Ask Dr. Z

I have run across a couple of situations (post-discharge) where the order and the radiological exam do not match exactly. For instance, a patient came in through the ED with pain that radiated from her abdomen down to left leg with history of pelvic fx last year. Pelvic x-ray was negative and lumbar x-ray w L3 fx indeterm age. So, the physician ordered MRI. The computerized order was for “MRI Lower Extremity Joint Left WO Contrast” (CPT 73721). It doesn’t look like the physician was actually looking for joint pathology. So, based on medical necessity, and the MRI report makes no mention of joints (mentions no fem neck fx or pelvic fx, etc.), it looks like the order should have been for non-joint (as in 73718 or 72195). Ideally, this order should have been corrected at the time of service. As this issue has been found after the procedure was provided and the patient was discharged, what is the best way to compliantly handle this situation? Code 73721 has been denied for medical necessity, and I would like to re-bill this with code3 73718, as this appears to be what the order should have been.

I could not find a CPT code for this px. Is code 76000 sufficient? "Transnasal sphenopalatine block. Clinical history: 35-year-old female with chronic headaches, referred for a Sphenocath procedure. The patient's nostrils were first anesthetized with 2% lidocaine via an atomizer. A Sphenocath catheter was then inserted in the left nostril with the patient in supine position with the head tilted back and in Trendelenburg. 1.5 mL of a mixture of Visipaque and 4% lidocaine was injected in the right nostril with the spheno-catheter in appropriate position. Fluoroscopy confirmed that the mixture of contrast and lidocaine accumulated in the sphenoethmoid recess. The catheter was removed and placed in the right nostril. The procedure was repeated as above. Conclusion: Successful injection of transnasal lidocaine and contrast into the sphenoethmoid recess. Fluoroscopy time 1.1 minutes Air Kerma 1 Dose area product of 0.21 cm square."

Can code 37250 be reported in conjunction with code 37215? Or is it considered included?

Original Question: What would be the proper coding for a stent graft revision and bilateral renal stenting?

Follow-Up Info Provided: The original stent graft was an Endurant II stent graft, and the physician placed an Express SD renal stent into both renal arteries.  It was a percutaneous approach for the renal stenting.

We had a patient who needed a pacemaker in place for anticipated surgery, but could not have a permanent pacemaker due to infection. So a permanent lead was placed in the right ventricle through the jugular vein and attached to a new single chamber permanent pacemaker externalized. What can I charge in this case?

"Patient with large bilateral Saddle embolus. Access via RCFA. Catheter was used to select the main pulmonary artery. Angiogram was performed, confirming thrombus present in all lobes. 5 mgs of tPA was administered intra-arterial on the left. Right common artery was then selected. Angiogram was performed, confirming thrombus present in the right upper and middle lobes. 5 mgs of tPA was administered on right. Catheter was removed. IVC filter was then placed, and IVC-gram done before and after filter placement. Bilateral selective renal venogram was done." Per your seminars I am saying that we can't bill a procedure for the injections of the tPA. Is this correct? If a procedure can be billed, what CPT code would be used?

Patient with a stent graft in the proximal to mid descending thoracic aorta who is 8 months out s/p. Now with enlargement of not stented area (thoracoabdominal aneurysm repair). Physician performed the repair with stenting thoracic and abdominal aorta with total of four stents starting from abdominal aorta bifurcation and last one overlaps the previous stent in thoracic aorta. Is this correct to code aneurysm repair in the thoracic aorta (36200, 33881, 75957) with proximal extension (33883, 75958) and abdominal aorta aneurysm repair (34800, 75952) separately? Does the way the physician builds the grafts in thoracic aorta (proximally or telescopic way) affect coding (e.g. in this case the main body first in distal thoracic with one extension proximally to overlap with previous stent)?

Do I need a modifier on code 93458 for the initial diagnostic exam with the C-codes for the PTCA?

I have always used these together, per your instructions, for catheter checks. "Patient had a non-functioning port. Port is accessed and contrast injected. After which, a thrombolytic is injected." The new coding system that we are using is giving me an edit that states they are mutually exclusive. Has something changed?

When a right hypogastric artery embolization is performed along with a stent and angioplasty in the right external iliac artery, may we also code the catheter placement for the embolization? Or is it included in the external iliac intervention?

Physician harvested saphenous vein endoscopically (33508). Vein is no good, so same procedure is performed on the opposite leg. Can he bill code 33508 two times?

A physician is doing a dual chamber pacemaker exchange and finds the RA lead has fractured and the RV lead has dislodged. He removes the device, removes the RA lead, places a new RA lead, repositions the RV lead, and then replaces the device. We were told to report codes 33206, 33235, 33233, and 33215. I see that code 33215 is an NCCI edit to code 33206. Can they be charged together?

We are debating over two sets of codes for this situation. The patient presented for a generator replacement of a dual chamber ICD. They discovered the old RV lead was defective, so they capped the old RV lead, inserted a new RV lead and a new dual chamber ICD, and lead and device testing were performed. The department reported code 33241 for removal of pacing ICD generator only, 33249 for insertion/replacement of ICD system with single or dual leads, and 93641 for DFT testing at time of implant. The coding department chose code 33263 for removal and replacement of ICD generator and dual lead system, 33216 for insertion of a single transvenous electrode, and 93641 for DFT testing at time of implant. Which set is correct and why?

In your Diagnostic Radiology Coding Reference book, page 212, item 10, it states it is appropriate to report code 76645 when ultrasound is used to externally mark the breast for subsequent biopsy or aspiration. Does this concept apply to all biopsy/aspiration procedures (e.g., thyroid biopsy)? If yes, do we need to append a -52 modifier to the limited scan CPT since it is not a complete scan?

Is code 38382 appropriate for percutaneous embolization of thoracic duct, or should I use an unlisted code? The procedure is described as follows:

Abdominal percutaneous approach. After reconfirming the intraductal location of the catheter, 6 fibered platinum embolization coils were deployed from the distal chest down to the cisterna chyli in the proximal abdomen. Subsequently, a 2:1 Ethiodol and N-butyl cyanoacrylate glue mixture with tantalum powder was injected through the catheter to complete the embolization of the distal thoracic duct and cisterna chyli. The catheter was removed while aspirating to minimize extravasation. Final spot radiographs of the chest and abdomen were then obtained to document the position of the embolic implants. Findings: Coil embolization of the thoracic from the distal chest down to the cisterna chyli. Distal thoracic duct and cisterna chyli sealed with N-butyl cyanoacry liquid embolic glue.

How would I code the following stent placement?

A 5 French terminal angled glide catheter was advanced over a Glidewire through the right femoral sheath into the right internal jugular vein. Right internal jugular venogram was performed. This confirms the placement within the normal-appearing jugular vein. The 5 French angled glide catheter was then advanced through the femoral arterial sheath into the right internal carotid artery. Cerebral angiogram was not performed. This shows a normal appearance of the internal carotid artery as well as the anterior and middle cerebral arteries. The parenchymal phase is normal. The venous phase is normal aside from the severe stenosis of the right transverse sinus. The microcatheter was exchanged over an exchange length Synchro 2 microwire. A Precise stent 9 mm x 30 mm was advanced over the wire into the internal jugular vein. By advancing the guide catheter into the sigmoid and transverse emesis, the stent was delivered across the stenosis and deployed.

My physician did a select catheterization placement in the bilateral common carotid, bilateral internal carotid, bilateral external carotid, bilateral vertebral, and bilateral thyrocervical trunk. Would it be correct to report code 75774 x 2 for the thyrocervical trunk catheter selections?

I have coded a sacroplasty with 0201T and 72291 for S1-S2 cement augmentation. Medicare is telling me that this code is invalid (0201T). I have referred to your book, and this is what you have suggested. Could you shed any light you have on this please?

If a patient has a superior vena cavagram and then a tunneled dialysis catheter without port, can you report both codes 75827 and 36558?

Just wondering your thoughts about multiple lymphangioma reporting.

Sonographic guidance was used to evaluate and gain access to the macro and microcystic lymphangioma extending posterior lateral to the right sternocleidomastoid muscle and along the anterior margin of the right upper trapezius muscle. Utilizing 22 gauge Angiocath needles, as well as the 21 gauge micropuncture needle, four separate macro and microcystic regions of the right supraclavicular lymphangioma were accessed. Access was confirmed via injection of contrast, as well as aspiration of clear yellow fluid. The largest of these complexes at the right neck base was injected with approximately 7 mL of doxycycline at a concentration of 10 mg/mL. Three additional regions were accessed, confirmed with contrast, and injected with lesser amounts of doxycycline.

Which code do we use to report RF ablation of adrenal tumors? Do we charge guidance separately?

The physician tried an Easytrak 2 lead (LV lead) and was unable to get satisfactory thresholds, so he exchanged with an Easytrak 3 lead. We obviously only ended up with one lead in the patient, but we used two and we were charged for both. Is there a modifier for this? What is the appropriate charge situation for the supplies used?

We have a case where a PTCA occurred in the RCA, and an attempt was made to stent the mid lesion (there were three lesions in the RCA), but "due to profound calcification and tortuosity, unable to cross the lesion site. There was TIMI-3 flow with good results and the procedure was aborted". Does this description qualify as the procedure being terminated at "the provider's discretion", as relates to the stenting? In other words, would you code the attempted stenting (92928) with modifier -52, or would you just report code 92920 for the PTCA? We are an OP hospital, in case I didn't mention it. The type of stent was not mentioned in the dictation.

The patient had infrarenal aortic aneurysm repair using stent graft with two docking limbs years ago. Now patient comes in with right iliac aneurysm. The doctor treated this with "Cook 20 mm x 90 mm iliac-iliac limb prosthesis". Will this be reported with code 34900 or 34825? Can you please explain when we should use code 34900 and when to use code 34825 in cases when patient already had prior AAA stent graft (with docking limbs) and now develops iliac aneurysm?

I know this has been addressed many times, but I'm still not totally clear on the requirements of the new ablation codes. The errata says to document the reason any components might not be performed in order to use code 93656, which doesn't seem logical to me since the new descriptor states "when possible". I would think the reason for not performing would be needed on 93653 and 93654 instead. Do you recommend including the reason for not performing on all three ablation codes? I realize that would seem to be the easiest fix; however. I'm still struggling to get my physicians on the bandwagon and don't want to ask for more than I need.

Does this documentation support assignment of a selective angiography (36222-50)? The findings show right and left common carotid, right and left external carotid, and right and left internal carotid results.

PROCEDURAL TECHNIQUE: The patient was brought to the lab and prepped and draped in sterile fashion. Local anesthesia was given. A 5 French sheath was placed in the right common femoral artery using anterior wall puncture. Next, 3000 units of heparin was administered. A 5 French pigtail catheter was advanced to the level of the ascending aorta and aortic arch. Angiogram was performed in the LAO projection. Bilateral selective carotid artery angiography was performed using a JR4 diagnostic catheter. The patient tolerated the diagnostic procedure well, and hemostasis was obtained using a Mynx device.

In performing an angioplasty and stent implant, the balloon ruptured. Several attempts were made to remove the balloon to no avail; however, the physician made certain it dislodged into a secondary branch of the left lung middle lobe. I believe it should be reported with code 37799 with modifier -22. I believe it probably needs to be coded as an unlisted code, as I don’t think you’re going to find any code that describes this. However, there is another employee who believes it should be reportd with code 37197 with modifier -52. I disagree, as nothing was retrieved. Any thoughts??

"Patient indications of A-fib, A-flutter. All pv isolated, ablation performed, and isuprel infused and re-interrogated. PV persistent electrically. Ablation then performed for atrial flutter as stated in dicatation. Ablation performed at cavotricuspid isthmus to achieve bidirectional block." My question is, will we be able to charge code 93655 (additional ablation) since it is A-flutter and not a spontaneous or induced rhythm? Or will he just get code 93656?

A patient presents with biventricular ICD pulse generator change due to ERI along with LV malfunction. The provider removes and replaces the generator and decides to cap the malfunctioning LV lead and then inserts a new LV lead, all at the same session. Would it be more appropriate to report codes 33249 and 33241, as CPT only indicates lead (table on pg. 177) without clarifying which one(s)? Or would it be appropriate to bill as you would for an upgrade with codes 33225 and 33264? Also, per CPT Assistant June 2012, Vol. 22, Issue 6, there is a tip indicating that code 33225 can be used with 33264, yet indicates this is for generator upgrade... and goes on to say for code 33264: "Codes 33262-33264 should be reported when the sole procedure is the replacement of a pacing cardioverter-defibrillator pulse generator and the procedure does not include the insertion or replacement of a right atrial and/ or ventricular electrode(s)." It does not clearly indicate if the ventricular electrode(s) are right or left. How would you recommend coding the above scenario?

My provider dictated that he performed an angioplasty but then also utilized mechanical thrombectomy with an AngioJet. "The AngioJet proxi mechanical thrombectomy catheter device was used to perform mechanical thrombectomy through the distal SFA within the occluded stent. A subsequent angiogram revealed patency through the stent with persistent severe narrowing. Angioplasty was then performed. Impression: Occluded distal left superficial femoral artery with an indwelling stent treated with a combination of mechanical thrombectomy and angioplasty with excellent final angiographic results." I've researched and couldn't find anything that would seem to preclude reporting both codes 37224 and 37186. 

My understanding of code 33877 is that carrel patches and reimplantations are included. In the case I am asking about, the provider did 33877 with no reimplantation of visceral vessels. Instead, he used a trifurcated graft and added an additional limb to this graft. He then ligated the celiac, mesenteric, right renal, and left renal arteries. He then used the graft for an antegrade bypass to the celiac, SMA, and right/left renal arteries from the aortic graft. Can I bill the four bypass grafts (35631) in addition to 33877, or would you consider this included since no patches/reimplantations were done? If they are separately billable, would you report code 35631 x 4 or use an unlisted code?

I would like clarification on your recommendation for physicians to consider using code19499 for clip placement when not in conjunction with percutaneous breast biopsy. Would you recommend that facilities use this code, for example, when a clip is placed after an axillary lymph node biopsy and that is all that is done? How about when there are two sites, one lymph and one breast, and two separate site clip placements - 19295 x 1 and 19499 x 1?

What are the correct codes to submit for aortogram with bilateral lower extremity run-off with right femoral artery puncture?

What is the correct CPT code for the following?  "Pigtail catheter was advanced into the left ventricle, and pressure measurements were done."

I have never seen gold seeds used for localization of a lesion before surgery. There was increased activity in the paraspinous tissue L1 area on a PET/CT scan.. The patient's mid back is prepped and draped in a sterile manner. Under CT guidance a 18 gauge needle was advanced into the area of interest to the left of the L1 vertebral body. Two gold seeds were placed 0.8 mm x 5mm. The seeds were placed lateral to the left fusion rod and medial to the left 12th rib in the area of increased activity. The patient will have a PET CT scan to identify the relationship of the gold seeds to the area of increased activity. "Impression: Status post CT-guided placement of localization gold seeds." I was thinking of using code 77012 for the guidance and an unlisted code for the gold seeds... not sure of the correct unlisted code 20999 (musculoskeletal) or 22899 (spine). What would you suggest?

We placed an ECMO via the right common femoral vein and right common femoral artery. The next day we added an additional arterial cannula in the right subclavian artery. A few days later, we converted from a VA to a VV ECMO, with the repair of the right common femoral artery. Then we removed the ECMO a day later. Please advise me on this scenario, and please give me the documentation requirements for the maintenance codes 33960 and 33961.

My question on the case that follows is regarding the unsuccessful recanalization of the SFA with a Crosser catheter. The physician was able to pass the Crosser catheter through the occlusion of the SFA, but was not able to proceed with any other interventions due to not be in the true lumen. Based on the documentation in the operative note below, would code 37225 be reportable?

Operative report: PROCEDURES PERFORMED: 1. Abdominal aortogram. 2. Right lower extremity distal runoff, third order catheter placement. 3. Percutaneous transluminal angioplasty and stent placement, right external iliac artery. 4. Crosser atherectomy, right superficial femoral and popliteal artery. INDICATIONS: Woman who presented to the office with ischemic rest pain of the right lower extremity. Physical examination as well as noninvasive studies confirmed the atherosclerotic etiology, and she is, therefore, undergoing angiography with hope for intervention and limb salvage. PROCEDURE: The patient is taken to the Special Procedures Suite and placed in the supine position. After adequate sedation is achieved, both groins are prepped and draped in a sterile fashion. 1% lidocaine is infiltrated in the soft tissues overlying the left common femoral impulse, and access to the left common femoral artery is obtained with ultrasound guidance. Ultrasound is placed in a sterile sleeve. Ultrasound is utilized secondary to lack of appropriate landmarks to avoid vascular injury. Under direct visualization, the common femoral artery is identified. Image is recorded for the permanent record. The artery is noted to be pulsatile and homogeneous indicating patency. Micropuncture needle is inserted into the anterior wall with direct ultrasound visualization. Microwire followed by micro sheath, J-wire followed by 5 French sheath and 5 French pigtail catheter are then inserted. Pigtail catheter is positioned at the level of T12, and AP projection of the abdominal aorta is obtained. Pigtail catheter is repositioned to above the bifurcation, and an LAO projection of the pelvis is obtained. Previously placed stents in the common iliac arteries are identified, and both are patent. Occlusion of the right external iliac artery is identified with reconstitution of the common femoral. 5000 units of heparin is given and using a combination of VS-1 rim, and the pigtail catheter and a stiff angled Glidewire the aortic bifurcation is crossed. Initially the VS-1 is successful. The Glidewire and VS-1 catheter are then negotiated across the external iliac and into the common femoral artery. Hand injection of contrast demonstrates patency of the common femoral and intraluminal placement. The catheter is then advanced into the profunda femoris, and the 5 French sheath is exchanged for a 7 French Balkan sheath. Balkan sheath is positioned in the mid common iliac on the right, and a 6 x 10 Rival balloon is used to angioplasty the external iliac artery. Follow-up angiography demonstrates it is patent. There is a significant intimal flap; however, this does allow advancing the Balkan in so that the tip is now in the common femoral. Additional heparin is given. The S6 crosser with an angled Usher catheter is then positioned at the small cul-de-sac, and Crosser catheter is used to advance down to the popliteal. Ultimately, however, we were not able to re-enter the true lumen in the mid popliteal, and further attempts at treating the SFA were abandoned. The Crosser catheter and Usher catheter were then removed. There was an exchange for a 0.035 Magic torque wire, and a Life Star 7 x 80 stent was deployed across the external posted with a 6 mm balloon. Follow-up angiography demonstrated the iliac system is now widely patent flowing into a common femoral and profunda femoris, which were widely patent. The sheath was then pulled into the external iliac on the left side, oblique view obtained, and subsequently the sheath was exchanged for a 7 French 11 cm sheath. ACT was checked, which was noted to be 200, and the sheath was later then pulled and pressure held. There were no immediate complications. INTERPRETATION: Initial views of the abdominal aorta demonstrate diffuse atherosclerotic changes. However, there are no hemodynamically significant stenoses. The aortic bifurcation is diseased but patent. There are bilateral common iliac artery stents. They do not extend up into the aorta. They are both patent. The right external iliac artery appears occluded. Internal iliac artery is patent. There is reconstitution of the common femoral and profunda femoris. Superficial femoral artery is a flush occlusion. The popliteal is reconstituted in its midportion at the level of the femoral condyles, and there appears to be single vessel runoff to the foot. Following angioplasty there is a flow-limiting dissection in the external iliac. This was later treated effectively with a Life Star stent and postdilated to 6 mm. Attempts at crossing the SFA using a crosser atherectomy catheter were successful at achieving the catheter and negotiating down into the popliteal; however, we could not re-enter the true lumen and, therefore, no further interventions were performed at this time. SUMMARY: 1. Successful recanalization of the iliac system. 2. Unsuccessful recanalization of the SFA.

We coded the case that follows with codes 93656, 93613, 93662, 93623, and 93657 x 3 (or should it be x 4??). Is this correct? Are the posterior wall, left atiral septum, linear line connection the LIPV to mitral annulus and the right atrial isthumus each a separate ablation that can be billed with code 93657?

Patient with atrial fibrillation was brought in for ablation. ICE and 3-D mapping are documented. Physician documents wide area circumferential lesions set were created around the four pulmonary veins to isolate the ostium of the veins from the left atrium. Isolation was confirmed. Patient then had ablation of the CFAE sies on the posterior wall and left atrial septum. Linear line was created connection the LIPV to the mitral annulus. Atrial flutter was then induced, and ablation of the right atrial isthmus was done. Isuprel was administered, and atrial flutter could not be induced. Procedure ended.

A SC ICD, RV lead, (that is under advisory), and an old capped RV lead were removed. Then a CRT-D, RV, RA, and LV leads were inserted. This was for physician only. Would the appropriate codes be 33249, 33241, 33244, and 33225? Or 33264, 33244, and 33225? Are the removal and replacement codes used only when no leads other than LV are inserted, adding 33225 to 33264 if LV lead is inserted? And would this be coded the same for both physician and hospital?

Hi! I'm hoping to get some insight on coding this procedure. Some think it could be a exploration, a repair of a vessel, or a revision.

BRIEF HISTORY: The patient is a 42-year-old gentleman who has had multiple AV access operations performed on his right arm. He presently appears to have a hybrid access with a vein to artery anastomosis but a more distal graft. He came to the hospital with this access thrombosed. He underwent percutaneous intervention for opening of the access and this was successful; however, the procedure resulted in a large hematoma in the antecubital fossa. This has been painful. It has not shown any sign of resolution. We studied it in the vascular laboratory yesterday because it was pulsatile. We did not find a false aneurysm. However, I reasoned that the hematoma had sealed or at least was causing intermittent sealing of the puncture site. Given the size of the hematoma, the patient required evacuation and exploration. He comes to the operating room at this time for this purpose. DETAILS OF PROCEDURE: The patient was brought into the operating room and placed on the table in the supine position. His right arm was placed at his side on an armboard and was prepared with ChloraPrep and sterilely draped in the usual manner. Supplemental oxygen was given. Vital signs were monitored. Sedation was induced. Timeout was performed. Operation was initiated with the infiltration of 1% lidocaine and 0.5% Marcaine solution into the skin and subcutaneous tissues of the antecubital fossa. Then, a transverse incision was made incorporating the puncture site. Incision was carried into the subcutaneous tissues. The hematoma was encountered and there was some bright red blood within the hematoma. I evacuated the hematoma and as soon as I did, I was met with pulsatile bleeding. I put my finger on the source of bleeding and then opened the incision wide enough to gain access. At the depths of the hematoma, the AV fistula had a puncture site that appeared to be about 8 French in size. Suction was held to control the stream of blood flow and the puncture was closed with 4-0 Prolene suture. Approximately 200 milliliters of blood was lost during this maneuver. Once the puncture site had been sutured, the wound was irrigated and the hematoma and walls of the false aneurysm were further evacuated. Then bleeders were controlled with electrocautery. Subcutaneous tissues were closed in 2 layers of interrupted and then running 3-0 Vicryl. Skin was closed with a running 4-0 Monocryl suture reinforced with skin sealant. A sterile compression dressing was applied. The patient tolerated the procedure well. As noted, blood loss was about 200 milliliters. No blood replacement was required.

Would a laser thrombectomy qualify for a 92973 thrombectomy add-on code?

HOW do we code chemoperfusion, catheter placements, angiographies, and chemo administration intra-arterial for the case that follows?

INTERPRETATION: Clinical History: Advanced parotid cancer. Procedure: Informed consent was obtained, which included a discussion of possible complications including but not limited to bleeding, stroke, non-target chemoperfusion, arterial injury, and contrast reaction. The patient was placed in the supine position and the right groin prepped and draped in sterile fashion. Physiologic monitoring was performed throughout the procedure. Moderate sedation was provided for three hours. Chemotherapy to be delivered intra-arterially included the following: 5FU 500 mg diluted with contrast, Gemzar 1000 mg (20 mg/cc) diluted with contrast and Oxaliplatin 100 mg diluted with contrast. The right common femoral artery was accessed with a micropuncture set, and a 5 French vascular sheath was placed. A 5 French pigtail catheter was advanced to the ascending thoracic aorta, contrast injected, and digital subtraction arteriography (DSA) performed. This catheter was exchanged for a 5 French H1 catheter, which was positioned into the right subclavian artery with contrast injected and DSA performed. A microcatheter was advanced coaxially and placed into the right costocervical trunk, with contrast injected and DSA performed. Two thirds of the chemotherapy was administered into this trunk. The H1 catheter was then positioned into the right common carotid artery and DSA performed in the lateral projection of the neck. A microcatheter was positioned into the right facial artery and DSA performed. The remaining one-third of the chemotherapy was administered. The catheter and sheath were removed, and hemostasis was achieved using manual compression. The patient tolerated the procedure well and left the department in satisfactory condition. There were no immediate complications. Findings: There is classic branching of the thoracic aorta. The visualized portion of the innominate, left carotid, and left subclavian arteries are widely patent. There is extensive tumor vascularity supplied by branches of the right costocervical trunk over the periclavicular area, which is the region of known tumor. Two thirds of the chemotherapy was administered in this location. The common, external, and internal carotid arteries are widely patent. A smaller area of tumor vascularity is supplied by the right facial artery. The remainder of the chemotherapy was administered into this vessel. A moderate narrowing is seen in the proximal lingual artery. Impression: Chemoperfusion of right parotid cancer metastatic to the right upper chest and lower neck as described.

I have an interventional radiologist who performed a right internal jugular hickman catheter exchange (36581) with fluoroscopic guidance (77001) and then accessed a dialysis graft to obtain a blood culture. Can the blood culture be reported with code 36500? The report reads as follows: "The patient's left arm HeRO dialysis graft was accessed with a micropuncture kit. Over a stiff Glidewire, a Berenstein catheter was advanced through the graft to the right atrium. Blood culture was acquired through the catheter as it was slowly withdrawn through the dialysis access. The catheter was removed, and hemostasis was achieved with manual compression. Fluoroscopy was used intermittently during the case."  This question is for professional billing. What would you code in this situation?

I have a question in reference to Question ID 4429. There the question is posed: "I have a question for you from the webcast on Tuesday regarding the acute MI code. There is much confusion on whether or not a non-STEMI is an acute MI. Are we to assume that a non-STEMI is an acute MI? If so, what clinical indications (documentation) would need to be present?" Your response was: "We have asked the societies that created the code and left out their definition of MI. I know this is an issue with MDs. We will let you know when that definition is published."

Could you tell me if this has been clarified, and if so, what is the definition?

I received this memo from CAHABA regarding new changes to -59 modifier effective July 1, 2013

CHANGES WITH MODIFIER -59, Effective July 1, 2013, Modifier -59 can only be used, when medically necessary, to unbundle a procedure code that has been bundled related to the National Correct Coding Initiative (NCCI). Claims billed with the same procedure code two or more times for the same date of service should be submitted with the appropriate repeat procedure modifier rather than using modifier -59.

Multiple Procedure Modifiers -76 and -91, Modifier -76 is used to report a service or procedure that was repeated by the same practitioner subsequent to the original service or procedure. Modifier -91 is used to report repeat laboratory tests or studies performed on the same day on the same patient. Modifiers -76 and -91 do not replace modifiers such as -RT, -LT, -50, -E1-E4, -FA, -F1-F9, -TA, and -T1-T9. If billing a procedure code two or more times for the same date of service, the claim should be submitted with the procedure code listed on one line without the -76/-91 modifier and each subsequent procedure listed on a separate line with the -76/-91 modifier.

My question is... does this apply to same procedure codes done on different vessels in the same setting (which is so common in IR)? For example, a superior mesenteric artery was selected and imaged, and at the same setting the inferior mesenteric artery was selected and imaged, resulting in two procedure codes of 75726. Would I append a -59 or a -76 modifier now?

Good afternoon. How would you code the following scenario? Would modifier -73 or -74 be appropriate to report in this instance since this is a radiology procedure? Would the modifier be applied to the RS&I or surgical component or both? "An attempt was made to perform a stereotactic biopsy. The calcifications could not be localized with stereotactic technique. The biopsy could not be performed. The patient understood the explanation. The microcalcifications may have to be biopsied with needle localization technique."

This question was brought up, and I would like to have your opinion. Prior to 2013 there were only three coronary arteries recognized by CMS. Therefore, prior to 2013, you could bill 92978 x 1 and 92979 x 2 for IVUS during PCI, if performed. Now that 2013 AMA and CMA both recognize five coronary arteries (LM, LD, LC, RI (if applicable), and RC) could it be possible to bill IVUS more than a total of three times?

Do you know if the Crosser Catheter system has been approved for use other than atherectomy? An issue has come up with the product being used for "recanalization of an occluded vessel" prior to proceeding with angioplasty. Product has a C-code of C1714, which is going to edit since documentation only supports the angioplasty procedure. Is "recanalization of occluded vessel" enough to justify changing this procedure to an atherectomy? I don't feel that it is.

Can you please explain why when fibrin sheath PTA is done via the same access in a hospital facility modifier -52 is not utilized only on the physician side? This modifier is used in other outpatient hospital coding and is approved per the CPT Manual (where modifiers are listed). I know this is in your literature but not the explanation behind it.

Can you please indicate the correct coding for vertebroplasty done on T12, L1, and L2? I recall in your lecture that now you would report that with codes 22520, 22522, and 22522, as well as three imaging charges (72291).  Is that correct?