Ask Dr. Z

I have a coronary CABG case where the cardiologist engaged the RC and LM then did root shot for venous graft info and subclavian shot for LIMA info (B.P. cuff blown up). Would you report a graft code because he selected the subclavian?

There is a dedicated Category III code for this procedure in the uterus (0071T). We are doing this for tremor in the brain, in MRI, and I guess using the unlisted code 64999. There is an MRI code 77022 for ablation. Would you bundle it?

Codes 33970/ 33967... Can we charge these codes more than once on the same patient with the same date of service?

Patient came with both a-fib and a-flutter.  HRS suggested using code 93657 for a-fib after a-fib ablation; however, in our case after complete EP study initial rhythm noted a-flutter, RFA energy applications were delivered along the cavotricuspid isthmus, which was successful at terminating the patient to restoring sinus rhythm. Following ablation of a-flutter, pulmonary isolation was done for a-fib. My question is, to report codes 93656 and 93657 first pulmonary isolation done then if ablation performed for a-flutter?  Or doesn’t matter what sequence for these scenarios for codes 93656 and 93655? Please advise.

For the following case I reported codes 36831, 36147, 35475, 75962-26, 37205, and 75960-26. I was told I should use code36870, but embolectomy appeared to be open not percutaneous. I also questioned the two sheaths that were placed...can I bill for both??

"Patient presented with malfunctioning AV graft. DESCRIPTION OF PROCEDURE: The patient's left arm was sterilely prepped and draped after he received general anesthetic. Over the old graft on the distal part of the arm, a small incision was made approximately 1.5 cm. The graft was identified. An arteriotomy was performed of the graft and a 4 Fogarty was passed proximally. There was some resistance with the brachial artery anastomosis and there was poor inflow. Also, it was passed into the graft, into the subclavian vein and much thrombus was removed. After this was done, I now repaired the arteriotomy with a 5-0 interrupted Prolene. A sheath was placed in an antegrade and retrograde fashion so that crossing sheaths were in place. With the first sheath, a wire was passed over into the brachial artery. A KMP catheter was passed to prove that it was in the true lumen and then a 6 x 40 was gently insufflated across this area. A fistulogram had been previously performed that showed that there was a large amount of thrombus still present at the brachial artery anastomosis and this was softly/gently dilated. Now, there was good inflow into the graft. Through the other crossing sheath that was in place through the arteriotomy, a venogram was performed through the arm and followed centrally. The flow was very slow and sluggish. There was a high-grade stenosis at the venous anastomosis at the axillary vein within the chest. At this time, a 5 x 40 balloon was insufflated as this was a 6-mm graft. A 6 x 40 balloon expandable stent was then placed across the high-grade stenosis at the venous anastomosis. A venogram was now performed and showed that there was good flow through the graft and this was followed centrally and there was good flow into the SVC into the right atrium."

My question involves tPA infusions. Patient is at our private practice cath lab on 1/25 undergoing a procedure for lower extremity stent and thrombectomy. At the end of the procedure, long-term thrombolysis (37211) is started, and the patient is tranferred to an acute hospital where it is continued. On the same day, 8 hours later on 1/25, our doc goes to the hospital and does a re-look angio only, and tPA is discontinued. Once the patient is transferred to a new location, would the tPA infusion be reported as initial again with code 37211? How would the hospital portion be coded?

My question is... with the new thrombolysis codes and AV graft overnight thrombolysis, would you still use code 36870?  And if so, how do you code the follow-up the next day?

In the 2013 Interventional Radiology Coding Reference on page 424, it advises: "(#10) Use code 20610 for Baker's cyst aspiration." In Dr. Z books for years past, that code has been listed as 10160. CT guidance is the primary method used at our facility (77012). I have questioned a couple of other coders who say they have been advised that code 20612 is more appropriate than 20610. Can you please advise on why the change for 2013 and how code 10160 vs 20610 vs 20612 would make the more correct choice?

I’m a bit confused with correct coding for this one: sclerotherapy “infusion” (embolization?) of microcystic spaces/lesions. I’ve never seen an “Angiocath needle was advanced into the mid-inferior aspect of the tongue bilaterally” – also the floor of the mouth bilaterally. Obviously non-CNS, but is it codes 61624/75894? No idea on “catheter” placement either. Please advise.

We have some confusion on this report. They are placing an endologix and a snorkel. Would you report this with code 34804-62 with 0078T, or would we go with the 34825-62 in this one? Not sure really where the T codes come in with the -62 modifiers. We looked at this and looked for examples on the site, and I saw where there was a question on the site about the snorkel and they were using the 0079T x 2 on that one, but nothing we saw with this kind of craziness. Also, is the iliac stent billable? We know the work in the common iliac is part of the deployment area, but this is really strange.

PROCEDURE: ENDO REPAIR INFRARENAL AAA SI.

Clinical history: The patient has a small infrarenal abdominal aortic aneurysm measuring about 4 cm in diameter, but occlusive distal aorta and common iliac arteries bilaterally. The plan is to place an Endologix endograft to treat the abdominal aneurysm and to treat also the occlusive disease of the common iliac arteries bilaterally. In the preplanning of this abdominal aortic aneurysm endograft it was planned to place a snorkel stent into the left renal artery due to the short neck and extending the cuff into the right renal artery, which is about 8 mm higher than the left. After discussing the benefits, risks, and alternative therapy an informed consent was obtained. The procedure was performed in conjunction with Dr. X.

Technique and findings: After initiation of general anesthesia the abdomen and groins were prepped and draped in the usual sterile fashion. The procedure was performed through an open right common femoral cutdown, which Dr. X performed and obtained proximal and distal control. The left common femoral artery was accessed percutaneously. Limited ultrasound was performed and the left common femoral artery was identified and is patent. A hardcopy image was saved. A needle was advanced to the left common femoral artery using ultrasound guidance and 2 Perclose devices were placed. An 8 French sheath was placed. Angiogram was performed and demonstrated high-grade stenosis of the common iliac artery, almost occlusive. Predilatation of the common artery was performed bilaterally to allow the passage of the endograft using a 4 x 4 Rival balloon bilaterally. That was not adequate and subsequently we placed a 6 x 80 balloon to dilate the common iliac arteries bilaterally. From a right approach, the Endologix sheath was placed over a stiff wire. The main Endologix bifurcated unibody was introduced through a right femoral approach. 25-80/116-40 and the wire was snared and pulled out through the left common femoral artery. The body was then pulled down over the aortic bifurcation. The iliac limbs were then dilated, placing 10 x 4 high-pressure Dorado balloons bilaterally in a kissing fashion. That was opened up after increasing the pressure to 12 atmospheres. A marked Omni Flush was placed and arteriogram was performed to mark the level of the renal arteries. From a left brachial approach I gained access into the left brachial artery using ultrasound guidance. Limited ultrasound of the left forearm was performed and the brachial artery was identified and is patent. A hardcopy image was saved. I placed a 7 French sheath 70 cm in length, which was not long enough to gain access into the left renal artery and subsequently exchanged for a 7 French 90 cm Shuttle advanced over Rosen wire into the abdominal aorta. Arteriogram was performed and then using a Cobra catheter, again access into the left renal artery and subsequently advanced a 7 French sheath into the left renal artery. Through the 7 French sheath in the left brachial artery I placed a iCast covered stent 7 x 38 mm into the left renal artery extending it higher up and then unsheathed it pulling the sheath back into the aorta. From a right femoral approach we placed a renal cuff measuring 34-34 80 cm. The cuff was deployed first and subsequently I deployed the iCast balloon, 6 x 38. Angiogram was performed prior to that identifying the takeoff of the right renal artery. Subsequently, we placed a Reliant balloon dilating this cuff and at the same time inflating the balloon in the iCast renal stent to maintain patency. Final angiogram was performed and demonstrated excellent flow through the renal arteries bilaterally. There was a deformity seen within the cuff placed and that is as a result of a heavily calcified plaque formation on the right side of the infrarenal aorta. That was dilated with a Reliant balloon 2 eliminate it but it still remained. Final angiogram was performed and demonstrated excellent flow through the renal arteries bilaterally and the endograft. The hypogastric arteries are patent bilaterally. The sheath was removed from the right side and Dr. X performed closure of the right femoral artery. A Perclose device was used to close the left femoral artery.

IMPRESSION: Endovascular abdominal aortic aneurysm repair as described above using an Endologix stent graft and placement of a renal cuff and a snorkel covered stent into the left renal artery, as described in details above.

When is it okay to bill catheter placement with the revascularization codes (multiple access sites)?

We have a case where patient had Tetrology of Fallot and now with transplanted heart came for possible rejection.  Both right heart catheterization and biopsy are performed. Biopsy came back for rejection. Is the right heart catheterization reported with code 93451 or 93530? According to your 2010 book, once the patient is diagnosed with congenital anomaly, even with transplant heart, you use congenital heart cath procedure codes. Per 2011 HCPCS Coding Clinic and your update coding instruction in 2013 book, the advice is if there are any residual anomalies or shunts, code congenital otherwise regular heart cath codes. In the case of TOE how do we know if there is any residual condition still there?  Or it is a new heart so code with regular heart cath codes? This instruction is not clear since some of these anomalies repaired involve more than heart. Is it safe to assume if they don’t do any shunt angiograms to consider no congenital anomalies and code with regular heart cath codes? We are seeing increasing number of transplant patient at Hermann, and since for 93530 insurance is not paying with heart complication/V58.44/V42.1 or with V13.65 as in this case with TOE. Please advise.

One of our physicians has begun to do upper extremity atherectomies, and I was wondering if I could get your coding advice on the following procedure. The CPT codes I believe to be correct are 0237T, 36216-RT, 36215-LT, and possibly 35475. Any recommendation you could give me would be greatly appreciated.

REASON: Critical limb ischemia of the right upper extremity.

PROCEDURE: 1) Bilateral upper extremity angiography at the level of the right and left axillary arteries selectively.  2) Successful atherectomy and percutaneous transluminal angioplasty of a right ulnar artery 80-90% calcified stenosis with a 1.5 Classic Diamondback and a 2.0 x 120 Cook LP balloon.

DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the cardiac catheterization laboratory. Using approximately 10 mL of 1% lidocaine, the right groin was anesthetized and 5 French sheath placed in the right femoral artery. I placed a Glide catheter to the level of the right axillary and performed selective angiography of the right upper extremity. I then placed a Glide catheter selectively at the level of the left axillary and performed selective angiography of the left upper extremity.

FINDINGS: Right upper extremity runoff, widely patent right axillary artery and brachial artery, both of which are heavily calcified. Widely patent radial artery; again, heavily calcified. It fills half of the palmar arch. The interosseous branch is widely patent. The right ulnar artery has multiple 80% calcified stenoses and then fizzes out at the hand. There is no obvious flow going to the right fourth finger.

Left upper extremity: Widely patent axillary, and brachial artery is widely patent. AV fistula, radial and interosseous arteries are widely patent. The ulnar has a 100% restenosis at the level of the prior drug-eluting stents.

INTERVENTION: I then accessed the right brachial artery antegrade stick under fluoroscopic guidance and placed a 5 French sheath antegrade into the ulnar artery, anticoagulated with heparin to an ACT greater than 200, then advanced a Whisper wire to the level of the distal ulnar artery, then switched out for a Viper wire and then used a 1.25 Classic Diamondback at low, medium revolutions and performed atherectomy of the ulnar artery. This resulted in no reflow, therefore, gave vigorous nitroglycerin and perform PTA with a 2.0 x 120 Cook LP balloon resulting in less than 30% residual and improved flow to the ulnar artery.

ASSESSMENT AND PLAN:  1) Successful atherectomy and percutaneous transluminal angioplasty of right ulnar 80% calcified stenosis to less than 30%.

If an ultrasound is needed for an access in a lower extremity endovascular revasularization, and the physician documents that they used ultrasound (but didn't state that the images became part of the patient's account), can we code for the ultrasound if we see the images in the patient chart?

Can you please help and tell me if I’m on the right path of thinking with these new cardiac intervention codes? For the following case, I coded: C9606-RC, C9601-RC, 92920-LC, 92921-LC, 93458.

PROCEDURE: Left heart catheterization, coronary arteriography, left ventriculography, placement of drug-eluting stent and percutaneous transluminal coronary angioplasty.

INDICATIONS: Acute ST-elevation MI.

HISTORY: The patient is a 60-year-old gentleman with no significant past history who presented with chest pain for several hours duration and presented with an acute inferior ST-elevation MI.

DESCRIPTION OF PROCEDURE: 1) PREMEDICATION: Versed and fentanyl IV in the cath lab. 2) CATHETERS USED: 6 French sheath, 6 French 4 curve, right and left Judkins, 6 French pigtail. For PTCA, FL 3.0 guide, Runthrough wire, BMW wire, 2.25 x 12 NC Trek, 2.25 x 12 NC Trek, 2.25 x 12 Xience stent, 2.25 x 12 Xience stent. 3) MEDICATION DURING THE PROCEDURE: Versed and fentanyl for anxiety. Heparin, Integrilin, and IC nitroglycerin. 4) COMPLICATIONS: None. 5) COMMENTS: Right femoral artery was used without complications. Perclose was used for hemostasis.

ANGIOPLASTY PROCEDURE: Initial arteriography revealed an occluded distal circumflex. It was hard to tell if that was the culprit vessel. In any case, we did put a JL 3.0 guide. A VL guide would not fit; hence, only a JL was used. A Runthrough wire was advanced and initially tried to do a Pronto catheter extraction but Pronto would not advance to the distal circumflex. Then we abandoned that and put a 2.25 x 12 NC Trek and dilated. Subsequently, the same wire was removed from the distal circumflex and into the OM3. That was also angioplastied using the same balloon. Actually, initially we used a 2.5 balloon with low pressure and then realized that the size of the vessel was very small. Then we used a 2.25 x 12 NC Trek. End result was adequate. The vessel was quite small distally and decided not to stent it. Attention was then directed to the right system. I not 100% sure which vessel was responsible for the ST elevation. A 6 French JR4 guide was placed. Runthrough wire was advanced into the PDA and BMW into the PLV. A 2.25 x 12 NC Trek was used to predilate both. Then we used kissing PTCA for both. There does appear to be a dissection or rupture in the PDA side of the lesion so decided to stent it. A 2.25 x 12 Xience stent was advanced to both, but we could not get it beyond the guide. At that time, we removed the whole equipment and changed it to a 7 French system. Once the 7 French system was in place, it was very easy to put both the stents. A 2.25 x 12 was placed into the PLB and another 2.25 x 12 into the PDA. Both were simultaneously inflated up to 14 atmospheres. End result was excellent. Case was terminated. He was sent to the floor in a stable condition.

FINDINGS:

LEFT VENTRICULOGRAM: Left ventriculography was performed in the RAO projection. Left ventricle is normal in size with distal inferoposterior hypokinesis, ejection fraction 55%. No mitral regurgitation.

HEMODYNAMICS: Elevated left ventricular end-diastolic pressure at 22.

CORONARIES: Right dominant system. A) Left main: Left main is free of disease. B) LAD: LAD has a 60-70% mid stenosis with extensive luminal irregularities as well as calcification. C) Circumflex: Circumflex is nondominant and is occluded distally which after PTCA is less than 30%. D) Right coronary artery: The right coronary artery is dominant and has a 90% PLV and a 90% PDA which after kissing stents both were 0%.

CONCLUSION: 1) Severe two-vessel coronary artery disease involving the distal circumflex and distal right coronary artery with successful percutaneous transluminal coronary angioplasty to the distal circumflex/obtuse marginal 3 and kissing stents to posterior left ventricular and posterior descending artery. 2) Borderline stenosis in the mid left anterior descending. 3) Normal left ventricular size and function with distal inferoposterior hypokinesis, ejection fraction 55%.

I had a physician who placed a covered stent to exclude a renal artery aneurysm.  There is no mention in the dictation of any stenosis.  Would it be more appropriate to code this as a stent placement (37205) or as an unlisted procedure (37799)?  Your help with this is very much appreciated!

In regards to the ultrasound guidance for vascular access code 76937, in my 2013 IR book it has the following statements: "3. Code 76937 (ultrasound guidance for vascular access) includes and requires documentation of ultrasound guidance for evaluation of potential access sites, selected vessel patency, and realtime visualization of vascular needle entry. 4. Code 76937 also requires permanent recording and reporting in the documentation." Does that mean that in the radiologist dictation he has to state "a permanent image recording was saved to PACS"? Or just dictate the evaluation, vessel patency, etc. within the report?

We did a vertebral angiogram of the third order and beyond with a setup for embolization (i.e., guide catheters and microcatheters in place zeroing in on an arteriovenous malformation of the P1 and P2 arteries with the intent to emboliz), but the doctor pulled back and stopped. Can we report intracranial embolization, code 61710, with a -52 modifier for reduced service?

A patient was taken to cath lab for hemodynamic catheterization and device closure of ASD. Two devices were attempted but not successful. After several attempts, a third device was placed, and the patient was transferred to recovery room. While in the recovery, patient started having palpitations and ectopy. An echocardiogram revealed migration of device to the LV outflow tract. It was decided to take the patient to the OR for surgical retrieval and ASD closure rather than attempt retrieval in the cath lab. We may or may not receive credit for the devices from vendor. Since ASD was closed surgically on same day, do we report only the hemodynamic catheterization, or code 93580-74 for attempted ASD closure?

I have a very complicated carotid endarterectomy with resection of part of the internal carotid artery and reimplantation of the ICA into the common carotid. Haven't seen anything like this before and would so much appreciate your input: "Common and external endarterectomy performed then due to arterial curves, patch was avoided due to potential kinking. Common carotid was primarily closed then an end-to-side anastomosis of the ICA to CCA was performed." Would you add modifier -22 to code 35301?

I have a question relating to PICC line placement. If a nurse attempts to place a PICC line but cannot place the catheter centrally, how do you code for this? The catheter terminates in the arm, short of the axillary vein. I'm told they can last up to two weeks in this position. Thanks so much!

A patient with a history of CABG has a left heart catheterization and bypass graft angios revealing the saphenous graft is totally occluded with a thrombus. The physician uses a quick cath and several balloons to remove as much thrombus as possible. The decision is made to anticoagulate the patient by IV infusion overnight. The next day the patient is brought back and repeat angiography of the saphenous graft is done, as well as an arch angio to look for any grafts that might have been previously missed. There has been no change in the patient's status and no other intervention is done. How would you report the second procedure?

I have a question regarding code 37186. Since 37186 bundles into primary mechanical thrombectomy, there is an NCCI edit with codes 37186 and 36870. What happens if primary thrombectomy is performed of graft, and arterial angiogram confirms thrombus in native artery outside the graft in addition to 36870? Since these two codes bundle, how can we communicate both the thrombus in graft and in native artery? Thank you!

How do we code for a carotid occlusion test when a diagnostic angiogram is completed at the same time? Also after the occlusion test they complete an embolization. 

My question today is how to code for a CT cystogram. We have been charging CT pelvis with and without contrast, CPT 72194. In the 2013 Diagnostic Radiology Coding Reference, it says to charge the anatomy that is imaged, but does not mention using code 51600 for the delivery of contrast into the bladder. On the Z website there is a Q&A regarding this that says to add the injection code 51600 (but it is from 2008). We are getting more and more outpatients for this procedure, so I want to make sure we are charging correctly.

This is a Protocol. Patient has a kidney or liver biopsy. Radiologist has technologist perform a limited ultrasound two hours post biopsy to check for possible complications. Would you consider this part of the biopsy procedure? My feeling is yes, if there were no signs/symptoms of a problem, just routine follow-up. But if there are signs/symptoms, then charge the limited ultrasound. Your comments are appreciated.

I have a question on embolization. I have a report where we went through the celiac artery, advanced in the common hepatic, ended in the gastroduodenal artery, and did coil embolization. The radiologist then went into the superior mesenteric artery and found additional bleeding went into the pancreaticoduodenal artery and did an additional embolization. My question is, can I code for both embolizations?

I have two EP questions. Is there a code to describe lead extraction by laser? Our EP technologists say that removal by laser takes longer and is more risky when the lead has been in for more than a year. If there isn't a code, is there something that the cardiologist should do to work toward Medicare to create one? Can you or would you use NIPS code 93624 with 93642 if they do a DFT?

A medically necessary question! Patient had a bilary stent placed with external drain left in on January 11th. Patient came back on February 13th to evaluate and check patency of the stent.  There was no output from catheter for a week. Choli was normal and external biliary tube was capped. Radiologist dictated in report to have patient return in a few days for a check and to see if the patient's biliary tube can be removed. Patient comes back on February 15th, and cholangiogram is done again and biliary cath pulled. Since there is a big crack down on doing procedures that are not medically necessary, I just wanted to make sure I can charge for the second cholangiogram.  Was it really needed after one just performed two days ago (no new problems or pain reported)? Is this normal practice accepted as medically necessary?  If I shouldn't charge the choli code, what can I charge, or what modifiers can I use with the choli charge to bill it?

We are going to start doing PM/ICD progamming and interrogations. Do codes 93279-93289 require a physician interpretation/report?

When IABP insertion and removing on the same day, Medicare has '0' edit.  However, recent cardiology coding alert suggested using a -59 modifier to charge both. Can you please clarify?

I have a patient who developed breast cancer. The physician wanted to place a port, so the pacemaker was removed from one side and replaced on the other side. Old leads capped, new leads inserted. I wanted to report it with the removal code 33233 and the insertion with code 33208. I am now getting an edit to add a device "C" code. My concern is we did not add a new device; we used the existing pacemaker. How should I code this case?

This patient came in for PICC placement. However, angioplasty of the subclavian vein was performed because it was occluded. My question is, can I report code 36005 for access to the extremity prior to angioplasty and still report code 36569 for PICC placement?

"The patient's right arm was prepped and draped using sterile technique. 1% Lidocaine solution was used for anesthesia. Under real-time ultrasound guidance, a 21 gauge needle was used to puncture the right basilic vein and 0.018-inch wire was passed into the right subclavian vein. The needle was then exchanged for a 5 French peel-away sheath system. Through the peel-away sheath dilator venogram was performed, which demonstrates at least two focal high-grade stenoses within the right subclavian vein and a focal high-grade stenosis at the right subclavian vein/brachiocephalic vein junction. The superior vena cava appears patent. Then over a 0.018-inch wire a PICC line was advanced into the right subclavian vein however the PICC line could not be advanced through the stenoses in the right subclavian vein. PICC line was removed. A 5 French Kumpe catheter was advanced into the right subclavian vein, and a 0.018-inch Glidewire was advanced into the superior vena cava through the multiple stenoses and into the superior vena cava. Then the catheter was exchanged for a 5 mm x 4 cm in diameter balloon. Then the focal high-grade stenosis in the right brachiocephalic vein as well as the right subclavian vein were angioplastied to 5 mm diameter. This was done to accommodate the new PICC line. Then the balloon catheter was removed. A new 5 French dual-lumen power PICC line was advanced over the guidewire into the superior vena cava, and the tip was positioned close to the cavoatrial junction. The PICC line functioned well at the time of insertion. The peel-away sheath was removed. The PICC line was secured to the patient's right arm. It was flushed using saline and heparin."

When I read about code 76001 in the 2013 diagnostic book, I understood that as a hospital-based radiology department that the department cannot use code 76001 for any fluoro exam. The radiologist have their own billing that is separate from the hospital. So I sent: "01-01-13 76001 is non-reportable by hospital billing. Delete from CDM" to the chargemaster analyst. I received back: "The CPT code 76001 is reportable but just not paid by OPPS. Reimbursement Code 76001 - FLUOROSCOPE EXAM EXTENSIVE Date Of Service 2013-01-01 Wage Index 0.82870 Status Indicator - B Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). Not paid under OPPS. May be paid by fiscal intermediaries/MACs when submitted on a different bill type, for example, 75x (CORF), but not paid under OPPS. An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x) may be available." So now I am confused. Should it stay in our CDM or not?

We would appreciate recommendation for appropriateness of charging closure device C1760 for patients with radial artery access for cardiac catheterization.  (Femoral artery, usually Angioseal or Perclose, which we do charge C1760).  Our hospital is using a Vascular Solutions, Inc. D-Stat Rad-Band topical hemostat (model 3501).  The product description says this supply "uses the science and clotting power of thrombin to stop bleeding, and is designed to prevent compression of the ulnar artery".  If this does not qualify as a C1760 closure device (even at a different cost level than the Angioseal/Perclose), is there another category to which it would be appropriately charged?

Can we report both codes 75630 and 36251/36252 together with clear findings of the distal aorta, both iliacs, femorals, and selective right/left renal angiography with findings for the renal artery? The only instruction we have in the book is "do not code 75625 and 36251/36252 together".

I am helping out with some surgical procedures while they look for a coder, and I wanted your opinion on the following situation: "Physician does open heart surgery. In the operating room are two first assistants who are both PAs. One of the PAs assists with the open heart surgery, while the second PA does the vein harvesting only. I would bill the charges for the surgeon. Bill first assist using the -AS modifier. You cannot bill a second assist. But the second PA in the room harvested the vein. Would you bill code 33508 with him as the billing provider? Or would you bill code 33508 under the surgeon and bill code 33508 with modifier -AS under the first assist and bill nothing for the PA who actually performed the harvesting? Or would you bill the surgeon's codes and the PAs' using the -AS modifier and then bill code 33508 only using the second PA's provider numbers who actually did the harvesting? The surgeon and both PAs are employed by the hospital. What do you think?

In the process of creating an AV fistula, the physician removes a thrombus from the basilic vein with a Fogarty balloon. He goes on to anastomose the basilic vein with the brachial artery. Would it be appropriate to report the thrombectomy with code 36831 and the creation of the fistula with code 36819-59?

Patient came for transjugular liver biospy. Order is for trasnjugular liver biopsy with hepatic vein pressure gradient. Report as follows: "Balloon occlusion catheter was advanced over-the-wire. Venogram was performed using catheter followed by inflation of the balloon and the catheter was wedged in the hepatic vein. Pressures well documented. Then two 20 gauge core biopsies were obtained from the right hepatic veins. No findings for the venogram." Can we charge this with codes 37200, 75970, 36012, and 75889-74 (for the pressure measurements)? Or nothing for hepatic venogram?

Should we bill code 37195 if "catheter was advanced in common carotid artery, and it was difficult to cross the extreme tortuosity of the cervical internal carotid artery, then intraarterial TPA was adminsted in common carotid artery. A total 15mg TPA was administered and angiography was done 10 and 15 minutes after the administration." I think for us to bill code 37195 the physician should document that the tPA is running over 15 minutes. Please advise.

My physician placed a bifurcated endovascular stent graft for an abdominal aortic thrombus (not aneurysm). Should I use the endovascular codes (34800-34805), or would it be better to use code 37799? I'm really stumped on this one.

Patient has a renal cyst that is being drained by a catheter which is left in.  Code 50390 is needle aspiration, and code 50021 is abscess drainage.  Would you consider this an unlisted renal procedure? Another question... I don't know why some patients come to the hospital for foley catheter changes, but they do.  These are done over guide wire exchange transurethral... suggestions?

Is code G0269, the closure device, bundled in cervicocerebral angios?

I didn't see this scenario in your data base. The patient has a dual outflow with the major basilic vein outflow and the anastomosis from the brachial artery to the antecubital vein. The physician ligates the distal basilic vein, but the desired results weren't achieved, so he decides to place a coil in the distal basilic vein. Can only the embolization codes (37204/75894/75898) be assigned, or is it appropriate to code for the ligation (36832) as well? When Medicare says to code for the completed procedure, does this mean to only code for the procedure that produced the desired results? Thank you!

Can we charge for non-coronary IVUS when using the Pioneer catheter to re-enter a peripheral vessel during peripheral intervention? The Pioneer utilizes Volcano IVUS technology; however, no images are archived to WITT/PACS. Basically, the IVUS helps guide the physician to enter the true vessel when they are sub-intimal.  I don't think so, based on the premise that ultrasound procedures generally must have images, but I wanted your take on this. Thanks!

In the 2013 Medicare physicians fee schedule, procedure code 19295 has had the PC/TC indicator changed from a 0 to a 3, which only allows payment for technical component, and now we are receiving rejections for our radiologists who are doing the clip placements. Do you know why Medicare changed this indicator, or if they are going to change it back? How/can we fight this rejection?

I am confused about the 2013 cervicocerebral coding. The more I look, the more confused I get. For hospital billing, when bilateral ICA arteriograms are done, do we use the -50 modifier, or do we charge code 33224 twice? The 2013 CPT Code Book and ZHealth Publishing books say to use the -50 modifier when performed bilaterally. The back side of the anatomical chart from ZHealth says to report the codes twice. When I looked online, the latest question answered about this subject only said, "For hospital billing, these codes are assigned status indicator Q2, so only one is reimbursed by Medicare when multiple cervicocerebral codes are submitted."  But, that doesn't really tell me which way I should be coding this. Please help me with this very confusing subject!

Would it be appropriate to report code 50387 for a patient who, in IR, has a nephroureteral catheter removed OTW and two wires and a sheath left in place to provide access for a nephrolithotomy to be done in OR later in the day? Since the work of creating the access was done in a separate session, code 50395 doesn't seem appropriate.

Can you please explain the rationale behind code 50393 with an MUE of 1, and its coding pair 74480 with an MUE of 2? I find this contradictory if bilateral stents are inserted. Thank you.

We have a patient whorecently underwent a TEE for the evaluation of a patent foramen ovale. It was inconclusive, and patient was then sent for an intracardiac echo and an agitated saline contrast study. The CPT code for the ICE is an add on-code. How should we bill for the contrast study... 93799? If so then will we be able to bill for the ICE add-on code 93662? Thank you for your help.