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Using an existing graft to extend with new PTFE

Dr Z, Patient had left upper extremity brachial artery to axillary vein graft. Because of problems MD had to create an axillary artery to axillary vein av graft. Later brought back the patient ligated graft at the arterial anastomosis then tunneled new PTFE graft with anastomosis and then to the existing graft. He replaced more that 50% of the exsiting graft. Would this be considered just a revision or would you could also for the PTFE? Thank you, Suzan

Diagnosis codes for cardiac cath following tetralogy of Fallot repair

Dr. Z,

I need help with diagnosis question.  When the patient comes in for heart cath (TOF repair in 2009) now diagnosis are RPA stenosis, MPA stenosis and severe pulmonary regurgitation. Performed both PTA of pulmonary artery and Pulmonary valve.  Since pulmonary stenosis also part of TOF is this still considered TOF even though it is repaired? Sometimes the patch/Conduit has stenosis so is this complication -996.72? Or congenital Pulmonary valve stenosis? Can we code 746.09 and V13.65?

Wire localization of a lung nodule 32999

Dr Z, What would be the most appropriate code for a wire localization of a lung nodule? This is a procedure performed very similarly and for the same reason as a pre-op wire loc of the breast, except it is in the lung. We are thinking 49999. Thank you, Debbie

ao/ro 75630 and 75710

Please do NOT include any actual patient medical records with your question. Dr. B performed sugery for severe claudication of left lower extremity. The operation include Aortogram with runoff, selective angiograms of left common femoral, superficial femoral,poplitealand peroneal arteries. Then he perfomred angioplasty of left tibioperoneal trunk, angioplasty and steneting of SFA. I know how to report stent and angioplasty, but I need confirmation of reporting diagnostic S&I codes. I would report 75630-26/59 and 75710-26/59 or I should report 75625-26/59 and 75710-26/59 Please advise, Renata

MRI of the prostate, MRCP only

1. (Medicare account) Would it be appropriate to bill for an MRI of the pelvis when imaging of the prostate is done with or without contrast if no other organ structures are imaged or reported. Would it be appropriate to append a modifier -52 if the only findings are related to the prostate since complete imaging of the pelvis was not performed. 2. (Medicare account) Would it be appropriate to bill for an MRI of the abdomen if the procedure performed was an MRCP without 3D rendering. The findings are only related to the bile ducts and gallbladder, the other organ structures are not mentioned. Would it be appropriate to append a modifier -52 if the only findings are related to the gallbladder and bile ducts since complete imaging of the abdomen was not performed.

PICC placement 36569

Dr. Z I would greatly appreciate your guidance with the following situation. In our hospital facility we have PICC line Rns that place PICC lines with fluoro guidance (36569, 77001). The PICC team performs PICC placements in a special procedure room and has an agreement with the radiologists to use fluoro. Occasionally the PICC RN cannot successfully advance the line and a radiologist is called for assistance. The radiologist will go to procedure room and advance the PICC line under fluoro. Is it appropriate for the Radiologist to charge for a PICC reposition (36597, 76000) or for a PICC placement(36569-59, 77001-59)? Does the PICC Team need to modify any of their charges? I was told we could not bill for a reposition during an initial picc placement. Thank you for your assistance.

37221

Please do NOT include any actual patient medical records with your question. Would you be able to clarify for me how to report the two separate common iliac stents (right and left) with independent/separate femoral access for each. 37221 37221-59 Or 37221-50 Thank you in advance for your help.

Limited TEE

In regards to 93312 - is there a standard for bare minimum required findings? The only finding is "no clot found on TEE prior to ablation", would you add a modifier or not bill based on these limited findings. In regards to ablation, we do a follow-up TEE , usually to r/o pericardial effusion prior to discharge(usually next day). Many times the findings state "no effusion". Is this billable and what code would we use? Lastly, still in regards to ablations. How do we correctly bill 93462 transeptal puncture with ablations? *We have some payers reimbursing only $4-5,ooo when we use 93462 with 93651 and 93652. If we don't submit 93462 on the bill, we have the same payers reimbursing $45,000+. Many thanks for your time and assistance! Lori Sprenger

Neurointervention 37215

Would you please clarify your statement regarding diagnostic angiography prior to intervention of carotid artery? On page 324 #11 it states "do code" for this IF not recently performed, if there is a change in clinical status or vascular distribution distant from site of intervention. On page 325 #26 it states diagnostic imaging is bundled into intracranial, carotid an vertebral stenting (specifically in our case we are looking at 37215 for carotid stenting w/diagnostic angiography during same session prior to procedure with no previous diagnostic angiogrpaphy). Under what scenario would you be able to bill for the diagnostic angiography at time of intervention? It doesn't seem to make sense. Thank you for your help in clarifying.

PET non-covered codes

In what circumstances would you use the following codes? 􀂃 Level ll Codes G0219, G0235, or G0252 for Medicare non-covered indications. Thanks

37224, 35371, 37224-53

could you tell me how you would code this for physician billing…this is what I'm coming up with from what's in the note

35371
37224-51
36246-59-51
75710-59

thanks!

OPERATION PERFORMED:
1.  Right common femoral endarterectomy.
2.  Right superficial femoral artery angioplasty with 5 mm x 6 cm balloon.
3.  Third-order selective catheterization of the left superficial femoral artery.
4.  Aortoiliac angiogram.
5.  Bilateral lower extremity arteriogram.

ANESTHESIA:  General endotracheal anesthesia.

INDICATIONS:  This 71-year-old female with a history of tobacco use and bilateral lower extremity claudication presented for a second opinion regarding her lower extremity claudication in trying to avoid bypass surgery.  I reviewed her angiograms and we performed a duplex and I felt that endarterectomy of the common femoral artery with concomitant angioplasty may be of benefit to her.  She understood these 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, the right groin was prepped and draped in a sterile fashion.  Via an oblique incision, the soft tissues were divided and the common femoral, profunda femoris, and superficial femoral arteries were looped gently with vessel loops.  There was a very focal, approximately 2 cm area of near occlusive plaque palpated in the mid common femoral artery.  The patient was systemically heparinized with 5,000 units of heparin.  After 3 minutes, the vessels were controlled and a longitudinal arteriotomy created in the common femoral artery.  There was a 2 cm length plaque, near occlusive which was endarterectomized.  A bovine pericardial patch was then anastomosed with 5-0 Prolene suture and the anastomosis was completed.  Seldingerneedle access was then gained in an antegrade fashion through the patch and I was able to traverse the chronic total occlusion of the superficial femoral artery.  A 6-French sheath was placed and with the 5-French Glide catheter, and 0.035 angle-tipped stiff Glidewire, I was able to gain true lumen reentry in the mid superficial femoral artery as confirmed by arteriography.  Balloon angioplasty was then performed with a 5 mm x 6 cm balloon with excellent results.  The patient had 2-vessel runoff via the peroneal which reconstituted the posterior tibial artery.  The anterior tibial artery appeared to occlude in the mid calf.  This sheath was then removed and the wire access closed with an interrupted 5-0 Prolene suture.  Next, retrograde access was obtained in the patch and aortoiliac angiogram performed showing no significant occlusive disease.  With an 0.035 angle tipped stiff Glidewire, I cannulated the left common iliac, external iliac, and common femoral artery, and the 5-French Omniflush catheter was advanced over the bifurcation with the tip positioned in the distal left external iliac artery.  A left lower extremity arteriogram was then performed showing a flush occlusion of the superficial femoral artery.  This was reconstituted in the distal SFA just proximal to the <_____> popliteal artery and continued down below the knee with again a 2-vessel runoff essentially via the peroneal and posterior tibial artery.  A 6-French 45 cm Destination sheath was then placed with thetip positioned in the distal common femoral artery on the left.  With the Quick-Cross catheter and 0.035 angle tipped stiff Glidewire, I was able to cross the occlusion; however, we had difficulty getting back into true lumen.  At this point, I felt that we would continue with medical management of the patient and see how things went with regard to her left leg from a clinical standpoint.  At this point, the sheath was then removed and the patch repaired with figure-of-eight 5-0 Prolene suture.  The incision was inspected for hemostasis and when this was assured, the layers were closed with running 3-0 Vicryl followed by 4-0 Monocryl and Dermabond to the skin.  Patient was awakened from anesthesia and appeared to tolerate the procedure well without immediate complication.  Sponge, needle, and instrument counts were reported as correct at the end of the case.  I was present for the entire portion of the procedure.

diagnostic catheter placement followed by intervention that includes it

Dr Z and/ or Dr Dunn: I think I am confusing myself but want a little clarification. Cath placements for diagnostic purposes and then cath placements for the purpose of the intervention in the cerebral artey(s) can be billed/coded seperately correct? This would be in the same setting/time. I am getting conflicting information and want to check myself. Thanks

37201 vs 37184

Dr Z or Dr Dunn: Our Cath tech is charging for a 37184 and 37201 of the Anterior Communicating Artery. I am not sure that the below docummentation is enough to support the use of both CPT codes - I am inclined to go with CPT code 37184 only. Your advice would be greatly aprreciated. Documentation reads as - "I assembled a Prowler Select Plus and slecetively catherterized the ACA, and with the Prowler Slect Plus we navigated and identified the area of occlusion, and we crossed the lesion. There is evidence of stasis distally. Tha main trunk was reopened by passing the catheter through. We infused a total of 3mg of TPA on the ACA to prevent further stenosis, and we infused 1 mg of Reopro. There were no Complications." Thanks in advance for your advice.

Please do NOT include any actual patient medical records with your question. Hi Dr. Z, I am looking for assistance with this case. I am thinking that I should code 36010, 75827 36005(59) and 75820. I also was wondering about using the modifier 74 since they code not get into the SVC. Initially, the right groin was prepped and draped in the usual sterile fashion. Next, the right common femoral vein was punctured with a micropuncture needle and subsequently a 7 French sheath and catheter and wire combination were then advanced. This was then advanced to the right atrium and attempts were made to pass a wire into the superior vena cava. This met with resistance. Followup contrast injections demonstrated a blind-ending pouch with the superior vena cava seen extending to the right atrium with no reflux of contrast further superiorly. Multiple different catheter and wire combinations were employed and these were all unsuccessful. Next, contrast was injected via the patient's right arm IV while imaging over the central veins. This demonstrated filling of the brachial or basilic vein centrally which is then seen extending to the chest wall where flow then turns inferiorly. No filling of the subclavian or superior vena cava or azygos veins are seen via this right arm injection. It was then decided to abandon this right groin approach. The right neck was then prepped and draped in the usual sterile fashion and the right internal jugular vein was then punctured. Subsequently a sheath was placed. Venogram demonstrated flow of contrast from the right neck which extends to the left subclavian and axillary veins as well as multiple collaterals. No stump of a residual origin of superior vena cava is seen. Multiple different catheter and wire combinations were employed in order to see if we could manipulate into an old occluded SVC. None of these worked and the catheter and wire combination all immediately extended to the left subclavian vein. Thank you in advance for your time and assistance with this request. Respectfully, Cindy

Pelvic drainage

Hello! I recently purchased the 2012 coding charge sheets from ZHealth (which, by the way, are wonderful!!)and had a question regarding the updated coding suggestion for an abscess drainage of the pelvis via transrectal approach (for males). It lists the code as 49021, shouldn't this be 49061 since it is labeled as a pelvic abscess;transrectal approach? I understand that a pelvic abscess could extend into different areas such as the peritoneal cavity, however wouldn't the code depend on what area the catheter ended up in? Example-anterior pelvis and/or peritoneal would be 49021 and 49061 for retroperioneal and/or transgluteal abscess.

Open carotid stent

How would you code placement of a left internal carotid stent with distal protection device via a left common carotid cutdown (due to prohibitive left internal carotid and aortic arch tortuosity)? (Also carotid endarterectomy was prohibited for this patient.) Left carotid and cerebral arteriography were also performed. Thanks so much for your help on this one.

75710 with 75791

Dr. Z, We have an interventionalist, new to our angio suite, who wants to charge either 1) an extremity angiogram-75710, or 2) a retrograde brachial angiogram-75658, when he uses compression on one limb of the AV graft to force contrast into the brachial and/or radial artery. I am unsure that this is correct. 

G0290, DES

The CPT code book lists one CPT code for coronary stent initial and one CPT code for additional - no reference to type of stent used. There are G codes for CMS patients and those state drug eluting stents. My question: do we charge differently based on bare metal stent placement or drug eluting stent placement? We have been told to have charge codes for bare metal stent placement at one price, and another charge code for drug eluting stent placement at a different price for non-CMS patients. Is this correct?

MRI of the breast and MRI guided breast biopsy

Hi Dr. Z, Could you take a look at this for me? Im not sure that i agree with what our department coded. Procedure: MRI is performed both prior to and following intravenous administration of 20 cc multi-Hance. Lateral breast mass is not as well defined as on the prior MRI. An ovoid area od enhancement is selected to be biopised as this is the most closelt approximates the mass seen on prior MRI. The skin is terilized. Local anesthesia is obtained using 2% lidocaine subcutaneously as well as a 1% lidocaine and epinephrine solution to the deeper tissues. Using CAD stream grid localization, the mass in the lateral half of the breast is targeted. Incision is made in the skin and through this incision an 8G vacuum assisted core biopsy not needle is placed and confirmed with MRI. Incision was approximated using a Steri-Strip and a Band-Aid. Patient tolerated the procedure well and was given instructions for post biopsy care. Specimen was submitted to pathology. This is what the department coded: 19103RT 77021 C8908 0159T A9577

Rotational fluoroscopy

How do I code for "rotational fluoroscopy" done as a one year follow up to a CoreValve implantation. No fracture or embolization was found. Thanks

Epidural steroid injection post discectomy

Dr. Z, Our radiologist did a discectomy 62287 and a week later the patient came back in because the pain was not gone. He did an ESI and transforaminal injections. My question is there is a 90 day global for the discectomy. Do I not bill for the ESI and transforaminal injections? Thanks

61630

Hi Dr Z, Need clarification please, our physician is coding a 37184 for a percutaneous transluminal balloon angioplasty of the basilar artery. This was confirmed 99% stenosis of the basilar just distal to the ICA on the right. They obtained a roadmap image of the left vertebral artery and used a Glidewire to position the diagnostic catheter to the distal cervical vertebral artery up to the V4. Wouldn't this be a 61630 and all ipsilateral catheters and angio's included? The final angiographic/impression states: successful PTA of the basilar artery, resulting in interval improvement of caliber of the artery. The P1 segment is seen to fill following balloon angioplasty. Please advise. Thank you in advance.

Working under the same tax ID

We have a group of cardiologists in the same practice working under the same tax ID. If one cardiologist performs a heart cath (93458) and an interventionalist steps into the case to perform FFR (92978), what is the proper way to bill since the interventionalist charges are add-on codes?

OCT of renals

Dr Z, Would you still suggest CPT 93799 for optical coherence tomography of the renal artery at time of stent placement? I know new category III codes (0291T & 0292T) have been created but believe those are for use on coronary vessels only. Thanks.

50382

Dr. Z, Please advise on how to code a removal of indwelling double-J stent and placement of nephroureteral stent. PROCEDURE: This is a percutaneous nephroureteral stent placement with snare retrieval of indwelling double-J ureteral stent under fluoroscopic guidance. Following obtained informed consent via standard flank approach, a 21-gauge needle was successfully introduced into the collecting system of the left kidney under fluoroscopic guidance. Then guidewire exchange was made for a 6-French sheath through which the renal end of the indwelling double-J ureteral stent was successfully snared and the stent was partially withdrawn. Then, through the stent a guidewire was advanced into the urinary bladder and exchange was made for an 8-French 26cm nephroureteral stent secured with internal locking loop mechanism as well as with a 2-0 monofilament suture at the skin entry site. A postplacement nephrostogram was performed demonstrating the stent to be working well and well positioned was obtained for documentation. Scant amount of thrombus in the renal collecting system was noted. The catheter was left open to gravity drainage via a leg bag. There were no complications. The patient tolerated the procedure well. IMPRESSION: Successful removal of indwelling double-J ureteral stent and placement of nephroureteral stent.

Ureteral stent exchange

I received the 4-23-2012 errata. On page 2 of the errata (page 290 in the book)item 14. It says "the patient has both a nephrostomy and a double pigtail stent and both are removed and replaced over guidewires at the same setting use code 50382 for ureteral stent exchange and codes 50398 amd 75984 for the nephrostomy tube change." 50382 is for percutaneous not externally accessible. 50387 is for externally accessible. If there is a nephrostomy tube in already in place wouldn't that make the stent is externally accessible and 50387 should be used? thanks

MRI of the brain and IAC

Dr.Z I did read your 2009 reply regarding brain mri in addition to iac mri, but wonder if there are new edits prohibiting appending 70553/70553-59? is the following dictation sufficient to attach both codes? thank you. MRI Head and IAC w/wo IV Contrast FINAL REPORT Clinical Notes: WORSENING DIZZINESS MRI HEAD: HISTORY: Headache. Worsening dizziness. TECHNIQUE: MRI of the brain with and without IV contrast. Multihance administered by the technologist per PIH protocol. DESCRIPTION: MRI of the brain with and without IV contrast on the 3 Tesla unit was performed demonstrating normal flow voids within the carotid siphons and basilar arteries. No evidence of retrobulbar mass. Suprasellar cistern is intact. Meckel's cave and CP angles are symmetric. Optic chiasm is intact. No evidence of abnormal intracerebral enhancement. Cisternal portions of the fifth nerves are symmetric. Extraocular muscles are symmetric. No acute infarct, mass, or hemorrhage. IMPRESSION: MRI OF THE BRAIN WITH AND WITHOUT CONTRAST IS UNREMARKABLE OTHER THAN PARANASAL SINUS DISEASE INVOLVING THE SPHENOID SINUS. NO CP ANGLE MASS. MRI IAC: TECHNIQUE: MRI of the IAC with and without IV contrast. HISTORY: Dizziness, progressively worsening. DESCRIPTION: The fifth nerves are symmetric. Meckel's cave and CP angles are symmetric. No evidence of acoustic neuroma or vestibular schwannoma. Mucoperiosteal thickening in the sphenoid sinus. No evidence of enhancing masses of the eighth nerve. IMPRESSION: NO EVIDENCE OF ACOUSTIC NEUROMA or vestibular schwannoma. No evidence of intracerebral mass. CP angles and Meckel's cave are symmetric. IMPRESSION: MRI OF THE INTERNAL AUDITORY CANALS IS UNREMARKABLE.

Bill for ReoPro infusion

Dr Z, Need claification on the infusion code 37201 (physician billing). Our physicians administered a total of 10 mg of intraarterial ReoPro to achieve antiplatelet effect, and the injection was repeated after they performed an embolization in the left ICA. It demonstrated excellent filling of the branches in the ica territory including the ACA and the MCA. Can our physicians bill for ReoPro infusion? I thought they couldn't. Please advise. They keep coding for this.

Ultrasound guidance for vascular access

If two punstures are made into an av graft or fistula under ultrasound guidance can 76937 be billed twice if a patency study and permanent us image are obtained?

Spider filter to remove thrombus from the peroneal

Dr Z MD does atherectomy of SFA and then uses a spider filter to remove thrombus from the peroneal. What should he bill? He marked 37203 and 37225. I think 37184 and 37225. Help. Thank you,

NG tube is placed by the radiologist and left in place

I saw the question and answer below. My question is if the NG tube is placed by the radiologist and left in place to feed the patient until they start using the G-tube would you then code the 43752? Question: Hi Dr. Z When we place a G-Tube(49440) we put a NG tube down so we can inflate the stomach. We have been charging 43752, but a person at another hospital said your not to charge that because its part of the procedure. We do pull out the NG when the case is finished. Thank you for your time Answer: 43752 should not be used for a G-tube placement. Code 49440 for G-tube placement includes fluoroscopy, NG tube placement, all guidance and imaging to perform the procedure. Dr.z Revised 02-18-10

Percutaneous placement of a drainage cathter into an anterior abdominal wal

How would you code percutaneous placement of a drainage cathter into an anterior abdominal wall fluid collection? The fluid is located between the abdominal wall and the peritoneal lining. The CT scan prior to this procedure says the fluid collection is adjacent to the inner abdominal wall in the midline and extends inferiorly to the left into the pelvis. There was spontaneous drainage of brown, partially clear fluid from the tube when it was placed. Is it unlisted CPT 49999 and 75989?

Can an add on code, such as 93462, be left off a claim

This is more of a billing question. Can an add on code, such as 93462, be left off a claim if it is causing the main procedure, such as 93651, to be overlooked? Thanks for your time.

37186

Please do NOT include any actual patient medical records with your question. contralateral catheterization of SFA(36247)with ekos lytic catheter infusion (37201, 75896) performed on first day of the SFA; patient returns following day and follow up angiogram (75898) finds occluded peroneal artery and peroneal artery is selectively cannulated and AngioJet Thrombectomy is performed of peroneal artery (37184)---Do we code the catheter selection of peroneal artery (36245)on second day or is it still the same catheter placed on the first day and only 37184 and 75898 would be coded for following day? Thank you.

Difference between a device interrogation and a device programming

Please do NOT include any actual patient medical records with your question. Could you please clarify the difference between a device interrogation and a device programming? When our Docs do a device check,93279-93281 and 93282-93284, I am being told that when the doc does the check he will make changes to the device, i.e. check the impedance level and parameters, to check it and then set the program back to the original setting, and this should be considered a reprogramming, CPT codes 93279-93281,93282-93284. I have also been told that these codes depend on whether or not the doc made changes to the final programming of the device, if he changed it from the original setting prior to the device check. I also was under the impression that If the doc did a check and made no changes to the device, "the final program" that this would be considered an interrogation of the device and to use 93288 or 93289.Your input on this would be appreciated. Thank you! Rick

Documentation of aorta for use of 75630

Please do NOT include any actual patient medical records with your question. Hello Dr. Z, I have a physician who dictates abdominal aortogram performed, along with unilateral or bilateral peripheral angiogram. However, findings start with the iliac arteries and proceed down the leg. Does a description of iliacs support 75625, or do I need to have a description of the abdominal aorta or renal arteries to support 75625? I have been coding 75710 or 75716 unless there are findings describing the abdominal aorta or renals, at which time I code 75625 along with 75710 or 75716. Thanks!

Attachment of an LV lead to an existing generator

If patient presents for replacement of an LV lead with attachment to previously placed BIV ICD generator, is 33244 and 33224 appropriate to describe theses services? I think that since the new revisions have come out to the CRM codes that the definition of "replacement" seems to be gray- some people interpret this as one word describing two actions-removing an old item and inserting a new one, while others interpret this word as meaning just inserting a new item. 33224 seems confusing additionally in this matter as it reads "Insertion of pacing electrode, with attachment to previously placed pacemaker or pacing cardioverter defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator). Are we supposed to assume that the text within the parentheses is discussing removal and insertion of a pulse generator only, or are they inferring that removal of the old LV lead is included in the code? Which way you land on this debate has a heavy RVU impact, as the addition of 33244 adds 15.23 ceus to this case! Please help!

Medicare coverage of sacroplasty

We are trying to determine if sacroplasties are covered by Medicare with the diagnosis of compression fracture (w or w/o osteoporosis/osetopenia). We have had claims denied in the past for medical necessity but we cannot find a LCD or NCD for Michigan indicating what is considered medically necessary. Do you have any information on this?

AV fistula 35476

Please do NOT include any actual patient medical records with your question. Dr. Z, patient has brachial basillic arteriovenous fistula came for fistulogram and PTA. Fistulogram confirmed presence of stenosis in the proximal aspect of the arteriovenous fistula. Is this 35476 or 35475? Thanks

Mechanical thrombectomy on mutliple dates of service

Can I use 37184 per Date of Service. Lets say that a the radiologist does a mechanical thrombectomy on the same patient multiple days (same leg) while the patient is going through thrombolisis infusion.

Thanks,

NCCI edits and children with congenital heart defects

Do you know if there is any place in one of Dr. Zielske's books where it says certain edits do not apply to children with congenital heart defects?  I'm specifically wondering about angiography prior to an intervention.  CPT says the intervention includes all angiography for roadmapping and hemodynamic data, but the physician says this edit doesn't apply if it's a child with a congenital heart defect.   I'm trying to find a place in one of his books to support the fact that 93531 is included in 92997 unless the angiography a true diagnostic procedure as defined by CPT.

CPT says:  Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:
1. No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR
2. A prior study is available, but as documented in the medical record:
a. The patient's condition with respect to the clinical indication has changed since the prior study, OR
b. There is inadequate visualization of the anatomy and/or pathology, OR
c. There is a clinical change during the procedure that requires new evaluation outside the target area of intervention.

Thanks for your help!  Jane

Difference between codes 34201 and 35371 or 35372

I am wondering how this should be coded....we have had many a discussion on the difference between the two codes of 34201 and 35371 or 35372. We were hoping you would be able to clarify the difference. The procedure is as follows: 7 cm incision was made just below the inguinal ligament...dissection was carried distally to the deep and superficial branches of the common femoral artery. A puncture site was noted with clot coming out of it...arteriotomy made through arterial puncture site..clot was removed. Fogarty catheters were placed....no more clot was retrieved. The arteriotomy was closed with a Hemashield patch in both directions with 6-0 Prolene suture allowing backbleeding and forward bleeding before tying the last stitch.

Codes 33225 can be added-on to

Please do NOT include any actual patient medical records with your question. We are using 33264 and 33225 for the removal and replacement for the ICD and the insertion of the CS lead to new device for the upgrade to a BiV ICD system. My concern at this time is that as an add on code 33225 does not show 33264 as a primary procedure code. Is this an error of omission on the part of the AMA?

37221 vs 34900 (dissection with incidental small iliac aneurysm)

A recent comment by a vascular surgeon caused me to research the appropriateness of using Iliac Vascular Repair(75954)vs. Iliac Stent(37221). Ex.1 - A patient developes a dissection in External Iliac Artery during a procedure. Attempt to "tack it up" with angioplasty is unsuccessful leading to a Viabahn covered stent placement. Ex. 2 - A patient presents for stenting of External Iliac and small aneurysm is found when roadmap image is taken. Use a Viabahn covered stent for stenosis and to cover area of aneurysm. The comment was made that anytime you "repair" an iliac regardless of product used - it is 75954. The CIRCC study guide states the codes are specific to the devices and techniques used and to the location of the abnormalities. So does 75954 require a specific device in addition to technique and location? Thank you for clarifying and for your assistance!

Third order selective catheterization of renal artery

Dr Z My question is regarding the new renal angiography codes and embolization. The physician does a right renal diagnostic angiogram from the right main renal artery. He then moves into 3 branches off the main renal artery to embolize a renal mass (37204, 75894, 75898). Although the diagnostic angiogram was from the main artery (36251) should I use 36253 instead since the catheters were moved super-selectively to do the embolization? As always, thank you for all your help.

Replacement of generator and RV lead with repair of atrial lead

Dr. Z, The patient came in for replacement of an AICD generator (dual chamber) due to battery reaching end-of-life and replacement of the RV lead due to there being an increased risk of fractures. During the procedure, it was noted that the atrial lead had an insulation break which was also repaired. With the new Pacemaker/AICD codes, is the advice given on July 13, 2011 still correct - 33249/33241/33220-52 - since the lead repaired was not the same lead that was replaced? Also, wouldn't the 33249 need a 59 modifier based on the NCCI edit that states it is mutually exclusive with procedure 33220? Thanks for your assistance.

76937 with lower extremity revascularization

76937 is allowed to be billed with the lower extremity revasc. codes correct?  Encoder doesn't show those codes as appropriate primary procedures for 76937, so I wanted to verify.  I'm also hitting a billing edit for it because of the prim. code.

thanks!

Foley catheter placement in the cath lab or EP

Can we code/charge for foley catheter placement in Cath lab or EP lab? It's done prior to long procedures in EP. It's done in the Cath lab if the bladder is too full or patient will have difficulty using bed pan after procedure. As always, we appreciate your assistance! Thank you!

Catheter placement at time of SFA intervention

Dr. Z. Can you please provide clarification on the below scenario below: Catheter placement if from a RT femoral access site, catheter is advanced to the aorta, contrast injectected with run off of both extremities. Catheter was exchanged for a SOS 2 cath which was manipulated anegrade in direction and advanced into the SFA. The area of stenosis was angioplastied. Can we use the catheter placement of 36200-59 for the aorta as this is technically another tree as this was retrograde, then physician went antegrade and performed angioplasty. As this has been allowed previously, new literature is only providing generic information stating that a cath placement cannot be charged in addition to intervention. I cannot find anything concrete for documentation to show coders who have this question. Thank you, Tami

KUB

Patient is pre-op for planned gastric bypass. 74241 was coded. The question is whether 74246 would be more appropriate. Coder is questioning with KUB. No diagnostic info regarding kidney/ureter/bladder is given, but in the coders desk reference KUB is referred to as a general abdominal exam. Is diagnostic info pertaining to kidney/ureter/bladder necessary to append code 74241? Clinical Notes: Pre-Op Gastric Bypass ESOPHAGRAM AND UPPER GI SERIES - 4/6/12: HISTORY: Obesity. FINDINGS: Preliminary film of the abdomen is unremarkable. The patient swallowed barium without any difficulty. There is no evidence of a hiatal hernia or gastroesophageal reflux. The esophagus is unremarkable. The stomach shows normal motility and distensibility. Mucosal folds of the stomach are unremarkable. Duodenal bulb and loop are well seen. There is no evidence of peptic ulcer disease. CONCLUSION: THERE IS NO EVIDENCE OF A HIATAL HERNIA OR GASTROESOPHAGEAL REFLUX. THERE IS NO EVIDENCE OF PEPTIC ULCER DISEASE. ROOM TIME IS 45 MINUTES. FLUOROSCOPY TIME IS 2 MINUTES 45 SECONDS.

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