Ask Dr. Z

embolization later in day

I have a patient who had an Embolization of GDA in the morning (9:00 am) but after subsequent flow study there was evidence of extrahepatic flow with MAA injection. On correlation with prior angiogram and CT, it was evident that a unusual branch arising from the cystic artery was supplying extrahepatic omentum;therefore, a decision was made to bring the patient back for embolization of this small branch. In the afternoon (15:00 same day) embolization of an extrahepatic branch arising from the cystic artery was performed. Are we able to bill this additional embolization/cath placements/angio's? I am trying to locate information about how to do this if it is allowed. If so, would we use modifier 59 on these or 76? It is a repeat embolization but of a different area and many hours later. Any suggestions would be most appreciated! Thank you,

Additional information received subsequently:

I should have inquired about cath placement/imaging as well.  As it turns out this patient did have the sheath still in, so there was not a new access.

Would we be able to bill the cath’s and angio’s for the afternoon procedure?

I really appreciate your assistance!  My co-worker and I are really looking forward to your conference, but it looks like we won’t be scheduled until early next year.
 

33263, 33216 generator exchange with pacing lead placement

I have an unusual situation. I had a doctor bring in a patient for a dual lead ICD generator replacement. During the procedure he decided to replace the RV lead, but replaced it with a PM lead instead of an ICD lead. Is this still coded as 33249? It has been suggested we code this as 33263 and 33216, but I'm not sure this is correct (although it would solve the issue with this account hitting device to procedure code edits). I can find no guidance on which is the appropriate way to code this. Your help with this would be greatly appreciated!!!

PICC line placed by nurse in hospital setting

Hello, If i have a nurse inserts a PICC line can the hospital bill for that service. Thank you

Open aortic access for thoracic stentgraft access

Dr Z or Dr Dunn, Patient has descending thoracic aortic aneurysm. Patient is an endovascular candidate but upon review of imaging it was apparent that patient could not do ileofemoral access. So an retroperitoneal approach to the infrarenal aorta with direct aortic access for conduit purposes would be necessary. Open access of retroperitoneal plane and access to the infrarenal aorta was obtained. Also, percutaneous access to right common femoral artery was obtained with cath to aorta for diagnostic imaging of the of arch and thoracic artery. Medtronic Tallent thoracic graft with delivery system is placed from the aortic access along with two distal extensions just proximal to the celiac axis. After placement of thoracic graft retroperitoneum was closed and R femoral puncture site was closed. I'm not sure what codes to use for this case. 33881 75957 are endovascular codes and clearly the graft was placed through the aortic access. The only artery exposure codes with creation of conduit I can find are 34833 (iliac artery) 34834 (brachial) which does not fit in this case. Any help in coding this case would be very much appreciated.

33990

CAN YOU PLEASE TELL ME WHAT IS THE CODE FOR THE PLACEMENT OF IMPELLA DEVICE. THANK YOU.

37221-50

Hello Dr. Z, I have a question about diagnostic angiography performed with stent placement in bilateral iliac artery. I think it is ok to bill 75630 with modify 59 for diagnostic angiography, but I was told not to. Please advice, thank you. By the way, can we bill 37220 with modify 50 for bilateral in this case? Arteriogram confirmed that the puncture was in the common femoral artery and a Bentson wire was uneventfully advanced up into the abdominal aorta. An Omni Flush catheter were then advanced and a angiogram was performed. Findings showed the proximal common iliac artery stenosis which was near occlusive with a patent hypogastric artery and external iliac artery. The left side and had normal flow with no flow-limiting stenoses in the common iliac, external iliac artery, or internal iliac arteries. Next we proceeded to gain access on the right side. Using a micropuncture set, the common femoral artery was punctured and a Bentson wire was advanced up to the near occlusion. A glide catheter was then placed over the wire and this was advanced to the stenosis. A glide wire was then advanced through the glide catheter and this traversed the near occlusion into the abdominal aorta and the glide catheter was then advanced over this into the abdominal aorta. The Glidewire was exchanged for an Amplatz wire and the glide catheter was removed. We then proceeded to place an 8 x 58 mm Omnilink stent on the right side, which was a balloon-expandable stent, and a 9 x 38 mm balloon expandable Omnilink stent on the left side. This was advanced into the abdominal aorta with about a 1 cm overlap and these were inflated simultaneously in a kissing fashion. A repeat angiogram was shot at the conclusion of this which showed still some waist in the right common iliac artery. Thus a decision was made to perform an angioplasty at this level with a 9 x 20 mm EverCross balloon. At the conclusion of this, another angiogram was shot which showed resolution of the stenosis and no flow-limiting areas within both stents. The entire iliac system was patent.

34832, open repair of old, failed endovascular treatment of AAA

I am not sure how to code for the removal of an endograft (AAA, due to Type 2 endoleak). An aortobifemoral bypass was done, but I am not sure how to code the explant. 37799?? 22 modifier on the 35646? Something else? Since it was not infected, I hesitate using 35907.

Catheter placement for endograft placement

Dr Z, This is for clarification, when doing a Endo AAA repair must catheters be placed in the aorta from both the left and right or can you count the placement of the endograft as one of the catheter placements? Thank you

36832

Please do NOT include any actual patient medical records with your question. Patient came in status post endovascular repair of left arm AV fistula pseudoaneurysm usign a viabhan stent graft. The patient has developed an AV fistula complication consistent with stenosis. Fistula cannulated and fistulogram obtained. Stenosis noted in cephalic vein and two pseduoaneurysms noted.PTA was performed on cephalic vien. Attention was turned to the pseudoaneurysms. The pseudoaneurysm clsoer to the elbow appreared to be large. Due to the size of teh pseudoaneurysm, the decision was made to proceed with incision, the pseudoaneurysm was exposed. A pseudoaneurysm was then opened under direct vision. Approximately 20ml of old organized thrombes was evacuated. The pseudoaneurysm was then reparied primarily using prolene suture. not sure what to code for the driange of pseudoaneurysm? Please advice. Thanks

Order specific for with or without contrast that change

I code outpatient procedures for an OPPS hospital. We frequently receive MR and CT orders, and based on the diagnosis stated on the order, the radiologist believes that the exam would be more beneficial if performed without contrast or with contrast, however, the order requests the opposite. Do we need to obtain another order for "without contrast" or "with contrast" or can the study be performed per the radiologist's request as test design? Does Medicare offer specific guidance on this topic?

Y-90, Yttrium embolization of liver metastasis

Dr.Z, My radiologist has told me that we are going to do a Ittrium Y-90 radio-embolizaton on a patient with Colo-recto mestastasis. We will do angiograms for a road map,with embolizations and the MAA injection. We will bring the patient back in for the radio embolization two weeks later. Will I need any specific codes for the radio-embolization, or is it still coded as 75894/37204? I have the case of the month,November 2011-Visceral Angiogram w/Embo and Injection of MAA for guidance. I just want to make sure that I have the correct codes for the radio embolization procedure. Are there Nuclear Medicine codes that need to be considered? Thank you, R. Mercer 8-30-12

Chemical cardioversion

One of our providers performed a chemical cardioversion in the office for a symptomatic patient using adenosine. Is this service billable in addition to the IV Push, the drug and the separately identifiable office visit? We have located information indicating it is considered inclusive to the E/M visit and other information indicating an unlisted code should be used. Please advise. - Thank you.

facial sclerotherapy

Hello Dr. Z A percutaneous neuro sclerotherapy was done on facial venolyphatic malformations. The ethanolamine was injected through a direct puncture 22 gauge butterfly needle of the mandible lesion with live fluoro Should the 37799 or 36470 code be uses along with the 77002 for needle placement guidence?

Migrated stent redeployment

We have an unusual case and I am hoping you can advise what is the best way to bill for the procedure. Thank you. Patient had a previously placed subclavian stent. It was found on CTA that the stent migrated to the bifurcation of the aorta and lt common iliac. The physician went in and snared the stent and repositioned it in the left common iliac artery. He has also dictated a complete lower extremity angiogram. Since he did not remove the stent would you use an unlisted code? I don't think there is medical necessity to bill for the angiogram even though it shows Lt SFA stenosis needing angioplasty at a later date. Thank you.

Chemoembolization

Please help code this one. INDICATIONS/COMMENTS: HCC/ HEPATIC CHEMOEMBOLIZATION RESULT: COMPARISON: 5/28/2012 HISTORY: 68-year-old male the history of and hepatocellular carcinoma. PROCEDURE: Chemoembolization. After obtaining informed consent patient placed in supine position on the angiographic table. The right groin was prepped and draped in the usual sterile fashioned. Ultrasound imaging of the common femoral artery was performed and access to the common femoral artery was obtained. A 19-gauge needle was inserted into the artery and ultrasound observation an 035 wire was advanced into the abdominal aorta. 5 French vascular sheath was placed at the arteriotomy site. Following this, Cobra 2 catheter was advanced into the abdominal aorta and used to select the origin of the celiac artery. Contrast was injected and images obtained. Due to the inferior course of the celiac artery, the Cobra catheter was exchanged for a Simmons 2 catheter. This catheter was placed in the origin of the celiac artery and advanced into the hepatic artery. Contrast was injected and images obtained. Following this, microcatheter was advanced coaxially through the catheter. The renegade high flow catheter and microwire were used to select the origin of the left hepatic artery. Chemoembolization was performed infusing approximately 20 mg of Doxorubicin on hepatic spheres. Antegrade flow was monitored throughout. The microcatheter was then pulled back into the main hepatic artery and advanced into the right hepatic artery. Only a small amount Doxorubicin was infused as the patient has a known portal vein occlusion. Antegrade flow was monitored continuously to ensure or the hepatic artery would not be compromised. Incidental note is made of vascular staining in the dome of the liver and in the posterior segment right lobe of the liver consistent with known tumors on CT.CONCLUSION: Limited chemoembolization of the left and right hepatic arteries as described above. A total of 60 mg of Doxorubicin on hepatis spheres was infused. Antegrade flow remained present throughout the procedure in both lobes of the liver. The star close device was used to achieve hemostasis at the right common femoral artery.. I have 75726, 75774, 36247, 36248, 37204, 75894, G0269, 75898. This is an inpatient in the hospital. thanks

76937

We need clarification about code 76937. Is there a list of appropriate primary codes that 76937 is billable with? thank you

Ultrasound of bony protuberance of xyphoid

Please do NOT include any actual patient medical records with your question. PLEURAL EFFUSION SONOGRAM: EXAMINATION: SONO CHEST CLINICAL HISTORY: Bony protuberance. TECHNIQUE: Real time gray scale sonographic evaluation was performed of the chest. RESULTS: Ultrasound over the region of the bony protuberance was performed. This appears to correspond to the xiphoid process. Correlation with chest x-ray may be considered for further evaluation. IMPRESSION: Sonographic findings over the region demonstrate what appears to be prominent xiphoid process. my question on the above is whether I can bill CPT 76604? with the attached documentation? is there specific documentation required?

93455

Dear Dr.Z, Could you please help me with following coding question. Diagnostic Cath: LHC/Coronaries/Vein grafts with no LV gram. For this I am coding as 93459. Procedure Summary: 1) Normal functioning bileaflet mechanical aortic valve. 2) LM: 40% proximal stenosis. 3) LAD: 100% stenosis 4) LCX: no instent restenosis. 5) RCA: 100% mid segment. 6) Patent LIMA to LAD with diffuse distal disease. I am clear about above all except mechanical aortic valve. Q) what is the CPT code for Bileaflet Mechanical Aortic Valve Functioning, along with 93459.? Thank you very much

33264

Please do NOT include any actual patient medical records with your question. I have a physician who brought a patient in remo-repl biv-icd he was unable to induce VF with repeated pacing with low-energy shock programmed or high-frequency voltage induction. There were frequent burst of non-sustained polymorphic VT. For that reason a 1 Joule shcok was test and the shock impedance was 44ohms. would you code 33264, 93641? Please let me know asap. Thanks, Marsha Richardson Chatta, TN

Reporting 37186 and 37226 together

Dr. Z, My question concerns coding 37186 and 37226 togther, I recently received a denial from Medicare stating that 37186 was an add on code, and 37226 was not a primary code "approved" for billing with 37186. It states that the only codes allowed are 37224,37227,37228, 35470-35475, 35490,35495, 37205,37206. I can't find information about this. I would like to appeal this but I want to be sure that I am correct. Thank-You.

Stress test and echocardiogram

Some of our doctors frequently perform a stress test on the same day as an echo. However, the report for the echo will sometimes have CPT 93306 (not the code for the stress echo). Is it always to be considered a "Stress Echo" when the same doctor performs both tests on the same day? Thank you!

Filter retrieval from the pulmonary artery, 37193

Dear Dr. Z: IVC filter migrated into the right lower lobe pulmonary artery requiring removal. Would 37203, 75961, 36014 be reported or would we report the standard filter retrieval 37193? Thank you. mlb

cath placements for thrombectomy via same access as IVC filter in separate

Hello Dr.Z, Do we need to code catheterizations(36011/36012) and imaging for lower extremity veins(popliteal/tibial) if IVC filter placement is performed and through the same access(IJ vein) thrombectomy of veins is also performed for DVT. Is 37191 includes catheterization includes all the way to lower extremity veins and imaging? Please clarify Prabhavathi

Injecting radiopharmaceutical with no imaging

Please do NOT include any actual patient medical records with your question.RADIOPHARM INJ W/O IMG: Order Number: 90003 Date of Exam: Jan 31 2012 7:40AM EXAMINATION: RADIOPHARM IV INJECT W/O IMAGING CLINICAL HISTORY: Hyperparathyroidism. PROCEDURE: Radiopharmaceutical Injection Without Imaging RESULTS: PROCEDURE: 10.5 mCi Tc 99m Sestamibi was injected intravenously and no imaging in the Nuclear Medicine Department was performed. The patient was sent to Surgery for intraoperative localization of possible parathyroid tumor. IMPRESSION: 1. Please see above. what if anything can the Radiologist charge on the above for the professional portion?

36147

Please do NOT include any actual patient medical records with your question. The patient is a 54-year-old woman with a history of end-stage renal disease who is status post creation of a left forearm arteriovenous fistula at an outside hospital. SURGICAL PROCEDURE IN DETAIL: the left upper extremity was prepped and draped in standard surgical fashion. A forearm arteriovenous fistula was present. This fistula was cannulated using a micropuncture set and a fistulogram was obtained. The study revealed an antecubital arteriovenous fistula with outflow to both the cephalic and basilic veins. The central veins were unremarkable. The decision was made to proceed with a left brachiocephalic arteriovenous fistula. Through a transverse incision above the elbow, the cephalic vein was circumferentially dissected and transposed onto the brachial artery. An end-to-side anastomosis was performed using a running 7-0 Prolene suture. The proximal anastomosis of the antecubital vein arteriovenous fistula was dissected through the same incision. This fistula was ligated and divided between clamps and oversewn with Prolene suture. My question is - is this a revision since patient has forearm fistula a new fistual from basillic to brachial, if it is new fistula how do we capture the fistulogram and ligation of old one? Thanks

Flair and Fluency stent grafts

Hello. My question is regarding C1874 stent coated/covered with delivery system. Is the flair stent inserted in this example a drug eluting stent? Does the HCPCS code C1874 necessarily equal a drug eluting stent? thanks for your help! Utilizing 2% lidocaine as local anesthesia a 21-gauge needle was corrected into the arterial limb of the AV dialysis graft directed towards the venous anastomosis. Subsequently, a AV shuntogram was performed demonstrating a high-grade focal stenosis involving the venous anastomosis. A 6 French sheath was placed and the anastomosis crossed. This was then dilated to 7 mm which appeared to improve flow, however, residual intimal regularity remains. As a result, a 7 mm x 5 cm fluency stent was deployed across the venous anastomosis. This was then dilated to 7 mm. The graft also demonstrates mild diffuse intergraft stenosis. This was also dilated to 7 mm. A post procedure shuntogram demonstrates no significant residual stenosis, however, the thrill was suboptimal following this procedure. As a result, the arterial anastomosis was evaluated. This demonstrates a high-grade arterial anastomotic stenosis. A 21-gauge needle was then directed into the venous limb of the graft directed towards the arterial anastomosis. A 5 mm x 2 cm balloon was then inflated across the anastomosis. A post procedure fistulogram was then performed demonstrating no significant residual stenosis. A nice palpable thrill was achieved within the graft. As a result, the access guidewires, vascular sheath, and balloon catheter were removed.

10022 10160

I have two questions regarding breast procedures. 1.) If a drain is placed and left in place (due to suspected abscess) would the proper code be 10160 (catheter drainage) or 10022 (diagnostic needle aspiration)? Does 10022 require that a needle be used? 2.) If FNA's of masses are performed at 12 o'clock and 3 o'clock (same breast) can 10022 be billed more than once? I believe in your book it does state that guidance can only be billed once per session. Thank you so much,

Mammogram post needle localization

A patient presents to radiology for a localization wire placement in the breast. The patient has had a biopsy and clip placement on a preivous date of service. On today's visit the localization wire is placed in the breast under ultrasound guidance. The patient then has a mammogram after the wire is placed to confirm wire location. These films are sent with the patient to surgery for a lumpectomy. Should any codes be awarded in this scenarios for the post wire placement mammogram?

axilla ultrasound with breast ultrasound

Can you plesae tell me what ultrasounds should be billed with this breast/related area Ultrasound and Ultrasound Guided Biopsy? Our primary confusion lies in the ultrasounds performed at the same time of the breast ultrasound/biopsies. Also, in order to bill the post procedural mammogram is there anything specific required? Examination: Bilateral Breast Ultrasound (76645); Ultrasound of the Right and Left Axillary (76882-RT, 76882-LT), Infraclavicular (?), & Internal Mammary Regions (?); Ultrasound of the Right Supraclavicular Regions (76536?); Ultrasound-Guided Left Breast 3 O'Clock Position Needle (per doctor FNA) Biopsy (10022/76942); Ultrasound-Guided Right Axillary Lymph Node Needle Biopsy (38505); Ultrasound-Guided Right Breast 10 O'Clock Position Needle (per doctor FNA) Biopsy (10022-59); Ultrasound-Guided Right Breast 12 O'Clock Position Core Biopsy (19201) and Clip Placement (19295); and Post-Procedural Right Breast Mammogram (G0206) Any assistance you could provide would be greatly appreciated! Thank you so much!

Code for microwave ablation

This is a general coding question about the use of the radiofrequency code for a microwave ablation.  The last information that I can find on dr z’s questions and answers say to  use the unlisted for the microwave ablation.  Is that still the position?

The procedures would be for microwave of the liver tumor and microwave for a spleen tumor.

Thank you for your help.

Carotid stent placement when unable to place EPD

If the physician plans to do a carotid stent but after several tries is unable to place the protection device, would you do that as a 37215-53?  She did angioplasty to assist the device but was still unable.

Thanks!

Expression of blood post plebectomy

If a patient comes in to have a varicose vein procedure (phlebectomy 37766/endovenous ablation 36478) and they’re within the global period of having the same procedure done on the opposite leg, and during this visit the physician nicks and expresses old blood from the previous wounds, would 10140-79 be appropriate for that?  I put a -58 on the 37766/36478.  Or wouldn’t the 10140 be billable?

Thanks!

Rt Internal Jugular: Hickman Catheter Placement and Port Removal

My question this time is on CVC placement and Port Removal via the internal jugular vein.  Can you clarify for me when this is performed in the same vein would this be consider an Exchange or Removal with Placement of “new”?  Indicated below is how the dictation is worded:

________________________________________________________________________________________________________________________________________________________
.  .  .  .  . indwelling port was removed en-bloc using a combination of sharp and blunt dissection.  The port pocket was flushed with antibiotic solution.  The pocket was closed with interrupted 2-0 and subcuticular 4-0 Polysorb suture. 

The right internal jugular vein was accessed, . . . . . . . . the double lumen Hickman catheter was then tunneled through the subcutaneous tissues of the right chest,  . . . . .terminated in the superior caval  atrial junction.  The catheter was aspirated and flushed . . . . . .

Rt internal jugular PortaCath removal.  Successful right internal jugular Hickman catheter placed.

Interpretation of spot films

Please do NOT include any actual patient medical records with your question.FLUORO NON RAD DOCTOR OVER 1 HR: Order Number: 90005 Date of Exam: Aug 13 2012 10:54AM EXAMINATION: FLUORO-NON RAD DR OVER 1 HR CLINICAL HISTORY: Cervical fusion. COMPARISON: None. TECHNIQUE: Frontal and lateral views of the cervical spine. RESULTS: There is anterior fixation of C3, C4, C5 and C6 with prosthetic disc material in the intervening disc spaces. Surgical drain in the prevertebral soft tissues. There is anatomic alignment without evidence of hardware failure. IMPRESSION: ACDF C3, C4, C5 and C6. I do the billing for the Radiologist portion and our hospital bills for the tech component and I wanted to know if I can bill for a 2 view cervial x-ray for the above (72040).

Cardioversion and ICD reprogramming

Can I code 93287 with 93260? The operative report states Procedures: 1. Elective direct current cardioversion 2. Dual chamber implantable defibrillator interrogation and reprogramming.

One night inpatient admissions

Dr Z. We are continuing to have physicians who admit their cath lab patients as inpatients rather than outpatients and then send them home the next day. In your seminar you addressed this issue however I am unable to find written documentation of what you said. So, would you please cover this topic in this format? Thank you!!

Iliac angioplsty with EVAR placement

Dear docs-I was hoping you could help with when can you charge ballooning the iliac for an EVAR placement (and anything else I might be missing)Can I charge 37220 for stenosis when I am not sure that this isn't just for the clearing the way for deployment? And is there really an extension being placed? (including preop discussion, hopefully that helps) In the office in the preoperative area, we had a discussion with the patient regarding the difficult nature of the aneurysm including poor iliac access, high-grade stenosis of the iliac and the need for fem-fem bypass graft. We explained the creation or placement of an aortomonoiliac bypass graft with a fem-fem crossover. Bilateral groins were opened in a vertical fashion. We dissected down to the common femoral, profunda femoris, superficial femoral artery junction. 34812-50 I cannulated the right common femoral artery without complications or difficulty and inserted a wire into the aorta. This was followed by a sheath, flush catheter and then the wire was switched out for stiff wire. Catheter and wires were removed as needed to perform angiography. Please recall that the left common iliac artery is completely occluded. 36200-59RT We performed balloon dilatation of the external iliac artery prior to deployment of the stent graft. 37220-LT The patient was heparinized prior to any ballooning and we planned for the placement of a distal extension and this was carried out by placing a 1610 limb with 124 length in the aneurysm sac and out into the common iliac artery through preexisting stents. 34825/75953-26 A 20 20, 82 limb was then placed with sufficient overlap with the 10 16, 124 graft and finally an Endurant cuff, which was a 32 32 x 49 was placed in an infrarenal location. 34802-75952-26? Completion angiography demonstrated patent renal arteries bilaterally, no evidence of endoleak and widely patent aorto-mono-iliac bypass graft. Having this in mind, we removed the wires, catheters and sheaths and tunneled a piece of 8 mm ringed Gore-Tex from one incision to the other, created arteriotomies on the common femoral arteries and performed anastomosis of the end of the 8 mm bypass graft to the side of the common femoral artery with 6-0 Prolene suture. 34813 thank you so much for your expert opinion!!

Modifiers when cardiac cath and drug eluting stent performed

Please do NOT include any actual patient medical records with your question. Hi Dr. Z: We are trying to determine if modifier -59 is required on CPT 93458 - LHC, when it is reported with G0290-RC & G0291-LC. This is for OPPS billing. I cannot find any documentation that it is required or should be appended to 93458, when reported togather w/G0290. There are no NCCI edits or OCE edits. Thanks for your help!!

Thrombectomy and ligation on occluded fistula

Dr Z, The patient came in and had a diagnostic fistulogram performed showing severe calcification/stenosis in arterial side along with formation of thrombus. The MD performed an arterial PTA and then opened the graft and removed thrombus. A follow-up fistulogram was done but complete occlusion was noted in the cephalic vein and attempts to cannulate were unsuccessful. The MD decided that this fistula was beyond repair and performed a ligation. A temporary dialysis catheter was placed. Since the PTA was through a separate access, I was thinking 35475/75962. However, I am not sure how to capture both the thrombectomy and ligation - since the fistula is no longer functional. Any assistance would be appreciated. Thanks.

G0278 for iliac imaging during heart cath

Please do NOT include any actual patient medical records with your question. My physician have started doing abdominal arteriogram (75625) on patients who come in for LHC and RHC for possible TVAR procedures.Here is the preop diag. and the finding below. preoperative diag: The pt has moderate to severe aortic stenosis by suface echo and present for evaluation of his coronary arteries and aortic valve for consideration of possible percutaneous aortic valve replacement vs tranditional repair. Findings: Abdominal Aortography: The patient was found to have calcified iliac vessels..diameter 1.6cm lt and rt iliac. My question is should I code G0278 or 75625 or can you code for this procedure when there is only a possible of a TVAR?

CPT code for marking chest for subsequent thoracentesis

DR. Z, I am a coder having a disagreement with another department on coding a tunneled PleurX catheter for malignant pleural effusion. The doctor writes in the progress notes " 12 pleural cath ..place via ultrasound guidence 1600m of fluid removed. He types up a report that states "ultsonography guided right pleurX catheter placement...Ultrasonography was performed at the bedside and revealed a large right pleural effusion which was echoic in nature, suggesting blood or thick fluid. A mark was placed in the patient's chest for proper needle placement. The patient was then cleaned with ... and a drape was placed. The right pleurX cahterter was placed in the right midaxillary line. It was tunneded under the skin to about 7 mm into the chest. There was good drainage of serosanguineous fluid which was removed without difficulity. I think the codes should be 32250 and 75989 but the department insist that 78989 should not be added because the ultrasound guidence is FOR LOCALIZATION: THis is the response representing the department: I have to ask whether the procedure was actually guidance vs. localization. To report ultrasound guidance I would expect documentation to support continuous ultrasound guidance as the following Thoracic Intervention Seminar demonstrates. This particular patients procedure note only describes using ultrasound to locate a large pleural effusion.The operative report does state Ultrasonography Guided Right PleurX Catheter Placement. It may be poor physician documentation but I would imagine that it was used only to localize. Thoracentesis under ultrasound guidance is usually performed with the patient in a sitting position on the edge of the bed, leaning forward with the patient's arms resting on a bedside table. When the patient is not able to be placed in a sitting position, the lateral decubitus or supine position can be used. Preprocedural ultrasound evaluation can localize the pleural fluid pocket and skin entry site at the posterior intercostal space, which is prepared and draped in a sterile manner. A skin entry site is then anesthetized using 1% lidocaine with epinephrine. The access site should be along the superior margin of the rib to avoid the injury to the intercostal artery, which runs along the inferior border of the rib. After making a small skin incision, an 18-gauge over-the-needle sheath is then advanced into the pleural fluid under continuous ultrasound guidance." What do you think should be coded for this procedure 33251 and 75989 or just 33251? I think they are getting 75989 mixed up with 76937. Thanks so much for your website and books. I could not do my job without them!! Kelly Hill Coder

Optical Coherence Tomography for renal

Dr. Z, What do you suggest for Optical Coherence Tomography during selective renal catheterization (36251-36254). Thanks

Angioplasty for leak

Patient had a LHC w/ coronaries and LV using right radial approach. Here is an excerpt from the report that is causing us some confusion. " After the diagnostic procedure, we advanced a 6-French guiding catheter. However, we could not advance it beyond the tip of the radial sheath. When we took angiogram through the radial sheath, we found there was extravasation of dye through the radial artery. We treated that with long inflation with a 4.0 x 30 balloon. However, extravasation continued, so we reversed the heparin with protamine and achieved hemostasis with compression bandage, and we also removed the arterial sheath, achieved hemostasis through a D-Stat." Our question is whether we can code for the PTA 35475/75962 of the radial artery. Since this was not a stenosis, are we not allowed to code it? Thank you.

Revision of intrathecal drug pump

Procedure: Revision of intrathecal drug delivery pump. Indication: The patient currently has an intrathecal drug delivery pump in bad position, the pump has not been sutured down to the fascia so the pump has slipped and the pump is not usable and cannot be refilled. Description of Procedure: The area of the left lower quadrant of the abdomen was prepped and draped, surgical site was covered with ioban. An incision was made along the previous incision in the left lower corner of the abdomen which allowed exposrue of the intrathecal pump. the incision was carried down until the intrathecal pump was exposed and it was taken out of the pocket. Hemostasis was applied. then an incision was made about 1 1/2 inch anterior to the previous incision in the left lower quadrant of the abdomen. An appropriately sized pocket to implant the drug delivery pump was created using blunt dissection. Hemostasis was applied. the catheter was disconnected from the pump and it was passed to the new pocket. the catheter was reconnected to the pump. Aspiration was done through the side port of the pump. About 2.5 ml of CSF was aspirated. the pump was filled with preservative free morphine 10 mg per ml with 20 ml solution. Both pockets were irrigated with bacitracin solution. the pump implant was placed into the new pocket and was anchored down to the fascia using 5 ethibond sutures. both incisions were closed using 2.0 vicryl suture in the subcutaneous layer. the skin closure was done with staples. The surgeon describes the device as a pump and not a subcutaneous reservoir, the pump was sutured to fascia, so i did not feel CPT 62360 was correct. i get a device edit with CPT 62362 - the pump was not replaced with a new pump. 62350 appears to describe repositioning of the intrathecal portion of the device rather than the LLQ abdominal pump portion. Can you please advise? thank you. 62362

Modifier 52 versus modifier 74

For a limited (unilateral) noninvasive physiologic study of an upper or lower extremity (93922), you’re to add a -52 on the professional charge.  Does a -74 go on the technical portion then?

35876

Would you code only the embolectomy or both the embo and endarterectomy?
34201…35372

Thanks!

OPERATION PERFORMED:
1.  Right femoral thromboembolectomy.
2.  Right common femoral and profunda femoris endarterectomy.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  150 mL.

COMPLICATIONS:  None apparent.

SPECIMENS:  None.

FINDINGS:  Thrombosed right aortobifemoral bypass graft limb with outflow stenosis in the superficial femoral artery and profunda femoris artery.

INDICATIONS:  This 61-year-old male had undergone an aortobifemoral bypass graft with Dacron back in 2006 by Dr. David Han.  The patient was seen in followup for suture removal, however, did not return for any surveillance scanning beyond October of 2006.  For the last several months, he has been noticing claudication at a short distance in his right thigh and hip, however, this became suddenly worse, waking him out of asleep at approximately 11 p.m. last evening.  He presented to Harrisburg Emergency Room last night approximately 1 a.m. and was transferred here, anticoagulated, motor intact with mild sensory deficits.  At that time, I evaluated in emergency room.  His cap refill had improved, however, still sluggish and no Doppler signals are obtainable on the right foot.  Emergent operation was recommended for thrombectomy and possible angiography.  He understood the risks and benefits and wished to proceed.

OPERATION:  The patient was brought to the hybrid operating room and placed in a supine position.  After adequate general endotracheal anesthesia was achieved and time-out performed, leads placed, the groin and right leg were prepped and draped in a sterile fashion.  A longitudinal incision was made over the previous incision and carried down through the soft tissues.  The limb of the bypass graft was then encountered and dissected free from the surrounding structures.  The femoral bifurcation was dissected free from surrounding structures as was the superficial femoral artery and the profunda femoris.  These vessels felt soft approximately 1 cm beyond their origin; however, there was a firm calcific plaque appreciated at the origin of the superficial femoral artery.  The profunda had a posterior takeoff noted externally.  The patient was systemically heparinized with 5000 units of IV heparin.  After 3 minutes, the aortobifemoral limb was clamped with a Fogarty Hydragrip and the profunda femoris and superficial femoral artery secured with vessel loops.  A longitudinal atriotomy was created and fresh thrombus encountered.  A #5 embolectomy catheter was passed proximally with retrieval of a marked amount of thrombus as well as the meniscus with excellent inflow.  There was granular atheroma noted at the orifice of the profunda femoris artery which had a posterior takeoff and significant granular atheroma and plaque noted at the origin of the superficial femoral artery.  These were gently teased away and endarterectomy performed.  The #4 Fogarty embolectomy catheter was passed approximately 20 cm into the superficial femoral artery with no retrieval clot and vigorous back bleeding.  At this point, once the endarterectomy was completed, a bovine pericardial patch was then used to close the longitudinal arteriotomy.  Prior to completion of the anastomosis, antegrade and retrograde flushing was performed with excellent flow.  The anastomosis was secured and appeared to be hemostatic.  The Doppler signals were present in the profunda femoris artery as well as the dorsalis pedis and posterior tibial arteries.  The incision was inspected for hemostasis and when this was achieved, the wound was closed in layers with running 3-0 Vicryl suture followed by interrupted 4-0 vertical mattress of nylon and a sterile dressing.  The patient awakened from anesthesia and appeared to tolerate the procedure well without immediate complication.  Sponge, needle, and instrument counts reported as correct at the end of the case.  I was present for the entire portion of procedure.

93286, 93287

When a patient comes in for a PPM or ICD replacement, does 93286 or 93287 apply since the patient is here specifically for a change out? Obviously the original device will have to be turned off.  Also, when a patient is pacer dependent, and only the shock portion of the device is turned off, can you still code the 93287?  In documentation where it is clearly documented that the device was turned off, but not specifically written that is was turned back on, is it still acceptable to code twice with a 59 modifier?

ECMO

This is the first time I’m seeing a case done like this…have you seen this before and/or do you know how it’s being coded?  The only ECMO code that I’m aware of is 36822…not sure how to code for the graft part.
Thanks!

PREOPERATIVE DIAGNOSES:
1.  Ischemia of right lower extremity secondary to ECMO catheter.
2.  Need for new ECMO access.

POSTOPERATIVE DIAGNOSES:
1.  Ischemia of right lower extremity secondary to ECMO catheter.
2.  Need for new ECMO access.

OPERATION PERFORMED:
1.  Left groin cutdown, left common femoral artery exposure.
2.  Creation of conduit for ECMO ( 8-mm PTFE graft pulled through a 10-mm Dacron graft to left common femoral artery).
3.  Insertion of ECMO cannula arterial to left PTFE conduit.
4.  Right groin cutdown with right common femoral artery repair with bovine pericardial patch, decannulation of ECMO.
5.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm2, left groin.
6.  Evaluation and placement of negative pressure VAC therapy, less than 25 cm in the right groin.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 100 cc.

DRAIN PLACED:  Bilateral groin VAC.

IV FLUIDS:  400 mL of crystalloid, 2 units of packed red blood cells, 2 units of FFP, 1 unit of platelets.

CONDITION:  Critical.

COMPLICATIONS:  None immediate.

INDICATIONS:  an 18 years old female, who has been an ICU patient.  Her initial diagnosis was infectious mononucleosis, it was complicated by respiratory failure as well as cardiac myopathy as well as liver failure and the necrotizing pancreatitis.  The patient had right ECMO catheter placed for about 2 weeks.  Patient initially had intermittent signals in her right lower extremity, but appears that in past over the span of past 24 hours, the ischemia of the right lower extremity has got worse with mottling of right lower extremity.  Patient did not have great volumes on the right lower extremity.  Therefore, decision was made to proceed with this procedure for decannulation of the ECMO from the right side to improve the perfusion of the right leg and therefore help possible viability of right leg and to get access to the left leg for ECMO.  Patient was a very high-risk procedure.  I explained clearly the multiple risk of the procedure including risk of death.  The patient's parents wished to proceed with the operation.

OPERATION:  After the informed consent obtained, the patient was brought to the operating room, placed in supine position.  General anesthesia was induced by anesthesiologist.  Patient's bilateral lower extremity was prepped and draped in standard sterile surgical fashion.  Anatomical landmarks were marked in the left groin including anterior superior iliac spine and pubic tubercle.  Vertical cutdown was performed in the left groin.  Skin was incised with a scalpel, soft tissue with the Bovie cautery.  There was massive tissue edema with infiltration with vitreous fluid.  Femoral artery was identified, common femoral, superficial femoral, profunda femoral artery were identified.  Vessel loops were placed across these vessels.
Next, a 6-mm arteriotomy was created into the common femoral artery.  An 8-mm PTFE graft was then sewed end-to-side to this arteriotomy with the help of a running 5-0 Prolene in a 4-quadrant fashion.  After the anastomosis was completed, proximal and distal clamps were released, forward flush, backward flush performed.  Anastomosis appeared intact.  This PTFE graft was tunneled inside a 10-mm Dacron graft.  Both of these grafts were then tunneled underneath the skin area and then brought through a separate stab wound distally.  The PTFE graft was then connected to the ECMO arterial cannula.  Arterial cannula was then connected and appeared to have good blood flow through the arterial catheter.  At this point in time, distal stab incision was closed with the help of interrupted nylon in a vertical mattress fashion.  Wound VAC therapy was placed in the left upper groin because of the bulging nature of the wound.  On the right side, a groin cutdown was performed.  Skin was incised with the scalpel and subcutaneous tissue with the Bovie cautery.  The muscles appeared dark in the right thigh area and they were not responsive to Bovie cautery at all.  The right groin arterial catheter was removed.  Fogarty was passed proximally and distally in the common femoral artery as well as in the superficial profunda femoral artery.  There appeared to be no clot.  There were no thrombus.  There was good inflow and there was good back bleeding through both SFA and profunda.  All these arteries were flushed with half saline in an olive-tip.  Next, a bovine pericardial patch was used for performing the femoral patch angioplasty of the common femoral artery with the help of 5-0 Prolene, just before completion of anastomosis, forward flush, backward flush were performed with anastomosis appeared intact.  Anastomosis was completed and the flow was released.  There were palpable pulses in the superficial femoral artery and profunda femoris artery; however, we were not able to obtain Doppler signal in the foot.  However, at this point in time, the patient has been hemodynamically unstable, and we were in the OR for more than an hour.  Since the muscles of the right lower extremity were not contractile, I made a decision not to perform further revascularization of right lower extremity because of the concern that the leg may not be viable at all and the fact that the patient may not tolerate any more surgery at this point in time.  We placed the VAC therapy in the right groin where plan is to follow the right leg for next 24 to 48 hours.  Even after restoration of the blood supply  if her legs remain mottled for next 24 to 48 hours, she may need a high amputation possible above knee amputation, possible  amputation hip disarticulation level.  Wound VACs were placed and the patient was transferred back to Intensive Care Unit in critical condition.

Lung biopsy and thoracostomy

I have a patient who had a lung bx at 13:05. At the time of the bx, he had a large pleural effusion. Following the bx, he developed a hydropneumothorax which resulted in the low oxygen saturation. The patient was brought back to the angiography suite for placement of chest tube. Because of his effusion as well as pneumothorax, a decision was made to place two cathers, one for drainage of the effusion (right lower pleural cavity) and one for the drainage of the pneumothorax (upper pleural cavity) at 17:53. DOS - 08/11/11 Coded as: 32405 - lung bx 77012 - CT guidance 32551 - thoracostomy tube 75989-26 - imaging guidance for tube 32551-59 - 2nd thoracostomy tube 75989-26-59 - 2nd imaging guidance for tube What would be the proper modifiers in this scenario?

36147

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. d :)