Ask Dr. Z

Embolization of superior and inferior left throcervical, internal mammary

Dr. Z, Coil occlusion of superior and inferior left thyrocervical artery, right internal mammary artery and right innominate vein, would these be coded with 37204 or 61626? Thank you

36147

Please do NOT include any actual patient medical records with your question. Dr. Dunn, Open thrombectomy and open PTA- of AV graft performed. Then in a retrograde fashion, fistula accessed and fistulogram performed and stenosis at arterial anastomosis. PTA performed over a guidewire, my question - is it 36147 or 75791 since first fistulogram performed is not through direct fistula cannualtion. And my second question can we code only one PTA here 35475 along with 36831? Thanks

US guidance for vascual access with lower extremity revascularization

Please do NOT include any actual patient medical records with your question. We have been billing 76937 with our lower extremity interventions 37220-37231 if a hard copy is documented/saved for the ultrasound guided arterial access. We are now getting edits that the add-on 76937 is only to be used with catheter procedures(36100-36248)and procedures 37220-37231 are not included as part of the list for 76937. Would you still bill out 76937 with lower extremity interventions 37220-37231 since the selective catheterizations are now included with these interventions and disregard the edits?

Discontinued galactogram

If a patient comes in for a Galactogram (77053, 19030) and the radiologist cannot to get into the duct, can we charge due to the amount of room time, tech time and radiologist time and supplies. The biggest difference between these to me is that this patient has had invasive procedure done before they have to stop the exam. How would you code this?

Diagnostic or screening mammogram when only one breast is symptomatic

Please do NOT include any actual patient medical records with your question. We have some confusion on how to charge for mammograms on patients where one breast is asymptomatic and the other breast is symptomatic. If physician orders a unilateral diagnostic mammogram and unilateral screening mammogram because a patient has symptoms in one breast and it is also time for the other breast to be screened should change the order to a bilateral diagnostic exam? I have always been under the impression if one breast is asymptomatic that the exam automatically becomes a diagnostic bilateral exam to compare breast tissue. Also, if a patient has had prior unilateral diagnostic exams for an area that is being watched or a past biopsy and that breast is due for a six month followup unilateral diagostic exam but, it is also time for a screening exam on the other breast can we then charge for unilateral screening mammogram and a unilateral diagnostic mammogram or should that also be a bilateral diagnostic exam? Thank you for your advice! Sorry if the

Hepatic venous sampling after arterial infusion of calcium gluconate, visce

Is there a code for the calcium stimulaton?
thanks!

PROCEDURE: Following informed consent, and verification of the appropriate patient identification and procedure be performed, the right groin was sterilely cleaned, prepped and draped. Local anesthesia was achieved with lidocaine 2%. Via a right common femoral vein a 5-French vascular sheath was placed.  Through this a 5-French Simmons-2 catheter (modified with two extra side holes 0.5 cm from the tip) was advanced over a wire into the right hepatic vein (second order). Selective right hepatic venography was performed confirming location.  Subsequently via a right common femoral artery puncture a 5-French vascular sheath was placed. Through this a 5 French RC-I catheter was advanced into the celiac artery and celiac arteriography was performed.

Subsequently the catheter was advanced to 5 super selective vessels. These included A: The distal splenic artery just proximal to the pancreaticomagna artery, B: The proximal splenic artery just proximal to the dorsal pancreatic artery, C: Proximal common hepatic artery,  :  The gastroduodenal artery proximal to the superior pancreaticoduodenal arcade and E: The superior mesenteric artery proximal to the inferior pancreaticoduodenal arcade. In each super selective site catheterized, selective arteriography was performed. Following selective arteriography the patient was administered calcium gluconate, 10%, 5 cc (0.025 mEq of calcium/kg) intraarterially and right hepatic venous blood samples were drawn 0 seconds, 30 seconds, 60 seconds, and 120 seconds following administration of the intraarterial calcium. This resulted in 20 samples obtained from the right hepatic vein sent for insulin level analysis. The catheters were removed and hemostasis obtained at the puncture sites.

FINDINGS: There is classic celiac anatomy. The dorsal pancreatic, pancreaticomagna, gastroduodenal artery, superior pancreaticoduodenal arcade and inferior pancreaticoduodenal arcade are normal. The superior and mesenteric artery and its branches are normal. The right hepatic venogram is normal. No hypervascular tumor was identified angiographically.


IMPRESSION: Super selective mesenteric angiography with calcium stimulation and simultaneous selective hepatic venous sampling for insulin levels.

 

36215 36147 36148

Dr. Z, Appealing to you for clarification. 2012 guidelines allow for 36215 to be billed in conjunction with 36147 when catheter is advanced beyond the AA for suspected inflow problem separate from graft. If the initial cannulation of AVF/AVG (36147) does not result in arterial catheterization, but the second cannulation (36148) DOES, do the selective cath rules apply and 36215 supercedes 36148, or can 36148 and 36215 be billed in conjunction? I don't feel that they can but want to clarify. Thanks for all your assistance! If Dr Z has groupies I would be in the front of the pack!!

Screening ultrasound

Dr. Z. At your Phoenix seminar I understood you to say that if a patient had a duplex scan showing stenosis prior to an intervention, that you can bill for a diagnostic study/angiogram (if done) in addition to the intervention. If a CTA/MRA was done then the physician needs to document reason for the repeat exam/angiogram. A coder is arguing that you stated that when "any diagnostic" exam that documents level of diease is done prior to an intervention, then you cannot bill for a diagnostic angiogram of that area. Can you please clarify

Upgrade a dual chamber ICD to BiV ICD with generator exchange

Please do NOT include any actual patient medical records with your question. Dr. Z, I'm confused about your response to Q&A 3531, pasted below. From my understanding, I thought the 33262-33264 code set was only used when no lead changes were made. Please explain. Thank you in advance!! ZHealth Online Q&A 3531 Date: Monday, March 05, 2012 Question: Please do NOT include any actual patient medical records with your question. Dr. Z, I have a question about the new ICD coding. If a patient is having an upgrade from a dual chamber ICD to A Biv ICD with removal of old gererator and insertion of new geenerator,and LV lead insertion only, do I use 33263 and 33225, or 33264 and 33225, or other? Thanks. D Answer: I would recommend using the generator that was placed (not removed), which in this case would be 33264 along with 33225. This also applies to patients where you start with a dual lead system and end with a single lead generator......code for the single lead generator. Dr.z

Aorta, renal, iliac, femoral, and tibial imaging from one catheter position

Indication: AAA, ASPVD w/claudication, S/P iliac-SFA bypass Procedures: From right SFA access, the catheter was placed at the level of the renal arteries and abdominal aortography was performed with contralateral lower extremity runoff. The catheter was removed. Ipsilateral lower extremity runoff was performed through the sheath. Findings reported include full interpretation of abdominal aorta, renals, iliacs, femorals, and tibials. Is it appropriate to code 36200 with 75625 and 75716?

Fibrin sheath disruption with a balloon

Distruption of fibrin sheath with angioplasty balloon 2011 Z Health Vascular & Endovascular Coding Reference lists 36595-52 & 75901-52. Distruption of fibrin sheath with angioplasty balloon 2012 Z Health Cardiovascular Coding Reference lists 36595-52 & 75901 without the 52 modifier. Why the difference in 2011 & 2012?

Coronary artery MRI

At our facility, we are coding C8909, C8910, or C8911 for imaging of the coronary arteries only; the radiologists are NOT evaluating diseases of the cardiac muscle. The patients' orders document the diagnosis of ARVD (Arrhythmogenic Right Ventricular Dysplasia). Are we correct with our coding or should we use CPT 76498? If we are not correct, can you explain why we are not?

Documentation

Dr. Z, In the description of Procedure portion of a Left Heart Cath an Abdominal Aortogram with runoff is described. But that's it. There is no description of the renals or legs. I've requested an addendum asking for the findings for the Abdominal Aortogram and runoff as well as the reason for it (medical necessity). In his addendum it only included the "uncontrolled hypertension" as the reason. For the purpose of any potential future audits, shouldn't there be 'findings' of the abdominal aortogram and runoff describing the condition of the renals, abdominal aorta, and legs?

Renal stent

Dr. Z. Pt had bilateral selective renal angiography (36252) Pt had 2 arteries on the left, both were stented. Can we bill for both stents placements (37205, 37206 and 75960 x2) or are we only allowed 1 per surgical site? Thanks!

Embolization of inferior epigastric branch artery

Dr. Z, I am having a bit of a dilemma over a procedure that was done in our IR lab. The patient presented with bleeding to the abdominal wall post op hernia repair. The radiologist did a distal aorta and bilateral iliac angiogram. He then selected the lt internal iliac ( to"confirm its position"). He then selectively catheterizes a branch of the lt inferior epigastric and proceeds to embolization. No mention of an angiogram for the internal iliac. He does perform an angiogram of the inferior epigastric artery branch. He then catheterizes the inferior epigastric (lt), does an angiogram, embolizes it and finally, a LIMA catheterization with angiogram. I have 2 concerns--1. What, if any, diagnostic angiogram code should I use? From his report, it would seem like I could use 75756 and 75716 with possibly 75774 but i am hesitant about the 75716. 2. For the selective catheterizations, would it be 36456 (inferior epigastric branch, 36246-59 (lt internal iliac), and 36215? I know that I need 75894, 37204, and 75898 for the embolization and follow-up. Thanks for any help. Chris

Pocket revision

We had a plastic surgeon come to the Lab to perform a subfascial/submammary pocket. The ICD was explanted from one area and moved to this new pocket. I am thinking this is more than a pocket revision code...? 15734,but not sure. What do you think?

77012 with translumbar

Hi Dr. Z. I have a patient that is status post EVAR with an endoleak. He was brought to our IR lab for embolization of the aneurysm sac and because the doc could not clearly define the endoleak under US and Fluoro for safe access into the sac, he sent the patient to CT to embolize the sac there. He did a CT guided percutaneous needle access into the aneurysm sac of the abdominal aorta. He then did a catheter directed embolization, using coils, into the sac. How would I code this? I've never had a patient go to CT for embolization for an endoleak. Is it still a 37204,75894,75898? thanks so much!

33225 and 33264

In reference to your answer on March 8th to question 3536 to code 33264 and 33225, per 2012 CPT 33264 is not listed as one of the primary codes for add on code 33225. So, we had to not code 33225 and since C1900 had no procedure to go with, we had to not charge for the LV lead. Any ideas on a solution for this? Thank you.

IVUS

Dr. Z. Pt had a LHC whcihc showed 90% stenosis in LCX. 2 weeks later pt was brought to the cath lab for staged intervention. Physician did and IVUS which showed less than 50% stenosis and therefore did not procedure with the intervention but rather ended the procedure. Can we bill anything for the IVUS? Can we bill for the intended stent placement procedure with a modifier -74? Thanks!

19102

When coding 19102 (breast biopsy)we can code the 76942 for the physician correct? There is some misunderstanding and I want to clarify that this is correct. Thanks

76000

Please help with the CPT code I have never seeing this before and not sure at all what to bill? Thank you as always for you guidence. Procedure: Fluoroscopy of the patient's right and left hemidiaphram. Preoperative diagnosis: Patient with dyspnea and x-ray yesterday that was supposed to be inspiration and expiration but only insporation and today's x-ray of expiration showing what appears to be little movement of the rt hmidiaphragm. The patient is approximately 10 days status post Pulmonary vein isolation. Postoperative diagnosis: fluoroscopy demonstrates paralysis of the right hemidiaphram. Lft hemidiaphragm moves normally.

vericose vein therapy ClariVein

Dr Z, I am hoping you can help me with a new issue. You may want to remove the name of the product to protect the company. One of our physicians went to a vascular conference and saw a product called "ClariVein". The Rep came to our office today. In a nutshell, it is a "peripheral infusion device" with which they are treating below the knee venous insufficiency. The device rotates, causing scarring to the vein. It also allows for delivery of a sclerosing agent directly to the “insulted” vein. He told us that doctors are billing it as an embolization, using 37204/36011/75894 and that Medicare pays for it. When I looked in my EncoderPro, ICD-9 459.81 is not listed as one of the diagnosis codes that is submitted with this CPT code. (Might not want to publish this: Of course, I explained to him that because they are legitimate codes Medicare will pay, but that is not to be confused with legitimate usage of the codes. I am apprehensive because he then stated that BCBS considers it an investigation procedure and will not pay. He also stated that the doctors needed to call it an embolization and not a sclerotherapy procedure because sclerotherapy is often considered cosmetic and this would be for venous insufficiency. He also stated that doctors are trying it out on Medicare patients because they don't have to jump through the prior authorization hoops.) He stated that it is an FDA approved device for "peripheral infusion device using drug of physician specification" but is not FDA indicated for vein occlusion. When asked if this was an off-label use of the product, he stated that it was no different than when biliary stents were used in arteries. He also stated that information available on the European web site was much better than the USA web site. (clarivein.eu) Your expertise on this matter would be greatly appreciated. If this is legitimate use of the product and coding, we would like to try it on a few patients. Thanks, Diane M. Carl, RT(R), CIRCC Billing Coordinator Advanced Vascular Surgery, PC (269)492-6511 .

pedal access 36140

Dr. Z- Could you please direct us on a catheter placement code. The physician did a right pedal access and selected the right SFA. Thank you in advance for your help!

35903 37607

Can we use cpt 36832 for excsion of AVG or we have to use an ulisted code? Thanks, Renata

I-131 administered through gastric feeding tube.

Hello, Please clarify cpt coding for iodine 131 administered through the gastric feeding tube for papillary thyroid cancer (thyroid surgically removed). Is it unlisted? Thank you

33206 33225 33233

Dr Z, I have a question in regard to the new generator replacement codes for January 2012. A patient has a dual-chamber pacemaker with a malfunctioning atrial lead and came for replacement of the lead. However, due to worsening of the patient's condition, they also decided to upgrade to a bi-vent pacemaker at the same time with insertion of the LV lead. Is it appropriate to code as 33206, 33233 and 33225 since a new Atrial lead was also inserted or should we report with new CPT 33229 along with 33225? Thanks.

Use of unlisted CPT codes for direct puncture embolization

Hi Dr Z. When coding for direct puncture embolizations of AVMs should the unlisted code 37799 be use twice if 2 different fields are treated (i.e. the knee and the foot)? Also can 77002 for fluoroscopic guidance for the needle placement be used twice or can it be used only once per encounter? Thanks

Placement and removal of an event recorder on the same day

Dr. Z, In the outpatient setting, how would you report the replacement of an implanted cardiac event recorder at a single session due to its end of life? There is a CCI edit for mutually exclusive procedure between 33282 and 33284. Thank you!

Stand-alone coronary artery aspiration thrombectomy

Per the August 2011 newsletter, code 93799 is assigned when a coronary artery aspiration thrombectomy is done as a stand alone procedure. Is that also the case if a diagnostic heart cath is done and aspiration thrombectomy is performed without PTCA/Stent insertion? Or, would we just code the heart cath e.g. 93458 without 93799? Thanks so much.

Subclavian embolization CPT code

Subclavian embolization. Should this be coded with CPT 37204 or 61626. Thanks!

Cardiac device check without reprogramming

Good afternoon Dr. Z, Could you please help me out with the pacemaker\ICD programming codes. When our doctors do a device check and they check the leads to make sure they are functioning properly as well as the generator and also check the battery life, but make NO changes as far as the programming of the device, and also they state on their report that they have made no changes to the device is it appropriate to report 93288 for pacemakers and 93289 for ICD's. I was told that device reprogramming codes are 93279-93281 for pacemakers and to use 93282-93284 for iCD's. Thank you Rick

Documentation of induction of arrhythmia and mapping

Hello Dr. Z- We're having difficulty coding EPS Studies and Ablations. Specifically we're having trouble determining if an induction of arrhythmia was performed and if the mapping that was done was 3D or not. We're being told that these things are being done but we don't see them in the documentation. If you would look at the following procedure note & tell us how it should be coded we would be very grateful! Procedure: The patient was brought to the lab in the fasting state, catheters advanced to the high right atrium and into the HIS bundle region and the RV apex. A catheter was left in the HIS region. There was a CS catheter advanced to the coronary sinus, his revealed proximal to distal atrial flutter. A mapping catheter was placed into the right atrium. He had a patent foramen ovale and the left atrium was mapped as well briefly. Catheter was pulled back quickly to the right atrium. The right atrium was mapped as well. He had a head meets tall counter-clockwise flutter which was typical flutter, energy applications along the cavotricuspid isthmus terminated flutter back to sinus rhythm. He had unidirectional block post procedure. He was in sinus bradycardia at the end of the case. He tolerated it well. There were no adverse complications.

CCI edits for lead repair

Hi, I have a Pacemaker at ERI with pocket revision and lead repair noticed during the PM Gen replacement. However CCI is saying that codes 33228 and 33218 can not be coded together even with a modifier because it is a component of column one. So I don't know how to code this lead repair with the new codes, please help. Below is part of the dictated report: Pre op: Pt pacemaker at ERI. In addition skin has been thinned over the pm superior aspect of the incision line. "The ventricular and atrial leads worked well. There was a crimp in the ventricular lead, although there was no alteration of functon and no palpation of any wire. The insulation was repaired in that location with medical adhesive and a silicon sleeve. It was tested again and worked well." Post op: Successful removal and insertion of dual PM. Repair with silicon sleeve and medical adhesive of crime in the venricular lead. Successful revision of the PM pocket to allow the PM to sit more deeply in the pocket and take pressure off the superior incision line.

33282, 33284 loop recorder

Dr, Z. Pt's loop recorder was not sensing R waves so pt was brought in and the recorder was removed from the original pocket which was sutured closed and then the same device was placed into a newly created pocket and device was ubterrigated. Is it appropriate to code 33282 and 33284 or is there something better?

Documentation of mapping

Is it always necessary to do mapping prior to the SVT ablation? I was told that even if the mapping isn't stated in the dictation, it is always required so I should code it. I disagree with this. Below is a dictation that I don't see "mapping" but was asked to add the 93609. The codes I used are 93620, 93621, 93462, 93651. PROCEDURE: This patient with a history of recurrent, symptomatic PSVT was brought in for an electrophysiologic study and/or ablation. The patient presented to the EP laboratory in sinus rhythm. Catheters were placed in the right atrium, His-position, coronary sinus, and right ventricle for pacing and recording. Baseline measurements were recorded. During PSVT, the fastest tachycardia cycle length was 380ms with eccentric atrial activation (CS 3-4 was earliest when CS catheter was in the coronary sinus). Transeptal puncture utilizing fluoroscopy was used to access the left atrium. The catheter was then placed at the position of CS 3-4, where there was noted to be a fusion of the ventricular and atrial potentials. Upon ablation, within 4 seconds, the patient's tachycardia broke, and the patient returned to sinus rhythm. Many ablation points were done at and around this area. Afterwards, when ventricular pacing was performed, whereas previously there was eccentric atrial activation, after ablation, there was concentric atrial activation. Also, after ablation, when performing AV Nodal ERP, there were no evidence of accessory pathway echos, whereas prior to the ablation, we saw many accessory pathway echos. We were not able to induce tachycardia after the ablation was complete. Ablation was performed in the left atrium, at the 5 o'clock, 5:30 o'clock position on the mitral annulus (in LAO view). After ablation was complete, post-procedure measurements were obtained. Attempts to induce the arrhythmia were performed with programmed stimulation or rapid pacing. Procedure went well without any complications. Thanks. Your assistance would be greatly appreciated.

36830 and stent graft

Hi Dr Z, et al. Would it be correct to code CPT 36830 and also code for an open stent placement for placement of a Gore hybrid AV graft that includes a stent in the graft? This is a nonautogenous graft with a small 5 cm stent embedded. Thanks!

Replacement genertor and leads

What would be the appropiate procedure codes be when a Single Chamber cardioverter-defibrillator in removed and is upgraded to a CRT cardioverter - defibrillator with the insertion of a Left Ventricular and Right Atrium Leads Also when a Dual Chamber Cardioverter-defibrillator is removed and upgrade with a CRT cardioverter-defibrillator and insertion of a Left Ventricular Lead. Thanks for your help.

Heart catheterization documentation

Hi Dr. Z and Dr. Dunn, I have a couple of questions regarding required documentation. If a report lists hemo measurements, including systolic and end diastolic LV pressures, does the note also have to have specific verbiage stating 'the catheter crossed the aortic valve' or 'the catheter was pulled back (out of the valve)'? Wouldn't the documentation of those measurements be sufficient enough to bill for a left heart cath? On a similar note, does the report have to specifically state 'the coronary arteries were selectively injected' if the purpose of the exam is to evaluate CAD and the coronary vessels and any disease is described? CPT states that 'catheter palcement(s) in coronary arteriy(ies) involves selective engagement of the origins of the native coronary artery(ies)for the purpose of coronary angiography.' I would interpret this as catheter placement in the coronary artery itself or in the aorta at the origins of the left and right arteries. Your thoughts? Thank you so much.

New generator and LV lead only

2012 Codes - Patient comes to EP Lab for ICD upgrade to BiV ICD. Box upgrade and LV lead addition. What are the appropriate codes?

Cardiac device edits

I have 2 coding situations that, no matter what codes I use, there is a zero edit. Both deal with removal and replacement of a device and, at the same time, capping an old lead and implanting a new lead. 1. A BI V ICD was removed and replaced with a new BI V ICD. They also had their old LV lead capped and a new LV lead placed. 2. Old single chamber pacemaker removed and RV lead capped. New single chamber Pacemaker and RV lead implanted. Am I totally missing something or are the codes for PM and ICD missing something? Thank you for your help.

Catheter placement and multiple interventions in lower extremity

Do you code the catheter placement after Infusion therapy such if the patient comes back and a mechanical thrombectomy has to be performed. please see the case below..the doctor is saying mechanical thrombolisis but i am coding it as a thrombectomy after infusion 37184,37185 for leg thrombectomy and 37184-51 for the Aortic thrombectomy, 37224, 75989 x2 as there is to different access sites. My guestions is also on the catheter placement codes. do I code 36245 for Iliaca balloon occlusion. Thanks PROCEUDRE: 10 hour thrombolysis follow-up. CLINICAL INDICATION: Aortic thrombus and left lower extremity thrombus. OPERATORS: Bick-Forrester (Fellow), Hardley (Attending) CONSENT: The patient was informed of benefits, risks, and alternatives to the procedure and agreed to sign informed consent. Any and all questions were answered at the time of consent. MEDICATIONS: Vancomycin 500mg IV, Heparin 5000 units IV, Fentanyl 100mcg IV, 5mg metoprolol, 1 mg Versed IV. CONTRAST: 78 mL FLUORO TIME: 25.5 min. TECHNIQUE: The patient was placed supine on the angiography table and the existing sheaths and catheters in bilateral groins were prepped and draped in standard sterile fashion. Angiography was performed through the existing infusion catheters, showing no significant improvement. Both infusion catheters were removed, and the Angiojet device was prepped. The bilateral existing 5F sheaths were exchanged for bilateral 6F sheaths. The 6F Angiojet thrombectomy device was then advanced through the left groin into the infrarenal aorta, and mechanical thrombolysis was performed. The Angiojet device was then advanced through the right femoral sheath, over the bifurcation, and into the left common femoral artery. Mechanical thrombolysis was then performed in the common femoral artery to the superficial femoral artery. A pigtail catheter was then advanced through the left common femoral sheath into the aorta and angiography was performed, demonstrating persistent thrombus in the infrarenal aorta and extensive irregularity of the left common femoral artery. The pigtail catheter and left femoral sheath were removed, and an 8F sidearm vascular sheath was advanced into the left common femoral artery. A 5F Fogarty balloon was advanced from the right femoral access site to the origin of the right common iliac artery and was inflated to occlude the right iliac origin. A second, 6F 80cm Berenstein balloon was advanced proximal to the aortic thrombus, inflated, and retracted into the left common and external iliac arteries. Repeat angiography in the aorta showed no residual aortic thrombus, but significant thrombus in left common and external iliac arteries. The Fogarty balloon was removed, as was the right femoral sheath which was exchanged for 6F 40cm up and over Balkan sheath. Angiojet thrombolysis was then again performed throughout the left common iliac, external iliac, common femoral, and superficial femoral arteries. While significant improvement was noted on angiography performed through the Balkan sheath, there is persistent irregularity and stenosis of common femoral artery. No definite thrombus is noted to persist in the common iliac, external iliac, or common femoral arteries. There is persistent thrombus noted in the distal superficial femoral artery into the popliteal artery. The left femoral arteriotomy site was closed with an 8F Angioseal device which achieved immediate hemostasis. Angiojet thrombolysis was again performed from the popliteal artery to the common femoral artery, and angiogrpahy was again performed showing marked improvement. No significant thrombus is noted from the iliac vessels to the the trifurcation, however there were areas of irregularity and stenosis in the common femoral artery and popliteal artery. The popliteal artery demonstrated long segment of marked narrowing from the abductor hiatus to the trifurcation. There is minimal antegrade flow noted. A 5 mmx4cm ultra-thin Diamond balloon was then used to perform angioplasty from along the course of the popliteal artery. Repeat angiography was performed showing some improvement. Angioplasty was again performed from the level of the trifurcation proximally to the common femoral artery. Angiography showed marked improvement in the arteries from the pelvis to the trifurcation. There was persistent decreased and absent flow distal to the trifurcation. A 5F angled glide catheter was left in place just proximal to the trifurcation, and TPA infusion initiated at 1mL/hour. IMPRESSION: 1. Initial angiogram shows persistent aortic and left external iliac thrombus extending distally, not significantly changed from prior angiogram. 2. Aortic thrombus resistant to Angiojet mechanical thrombolysis was retracted into left common iliac artery with balloon. Aorta now angiographically free of thrombus. 3. Left common iliac, external iliac, common femoral and superficial artery thrombus treated with Angiojet mechanical thrombolysis, with good result. Several areas of persistent stenosis and irregularity noted, most prominently in the common femoral artery and popliteal artery. 4. Balloon angioplasty performed along length of common femoral artery, superficial femoral artery, and popliteal artery with good result. 5. Persistent absence of antegrade flow distal to trifurcation. 5F angled glide catheter left just proximal to the trifurcation for infusion of 1mg/hr TPA. Plan follow-up angiography in approximately 4 hours.

Ilioplasty

How do you code for an ilioplasty (bone).  Would you think this is unlisted or do the T codes apply?

Breast biopsy with Suros device

Would you assign 19102 or 19103 for documentation of breast biopsy using the following devices
 
Suros
Suros Celero

Thank you very much. 

Pulmonary artery pulmonary vein fistula with shunting

Dr. Zielski,

Good afternoon it has been a while since I have sent you a question. I love the 2012 book by the way!

I have a question that I would like to ask as it is a rare situation that occurred and now I am trying to figure out how to code it.

A patient came to the ER hypoxic and not doing well, went to ICU and was there for several days.  The patient was found to have a right pulmonary artery/pulmonary vein fistula and was shunting past the left atrium.  The patient was not a surgical candidate and on high levels of oxygen. 
This case was a combined effort with the Interventional Radiologist and the Interventional Cardiologist (just like Amir Motarjeme once told me that it would be)
where the Radiologist did the diagnostic and filming via low resolution CT and the Cardiologist managed the intervention (has does the ASD/PFO closures in the Cardiac Cath Lab and is very familiar with the device)

The fistula was closed with an amplazter septal occluder (not vascular plug as there was no "tunnel/tube").
The patient's oxygen saturations immediately increased. The patient was returned to ICU and walked out of the hospital on room air a few days later.

Now my fun begins.  I was thinking of using the embolization codes of 37204/75894. The C code for the device is C1817.
There are no "procedure to device edits" per the Jan. CMS list for procedure 37204.

The patient was an inpatient but all of the charging of procedures are attached to CPT codes as per the chargemaster.

Thank you for your time and consideration.

ICD and pacemaker

Dr. Z,
              I attended the course in Nashville as well as the one in Vegas the year before. We are having issues with the CPT code 33224 LV lead placement. In the past, we have charged for the generator removal (pacemaker usually) 33233, place the LV lead and put in the new ICD (usually) generator. So, we would have had 33233, 33224 and 33249 (because they would put in an ICD lead also), as well as fluoro. We didn’t realize that 33224 last year included the removal and replacement of the generator, which was always a new generator because the old generator couldn’t hold all three leads. My problem is that we were charging for the old generator to be removed and a new one placed and didn’t realize it was included in the code 33224. So our cost was much more than what it should have been, we are now realizing. One thing that might have kept us not getting any edits or have any other type of issue, is that the coders probably didn’t code that for payment(generator removal.) Our finance department can’t understand why the cost for an ICD placement is higher than a pacemaker placement. We are trying to stay budget neutral until this budget year is over. Ours runs from June 1 to May 31. Is it normal for the ICD implant cost to be higher? I don’t have anything to do with setting cost, but need to try and help make this correct from here on out. Again, we didn’t have any issues with the bills or payments, so I feel that the coders were correcting the bill before it dropped for billing. Any insight would be very much appreciated. Hope to attend the Nashville seminar again this year. Thanks,

Cardioversion billing in a hospital setting

We perform Cardioversions in an a department in the hospital.  Our physicians bill the 92960 on the pro fee side.  The facility is wanting to charge for this.  I explained to them that this is not a split code and to bill the supplies that are used.  Do you know if there is a code they can bill on their side for the services that are being preformed?
Thanks!

Question for Pulmonary vein ablation

Dr. Z,

Our cath lab wants to charge complete EP study when they place a spiral catheter in pulmonary veins and pacing and recording to isolate them. When asked for rationale – catheters are positioned in many veins and that’s they are charging complete EP study. But per CPT book and CPT assistant catheters must be in right heart (RA/RV/HIS) for pacing and recording at least two areas (or one area with ‘52’ ) and these cases they are only placing a catheter in CS and an ICE catheter in RA and a spiral catheter in one of the pulmonary veins to perform ablation for A-Fib.  Not sure this constitutes a complete EP study.  We would like to explain our cath for documentation requirements, please explain.

Cojoined spinal arteries

Good morning Dr. Z,

I have a question on the selectively order of conjoined arteries.  In my research I found that a conjoined (combined) vessels share the same root and are nearly always unilateral.   Would this be correct?

This question is raised from a recent Spinal Angiogram done on patient with conjoined T6-L6 radicular arteries and I do not have the nervous system illustration of this spinal anatomical variant. My thinking is that the nerve root is first order vessel and this would change the selective order. Example: the conjoined RT  (T5 – T7).  36216-T6, 36218-T6 and 36218-T7.

Your feedback will be greatly appreciated.

Leads and fluoroscopy

Please do NOT include any actual patient medical records with your question. Dr. Z. I have a question in referece to th recalled ICD Riata lead. One of our physicians dictates a sepatate report for fluoroscopy of the thorax on patients having an Icd gen change who have a riata lead. He states that the flouroscopy is medically necessary and mandated by the FDA. Should 76000 be charged in this situation? Thanks. D.

IVC Filter Placement and Removal during same session

I’m sorry I was not able to make it the Las Vegas conference this year but I do plan to attend your 2012-Tennessee conference.  As always, I always come to you guy with the tough questions.

What is your coding recommendation for coding a IVC filter Placement and Removal during the same session and same access?  First time I’ve have ever seen this.  Patient has extensive IVC and bilateral iliacs thrombus and is on day 3 for thrombolysis.  F/U angiogram via bilateral extremity, Filter placed via rt internal jugular, Venoplasty via rt fem vein access, Thrombectomy and Stent placement of IVC via rt inj access and rt com femoral vn, bilateral venoplasty of iliac veins and then IVC filter was removed at the end.

Your feedback is greatly appreciated.

Thank you,