feeding tube and removed the tube in the same setting, due to patient having pain/complication. What codes do you think best describe this scenario? Yes, code 43752 for placement, but since there is no code for removal of feeding tube, could we consider using unlisted code 43999 for the whole encounter?

93454 with 92941

Is it appropriate to report both codes in this scenario? Complaining of epigastric/chest pain. ECG showed ST elevations and Q waves V2-V4. Patient was taken urgently to cath lab for LHC and possible PCI. The report indicates, "Mid LAD lesion and decision for PCI."

93456

"AO 134/71. Aortic valve was not crossed. Right heart catheter was inserted into the right heart. Appropriate RH pressure measurements were obtained. 02 saturations were obtained, and cardiac output results calculated."

Provider billed 93456, but I think it should be 93451. What are your thoughts?

Dialysis device placement with IJ balloon coding

My physician is placing a central venous access device. The internal jugular is blocked, so he inserts a balloon. Would I report code 37248 along with the device code?

99223 and high risk drugs

In a review of onpatient E/M leveling for cardiology, the providers questioned the risk portion of medical decision-making due to patients being on a Cardizem drip (99223 for initial and 99233 for subsequent hospital visits). The providers believe medications adenosine, IV Lopressor, or Cardizem automatically qualify the patient as "high risk " for MDM and therefore the highest-level E/M should be reported. These drugs are not included in the list of high-risk medications. Is there an expectation that the providers should document the importance of administering these drugs in the care of the patient to substantiate meeting high risk MDM? The providers stated a coder should know to move to high risk if the patient is on telemetry. Please advise.

Use of modifier 52 with a non-successful Cardioversion 92960

If physician performs a cardioversion on a patient, and the procedure was performed completely but were unable to convert the patient to normal rhythm, would we need to append a -52 modifier to report?

50431

When a stent is placed into the aorta for stenosis, is the aorta then considered "selective"? From the Dr. Z IR guide: "Code separately for selective catheter placement when using codes 37236-37239. Iliac stent grafts, EVAR, and FEVAR procedures bundle certain catheter placements." Example given in IR guide: "Patient with known abdominal aortic stenosis presents for stent placement. A catheter is advanced from the right femoral artery to the aorta (36200), and aortography confirms the stenosis (no code). Pre-dilation with an 8 mm balloon (no code) is performed followed by placement of a 14 mm stent (37236). The stent is post-dilated to 16 mm (no code). Follow-up angiography shows excellent results (no code)."

The 36200 is added because the aorta is considered "selective" in this case?

Pelvic sidewall biopsy

"Utilizing spot CT fluoroscopy, a 19 gauge coaxial needle was advanced into the lesion from an anterolateral approach paralleling the anterior margin of the lower iliac bone. Epigastric and iliac vessels were avoided. 1% buffered lidocaine was utilized for local anesthesia. Multiple 20 gauge core samples were obtained through the coaxial guide with CT fluoroscopic confirmation of biopsy position. IMPRESSION: Uncomplicated CT-guided core biopsy right pelvic sidewall mass in a patient with history of colon carcinoma. Path: Metastatic colorectal adenocarcinoma, moderately differentiated."

We reported code 20206. Is this correct?

92941 and 92928 in the same vessel.

Patient presents with STEMI involving both left anterior descending and left circumflex coronary arteries. Provider places drug-eluting stent in proximal LAD, mid LAD, second diagonal, and 3rd marginal branches. Based on being allowed to bill 92941 once during the procedure, would appropriate coding be 92941-LD, 92928-LD-51, 92929-LD (as hb charge), and 92928-LC-51? Or would the second stent in the LAD be considered part of the 92941 and should we only bill 92928-LD as a facility charge in the diagonal branch?

isolated PFO closure

We understand that for the CPT coding of cardiac caths and echos, an isolated PFO is not considered to be a congenital heart disease. That being said, when percutaneous transcatheter closure of an isolated PFO is performed, may we use code 93580? This code specifically states "congenital". Should we use unlisted code 93799 instead?

EKG done on same day as Interrogation cardiac device evaluation

Are there any billing guidelines regarding this issue? Is EKG 93010 considered to be part of the interrogation cardiac device evaluation (e.g., 93279) and not billable with device? We get an NCCI edit that 93010 has unbundle relationship with the procedure 93279. The procedures are performed on the same DOS.

Coronary IVL lithotripsy stent and atherectomy

For hospital reporting: procedure was atherectomy and intravascular lithotripsy with drug-eluting stent to the proximal circumflex. We are getting an edit that C1761 (lithotripsy balloon device) cannot be reported with C9602. The atherectomy of the circumflex was performed prior to the lithotripsy. Would this not be correct?

76937 with 33418

Can code 76937 be reported with 33418, or is it bundled in the procedure?

Discharge visit after a planned ablation procedure

Is a discharge service reported the next day after a planned ablation procedure?

CPT 37184- 37185

Mechanical thrombectomy of left popliteal artery and mechanical thrombectomy of left peroneal artery, two different accesses. We coded 37184 and 37184-59. Is that correct, or should it be coded 37184 and 37185?

VOM injection during Afib and or Atrial flutter ablation

Our EP doctors are wondering if there is a way to capture a vein of Marshall ethanol injection during A-fib and/or flutter ablation? Should this be coded as unlisted? If so, do you feel that 93799 or 33999 would be a better fit?

cardiomems

My physician did a left and right heart cath and CardioMEMS implant at the same time. I reported codes 93460 and 33289. Medicare is declining to pay for 93460. I'm wondering if the right heart cath is included in 33289, and maybe I should have billed 93458 and 33289. Please clarify. Also, do I need an -XU modifier on the cath?

Prostate embolization

In IR for embolization of the prostate for a diagnosis of prostatomegaly (right and left) the doctor catheterized both iliacs and left and right prostatic arteries. He also did angiograms in all these areas (a total of five). Can we bill for all the angiograms performed?

Catheterization of the torcula with venography.

If the catheter is placed to the torcula and venography performed of the transverse sinuses, would the codes be 36012, 75870 one time? Documentation: "Access was obtained at the left common femoral vein using micropuncture set. 8 French sheath was placed. Neuron MAX catheter was advanced into the right internal jugular vein. 4 French angled taper catheter was advanced to the torcula. Venography was performed, showing minimal narrowing of the transverse sinus bilaterally."

LHC performed due to abnormal stress test and hx of chest pain

When a left heart catheterization is performed in the outpatient setting due to an abnormal stress test and history of chest pain, and the findings are "mild coronary artery disease", would the first listed diagnosis be the abnormal stress test or CAD? Would the abnormal stress test even be coded in this scenario? The provider doesn't make any recommendations for further testing, only states "continued medical therapy" in the Impression.

duplex doppler of jugular veins

What would be the best code for a duplex Doppler ultrasound of the internal jugular veins?

Aborted Dual Chamber PM upgrade to CRT-P

Per provider documentation: "We then attempted to wire the vessel to see if we could open any potential branches and none were visualized. We contemplated placing a lead anyway, but the vessel was so tiny in LAO not even crossing the spine. We then decided to abort the procedure. The pocket was flushed with antibiotic-containing solution, and the old DDD generator (see data below) was connected to the leads, and the leads and generator were inserted into the pocket."

Do we report code 33225 with modifier -74 and 33249 with modifier -74 since the procedure was aborted due to small atretic coronary sinus and no LV lead could be placed? Please advise.

Diagnostic Venography and IVUS to determine May Thurner

Provider performs a diagnostic procedure to determine if the patient has May-Thurner syndrome.

From the right jugular vein, the provider selects the left renal vein and performs a venography (36011-59LT, 75820-LT). The provider selects the left common femoral vein and performs a venography (36012-LT, 75820-LT). He then performs IVUS and takes measurements of the common femoral, external iliac, common iliac and IVC (37252, 37253x3). Next the catheter is placed in the right femoral vein and takes IVUS measurements of the common femoral, external iliac, and common iliac (36012-RT, 37253x3). Right side venography was NOT performed.

I know 37253 has an MUE of 5. My question is whether it is okay to bill for all these IVUS codes? Since he was performing a diagnostic study to determine whether this patient had May-Thurner, I thought this may be appropriate? I know we are not supposed to bill additional units of IVUS for routine pullback. I am having difficulty determining what would constitute pullback during a diagnostic or interventional procedure.

Coronary IVL C1761 with C9602

Do you have any information regarding reporting C1761 during coronary interventions for hospitals? Our physician performed an orbital atherectomy, DES placement, and Shockwave IVL therapy to a 90% stenosis on the RCA. According to the manufacturer, C1761 is paid a pass-through payment when reported with C9600 or 92928. We are wondering if we can report C1761 with C9602 as well.

Abdominal cutaneous nerve block 64420

Patient presents with flank pain for a nerve block injection, with the abdominal cutaneous nerve entrapped by a muscle of the right flank. Although not specifically documented, this sounds like anterior cutaneous nerve entrapment (ACNES), which would involve the nerve endings of the lower thoracic intercostal nerves. One injection is made into the flank muscle near the entrapped nerve, as demonstrated by injection of contrast and fluoroscopy. Would you recommend 64420 intercostal nerve block for this, or another code like 64450?

Internal Carotid Stenosis endareterectomy with Stent

Two vascular surgeons performed left carotid endarterectomy with patch for severe carotid stenosis. For the areas of stenosis they couldn't endarterectomize they placed a 6x5 Viabahn stent. Can we bill both 35301 and 37215, or the stent is included with the endarterectomy procedure?

Axillary Lump ICD-10 Coding

What are your recommendations when coding axillary lumps when the breast is also imaged? Should the breast axillary tail lump codes N63.3- be used or upper extremity lump codes R22.3- be used? How do we know if a lump is specifically in the "axillary tail" versus truly in the axilla when typically the only indication is "axillary lump"?

Would maybe a good rule of thumb be to use the breast axillary tail lump if study performed is a breast ultrasound (which includes the axilla when imaged) and to use the upper extremity lump codes if only the axilla is ultrasounded to match the upper extremity ultrasound code for an axilla-only ultrasound?

Tricuspid Valve Repair

When doing a MitraClip procedure and a tricuspid clip at the same time, can these be coded together as 33418, 0569T? Is the MitraClip device approved for use on the tricuspid valve?

Endarterectomy Extremities

At the same time as common femoral artery endarterectomy is performed, balloon angioplasty is performed of the superficial femoral and popliteal arteries on the ipsilateral side. Is this reported separately or considered a way of establishing outflow? Establishing inflow and outflow is included in all of the lower extremity endarterectomy codes.

76010 foreign body

There is only one code that addresses x-ray imaging for a foreign body - code 76010 (Radiologic examination from nose to rectum for foreign body, single view, child). I know that a 1-view chest and a 1-view abdomen should be coded when it takes two images to include nose to rectum on patients longer than 17 inches from nose to rectum. However, how should a 1-view image that goes from the nose to the top of the pelvic bones with the foreign body seen within that one image be coded? The intent is to see where the foreign body is.

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