Ask Dr. Z

Could you please assist with coding the following?

Indications and findings: ESRD patient noted swelling in the region of his LT chest/shoulder. MRI suggested a subcu mass superficial to the mid clavicle, suspicious for a complex loculated fluid collection, with angulation of the stent. The patient's stent graft in the axillary vein was known to be thrombosed.  I&D of abscess was performed; however, after one month, the wound has not completely closed. Today, the patient was found to have a chronic draining sinus, which extended down below the clavicle. There was an infected stent graft within the axillary vein identified at this level. The vein wall appears to have necrosed, and purulence was identified associated with the graft. After establishing proximal and distal control, the stent graft was removed. (From body of note:) ...I then made a curvilinear incision around the base of the previous LT shoulder wound....this was deepened and extended toward the clavicle....we also began exploring the base of the wound...the center of the wound...could be probed down and there appeared to be a sinus tract going below the level of the clavicle. We continued our excision of the surrounding tissue in an elliptical fashion along this sinus tract. At the base of the wound, we identified an FB...we identified a stent graft, going along with the history of previous LT axillary stent graft placement...we extended our incision medially and laterally along the course of the clavicle. This gave us better exposure along the segment of the axillary vein.

This procedure does not fit codes 35903 nor 35905 [site is shoulder/chest, instead of extremity or thorax (within pleural space)]. Do we need to go with an unlisted procedure code?

What are the correct codes for replacement of dual chamber pacemaker with insertion of new LV lead? During the replacement of a dual chamber pacemaker generator, the LV lead is found to be nonfunctional, and a new LV lead is inserted. The old RA lead and the new LV lead are attached to the new dual chamber generator.

We are still confused about the new coding for arch angiograms. How would you code the following surgery? We came up with codes 36221, 36217, 36218, 75710, and 75774. Please help with explanation!

PREOPERATIVE DIAGNOSIS: Clinical steal syndrome, right upper extremity. POSTOPERATIVE DIAGNOSIS: Clinical steal syndrome, right upper extremity. OPERATION PERFORMED: 1. Arch angiogram. 2. Unilateral right upper extremity arteriogram. ANESTHESIA: Local with moderate sedation. INDICATIONS FOR OPERATION: The patient is a 31-year-old male with a history of end-stage renal disease. He has clinical steal syndrome, right upper extremity. Presents now for arteriogram. FINDINGS: 1. The patient had no branch stenosis of the supraaortic trunk; specifically, subclavian, right and left common, and right subclavian arteries were widely patent. 2. On the right upper extremity axillary and brachial artery were widely patent. The fistula anastomosis was visualized, and distal to the anastomosis clinical steal was occurring, as blood was flowing retrograde up the fistula from the more distal aspect of the brachial artery. Intrinsic arteries of the forearm, namely brachial, interosseous, and ulnar artery were otherwise widely patent. Palmar arch was predominant and from the ulnar artery distribution and with an intact palmar arch. DESCRIPTION OF OPERATION: After satisfactory monitoring lines were placed, the patient underwent moderate sedation. Single puncture access right common femoral artery with up size to a 5 French sheath over a Bentson wire. Pigtail catheter advanced into the ascending aorta where an arch angiogram was obtained. Selective catheterization then undertaken into the innominate artery and down the right subclavian artery. Sequential films were taken down the right upper extremity with advancement of a Mariner catheter. This included all the way down to the magnified view of the right hand. Catheter was then removed, and the sheath removed. A StarClose device was deployed uneventfully with satisfactory hemostasis achieved. The patient tolerated the procedure well with minimal blood loss. PLAN: Based upon the above angiographic findings, the patient will need to undergo a right upper extremity distal revascularization with interval ligation to improve flow to the right hand.

For the case that follows, I came up with the following: right subclavian 36225-RT, right vertebral 36226-RT(delete 36225), right thyrocervical 36217-RT/75774-RT, right costocervical 36217-59RT/75774-59RT, left subclavian 36225-LT, left vertebral 36226-59LT (delete 36225), left ascending cervical 36216-LT/75705, left thyrocervical 36216-59LT/75774-59LT, left costocervical 36216-59LT/75774-59, and right and left bronchial 36216-50/75705-50.

INDICATIONS/COMMENTS: Upper thoracic possible intradural/subarachnoid hemorrhage to rule out AVM. HISTORY: Acute onset of the upper thoracic spine pain and chest pain. Cardiac workup has been negative. Questionable findings on total spine MRI. Please evaluate for vascular malformation in the upper thoracic spine. PROCEDURE: The risks and benefits were discussed with and accepted by the patient. The right groin was prepared and draped using maximum barrier sterile technique. Dermal and subcutaneous local anesthesia was given with 1% lidocaine. Moderate sedation was administered under my direct observation using continuous oximetric and hemodynamic monitoring. The patient received small titrated doses of Versed and Fentanyl, remained hemodynamically stable, and maintained oxygen saturation levels comparable to preprocedure levels. Total time of conscious sedation was 120 minutes. Catheter tip was placed in the right subclavian artery, contrast injected and images obtained over the upper chest and neck. Catheter tip was subsequently placed in the right vertebral artery, right thyrocervical trunk, and right costocervical trunk. At these locations, contrast was injected and images obtained over the right shoulder, neck, and upper thoracic spine. The catheter was placed into the left subclavian artery. Contrast was injected and images obtained over the neck and upper chest and shoulder. The catheter was subsequently placed into the left vertebral artery, left acsending cervical artery which had a separate origin from the left subclavian artery, the left thyrocervical trunk, and the left costocervical trunk. Then we made numerous catheter exchanges and placed a catheter tip in left and right bronchial arteries and numerous intercostal arteries in the upper thoracic and middle thoracic aorta. Catheter tip was removed and hemostasis was obtained with an Angio-Seal. RESULT: The anterior spinal artery is well identified in the cervical spine and upper thoracic spine down to the T2 or T3 level. It is very small with no nidus or early venous filling identified. In the middle and lower thoracic spine, I believe we can identify radiculomedullary branches but we never identify the anterior spinal artery. The anterior spinal artery is a direct continuation of radicular medullary branches, so that vessel must be very small. No abnormal blush or enhancement is identified in the paravertebral regions. CONCLUSION: 1. No significant abnormality.

Patient was being treated for a GBM.  After completion of cerebral angiogram, a guide catheter and a Terumo guidewire were used to selectively catheterize the distal LICA.  A roadmap technique demonstrated best view of the feeding pedicle.  Once this was achieved, a microcatheter and Precision Microwire were used to selectively catheterize the distal M2 segment.  Superselective angiogram revealed a discrete tumor blush. Once this was achieved, 35 mg of mannitol, after being filtered, was slowly injected.  This was followed by a total dose of 400 mg dosing selectively injected into the distal MCA.  He does say that this is an off-label non-FDA approved and compassionate use procedure.  The only codes I can see to use are either 37202 or 37211, but neither seems to fit.  And would I assign code 36228 for the superselective angio of the M2 segment even though done by roadmap technique?

Should a TEE be charged separately if done during a CT operating room procedure?  Or, should it be included in the operating room Level Charge?

I have a hospital that charged for temporary pacing prior to cardiac intervention. Here is the documentation:

After written informed consent was obtained, right groin was anesthetized with 2% xylocaine. Using modified Seldinger technique, a 7 French sheath was inserted in the right femoral artery. A 7 French CLS-4 guiding catheter was used to cannulate the left coronary artery. Angiomax was given per protocol. A 6 French sheath was inserted in the right femoral vein, and a transvenous pacemaker was placed at the RV apex to prevent bradyarrhythmias. After which, a choice PT extra support wire was advanced distally to the OM. Over wire exchange was done for a Roto extra support wire. Rotational atherectomy was performed with a 1.5-mm burr. Thereafter, a 2.5x10 cutting balloon was placed and inflations were done with a cutting balloon. Thereafter, IVUS was performed. IVUS revealed heavily calcified vessel, diffusely diseased approximately 2.75 vessel distally and a 3.5 vessel proximally. A 2.75 x 30 Resolute drug-eluting stent was deployed. A second Resolute 3.5 x 12 was deployed proximally. Post-stent deployment, IVUS revealed good stent wall apposition. There is TIMI-1 flow into the second OM. The wire was then repositioned into the OM, and a 2.25 x 12 Sprinter balloon was inflated across the second OM. There was TIMI-3 flow, less than 10% residual stenosis. Wire was removed. Final images obtained. Femoral angiogram revealed access to be in the common femoral artery above the bifurcation. There was no severe atherosclerotic disease. Angio-seal closure device was deployed with good hemostasis. Patient tolerated the procedure well and left the cardiovascular lab in stable condition. The left main had mild disease, and bifurcates into the left anterior descending and circumflex arteries. The left anterior descending artery has widely patent stents in the mid segment. The circumflex artery has a heavily calcified 90-95% proximal stenosis followed by a 95% stenosis in OM1. Femoral angiogram revealed access to be in the common femoral artery, and Angio-Seal closure device deployed with good hemostasis. Patient tolerated the procedure well and left the cardiovascular lab in stable condition. (I think this last sentences is a repeat of what he said above?)

Department reported codes 92953, 92978, C9602, and 33210.  I'm not sure that code 33210 should be charged. Wouldn't it be considered part of the procedure? Please advise.

My question to you is regarding when the physician starts at the access site internal jugular vein (36012) and moves the catheter through the heart down towards the superior vena cava and places the catheter and also images the superior vena cava (36010, 75827), and also performs a congenital right and left heart catheterization (93531), and the exit site of the catheter is back through the internal jugular vein (the access site). Also, while using the access site as the same exit site, the physician decides to perform a selective injection and also image the internal jugular vein (36012, 75825) as he exits the body.  I'm thinking that the codes that need to be selected would be the following: 93531, 75827, 75825, and 36012.  I'm thinking that you would not report code 36010 because it's a major vessel that leads to and from the heart, but can also pick up the image code for the superior vena cava.  Is this correct thinking for facility billing?

I think I have been misinterpreting the definition of ICD replacement codes 33262, 33263, and 33264. My understanding of these codes was that the number of chambers explanted had to match the number of chambers implanted. In the case of a dual chamber ICD generator only being explanted and a multi-chamber ICD being implanted with use of two existing leads and implantation of a left ventricular lead, we are being instructed to use code 33264. I thought it should be reported with codes 33241, 33230, and 33225. However, I see that the CPT parenthetical notes under code 33230 for implant generator only with existing dual leads instructs us to NOT report code 33230 with 33241 for removal and replacement of the ICD pulse generator and to use codes 33262-33264 when pulse generator replacement is indicated. Code 33241 is for removal only not replacement.  Is this a misprint in the parenthetical notes?  If we are to use codes 33262-33264 in this instance, am I understanding that it doesn't matter what we are explanting, we only code by what we are implanting?

What would be the appropriate code to report mechanochemical ablation of great saphenous vein?  Can code 37204 be used, or do we have to use an unlisted code?

I'm looking at a case trying to help another coder out and now I'm confused. SMA/portal vein confluence. I'm leaning towards an unlisted code at this point...your thoughts?

PREOPERATIVE DIAGNOSIS: Pancreatic cancer, status post neoadjuvant therapy. POSTOPERATIVE DIAGNOSIS: Locally advanced pancreatic head adenocarcinoma with invasion of the superior mesenteric vein, status post neoadjuvant therapy.. OPERATION PERFORMED: End to End reconstruction of the superior mesenteric and portal vein confluence. INDICATIONS: Mr. xx is a 53-year-old gentleman, who was undergoing a Whipple procedure by Dr. xx and was found to have a locally invasive pancreatic head adenocarcinoma involving the superior mesenteric vein. I was consulted in the operating room for the superior mesenteric vein reconstruction as it appeared that a portion of the superior mesenteric vein at the level of the confluence of the splenic vein was attached on the right lateral aspect to the pancreatic head cancer and could not be separated. Please refer to Dr. xx operative report relating to the indications for the Whipple procedure. OPERATION: The patient was already in the supine position and Dr. xx had performed the major portion of the Whipple procedure, other than the section where the pancreatic head cancer was attached along the right lateral aspect of the superior mesenteric vein at the level of the confluence of the splenic vein and at the start of the portal vein origin. There appeared to be a slight aneurysmal dilatation on the anterior wall of the superior mesenteric vein at the point of entry of the splenic vein. The patient was given heparin intravenously by Anesthesia and approximately 5 to 10 minutes later, the superior mesenteric vein, the portal vein, and the splenic vein were each individually clamped with 3 separate pediatric Potts clamps. Dr. xx excised an oval shaped section of the right lateral aspect of the superior mesenteric vein just across from the point of entry of the splenic vein. The Whipple specimen was then handed out for pathology. At that point, the vein was flushed with hep-saline solution and I divided the superior mesenteric vein by extending to the left aspect to just below the point of entry of the splenic vein. I then approximated the 2 cut ends using 5-0 prolene on either side. An end-to-end anastomosis was performed using a continuous suture of 5-0 Prolene involving first the posterior wall and then the anterior wall. A growth factor of approximately 1 to 1-1/2 cm was placed and the total reconstruction took 17 minutes. The clamps were removed and the superior mesenteric vein expanded through the growth factor. There was a small area of bleeding on the right lateral aspect and this was controlled with a U-stitch of 5-0 Prolene. An intraoperative duplex was obtained, which showed slight turbulence in the area of the aneurysmal dilatation just above the anastomosis at the confluence of the splenic vein. There did not appear to be any area of stenosis and there was excellent flow without evidence of any thrill distal to the anastomosis. Dr. xx went on to complete the operation with the assistance of Dr. xx and Dr. xx. I was only present for the consultation relating to the revision/reconstruction of the superior mesenteric vein at the point of confluence with the splenic vein. I left the operating room and Dr. xx continued with completion of the Whipple procedure.

Can you tell me which drain code should be used for an inguinal fluid collection? Would this be code 10160, 49021, or 49061?

Patient had AAA graft earlier in the day with bilateral cutdown. Patient started complaining of limb and back pain. Returned to OR. Re-opened bilateral cutdowns. Embolectomy of iliac artery and aorta. There was narrowing of the left limb of graft at level of aortic bifurcation. Decided to place kissing stents. Repair of femoral arteries. So, they placed kissing stents inside the AAA graft. Would this be billable with codes 34825/34826 or 37221- 50?  Also, can we bill for code 34201 since it was the original treatment option with a decision to place stents?

If we went through the whole process of performing a lumbar puncture after anesthetizing the area and could not obtain any fluid, do I have to modify the procedure as attempted but failed?

Is the following coded as a fibrin sheath (36595-52), a PTA (35476), or both?  "A pull-back SVC venogram was then performed, revealing a fibrin sheath and stenosis at the superior cava/right atrial junction. The existing catheter was exchanged for an 11 French vascular sheath. Balloon angioplasty was performed using a 12 mm balloon, followed by a 14 mm balloon for fibrin sheath disruption and stenosis dilation. Follow-up venogram demonstrated satisfactory results with disruption of the fibrin sheath and slight improvement in the SVC stenosis."

I'm wondering if you can share when you would use ICD-9 code 440.3x and when you would use ICD-9 code 996.74.  Most of our occluded bypasses, whether vein or synthetic, are due to atherosclerosis; however, the description of code 996.74 mentions stenosis, occlusion, thrombus, etc. Thank you in advance for your help!

"Accessed the right greater saphenous vein, and a venogram was done. The catheter was then advanced into the right hypogastric vein, and venogram was done again. The catheter was then advanced into the left hypogastric vein, and a venogram was done. The catheter was then advanced into the left femoral vein, and a competent valve was encountered at the saphenofemoral junction. Contrast was injected. None was refluxed into the leg. Catheter was then pulled back, and a completion cavogram was done. The catheter then was advanced into the left renal vein, and a selective renal venogram was done. Several unsuccessful attempts to locate the gonadal vein, and it was not identified on the cavogram. The right renal vein was selected, and a venogram was done."  The codes we came up with are 36012, 36011, 36011, 75833, 75825, and 75822. I am questioning the catheter placements mostly.  Can you clarify this?

We are performing SIR sphere embolization for hepatic cancer at our facility, and it is done in two encounters. The first time the patient is seen, extensive angiography is done of the celiac, common hepatic, right hepatic, etc. Sometimes the gastroduodenal artery is embolized with coils. MAA is administered. A few weeks later, the patient comes back for the SIR sphere embolization, and the physician does some angiography of the same vessels as in the previous encounter. Since the patient has already had diagnostic angiography during the first encounter, can we bill for angiography again for the second encounter since the embolization of the GDA may have altered the blood flow to the lesion?

Is there anything that can be coded for the physician in the following scenario?  "Patient has a left femoral arterial line that is no longer needed for monitoring in the ICU. The patient is taken to the interventional suite, and angiography is performed for placement of an Angioseal plug. No other intervention is performed on this day. The patient had intracranial embolization five days earlier with Angioseal placement on the contralateral side (right side)."  I don't see a way of coding anything, but I want to be sure I'm not missing anything.

I have not encountered this before.  The patient came in for a left heart catheterization done by one cardiologist, and because of continuing parascapular pain, a second cardiologist repeated the left heart catheterization the same day, the same outpatient encounter.  I bill for the hospital and understand that most procedures in the hospital have a one day global period.  I am unsure if this would apply to the left heart catheterization (93458) and if this would be billed only once, which is how I believe it should be, or if it would be appropriate to bill twice with a -59 modifier because of the continued symptoms.

If one cardiologist does the diagnostic catheterization, and his partner does the intervention, do they have to apply a modifier?  If so, which one (same day, same encounter with the patient)?  I'm not sure if modifier -62 applies.  I'm seeing more and more of this with physician groups.  One reason is cheaper malpractice insurance.

A patient has a port-a-cath, and while in the hospital the catheter is noted to be in the subclavian artery instead of the internal jugular vein. The physician takes the patient to angio to remove the catheter. From the femoral artery he places a catheter in the subclavian and performs an angiogram of the extremity and removes the port-a-cath.  The physician then inflates a balloon for hemostasis. A coder is telling us we can report codes 35475, 36215, 36590, 75710-2659, and 75962-26.  I do not agree with the arterial angioplasty codes, as there was no stenosis. Nor do I agree with code 36590, as it was not in the venous system. I'm thinking this should be an unlisted code along with the diagnostic angio. Can you give me your thoughts?

What would be the appropriate code for a vertebral artery angioplasty? The angioplasty was performed months after placement of a vertebral artery stent and was performed to revascularize the in-stent stenosis.

I want to confirm when performing angioplasty with infusion if you should report codes 61640, 37202, and 75896... or, is code 75896 dropped since the catheter placement is included in code 61640?

I have a question about code 93657. The physician did a pulmonary vein isolation for atrial fibrillation. The veins were completely isolated. However, right atrial pacing medial and lateral to the cavotricuspid isthmus failed to demonstrate isthmus block. Therefore ablation was performed in the isthmus. I know code 93656 is correct, but can I also report code 93657 for the ablation of the cavotricuspid isthmus?

There are physicians at our facilities who state in their documentation “X catheter was attached to heparinized saline with nitroglycerin for the prevention and treatment of catheter induced vasospasm”.  There is no documentation that vasospasm has occurred.  My understanding is that code 37202 is not to be used for preventative treatment, but the IR coders state that this is an allowable charge.  We all want to make sure that this is being done correctly. Please clarify.

We have cases where the patient is scheduled for an MRI-guided breast biopsy. The MRI guidance is performed, and a lesion could not be found, so the biopsy is canceled. Report example: "After discussion of potential risks, alternatives, and benefits of the procedure, the patient gave verbal and written informed consent for the procedure. She was placed prone on the table, and her breast was placed in the compression grid. Initial noncontrast fat suppressed T1 images were obtained. This demonstrates satisfactory positioning. Subsequently, three sets of postcontrast fat suppressed T1 images were obtained. These do not demonstrate the finding of interest seen on the initial mammogram. On today's exam, there is just scattered normal background parenchymal enhancement. It is felt that the initial finding represents part of this normal background parenchymal enhancement. Since the finding was not reproduced, no biopsy could be performed. The procedure was then terminated. Findings were discussed in detail with the patient at the time of interpretation. The recommendation is for six-month follow up breast MRI to evaluate stability. There are no suspicious areas of enhancement to biopsy on today's exam. Impression: Previously identified 8 mm enhancing mass left breast is not reproduced on the current exam. It is felt that this may represented background parenchymal enhancement. As it is not reproduced, no biopsy is performed."

Per Coding Clinic for HCPCS, 2nd quarter 2008, it has an example for a canceled stereotactic breast biopsy. "Q. A patient was scheduled for stereotactic breast biopsy of the left breast. Stereotactic images were performed; however, the lesion to be biopsied was not visualized. Anesthesia was not administered and the biopsy was not performed. How should this encounter be reported? A. It would be appropriate to report the CPT codes 19102 with modifier -LT, and 77031 for stereotactic localization, for the procedures performed. Although the breast lesion was not visualized, the biopsy was planned; therefore, CPT code 19102 should be reported with modifier -73 only if taken to the treatment room."

Does a canceled MRI-guided breast biopsy follow the same rules as a canceled stereotactic biopsy? Should we only bill for a breast MRI (77058) on both the FAC and PRO side, or should we bill codes 19102-73 and 77031 on the FAC side and only 77031 on the PRO side? Also, is the guideline for the canceled stereotactic biopsy okay to follow, or has that changed? Since we bill for both FAC and PRO, please address both.

I noticed in your radiology and IR reference books that effective for 2013 mammography following image-guided wire or clip placement is not reported separately. Does this also include when the breast biopsy was done with ultrasound guidance?

In the hospital setting, if they use code 93351 they say it doesn't include any reimbursement for the physician. However if you look at what 93351-26 pays, it appears to only cover code 93018 and 93350-26. Is code 93016 included in code 93351 for the hospital? I know it states there is no physician reimbursement, but isn't reimbursement for the APC figured by the cost report submitted by the hospital? If the hospital paid the physician, wouldn't that be in the cost report and thus be covered under code 93351? Just trying to make sure I understand it correctly.

I'm not sure what I should bill for the following:

INDICATIONS: This lady had a stent-assisted coil embolization of left cervical ICA. This is a follow-up angiogram. Benefits and risks were discussed in detail with the patient, including bleeding, femoral artery injury, loss of blood supply to the leg, loss of the leg, dissection of the aorta, stroke, TIA, and dissection of the carotid and benefits. The patient consented procedure and was brought to the operative room. DESCRIPTION OF OPERATION/PROCEDURE: The patient was brought to the operative room by the Neuro Anesthesia team. Monitored aesthetic care was induced in supine position. All the pressure points were padded appropriately. The groin was prepped and draped in the usual sterile fashion. Lidocaine was injected along the right groin crease. Skin knife was used to make 2 mm skin incision. Eighteen gauge needle and single wall technique was used to access the right common femoral artery. 5 French sheath was placed over the guidewire provided. Using 5 French Berenstein diagnostic catheter and Terumo 038, multiple coils vessels were imaged. FINDINGS: Right common femoral artery selective injection: The right common femoral artery was selected. The catheter was advanced in it. AP view showed the internal iliac artery, right common femoral artery, right superficial, and profunda femoral arteries to have normal caliber and branching. The puncture site was appropriate for Angio-Seal device deployment. Common iliac selective injection: The right common iliac was selected. The catheter was advanced in it. AP view showed there was a possible dissection of the common iliac artery. Thoracic aortic injection. Thoracic aortic injection. The catheter was kept in the thoracic aortic area. An injection was noted that there is a dissection. At that time, the patient was complaining of chest pain and we consulted the Vascular Surgery and Cardiothoracic. The patient was then intubated and a TEE was performed to ensure there was no dissection of the ascending aorta or the arch. Following that, the patient was transferred to the CT for obtaining a CT of the chest and abdomen. Also, we sent for labs to make sure there is no troponin increase or worsening of the creatinine. I applied manual compression for 15 minutes.

If, following an a-fib ablation, the physician performs nine CFAE ablation sites in the left atrium, would code 93657 be reported once for the one site of operation (left atrium)?  Or would it be reported nine times for each specific site in the left atrium? Thanks for your assistance.

Is there a difference in an MRI venogram and an MRA?

I would just to ask a follow-up question to question ID #4783. After the AV fistula aneurysm was excised, they didn't revise it anymore because the patient didn't need the dialysis access anymore. Do we still code that as revision even though the fistula wasn't revised? At the end of the case the fistula was nonfunctional or totally closed.

Would you please guide us through coding this case?  What would be the correct diagnostic code for splenorenal shunt outflow venography? The report is included below:

SPLENORENAL SHUNTOGRAM AND GASTRIC VARIX EMBOLIZATION (BRTO) CLINICAL INDICATION: Portal hypertension with spontaneous splenorenal shunt and large gastric varix. The patient has developed refractory encephalopathy. Right common femoral vein accessed. Selective catheterizations of the left renal vein were performed with a 5 French multipurpose catheter, which was ultimately manipulated into the splenorenal shunt outflow vein (36012), and venography was performed (75887) OR (75810). A 16 mm x 4 cm Atlas balloon catheter was then positioned across the splenorenal outflow into the left renal vein. The balloon was inflated, and contrast was injected. Venography revealed opacification of a gastric varix with a couple of small veins extending toward the gastroesophageal junction. The splenorenal shunt was occluded with the inflated balloon.with the balloon inflated, embolization was performed with foam (37204, 75894). A total of approximately 25 mL of foam was delivered until complete opacification and stasis in the gastric varix was noted at fluoroscopy.The inflated balloon and introducer sheaths were then fixed in the right groin, and a sterile dressing was applied. The patient was transferred to the PACU in satisfactory condition with no complication. FINDINGS: Balloon occluded shuntogram reveals opacification of the large gastric varix projecting over the medial aspect of the gastric body. No collateral flow into the IVC nor portal vein is appreciated. IMPRESSION: 1. Large gastric varix emptying into a spontaneous splenorenal shunt to the left renal vein. 2. Successful gastric varix embolization 3. Followup venogram will be performed in 4-6 hours. Following routine sterile preparation and local infiltration with 1% lidocaine around the indwelling 9 French right transfemoral venous sheath, injection of the occluded balloon in the splenorenal shunt demonstrate stasis alongside the gastric varix cast (75898).The balloon catheter was then slowly deflated and withdrawn, with no evidence of washout from the gastric varix. The left renal vein remains patent with brisk antegrade emptying into the inferior vena cava. IMPRESSION: Successful occlusion of gastric varix and spontaneous splenorenal shunt following BRTO.

Can both angioplasty and stenting be coded if performed in the same vein?

I have a question regarding the use of the "branch" add-on codes for coronary interventions. If the patient has a stent placed into the RC and also has an angioplasty of the OM, would the OM be reported as a "branch", even though it is not a branch of the RC? Would this be reported with codes 92928-RC/92920 (OM), or would it be reported with codes 92928-RC/92921 (OM)? Thank you! You are our go-to guru!

Physician selectively catheterized the LCCA, left external carotid artery, and left occipital artery branch #1, #2, #3. Are codes 36223, 36227, and 36228 x 2 the appropriate ones to report?  Please advise.

A left heart catheterization was performed with an LV-gram. There was a 99% thrombus burden found in the right coronary. A temporary pacemaker was placed, and AngioJet thrombectomy was performed in the right coronary with multiple runs. Bolus injections of Integrillin were given. One more AngioJet run was done, and the patient had a VT arrest and needed to be shocked. Post procedure films showed the 99% thrombus burden was reduced to about 85%, but there was TIMI 2.5 flow and a satisfactory result considering the thrombus burden. Via a 1.5 x 20 Clearway, 2.5 verapamil and 200 mcg of Nipride were given. Since code 92973 is an add-on code to a primary coronary intervention procedure, what can be billed?

Does the physician have to specifically state "CHRONIC total occlusion" to use CPT code 92943? What if they only state 100% occlusion?

The patient presented with a dual chamber defibrillator and a planned upgrade to a biventricular ICD. The right ventricular lead was replaced, with the existing right ventricular lead removed. The atrial lead was existing and attached to the new generator. The left ventricular lead was inserted, but was unable to be advanced through the CS OS and was eventually removed and the LV port capped. Would this be reported with code 33249?  Or with codes 33263, 33216, and 33244?

Is there a specific code for placement of ICY catheter for patients who have had cardiac arrest and are being treated per the hyperthermia protocol?

If we have a stent placement in the cervical ICA, we use codes 37215/37216.  Do we use code 61635 if the stent is placed in the intracranial portion of the ICA?

This is my first time coding for a diagnostic cervical angio. I've done thoracic and lumbar. Are there specific codes for the cervical?

We have a vascular surgeon who performs IVUS imaging on patients with venous congestion syndrome or venous hypertension. He routinely images the IVC, bilateral common iliacs, external iliacs, and common femoral veins. Venography is not done during these procedures. When no intervention is done, how should I be coding for the IVUS? What I have been doing is coding for the bilateral catheters placements in the IVC (36010, 36010-59) and for the S&I portion of the IVUS (75945, 75946 x 6). Is this appropriate coding?

Below is a report from one of our physicians. Both coders disagree on the coding, and I would like your input, as it involves parent codes 93653 with 93654. Coder #1 reported codes 93654 and 93623. Coder #2 reported codes 93653 and 93621.

PREPROCEDURE DIAGNOSIS Supraventricular tachycardia. POSTPROCEDURE DIAGNOSIS Typical atrioventricular nodal reentrant tachycardia. PROCEDURES PERFORMED 1. Comprehensive electrophysiology study with coronary sinus pacing and recording. 2. Arrhythmia indJction. 3. Drug infusion with isoprotereno~ 4. ~electroanatomic mapping. 5. Radiofrequency ablation of typical AV nodal reentrant ta~rdia with modification of the AV nodal slow pathway. HISTORY OF PRESENT ILLNESS This is a 61-year-old female ~.~tmedical history significant for recurrent frequent episodes o~dpalpitations. The patient had a recent visit to the hospital at Flagler where she was noted to have heart rate of approximately 200 beats per minute, which terminated with adenosine. The patient now presents to electrophysiology laboratory for further evaluation and management. DESCRIPTION OF PROCEDURE The patient was brought to electrophysiology laboratory and appropriately identified on the table. Twelve-lead ECG electrodes were placed in the patient and vital signs were recorded at baseline. A conscious sedation was administered by the nursing staff with intravenous fentanyl and Versed. The patient was prepped and draped in standard sterile fashion. Sheaths were inserted using modified Seldinger technique as indicated below. Catheters were then subsequently advanced to the sheath and placed in the heart under a cardiac fluoroscopy. Baseline intracardiac recordings were obtained followed by standard EP study. During the entire procedure, the patient's vital signs were continuously monitored, remained stable. Details of the EP study and subsequent ablation were outlined below. The patient remained hemodynamically stable and com£ortable throughout the en~ire procedure. At the conclusion of the procedure, all catheters were removed from the heart and woa~d sites were then dressed and the patient wls transferred to t~e Recovery Room '£~ea in stable condition. The postoperative orders were wfitten at that t~e. ; SUPPLIES < Diagnostic catheters were placed at the level of the high right atrium, His, right ventricular apex. A diagnostic catheter was also placed in the main body of the coronary sinus. A 4-mm radiofrequency ablation bidirectional catheter was used for right atrial mapping and ablation. BASIC EP STUDY FINDINGS 1. The AH interval was 101 msec, the HV interval was 39 msec. 2. The VA Wenckebach cycle length was 360 msec at baseline. The right ventricular effective refractory period while pacing from the right ventricular apical catheter was 220 msec at a pacing cycle length of 600 msec. 3. The AV Wenckebach cycle length was 400 msec while pacing from the high right atrial catheter. 4. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec. ARRHYTELl\,fIA AND ABLATION The patient presents to the electrophysiology laboratory in normal sinus rhythm. Following administration of conscious sedation, we proceeded with a basic EP study. The patient had normal EP study findings at baseline. Upon insertion of the catheter, she immediately went into a spontaneous supraventricular tachycardia. The tachycardia was typical AV nodal reentry for the following reasons. 1. The septal VA t~~e during SVT was approximately 0 msec, making typical AV nodal reentry the likely diagnosis. 2. The SVT tachycardia cycle length was 410-420 msec. 3. During a right ventricular apical pacing, the atrial activation sequence in the coronary sinus catheter was concentric, making left lateral pathway and AVRT unlikely. 4 .. During SVT, entrainment from the right ventricular catheter revealed a VAHV response to pacing, making atrial tachycardia unlikely. 5. During supraventricular tachycardia, right ventricular entrainment revealed a post-pacing interval minus tachycardia cycle length of 145 msec, making AV nodal reentrant tachycardia the likely diagnosis. 6. His-synchronized ventricular premature depolarizations during SVT did not reveal the presence of a septal bypass tract and was not able to the atrium. The patient had easilY sustained episodes of supraventricular tachycardia, which were spontaneous and also reproducible with both ventricular and atrial extrastimuli from the high right atrial, coronary sinus, and right ventricular catheters. We observed both echo beats and sustained tachycardia. At this t~~e, we proceeded with modification of the AV nodal slow pathway. The ablation catheter was positioned across the posterior septum just posterior t{ i the coronary sinus ostia. 3D electroanatomic mapping prior to this was used to identify the dehisced as well as the coronary sinus ostia. Ablation catheter was positioned across the tricuspid valve annulus with an A-V ratio of approximately 1-4. Using power controlled settings of 50 watts and 55 degrees under temperature, serial ablation was performed in this area. We monitored the AH and HV intervals during this time and a junctional ectopy was observed throughout the duration of these lesions. At final conclusion of my ablation, I rechecked the patient for dual AV nodal physiology. No sustained tachycardia was observed. Isoproterenol w~started up to 2 mcg per minute and no evidence of inducible SVT was no~ecr. With frequent atrial and ventricular extrastimulus pacing, the patient did have 1 echo beat with atrial extrastimuli; however, with continued decremental pacing on our extrastimulus beat, the patient would block on the subsequent beat. At this time, this was considered an acceptable endpOint as the patient previous to my ablation had easily inducible SVT. After waiting period, we attempted arrhythmia induction again and SVT was no longer observed. At this time, the procedure was terminated. AH and HV intervals remained stable and comparable to baseline. The postablation AH and HV intervals were 85 and 42 ITsec respectively. The fast pathway effective refractory period was 300 msec at a pacing cycle length of 600 msec at this time. The catheters and the sheaths were then removed from the heart and body. Hemostasis was achieved. The patient made a complete neurologic and hemodynawic recovery. CONCLUSIONS 1. Normal EP study findings. 2. Typical AV nodal reentrant tachycardia. 3. Successful ablation of typical AV nodal reentrant tachycardia with modification of the AV nodal slow pathway.

The echo department does a diagnostic exam. Cath lab performs a pericardiocentesis utilizing fluoroscopy only, and we suture the catheter in place.  Would the correct codes be 33015 and 75989?  Or would code 77002 be more appropriate? You do not cover fluoroscopy only in your 2013 book.

Regarding question ID #4781 on the difference between codes 36832 and 37607... is it permissible to report both codes when the AV fistula is banded due to steal syndrome and parasitic veins are ligated during the same session?

Can you take a look at this case for me? I have seen a few of these, and I am not sure if I am coding these correctly. The codes that I am coming up with are 76937 (ultrasound), 36246 (left internal iliac), 75736 (left internal iliac), 37204, 75894, 75898 (embolization), G0269 (Mynx), 36245 (right L3 lumbar artery), 36245, and 36248 (left L3 artery including 2 feeding ascending lumbar pathways). Please let me know if I am close and thank you for your help.  Here is the procedure:

Reason for Exam: Abdominal aneurysm.  Findings Exams: Abdominal aortogram with selective left internal iliac arteriogram disease (3rd order), embolization non-neuro, placement of vascular closure device. History: Abdominal aortic aneurysm, status post EVAR with type II endoleak and enlarging aneurysm sac Technique: Intravenous conscious sedation with Fentanyl and Versed was administered in my presence. The patient was continuously monitored by a special procedures nurse for a duration of one hour and 30 minutes. Fluoroscopy time: 28 minutes. The left groin was prepped and draped with the maximum sterile barrier technique. Ultrasound was used to identify a patent left common femoral artery and image recorded in PACS. Using ultrasound localization, sterile technique, and lidocaine anesthesia, a 21 gauge needle was placed into the upper left superficial femoral artery and exchange made for a 5 French sheath. Aortogram, selective arteriography, and intervention is as detailed below. Findings: Abdominal aorta: AP aortography shows no evident type I endoleak, however delayed imaging shows prominent flow through the left ascending lumbar artery with retrograde flow into the left L3 lumbar artery and perfusion to the endoleak cavity. The inferior mesenteric artery fills via the marginal artery, but does not course back to the aneurysm sac and is not felt to be a contributor to the endoleak. Both renal arteries show mild stenoses with some irregularity of the main renal arteries which may be due to fibromuscular disease. Left internal iliac artery: Selective injection shows prominent ascending lumbar artery which bifurcation shortly after its origin and filling of a large L3 lumbar artery which is patent to the endoleak cavity. This felt to be the etiology for the endoleak. Catheterization of the ascending lumbar artery with negotiation of the multiple turns required to catheterize the endoleak cavity was quite difficult, but eventually was achieved with a Progreat catheter. Injection within the endoleak cavity confirms appropriate placement with outflow via the right L3 lumbar artery. The endoleak cavity was then filled with multiple 8 and 10 mm Nester microcoils. Catheter was negotiated into the proximal right L3 lumbar artery and occlusion done with 6 mm microcoils. The left L3 lumbar artery as well as 2 feeding ascending lumbar pathways were occluded with multiple 2 mm to 4 mm Nester microcoils. Completion and spot films show no residual filling to the endoleak cavity. The left femoral access site was assessed and closed with the Mynx closure device. Good hemostasis was achieved. Impression: 1. Type II endoleak via the left ascending lumbar and retrograde flow in left L3 lumbar artery. Successful coil occlusion of the endoleak cavity and feeding arterial pathway was done as detailed above.

I have a chart where the doctor is stating procedure reason is "to place internal stent". The history says, "Patient returns for diagnostic antegrade pyeloureterogram and stent placement." The dictation says, "The contrast through existing tube. Cath was cut and removed. Fluoroscopy confirms uretral stone. Double J stent placed, new percutaneous catheter was placed, contrast confirmed position, and tube placed to gravity drainage." (I am shortening this a lot.) In the findings, doctor says pyelogram shows decompression and dilation of ureter, 1 cm stone that has migrated, ureter is obstructed at the level of the stone, and calcified uterine fibroid noted in pelvis. I know I can report codes 50393/74480 and 50398-59/75984, but is this enough info to also report codes 50394/74425?  Your book says it has to be diagnostic to be coded, and I feel this is diagnostic, but I'm not sure. Can you explain what I need to look for to be able to code diagnostic grams?

AMA has clarified information on EP coding, but CMS Transmittal 2636 conflicts with the AMA's revision, so I'm questioning if we will continue to see issues with these codes until CMS updates their information. NCCI also lists a bundling issue with codes 93623 and 93653, and I'm not sure that it would be appropriate to append a modifier to unbundle. Thoughts?