Ask Dr. Z

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.

The left anterior chest wall was prepped and draped. Both venous and arterial ports of the catheter were de-heparinized with a 5cc syringe. Venous and arterial ports were aspirated, and small amounts of clots extracted from the catheter lumen. A central venogram view was performed identifying good flow into the right atrium. No clots or abnormalities noted. F/U completion venography noted widely patent central venous system with catheter tip position near the Cavo atrial junction. Excellent aspiration from the arterial port and venous port was noted. Both ports were flushed with normal saline. Findings: Preliminary scout film of the chest demonstrates an indwelling tunneled right IJ hemodialysis catheter with the tip positioned in the right atrium.

I am not sure how-to code for the clot aspiration along with the central venogram.

Right heart catheterization was performed thereafter. A 7-French Swan-Ganz catheter was then advanced under direct fluoroscopic guidance into the distal pulmonary artery. Right atrial, right ventricular, pulmonary arterial and pulmonary capillary pressure tracings were obtained. Measurements were obtained for calculation of a FICK cardiac output. Thermodilution was performed. The Swan was then pulled by to RA and advanced into hepatic vein. Pressure checked there. Swan balloon was inflated and portal vein pressure (confirmed by contrast) was checked. Swan was removed after that.

93541 & 36011

Patient has a dual chamber PM for 3rd degree AVB at end of life. The physician noted that the atrial lead has become dislodged and is tested and not found to be sensing. The ventricular lead is functioning without issue. The physician and patient discussed and agreed to leave the dislodged lead in place, and it is attached to the new dual chamber generator along with the ventricular lead. Would this encounter be reported with 33228 since both leads are connected to the PM or 33227 since only one lead is actually functioning?

If a patient comes in for a abscess drain check and/or exchange and the diagnosis for the visit is one of the T codes that receive the 7th character A,D,S, would it still be considered active treatment "A" on each return visit until the drain is removed? Or would the return visits be coded with "D" for subsequent for all the drain check/exchange visits following initial placement? If they are still treating/managing the abscess with checking, evaluating, and sometimes replacing the drain, wouldn't this be considered "active" treatment on the return visits?

I am one of the professional coders for Interventional Radiology. I am trying to get clarification on best practices for when to use a modifier (52/53) to reflect a discontinued procedure vs coding for what actually took place. The below scenario comes up quite frequently:

An order is placed for a CT-guided percutaneous drain placement; however, preliminary CT showed resolutions of the right lower quadrant fluid collection. Therefore no drain was placed, and only imaging took place. The acute side reports 49406-74 (I understand they are bound to report whatever was ordered), but on the professional side we feel it is most appropriate to report 74174-26, since that is all that took place. Is that correct thinking? Or should we be reporting 49406-53? Do the professional and the acute side HAVE to match?

I have a patient who had:

Explant of CRT-pacemaker, laser lead extraction of RVlead, placement of RV ICD lead, placement of CRT-D and threshold testing. I believe I should use 33233 for the removal of CRT-P, 33231 for insert of CRT-D, 33234 for the RV lead removal by laser extraction and 93641 for the threshold testing. However, what would I use for the new RV lead insertion to the CRT-P?

Am I correct that we do not bill for the contrast that is administered for localization such as the injection of omnipaque prior to performing a joint injection being done under fluoroscopic guidance?

We are performing the following MRI for a cervicomedullary imaging protocol. Based on the order, instructions to the tech, and findings, would CPT 70553 be the only code we would report? We can image all the way to C7/T1 depending on the tumor.

Order: MR Brain w & wo

Instructions for tech: Precontrast Cervicomedullary - 3 PLANE LOC, SAG 3D T1 MPRAGE, TRAN rDWI, SAG T2 TSE. Cervicomedullary Coverage- All transverse imaging (including rDWI) have the same placement, If tumor extends past C7, tech will increase slices and/or FoV to include entire tumor. Postcontrast Cervicomedullary- TRAN T2 TSE, TRAN T2 FLAIR, SAG 3D T1 MPRAGE, SAG T1 SPACE

Findings: Persistent T2 & T2 FLAIR hyperintense non-enhancing expansile intra-axial mass centered upon the R paracentral medulla. The superior margin of the mass is at the R pontomedullary junction, with inferior extension into the cervical cord to the level of C3-C4. Stable mass effect upon the R lat aspect of 4th ventricle.

Impression: Stable intra-axial lesion of the brainstem & upper cervical cord, asymmetric to the R.

Please help us with this one. The Order is for a CTA CHEST W/IV CONTRAST W/DYNAMIC AIRWAYS with 71275 only attached. We are asking whether we should also be billing 71260.

TECHNIQUE: Ct Angiography of chest done using ECG-triggered dual source, high pitch Cardiac FLASH technique. IV Contrast given. Delayed images not obtained....Dynamic airway CT was performed using cine CT Technique. A 4 cm field of view was placed over area of interest, and CT was done over 1 to 2 respiratory cycles. Low dose technique was utilized. Images were reconstructed in axial, coronal, & sagittal planes. 3-D images were generated on independent workstation for better demonstration of c-v & airway structures.

IMPRESSION: Aorta anatomy as above (described in report). Artery of Adamkiewicz not clearly identified. No evidence of tracheobronchomalacia during dynamic evaluation.

Is the Dynamic evaluation part of the CTA, as 3D is employed?

71275 & 71260-59 or just 71275??

We would really like to settle this discussion.

Botox-

100 units of Botox was diluted in 4 mL normal saline.

Real-time sonographic guidance was utilized to advance 25-gauge needle into each of the 4 major

salivary glands (bilateral parotid and bilateral submandibular) with injection of 20 units Botox

across each gland diffusely under constant sonographic visualization.

Ablation-

Real-time sonographic guidance was utilized to advance 25-gauge needle into each of the

submandibular glands which were each laced with 0.5 mL 3% Sotradecol (dehydrated alcohol not

available).

IMPRESSION:

Ultrasound-guided Botox injection of all for salivary glands (20 units each)

Ultrasound-guided chemical ablation of the submandibular glands (0.5 mL 3% Sotradecol each)

dx: sialorrhea

would the ablation be coded separate from the 64611? And would it be unlisted 42699?

Is it appropriate to code CV and TEE if they are both documented in the same report? In the past we have been told that TEE and CV each needs its own report. If MD only does a TEE report with quick reference to CV do I charge/code TEE only?

MD did a full left heart cath with LV pressures and imaged the radial artery graft to LAD. Would we still use code 93459?

"Radial artery graft angiography: A soft-tip guide wire was advanced to the level of the axillary artery. This catheter was used to engage the ostium of the radial artery graft. Arteriograms were conducted in multiple projections. This catheter was withdrawn over the soft-tip guide wire."

Upper extremity vein harvest (35500) can only be used with bypass codes. So is the upper vein harvest included in an aneurysm repair such as 35141? Or is only the saphenous vein included and can we use 37799 for the upper vein harvest?

Would this be a non selective PA angio from the RV or a bilateral selective PA angio due to this additional note? RV: Antegrade RV angiogram shows normal systolic function with mild to moderate

TR. The RV-PA PECA conduit is widely patent. There is to an fro flow across the

valveless conduit. Well-developed, dilated bilateral pulmonary arteries are present. The

RPA measures 20 mm and the LPA measures 23 mm. Levophase demonstrates

unobstructed bilateral pulmonary venous return to the left atrium. No discernible atrial

level shunting is present.***Due to her anatomy and atrial baffling, the RV was difficult to enter using the

conventional wedge catheter. A 5Fr AR1 over an exchange length glide wire was used

to enter the RV then pulmonary arteries. The AR1 catheter was exchanged over the

glide wire for a 0.035 Quick Cross catheter. An 0.035 Amplatz ES wire was used to

exchange for pressure measurement with a glide catheter and 5Fr pigtail for angiogram.

The patient came in for an aortic valve replacement (33405). After the valve was placed, a hematoma was discovered and a repair with a wrap took place. Code 33859 states for aortic disease other than dissection. We are unable to locate a resource that shows a hematoma would fall within the guidelines for the graft placement. Would the hematoma/wrap be best supported with 33999 compared to the 33859?

"Normal functioning of the mechanical valve with no evidence of valvular nor perivalvular insufficiency. The heparin effect was reversed with protamine and decannulation was carried out surgical hemostasis was assured. Patient did have evidence of subadventitial superficial hematoma overlying the mid ascending aorta just distal to the aortotomy site in this area of the aorta was reinforced with an adventitial wrap of using a Dacron graft and a running 3-0 Prolene suture."

Please advise if documentation supports both 34201 & 35256 or 35302 only. Provider reported 34201 and 35256. 

Patient S/P TAVR w/occlusion of RT CFA/SFA @ site of closure device w/intimal disruption, dissection. Vertical incision made & closure device removed. Extended arterial puncture site w/Potts proximally then distally into the proximal SFA. Performed endarterectomy of CFA/SFA & tacked distal intimal edge w/multiple sutures w/sluggish backbleeding from SFA. Proceed w/FEM-POP catheter thrombectomy, #4 Fogarty thrombectomy, distally into SFA w/ retrieval of minimal thrombus. Segment not amenable to primary closure due to extent of arterial wall loss. Proceeded with harvesting of short segment of great saphenous vein. Vein graft sewn in place to the CFA/SFA in a patch angioplasty manner. Endarterectomized segment was flushed antegrade & retrograde prior to tying of our anastomosis. Closed the femoral sheath w/running 2/0 PDS. Closed the subcutaneous tissue in layers, closed the skin w/ running 4/0 Monocryl.

Our physician completed an embolectomy through the RT CFA. He found significant atherosclerotic disease in the RT CFA and decided to treat with the Endarterectomy as well. There was only one arteriotomy we explained that only one would be billable. But in this case, he is questioning it since there was the finding of the significant atherosclerotic disease. Can you please let us know if both would be billable in this case?

"Arteriotomy in the CFA which was extended through the femoral bifurcation onto the SFA. Large amount of calcific plaque was identified in this area and an endarterectomy was performed. Embolectomy catheter passed retrograde, artery crossclamped. Embolectomy catheter passed down profundofemoral artery distance of about 20 cm with no return. Embolectomy catheter passed down SFA down popliteal and into the peroneal artery. It was passed to 65 cm. Thrombus was removed. Saphenous vein in the groin was then harvested spatulated reversed and using a running suture was sewn in a patch angioplasty type fashion to the arteriotomy on the CFA."

When CPT code 93880 is reported and bilateral common, internal, external carotids and vetebral arteries are imaged and noted in report, is it adequate to report that the vetebral arteries have antegrade flow or do pressures also need to be reported?

Would additional catheterizations and imaging (LT innominate, RT brachiocephalic) outside of the target treatment zone be separately reportable in the case below or is this included in 0644T?

"Right common femoral vein access. Catheterized Right external iliac vein. Venography was necessary due to questionable thrombus noted on ultrasound. Additionally, the patient has a left groin dialysis catheter which can make the patient more susceptible to thrombi. There is concern that the catheter may

either induce a scar, stenosis, or thrombotic event that would be worsened by advancement of large sheath.

Findings: Widely patent external and common iliac veins as well as the inferior vena cava. No evidence of high-grade stenosis, occlusion, or thrombus formation.

Catheterized Left innominate vein. Findings: Widely patent left innominate vein. With patent superior vena cava and right atrium. Suspicion for continued fibrin sheath within the superior vena cava. No evidence of complication such as active extravasation.

Catheterized Right brachiocephalic vein.

Findings: Patent right brachiocephalic vein and superior vena cava. Small residual fibrin sheath noted. No definite complication. No obvious large pulmonary thrombus.

Mechanical or aspiration thrombectomy Venous segment treated: Right atrium and superior vena cava

Transesophageal echocardiogram findings: TEE was performed by the anesthesiology service.

This was used to successfully advance the flush catheter to the fibrin sheath with subsequent aspiration of the vegetations. Selection and aspiration was performed under real-time TEE guidance. There was visualization of the thrombectomy. No evidence of embolization material by TEE."

When a fluoro-guided injection for arthrogram is performed in x-ray, should code 73040 be reported, as it specifies for arthrogram, rather than 77002? It also instructs to code also arthrography injection procedure (23350).

An IFR (without stress agent) is performed, and then the physician decides to perform an FFR (with stress agent) of the same coronary artery. Are codes 93571 and 93799 both able to be reported for the same artery?

Some radiology codes state that two studies should not be coded on the same day unless performed during "separate encounters", in which case modifier -59 should be applied.

The question is how is an encounter defined? What constitutes a different session? Separate reports? If times are the same or within a few minutes, is this a separate session? We always have two separate reports - two orders - but the images were done minutes apart (the patient certainly never left the scanner). Is there a specific amount of time that needs to pass for it to be a new encounter? We have this issue come up with our US abdomen studies.

Hello Dr. Z. Pacemaker and AICD insertion codes include a subcutaneous pocket creation. If the pocket is created under the pectoral muscle at the time of implant, is the pocket creation still included? I see your advice on relocation to a subpectoral plane but nothing on initial insertion to a subpectoral location. Our plastic surgery providers will work with our EP providers to create the subpectoral pocket. Should we code this with the device insertion only or should we code the device insertion along with an unlisted code for the subpectoral pocket? Thanks Dr. Z!

Codes 35371 and 35875 (fem-pop bypass) do not bundle, but I believe since these are performed through one arteriotomy that only 35371 should be billed. Is this correct?

"At this point we placed profunda clamps on the profunda artery and cinched our vessel loops to obtain proximal control of the common femoral artery. We made an arteriotomy along the lateral aspect of the common femoral artery using 11 blade scalpel. Using Potts scissors we extended our arteriotomy proximally and distally onto the profunda artery. We performed endarterectomy of significant intimal hyperplasia using a freer elevator. At this point the two branches of the profunda artery appeared patent and healthy at this level as well as had good backbleeding. At this point we used a 4-0 Fogarty to perform thrombectomy of the right lower extremity graft. When we were no longer retrieving clot and had good backbleeding we stopped. At this point we performed a patch angioplasty of the femoral and profunda arteries using bovine pericardial patch with a 5-0 running Prolene suture."

Does 75893 and 76080 RS&I codes include ALL Imaging Guidance or only Fluoro Guidance?

When adrenal vein sampling is performed and fluoroscopic spin CT guidance is used, should we code 77012 in addition to 75893 (and of course 36500)? There is not a CCI edit between these codes.

Same issue with abscess/fistula tract 76080 study for abscess drain checks. It has been suggested this code only includes fluoroscopic guidance, however this isn’t explicitly stated in the code description and there are no CCI edits between code combinations such as 49424, 76080, & 76380.

Can you clarify if codes 75893 & 76080 include only fluoro guidance, or ALL imaging guidance? Is it appropriate to also code 77012 or 76380 as appropriate if Fluoroscopic spin CT guidance is used?

Patient has a functional LUE AV fistula and non-functional aneurysmal RUE AV fistula, causing pain - no infection. The physician decides to remove the RUE cephalic vein.

"We started with dissecting the cephalic vein down to the brachiocephalic anastomosis. The cephalic vein was noted to be extremely calcified and aneurysmal as it was transected close to the brachiocephalic anastomosis. An extensive endarterectomy had to be carried out including the brachial artery, requiring three sutures distally to tack down the distal endpoint. We were then able to close the cephalic vein close to the brachiocephalic anastomosis, closing the arterial venous anastomosis over the brachial artery. The suture line was in the cephalic vein, close to the brachiocephalic anastomosis, and endo venectomy had been carried out here too. We continued to excise the rest of the cephalic vein along the entire length of the arm, to the shoulder with, extensive mobilization."

Is this a revision 36832 or partial excision 37799? Is the brachial artery endarterectomy separately reportable?

Mammo/tomo biopsy is new to me, is one or the other guidance the deciding factor for code selection? Medicare is denying 19081 as not medically necessary.

Patient is seen for a tomosynthesis guided biopsy of calcifications in the 9 o'clock position of the right breast at a posterior depth. The patient's right breast was positioned and digital tomosynthesis images of calcifications in the 9 o'clock position of the right breast at a posterior depth were obtained. The lesion to be biopsied was localized, marked and targeted. The skin was prepped. 1% lidocaine was used for local anesthesia. A 9 gauge  EVIVA probe was inserted from a lateral approach and advanced into the tissue.  Core samples were then obtained. A total of 5 core specimens were obtained.

Digital specimen radiograph confirmed the presence of calcification in the core samples.

CONCLUSION: Successful tomosynthesis guided core needle biopsy of calcifications in the 9 o'clock position of the right breast at a posterior depth.

I am looking at CPT 33858 vs 33863. For repair of aortic tear with Aortic root replacement with a 32 mm graft and 25 Edwards Inspiris valve with reinsertion of right and left coronary buttons. Physician used a 25 valve and 32 graft conduit . There was no aneurysm this was a tear at the aortic root.

My providers have begun to use only Rutherford score as indication for lower extremity revascularization. Would this be acceptable from a coding perspective? Rutherford score 6 was documented, and it looks like that could fall under ulcer or gangrene. What are your recommendations?

"Through incision & under US guidance visualization of needle penetration of the bladder Yueh needle placed in bladder. Needle removed & urine drained. Dilating the tract was difficult despite using surgilube & serial dilators incl 6, 7, 8, 9, 10, & 12 French. This required us to resort to balloon dilation of the tract from skin to the bladder. Inflation performed 4mm balloon. Calcium within wall of bladder & thick wall of bladder a 10 French catheter was successfully placed. It was placed to facilitate upsizing & cystoscopy being performed by urology this week."

In addition to 51102 and 76942, could I report 50436 or 50437?

Please help! Should this be coded with 64479 or 62321? "1% lidocaine was used for local anesthesia. Under CT guidance, a 22-gauge needle was advanced to lie with its tip adjacent to the verve root. Appropriate needle position was confirmed with CT imaging and injection of myelographic contrast. A mixture containing 0.5 mL of 0.25% bupivacaine, and 10 mg of dexamethasone was then administered in and around the nerve root. the needle was then withdrawn. Pre-procedure pain score; 7. Post procedure pain score: 2. Successful CT-guided right C5 selective nerve root injection." The indication is for Foraminal stenosis of C-spine, radicular pain of RT upper extremity. Pt is S/P C-spine fusion (order does not specify the level of fusion). The facility is reporting 64479. The coder wants this changed to 62321 because there is no documentation of transforaminal. Do codes 64479-64484 require documentation of transforaminal? How should this be reported? Thank you!

We are wondering how to code this procedure. There is the question of the PA and PCWP. Would this be a right and left heart cath? And would there be additional reporting for the thermodilution and PCWP?

"The patient was brought emergently to the Cath Lab in cardiac arrest. The right femoral artery was engaged and selective angiographic images were obtained in multiple views. 6F and JL4 were used and the Left coronary artery was selectively engaged angiographic images were obtained.

We then obtained femoral venous access and a 6F sheath was placed in the same fashion as above. I then advanced a 5F Swan into the RH and the RA, RV, PA, and wedge pressures were recorded. PA sat was drawn. Thermodilution cardiac output was performed. Swan was removed. The patient tolerated the procedure well."

the procedure was to remove an existing leadess pacemaker from RV and insert a new leadless pacemaker in the RV. Our provider is dropping CPT 33274 for insertion and 33233 for the removal. Would that be the correct codes for this?

Is it permissible to bill 0715T with C9600?

My surgeon was called emergently to the OR during another procedure due to a rupture of the paravisceral aorta. He ultimately placed an Endurant II aortic extension cuff in the distal thoracic aorta to the paravisceral aorta to cover the celiac artery down to proximal to the SMA. Since this is the abdominal aorta I would like to use code 34702. However, the description states "repair of infrarenal aorta". What would you code in this situation?

Code 33745 would be billed if we were placing a stent in the pulmonary vein for congenital stenosis per page 414 (e book #19 & page 431#40) & page 647 in Chapter 10 (e -book #74) shows to report 33745 for stent placement for pulmonary vein stenosis in patients with congenital heart disease. What would be the appropriate way to report venoplasty of an existing pulmonary vein stent for congenital disease? Would we bill 37248 for venoplasty of existing pulmonary vein stent for congenital disease or do you recommend 33745-52 (#74 page 647 e-book) or is that for only the RVOT or 33999 (pg 648 #80 e book) since it is an existing intracardiac shunt?

Our IR dept reported 36223-50 and 36225, and insurance denied based on incorrect modifier. Should an add-on CPT code be reported? 

Left PCA aneurysm, SP coil embolization.

"Fluoro identified right femoral head introduced a 5 x 10 sheath into the right femoral artery using US, micropuncture and Seldinger technique. Angiography demonstrated adequate placement. Then introduced a 5-French catheter over an 0.035 Glidewire. Patient had very tortuous origins of her great vessels. I selectively catheterized the right brachiocephalic artery after attempting to catheterize the right common carotid artery. I evaluated the brachiocephalic artery for visualization of the vertebral artery and carotid artery. I then selectively catheterized the left common carotid artery and left subclavian artery to image the left vertebral artery. Each vessel was evaluated using multiple projections including the angiogram. I removed the catheter and sealed the arteriotomy."

Is this enough documentation to bill 93986 performed during the same session as the creation of the AV fistula?

"Ultrasound was used to map out the superficial femoral artery, femoral vein, and great saphenous vein in the right groin. The site in which they were closely related was marked on the skin."

Is the note "with direct ultrasound visualization" enough documentation to use CPT code 76932 for ultrasound guidance of endomyocardial biopsy? Example: "With direct visualization the right internal jugular vein was cannulated via modified Seldinger technique with a micropuncture system. A J-tipped wire was advanced and a 7Fx23cm sheath was placed. A 7 French bioptome was then used for the endomyocardial biopsy using fluoroscopic guidance."

Also does the provider's documentation have to state endomyocardial biopsy using/or under ultrasound guidance?

Would it be appropriate to report code 75820 in addition to 21615 when performed to demonstrate that no bypass or patch be needed? The provider also passed the vein outside of the treatment zone.

Would you code the repair of a gunshot wound in the thoracic aorta as a TEVAR 33881, 75957 or 37236, 36200?

In Question 17097, you recommend reporting 33999 for Lampoon procedure of the mitral valve at the time of other percutaneous mitral valve procedures. Can you clarify if you would report the other mitral valve procedure separately along with the 33999, or do you recommend reporting just 33999 for the entire surgical procedure ?

In my case the Lampoon procedure was performed in conjunction with a transcatheter mitral valve in valve replacement for which I would normally code 0483T. Do you recommend 0483T and 33999 in this case ? Thank you

Could you please resolve a coding issue btw coders. Is the below procedure CPT 62321 or 64479. And the reason for the code selection. Thank you! History of previous cervical spine injury. Exam consistent with an element of right C6 & C7 nerve root irritation. MRI documented pathology with foraminal compromise. A sterile prep of the cervical/thoracic spine. A local wheal was raised over the T2-3 interspace. Utilizing the LOR technique, a 15 gauge, epidural needle was advanced into the epidural space toward the ipsilateral side of the patient's pain. Negative aspiration for heme and CSF observed. A soft navigable epidural catheter was threaded under fluoroscopic guidance to each appropriate level/nerve root exit site. (right C6 & C&) and a total of 3mg of dexamethasone and lidocaine was gently and slowly injected toward the foraminal opening of each respective nerve root exit after a small of contrast confirmed proper placement in the epidural space along the ipsilateral side of the patients pain as well as at the level of suspected pathology.

What is the CPT for administration intraventricular thrombolytics through an existing EVD?

A patient has a diagnostic cath, which showed 75% stenosis in the LCX, and a stent insertion is planned. A month later he comes in for the stent, but angiography done at that time shows only 60% stenosis and no stent is placed. What procedure codes should I use for the second encounter?

What is the appropriate CPT code when TCAR is aborted and carotid arteriogram is performed via open exposure?

"Planned TCAR for internal carotid artery stenosis with associated occlusion of the external carotid artery. The common carotid artery was exposed and microsheath and arteriogram documented occlusion of the distal internal carotid artery at the level of the carotid bulb. The internal carotid artery was not visualized in the neck. The external carotid artery was occluded. It was decided to conclude the procedure based on these findings."

Our docs say we should be using 76492 with cath codes and interventions procedures (92920, 92928 and 37224, 37220). I have never billed this code with these procedures before. Please clear this matter up for our coders.

How would the following be reported during a mitral valve replacement (aortic valve exploration no repair or foreign body/mass or thrombus removal)? 

"There was questionable thickening of the aortic valve involving the noncoronary cusp. Due to the questionable nature the decision was made to explore the aortic valve. An aortotomy was then created above the right coronary artery. The aortic valve was then inspected this demonstrated small lumen like sac lesions along the left coronary cusp and there was some calcification on the ventricular side of the noncoronary cusp however there were no obvious vegetations. The aortotomy was then closed with a running 4-0 Prolene suture."

Would this also be reported, and with unlisted code 33999?

A SVC cavogram was performed through the catheter which showed a fibrin sheath in SVC. A 12 mm angioplasty balloon was advanced over the guide wire. The balloon was inflated in three different segments of SVC. A follow up cavogram showed widely patent SVC without any fibrin sheath. Subsequently a new tunnelled dialysis catheter was advanced over the guide wire. The 13.5F dialysis catheter wa tunneled under skin over right upper chest and then introduced over the guide wire with the tips positioned in right atrium under fluoroscopy guidance. The catheter was flushed with heparinized saline and sutured to skin with 2.0 Silk. IMPRESSION: 1.Successful replacement of a right jugular tunneled dialysis catheter. 2. Successful removal/disruption of fibrin sheath with angioplasty balloon. Is it appropriate to bill: 36581, 77001, 36595-52? Thank you.