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US Scan for AAA

Is there a CPT Category I code for 3D ultrasound for AAA? HCPCS Level II code G0389 seems appropriate for Medicare; however, I am looking for a non-Medicare CPT Category I code that is comparable.

Blood Work During Cath Lab Procedures

Should blood glucose testing and ACT checks during heart catheterizations be separately reported for hospital charges? These can get quite numerous during a case.

CT Perfusion

At our institution, CTA brain and separate perfusion analysis with Diamox challenge is performed. We've referenced your 2014 Diagnostic Radiology Coding Reference, which states to code only non-contrast CT. We're performing CTA; how should we code the study? Can you explain to us why it is or is not appropriate to code 70496 and 0042T?

Pulmonary Vein Stenosis

How would you code the following? "Patient had a right and retrograde left heart catheterization with transseptal puncture, left atrial angiography, selective left pulmonary vein angiography, and selective right inferior and right superior pulmonary vein angiography. Patient found to have stenosis, and then left common pulmonary vein was stented, and the right inferior pulmonary vein was angioplastied." I came up with the following codes: 93460, 93462, 92997, and 37238.  What are your thoughts?

Documentation of Cerebral Angiography

We have a question concerning documentation. Is it enough to charge for fluoroscopy during a VAD insertion when the fluoroscopy is only documented in the list of procedures and not mentioned in the body of the operative report? Also, is the following sufficient to charge? Again, the actual selective vessels are listed at the top of the report, with the “select the above mentioned vessels” in the body of the report. The findings are documented. We do believe this documentation is sufficient, but I want to ensure it would hold up on an audit. "Vessels catheterized: 1) Right common carotid artery. 2) Right vertebral artery. Technique: Cerebral angiogram performed. Next, using a micro-stick singlewall puncture, the right common femoral artery was accessed and a 5 French sheath placed with a modified Seldinger technique. A 5 French DAV catheter and 035 Glidewire were navigated under fluoroscopic guidance to select the above-mentioned vessels. Multiple angiographic images were obtained. At the end of the procedure, all catheters and wires were removed."

Catheter Placements Fem-Pop Graft, then Popliteal, then Tibial

Could you please confirm catheter placement codes on this sample case? "Contralateral approach: A catheter was used to select the origin of the left femoral-popliteal arterial bypass graft. Catheter and wire were advanced through the thrombosed graft (36247) into the proximal popliteal artery (36247 or 36248??). The catheter was then used to select the anterior tibial, posterior tibial, and peroneal arteries (36248 x 3???)."

PDA Ductal Occlusion Coding

For 2009-2013, was it incorrect to use codes 37204, 75894, and 75898 for PDA occlusion with an Amplatzer plug device through either the femoral venous or femoral aortic approach? Follow-up angiography was performed in the descending aorta with each procedure.

Code 33881 vs 33886

Placement of catheter in the aorta x 2; endovascular thoracic aortic repair without coverage of the left subclavian artery. Use of non-coronary IVUS, graft used 42 x 42 x 150 proximal main graft, extension of 46 x 42 x 150. Patient had a rupturing thoracic aneurysm. The patient had previous stent grafts, and the components had separated. The decision was made to bridge the separation of the components as well as extend past the aneurysm to cover the aneurysm. It was felt that we would bridge the components with a 42 x 42 x 150 graft. This was passed over the wire. Pigtail catheter was utilized to confirm position using LAO picture view, and the bridging component was placed. Angiogram was again obtained, again localizing the celiac artery, and a second distal extension was placed. The grafts and attachment sites were ballooned. Would the bridging of the prior thoracic components be reported with code 33881 or 33886 since the patient had prior stent grafts? I know we can't use both 33881 and 33886. The physician states that 33881 is the correct code.

Neuro Intervention Catheter Placements

I have a question regarding catheter placements during neuro interventions. Often times, a diagnostic study is performed with catheter placed in a lower vessel (e.g., the internal carotid) along with the corresponding imaging. This would be reported with code 36224. There are findings related to intracranial (e.g., middle cerebral artery) blockages, which can be treated with thrombectomy, embolization, etc. I know the catheter must be placed within these intracranial vessels in order to perform the intervention; however, since there is not a diagnostic study to go along with the catheter placement, you cannot report code 36228. What, if anything, can be reported for the catheter placement within an intracranial branch artery during a neuro intervention when a diagnostic study was not performed in that branch?

Post Ultrasound Guided Breast Biopsy

I understand we can now bill for a digital mammogram if performed after an ultrasound-guided breast biopsy. However, if the mammogram is performed for the intent of verifying the clip placement only, the mammogram would not be considered a diagnostic study, correct? In other words, does the digital mammogram need to have diagnostic findings in addition to the verification of the clip placement in order to be billed? As well, does the radiologist have to be a different doctor than the doctor who performed the biopsy?

Pelvic Embolization 37242

I have a case, and I don't know if there are too many codes for this one. Please let me know if I have the correct codes: 37242 x 2, 75736 x 2, and 36247 x 2. Cervical ectopic pregnancy; selective catheterization of the left iliac artery is performed. DSA imaging is performed followed by superselective catheterization of the left uterine artery. There is hypervascularity of the uterus, in keeping with the patient's gravid state. Increased flow is noted in the region of the cervix. Embolization is performed with PVA particles and embolization coils until near stasis is achieved. Next, catheter is advanced to the right internal iliac artery, and DSA imaging is performed. Similarly, superselective catheterization of the right uterine artery is performed followed by similar embolization. The patient tolerated procedure well. There are no immediate procedure related complications. Hypervascular uterus. Successful bilateral uterine artery embolization."

Repositioning chest port

When a CVC is repositioned (indication: "Malposition of chest port") can cath placement, Sup vena cavagram, US access also be billed? What if the CVC is initially repositioned but then (after re-positioning/snared) it is removed and a new one placed in this location? Would this then be a replacement only or in addition to repositioning? I would reallly appreciate your expertise as we are trying to better understand the correct billing of these?

Code 76937

Does the following procedure technique support reporting ultrasound guidance code 76937? "Under sterile technique and intravenous sedation, the RIJ vein was punctured using ultrasound guidance. Hardcopy ultrasound images of the RIJ were obtained and stored. The RIJ was patent by ultrasound."

Abandoned Radial Access

I’m having a debate with myself on how to code this: "Radial access obtained. Resistance with attempts to advance a 5 French sheath and the patient complaint of pain. Angiography showed a small patent radial artery without focal stenosis, dissection, perforation, or other complications. As the 5 French was completely occlusive and could not be advanced, it was removed and hemostasis was obtained. We then obtained femoral access and completed the procedure." Would you code the angiography or radial access? And, if so, with what codes? I am leaning toward just reporting code 93458 since I do not have a diagnosis found on the angio... and the access would be included?

Code 37243 with 36245

The below SIR-Sphere procedure was reported with codes 37243, 36247, and 36245.  Should modifier -59 be added to codes 36247 and 36245?

PROCEDURES PERFORMED: 1) Celiac arteriogram. 2) Superior mesenteric arteriogram. 3) Selection of the replaced accessory hepatic artery with arteriogram. 4) Yttrium-90 SIR-Spheres radioembolization delivered via the replaced accessory right hepatic artery by operating IR in conjunction with the authorized user supervising the procedure. 5) Post embolization arteriogram of the replaced accessory right hepatic artery. 6) Fluoroscopic guidance for the above.

Code 9728

How would you code a needle loc of the buttock region?

Pre-Operative Pain Injections, Code 64450

What are the documentation requirements for the pre-op nerve block (e.g., intrascalene 64450) for post-op pain? Is it necessary to have a separate written order from the surgeon for the procedure? Or is it acceptable to have anesthesia document that it was requested by surgeon for post-op pain control? Is it required that the anesthesia professional doing the procedure be a different person from the anesthesiologist of record for the main surgery?

Codes 10140, 97605

I have a procedure described as an I&D with debridement. "Patient has a working AV fistula in the same arm. A vascular surgeon opened a lymphocele in the arm 15 cm, which produced bloody serous fluid, no apparent infection. Blood clots observed around base of the wound with no active bleeding. Cautery used for hemostasis of would edge. Culture taken. Attempted fistulogram by several attempts to access the brachial artery with ultrasound failed to obtain access. Wound packed open for future placement of wound VAC." I am finding unlisted procedure code 37799 to describe the open surgical portion of this procedure and 36147 with a -74 modifier for the attempted AV fistulogram. Is there a more appropriate CPT code to describe this procedure?

CMS Pacemaker/ICD Interrogation and Programming Services Guidelines

Have there been any updates to the CMS Pacemaker Clinic services guidelines? I remember hearing that there was supposed to be an updated NCD update to these very old guidelines.

Hypoplastic Left Heart Syndrome

Hypoplastic left heart syndrome consists of several defects - mitral and aortic valve, aorta, and left ventricle. The question came up about whether other related conditions should be separately coded out with ICD-9 codes (mitral stenosis/atresia, aortic valve stenosis, coarctation of the aorta/aortic arch) or if all of these conditions associated with hypoplasty left heart syndrome would fall under the one ICD-9 code.

Code G0365

Code G0365 confuses me. Code 93971 is a complete upper or lower extremity study. For code G0365 to be used on the same day it has to be a different site. That would have to be a different extremity, correct? It says code G0365 may only be utilized in patients who have not had a prior hemodialysis access prosthetic graft or autogenous fistula and is limited to two times a year. Then it says, if code G0365 is performed on the same date of service as 93990, append modifer -59 to code G0365. Does the second statement mean that if the graft/fistula becomes unusable then the first statement does not apply and code G0365 can be used on a site away from the graft?

Collateral Artery Coding

Thank you in advance for your help: Access right femoral artery unsuccessful. Left femoral artery entered percutaneously & sheath placed. Cath inserted into arterial sheath advanced to systemic ventricle with guidewire. Oximetry & blood gas obtained from descending aorta. Pressures obtained from descending & ascending aorta, left ventricle. Thoracic aortogram performed cath removed. Cath inserted into arterial sheath advanced to mid-thoracic aorta. Visualize collateral arteries. Intercostal artery angiogram performed. Transit cath inserted & advanced to lower left collateral artery. Tornado coils injected through transit cath, transit cath removed. Visipaque used to visualize higher collateral artery. Transit cath advanced over glidewire into second intercostal artery, coils injected through transit cath, transit cath & glidewire removed. Cath & guidewire advanced to mid-thoracic aorta. Middle left collateral artery engaged, cath recoiled. Artery reentered, no flow, descending thoracic aortogram performed.

Cancelled Cardiac Ablation

We have a patient who was scheduled for a cardiac ablation. The EPS catheters were inserted; however, when they got to the IVC they were unable to advance further. Imaging was done of the IVC, which showed occlusion. At this point, the procedure was cancelled. Do you recommend coding the ablation procedure with a -74 modifier (93653-74), or do you feel it would be more appropriate to code the venous catheterization with IVC imaging only? I'm not sure if what was done is enough to justify coding an attempted procedure.

Pacemaker Dual Replaced with Biventricular ICD

These cases still confuse me. Patient had a dual pacemaker and right ventricular lead replaced with a biventricular ICD with left ventricle lead. It's the replacing of the generator that throws me off because we are replacing a pacemaker with an ICD.

Professional Report

What is the appropriate DOS that shoud be used when billing for the interpretation/report of a diagnostic test (when the interpretation/report are done on a differant date than the diagnostic test itself)? Would you use the date the test was performed or the date the physician did the interpretation/report?

Bilateral tPA Infusion

Our patient had bilateral tPA infusion catheters placed in each radial artery for frostbite in thumbs and fingers. On the subsequent day, follow-up angiography was done through each catheter. The catheter in the right arm was removed, as flow had improved. The catheter in the left arm was exchanged and tPA continued with hopes of improvement in flow to the digits in this hand. The plan is to return in the morning for another follow-up. I get edits if I try to put code 37213 for the left arm and 37214 for the right arm. What are your thoughts on how to charge this bilateral follow-up/cessation of the tPA infusion?

75710 vs. G0278

When billing for non-selective injection of the ileofemoral system during cardiac catheterization, Medicare recognizes code G0278. For carriers that do not accept this code for this service, can we bill code 75710 or should we not bill for this service at all?

Ligation of Axillary Vein

How would you bill for ligation of axillary vein and its tributaries to control bleeding from a gunshot wound?

Procedure in detail: Patient's right anterolateral thoracotomy generously exposed the third portion of the axilla and the axillary artery and vein. Myriad tributaries and the axillary vein itself were lacerated, both by direct impact and cavitation. Serial Prolene 4-0 sutures over sewed, ligated the venous tributaries, as well as the anteromedial wall of the axillary vein itself. Copious irrigation was used. Hæmostasis was achieved, though the pectoral muscles (minor and major) were injured from the GSW blast. The axillary artery was palpated, and no overt injury was noted. Closure is under the ægis of Dr. X.

Code Q9967

For place of service 11 (doctors office) can we bill code Q9967 (contrast material) when we are performing a procedure such as fistula angioplasty, fistula angiogram, etc.? And, if we can, are there any Stark rules we should be aware of?

Snorkel of Subclavian Artery

The physician performed a TEVAR with coverage of left subclavian artery (open exposure to left brachial and right CFA) with an "added iCast stent in the left subclavian to achieve nice Snorkel technique hybrid type repair". No detail other than this sentence. "T" codes are gone, but they were for renal Snorkel. Is there a code for a subclavian Snorkel, or is it included in the "coverage of subclavian"?

37213, Selection of Third Level Vessel

The physician here wants to charge for selection of third level vessel on the second day of thrombolysis. From what I am reading, catheter repositioning or exchange of previous placed intravascular is included. An example of dictation is as follows: "There is apparently a stenosis in the proximal anastomosis site probably that is the culprit causing the shutdown of the graft. There is still a decent amount of thrombus also in the anterior tibial artery, which is her main runoff, and there is a lot of thrombus in that artery, so we decided to do thrombolysis further into that artery. I was able to pull the catheter from the peroneal artery, which was a donor before, and then reselect the anterior tibial artery. Then we changed a new catheter and pushed the catheter into the artery, and we could not push further, just to the mid calf, so we then placed an infusion wire over that catheter and into the distal end of the anterior tibial artery. We could not do thrombolysis again today, so we are going to take patient back to check."

Shoulder Arthrogram 73040 vs. 77002

During a shoulder arthrogram, I understand that you report code 73040 if images were taken before and after injection. If only spot films were taken, you would use code 77002. Can you tell me if it matters what kind of images were taken? I am including a clean copy of the report for your review. "Exam: Right shoulder arthrogram. History: Right pain since October. History of prior rotator cuff tear. Scout images of the right shoulder were obtained. An appropriate site for skin entry was chosen, marked, prepped, draped, and anesthetized in the usual sterile fashion. The right shoulder joint was entered using a 22 gauge spinal needle and 9 mL of the standard mixture of non-iconic intravenous contrast and gadolinum were injected. The needle was withdrawn, bandaid applied, and no complications were noted. Contrast is suspected in the subacromial/subdeltoid bursa, and the appearance is certainly worrisome for and compatible with rotator cuff tear. 3.5 minutes of total fluoroscopy time was used. The patient was sent to ME in stable and satisfactory condition."

Bilateral Breast Biopsy

In your 2014 Interventional Radiology Coding Reference, you instruct to code by lesions not by the breasts - if biopsy was performed in right and left breast (using the same guidance modality) to code using a primary code with an add on code. It's conflicting with 2014 CPT Codebook, which instructs you to use one code (the primary one) with modifier -50. Thank you for your help in advance. 

Excision of Seroma Capsule

I have asked other coders and no one really can give me a clear answer on this... A patient develops a seroma, and an incision is made and it's drained, then the decision is made to excise the capsule. Since it is connected to the artery normally, it is more complex than just an incision and drainage. So what would you code the excision as?

Diagnostic Angiography

From a claims review perspective for interventional radiology procedures that include angiography in the CPT description, would the procedure note include documentation to support billing a diagnostic angiography procedure? It's not always clear, especially if there is no prior angiography, change in the patient's condition, etc. referred to in the note and could result in non-reimbursement of a code (which is unfortunate considering the work that was done).

Snorkel Stent CIA for 2013

Can you help with coding for the Snorkel repair in 2013?

"DX: infrarenal abdominal aortic aneurysm. 2. L & R common iliac artery aneurysm 1. Percutaneous endovascular repair of the abdominal aortic aneurysm as well as the common iliac artery aneurysms using the Endologix AFX graft (main graft 22 mm x 120 mm x 16 mm in diameter for both limbs with suprarenal extension measuring 28 mm x 75 mm and a second suprarenal extension placed for proximal endoleak measuring 28 mm x 75 mm. 2. Left limb extension 16 mm x 75 mm and right limb extension 20 mm x 120 mm. 3. Snorkel repair of left hypogastric artery using an 8 mm x 15-mm Gore Viabahn covered stent...The left hypogastric artery was then selectively cannulated using a crossover sheath followed by deployment of an 8-mm x 15-mm Gore Viabahn covered stent in this area and a left-sided limb extension was then placed measuring 16 mm x 75 mm. On the right side, a right-sided limb extension was then done using a 20 mm x 120 mm in length covered stent sealing above the right hypogastric artery. Balloon angioplasty was then perfo..."

Code 19081

Is a mammogram separately reimbursed when performed either before or after the surgical procedure when using the new CPT code 19081?

Code 50395

Would you report the following with code 50395 or codes 74475/50392/74480/50393? "Percutaneous access for PCNL contrast. Air was injected, and spot film imaging was performed as a percutaneous antegrade pyelogram. A 5 French Bernstein catheter was advanced into the distal ureter. Over the Amplatz Extra Stiff wire, a 10.2 French Dawson Mueller was placed."

Chemical Thrombectomy

I'm unsure on what to code for the chemical thrombectomy in the following case?  "Using SL10 and SynchroSoft, the left posterior communicating artery aneurysm was accessed, and multiple coils were deployed successfully, and the purpose was to partially thrombose the aneurysm. Then using Marksman and SynchroSoft, the pipeline stent was deployed successfully across the aneurysm and below the bifurcation. This pipeline measured 4.0 x 18. At the final deployment, we noted that at the middle of the stent, it was narrowed as a sand hourglass. We did multiple attempts to open this stent; however, we were unsuccessful. At one point, the ICA was completely occluded and that was for only about 30 minutes to 40 minutes. We were able to finally use a balloon and were able to angioplasty the stent and open it up completely. At the end, the aneurysm was at a stagnant flow, and there was filling of both the ACA and MCA as a baseline. There was no extravasation except for a small fistula created between the carotid and the cavernous sinus. There was also no hyperemia or pathologies noted."

FNA vs. Core Biopsies

I have a radiologist who has told me whenever he does a biopsy of the thyroid it is always core; however, he never dictates "core" in his reports... he always just says "tissue". Pathology from the hospital always says FNA. So my question is, do I report code 60100 because that's how he instructed me to code, or do I go with the pathology and report code 10022?

Crossing Septum for Congenital Heart Catheterization

When we do a congenital right and left retro catheterization (93531) and take sats in the LV, then later in the case they go across the ASD to the LA (and don't take sats), but go on into the pulmonary veins for pressures or angio, how do you code the catheterization???  With code 93531 or 93533? Is going across the septum for any reason cause to change to code 93533?

Breast Biopsy with CT Guidance

How would you code a CT-guided breast biopsy? The patient was an inpatient and unable to go into MRI scanner, and this radiologist prefers CT guidance over ultrasound. I am at a loss.

Code 36475

I know I asked you previously about the Baylis Power Wire. The question of the use of code 36475 for these upper extremity (subclavian primarily) cases has come up. Is there any recent data that restricts the use of code 36475 to the greater saphenous vein or its branches (as this has been the most common site)? Would the use of the Baylis Power Wire qualify these cases as an RF ablation?

Radial/Ulnar and Brachial Thrombectomy

Is it appropriate to report codes 34111 and 34101 when two separate incisions are made, but there was only thrombus in the brachial artery? The report states the following: "Brachial artery was opened transversely at the site of catheterization. A thrombus was present. This was thrombectomized with a 4 Fogerty catheter. Several passes were made and an excellent inflow obtained. Fogarty catheter was then passed down distally with further thrombus returned. The transverse arteriotomy was closed, and clamps were removed. At this time, distal dissection was carried along the brachial artery down to the orgin of the radial and ulnar arteries, which were encircled with vessel loops. The brachial vessels were controlled with clamps. A transverse arteriotomy was made in the brachial artery proximal to the takeoff of the forearm vessels. A 3 Fogarty was then passed down the radial and ulnar arteries. No significant further thrombus was removed."

76937 Ultrasound Guidance

We have a vascular surgeon who wants to start performing and billing ultrasound guidance (76937) for every patient. He said it is a clinical decision he made based on quality data from the VSGNE. My question is, can he routinely do this, or does it need to be based on the patient's condition? If he can, is there any special documentation that needs to be done?

Lymph Malformation Direct Access Treatment

Please tell me which codes you recommend for this procedure that was performed in 2013.

"PROCEDURE:Ultrasound and fluoroscopically-guided sclerosis of a venolymphatic malformation in the subcutaneous tissues of the right buttock. CLINICAL HISTORY:  Female with painful subcutaneous venolymphatic malformation in the subcutaneous tissues of the right buttock. TECHNICAL DESCRIPTION: The patient was brought to interventional radiology and positioned prone on the fluoroscopy table. The right buttock was sterilely prepped and draped. Under ultrasound guidance, the venolymphatic malformation was accessed with a 25 gauge needle. Contrast was injected through the needle to verify positioning within the malformation. Approximately 3 mL of Sotradecol foam (four parts 3% Sotradecol, four parts air, one part lipiodol) was injected into the malformation under intermittent fluoroscopic visualization. This was repeated at two additional sites of the malformation. Needles were removed from the patient. Hemostasis was achieved with manual compression."

Aspiration Thrombectomy Coronary Branches

Patient had a stent intervention in the right coronary and then aspiration thrombectomy in the PDA. Should the unlisted code be assigned for the aspiration thrombectomy, and if so, do we use a modifier for this?

Code 76377 3D with Echo, CCTA

The 2014 version of your Diagnostic & Interventional Cardiovascular Coding Reference it says (page 526, #3): "There is no code at this time to report 3D echocardiography. When 3D echocardiography is performed for medically indicated reasons and requested by the treating physician, report code 76376 or 76377 in addition to the echocardiogram code depending on whether an independent workstation is utilized for the 3D rendering."  Then page 557 indicates the following: "10. Do not report 3D reconstruction codes separately (76376 or 76377). 3D reconstruction is included in the basic procedure codes." I am billing for a diagnostic echo, and the above two statements seem to be contradictory. Is the second statement referring to surgical procedure vs. diagnostic procedures? Is code 76377 appropriate to bill with a diagnostic echo when medical necessity is documented? 

Remove of Skin Lesion

Patient scheduled for a pocket revision, but the day of the procedure only two superficial skin lesions near the pacemaker incision were removed and placed in Formalin. What should the hospital code?

Methylergonovine Challenge during Left Heart Catheterization

I have something different to code that I have not come across before - a Methylergonovine injection into the RCA during a heart catheterization. Is this separately coded? And, if so, what would the code be? I have looked everywhere for this and the only thing that I found was that you should not report code 37202 or 93463 for injection of drugs into the coronary arteries. Note states: "Methergonovine challenge to the right coronary artery in view of the patient's persistent symptoms and unchanged anatomy decided to continue with a metahemoglobin challenge to the right coronary artery. Methergonovine was given in three-minute intervals, initially at 0.05 mg up to 0.15 mg with presence of angina, as well as diffuse coronary spasm of about 70% to 80% stenosis, especially distally in the posterior descending artery and posterior left ventricular branches."

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