Ask Dr. Z

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 :)

47552

Dr Z: Would a brush biopsy of the common bile duct be coded 47552 or 47553? Thank you.

33210

A patient presents with an infected pacemaker system. The patient's system is completely removed, but the patient is pacer dependent, so temporary pacing is warranted. Instead of using a typical temporary pacing wire with booker box, the provider takes the patient's old generator, and uses it as the temporary pacemaker generator by externalizing it (taping it to the patient's chest). The patient will return in the next couple of days for reimplant with a completely new system (new gen and leads). Would you bill 33210 for this procedure, or go unlisted with 33999?

3-D reconstruction with echocardiography

Dr. Z, Can you charge 76376 with 93306? Our echo department is charging this #D reconstruction charge. I get an edit stating "Check base procedures". Is 76376 only to be used when appropriate for ultrasound and not doppler procedures. Michelle

Ultrasound and CT guidance

Dr. Z, We had a patient at our hospital that was scheduled for an ultrasound guided renal biopsy. After prepping the patient, the ultrasound imaging was unsatisfactory for biopsy so the patient was moved to CT where the biopsy was performed. I now have both departments trying to submit charges for this biopsy. I believe that we should only code for the CT guidance (77012) and 50200. Is this correct? Should we also be using the code 76942-74? Thanks for your help. Chris McCoy

ICD-9 code for endocarditis of the aortic, mitral and tricuspid valves

Please do NOT include any actual patient medical records with your question. We use ICD9 Code 424.0 for Mitral Valve disorder, 424.1 for Aortic Valve disorders and 424.2 Tricuspid Valve disorder., But our doctors want Endorcaditis of the Aortic, the Mitral and Tricuspid.Is theres such a ICD9 code for Endocarditis of the Aortic Valve, Endocarditis of the Mitral Valve and Endocarditis of the Tricuspid. Please Help. Thank You!

61624

Hi Dr Z, My doctor treated a very large right temporal lobe AVM. He selected and treated 2 separate vessels(supraclinoid and middle meningeal arteries)which supply the AVM. He wants to code for both arteries coiled – but since both vessels supply the same AVM – I was thinking it would be considered one surgical sight and he should only charge 61624,75894,75898 one time. Thanks for your help!

36245

Dr. Z, My interventionalist has done a left lower extremity angiogram using right radial artery access and selective catheter placement into the left common iliac artery. I feel 36245 and 75710-26 are appropriate from a contralateral femoral access perspective but I am not sure with the right radial access. Your help is appreciated. thanks, jeannette albert jalbert@tulane.edu

AV graft revision followed by graft relocation

Please do NOT include any actual patient medical records with your question. Dr.Z, We have a patient with upper extremity autogenous AV graft came with graft malfunction. open thrombectomy and open PTA performed then residual stenosis noted and decided the graft is not amenable to revision. So created new AV fistula in the same extremity basillic vein to brachial artery. My question since they are not using the graft can we still use 36833 and 75791 for the graft procedures along with 36821? Please advice. Thanks

37191

Please let me know how you would code this scenario. Patient has an an existing IVC filter in place, but has a new pulmonary embolism. There is a filling defect of the right renal vein on a CT. Plan is to evaluate and place a second IVC filter is needed. The right renal vein is selected and venography is performed. Patien has a free floating clot in the right renal vein. Previous filter is preventing the clot from exiting the vein. A second IVC filter is placed above the level of the renal veins. Would you use anything in addition to 37191?

Mitral valve intervention 0256T

Our cardiovascular group has begun using transcatheter mitral valve-in-valve implantation for treating mitral paravalvular leaks in patients with failing bioprosthetic valves. Would it be correct to use 0256T for this procedure? Thanks

Bilateral upper and lower extremity non-invasive venous imaging

Please do NOT include any actual patient medical records with your question. Our Doctors did Both a Venous Study Bilateral of the upper extremity and an Venous study Bilateral of the Lower extremity. 93970-26 Can we bill for both using same code twice and do we need any additional modifier besides the 26 to defferntiate?

37201

Could you please advise on changing overnight thrombolytic catheters? Pt had popliteal vein accessed for thrombolytic yesterday 37201,36140,75986-26 for thrombus in the femoral vein, IVC and iliac veins. The next day dr removes EKOS cath for new brite tip sheath and leg and venal caval gram were performed. 75898-26, do I charge for the cath change also? 35900? PTA was perfromed of the external, common iliac, and common femoral. So that would be just one venous angioplasty of 35476-75978-26? Would the defining difference be whether they kept the thrombolytic going to be able to charge for cath change? Thank you so much for your help!

Differences between 76937 and 76942

Can you elaborate please on when it is appropriate to report codes 76937 and 76942? Can these codes be reported by both the hospital and the physician when ultrasound is used to to locate vascular access? From the facility side, we report 76937 when placing central venous access devices, such as dialysis catheters. The Interventional Radiologists also frequently use the Sonosite ultrasound device to locate vascular access during lower extremity diagnostic and interventional cases and fistulagrams. Is it appropriate to report 76937 for the routine use of the Sonosite during cases other than central venous access cases? (Provided that images are saved and ultrasound use is documented in the dictation). The physician coders and the facility coders are trying to be sure that we have the correct practices in places in regards to these codes. Thank you so much!

75630, 75716

Dr Z or Dr Dunn: Our interventional Dr's routinely state that they are bringing the cath to the level of the renals and injecting, I get imaging results ususally of the renals, aorta and the iliacs. They then go contralateral and do selective imaging of the extremity and then do a pull back to site of puncture and preform imaging of that leg as well. Is 75625 & 75716 approriate on this one cath position at the level of the renals or is 75630 & 75716 the more appropriate code combination. This is all for a base study and no medical indication is given for further exam after base study. Thanks for your guidance in advance.

G0278

You have written much about G0278 amd G0275. I understand how to code for these and when to use it. However, I have an MD that codes for this but the indication for Cath does not address PVD. Wouldn't you have to mention this in the indication for Cath?

Follow-up angiography following cerebral aneurysm embolization

Please do NOT include any actual patient medical records with your question. DR Z I have a general question about Follow-Up (75898 ) charges. We coiled a cerebral aneurysm. Nine coils were placed into the aneurysm but only the last 2 were deployed.The other seven were removed because the DR did not like their placement. After each placement a follow-up angio was performed. Do you charge 9 follow-up's or only 2 for the 2 coils that were leftin for the embolization? I say you only charge Follow-up for the coils that actually embolized not the ones that were removed. TY

37799 for carotid psuedoaneurysm stent graft

I'm not sure what stent code to use. Pt. was involved in a motor vehicle accident,sustained a pseudoaneurysm of the right carotid artery.A VIABAHN stent was placed.Our facility is not part of a Class B IDE study.This is a non medicare pt. I'm thinking either 61616(without distal embolic protection or unlisted code 37799. thank-you.

AXERA access device

I’m just wondering if you might have any information on coding for the AXERA access device. The company says they have no reimbursement code at this time and that many places are using regular closure codes to show that a device was used. (G0269 with C1760)
In your travels, emails, etc – have you come across this device or questions about the device? It’s actually an access device for your arterial stick that makes manual pressure hemostasis easier and quicker – so I would have an issue using G0269 myself.
We are trying to determine if there is a way to offset the cost of the device before bringing it into our lab.

Thanks so much for your time and any assistance you can give me,

Renal Angiography 2012 code recommendation

I hope is well!  I need your assistance on the coding recommendation of a Renal Angiography, case example:  RT Renal, superselective in to multi branches and LT Renal main renal , only.  My thoughts are to code both unilateral codes to support the service provided 36253–Rt  and 36251-Lt.  Would this be correct?

76937 and 37220 - 37235

I thought I had read before that 76937 can be used for revasc. Procedures (37220, etc…)  but since those codes are not listed as a primary procedure for 76937 (at least not that I saw), how do I get around that?  I checked Encoder and the 37XXX codes are not listed as appropriate primary procedures for 76937.  I have a case where the 76937 is documented but got a denial for being an add-on code.

Nephroureteral stent with ileal conduit

With the changes in the rules for coding nephroureteral stents earlier this year,  I’m a bit confused though. In light of the recommended changes,  I believe that I would code ( report below) the left side with CPT 50393 and 74480 even though it involves an ileal conduit. Correct?

The right side is where I’m a bit confused. This side also involves an ileal conduit. Is this now correctly coded with CPT 50398 and 75984? TIA for a timely response!


Reason For Exam
bilat convert perc neph convert to NU STENT PLMNT
Report
PROCEDURE: Bilateral nephroureteral stent placement

CLINICAL HISTORY: 61-year-old male with a history of bladder cancer with ileal conduit reconstruction.  Hydronephrosis was subsequently diagnosed and bilateral nephrostomy tubes were placed.  He now returns for internalization.


FLUOROSCOPY TIME: 14.7 minutes

TECHNICAL DESCRIPTION: The patient was placed in the prone position.  The indwelling nephrostomy tube areas were prepped and draped in a sterile fashion.  Initially, dilute contrast material was injected through each of the nephrostomy tubes.

The left-sided nephrostomy tube was removed over a guidewire.  After advancing a guidewire through a hydrophilic catheter into the ileal conduit, an 8-French internal/external drainage catheter was advanced over the guidewire until the pigtail portion lay within the ileal conduit with proximal sideholes along the ureter.  Contrast was injected to confirm position.

Attention was turned to the right-sided nephrostomy tube.  Again, following infiltration of the soft tissues with 1% lidocaine, the nephrostomy tube was removed over a guidewire.  Guidewire and catheter technique were used to traverse the anastomosis into the ileal conduit.  However, the internal/external drainage catheter could not be advanced across the stenotic anastomosis.  As a result, a 5-French pigtail catheter was advanced over the guidewire across the anastomosis and left with its pigtail portion within the ileal conduit.  Over a separate guidewire, an 8-French nephrostomy tube was advanced and left with its pigtail portion in the dilated right renal pelvis.  Contrast was injected to confirm position.

The catheters were flushed, fixed to the skin, and left attached to gravity drainage.

The patient tolerated the procedure well and there were no immediate complications.  He was later transported back to his ward in stable condition.

DIAGNOSIS:

1.  Successful internalization of the left percutaneous nephrostomy tube for an 8-French internal/external nephroureteral stent.
2.  Although an internal/external stent could not be placed on the right side, a 5-French pigtail catheter was left across the right-sided anastomosis to the ileal conduit.  In addition, an 8-French nephrostomy tube was left in the right renal pelvis.
3.  A tight residual stenosis is noted at the right ureteral implantation anastomosis.
4.  No definite stones were seen on this examination.

PLAN: The above findings were discussed with the referring team for operative planning

Treatment of ostial stenosis of common iliac and external iliac stenosis

Hi Dr Z/Dr Dunn, I have a question regarding the coding of an anigoplasy & stent placement of an ostial stenosis of the common iliac artery in addition to angioplasty & stent placement of external iliac arterty stenosis. My question is, how would the Ostial common iliac stenosis intervention be code-a aortic stent Or a common iliac stent 37221? I don't see a code for an aortic stent so presumably one could code 37221 & 37224(ext iliac stenosis) thank you.

Reprogramming pacemaker on day of HIS ablation

Would you code for reprogramming (to DDDR w/ mode switched on) same day after HIS ablation/93650? with the peri-procedural code? I haven't been because it seemed like part of the procedure...after creating HB the pm would need to adjusted. thanks for the info, appreciate it.

3-D reconstruction and MRA

Dr. Z: I am aware that in order to bill CTA codes, 3D reconstruction would have to be performed and documented. 2D reconstruction is insufficent. Does this same rule apply to MRAs? I have not seen any instructions/directives that indicate 3D is required, but this is now being questioned by some coders. Thank you very much for your assistance.

Ultrasound for nephrostomy with no hydronephrosis found

How would you code this? HISTORY: The patient is an 80-year-old female with suspected left obstructive nephropathy. She is referred for percutaneous nephrostomy. Prior to the procedure, ultrasound examination of the kidney was performed to localize the dilated calyces. No significant hydronephrosis was evident. The patient is afebrile. Findings were discussed with Dr. Rabon. It was elected to forego percutaneous nephrostomy at this time. Thanks

Venogram through existing catheter

A patient that is receiving long-term antibiotics via peripheral IV is brought to the vascular lab due to suspected subclavian vein stenosis. The pre-existing peripheral IV is injected with contrast to evaluate the entire upper extremity to the SVC. We are reporting 75820. The question is, can we also report 36005 for the injection, or is that not reportable because there was no catheterization involved on this DOS?

Ultrasound guidance and IVC filter placement

If an IVC Filter is placed via femoral access (37191) and a non tunneled central line placed via the internal jugular (36556) using ultrasound and fluoro guidance, would it be appropriate to report the guidance for the central line with -59, or is it bundled into the filter placement?

HERO graft insertion and device code

What should we charge for HERO Graft insertion? Unlisted or is there a code to discribe the procedure? Thank you!

Pipeline, 61624

Should treatment of an intracranial aneursym with a flow diverter be coded as an intracranial embolization or a stent placement (61624/75894 or 61630)? The device seems to be considered an methof of embolization in some the literature I have found online about them but the device is a stent, correct?

Observation consult visits

Please do NOT include any actual patient medical records with your question. We need clarification on correct Observation Consult Codes and Subsequeent visits in Observation status for Medicare and Medicare Replacement Plans. For Obs Consult for Medicare Patients It is correct to use 99201-99204 or 99211-99215 if is an stablish patient in the onservation Hospital setting. For Observation Subsequent visits for Medicare and Medicare Replacement Plans is it correct to use 99213-99215 as Consulting Dr's., if Admitting Dr.99224-99226. Can You please clearify if this is correct if not can you advise. Thank You

Renal calyx diverticula imaging

Following informed consent and verification of the correct patient identity and planned procedure, the patient was placed in the prone position and the right flank was prepped and draped in the usual sterile fashion. Under ultrasound guidance, a 4Fr Micropuncture set was used to access the patient's calyceal diverticulum. Contrast was injected and spot film imaging was performed. Over an Extrastiff wire, an 8.5Fr Dawson Mueller Drain was placed. The pigtail was formed and locked. The catheter was sutured to the skin and placed to external drainage.

Clear fluid was returned from the diverticulum. The rest of the collecting system was not seen in contrast injection.

INTERPRETATION:
1. Successful percutaneous drainage of the right kidney calyceal diverticulum as described.


Would you consider this a 74475/50392?

Thanks!

Left heart catheterization with failed stent placement

Please do NOT include any actual patient medical records with your question. Question about failed stents Chronic total occlusion of the left anterior decesending, which is unsuccessfully crossed percutaneoulsy due to the inability to see the origin of the occlusion. Successful deployment of StarClose device. Cardiac catherization reason for procedure: Continued angina despite maximal medical therapy. How do I code the cath and the failed stent? The cath is a LHC. Thank you Marchelle Cagle 205-327-7728

Clarification of ZHealth Newsletter on imaging subclavian anastomosis

Can you please clarify why code 36200 is reported for the following from your July 17, 2012 newsletter. I need help with the anatomy as it seems that access to the axillofemoral graft to the subclavian wouldn't involve the aorta? Thank you very much! Coding Question "The physician cannulated the axillofemoral graft at the level of the umbilicus. The catheter was advanced to the subclavian artery where an arteriogram was performed. Following this, runoff angiography was performed at the subclavian anastomosis. The runoff showed the fem-fem anastomosis, the SFA, CFA, PFA, and popliteal artery to be open and that there is two-vessel runoff in both calves.  How would we code this?"

TAVR

Hi Dr Z, I hope you can help me with this coding question. I realize that the TAVR is coded with 0256T. Would it be appropriat to charge for the femoral cutdown with 34812? What about the subclavian cutdown for the bypass and can we charge for the temp pacer? PROCEDURE: Transfemoral aortic valve replacement (TAVR) Procedures: Femoral artery and vein sheath insertions retrograde. Left common femoral artery surgical exposure and cutdown for vascular access. Placement of a 5 French transvenous temporary pacing electrode right ventricular apex via right femoral venous access. Initiation of cardiopulmonary bypass via right subclavian artery and left femoral vein. Implantation of a transfemoral aortic valve (TAVR). Application of a vascular hemostasis closure device (Angio-Seal), right common femoral artery. Thanks for any help you can provide.

34802

Please tell me how you would code this case? Is there a code for the contralateral limb? or is it included in the 34802. we placed 2 Perclose devices after accessing the right common femoral artery. We then placed a 7 French sheath in each common femoral artery and then advanced an angled guidewire into the right common femoral artery, up into the distal abdominal aorta. With this in place, we then used a 5 French pigtail to perform our first aortogram and runoff. With the first aortogram and runoff, we identified the takeoff of the right and left renals. We did have some overlapping on the left side with the inferior mesenteric artery. It required 2 extra aortograms with 1x magnification to fully delineate the takeoff of the left renal. Once we had this in place, we at this time changed our II to a craniocaudal angle of 15 degrees. With this positioning, we fixed the bed, fixed the II, and then introduced the main body device on the left side over a stiff Amplatz wire. With the main body device introduced, we selected out a 36 x 20 x 166 bifurcated main body device. We advanced this into the distal abdominal aorta just above the renal arteries. Once we were satisfied with this placement, we began the deployment. We deployed the device down to expose the contralateral limb and held it in place. We then took one more selective aortogram at the level of the renal arteries and noted that the device was in good position. We then removed our pigtail from behind the bifurcated device using an angled wire and then exchanged out the pigtail for an FR4 catheter. The FR4 catheter, however, with the angled glide could not be used to cannulate the contralateral gate. We therefore switched the FR4 to an MPA and with the MPA 5 French catheter, we were able to cannulate the contralateral gate with the stiff-angled glide. With this done, we then exchanged out the MPA for a 5 French pigtail. This was brought into what was seen to be the graft body. We were then able to spin the pigtail nicely and then injected approximately 10 cc of contrast. We could see very selective filling of the graft and then down the contralateral limb and then back up into the closed left iliac limb. Satisfied with the placement, we then brought in the contralateral limb. We selected out a 16 x 20 x 124 Endurant contralateral limb. This was positioned nicely over a stiff Amplatz wire and deployed. Once this was completed, we then released the proximal renal fixation and then withdrew our graft on the left side so as to complete the deployment. We then removed our MPA device and brought in a Reliant balloon from the right side. We ballooned proximally. We ballooned the gate and then we ballooned the distal iliac components on the right to obtain a good seal. We then brought the balloon to the left side and again ballooned proximally and distally on the left iliac limb. Once this was completed, we performed our aortogram with runoff. We noted that we had a good proximal seal initially but then had either late, Type 1-A endoleak or a Type 2 endoleak proximally. We had good sealing at the gate and good sealing at the distal iliac limbs. We then brought the balloon back in and inflated once more just above the graft sitting at the renals and then just below it so as to get a much better seal proximally. We felt that with this aggressive ballooning, we optimized our seal and then we repeated our aortogram. We noted a much better control and had a very tiny, Type 2 endoleak from the lumbar artery. With this completed, we then removed our devices, deployed our Perclose sutures, and got good hemostasis. We gave the patient a total of 80 mg of protamine. Of note, during the course of the procedure, we gave him a total of 14,000 units of heparin and had the ACT above 250 at all times. With the completion of the procedure and the administration of the protamine, we checked for pulses. We had good distal pulses. We had no bleeding at our access site.

33210 with 92980

Per the Q&A below code 33210, should not be billed when done with an intervention. Is that because the TVP was removed at the end of the intervention? Has this guideline changed since 2010? The doctor states that it takes additonal work and time to insert the pacemaker and he should be getting reimbursed for it. If we cannot bill 33210, when done with an intervention, should we append modifier 22 to 92980/92982 etc? Also, what if only a diagnostic heart cath/coronary angiogram is being done and the pt has episode of bradycardia. Can 33210 be billed? Date: Friday, April 30, 2010 Question: Please advise when to report temporary pacemaker with modifier -59. The Q & A's that I reviewed (#325 & 1554) do not match my billing scenario. Patient is admitted for complex percutaneous coronary intervention on three vessels (third redo). LVAD is inserted into the left ventricle which caused a complete heart block. Temporary pacemaker was then inserted. At the completion of the complex procedure, the LVAD was removed along with the pacemaker. Can 33210 be reported with modifier -59? Thank you Answer: Again, we would not recommend using 33210 as it is considered part of any coronary artery intervention. The use of a Percutaneous non-transseptal LVAD, such as Impella, is 33999. Dr.z Thank you for all of your help.

Balloon deployable stent as an angioplasty

Dr Z, If a doctor is using the balloon expandable stents, can he bill for angioplasty and stent? Thank you, Suzan

Pocket revision at the time of generator change

Z-Health Diagnostic and Interventional Cardiovascular Coding Reference book, page 406 number 9, states "Do not code pocket revision during generator change to accommodate a different shaped or larger sized generator. This is considered part of the replacement, just like a pocket creation is considered part of an initial insertion of a new device". Per the above, codes 33262,33263 and 33264 should not be billed with 33223 if done only to change the size of the pocket. What if the physician had to remove scar tissue or debride the pocket at the time of ICD replacement, could we then bill for 33223? Per the CCI edits I can bill 33223 with the replacement codes and add a 59 modifier to 33223. Please help clarify this because the physicians want us to bill the 33223. Thank you

diagnostic at time of intervention with prior color flow doppler study

Please do NOT include any actual patient medical records with your question. Your guide states that diagnostic imaging (when medically necessary) is separately billable when done at the same time as LE revascularization if not recently performed but not for confirmation of a known lesion seen on prior cath-based angiograpy,diagnostic CTA or MRA. My question is, since I am not familiar with alot of these tests, if the patient had a vascular study done about a month prior and imaging was obtained using gray-scale, pulse wave and color doppler, would the diagnostic imaging at time of revascularization still be seperately billable since they had the vascular study? Would it make a difference if patients symptoms had changed or condition worsened? I'm just unclear in these kinds of circumstances and would appreciate any assistance you may be able to offer.

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.

Arterial angiography during dialysis fistula/graft evaluation

Is this one where you would use 75791 and a selective cath. Code?  36215?
Thanks!

TECHNIQUE: The risks, benefits and goals of dialysis fistula/graft evaluation with possible stent placement and possible angioplasty under conscious sedation were discussed with the patient prior to the procedure. The patient desired to proceed and signed informed consent. The patient was placed supine on the angiography table. The left upper extremity was prepared and draped in the usual sterile fashion. 2% lidocaine with epinephrine was used as a local anesthetic. Access to the fistula was obtained using US guidance and micropuncture technique directed toward the arterial inflow. Evaluation of the fistula outflow was performed with digital subtraction venography to the level of the right atrium. Reflux imaging of the arterial anastomosis was also performed. An angled glidewire was inserted and passed into the radial artery above the anastomosis, under direct fluoroscopic observation. A Kumpe catheter was inserted, and digital subtraction angiography of the radial artery was performed.The catheters and wires were withdrawn. Hemostasis was obtained with manual compression. During the process of obtaining hemostasis, a hematoma formed around the fistula, and extended along a portion of the fistula causing compression of the outflow. This resulted in a decreased thrill and increased fistula pulsatility. Additional pressure was held. The hematoma was massaged to soften it. Repeated US evaluation of the fistula was performed, demonstrating decreasing mass effect on the fistula. There was also an improvement in the exam, with increased thrill along the fistula. The patient tolerated the procedure well and exited the angiography suite in stable condition.

FINDINGS: There is brisk flow through the brachial artery-basilic vein fistula. The outflow is widely patent. The arteriovenous anastomosis is widely patent. There is sluggish distal flow in the brachial artery distal to the anastomosis, consistent with a steal phenomenon. US evaluation of the fistula after removal of access demonstrates a hematoma along the fistula, with mass effect on the fistula. The radial pulse remains strong.

IMPRESSION: 1.  Widely patent left upper arm brachial artery-basilic vein fistula. Difficulty accessing the fistula may be related to its depth.
2.  Finding consistent with a steal phenomenon. This corresponds with patient's complaint of poor circulation to his left hand, which is more pronounced during dialysis.
3.  Post-procedure peri-fistula hematoma as described above.

0079T

If bilateral renals are stented during a AAA snorkel procedure, would you code the 0079T x2/0081T x2?  It say for “each visceral vessel” 36245 x2.

Catheter placements outside of the zone of revascularization

If I access RCFA, go up and over to left superficial femoral and image then pull back to right iliac and fix – do I get my 3rd order cath placement for LSFA via RCFA even though I fix right iliac? A million thanks

Tikosyn EKG study

Dear Dr. Z, Thank you for all of the valuable information you have given me in the past, it is so nice to be able to turn to an expert whenever I am having difficulties. My question today is about a Tikosyn EKG study. This has been described to me as a series of EKGs at defined intervals of ½ to 1 hour with a medication given to see the reaction on the EKG. I think this should be coded as an unlisted procedure, CPT 93799. Is this correct or is there another CPT code I should be using, or should I not use any CPT code? Thanks in advance for your help. Deb Patterson, RHIT

Roller ball study of baclofen pump

What should I code when the patient has a baclofen pump and the physician fluoros to watch the balls inside move? He takes pictures in a timed sequence. There is no needle stick. He calls it a roller ball study.