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35907

In my research for excising an aorto-bifemoral graft, the only case I came across was one that was done on separate days of service. My question is, do I use code 35907 for the abdominal graft (they do incise the abdomen) and 35903-50 for the femoral grafts? Or do either of the codes include all of the graft? I am new to these vascular procedures.

Removal of Temporary Pacemaker

I was reviewing another coder's case, and they coded the removal of the temporary pacemaker. The situation is the patient comes in the ER during the night with symptomatic bradycardia and the on-call cardiologist puts in a temporary pacemaker (33210). The next day the implant physician places a dual chamber pacemaker and removes the temporary pacemaker. She is reporting codes 33208 and 33234. Is this correct?

Alcohol Ablation Splenic Cyst

How would you code a CT-guided alcohol ablation on a splenic cyst?

Abdominal Aortogram and selective extremity arteriogram

I have documentation of catheter placement at the infrarenals and the only impression is that of aneurysm and then movement of the catheter contralateral into extremtiy and ateriogram and impression of that entire extremity. Should the coding be 75630 and 75710 (with 59) or 75630 and 75774? I have no indication as to why they went selectively after the abdominal aortogram.

TAVR

I have a question regarding an open (33362) vs. percutaneous (33361) TAVR procedure. If the valve is delivered via percutaneous approach (i.e., modified Seldinger technique), but then the closure device fails at the end of the procedure, requiring an open femoral artery cutdown and repair, would you code the open procedure or percutaneous TAVR procedure? If you would still code as percutaneous TAVR, would you code separately for the cutdown (34812) and repair (35226)?

Attempted TIPS Revision via Combined Transhepatic and Transjugular Routes

How would you code for this thrombosed TIPS stent? "The RUQ was prepped, and under fluoroscopic guidance an 18 gauge Hawkins needle was used to access the proximal aspect of the Viatorr stent. A guidewire was successfully advanced into the right atrium. Then a gooseneck snare was advanced, via a previously placed left neck sheath, and used to capture the end of the wire. The wire was pulled through the vascular sheath and into the TIPS over the wire. A second wire and a catheter were inserted through the sheath into the Viatorr stent. The sheath was successfully advanced after the transhepatic Glidewire was removed, and it was advanced into the peripheral aspect of the Viatorr stent; however, multiple attempts that were made to recannulate the bare metal stent were unsuccessful. Procedure was aborted."

FEVAR

When choosing the code for repair of an AAA with a fenestrated device, is the code determined by the number of fenestrations or the number of stents placed in visceral arteries? The CPT code description says "including 1, 2, 3, or 4 visceral artery endoprostheses", which leads me to think the code is determined by the stents... but then how would I code a graft with four fenestrations and zero stents? My physician has done several cases where there are four fenestrations, and he only places stents in one, two, or three arteries.

New to Interventional Coding

I am also new to vascular coding. Which of your products (webinar, reference book, anatomical illustrations)would help to clarify catheter placement by order? Interventional cardiology is what I will be coding.

Arterial Thrombectomy

I have a physician who wants to charge for three arterial thrombectomies. Here is his documentation: "We then attempted AngioJet with a thrombectomy catheter, which did resolve about 30% of the clot. We then pulse sprayed 50 of the 100 ml, so approximately 10 mg of tPA, and let this dwell for approximately 15 minutes. Angiography demonstrated resolution of clot within the left popliteal. There was flow into the left anterior tibial, but again, no flow into the left posterior tibial or peroneal. CONCLUSION: 1. Severe thrombotic occlusion of the left popliteal, which was 100% occluded. There was no visualization of any of the three infrapopliteal vessels. 2. There is suboptimal mechanical thrombectomy of the left popliteal and tibioperoneal clot. An AngioJet thrombectomy with thrombolysis with pulse spray was performed of the left popliteal, left tibioperoneal trunk, and left anterior tibial arteries." So the question is, do we charge for codes 37184 and 37185 x 2? Or just report code 37184?

50395 and 74485

The radiologist and urologist are working together on nephrolithotomy cases. Is it appropriate to report code 74485 for the radiologist when they work together in the OR? For example: 1) The radiologist creates the tract (50395). The radiologist joins the urologist in the OR and dilates the tract for the stone removal and dictates a procedure report. Can the radiologist bill code 74485 for dilating the tract, or is it included with stone removal? 2) The urologist creates the tract, the radiologist and urologist work together in the OR, and the radiologist dilates the tract for the nephrolithotomy and dictates a procedure report. Can the radiologist bill code 74485 for dilating the tract in this situation?

Color Flow Documentation on Echo

I am being told that if the doctor dictates findings such as "left to right atrial shunt" or a "valve insufficiency" that this supports reporting code 93325 and that they do not need to dictate the technique used. My understanding is that color flow is a visual assessment, so you would need to note those findings were by color flow.

Aorta Graft Procedures

I'm trying to determine how to code this case correctly. "A midline sternotomy was performed. The physician replaced the ascending aorta graft (33860), total arch replacement with hybrid debranching graft to 10 mm branch to innominate artery, 8 mm branch to left common carotid, and 8 mm branch to left subclavian (33870, 35626 x 3). Then he performed a stent graft repair of descending thoracic aortic aneurysm with coverage of the subclavian with TAG graft (33880). A Dacon graft was sewn end-to-side to the innominate artery for the purposes of cerebral perfusion. Epiaortic ultrasound of ascending aorta (76998-26)."

Mechanical Removal Explanation

What specifically would be considered mechanical removal for coding? For example, what types of procedures would need to be performed for reporting code 49460?

Fluoroscopially-guided Balloon Dilation of Esophagus

Could you please tell me if unlisted code 43499 should be used in this scenario, or can code 43453 be used? I am thinking of the unlisted but need help. "A 5 French Berenstein catheter, in combination with a 0.035 inch Amplatz guidewire, was advanced through the oropharynx and cervical esophagus across the anastomosis and into the thoracic stomach. A 14 mm Atlas balloon was advanced over the guidewire and into appropriate position. The balloon was inflated. The waist resolved with inflation to 20 atmospheres. The balloon was left inflated for 1.5 minutes. The balloon was then deflated and removed. Repeat dilation was performed using a 16 mm balloon and inflated to 20 atm for 1.5 minutes. A repeat esophagram was performed. This demonstrated improvement in luminal caliber. There was no extravasation demonstrated."

Catheter Placement for Venous Thrombolysis

We are new to coding thrombolysis cases, and we are questioning what catheter placement codes we can bill. Our report states, "Venous access was obtained via the left popliteal vein. Next, the catheter was placed into the left common iliac vein. Contrast injection was then performed in the iliac vein and IVC to perform venogram at this location to make sure there is no thrombus there. We then performed popliteal and femoral vein angiography to the side port of the 6 French sheath placed in the popliteal vein." We have come up with codes 37212, 76937-26, 75825-26, and 75820-26 for the ultrasound guidance for the thrombolysis and for the venograms. We are questioning what catheter codes we can use. We currently have 36005, 36010, and 36011.

E&M

We are wondering if it is proper to charge an E&M code when we are performing a cardiac test on the same day in an outpatient setting. We would be the attending.

Rhythym Strip Before, During, and After Adenosine

The physician wants to perform this in the office during patient office visit. I do not think there is a code for this if done in the physician's office, but of course I can't find anything on it so maybe I'm wrong. Is there a CPT code for a rhythm strip before, during, and after adenosine is given? And is it supported when done in the office?

Cisternogram Injection Code

What CPT code do you suggest for the injection portion of the cisternogram, 62311? "DESCRIPTION OF PROCEDURE: Lower back was localized with intermittent fluoroscopy at the L3-4 level. The L3-4 level was marked, prepped, and draped in the usual sterile fashion. 5 mL of 1% Xylocaine was infiltrated into the skin and subcutaneous soft tissues of the lower back at the L3-4 level. Under fluoroscopic guidance, a 3.5 inch, 20 gauge spinal needle was slowly guided into the dural sac at the L3-4 level, yielding spontaneous return of clear cerebrospinal fluid. A shielded syringe continuing 1.5 mCi indium 111 DTPA was attached to the hub of the needle and injected intrathecally. The stylet was replaced, and the needle was removed."

Exchange of Tunnelled Pleurx Chest Catheter

There is no CPT code for the exchange of a Tunnelled Pleurx Chest Catheter. What is your coding recommendation for the case example below: a) unlisted CPT code or b) 49424/76080?? "Chest and abdomen were prepped and draped in usual sterile fashion. The right-sided chest tube was removed over a stiff Glidewire, which allowed for placement of an 11 French peel-away sheath. After successful creation of a subcutaneous tunnel, the 11 French Pleurx catheter was advanced through the tunnel and through the peel-away sheath into the right-sided thoracic cavity. The incision was closed with 4-0 Prolene. Catheter was secured to the skin at the exit site from the tunnel with 2-0 Monosoft suture."

Multiple Pelvic Hemorrhages

Please advise on the following. "History: Pelvic trauma and bleeding. Multiple pseudoaneurysms and one actively bleeding. The physician goes into the right internal and into anterior division and embolizes pseudoaneurysms. Then goes into the right internal iliac and into the anterior division and embolizes pseudoanerysms. Next, goes into the IMA and shoots angios of the superior hemorrhoidal artery - not bleeding. Goes into the middle sacral artery, which does show the vessel supplying the aneurysm, which was bleeding. It's embolized." Would this be considered all one surgical site and only code one embolization (37242 or 37244)?? Or do we code two different embolizations since one was for hemorrhaging and the other was to exclude non-bleeding aneurysms?

Carotid Angioplasty 35475

For PTA of an in-stent re-stenosis of the right common carotid near its origin, would I use codes 35475, 75962, and 36223 (findings were given on common, anterior, and middle cerebral arteries)? Or, would I use the unlisted px code 37799 with a -GZ modifier and 36223 for my catheter placement?

Venous Malformation Occlusion

If a patient is having a sclerosis as seen below, would I be able to use code 37241, or would I have to have an unspecified code 37799? "Multiple vascular malformation of left leg and left arm. Percutaneous track puncture sclerosis of vascular malformation. History: Multifocal venous vascular malformation. The patient presents for staged embolus embolization therapy of multiple focal low subcutaneous and superficial venous vascular malformations. Sedation: The patient received intravenous sedation with Versed and Fentanyl. Utilizing a combination of fluoroscopic and ultrasound guidance, access is gained to the multifocal malformation of the left leg and separately to the multifocal malformation of the left arm. With each puncture, embolization is performed utilizing Sotradecol mixed with contrast. Total procedure fluoroscopy time: 0.5 minutes."

Pediatric Congenital Cardiac embolization

I understand embolizations are reported per surgical site; however, I am confused as to how to apply that to pediatric congenital heart cases. If an embolization is performed both arterial and venous, is that only one embolization? Another example is embolization of the internal mammary and then embolization of the subclavian. I appreciate any explanation you can give me.

37217 vs. 37799

Should we use code 37217 or 37799 if the doctor directly exposes the carotid and inserts a stent that extends from the ICA into the carotid bifurcation? The stenosis is in the ICA. Code 37217 is intrathoracic, and ICA is not intrathoracic.

Multiple AVF Procedures, Different Zones

Could you please help with this coding scenario? The physician placed a stent in the innominate vein (37238) after accessing AVF (36147) and then placed a stent into the venous outflow, but also performed an angioplasty of the brachial artery. If the second stent is reported with 37239, can I report codes 35475, 75962 instead? Before, the rule was to code the arterial if they did both venous and arterial angioplasty.

Drainage Catheters

Our doctors were delighted to clear up the catheter drainage issue based on your respected publication regarding leave in or take out after drainage. The AMA/CPC and research I have done all agree with your original definition. The doctors said the extra work of catheter for drainage is the same whether it is left in or removed. And with the only publication I found that stated the catheter had to be left in when researched, upon further communication, the author stated it was her interpretation since 2005 that it should be left in and that it was not a direct quote from the AMA/CPC. So my question is, I am curious why the errata regarding catheter must stay in after procedure?

Stress Echos for Physicians

I recently started billing graphics again after many years. Since I last coded them I see they have added the option of a -26 modifier on code 93351. I would like to know if code 93351-26 includes the tracing (93017). My physicians do not do the tracing, so I thought I should be using codes 93350-26, 93016, and 93018. However, in a past question here, the answer stated that code 93351-26 includes codes 93350, 93016, and 93018 with no mention of 93017. In the CPT Codebook it says when all professional services of a stress test are not performed by the same physician to use code 93350 with the appropriate codes (93016-93018) for the components that are provided. Since my physicians do not perform the tracing, this sounds to me like I should be using codes 93350, 93016, and 93018 instead of 93351-26. Thoughts?

36224, 36223-59, No Catheter Placement

There is some disagreement on billing the following situation: "Patient presents with subarachnoid hemorrhage. Diagnostic cervicocerebral was performed with catheter placement in both right and left common carotid arteries. Angiography was performed, showing critical narrowing of the left middle cerebral artery due to vasospasm. There was also narrowing of the right middle cerebral artery. Catheter was removed. Then a microcatheter was positioned in the left internal carotid artery, which was confirmed by angiography. The catheter was infused with 10 mg of verapamil for 40 minutes. Follow-up angiography was performed after the 40 minutes of infusion." I would bill codes 37202-59, 36223-50, 75896-26-59, and 75898-26. Others feel code 36216 should also be billed for the microcatheter in position in the left internal carotid artery. What are your thoughts?

Attempted Upgrade Dual Chamber ICD to Biventricular ICD

"MD Summary Conclusion: Unsuccessful attempt to 'upgrade' a dual chamber defibrillator to a biventricular defibrillator due to unsuitable venous anatomy. The left ventricular lead could not be passed beyond two of four electrodes in any given vein branch. Three separate vein branches were cannulated during these attempts. Three hours and thirty-six minutes were spent attempting to place left ventricular lead before upgrade procedure was aborted." If I code for successful procedure, it would only be a venogram (36005), which we don't typically bill. If I code for attempted left ventricular lead insertion (33225-74), it will edit due to add-on code without primary. I was considering using code 33224-74 because it most captures this situation. What would you recommend?

Repair Catheter, 36575

Can this code be used for re-stitching the catheter place? Or is it only for replacing the hubs? Are there other uses for this code?

Unsucceesful Stent vs. Successful PTCA

The physician made several attempts to cross the lesion in order to place a stent. It was unsuccessful. He ended up doing a plain old balloon angioplasty. The stent will be replaced by rep. What should we bill for hospital, code 92928-74FD or 92920? And what codes for physician billing, code 92928-53 or 92920 (with location modifier added also)?

Carotid Bypass Excision and Revision

I am trying to determine coding for excision of previously placed carotid bypass and placement of another carotid-ipsilateral carotid bypass. Does this qualify for code 35501 or repair blood vessel code 35231, or is this unlisted procedure? "Procedure Description: We carefully dissected the common carotid artery bypass graft and then extended the dissection more distally and identified internal and external carotid arteries. These were encircled with vessel loops and clamped in order, internal, external, and common carotid. The graft was completely excised, and the proximal end of the greater saphenous vein was spatulated, and an end-to-end anastomosis between the vein and the very distal common carotid artery at the bifurcation was carried out using 6-0 prolene suture. Following completion of the anastomosis, the proximal common carotid artery was spatulated, the vein was cut to appropriate length and spatulated, and an end-to-end anastomosis was then created using 6-0 prolene suture."

Code 76536

We receive orders for patients with a history of thyroid cancer and enlarged lymph nodes. We are asked to perform an ultrasound evaluation of the thyroid postsurgical bed and to map the neck lymph nodes levels I - VI, bilaterally. Are we able to charge more than once for CPT code 76536 because of the amount of work involved and the different anatomical body parts?

Renal Hilar Mass 50200 vs. 10022

Can you tell me what code you would use for an FNA of a mass in the hilum of the right kidney? When I look at code 50390, it states it is used for cysts or urine in renal pelvis. Here is a portion of the report to help clarify. "Indications: An 81 year old female with history of infiltrating mass in the right kidney suspicious for malignancy probably transitional cell carcinoma, however, could also represent lymphoma. Under CT guidance, a 19 gauge guiding needle was advanced into the periphery of the right kidney. Through this access, a 22 gauge Chiba needle was utilized to fine needle aspirate the hilar mass. Three separate fine needle aspirations were performed, and the samples were sent to pathology. The needle was removed, and a sterile dressing was applied. Path report: Bloody material containing discohesive atypical cells and a few cytologically bland glandular appearing cells."

Venous Duplex with Vein Mapping

Patient presents for bilateral evaluation of lower extremity varicose veins and venous insufficiency. We perform a venous duplex Doppler examination that includes vein mapping. Are we able to charge anything in addition to code 93970 for the vein mapping?

Endovascular Aneurysm Repair with Aortic Cuffs

"Patient has history of end-to-side aorto-bi-femoral bypass and has developed a large AAA anastomotic aneurysm at proximal aorto-bi-fem bypass anastomosis. Aorto-bi-fem limbs are patent. After right fem incision, sheath was advanced up right iliac system. Surgeon placed aortic cuffs starting distally from old aorto-bi-fem bypass and building proximally up to infrarenal aorta utilizing 5 aortic cuffs overlapping. Proximal, distal, and junctions were ballooned. Angiogram revealed junctional leak. Reballooned. Persistent junctional leak. Two more cuffs were placed overlapping in midportion of previously placed cuffs and then ballooned. Leak improved, but was still faintly present. Patient not candidate for open repair. Surgeon feels that with heparin reversal and time this faint leak will seal." Is aneurysm repair with tube prosthesis 34800 and one cuff 34825? Or is the initial code 34825 since he used cuffs and it is for aneursym repair? I see the cuff code descriptions are for inital vessel and each additional vessel. This was all done in the aorta, so only one vessel had intervention. Seven aortic cuffs in all.

Single Chamber Pacemaker Upgrade to Dual Chamber

"Patient came in for elective subcutaneous pacemaker generator change. This was performed and seemed successful. But, prior to extubation, pacemaker lost capture. It was decided to replace the whole system. Patient was re-prepped and draped. A sternotomy was performed. Bipolar epicardial lead placement, with suboptimal parameters; a unipolar screw-in lead was then placed in the right ventricle at base of heart. Process was repeated, with same leads then placed in the right atrium free wall. Unipolar leads showed good threshold. The pacemaker pocket had been opened and subcutaneous pacemaker removed. All four new leads were tunneled to the pocket. Pocket was revised to hold new hardware. Bipolar leads were capped; original V-lead was also capped. New unipolar leads were connected to new dual chamber pacemaker." I know I need to report code 33202 for the epicardial lead placement. My dilemma is that the CPT Codebook says to use code 33202 with 33213 for pacemaker insertion with existing dual leads, but isn't code 33213 for when a previous generator is not being removed during same session? Would it be appropriate to bill either codes 33202/33228 or 33202/33214 for this scenario?

Modifier 74 with Ablation Codes

We are trying to come up with a guideline for this. What is your opinion? If the physician doesn't give a reason for doing less than a comprehensive diagnostic study before an ablation, I believe that modifier -74 should be appended by the hospital rather than the -52 modifier, since the time, staff, and equipment remains pretty much the same. If I remember correctly, modifier -74 is also appropriate to indicate that a planned surgical or diagnostic procedure was partially reduced at the physician's discretion.

Procedures on the Vessels of the Foot

What code(s) should be used when angioplasty, atherectomy, or stenting is done to the arteries or veins of the feet?

Percutaneous Conversion to Open Saphenous Vein Therapy

If attempting venous laser ablation of incompetent vein (36478) and encounter stenosis/blockage that you cannot get wire/cath through, and you abort procedure and do open ligation, would you only code the open ligation and omit code 36478-74 modifier entirely? I cannot find this particular example documented.

Attempt at Acute MI

Patient with AMI taken to lab. Diagnostic cardiac cath (93455) was performed, and upon trying to intervene on the culprit lesion the physician was unsuccessful in crossing the lesion and the procedure was discontinued. The physician does not document the intended procedure (i.e., angioplasty alone, angioplasty with stent, angioplasty with atherectomy, or all three). In the absence of clear documentation of the intended PCI procedure, considering code 92941 requires combination of angioplasty with either stent and/or atherectomy, should we report code 92920-74? Being conservative rather than assuming without documentation that a stent and/or atherectomy was planned?

Breast Localization Brachytherapy Sources

Would you please guide us with the following question? We’re going to start a new service where we inject radioactive seeds under mammographic guidance or ultrasound guidance for women who will have subsequent breast tumor removal. The seeds will be removed with the tumor during the operative exam. We need the localization and supply codes for the seeds.

Exchange of Biliary Draing

I have a patient that we are exchanging an external biliary tube with an internal external biliary tube. Would I just code for the placement of the new internal external tube?

ICM Remote Interrogation

If remote ICD and ICM interrogation is performed, can the next remote ICM interrogation be performed on day 31? Are the service periods separate for ICD and ICM?

Lombard AorFix Device

Physician used a Lombard AorFix device to repair a common iliac aneurysm that extended into the internal iliac artery. Internal iliac was embolized, and the device was placed just below the renal arteries, seated at the aortoiliac bifurcation, with one docking limb extending down the common/external iliac and covering the internal iliac. Reason for device was due to torturous aorta in a patient with multiple surgeries for colitis with a colostomy and a chronic abdominal fistula.

Mediastinal Node Biopsy

How would you code for a core needle biopsy of a mediastinal lymph node? The report stated the biopsy was challenging because the lymph node was close to the heart and pulmonary artery, so it definitely was not superficial. We didn't think code 38505 really applied here, but it is not abdominal or retroperitoneal, so we didn't know if we could use code 49180 here. Would it be appropriate to report code 32405 for a mediastinal lymph node or not?

Independent Interpretation of a Cardiac Cath

We've got a physician who just started with us who states that he has been able to bill for independent interpretations of cardiac caths that were previously done on a patient. Is that possible? What code would we use?

CPT 96420 for Chemoembolizations

I was reviewing chemoembolization guidelines, and it says that code 96420 can be reported per the 2014 CPT Codebook, but I always understood that code 96420 should not be reported in a facility setting for physicians (only in an office setting). I work for a cath lab in a hospital where they perform these procedures. It is considered an outpatient department for billing purposes even though inpatients and outpatients are treated there. I do charge capturing for the facility side and coding for the physician side. The physicians note in their reports that "chemotherapeutic agents were prescribed and administered by (physician name)". I have not reported code 96420 in the past or currently based on guidelines. I do use code 79445 for the Y-90 cases we do. But I've had some of the business staff and physicians asking if I'm coding this because they are doing the work, so they think it should be coded. Am I correct not to report code 96420, or should it be reported? I need some clarification on the guidelines.

Vasospasm Treatment

A question has come up about vasospasm treatment. Is vasospasm treatment always billable? For example, if the physician documents that there was a mechanically induced vasospasm (meaning that it was as result of the intervention or catheterization), can we bill for the treatment done during that same intervention or cath operative session? I seem to recall seeing somewhere that if we cause the vasospasm we can't bill for the immediate treatment done in the same operative session. However, now I can't find that documentation to support this.

Subclavian Brachial Artery Bypass Graft

My doctor was treating a patient in a motorcycle accident. He had a traumatic injury to the right subclavian artery with loss of blood flow to the right arm. Due to the extent of injury to the subclavian artery, he decided to do a subclavian-brachial bypass with graft. I’m not coming up with any CPT code to describe this based on the distal portion of the bypass being the brachial artery and the use of the graft instead of a vein. Should I use the unlisted code?

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