Ask Dr. Z

I'm coding a fluoroscopically-guided lumbar puncture and epidural blood patch. I understand the CPT codes for the epidural blood patch are 62273/77003, but I'm a bit confused as to whether I need to also report codes 62270/77003 for the lumbar puncture. "TECHNIQUE: Under fluoroscopy the L2-L3 interlaminar space was identified, and a 22 gauge spinal needle was advanced into the thecal sac. A total of 8 ml of clear fluid was obtained in four tubes and sent to the lab. At the L4-L5 level a 20 gauge spinal needle was advanced into the epidural space under fluoroscopy. Subsequently, 9 ml of autologous blood was injected into the epidural space w/o complication. The needle was then removed." Please advise regarding the correct codes to use for this procedure.

We have not been able to find specific information as to when it is appropriate to use radiology S&I code 74235 with code 43247 when performing removal of foreign body. Is there something specific we need to be looking for in order to report code 74235?

One of our doctors will soon begin doing fetal cardiac interventions (aortic valvuloplasty, pulmonary valvuloplasty, ASD creation, pacing) in conjunction with doctor from Maternal Fetal Medicine for the access to the fetus. Any idea how both doctors would bill for these procedures? Please help.

I was wondering if you have had anyone ask about a bundling edit we keep running into. We are a hospital facility and are reporting the new DES codes (specifically C9602-LD, 92921-LD, and 92978). We are getting an "add-on" edit and need to report the primary procedure. The new DES "C" codes are not on the list. If we were to report code 95933-LD, we would not get an edit, but we would get a denial on the CPT code. Were there any changes/edits there were missed that were similar to the EPS codes?

We have multiple opinions flying around on this one, so I wanted to run it by you. Patient has/had DVT of the lower extremities and had a filter placed. She is seen now to have a lower extremity venous ultrasound done prior to removing the filter to check the status of the DVT. On the left it looks to have resolved, but on the right it's undeterminable if it has completely resolved. Would you use the DVT diagnosis (453.41/453.42), a follow-up (V58.81/V58.89), or a pre-op (V72.83) diagnosis code? I'm leaning towards the DVT, but a few do not agree, so I was hoping to get your opinion on it.

What are the supervision requirements for stress and nuclear stress tests? Does it require "direct" supervision? General supervision? And does it have to be a physician or can it be an NP?

I am new to IR coding. I have an operative note for a fistula to the radiocephalic for dialysis. It looks like they did an anastomosis. Please help with the correct CPT and ICD-9 procedure codes.

I need advice with the following case please. "Intra-op direct exposure of superior opthalmic vein with angiocath access was secured. Patient then brought to IR department for embolization of carotid-cavernous fistula. In IR, angiocath sticking out of opthalmic vein accessed with microcath and moved to cavernous sinus with coil placement. After embolization, patient went back to operating room for decannulation and ligation of opthalmic vein."  Would you do anything for the catheterization into cavernous sinus from superior opthalmic (36211)? Unlisted (36299)? Or just stick with embolization codes and follow-up angio from RCCA? There is no mention of imaging findings through opthalmic vein, just advancement of microcath and coil embolization into cavernous sinus.

My doctor is doing dual isotope adenosine nuclear stress test. Isotopes are Myoview (A9502) and Thalium (A9505). For patients who are not able to walk on a treadmill we are using adenosine injecting along with normal saline (J7050) for creating the stress. Here I have two questions: 1) We are using code A9502 (Myoview) 30 mci, for which we are coding two units, and we are using code A9505 (Thalium) 3.6 mci, for which we are coding four units. Are we correct in billing these two and four units for these isotopes as per dosage? 2) We are giving adenosine IV in mixture with normal saline. Does the dosage of this normal saline have to be 250 cc? Because the HCPCS code for normal saline (J7050) is showing for 250 cc... so could someone help me with this? Is it mandatory to use 250 cc normal saline solution in order to inject adenosine?

For the following procedure, is code 0281T appropriate for the scenario?

PROCEDURAL DETAILS: 1. Accesses: Arterial access was established in the right femoral artery with difficulty. He has a history of right total hip replacement, which appears to have been a complete reconstruction, with femoral head way above the corresponding left femoral head. As such, the usual vasculature anatomy appears to be completely mal aligned.  Nevertheless, after some maneuvering, a 5 French short sheath was inserted into the femoral artery. This sheath was sutured at the conclusion of the case, and there was no hematoma. An attempt was made to obtain venous access on the right, again with difficulty, and ultimately, the left femoral approach was used. The left femoral vein was accessed easily, single puncture, allowing the passage of initially an 8 French short sheath. 2. Left heart catheterization was performed through the Mullins sheath. 3. Left atrial appendage angiography was undertaken through a 5 French pigtail catheter, placed in the mid body of the left atrial appendage, hand injection undertaken on multiple occasions. 4. A transseptal puncture: A Toray wire was advanced through the left femoral venous access, sheath removed, and a Mullens sheath advanced up into the SVC then retracted back to the fossa. This was all under fluoroscopic and echocardiographic guidance. The BRK 1 needle advanced into the Mullins sheath, and with hemodynamic monitoring, as well as echocardiographic guidance, a single transseptal puncture was attained yielding a satisfactory position, and left atrial pressure immediately. Throughout the procedure, ACT was maintained at a satisfactory level. 5. Transseptal delivery of Watchman 27 mm device: The initial TEE measurement under general anesthesia condition yielded 21-22 mm diameter for the LAA, suggesting at 24 mm device. The assessment on the previous day was a maximum of 24 mm. Nevertheless, the 24 mm device was delivered, however, not in a satisfactory position, and was retrieved. Given the suggestion that the 24 mm was not yielding a satisfactory compressions ratio, a 27 mm occluder was then used, and on deployment, it appeared that the delivery system was not intubated enough, most likely to do with the left femoral approach, biasing it superiorly. Nevertheless, a third 27 mm occluder was then used (second device fully deployed). This was after advancement of the pigtail catheter deep into the apex of the left atrial appendage, allowing the delivery sheath to be advanced three quarters into the left atrial appendage. On delivery of this 27 mm occluder, it was deployed satisfactorily, occluding the appendage with minimal/trivial Doppler flow, and a tug test demonstrated satisfactory deployment. At this point, the Watchman device was deployed, and the delivery sheath removed en bloc, and a figure-of-eight suture was placed satisfactorily, attaining hemostasis immediately. PROCEDURAL FINDINGS: 1. Opening aortic pressure 96/61. 2. Left heart catheterization: Mean LA 17 mmHg at the commencement of procedure. 3. TEE: See separate report. RESULTS OF INTERVENTION: Successful closure of left atrial appendage ostium with a 27 mm device with excellent position, anchorage, ceiling, and sizing parameters. CONCLUSION: Successful closure of left atrial appendage with a 27 mm Watchman device with no complications.

CPT codes C9608 (CTO) and 92944 read "each additional coronary artery or coronary artery branch". The other add-on codes for PTCA, stent ect read just "each additional branch". So, if two CTO primary vessels are intervened upon, do we report code C9607 twice?  Or codes C9607 and C9608?

Which ablation CPT code would we report for the following? Vascular clinic is saying liver code 47382 and HIM is saying unlisted biliary tract code 47999.  "RF device was placed through the biliary catheter into the bile duct for ablation of malignant biliary strictures and stents."

How do I code for a common femoral to profunda bypass using a Dacron graft same leg?

The physician performs embolization of an AVM by catheter-directed insertion of coils, glue, etc. He then performs additional embolization using a direct stick technique under ultrasound and fluoroscopic guidance on the same AVM. Should we be coding this with both codes 37204 and 37799? Or would the direct stick embolization be included in code 37204? Are the fluoroscopy and US guidance codes both assigned either with or without code 37799?

Physician selects left subclavian and performs angiography only to find that vertebral artery does not originate from the left subclavian. He changes to a SIMII catheter, catheterizes left vertebral artery, and performs complete angiography of cervical and cerebral portions of vertebral. Do we just charge for the vertebral angiography from a vertebral selection, or can we utilize both codes with a modifier?

My physician completed a right fem-pop bypass using saphenous vein. As the right external iliac was not clampable for an endarterectomy, he instead balloon angioplastied the stenotic segment and placed a stent through a micropuncture needle in the common femoral artery. I would only code for the bypass, as I would consider this part of localized inflow and outflow. My provider disagrees and thinks this should be billed in addition to the bypass. Can you please provide your thoughts?

We are report code 36832 for ligation of collateral veins off the AVF. If we have multiple cut-down incisions with more than one vein ligated, can we bill code 36832 more than once per encounter?

I'm looking for guidance on this case where the physician placed a stent but it was suboptimal, so the stent was removed via snare. "Then over a guide wire, a 8.5 French ureteral stent was advanced and distal loop placed in the urinary bladder. However the proximal was shortly deployed in the proximal aspect of the ureter possibly secondary to the tortuosity at this level in the ureter. The stent was pulled back in the ureter toward the urinary bladder. Using multiple maneuver and after a long period, we were able to retrieve the ureteral stent by advancing the snare into the urinary bladder and pulling out the stent in the retrograde fashion."

A documented pacemaker dependent patient was brought in for end-of-life pacemaker generator replacement. A temporary pacemaker single chamber was inserted, and the dual pacemaker was replaced. The patient was placed in observation where it was noticed that there was a sudden loss of ventricular capture due to the chronic ventricular lead being displaced. The patient was taken to the special radiology suite emergently and had a temporary pacemaker wire placed and then was taken to the cardiology suite where the chronic ventricular lead was replaced. This was originally billed as two sessions (33228 with 33210-59, and 33234 with 33216 and 33210-59). Code 33228 is not allowed with 33216 even with an appropriate modifier. Can we bill codes 33207, 33234, and 33210-59 x 2?

If an open AV fistula thrombectomy is performed and a stenosis is then identified at the venous anastomosis and treated with angioplasty, are we able to submit codes 36831 and 35460?

We bill for the radiologists who are employed by a hospital system. They are required to provide the interpretation for all imaging procedures performed and have decision-making authority for protocols, as well as provide supervision to the technologists. When they are performing the final written interpretation for radiology procedures that include an S&I component (particularly, e.g., angiography and aortography) we are billing with only a -26 modifier. I have seen recommendations that we should also append a -52 modifier, which I am challenging based on our organization structure and protocol. Also during some IR procedures (e.g., cholangiograms) I see recommendations that the interpreting radiologist can only bill for the intraoperative spot films performed instead of the cholangiography initial and additional sets (74300-74301). We have been billing the cholangiography. Should we only be billing the abdominal films (74000)?

A patient has a duplex scan that suggests significant increase in velocity of a high grade in-stent re-stenosis of the right internal carotid artery. The physician successfully treats by balloon angioplasty in the right internal carotid artery. Is there a code for this procedure, or is an unlisted code our only option?

Back in March 2009 a question was submitted asking how to code for the injection of blood as a patch for a pneumothorax. I would like to know since this time if there has been any clear guidance on which CPT code(s) to use when billing for the following procedure. The patient may or may not have a chest tube. If not, one will be placed. The proceduralist will then withdraw 100 cc's of the patient's blood and instill into the pleural space via chest tube. What is the appropriate code for billing?

I wanted to get your opinion on the use of the Avinger Ocelot PIXL atherectomy device. I am assuming based on the below op note that this would not be coded separately, as it is being used in a recanalization procedure prior to angioplasty (37224). I know in your IR book you do mention, "Crossing the lesion is bundled with codes 37220-37235. The angioplasty, atherectomy, or stent placement procedure is coded." Is that the case with the below as well? Just want to check to be sure I am advising correctly.

PREOPERATIVE DIAGNOSES: Total occlusion of the left superficial femoral artery involving the entire length along with the total occlusion of the proximal popliteal artery of the right leg. OPERATION PERFORMED: Right femoral arteriogram with distal run-off, recanalization of the superficial femoral artery and popliteal artery using Avinger Ocelot PIXL atherectomy catheter followed by multiple overlap balloon dilatations, then using 4.0 x 100 mm AngioScore AngioSculpt dilatation catheter, followed by using a 6.0 x 200 mm power PowerCross dilatation catheter, then a 6.0 x 200 mm Mustang dilatation catheter. POSTOPERATIVE DIAGNOSES: Total occlusion of the left superficial femoral artery involving the entire length along with the total occlusion of the proximal popliteal artery of the right leg with good recanalization but poor run-off distal to popliteal artery, diffuse disease. PROCEDURE: An informed consent obtained. The patient was taken to cardiovascular laboratory. Under routine sterile precaution, using 1% Xylocaine local anesthesia, the left femoral artery was punctured by the single-wall technique and the size 6 femoral sheath was placed in. The patient was given Angiomax IV bolus followed by an IV infusion according to protocol. A size 5 Omni Flush catheter was introduced along with the Terumo guidewire. The catheter was advanced into the right common femoral artery. The Omni Flush catheter was then substituted by a size 7 Destination sheath which was positioned at the right common femoral artery. Right femoral arteriogram was then obtained with a distal run-off. This revealed total occlusion of the right superficial femoral artery involving the entire length followed by reconstitution of distal popliteal artery. Avinger Ocelot PIXL 135 5-French atherectomy device was introduced along with the 0.014 Floppy guidewire. It was able to advance the atherectomy device with OCT and fluoroscopic guidance to the distal superficial femoral artery. There was a difficult time to advance the distal superficial femoral artery into the popliteal artery. But it was able to pass the 0.014 Floppy guidewire into the popliteal artery and deep peroneal artery. Size 2.0 x 210 mm NanoCross ev3 dilatation catheter was introduced and multiple overlap dilatation carried out to the entire occluded segment by inflating balloon up to 12 atmospheres up to 1 minute of duration. The balloon size was then increased to 3.0 x 210 mm NanoCross ev3 dilatation catheter. Again, multiple overlap dilatation carried out to the entire occluded segment of the superficial femoral artery and proximal popliteal artery by inflating balloon up to 10 atmospheres up to minute-and-a-half duration. Satisfactory opening was noted. Size 4.0 x 100 mm AngioScore AngioSculpt dilatation catheter was introduced and multiple overlap dilatation is carried out to the entire occluded segment. Repeat angiogram; however, showed no significant improvement of the lumen and flow. Size 6 x 200 mm ev3 PowerCross dilatation catheter was then introduced. Multiple overlap dilatation carried out by inflating balloon up to a minute-and-a-half to two minutes. A satisfactory opening was noted. Repeat angiogram revealed good improvementthe the lumen size with good run-off although there is some irregularity noted of the distal superficial femoral artery. Poor distal run-off below the popliteal artery. There is a small deep peroneal artery along with the prior occlusion of the anterior tibial and posterior tibial artery. A size 6 x 200 mm Mustang Non compliant balloon catheter was then introduced. Again, multiple overlap dilatation carried out to the entire length of the superficial femoral artery and proximal segment of the popliteal artery. The final angiogram revealed good patency throughout with no significant residual stenosis or local complication although there is poor distal run-off below the popliteal artery. The destination sheath was then removed and replaced by a size 8 femoral sheath. Left femoral angiogram performed. The common femoral sheath was removed and puncture site was closed with the size 8 Angio-Seal. There were no complications. TOTAL AMOUNT OF CONTRAST: 130 mL of the Isovue. ESTIMATED BLOOD LOSS: About 30 mL. IMPRESSION: Successful recanalization of the totally occluded right superficial femoral artery including entire segment and the proximal, one-half of the right popliteal artery with the successful recanalization using Avinger Ocelot atherectomy device and multiple overlap dilatations using small balloon size up to 6.0 balloon with a good result throughout although there is very poor run-off distally below the popliteal artery as described.

We see the following in a physician's dictation, and we aren't sure about using the additional ablation codes. We thought code 93657 was used if you assess after the PV ablation and find additional focus, but this reads as if he does the roof line after the PV and doesn't mention additional focus. Also we have been told the cavotricuspid isthmus ablation is A-flutter ablation... does it need to be worded differently?

Using the LassoNav and ablation catheters, a 3-dimensional map of the left atrium was created using the FAM technique. The anatomy as defined by this technique closely correlated with that seen on the CTA and ultrasound images. Particular attention was paid to the regions of the pulmonary vein antral regions and the ridge separating the left atrial appendage from the left pulmonary veins. RF lesions were then placed in a contiguous manner to isolate the pulmonary vein antral regions, across the left atrial roof, and inferiorly between the inferior pulmonary veins. (Does this meet criteria for code 93657?) RF application was continued until local electrogram abatement was seen. The catheter was then moved to the next target site. If the impedance either increased or decreased precipitously, or if the temperature measured in the sophageal temperature sensor increased by >0.5 degrees Celsius, RF application was terminated, and the catheter was repositioned. Cavotricuspid isthmus ablation was performed and bidirectional block was confirmed. (Does this meet criteria for code 93655?) After an appropriate waiting period, isoproterenol infusion was begun at a dose of 20mcg/min. The pulmonary veins were again interrogated with the circular catheter. There was no evidence of acute reconnection; no atrial fibrillation was induced; no significant atrial ectopy was present.

Our interventionalists are asking when an AMI patient has intervention in a bypass graft, is there an additional code available to report, since both drug eluting stent in bypass graft (92937) and STEMI/bypass acute total/subtotal occlusion (92941) are performed?

Does a separate report need to be created to support the filing of both codes 76380 and 76377 when a cone beam CT hepatic artery injection and 3D reconstruction are performed in conjunction with diagnostic hepatic arteriography in Y-90 planning? Alternatively, in reporting codes 76380 and 76377, is it sufficient to only note that the cone beam CT was completed during the angiographic procedure? Findings are reported as a single discussion without specifically noting what modality (angio or CT) was used, both having been completed. Reference is made to the angio and CT in the conclusion. How much documentation is required to support these codes?

How should we charge for contrast in interventional radiology? Do we charge the amount ordered or the amount us (if we order a vial 100 ml and used/injected only 50 ml) since the amount needed determined at the end of the procedure? My question is regarding if the contrast comes in a premeasured single use vial, and they don’t use all of it they can still bill the amount in the vial because it can’t be reused and what is not used is wasted. Can we charge the entire amount as long as there is documentation of the waste? How do we charge the contrast if it is not a single use vial? Then they can only charge for the amount given? I could not find any guidelines in the CPT Assistant since it is not a CPT code. Would you please inform us with your answer and any reference and guidelines from CMS, HCPCS, or Federal Register to support this. Here is a case scenario to support the question:

Patient is having abdominal aortagram 1.6 Creat.

• 50 ml Iohexol 300 on the table for test dose. 10 ml 50% diluted contrast used for test
• 50 ml Iohexol Injector 40 ml Injected 50% diluted contrast for Aortagram
• 100 ml Iohexol 300 Opened / 25 ml Iohexol 300 actually used

How should we bill?

My question concerns the coding of a temporary pacemaker during a pacemaker or ICD change out for patients who are pacemaker dependent.  If during the change out the physician documents that the patient was "quickly connected to a pacing system analyzer", is this codeable in CPT?  The PSA is used rather than the insertion of a temporary wire.  I'm not clear as to when this would be used rather than an actual temporary pacemaker.  Can you explain?

I am a little confused when a non-selective catheter placement of the aortic arch can be reported with a selective intervention of an upper extremity artery. It would seem in the report below that the physician had plans to perform the therapeutic procedure based on the history. In these cases, is the determining factor as to whether the non selective cath placement (36221) can be reported based on if it is related or not to the subclavian stent placement done? How would a coder make that distinction? Thanks.

PROCEDURE: LEFT GROIN CANNULATION WITH LEFT SUBCLAVIAN ARTERY CANNULATION, BALLOON ANGIOPLASTY AND STENT PLACEMENT. ANESTHESIA: 1% lidocaine for local with intravenous fentanyl and Versed for a nurse-monitored anesthesia time of 1.5 hours. ESTIMATED BLOOD LOSS: Minimal. PATHOLOGY SPECIMEN: None. PROSTHETIC IMPLANT: Genesis balloon expandable stent, 8 x 39 mm placed within the origin of the left subclavian artery. REASON FOR PROCEDURE: This is a 61-year-old gentleman with coronary artery disease status post coronary artery bypass grafting including a left internal mammary artery graft to the left anterior descending artery. The patient presented to ABC Medical Center with an acute myocardial infarction. Cardiac catheterization was performed demonstrating two patent coronary artery bypass grafts with a high-grade left subclavian artery stenosis. Patient was transferred to XYZ Hospital for definitive treatment including stenting of his left subclavian artery stenosis. I evaluated the patient and recommended left groin cannulation given his recent cannulation within his right groin with selective catheterization of the left subclavian artery and stenting as appropriate. The indication is to treat the subclavian lesion restoring perfusion to his left anterior descending artery bypass graft. The risks include bleeding, arterial injury, failure to revascularize his left subclavian artery as well as atheroembolization. In addition, potential recurrent stenosis. The patient requested we proceed. PROCEDURE AS FOLLOWS: On 02/26/2013, after obtaining informed consent, the patient was taken to the angiography suite and placed on the angiography table in the supine position. After prepping and draping his left groin in the usual fashion with ChloraPrep, patient identification and operative checklist was performed. Utilizing ultrasound guidance, the left common femoral artery was cannulated overlying the femoral head in a retrograde fashion with a Micropuncture needle. A Microwire was advanced under fluoroscopic guidance to the aortic bifurcation. This was exchanged through a coaxial dilator for a 5 French sheath and eventually a 6 French Raabe sheath, 55 cm. The guidewire was placed in the ascending aorta. Patient was heparinized with 4000 units of IV heparin. A pigtail catheter was placed in the ascending aorta. Arch aortography was performed with a steep left anterior oblique view demonstrating the left subclavian artery origin with subtotal occlusion with retrograde filling of the left upper extremity through the vertebral artery. The left internal mammary artery is identified distally and found to be patent. The left common carotid artery is patent as is the innominate. A 6 French Raabe sheath was then placed over the guidewire to the origin of the left subclavian artery. The left subclavian origin was selected with a vertebral artery catheter and a 0.014 inch Thruway guidewire. The guidewire was placed in the proximal brachial artery. Balloon angioplasty of the stenosis was performed with a 4 mm balloon angioplasty catheter followed by placement of an 8 mm balloon expandable Genesis stent. The stent was dilated within its mid segment and proximally and very gently distally. Selective angiography demonstrates a patent result without evidence of a residual stenosis. Guidewire and catheters were removed. Angiography of the left groin demonstrates extensive calcification just distal to the cannulation site, therefore, the catheter was removed and hemostasis was obtained with manual compression. The patient tolerated the procedure and was transferred to his room in stable condition. IMPRESSION: Successful balloon angioplasty with stent placement, left subclavian artery origin stenosis.

We (facility) had a patient come in for a parotid biopsy. The procedure was cancelled after the neck was scanned with ultrasound and no mass was found. This is how the report reads: "By ultrasound exam and palpation, no pathologic discrete lesion was found, and therefore, no attempts were made to perform a biopsy at this time. The area that he pointed out to me appears to represent a strained muscle with no underlying lesion by ultrasound. A thorough exam of the full neck by ultrasound including the parotid area was also conducted." The department wants to charge guidance code 76942 with a -52 modifier. This seems incorrect to me. I think that either we report codes 76942 and 42400-52 or 76536. Can you please give us some guidance for this?

For the following report, can the cardioversion be coded along with the EPS study and injection of Isuprel?

Patient was brought to the EP Lab in the fasting state, sedated by the Anesthesia Team. The right and left groins were prepped, and the right neck was prepped. A catheter was advanced. Patient had atrial fibrillation that was seen with catheter manipulation. This had to be cardioverted back to sinus rhythm. Patient had an EP study done and had no inducible SVT, no evidence for dual AV node physiology, and no evidence for an accessory pathway. VA conduction was not present. We started Isuprel, and the patient went into A-fib again, so we had to discontinue the Isuprel, and the patient received another cardioversion once the Isuprel was discontinued and went back to sinus, but then degenerated back into A-fib again. The patient also had an episode of atrial flutter that appeared to be typical flutter. Procainamide was ordered and was about to be hung, but the patient went back into sinus rhythm just as we were about to start the Procainamide. The patient was awake at this time with a baseline heart rate about 100. The EP study was repeated and again no VA conduction was seen during the awake state. The patient did have occasional episodes of a very short three to ten beat runs of nonsustained SVT that may have been an atrial tachycardia earliest in the high atrium, and it is possible that this may be the patient's clinical diagnosis. All catheters were removed. No ablation was performed. IMPRESSION: EP study significant for inducible atrial flutter, which was typical, atrial fibrillation and also a short atrial tachycardia that was nonsustained. Hard to know what is her clinical tachycardia. It may be the nonsustained atrial tach. The patient felt better on the Digoxin. We are going to resume Digoxin.

If a patient is having a ureteral stent placed via an ileal conduit, is it still reported with codes 50393/74480 since the code states the catheter is inserted through the renal pelvis?  Or would it be unlisted since it is via the ileal condiut?

Report: Conversion of a left nephrostomy tube to a left nephroureteral stent through the patient's existing urostomy. Clinical Information: This patient is an 80-year-old gentleman has a history of left renal obstruction. He is pulled out his tube from the urostomy in and now presents for conversion of his existing left nephrostomy tube to nephroureteral stent. Procedure: After the procedure was explained and consent obtained from the wife, the patient was placed in a decubitus position on the fluoroscopy table. The patient had the urostomy site and nephrostomy tube exit site prepped and draped in the sterile fashion. The patient was numbed with 1% lidocaine solution around the nephrostomy tube exit site. The nephrostomy tube was removed over a 0.035 guidewire and a 5 French vertebral catheter was then placed within the renal collecting system. This in conjunction with a 0.035 hydrophilic guidewire was utilized to access the left ureter. This is also used to pass the anastomosis and enter the ileal conduit. After this was then, the catheter and guidewire combination were used with fluoroscopic guidance to traverse the conduit with the catheter and wire protruding through the ostomy site. Exchange was made for a 0.035 Amplatz guidewire. After this was done, the catheter was removed. The patient was then placed in the supine position on the fluoroscopy table. A 10 French drainage catheter was then placed over the guidewire using fluoroscopic guidance into the proximal loop is located within the renal pelvis. The guidewire was then removed. A contrast injection with gadolinium demonstrates the tip of the catheter to be located within the renal pelvis. The patient tolerated the procedure. The patient received Versed and fentanyl intravenously for conscious sedation. Impression: Conversion of the left nephrostomy tube to a left nephroureteral stent which extends in a retrograde fashion through the urostomy site.

Recently, I noticed that some of our physicians are doing diagnostic heart catheterizations and then also doing bilateral renal or iliacs.  Rationale, since he is already in he may as well look at peripherals since majority of patients also have lower extremity issues.  Although S&I is chargeable, is the catheter placement also chargeable?  Example: 75625, 75716, and 36245?

Our physicians are wanting to schedule patients who may need an Impella 2.5 to assist during cardiac stent procedures as outpatients. Code 33990 is an inpatient-only procedure. 3M Encoder and CPT Assistant still lead to code 33999 for this type of intervention. Will there be updates to CPT Assistant or the 3M Encoder to relay the new 2013 codes, as we are in May 2013 now and still no updates? Does code 33990 cover any situation that an Impella 2.5 would be used including during a coronary stent procedure and removed at the conclusion of the procedure?

There are many different scenarios in which we have used the impella lately and would like clarification as to when we can charge the removal on the same day as insertion.  (Also trying to clarify definition of separate distinct session.)  For instance: Impella inserted in cath lab for procedure that would be done in different department later in the day.  At the end of the procedure in the other department, the Impella is removed. Impella inserted in cath lab for procedure in cath lab, but patient goes back to his room, and a few hours later when the MD is available, it is removed.  Impella inserted in EP procedure room by cardiologist for a left heart catheterization by cath lab staff, followed by an EP procedure by EP staff.  Hours later after the ablation, the Impella is removed by the cardiologist while still in the EP lab.  The IABP is a different class of assist device but curious as to when it's appropriate to bill removal on the same day as well.  We understand if put in for a procedure and removed at the end of a procedure, the removal is not billable.  However, when put in for a procedure but left in for continued support (for a few hours) and then removed, can the removal be charged?

There is much confusion at our hospital (physician billing) about biopsies with regard to wording of dictation (biopsy, aspiration, FNA, core biopsy, etc.).  There has also been confusion about the CPT codes appropriate for billing biopsies in various areas.  For example, is code 49180 appropriate for ALL biopsies in abdominal/peritoneal area (including muscle, lymph nodes, deep, superficial, etc.)?  Is code 38505 used for ALL superficial lymph nodes?  Only a few are listed in documentation we have found, but it would seem that others would also use this code (such as iliac lymph node).  We are trying to have a better understanding so that these are billed appropriately by everyone.  I would really appreciate your expertise.

Do you recommend using code 37204 or unlisted CPT code for endovascular closure of an ascending aortic pseudoaneurysm with a vascular plug?

I hope you can give some insight into this procedure. Basically the physician performed open revision with thrombectomy (36832), then performed fistulogram (36147), followed by percutaneous venous angioplasy (35476 and 75978-26), and then decided to ligate the entire fistula (37607) and create a whole new graft (36830).  Based on the below documentation, would you bill all those codes? Or should only the open procedure be coded as per NCCI Chapter 5, Section D, #9? Any assistance will be appreciated!

A linear incision was made in the fistula at the arterial anastomosis. I noted immediately that the thrombus was well organized and adherent to the fistula walls. It required mechanical removal. I carefully inspected the area of the arterial anastomosis, removing the fibrin plug. I passed a #3 Fogarty catheter distally in the brachial artery and retrieved no additional thrombus. I sounded the proximal brachial artery with the right angle, and there was no evidence of a stricture at the arterial anastomosis. I removed as much thrombus from the body of the fistula as allowed by the arterial cuff, which had been placed proximally. In order to control the arterial inflow and to avoid stricturing of the fistula, I acquired a bovine patch and partially closed the fistulotomy with the bovine patch and 6-0 Prolene suture. This allowed for application of an atraumatic clamp at the arterial anastomosis and removal of the proximal arterial tourniquet. I evacuated the clot from the remaining portion of the fistula body by vigorous manipulation beginning at the axilla. I removed a relatively small amount of clot. I did retrieve venous backbleeding. Heparinized saline was instilled, and an atraumatic clamp was placed on the body of the graft. The patch angioplasty was completed. There was a pulse within the graft with removal of the arterial tourniquet. This was not accompanied by a thrill though there was a continuous Doppler signal. I cannulated the patch with a 21 gauge micropuncture needle. I advanced the 0.018 guidewire under fluoroscopy. The needle was exchanged for a 5 French transitional dilator. I removed the inner stiffener and 0.018 guidewire, and through the transitional dilator, I performed a fistulogram. Although there was continuous flow in the fistula the fistula was noted to be quite sclerotic. This did not appear to be thrombus. A retrograde filling of the brachial artery revealed the arterial anastomosis to be widely patent. I attempted to pass a short 0.035 guidewire through the transitional dilator, but it would not negotiate the fistula. I acquired a 0.035 Glidewire, and with some manipulation the Glidewire traversed the fistula and was placed in the superior vena cava. I removed the 5 French dilator and advanced a 6 French short sheath. I advanced a 5 French Kumpe catheter over the Glidewire and exchanged the Glidewire for a 0.035 Rosen wire. I repeated the fistulogram documenting the fairly extensive sclerotic changes within the fistula. Again, these did not appear to be thrombus. I acquired a 5 French and subsequently a 6 French x 4 centimeter balloon catheter and proceeded to dilate the entire fistula from the end of the sheath to the basilic vein junction with the brachial vein. There was no evidence of a central stenosis. The balloons were inflated to pressures of 14 millimeters of mercury. Following the balloon angioplasty, I repeated the fistulogram. While there was some improvement in the luminal diameter of the fistula, it remained quite ratty and there was sluggish flow. I did not feel that further efforts at maintaining the fistula would be productive. I ligated the fistula just beyond the arterial anastomosis. I proceeded with an AV graft insertion. A short incision was made in the axilla, and I identified a 12 millimeter brachial vein. I carefully dissected between the nerve trunks and identified a 6-7 millimeter axillary artery. The artery lies medial and deep to the vein. A counterincision was made on the upper arm to allow for tunneling in a loop configuration. The patient was given an additional 1000 units of heparin. I carefully exposed the artery, placing no tension on the nerve trunks. An end-to-side arterial anastomosis was completed with 5-0 Prolene suture. Two of the three large nerve trunks lie medial to the graft and one lies lateral. Upon completion of the anastomosis, there was no anastomotic bleeding. The bovine graft was then withdrawn through the subcutaneous tunnel in two movements. It was allowed to lie in a gentle loop configuration. A partial occlusion clamp was placed on the axillobrachial vein, and an end-to-side anastomosis was completed between the bovine graft and the vein with a 5-0 Prolene suture. Whereas the arterial anastomosis is 5-6 millimeters in length, the venous anastomosis is 8-10 millimeters in length. Prior to completing the anastomosis, the vessels were vented and were flushed with heparinized saline. There was minimal anastomotic oozing. This was readily controlled with Fibrillar. Once hemostasis was confirmed, the three operative wounds were closed with two layers of absorbable suture.

I have a case that the physician accessed the right renal artery, and right renal arteriogram was performed, demonstrating filling of the adrenal artery with supply up in to the right lobe liver mass. The right adrenal artery was selective along with an adrenal arteriogram (the adrenal artery comes off the renal artery). Chemotherapy was then infused into the right adrenal artery slowly over 20 minutes. Embolization was then performed with a combination of 100-300 and 300-500 micron particles of biospheres. Because the renal code 36251 includes the renal arteriogram, how would I code for the adrenal artery that comes off the renal artery? Would you report codes 36246 and 75731-26, or just code 36251?

I have a group of cardiologists who are inserting a permanent pacemaker lead and then attaching it to an external device. The patient is often returned to his room like that. Since some of these patients are in observation status, I am getting a device edit looking for the procedure. But I also know that I cannot charge for a temporary pacemaker insertion in most of these cases. Should I just continue removing the C-code from the lead on the claim to remove the edit?

I am being questioned about how the following report should be coded: "Using CT guidance a Jamshidi needle was placed in the left posterior iliac line. A 15 cc aspirate was obtained and handed to cytopathology technologist. A core was attempted to be obtained through the Jamshidi needle; however, despite multiple attempts all that was gained was clot. Core specimen was not obtained."  Should this be reported with code 38220 or 38221, with/without a modifier? Is there any difference between the physician and facility coding in a case like this? Also I am being asked in what cases would code 38220 be reported? He thought just an aspiration (38220) would never be performed. Thanks so much for your help!

I have a case where the patient has two renal arteries coming off the aorta on the right side and an angiography was done on each. Would I report code 36251 twice because you have to come back out to the aorta to select the second renal artery, or is it coded once because the description for code 36251 mentions accessory arteries also, but does that just mean arteries that branch off the main renal? And if it is coded twice with 36251 would the second have a -59 modifier?

Patient has a native fistula that is clotted off. The fistula is accessed and imaging is performed, showing the venous end is thrombosed. Thrombectomy is performed, but there is residual clot. A 10 cm infusion catheter is placed, and overnight thrombolysis is started. Patient returns the next day for a follow-up angiogram. Can we report codes 36147, 37187, 37212, and 37214? Our coding staff is having a difficult time knowing when it is appropriate to code thrombolysis for AV fistulae. What is the anatomical landmark you would suggest?

I am having trouble coding one of our physician's dictation. He is trying to bill a left and right heart catheterization as well as left and right congenital heart catheterization. Is that possible?  He wants to bill the following: 93460-26, 93531-26, 93463, 93464-26, 93567, 93568.  Would this be appropriate?

CARDIAC CATHETERIZATION INDICATION FOR STUDY: Evaluation of hemodynamic significance of patent ductus arteriosus. FINAL IMPRESSION: 1. Angiographic confirmation of a 3.8 mm diameter patent ductus arteriosus with an associated QP:QS shunt fraction of 1.25. 2. Mild pulmonary hypertension. 3. Elevated left ventricular end-diastolic pressure. 4. Widened pulse pressures secondary to patent ductus arteriosus. 5. Normal pulmonary vascular resistance and pulmonary vascular resistance index and transpulmonary gradient. 6. Normal coronary anatomy. DISCUSSION: The hemodynamic significance of the patient's patent ductus arteriosus is likely a modest contributor to the patient's exercise intolerance and recent heart failure admission. Her QP:QS is likely underestimated as a definitive sample distal to pulmonary flow was difficult to ascertain, but was confirmed as best as possible via angiographic method using a JR4 catheter. Her other contributors to exercise intolerance include obstructive lung disease, the etiology of which is yet to be elucidated, particularly given her abcense of smoking history. Alpha 1-Anti trypsin serology is pending. Formal pulmonology consultation has been undertaken and her high resolution CT scan today evidences air trapping of unclear etiology. Consideration may be given to coiling of her patent ductus arteriosus or the usage of an Amplatz occluder. Formal consultation with pediatric cardiology at XX Hospital may be considered. PROCEDURE: Risks and benefits were explained to the patient. The patient was brought to the catheterization lab in a resting fasting state. The right femoral artery and vein were chosen for vascular access. JL4 JR4 catheters were used for selective angiography. Pigtail catheter was used for aortic angiography. A JR4 catheter was used for pulmonary arterial angiography. At the conclusion of the procedure, a StarClose device was deployed for hemostasis. No immediate complications were noted. CARDIAC CATHETERIZATION DATA: 1. Weight 56.7 kg. 2. Body surface area 1.56. 3. Blood pressure 109/41 with a mean of 60. 4. Oxygen consumption directly measured outside the catheterization lab was 208 mL per minute. 5. Respiratory quotient 0.78. 6. RA pressure, 8/60 (4). 7. RV 36/1, 7. 8. PA 26/ 3 (15). 9. With exercise, mean PA pressure was 20/8 with mean of 13. 10. Wedge pressure was 10/9 (7). 11. Aortic pressure 118/50, mean of 76. 12. LV pressure process 125/4, 19. 13. Saturations in the aorta were 96%. 14. PA saturation was 76%. 15. Pulmonary capillary wedge saturation was 92%. 16. Right ventricular saturation was 73%. 17. Right atrial saturation 64%. 18. Superior vena cava saturation 69%. 19. Inferior vena cava saturation 74%. 20. Attempts to cannulate patent ductus arteriosus, either from the pulmonary or arterial circuit were unsuccessful using a JR4 and IMA catheter. Wires including a BMW wire and Versa Core wire. Selective angiography of the pulmonary arterial tree did not evidence a communication with the aorta likely secondary to increased aortic pressures relative to pulmonary artery pressure; however, communication was identified from the arterial circuit to the main pulmonary artery in the LAO 60 degree position. 21. Hemoglobin 10.5. 22. Heart rate 65. 23 QP:QS 1.25. 24. Cardiac output and index by the Fick method were 6.12 and 3.92 respectively. 25. AVO2 difference 3.4. 26. Transpulmonary gradient 8. 27. Pulmonary vascular resistance 1.3. 28. Pulmonary vascular resistance index 2.04. 29. Right ventricular stroke work index 663. 30. Aortic root angiography demonstrated a 3.8 mm ostial diameter of a patent ductus arteriosus. The maximal luminal diameter of the ascending aorta was 34.9 mm. 31. Pulmonary artery angiography did not evidence a communication to the aortic circuit. CORONARY ANATOMY: Left main arose from the left coronary cusp, bifurcated into the left anterior descending and left circumflex coronary arteries, and left circumflex was dominant. The right coronary was nondominant and arose from the right coronary cusp. COMPLICATIONS: None. FLUOROSCOPY TIME: 30.9 minutes. TOTAL CONTRAST ADMINISTERED: 180 mL.

We have a case where they placed three needles for localization in the breast, each dictated in a separate report. They were placed at 12 o'clock posterior depth, 12 o'clock anterior depth, and 12 o'clock middle depth. In each impression it reads needle localization for the marker clip in the left breast at 12 o'clock middle depth, 12 o'clock anterior depth, and 12 o'clock posterior depth was successful. We asked the tech at the hospital if these were three separate lesions, and she said no they were three separate areas of the breast, not really a lesion. The patient did have three biopsies of these areas with the clip placement. Would we report this with codes 19290 and 19291 x 2?  Or just code 19290?

Patient comes into ER with back pain.  Coders are trying to code a retro limited x2 because there is a report for the aorta for AAA and then a report for the renals, and there is an MUE of 2 allowed.  In reading the info, renals and bladder were actually done, so retro complete should have been coded for renals, but they insist that there can still be a retro limited for the aorta also now.  I am thinking if just renals and aorta, then one limited... and if renals, bladder, and aorta then just one complete.

While performing uterine fibroid embolization, an accidental puncture of the uterine artery was made. This required an additional coil embolization. Is there any way to code this separately?

What is the correct code for reporting open angioplasty of AV graft, arterial side?

SFA is stuck and catheter goes antegrade to the anterior tibia...would the catheter placement be 36246 because it is same leg?  Or ,would it only be code 36140?  Same scenario, but in the veins SFV is stuck and catheter goes to (retrograde) anterior vein.  Would this be reported with code 36011 or 36005?  We have been having a long discussion in my office, and now I am confused.