Ask Dr. Z

MI for coronary intervention definition

I have a question for you from the webcast on Tuesday regarding the Acute MI code. There is much confusion on whether or not a non-STEMI is an acute MI. Are we to assume that a non-STEMI is an Acute MI? If so, what clinical indications (documentation) would need to be present?

Use of 50 modifier with cervicocerebral angiography

Hi Dr. Z - For 2013, when bilateral extracranial carotid angiography is performed with selective catheterization of bilateral common carotids, coding should be 36222-50. According to the MPFS released 11/1/12, 36222 has a bilateral indicator of "0". Does this mean that payment will only be based on one code rather than bilateral? Should we bill 36222, 36222-59 instead? Can you shed some light on this subject? Thanks!

Carotid and vertebral catheter placement codes with a cardiac cath

Do you have any supporting documentation that you can direct me to so that I can show my physicians that it’s okay to use the 36215 – 36218 codes.  I have a couple of physicians saying that these codes cannot be used because they are not part of the cardiac cath codes.  Thanks.

20225 38221 G0364

Dr. Z,

We are keeping you busy these days.  I have a question. We have a location that is dictating the bone marrow biopsies like this sometimes worded just a little different.  Is this still the 38221? It wouldn’t be a 38220 and a 20225 would it?  Also would you ever code the 20225 and 38220 and if so would it be rare?  Thanks so much!!


PROCEDURE: CT-guided bone marrow aspirate

CLINICAL HISTORY: 46-year-old male with anemia, pathological compression
fractures, and abnormal laboratory exam

COMPARISON: None.

TECHNIQUE: The entire procedure including all risks and benefits were discussed with
the patient and oral and written consent were obtained after all questions
answered to the patient's satisfaction.

All providers wore hats, masks, gowns, and gloves.

The patient was brought to the CT suite placed in the prone position and
the patient's pelvis was imaged using 3 mm collimation. A safe route into
the left iliac bone was identified, the overlying skin draped and prepped
in usual sterile fashion and anesthetized with 1% local lidocaine.

An 11-gauge Stryker needle was then advanced into the left iliac bone and
bone marrow aspiration and core bone biopsy was performed.

In the short. Of time required to transfer the marrow blood from the
syringe into the appropriate tubes the blood was found to be clotted. The
11-gauge needle was replaced, marrow reaspirated and rapidly transferred to
the provided brain top and purple top tubes.

Bone plug, clot, and marrow aspirate were sent with the pathologist.

FINDINGS: Left iliac bone biopsy and bone marrow aspirate under CT guidance.

Rapidly clotting aspirated blood

IMPRESSION:
Thank you for allowing us to participate in the evaluation of this patient.

-52 with 93656

Good morning Dr. Z, With the new EP ablation codes including comprehensive EP studies, we have a question. How do you recommend we code 93653, 93654, or 93656 if the doctor doesn't complete all the components of the EP study? Should we be using modifier 52 for reduced service? As always, thank you for your help!

Lariat LAA closure

We are contemplating the use of the Lariat device for LAA closure.  I see Dr. Dunn suggested using 33999 earlier this year for the device.

I am wondering why you thought that 33999 was a better choice than 0281T?     0281T Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation

If you look at the NUBC definition for implant, the Lariat device, meets the criteria.

The reason I am being doubly cautious is that I noticed almost all payers will not reimburse 0281T due to the investigational nature of the devices previously used for this procedure (the Watchman and the Amplatzer).

Thanks in advance!

Aortic Occlusion Balloon during embolization and trauma

Will you please review the following report and tell me what code, if any, can be used for the insertion of the  Aortic Occlusion Balloon.  I can not find anything close in CPT. 33967 was recommended, but I don't believe it is appropriate since it's a pump. Your response is greatly appreciated.
 
All elements of maximal sterile barrier technique were followed, including use of sterile cap, mask, gown, gloves, sterile sheet, hand hygiene and 2% cutaneous antisepsis. The left was prepped and draped in the usual sterile fashion. An 18 gauge needle was advanced into the left common femoral artery. Over an 0.035 inch guide wire a 11 French sheath was placed, and through this, a aorta conclusion balloon was advanced to the abdominal aorta and inflated because the surgical team did not have good control of the aorta. Access was then gained to the right common femoral artery with an 18-gauge needle under ultrasound guidance. And a 035 wire was advanced into the aorta. An Omni flush catheter was positioned in the aorta at the level of the renal arteries and angiography was performed after the balloon was deflated. The balloon was reinflated. The Omni flush catheter was then used to select the ipsilateral right internal iliac artery. This was then exchanged for a 5-French Kumpe catheter with was used to gain access to more distal aspect of the right internal iliac distribution. Angiography was performed. Gelfoam embolization was performed distally where probable anterior division branches were identified. Extensive coil and Gelfoam embolization were performed with multiple O35 Nester and Tornado coils extending across the proximal injury within a couple centimeters of the origin. Repeat angiography was performed. The patient began to stabilize pressure after this first maneuver. Access was then gained over the aortic bifurcation. There was difficulty passing a wire due to the occlusive nature of the occlusion balloon. A Glidewire was necessary to gain access to the external iliac artery. The Kumpe catheter was advanced over t the bifurcation then exchanged over a Newton wire for a ruc catheter. The left internal iliac artery was then selected and extensive Gelfoam embolization was performed within the superior gluteal artery, anterior distribution, and main trunk. Repeat angiography was performed with the occlusion balloon deflated. The right internal iliac artery was reselected and a very small amount of Gelfoam embolization was performed. The left internal iliac artery was selected a second time followed by Gelfoam embolization. The occlusion balloon was left deflated at this point. The catheter was then positioned in the left common iliac artery and angiography was performed after the occlusion balloon was removed. The catheter was positioned the right common iliac artery and angiography was performed. Both sheaths were sutured in position and the patient was sent to the OR.

O2 Saturations with right heart catheterization

I have a question regarding O2 saturations during a right heart catheterization.  The question was asked of me “how are we charging Avoximeter testing (O2 saturations) and what is the billcode (internal facility code)”.  Our charge sheets have O2 sats on there, but only to keep count, and is marked as “non-chargeable”.  My question is, is there a separate code for just O2 saturations?  Also, if we do a RHC without cardiac output (just record pressures) is there a different code, other than 93451?

ASD closure and Right and Left heart cath

We come across a patient to our cath lab with an incidental finding of ASD found on Echo as a preoperative evaluation for possible hysterectomy.  Apart from atypical chest pain and mild SOB, she had no other symptoms, but the echo revealed RV dilatation and she has been in sinus rhythm.  She has a history of smoking, and because of her symptoms and coronary risk factors it was decided to do a right and left heart catheterization for suitability and indication for closure, and to rule out any CAD at the same time. He got both venous and arterial access and documented coronary imaging with mild disease noticed in the coronaries with well documented RHC along with LV pressures.  According to the CPT book under CPT code 93580 includes both RHC and LHC and combined LHC and RHC, however we can charge 93454 separate.  Our cath lab says they spend an hour doing this procedure it is a unique case we have to charge ASD and R and L heart cath at least coronary angiogram. But to me we can’t unbundle coronary angiogram to charge separate. At the same time there is no separate guideline when a true diagnostic study performed we can charge this separate like the guidelines under 0281T.  Please advice.

Thanks

GTube exchange w/angioplasty of tract for stenosis

This is my first ever case where the physician is doing an angioplasty of the tract of a gastrostomy because of stenosis.  Wouldn’t I code for the angioplasty?  If so is this considered an open angioplasty or an unlisted code?

Your feedback is greatly is appreciated.

C9600 - C9608 for DES in coronary arteries

I've just noticed that new HCPCS codes for drug eluting stents have been added for January. It looks like G0290 and G0291 have been deleted, but similar codes have been added to the C-code section. Do you know the intention of these codes? They seem to be worded more as a procedure code to complement the new intervention codes, but are in the supply code section. Should they be coded as replacements for the G codes? C9600 Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed;single major coronary artery or branch C9601 Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) C9602 Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed;single major coronary artery or branch C9603 Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed;each additional branch of a major coronary artery (list separately in addition to code for primary procedure) C9604 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed;single vessel C9606 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure)

Ultrasound finds not enough fluid for thoracentesis

If a patient is scheduled for a thoracentesis but after the ultrasound is done, the Radiologist decides that there is not enough fluid so we only charge a chest ultrasound (76604). My question is, is it ok to charge 76604 if you don't scan the entire chest. Thank you!

Medial plantar artery, 37228, 37229, 37233

Dr Z How would you code angioplasty of the posterior tibia and the medial plantar artery? How would you code atherectomy of the anterior tibia, the dorsal pedal and the peroneal? Thank you 

Removal of pericardial drainage tube

Cardiologist inserted tube for pericardial drainage during critical care episode. A few days later, one of his partners removes the tube. Is removing it billable? If so, what code and does the doctor need to make a report? (Right now we just have handwritten notes).

PA stenosis treatments 92997, 92998

Hi Drs. Zielske & Dunn, A physician did dilation of the right lower pulmonary artery, superior segment of the right lower pulmonary artery, anterior segment of the right lower pulmonary artery, posterior segment of the right lower pulmonary artery, and the right upper pulmonary artery. When researching this subject in the Diag. & Interventional Cardiovascular Coding Reference book, I found the statement "Code 92998 for each additional separate pulmonary arterial branch treated for stenosis with angioplasty." How many arterial branches are there? Is it a separate arterial branch after each bifurcation or is it referring to the bifurcation which leads to the right upper lobe pulmonary artery, right middle lobe pulmonary artery and right lower lobe pulmonary artery? Should I only code 92997 and 92998 or should I bill 92997 and 92998 X4? If I only bill 92998 once, I assume I can't bill for each cath placement either? Thanks so much for your help!

Aortic Occlusion Balloon during embolization and trauma

Will you please review the following report and tell me what code, if any, can be used for the insertion of the  Aortic Occlusion Balloon.  I can not find anything close in CPT. 33967 was recommended, but I don't believe it is appropriate since it's a pump. Your response is greatly appreciated.

All elements of maximal sterile barrier technique were followed, including use of sterile cap, mask, gown, gloves, sterile sheet, hand hygiene and 2% cutaneous antisepsis. The left was prepped and draped in the usual sterile fashion. An 18 gauge needle was advanced into the left common femoral artery. Over an 0.035 inch guide wire a 11 French sheath was placed, and through this, a aorta conclusion balloon was advanced to the abdominal aorta and inflated because the surgical team did not have good control of the aorta. Access was then gained to the right common femoral artery with an 18-gauge needle under ultrasound guidance. And a 035 wire was advanced into the aorta. An Omni flush catheter was positioned in the aorta at the level of the renal arteries and angiography was performed after the balloon was deflated. The balloon was reinflated. The Omni flush catheter was then used to select the ipsilateral right internal iliac artery. This was then exchanged for a 5-French Kumpe catheter with was used to gain access to more distal aspect of the right internal iliac distribution. Angiography was performed. Gelfoam embolization was performed distally where probable anterior division branches were identified. Extensive coil and Gelfoam embolization were performed with multiple O35 Nester and Tornado coils extending across the proximal injury within a couple centimeters of the origin. Repeat angiography was performed. The patient began to stabilize pressure after this first maneuver. Access was then gained over the aortic bifurcation. There was difficulty passing a wire due to the occlusive nature of the occlusion balloon. A Glidewire was necessary to gain access to the external iliac artery. The Kumpe catheter was advanced over t the bifurcation then exchanged over a Newton wire for a ruc catheter. The left internal iliac artery was then selected and extensive Gelfoam embolization was performed within the superior gluteal artery, anterior distribution, and main trunk. Repeat angiography was performed with the occlusion balloon deflated. The right internal iliac artery was reselected and a very small amount of Gelfoam embolization was performed. The left internal iliac artery was selected a second time followed by Gelfoam embolization. The occlusion balloon was left deflated at this point. The catheter was then positioned in the left common iliac artery and angiography was performed after the occlusion balloon was removed. The catheter was positioned the right common iliac artery and angiography was performed. Both sheaths were sutured in position and the patient was sent to the OR.

Looking forward to seeing you in November.

Attempted fistulogram

Dr Z.
 
I have a question reqarding attempted recanalization of occluded fistula.  the patients left upper cephalic vein was punctured just beyond the av fistula and peripheral to a large thrombosed aneurysm. Multiple attempts were made in an effort to advance out of the thrombosed aneurysm into the outflow cephalic vein in previously stented segment but this was not possible. Ultrasound demonstrates that the aneurysm is thrombosed and that the cephalic vein is thrombosed to the central cehpalic vein. The previously placed stent is thrombosed. In light of the very large aneurysm and the inability to cross out of it, it was felt that the fitula is not salvageable. I'm questioning whether this can be consider a actual fistulagram since the aneurysm prevented him from  entering the fistula. Can you help with coding this?  Your comments would be greatly appreciated. 

G0278

Please do NOT include any actual patient medical records with your question. Can selective catheter placement be reported when documentation states: A4Fr JR 4.0 catheter was advanced to the aorta and positioned at the vessel origin(common iliac) under fluoroscopic guidance. Right and left side. Cardiologist documents R/L heart cath with cors in addition to bilateral iliac angiography for arteriosclerosis. Department reported 93460. Look forward to your response.

Catheter placement and new cervicocerebral codes

Please do NOT include any actual patient medical records with your question. With the new codes for 2013 for selective cath placements, will you still charge for the 36215rt or 36215 lt just an example.

SI joint arthrography and injection of anesthetic agent

If a medicare patient undergoes diagnostic SI joint arthrography and injection of anesthetic agent are both G0259 and G0260 assigned? Would I use both 73542 and 77003 for guidance? Thanks

77001 for fluoro with PICC removal

Please do NOT include any actual patient medical records with your question. Dr. Z, Can we charge 77001 alone or 76000 when the patinet schedules only for PICC line removal under flurooscopic guidance. Thanks

36247

rt common femoral artery is punctured and selective celiac angiogram and lt hepatic medial division angiogram are done. radioembolization is performed and catheter is removed. same access site new catheter, lt hepatic lateral division is catheterized and selctive angiogram performed and radioembolzation is performed. I coded 36247, 75726, 75774 for 1st cahteter. 2nd catheter should I code as 36247-59 & 75726-59 or 36248 & 75774 ? thank you

av shunt embolization, two puncture with venoplasty

Please do NOT include any actual patient medical records with your question. question regarding AV fistula (forearm) accessory vein embolization. Fistula accessed and fistulogram findings demonstrated 2 accessory veins and high grade stenosis in the region of cephalic vein. Then with wire and catheter one of the large accessory vein was embolized with multiple coils. Follow up embolization run demonstrated successful occlusion.Next a second antegrade access of the fistula was obtained and PTA of cephalic vein performed. Can we code this 36147 36011 35476 75978 37204 75894 75898? Please explain. Thanks

75898 after delayed followup

I have a question about systemic heparinization following tPa infusion. The patient comes to the department on day 1 for a lower extremity venogram and initiation of tPa infusion (75820-59, 37201 and 75896). The next day the patient returns for a follow up venogram (75898). The thrombus burden is significantly improved. The infusion catheter is removed and systemic heparinization is started through the sheath in the popliteal. The patient returns on day 3 for a follow up venogram and the catheter is removed. Is the systemic heparinization considered thrombolytic therapy? If so, the follow up venogram on day 3 would be 75898. If it is not thrombolytic therapy, the follow up venogram would be 75820? Thank you for your guidance.

blood patch and myelogram

Please do NOT include any actual patient medical records with your question. Dr. Z, Patient scheduled for both blood patch/Fluoro and complete myelogram with findings from plain film and CT myelogram. Reason for the exam consistent headaches and possible CSF leak. Impression: Possible CSF leak, a small intradural mass within the thecal sac to the midline at the L3 inferior endplate level. Can we charge this with 62284 72270 and 62273-59 77003-59? What would you suggest for diagnosis besides headache? Thanks

75710, 75774

Dr. Z, I am new to Vascular coding and I have a question regarding the 75710 when the catheter is in common femoral: What is considered the basic exam? What are the vessels that are seen from the CFA? I have a doctor who places the catheter in the CFA, SFA and popliteal and then does an arterigram at each point, can I bill 75710 and 75774x2? Patrice

Dear Dr.Z A very good morning Could you please answer my coding question, where I am feeling difficult. PROCEDURES PERFORMED 1. Peripheral angiogram of the right extremity with selective engagement of the catheter in the right superficial femoral artery. 2. PTA of the right anterior tibial lesion. 3. Infusion catheter placement in the right anterior tibial artery due to thrombus at the end of the procedure. INDICATIONS: 1. Nonhealing ulcer on the right lower extremity in the right over the ankle. 2. Severe claudication symptoms in the right lower extremity. 3. Severe peripheral vascular disease by CT angio of the lower extremity arteries. PROCEDUER DETAILS: A-5 French sheathe was introduced into left common femoral artery under local anaesthesia using Seldinger technique. After inserting a 5-French sheath I took a J-wire with 5-French catheter. Then, I brought to the catheter and wire over the iliac bifurcation in a retrograde fashion to the superficial femoral artery and placed the catheter there and took pictures of the right lower extremity. The angiographic results revealed the right distal superficial femoral artery shows disease. The right popliteal artery shows about 60% to 70% lesion. The right anterior tibial artery shows total occlusion in the mid portion with reconstitution above the right ankle. The right tibioperoneal trunk shows mild disease. The right posterior tibial artery shows mild disease. The right peroneal artery shows mild disease in the proximal mid segment with distal portion showing totally occluded and reconstitutes right above the foot. I used a 6 French 45 cm length destination sheath brought over the iliac bifurcation placed in the right common femoral artery. Then I used a 20 cm exchange length J wire and placed in the SFA. I brought the glide catheter and took the J wire out. Then, I used an Angiomax bolus drips as per weight-based protocol and creatinine clearance protocol. This is a Quick-Cross catheter. I took the guide catheter out and replaced the Quick-Cross catheter. Then I used a 0.014 guidewire, which is a length prowater wire. Then I used the wire and crossed the lesion in the anterior tibial artery and placed all the way at the end. Then, I used a balloon to inflate across the lesion. The balloon is 3.0x150 sleek balloon and inflated anterior tibial artery at about 10 atmospheres of pressure. Then I used a 5-French sheath tempo echo catheter, took the wire out and took good pictures. It showed there a good flow in the anterior tibial artery with a focal 95% stenosis in the mid portion. Then I went back with the Asahi Prowater wire used a 4.0x150 mm balloon and tried to dilate the entire tibial artery, especially across the lesion at about 6 to 7 atmospheres of pressures. Then I got good flow with good flow all the way to the foot but considering the severe calcification throughout the artery, to get better result, I went with 3.0 mm balloon again and dilated. After that last flow in the anterior tibial artery. Also I see the flow to the posterior tibial artery and the peroneal artery got slow and finally the flow became very faint in the distal portions of the posterior tibial artery, as well as the peroneal artey, which was not intervended at all, and never had a write placed in the artery. Then I realized that there was some thrombotic situation, likely from the Angiomax issues. Either not being given enough or the Angiomax given was not enough anticoagulation. We re-bloused the Angiomax at that point. Then I tried to reverse the leak over the wire balloon and tried to dilate many times, giving intra-arterial nitroglycerin and verapamil. Still the flow was less with thrombus. The flow is was scant. Then I used Activase intra –arterial with catheter placed in the anterior tibial artery area. Then I used a 10 mg IV bolus given initially and then I started infusion. I then inserted an ev3 infusion catheter. The catheter placed in the anterior tibial artery extending into the popliteal artery. At that time I left the catheter in the popliteal artery and left the catheter in place and gave another 2 mg IV push of Activase and started a drip. This lasted for 6 hours with plan to bring him back for repeat angiogram and possible PTA. The patient tolerated the procedure, hemodynamically, stable without any issue from respiratory or cardiac point of view. Also, another procedure was performed, which was PTA of the popliteal artery. There is a 70% lesion in the popliteal artery. I used a 4.0 balloon to do the PTA of the popliteal lesion at about 8 atmospheres of pressure. The balloon extended from the proximal ED into the popliteal artery. CONCLUSIONS: 1. 70% lesion in the right popliteal artery 2. Total occlusion of the anterior tibial artery in the mid portion. 3. Thromboembolism of the infrapopliteal arteries during intervention leading to poor flow into the foot, requiring Activase bolus and infusion using the infusion catheter. The infusion catheter is ev3 infusion catheter. 4. At the end of the procedure, the patient is to have posterior tibial Dopplerable and anterior tibial Dopplerable pulses. Recommendations: 1. Continue the infusion with Activase for 6 hrs. 2. Repeat angiogram after 6 hrs of Activase infusion. My coding is 37228, 37224, 75710-26, 59 & 36247(Infusion catheter placement not for Angiogram). Repeated procedure on same day: INDICATIONS: 1. Thromboembolic phenomenon in the infrapopliteal arteries to PTA of the right popliteal lesion, as well as the totally occluded anterior tibial artery. 2. Status post Activase infusion over 6 hours to see how the thrombus burden in the infrapopliteal arteries and the right lower extremity, and possible intervention. HISTORY: This is a 73 year old white male with a history of significant peripheral artery disease, with nonhealing ulcer on the right lower extremity above the ankle. He was found to have significant infrapopliteal disease. The patient had a PTA of the popliteal artery lesion, as well as intervention of the anterior tibial artery of the right lower extremity during which the patient developed thromboembolic phenomenon leading to a good flow in the infrapopliteal arteries with poor circulation to the foot. An infusion catheter was placed and infusion of the Activase was done over 6 hours. The Patient was brought for a repeat angiogram an possible PTA. Again, a 6 French destination, placed in the right superficial femoral artery beginning proximal portion on the right side. The infusion catheter was already in place which was in the popliteal artery extremity, anterior tibial artery. Then we cleaned this in a sterile fashion and changed the gloves, took an angiogram of the right lower extremity. RESULTS: 1. Angiogram of the right lower extremity showed the popliteal artery lesion was less than 30% 2. Anterior tibial artery flow was again not seen well. 3. Peroneal artery also showed good flow with distal reconstitution after occlusion in the distal portion. The distal portion of the reconstitution was right above the foot. Then I gave him 4000 units of IV heparin. Then, we used the same catheter. Through the same infusion catheter I inserted a Benston wire and placed in the anterior tibial artery all the way to the foot. Then, I used an angioplasty with a balloon which is 4.0x100 balloons. After PTCA the flow is slightly improved but not greatly. Considering his recent complication of thromboembolic problem in the lower extremities, we compromised with results and had partially successful results regarding opening the anterior tibial artery. The posterior tibial artery and peroneal artery were left as they were in the beginning. No complications. My Coding is: 37228-76 & 75710-26,76 I appreciate your help. Thanks & Regards Ronald

75989

I coded 10160 x2 and 77012 x1 for case below based on your Q&A 3439. However, why can't we use 75989 with 10160? drain placed in two sites for hematoma, chest wall. Chiba needle was advanced into the fluid collection. 2 French pigtail catheter placed into the fluid collection. blood were evacuated. The tube was locked in place Chiba needle was advanced into 2nd site. Aspiration of old blood. A 12 French pigtail catheter was placed. The access was dilated to 12 French, and a 12 French sump drainage catheter was placed into the fluid collection. Following placement of these 2 drains there is near-complete resolution of the chest wall hematoma. Thanks

37202, 75896, 96420, chemoinfusion

Please do NOT include any actual patient medical records with your question. Patient admitted for follow-up intra-arterial chemotherapy.(first IA chemo done 9/26/12) Diagnostic Cervical and Cerebral Angios done at that time) Access site RCFA Catheter placements LCA, Bilateral Internal Carotid arteries Angiogram runs LT Cervical angiogram via LCA,catheter advanced to LICA-angiogram LT Cerebral Angio Chemo infused via catheter in Left ICA Catheter flushed and Follow up angio performedCatheter repositioned to Right Common Carotid-Angiogram performed, Catheter advanced into RICA for Cerebral Angiogram.. Chemo infused via Catheter in Right ICA -catheter flushed and follow up angio performed. Codes used to bill services.75680, 75896 x2, 75898 x2, 96420 x2, 36216 My argument is that the intra-arterial injections 96420 is the injection and therefore 75896 even without 37202 is wrong. It should be noted they were charging 96420, 75896 & 37202 in prior case and I told them they were charging the patient twice for the same injection which has been remedied by the above. So if my argument holds and 96420 is the appropriate charge vs 75896 & 37202 is it appropriate to bill follow up angiograms for the images taken post chemo? And lastly, if there is not change in the patient's status should she be charged for the diagnostic procedures again? Thank you for any assistance you can provide. Sincerely, Melinda Martino,R.T.R.,CIRCC

35475

Hi Dr. Z I have 2 questions that I need some coding help. Thanks for all your help throughout the years I have been submitting questions. 1. If ultrasound guidance was utilized for accessing the AV fistula/graft in two separate sites, the medical necessity and all the necessary criteria for ultrasound guidance are documented for both access sites, would it be appropriate to report the ultrasound guidance for vascular access (76937)two times. 2. Dilation of stenoses of the juxta-anastomotic outflow cephalic vein of an AV fistula is this an angioplasty (35475 and 75962) or venoplasty (35476 and 75978) our physicians always report this as an angioplasty?

61624

Procedure was a dorsal spinal dural arteriovenous fistula (DAVF). Embolization of Right lateral Sacral branch accessed via lateral sacral trunk Off right internal iliac artery. Performed as an outpatient procedure. Should this be reported as 61624 (spinal) or 37204 ? Thanks!

33241, 33244 LVL lead removal

A patient has a BiV ICD and it is being completely removed - nothing is being replaced. 33233 PM removal 33235 Remove leads dual system Can we charge for the LV (CS)lead removal? Unlisted code or is there something we aren't seeing in CPT book? Thanks, Lori Sprenger

Balloon occlusion

PTA vs PTA - 74 or angio? This patient was brought to IR and aortobifemoral angiogram demonstrates severe and total occlusion of the SFA. A wire was used to go subintimal to cross this lesion and when he attempted to cross with the catheter he was not able to get through. It was then determined there was extraluminal contrast. A balloon angioplasty was performed for two minutes with a #4 balloon. There was no evidence of bleeding. What can we charge for this? Thanks again for all your help.

ICD-9-CM for postoperative compliction

I have question that maybe Ruth can help with concerning ICD 9 post op codes. I am not sure how long we can code for 997.1 post op complication. I see our physcians dictate post op afib after many procedures/ For Example: Pt has surgery by a "another" surgeon.. different practice. Develops post op Afib. Seen at hospital for post op Afib by one of our MDs. Placed on anti arrhythmic meds. Pt is seen a couple times over a couple month period while pt is on these new meds. 8-9 months after the initial hospital visit, the patient is seen back in office. MD has been trying to wean patient off the anti arrhythmic. Are we still using post op Afib at that 8-9 month visit?

IVUS and lower extremity revascularization

Bilateral kissing iliac stents IVUS bilateral common iliac arteries Can I bill for the IVUS With 37221; 37221-59 or is IVUS included in 37221? 37221,37221-59, 37250, 75945, 37251, 75946 Thanks for help,

3D with heart caths

Good Afternoon! 3D reformatting of a cath image was performed in Cath Lab. The 3D image is in WITT/PACS, and the report documentation states that a left ventriculogram was performed with the Dyna CT protocol during rapid right ventricular pacing at a rate of 100 bpm. The lab is asking if the 3D is billable. I am not sure, since I thought it would be part of the ventriculogram which is included in the charge for the cath. What do you think? Also, if billable, does this documentation meet the standard or should there be mention of volumetric shading a/o MIPS...etc., Thanks.

I have a question with regard to Venous Duplex in preparation for AV graft for a patient with Stage 4 or 5 Chronic Kidney Disease. Apparently the code used in the past in our practice has been 93990 though the guidance we have located (and based on a recent denial notice); medicare with pay for the procedure only in patients with ESRD. We are coding for physician services and would appreciate any guidance you might provide. Thank You. Deborah J. Dole, RHIT Coding Analyst SMG – Central Billing 1107 S. Mannheim Road, Ste 302 Westchester, IL 60154 dold@sinai.org 708 786-2962

Transvascular biopsy 37200

Hello ~ I can't seem to find a code for a biopsy of a left pulmonary artery mass. Per Path, mostly fibrin, possibliity of thrombus. We did this in IR.

Billing for procedures nurses perform

Dr. Z. One of our ICUs are asking if they can bill for the ICU nurses assisting a physician with bedside procedures such as temporary hemodialysis line placement, central line, pulmonary artery line placement, chest tubes, thoracentesis, tracheostomies, cardioversions, intubations, transvenous pacemakers (on occasion)and pericardiocentesis. Also can they charge separately for when the patient is receiving hypothermia treatment and continuous bladder irrigations? All the above would be done on inpatients. Your input on this would be greatly appreciated. Thanks!

Hello. For outpatient surgery, we append the Q0 modifier on CPT 33249 with 33225 for Medicare patients with necessary diagnoses for primary prevention. Our business office requested V707 for participation in a clinical trial in association with the Q0 modifer. Is this correct? Is this a clinical trial? My understanding is that all participants are entered in the registry, but is the registry a clinical trial? The basis for appending the Q0 modifier is Dr.Z's coding referece. Medicare patient with ischemic cardiomyopathy, documented prior MI, NYHA class II and III heart failure, and EF less than or equal to 35% OR Medicare patient with non ischemic cardiomyopathy greater than 9 months, NYHA class II and III heart failure, EF less than or equal to 35%. Is my coding correct for a biventricular AICD placement with left coronary sinus lead = 33249-Q0 and 33225? is this a clinical trial? should we append the V707 diagnosis code? thank you for all your help, Aileen

Aortic stentgraft to treat aortoiliac stenotic disease

Good morning. I hope you can help with this coding scenario. The patient had bilateral claudication so was taken to the endovascular suite for possible intervention. A catheter was placed in the brachial artery and guided to the aorta where and aortogram was done showing occlusion of the distal aorta and bilateral proximal iliacs. It was decided that they needed to reconstruct the aortic bifurcation to open up flow to the legs. Bilateral femoral cut-downs were performed. Wires were passed up both sides to the aorta and then catheters were passed up the wires on both sides. A unibody bifurcated stent graft was then placed to cover the distal aorta and bilateral iliacs. Although this is not a AAA repair, would the codes 34804, 75982 be appropriate since they used the same graft and did the same procedure they would do in a AAA repair? Or, would the stent code of 37207 for the aorta and 37221 for each iliac be correct? I'm just not sure on this one. Thanks for any guidance in this case.

37193

Hi Dr. Z. Would you please help me with this scenario? Patient came for an IVC filter removal. Vena cavagram performed, no thrombus; filter embedded in the vena cava, procedure abandoned after multiple attempts with a snare and other techniques. According to Coding Clinic for HCPCS, procedure should be coded: 36010, 75825, and 37193-74; however, 36010 and 75825 are inclusive to 37193. What is the best way to code the procedure? Thank you very much for your help.

Dr Z, Cardiologist did a common iliac stent patient had problems and he called in a vascular surgeon who the put in a covered stent and fixed the problem. The vascular surgeon wants to bill with a 62 modifier but that can't be done. When I talked to the coder for the cardiologist, she thought the vascular surgeon could bill 37221 with a 77 but I don't think we can. Patient was still in surgery so it can't be a separate session. Any thoughts? I think only 1 can bill for the stent.

Q0 modifier for ICDs

Dr.Z, Pacemaker dependant patient with complete AV block comes in for upgrade to biventricular AICD. Patient was recently found to have severe nonischemic cardiomyopathy, progressive CHF, ejection fraction below 35%. Procedure: Cardiologist replaced dual chamber pacemaker with biventricular AICD device, inserted ventricular lead and left corornary sinus lead, re-used chronic atrial lead (old ventricular lead was capped), performed DFT testing. Codes = 33249-Q0, 33225, 33233. Is it appropriate to add the Q0 modifier in this case? The patient had a dual chamber pacemaker, no ICD device. The precipitating symptoms occurred recently. Thank you.

76937

I have a general question regarding denial of 76937 for a Kentucky based practice. Medicare is denying the use of 76937 with any CPT that is in the range of 362xx. That means we cant use 76937 when we code 36246-36248 or any selective below diaphram access codes. We have a letter from ACR and SIR to Medicare dated 9/9/2005 asking them to add a huge range of CPT's to the 'Medicare Physican Fee Schedule Database' in order to be able to use 76937 with those codes. Bottom line is that ACR and SIR got Medicare to allow the codes they mentioned. However now for this KY provider Medicare is not allowing the 76937 with any 362xx code. I code for VA Drs and dont have any problems with this being denied ever. Medicare was sent this letter and this is what we were told: 'the codes are in house and that the coders should know how to code and that they can not give that information. They also said that coding changes year to year and the letter from the ACR is no longer valid. Do you have any info on this? What is your opinion on this shoud 76937 (if properly documented) be allowed when we do a 36246? Do you have anything that will help us get Medicare to allow 76937 if you agree it should be allowed? thank you for your help Julie Morris

two av shuntograms 36147, 36147-59

Please do NOT include any actual patient medical records with your question. Dr.Z, Patient came with bilateral AV fistulas and intervention performed on both fistulas, can we code fistulagra/access with 36147 36147-59? Thanks

36832

Patient with clotted AV graft with percutaneous venoplasty and open revision/thrombectomy. Can 35476, 36147, 36833 all be reported? The anterior half of the graft was accessed with 18 gauge needle with insertion followed by a guidewire. A Bernstein catheter was placed through the venous anastomosis and advanced to the basilic vein under fluoroscopy. With a lap chole device a percutaneous thrombectomy of the venous anastomosis was performed followed by balloon PTA of the stricture. Next a second puncture was made into the arterial anastomosis of the graft. A French introducer was placed followed by retrograde between the radial artery and graft. A stricture was encountered and procedure converted to open. A 3 cm incision was made in the elbow crease. The arterial anastomosis was dissected. The anastomosis was opened showing a complete obstruction due to fibrosis of the proximal radial artery. The anastomosis was redone by placing sutures at the end to the proximal side of the artery.

Core biopsy changed to FNA by radiologist

On an outpatient, if a biopsy is requested and the radiologist performs an FNA as he believes it is less invasive and decreases the chance for the patient to return due to an inadequate sample, is a new order needed? Should the radiologist include documentation in the report why FNA was performed instead of a core biopsy?

Color Doppler and duplex

I have a question about billing Dopplers and Ultrasounds. In the document below, there is discussion of 'grayscale color Doppler images' but they are looking for lymphadenopathy. We are being told that if there is any mention of 'color Doppler' we should use the '9' series of codes for Dopplers. I remember in my past job we billed regular '7' series ultrasounds for these as they, at times, would only do a quick look with Doppler (if that makes any sense). I am trying to find some type of documentation to show my supervisor as well as to help my co-workers choose the appropriate codes. Most of those we see are extremities, but there is much confusion between the various types of exams.... Duplex/Doppler/Physiologic Is there anything that you can point me to that may help clarify the difference in these exams and what we should be looking for in order to choose each one? Can you tell me what code should be used for the following? Examination: Ultrasound of the Left Axilla, 10/05/2012 Clinical History: Melanoma. Indication: Evaluate for axillary lymphadenopathy. Technique: Real-time grayscale color Doppler images of the left axilla were obtained by the technologist using linear array transducer and submitted for review. Findings: No evidence of abnormal lymphadenopathy in the left axilla. No other suspicious soft tissue lesions identified. Underlying vasculature in the left axilla is grossly unremarkable. IMPRESSION: No evidence of lymphadenopathy. Any help you could provide would be MOST APPRECIATED!

Wedge injection, 37200

Please do NOT include any actual patient medical records with your question. Dr. Z, After reading question # 3428 from your database i would like to clarify documentation regarding catheter placement for transjugular biopsy. Our physicians dictation goes like this. Internal jugular vein was punctured and a 10 french vascular sheath was placed and selective catheterization of the middle hepatic vein was performed and a venogram was performed. Pressures were obtained with the hepatic vein wedge pressure measuring 15mmHg and the free hepatic vein pressure measuring 10 mmHg. A cook quick-core device was used and 3 core specimen obtained. Please advice when we have wedge pressures and catheter used can we code as 36012 or wedge needs to be performed along with pressures to charge 36012? Our IR department thinks this is second order so charging this with 36012. Please advice.