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This is an outpatient acct where the patient was brought in for coronary angiogram. They found two lesions in the LC. One was intervened on with a DES. The second one was found to be only 60% occluded so the physician decided to treat that one medically. The procedure was concluded and the patient was brought to recovery. An hour later, the patient complained of chest pain. EKG revealed no acute changes (patient did become bradycardic and hypotensive) and the physician decided to repeat the coronary angiography where it was found that the lesion not intervened on turned out to be really 80% occluded so a stent was placed in that portion of the LC. Because the patient's medical condition had changed, can a second stent be captured? We understand that the repeat angio can be charged; we're just not sure about the second stent. Thank you so much!

Is a renal angiogram included in billed with 75630? Thanks

We have a vascular surgeon that performs AV shuntograms and PTA's of the shunt in a surgical suite. A radiology tech will typically provide the fluoroscopy. The radiology department wants to charge 76000, on the facility side only, for the work/time provided by the tech. Is this allowable? There are no CCI edits, on the facility side, when both 36147 and 76000 are used together even though 36147 includes fluoroscopy. There is a CCI edit when both 76000 and 75978 are charged. We instructed the radiology dept not to charge 76000 with 75978. However, we were uncertain when only an AV shuntogram was done and the tech provided the fluoro. Thank you for your help.
 

A physician emobolized the left cavernous sinus. He performed a direct puncture of the venous varix in the left cavernous sinus. How would the access be coded? Thank you

Hi Dr Z. Quick Question A "Bard Biopsy device" used for Breast Biopsies. Is this device a Percutaneous Vacuum assisted/rotating device 19103 or a percutaneous Needle core biopsy 19102 ? I am seeing cases where it is documented solely as "a Bard Biopsy Device" and other cases documented as a "10-gauge Vacuum assisted BARD biopsy needle" Please advice

Hi, Dr. Z! My question is in regards to cases where the physician does an atherectomy first - it is suboptimal and he then does an angioplasty. From what I have read, we are only allowed to bill for the successful procedure which would be the angioplasty in this case. Is it appropriate to bill the radiology S&I for the atherectomy (75992/26), since the physician did that reading as well? Thank you!

We are asking for further clarification when coding an Atherectomy of the Common Femoral artery. As advised by our Cath Lab staff the procedure documented below should code to 35492 Atherectomy iliac. We agree in Coding that the external iliac and the common femoral are the same vessel. But, CPT 2010 does not include in the index or in the Transluminal Atherectomy section any direction to code documentation specified to common femoral to the iliac. I have provided the case as documented below. ENDOVASCULAR INTERVENTION: SUCCESSFUL ENDOVASCULAR ATHERECTOMY OF THE LEFT COMMON FEMORAL 99% TO 20% AN ATHERECTOMY DEVICE WAS PLACE (MS-M FOX HOLLOW) IN THE LEFT COMMON FEMORAL ARTERY AND CUTS WERE PERFORMED. THE GLIDEWIRE WAS PLACED AND THE DEVICE WAS REMOVED. A BALLOON WAS THEN PLACED IN THE LEFT COMMON FEMORAL (6X4X130 EV3 EVERCROSS) AND INFLATIONS WERE PERFORMED. THE BALLOON WAS REMOVED. ENDOVASCULAR FINDINGS: LEFT COMMON ILIAC -- 50% (NO GRADIENT) LEFT COMMON FEMORAL -- 99% STENOSIS

Patient with a traumatic CCF had a diagnostic angiogram and treatment. Physician selects bilateral CCA, ECA, ICA and bilateral Vertebral with imaging.Giant The common carotid arteries are normal bilaterally. The right CC fistula is seen with poor flow intracranially. The left intracranial circulation is unremarkable. Both vertebral imaging procedures and external carotid imaging demonstrate lack of supply to the fistula and normal anatomy. RICA was selected and sacrificed with detachable coils. A follow up angiogram was performed in the RICA demonstrating complete occlusion and no further connection with the CCF. The LICA was selected again and an angiogram was performed demonstrating ACA and MCA arterial distributions. The ACOM appears robust and the right A1 and the right MCA artery show good flow. The right vertebral artery was selected again and an angiogram was performed demonstrating a patent right PCOM with flow seen in the MCA and ICA terminus. There is slow flow seen beyond the supraclinoid portion of the RICA in retrograde fashion to the coil mass. Can I code for the second catheter placement in the LICA and Right Vertebral. Can I also charge for 75898 x3?

Could you help me? Would this be coded 36247,35475 and 75962 or 36247,35475, 75978(angioplasty for the arterial side of the fistula)AND 36247 59,7507859 (angioplasty of the brachial artery)? The radiologist refuses to say native brachial artery. He also does not say how far above the anastomosis. I was audited a few weeks ago and now I am second guessing myself(I work for the hospital).I have your coding book and love it. Thank you. Frances () AVS(FISTULOGRAM) PROCEDURE - INDICATIONS: Poor blood flow at dialysis and pulling clots. RESULT: ARTERIAL VENOUS FISTULA: Technique: Informed consent was obtained from the patient. Access was gained into both the arterial venous side of the patient's arterial venous fistula. Contrast was then injected. This was then followed by angioplasty at the arterial side of the fistula with a 5 mm. balloon. The brachial artery was also angioplastied with a 5 mm. balloon. The catheters and sutures were then removed. Hemostasis was obtained. Complications: No immediate complications were encountered. Medications: 1% local Lidocaine to the skin, Versed and Fentanyl for conscious sedation. Approach: Fluoroscopy. Physical status: ASA-4 Findings: The patient demonstrates a brachiobasilic fistula. There is narrowing involving the arterial side of the fistula in the range of 80% to 90% with some mild aneurysmal formation. This was successfully treated with angioplasty with improved patency. There was an area of irregularity involving the brachial artery above the anastomosis which was angioplastied. This resolved after this. There is an indwelling stent involving the outflow venous structure. Just some minimal narrowing in this was identified but this was not treated because this was in the range of 20% to 30%. There is also an indwelling stent within the right brachiocephalic vein into the superior vena cava. This appears patent. IMPRESSION: Successful arterial venous fistulogram with arterial side angioplasty and brachial artery angioplasty for abnormalities.
 

One of our vascular surgeons is following a new protocal for looking for a discection in the ascending aorta using CT with the goal of using a minimal amount of contrast. He is placing a pigtail catheter in the ascending aorta in the Cath Lab and then we are immediately sending the patient to CT for a CT which is enhanced with the contrast infusion during the CT. We are not certain how to bill for the catheter placement in the Cath Lab. Can anything be billed other than supplies for the pigtail catheter placement only (no exam). Also, can they only bill for the standard CT angio of the chest (71275)for the CT exam? Thanks for any help
 

My question is regarding clarification of peripheral and central vessels in regards to A/V 2010 fistula/graft procedures. Is the cephalic vein and the brachial vein considered to be in the "peripheral" zone? (reasoning...I have some physicians who are documenting the cephalic and the brachial veins as being located in the "central" zone. Would a venoplasty in either of these sites be considered "central" or "peripheral"? Thank you Dr. Z!
 

If a physician punctures the dorsal pedalis and goes retrograde into the SFA....what would be the selection code?? Thanks for the help!

Please advise on coding and using 36147 in declot of severe stenosis with access obtained in cephalic vein in the mid foremarm, after attempt to access cephalic vein from basilic vein without success therefore the entry into cephalic via antecubital space was obtained and then angioplastied. A fistulogram was taken prior to procedure.Our endovascular lab coded using 36147; 75978; 35476; & 75791, but coding staff said that we should not be charging 75791 nor 36147 just the 35476 & 75978. Your expertise to clarify would be greatly appreciated as to the appropriateness of our original charges.

Hi Dr Z, This is for HOPPS. Can we code/charge for supplies related to an attempted embolization? We appended modifier -52 to the embolization code. The radiologist's dictation states: Following the diagnostic arteriogram, and through a left internal carotid artery approach, a single lumen occlusion balloon catheter was introduced in the inferior division of the left middle cerebral artery across the neck of the aneurysm. A microcatheter was then maneuvered in the fundus of the aneurysm. Multiple attempts to embolize aneurysm with platinum coils using the balloon-assisted technique proved to be unsuccessful due to the shallow nature of the aneurysm and to the tortuosity of the cervical segments of the left internal carotid artery. The endovascular procedure was then aborted without any complications. The post-treatment left internal carotid arteriogram showed no branch occlusion or other intraluminal filling defects. Thank you for your help!

How do you recommend coding a CT post discogram? CT with contrast or CT without contrast? Thank you!

Dr. Z, when performing Complete EP study, sometimes we see an arterial access catheter placed to measure and monitor pressures. They are not using this access other than monitoring the pressures. Can we charge 36620 with '59' along with 93620? Please explain. Thank you.

I am confused about code 47801 for choledochal stent. In one of your questions in 2006 a case was provided where code 47556 was recommended whether dilation occured or not prior to stent placement. I have a case where the physician placed a 10mmx6mm stent across the common bile duct with post angioplasty with 10mm balloon. Contrast injection to confirm patency. Since the intent of the balloon was for post dilitation would code 47801 be correct? I am confused about this code and when to use vs 47556 when stent is implanted. Thank you.

Dr. Z I have a Neuro-IR physician that performed at CT-guided transforaminal epidural and nerve root injections with fibrin glue. Levels were bi-lat T8/9; T9/10; T10/11 with contrast for needle verification. Would the correct code be 77012/ 64490-50/64491-50, 64492-50? A blood patch would not be the correct code or would it? In his dictation, he did not state any type of patch other than the fibrin glue. Thoughts? Thank you

Patient with a traumatic CCF had a diagnostic angiogram and treatment. Physician selects bilateral CCA, ECA, ICA and bilateral Vertebral with imaging. The RICA was selected and sacrificed with detachable coils. A follow up angiogram was performed in the RICA demonstrating complete occlusion and no further connection with the CCF. The LICA was selected again and an angiogram was performed demonstrating ACA and MCA arterial distributions. The ACOM appears robust and the right A1 and the right MCA artery show good flow. The right vertebral artery was selected again and an angiogram was performed demonstrating a patent right PCOM with flow seen in the MCA and ICA terminus. There is slow flow seen beyond the supraclinoid portion of the RICA in retrograde fashion to the coil mass. Can I code for the second catheter placement in the LICA and Right Vertebral. Can I also charge for 75898 x3?

Hi, have dictation for injection of a peritoneal dialysis catheter. What codes are used? Thank you.

Percutaneous Lymphocele Drainage (bilateral) Hi Dr Z how would I report CT guided catheter drainage of bilateral pelvic lymphoceles for a male patient? Do I report the Unlisted code once or twice (49999) with SI code 75989 x 2 please advise.

Dr. Z, I need a code for a localization done on a patient under CT guidance. The patient previously had a kidney removed due to renal CA. CT showed recurrent tumor in the kidney fossa. The radiologist placed two Kopan hook needles in the area and the patient went to the OR. I charged the CT guidance 77012, but I am unsure what surgical code to put with it. 19290--specifically for breast localization 49411--specifically for radiation therapy What would you charge with this code? Thank you!

Hello Dr. Z, please read below: Cone beam CT acquisition was performed during contrast injection into the right hepatic artery with two dimensional CT reconstruction demonstrating the dominance of supply to the tumor mass by posterior branches of the right hepatic artery. Post embolization cone beam CT acquisition which was also transferred to a separate workstation demonstrated retention of the oily contrast only within the tumor mass and not within the remainder of the liver. >From what I am told by the dept., a 3D image is produced but what is being questioned is the CONE BEAM CT...is there a separate CPT code for this procedure or is this just part of the 3D process?  I know what's missing is the 3D documentation, right. Can you please explain?

If a bilateral arthrogram is done on the shoulders can 77002 be coded twice with a modifier?

I have a question regarding a percutaneous valvuloplasty procedure. The patient arrived from another hospital. A heart cath was recently done and the referring physician stated the patient had normal anatomy with an ejection fraction of 45 percent. The patient was referred to our facility for aortic stenosis repair. The op report for the valve repair includes: Hemodynamics-pressures and cardiac output measurements documented for the right heart. The left ventricular end-diastolic pressure severly elevated. The description for the percutaneous valvuloplasty. Final hemodynamics reported. aortic root angiogram indicates no aortic insufficiency. Since there was a previous heart cath, I didn't think a second one could be coded. Is that correct? Is the only procedure that should be coded in this example 92986 for the valve repair? We have just started doing these and any guidance would be appreciated. Thank you.

I have a question regarding Fractional Flow Reserve performed in multiple vessels. Following angiography, an FFR is performed in the LAD, and then an FFR is performed in the 1st Diagonal Branch of the LAD. Can this be reported with 93571 and 93572? or does this procedure have the same rules as PTCA/Stents and is considered just one vessel for CPT coding purposes?

Hello! I am unsure if I can bill more than 1 set of 37204 & 75894-26 for the embolization part of this procedure. Also, an Amplatzer plug was used in internal iliac. I am OK with the cath placements. Dx: Growing AAA with a type II endoleak from multiple inferior lumbar arteries from different sources. 1. Coil embolization of a lateral lumbar and pelvic artery with the source coming from the internal iliac artery branch with a shared vascular supply from the contralateral internal iliac and coil embolization of 3mm Tornado and 5mm Tornado coils for a total of 5 coils. 2. Selective cath of an ascending lumbar artery and insertion of 0.75cc of NBCA embolization glue. 3. Selection of the origin of the right internal iliac artery and deployment of a 16mm Amplatzer plug to the right common internal iliac origin. Thank you,

My question is in regards to charging for the PICC line insertion on the hospital side when the line is placed by a RN. This is both for inpatient and outpatient. On the inpatient unit the lines are placed bedside. Outpatient lines are placed in the infusion center, emergency room and recovery room. The PICC line insertion charge is a treatment room charge, but is performed bedside on the inpatient unit, recovery room or emergency room. Is it ever appropriate to charge the PICC line insertion in addition to the room charge? What about if the nurse is declotting the PICC line bedside, is this billable or bundled into the room charge? Thank you for your help,

Dear Dr. Z, This is a procedure we've been unable to locate any coding advice on thus far: CLINICAL INFO: ESRD w/left upper arm fistula that is difficult to cannulate PROCEDURE: Skin overlying the Left Upper Arm fistula was prepped/draped...Ultrasound was used to mark the course of the fistula on the skin. Multiple sterile OR markers were used. Then, 22 gauge needle was used to abraid the skin through the ink. This resulted in small tattoo dots along the course of both sides of the fistula. IMPRESSION: Successful marking of he course of a left upper arm fistula. We have considered Unlisted Skin 17999 (APC 12, SI "T") with 76942 (SI "N"), but also wonder about Unlistd Vasc. 37999 and/or Unlisted Ultrasound 76999. Your opinion and advice would be much appreciated! Thank you in advance. It was great meeting you at our facility in November!

Dr. Z, Please give me your insight on this case. I'm just not sure which codes to use - patient with a CSF fluid leak has a lumbar puncture and contrast injected. The patient is tilted head down for 20 minutes then transported to CT for a maxillofacial and cerebral scan. Would the lumbar puncture be coded -- 62311, 77003 or 62284, 77003? We are coding the CTs separately. Thanks for your help.

Dr. Z- What is the correct code for this report? The radiologist indicates 78195 but I am leaning towards 38792 because he doesn't describe any lymph node imaging: Utilizing aseptic technique, a total of 600uC of Tc99 Sulfur Colloid was injected intradermally into the right breast. Scintigraphy confirmed uptake of the radiotracer. The patient was then transferred to the operating room for intraoperative localization. Please correlate wtih the operative report. Thank you.

A physician accesses both common carotid arteries and performed both bilateral cerebral as well as bilateral cervical angiograms. He then went back (same session) and accessed the right internal carotid and performed a second cerebral angiogram. Is the 2nd angiogram (75665) billable with the 75671 (bilateral cerebral angio) w/ modifier 59? The patient has moyamoya so he only accessed the commons before deciding to go into the right internal.

Pt had a PTA with stent insertion of the left internal carotid artery. What would the approptiate CPT and ICD-9 codes for this procedure. I was told that if they are in the internal/external carotid artery this is cerebral artery (intracranial). Please verify. Thanks
 

Selective Catheterization of Aortobifemoral Bypass Graft - What is the selective catheter code when documentation states "RIM catheter was used to gain access to the contralateral iliac limb of the aortobifemoral bypass graft. Once we gained access to the bypass graft with the wire into the common femoral artery, this catheter was removed and a 4-French straight catheter was advanced over top of the wire into the proximal limb of the right iliac system. Following this, a right lower extremity run-off arteriogram was performed...". A left arteriogram was performed via the sheath. It is coded as 36246 by the Rad Tech but I don't think this is correct. The catheter was in the aorta first from the left common femoral access. I thought the graft was 1st order off the aorta so is the iliac limb 2nd order???? Also, since left arteriogram was performed via sheath, a catheterization is not coded, correct? These always confuse me!
 

The H&P says the patient has a Fem-Tib bypass graph. The Preoperative diagnosis on the Op report says Stenosis of the left leg anterior tibial bypass. If this is an open procedure, do I code to the vessel that was bypassed or as a vein angioplasty 35460? The operative report reads as follows:

"A 1cm transverse incision was made over the vein bypass on the lateral aspect of the patient's left knee. A pursestring sture of 6-0 Prolene was placed and the patient was heparinized with 5000 units. Seldinger technique ws used with a micropuncture set and a 5 French sheath was placed. Catheter was advanced up to the area of stenosis near the proximal anastomosis and an angiogram revealed a 90% stenosis proximally. It was crossed with a 014 wire, dilated with a 3 mm balloon and it was improved to about 30% stenosis. No stent was felt optimal in this locatin in the groin and the heparin was not reversed. The flow in the bypass was much better and the pulse distally was palpable. The sheath was removed, pursestring tied. Wound was closed with 4-0 vicryl subcuticularly. Benzoin, Steri-Strips, and Opsite dressing were applied. "

Thank you again for your help.
 

When a vascular surgeon performs an angioplasty of a femoral vein graph and documents he made a 1 cm incision above the graph prior to utilizing seldinger technique, would the incision make this an open procedure? Does any incision make a procedure open even if the vessel is entered by seldinger technique?
 

Dr. Z. Do the imaging guidance rules of one per encounter apply to 75989?

Hi Dr Z, I am hoping you can provide some clarity for the CPT coding for use of the Impella 2.5 VAD in the cath lab. Recommendations have included unlisted CPT 33999 (Per CPT Asst 11/2009 P10) and 92970. Can you please advise what you are recommending for coding of this expensive device? Thanks in advance!

Hi Dr.Z, I have a question: is this statement qualifies for use of 75898: "Successful TACE of the right lobe hepatoma."  CPT Lay Description of this follow-up study states: "... the radiologist interprets the status of the blood vessel and the effectiveness of treatment rendered." Is status of the vessel should be reported or is it enough to document "Successful TACE"  Thank you. EE
 

PLEASE EXPLAIN YOUR ANSWER TO THE RECENT QUESTION REGARDING G0393 AND G0392, DOES THIS MEAN THOSE CODES ARE DELETED FOR 2010? THANKS

Dr. Z, Please help clarify an issue we are having with IV hydration in conjunction with CT scans, general x-ray exams involving contrast and angiograms. Is it ever appropriate to separately charge for the hydration (96360) in addition to one of the exams listed above and if so under what circumstance is it justified as a separate and distinct procedure? We have two opinions, one being that we are treating the patient with IV hydration for a medical condition (dehydration, renal disease etc) and the other being this is bundled into the procedure and not medically necessary regardless. Not all patients receive IV hydration prior to their exam. Thank you!

 Dr. Z, I hope you can help us resolve this coding issue. HIM and I are coming up with different codes. I read the following as an open procedure of an AV graft including angioplasty, thrombectomy, and thrombolysis. PROCEDURE: The patient was taken to the operating room and placed on the operating room table in supine position. General anesthesia was given. The right upper extremity was washed circumferentially and prepped and draped in traditional sterile fashion. A small transverse incision was made right over the graft above the bicipital fossa. Through that incision, the graft was identified and was encircled with umbilical tape. A small graftotomy was performed and then using a 5 French and then a 4 French Fogarty embolectomy catheter, thrombectomy of the venous limb was carried out. After removal of well organized clots, we noticed that the patient will develop new fresh clots right at the same time undergoing the thrombectomy. The patient was then given 5,000 units of heparin. Then thrombectomy of the arterial limb was carried out with return of brisk pulsatile flow. The graft was clamped proximally and a 6 French sheath was inserted, directed toward the venous anastomosis, and a fistulogram was obtained. It showed a slight narrowing at the venous anastomosis and then a patent right subclavian axillary system, high-grade stenosis at the level of the right innominate vein with flow being diverted to large collaterals. Superior vena cava was patent without significant stenosis demonstrated there. A 0.035 inch Glidewire was advanced through the 6 French sheath and then sequential balloon angioplasty of right innominate vein was performed, first using a 10 x 40 mm conquest balloon and then a 12 x 40 mm conquest balloon. Then using a 6 mm Fox balloon, we gently inflated the balloon at the venous anastomosis. A repeat injection of contrast was satisfactory with no residual stenosis demonstrated. Then the sheath was removed and the angioplasty of the right innominate vein was performed through a 8 French sheath and then the 8 French was removed. The graft was clamped toward the venous anastomosis. The 6 French sheath was inserted, directed to the arterial anastomosis. An injection of contrast demonstrated a patent anastomosis, however, there was thrombus present into the radial artery and the distal brachial artery. A .035 inch Glidewire was advanced through the brachial, then the radial artery, down to the level of the wrist, and then a Fogarty embolectomy catheter was used, and embolectomy was performed of the radial artery and the distal brachial artery using a 4 French Fogarty embolectomy catheter. A repeat injection of contrast showed a persistent defect into the proximal right radial artery. Unclear whether it was a plaque. It persisted after a repeat embolectomy. Then it was angioplastied using a 4 x 40 mm balloon. A repeat injection of contrast after angioplasty showed some improvement. Intraoperative infusion of thrombolytic therapy was used. Approximately 3 mg of TPA was administered. Then a repeat injection of contrast was satisfactory with no further defects demonstrated to be present and good flow going down the radial artery into the end. We then had a palpable radial pulse present. The sheath was removed. The small opening in the graft was closed using interrupted sutures of CV-6 Gore-Tex suture. The wound was closed in two layers using 3-0 Vicryl in the subcutaneous tissue and the skin was closed using subcuticular suture of 4-0 Monocryl. Dermabond was applied and a small sterile dressing. SUPERVISION AND INTERPRETATION: Following a surgical thrombectomy of the right arm arteriovenous graft, a fistulogram was obtained and the findings are as outlined above. Balloon angioplasty was performed, first of the right innominate vein using up to a 12 x 40 mm balloon and then at the venous anastomosis using a 6 x 40 mm Fox balloon. Subsequently, injection of contrast demonstrated there was interruption of flow and thrombus into the distal brachial artery and the proximal radial artery and was it treated with thromboembolectomy and intraoperative infusion of thrombolytic therapy and also balloon angioplasty of the proximal right radial artery where there was narrowing and what appears to be a plaque present. A repeat completion angiogram was satisfactory with good flow demonstrated to the brachial artery, the radial artery to the hand. Here are the codes that I think should be assigned: 36381, 75790, 75798-59, 35460, 75798-59, G0393, 34101, 34111, 75962, 35458, 75986, 37201. I should add that this was done during 2009. We need all the education and help we can get. Thanks,

 

Dr Z, We have a case where there was a stenosis of the main hepatic artery treated with balloon angioplasty. Following this there was poor antegrade flow and a small amount of thrombus within the main hepatic artery. This was treated with intra-arterial TPA and Papaverine. Final injection showed excellent flow within the main hepatic artery with markedly improved perfusion of the liver. Our question is, does this constitute billing for a secondary thrombolysis (37186) along with the angioplasty codes? Thank you!

This is in regards to the status indicator for 37215. In the final rule addendum E, CMS had removed 37215 from the inpatient only list. However, in the January addendum B list on the CMS website, they have it listed as inpatient only. Have you seen this discrepancy and know which is correct? Thank you. 37215 Transcath stent, cca w/eps C http://www.cms.hhs.gov/apps/ama/license.asp?file=/HCPCSReleaseCodeSets/Downloads/10anweb.zip

If a right heart cath is performed without a left heart cath but a coronary angiogram is performed, would you use codes 93501, 93508, 93545 and 93556? Or should you not code 93508 with 93501?

What kind of documentation would we see to support medical necessity for angiograms (75716 and 75710) on the same day as an intervention? Can you please help to clarify??? THANKS!!! We have seen your previous notes specifying that the bottom line is medical necessity. And the CCI edit says documentation must support medical necessity...."to further define anatomy and pathology." Can you give some examples of what things would support medical necessity? i.e. worsening claudication i.e. abnormal ABI or doppler.
 

Lap Band Port access with aspitation. Can you please help with coding the following? THANKS!!! The patient was taken to the fluoroscopy suite and placed prone. The port was accessed under fluoroscopic guidance and 5ml of saline withdrawn. Oral contrast was administered. Under fluoroscopic guidance the stomach was evaluated. The patient was placed in several positions in order to facilitate gastric outflow. Using fluoroscopic detail evaluation, contrast was followed through the proximal small bowel to the ileum. The lap band was released on the mid-aspect of the gastric antrum. With repositioning, oral contrast was observed to extend into the pylorus and duodenum. IMPRESSION. sucessful release of the gastric band.

The intent of the procedure is to declot a left arm graft by using an angioplasty balloon. The anastamosis itself was also angioplastied using a 5mm balloon contrast injection demonstrated clearing of the thrombus within the graft. please tell me if the above statement warrants an Angioplasty CPT code or just thrombectomy code?

I have read and re-read your information so far on the new AV fistula codes as well as CPT and CPT assistant and am going to take a stab at this (no pun intended, ha ha), but would really appreciate hearing your thoughts on the best way to code, given the information so far available on the application of these new codes. PREOP DX: Chronic renal failure, failing left thigh arteriovenous fistula. POSTOP DX: Chronic renal failure, failing left thigh arteriovenous fistula, stenosis of the arteriovenous fistula, long segment, approx 12cm. OPERATION: Right groin puncture, sonographic guidance into the right common femoral artery, aortic and left lower extremity angiogram, non-selective, sonographic-guided puncture of the left thigh arteriovenous fistula, fistulogram, and angioplasty of the arteriovenous fistula and the arteriovenous anastomosis. The patient has an AV fistula of the left greater saphenous vein in the left thigh. We have dilated about three weeks before and again the fistula was failing. We thought that there was some arterial component. We decided to do an angiogram first and then possible angioplasty of the AV fistula. DESCRIPTION OF THE PROCEDURE: Both groins and left thigh were prepped and draped. We then infiltrated lidocaine in the right groin and under sonographic guidance we did a direct puncture into the right common femoral artery. We then placed a wire and a 4-French sheath over the wire. We went in with a diagnostic Omni flush catheter into L1 and then proceeded to move the catheter down to the bifurcation and do a different injection. Findings were as follows. Abdominal Aorta: The abdominal aorta was patent with no evidence of stenosis. Both renal arteries were patent with no evidence of stenosis. The SMA was patent with no evidence of stenosis. The bifurcation was patent with no evidence of stenosis. The common iliac arteries bilaterally were patent with no evidence of stenosis. The left superficial femoral artery was patent with no evidence of stenosis. We then visualized the anastomosis. It was patent with a severe stenosis of the AV fistula right at the anastomosis, and beyond that a segment of approx 12cm. At this point, then we infiltrated lidocaine in the AV fistula. Under sonographic guidance, did a direct puncture into the fistula, and proceeded to do a fistulogram directly and then passed a wire through the stenosis. After that, we placed a 5X6 angioplasty balloon and inflated right at the anastomosis and beyond that, for a long area that was stenotic. After this was done, then we proceeded to do a completion fistulogram, and it showed that there was a complete patency of the AV fistula. There was no evidence of extravasation, and the fistula at this point was patent. There was a complete resolution of the stenosis. There was no residual stenosis. We then proceeded to pull on the sheath and the patient received 2000 units of heparin. We pulled first the puncture in the AV fistula. There was no evidence of any bleeding or hematoma at this point, patient was stable. Here are my questions: My initial thought was to code 75791 for the first puncture to the right common femoral artery. However, there is no description of any venous imaging/outflow on either the initial angiogram from the right femoral access, nor of the direct puncture of the AV fistula so would either 75791 or 36147 be appropriate? I know I can't use both of these codes together, but it really seems like this would be the answer if the lack of venous outflow imaging isn't an issue. 36147 would indicate the initial access to the fistula, and although 36148 refers to access for intervention, that seems to be for an additional access into the fistula and there was only one direct access. If I think about the reference to access for intervention I could choose 36148 but then I can't use that without using 36147 first. Should this be coded as an abdominal arteriogram 36200-75625, then 36147? I'm not clear on whether this is an angioplasty in the arterial side or the venous side and the whether the 12cm segment is within the graft? So it would be either 35474/75962 or 35476/75978? And if 36147 is supposed to include all catheter placements does that wipe out the 36200 if I go that route? The direct puncture came second but does that matter if it includes all catheter placements? I am really stumped. I realize I may just have to take my best shot and wait to see as info develops for these codes, but I'm really not sure what my best shot should be! Thanks, I'm sure you will want to edit as this is long winded, but you did ask for thought process!! I am not coding the sono guidance as I have no documentation or images captured for that. I also was hesitant to code an extremity angiogram as all he described of the left leg was the SFA and profunda femoral were patent. Thanks again!!!
 

Good morning from KC,MO. My question deals with the use of 3D imaging in conjunction with angiography, specifically cerebral angiography. Q: When fluoro is used to obtain the images from which a 3D rendering is performed is that billable with 76377 or 76376?? And what UB code do you recommend being used. Thank you again for you assistance.

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