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37191

Dr. Z, Patient comes in for IVC filter placement (37191). RT & LT renals were selected for venous inflow and the left iliac vein for venography. There is no findings for the renals & left iliac. Is this considered roadmapping? Thanks

Abscessogram and tube change in same setting

In your IR coding reference page 382 example 1 you state we can code an abscessogram and an abscess catheter change together with not modifiers. So for these we code 49424, 49423, 76080 and 75984. We have a situation where Medicare is denying the 49424 and 76080 is bundling with 49423. There is not NCCI edit saying any modifier has to be used as per your example. So my question is have you seen that Medicare is no longer allowing 49424 with 49423? Would you appeal these to Medicare? Thanks for your help. Julie

Device edit involving C1882

Question on the procedure to device and device to procedure edits. We inserted a new system for the first time (RA lead, RV lead, LV lead, & ICD generator). We billed for cpt 33249 and we are billing the device codes of C1882, C1900, C1777, and C1898. In looking at the procedure to device edits, we pass. However, in looking at the device to procedure edit, C1882 is failing as proc code 33249 was terminated as of 1/1/12, so is no longer listed as one of the procedure codes for the C1882 device. To me, this seems to be contradictory of each other. Any suggestions????

76930

Our cardiologist do pericardiocentesis with echocardiographic and fluoroscopic guidance. Would code 76930 be assigned for the echocariographic guidance? Thank you

36147 with cardiac cath and EP

Please do NOT include any actual patient medical records with your question. Can CPT code 76937 be reported with coronary cath/interventional and EPS CPT codes? Pediatric's here at our medical school have some patients that require ultrasound guidance when placing catheter(s)because of difficulty accessing the vessel. This happens rarely but there are times when ultrasound is necessary. Look forward to your response. Claire Shumate, RHIT, CCS, CPC Compliance Analyst WUSM - St. Louis

35661

Greetings, A patient has a fem-fem graft that adheared to the bladder wall. The physician transects the graft on the left and right side of the bladder and removes the graft and repairs the bladder wall. Next he places a PTFE graft on top of the rectus sheath and attatches this to the ends of the PTFE graft that was still attached to the left and right femoral artery. I'm thinking this is a unlisted 37799 and basing the RVU on 35881. I do not think I would code excision of the graft (bundled). Thoughts? LW

Renal mass ablation and biopsy

Dear Dr. Z: A CT guided needle biopsy of a renal mass was performed and then CT guided cryoablation of the same mass was performed (same patient encounter). Is it appropriate to code 50200, 77012-59 for the needle biopsy and 50593, 77013 for the cryoablation of the renal mass? Or should only 50593, 77013 be coded since it is the same mass? Thank you. mlb

Coil embolization of a biopsy tract

I am sorry, I had another question I forgot to ask in my submission a few minutes ago. After the hepatic access and ablation a coil was used to close the access site. Would this be 37204 without the follow up angiogram? Thank you again.

Venography with EP ablation

Adult patient with fontan baffle and bilateral occluded femoral veins comes in for SVT ablation. Direct hepatic puncture was done for access and an ablate catheter placed into the hepatic sheath. A 20-pole EP catheter was placed through RIJ access. LFV injection was performed and revealed already known occlusion. The access and injections were done by the Peds interventionalist and the EP/Ablation was done by the Peds electrophysiologist. I would not code for the access and injections. Would you? Thank you.

Unsuccessful attempt to place left ventricular ICD lead

Dr. Z, This patient was coming in for a dual chamber ICD generator replacement with a CS lead insertion. ( 33249 and 33225 ) The pocket was opened and the genertor was removed and detached from the endocardial leads. The pt. was paced off the R vent lead during the procedure. By use of a pertutaneous dilator and introducer a 7 french coronary sinus guiding cath was introduced and advanced to the R atrium. After several attepmts and several guiding caths used cannulation of the coronary sinus was unsuccessful. The generator was reattached to the leads and replaced in the pocket. Medical records coded 33249 and 33225. Is this correct? All that was done was removal and re-insertion of generator. Thank you, Kim H.

93613

Is it appropriate to report 93613 when the physician documents that he was unable to induce an arrythmia even when Isuprel challenge was done and "non-contact mapping was performed so as to produce activation maps"?

93799, 92973

Dr. Z. In your August 2011 newsletter you stated that per the AMA 92973 was to be used only when the thrombectomy was done with an angiojet. You further stated that 93799 could be used to report a "stand alone" aspiration thrombectomy of a coronary artery. And that a thrombectomy done by any other means is a part of any other intervention performed. At your Scottsdale seminar it was our understanding that the 93799 could be billed for all coronary thrombectomies that used catheters other than the angiojet. Please clarify what can be billed using the 93799. Thanks!

50390, 50394

Patient with kidney obstruction. Antegrade pyelogram was performed followed by insertion of a nephrostomy tube. The report says "it was injected with contrast, aspirated, and flushed with saline. The nephrostomy tube was secured in place." I know I can code 50390/74425 and 50392/74475. But what about also using 50394? Or is the nephrostogam in this case part of the placing the tube? Thank you for your guidance.

75630, G0275, G0278

Please do NOT include any actual patient medical records with your question. What codes do I need to bill if a patient is Medicare Pt., and what codes for a none Medicare. Procedure is: Left heart cath with Cors, with LV, and Abdominal aortography and bilateral illiofemoral run off.

35201

Please do NOT include any actual patient medical records with your question. Can you please clarify your Q&A 3525? Code 35141 does not fall into the range referred to in the answer. Can 35141 be reported for direct repair of pseudoaneurysm without insertion of graft? Date: Tuesday, February 28, 2012 Question: Greetings, Pt. has fem-peroneal bypass graft with spliced saphenous vein originating from the hood of aortobifemoral graft. At the hood connection of the vein a pseudoaneurysm develops. Pt taken back to the OR for repair. After draining partially thrombosed pseudoaneurysm he sutures the hole in the hood would you code this as 35141 or repair of a blood vessel Thanks, LW Answer: The note just prior to code 35001 states “For direct repairs associated with occlusive disease only, see 35201-35286”. Since this is a pseudoaneurysm I would not use the repair codes but stay with the aneurysm codes. Thanks, Dr. D

Aortic stent graft for trauma

If you stent graft an aorta due to trauma and not aneurysm, would you code 38400/75952? Thanks!

37186

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

35475

Just when I think I get these I always question myself and get confused.  Would you consider this a venous or arterial angioplasty?  Is there an easy way to “get these”  no matter how much I read on these I still get confused.

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 right 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 superior vena cava. A 6 Fr short sheath was inserted over a Bentson wire which was positioned into the brachial artery. Over the wire, a Bern catheter was inserted and positioned in the brachial artery. Digital subtraction angiography was performed to evaluate the arterial anastomosis and the perianastomotic region of the fistula.

Multiple segments of moderate-length narrowing were noted in the perianastomotic region.


A 5 x 4 angioplasty balloon was inserted and positioned such that multiple, overlapping angioplasties of the perianastomotic region were performed to treat the stenoses. The balloon was then positioned at the arterial anastomosis and angioplasty of the arterial anastomosis was performed. Post-angiography DSA was performed through a Bern catheter inserted into the brachial artery, demonstrating a good angiographic result with brisk flow centrally through this fistula. The catheter and wire were withdrawn. Hemostasis was obtained with manual compression. The patient tolerated the procedure well and exited the angiography suite in stable condition. FINDINGS: There is brisk flow through the fistula. There are multiple segments of 30-50 % narrowing in the perianastomotic region of the fistula, as well as at the arterial anastomosis. The outflow the brachio-cephalic fistula is otherwise unremarkable. IMPRESSION: Successful venous angioplasty of the peri-anastomotic region and arterial anastomosis of the right brachial artery-cephalic vein fistula. PLAN: The fistula can be used immediately.

36832

I'm stuck on this one, any info. on your end would be greatly appreciated.

this pt. had 36819 (Arteriovenous anastomosis, open; by upper arm basilic vein transposition) done in November.
I'm not sure what this is exactly…36832-58??

PREOPERATIVE DIAGNOSES:
1.  End-stage renal disease.
2.  First-stage right brachiobasilic fistula.

POSTOPERATIVE DIAGNOSES:
1.  End-stage renal disease.
2.  First-stage right brachiobasilic fistula.

OPERATION PERFORMED:  Second-stage superficialization of right brachiobasilic fistula.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

COMPLICATIONS:  None apparent.

INDICATIONS:  This 64-year-old male had failed autogenous access in the left upper extremity and had underwent a primary first-staged right brachiobasilic fistula in November 2011.  He presents now for creation of a second-stage brachiobasilic fistula on the right to superficialize the fistula.

SPECIMEN:  None.

FINDINGS:  Patent right brachiobasilic fistula.

OPERATION:  The patient was brought to the operating room and placed in a supine position.  After a time-out was performed, the right upper extremity was prepped and draped in a sterile fashion.  The brachiobasilic fistula was palpable with a thrill from the antecubital fossa up to the axilla.  This was marked and an incision sharply created over the arteriovenous fistula.  Any small additional side branches were divided between 3-0 and 2-0 silk ties.  The fistula was then mobilized and brought more anteromedial in a superficial position.  The subcutaneous tissues were then closed with running 3-0 Vicryl suture followed by 4-0 Monocryl and Dermabond.  The patient remained with a palpable radial pulse and an excellent thrill in the superficialized fistula.  I was present for the entire portion of procedure.  The patient was extubated and transferred to the recovery area in stable condition.

Diagnostic imaging at time of an intervention

Dr.Z, Before a Kissing Balloon and Stent placements were performed Bilaterally on the Common Iliac Arteries, an Abdominal Aortogram with the catheter positioned above the bifurcation for a Bilateral Lower Extremity Run-off Angiogram. In a case like this with intervention in the Common Iliacs, would 75625 and 75716 still be reportable? There were findings and interpretation provided for the abdominal aortogram and extremity angiograms.

77001

Dr. Z, We are having a coding stand-off and are hoping you can assist. All your coding manuals indicate during a catheter exchange that no further catheter codes (ie: 36010) should be coded if the only access point is the existing cath tract (for which I agree). For 75827 to be billable the SVC should be documented itself, not just "no presence of fibrin sheath". The question is as follows: If the descriptor is: "Contrast injection and superior venacavagram revealed no evidence of fibrin sheath stenosis", would that warrant a 75827? Part two: if the following occurred: Using blunt dissection, the catheter cuff was exteriorized. A 150-cm glidewire was advanced through the catheter and under fluoroscopic guidance into the IVC. The catheter was then removed and exchanged for a 9F sheath. The 9F sheath was advanced over a glidewire and under fluoroscopic guidance into the SVC. An SVC gram revealed a widely patent SVC. The sheath was then removed and exchanged for a new 14F 24-cm Medcomp split-tip catheter. A catheter was advanced over the glidewire under fluoroscopic guidance into the atriocaval junction", can a 36010 be billed if the only point of access is the catheter tract? We would love to have this dispute settled once and for all! Thanks for all your help!!

NCCI edits

I need clarification Column 1/Column 2 edits. With the Column 1 being the major component if a Column 2 code (71010 is perform after the Column 1 code)is performed, the column 2 code should not be coded/charged. Coding both codes would be unbundling. The column 2 code should only be charged if there is a new symptom post prodecure documented as reason for exam. Fluoro is not used. In the below it says "When billed together, 75625 (the Column 2 code) should not be paid." but they should not have been coded on the bill together at all. I want to make sure I understand it. Thanks Column 1/Column 2 edits, previously called Comprehensive and Component, are to detect when a procedure is billed separately that should be included in another procedure billed. When used together on a claim, these procedure codes are considered unbundled. The Column 1 code represents the major procedure. It requires greater effort and time as compared to a Column 2 code. The Column 2 code represents the lesser procedure or service, is Considered part of the Column 1 procedure, and is often represented by a lower payment. An example of this is code 75724, bilateral renal arteriogram, and 75625, abdominal aortogram. Code 75724 is the Column 1 code and is considered to include the work that is described by 75625. When billed together, 75625 (the Column 2 code) should not be paid.

The replacement of only an ICD generator (with a new dual chamber generator

Has there been any issues with Procedure to Device edits or Device to procedure edits that are causing coding issues? I know recently CMS identified C1882 issue with 33249 just this month which is scheduled to clear April 1st, 2012. Recently,I had a patient that returned for end of life Battery depletion. Incision is made & device pocket opened. Medtronic model D154ATG,which was a BI-VI was removed. The atril, RV shock & RV p.s leads were then tested and adequate pacing thresholds obtained. The new Biotronik Dual Chamber ICD was then attached to the leads and inserted into the pocket Model # 360346 DDDR. The subcutaneous tissue was first closed with interrupted stitching using 2-0, 3-0 Vicryl. The skin was closed with running subcuticular stitching using 4-0 Vicryl. After the procedure, the incision was secured with Derma-Bond and Steri-Strips and a sterile dressing. On leaving the Cath Lab, the leads were in proper position and patient was hemodynamically stable. A chest x ray was ordered and the patient was transported back to the Telemetry Unit in stable condition. Coded 33249 with C1721 attached to the Generator. Please advise if you have any additional information that will help us get this claim out the door. Thanks, MC

Multilead generator replacement with addition of LV lead

Dr. Dunn, I am getting conflicting information. I have been told that on one of your webinars that you say the new gen replacement codes such as 33264 can not be used with any new leads. In all the Zhealth products I have purchased I do not see that. Maybe this is new infromation I missed??...So even though it has been asked before: how do you code for multi lead gen replacement (33264) attached to exsisting RA and RV leads with a new LV lead inserted, DFT testing. I thought it was 33264, 33225 and 93641. Has this information changed? From what I have read from the Zhealth and other sites is that the new gen replacement codes cannot be coded with new RA and RV lead insertion because combined codes exist but the LV lead is different because there is not a seprate code that combines them so they are coded seperatly. Let me know if I missed something or maybe I am not understanding....Thank you for your help and hopefully I will understand it this time!

Stress echo without contrast coding

Please do NOT include any actual patient medical records with your question. What codes should a facility be reporting for a stress echo(without contast)? Would 93350-TC and 93017 be correct? Thanks.

Nitrous oxide administration with repeat cardiac catheterization

Hi Drs. Z & Dunn, I am coding a cath in which the patient has "tetralogy of Fallot, pulmonary atresia with continuous PAs. She is status post tetralogy of Fallot repair which included an RV-to-PA conduit and branchpulmonary artery. At the time of operation, her VSD remained open due to concern for small pulmonary artery caliber. Patient's more recent history is significant for respiratory insufficiency which progressed to full respiratory failure requiring intubation earlier this morning. She presents today for diagnostic cardiac catheterization." Patient had a right & left heart cath while on 30% Fi02. Then the Fi02 was increased to 100% and right & left cath was repeated. I realize there was no pharmacologic agent administration, but oximetries and hemodynamic measurements were done under two separate conditions. So I am asking if 93463 would be appropriate to bill in this scenario? Thanks so much for your help!!

35011

Greetings, A patient had a enlarging aneurysmal stump of a ligated BC fistula. It is starting to cause the pt pain. The physician excises the aneurysm and performs a patch to the artery. I think this would be coded as a 35011. Medical records is using a unlisted 37799. I do not think this would be a 36832 as the fistula was ligated over a year ago and is no longer functional. Do you agree with the 35001? Thanks, LW

Non-selective catheter placements and stents

Dear Dr. Z: It just came to my attention that non-selective catheter placement is not billable with stent placement codes 37205, 37206. It is unusual for the stent to be placed on the same side as vacular access but is it incorrect to bill 36299 for non-selective venous catheter placement when a stent is placed in an extremity vein (no diagnostic venogram is performed)? Thank you. mlb.

37607

Please do NOT include any actual patient medical records with your question. a patient comes in to have their AV fistula ligated. not sure what code i should be using. a short transverse incision is made. the underlying cephalic fustula is double ligated .

codes 93922 and 93925 together

Please do NOT include any actual patient medical records with your question. Can we code 93922 and 93925 together. What would be the appropriate documentation that we would be looking for?

Securing a port

What do you believe is the correct code for the following report? Fluoro was not used. Following informed consent and sterile preparation, an incision was made over the right chest port. There was considerable scarring encountered which was negotiated with blunt and sharp dissection. Eventually, the port was identified and was not flipped; it was, however, quite mobile. Sutures were placed in the port to secure it. The port was accessed and flushed and aspirated easily. The incision and pocket were generously irrigated with antimicrobial solution. The incision was closed with resorbable suture. It was noted that the port was deep to at least 1.5 inches of scar tissue and could not be relocated more superficially. It will require an extra long Hubner needle to access the port, of at least 2 inches. The patient tolerated the procedure well.

Upgrade of a dual chamber defibrillator to a biventricular defibrillator

Hi Dr. Z I looking for a clarification from a question posted from March 8, 2012 "Question: Upgrade of a dual chamber defibrillator to a biventricular defibrillator. Remove and replace generator, insertion/addition of left ventricular lead and attachment of generator to previously placed atrial and right ventricular leads. How would you code this utilizing the new 2012 cpt codes? Thank you! Answer: I would code the removal of a dual chamber generator and replacement with a multi-lead ICD generator (as the final device placed is a multi-lead) as a multi-lead generator replacement, along with the LV lead at time of generator change. So the codes are 33264 and 33225. Dr.z" My question according to 2012 CPT manual 33225, in the parenthetical note, 33264 isn't listed as a CPT code to use in conjuction with 33225. I apprciate any clarification to this matter. Thank you!

Upgrade of dual-chamber pacemaker at ERI to biventricular pacing system.

Hi Dr. Z -- Upgrade of dual-chamber pacemaker at ERI to biventricular pacing system. Pacemaker generator removal; addition of left ventricular pacing lead. Re-use of right atrial and right ventricular leads. Implantation of biventricular pacing pulse generator. Is this as simple as the lone charge of 33224? THANK YOU!

Left main coronary artery DES

Dr. Z, Hi -- would appreciate your opinion. MD placed LEFT MAIN DES. He describes "high-grade disease in the proximal circumflex" and subsequently describes intervention (DES) "distal left main." Cath Lab reviewed the films and says, "Treated lesion(s) are continuous - the distal left main and into high proximal circ/OM branch were target lesions. MD ballooned multiple times at this site. THE STENT IS CLEARLY IN THE LEFT MAIN." MD has summarized: "LM = DES and PTCA; Left circumflex = PTCA" Would you charge/code: G0290-LC only or G0290-LD with 92984-LC? THANK YOU.

AV fistula resection or excision

My question is in regards to an AV fistula resection or excision .. The patient presented with a hemorrhage at the AV fistula access site. He was taken to the OR. The ulcer site was opened. The fistula was mobilized both proximally and distally to the site of the perforation. Clamps were applied proximally and distally. The doctor excised the ulcerated segment of the fistula, then mobilization of the arterial end allowed for an end-to-end anastomosis between the arterial end and the venous end of the fistula. Would this just be a revision of an AV fistula (36832) or is this more in depth? I am struggling with finding a code that fits this procedure.

Renal transplant non-selectively 75710

Good afternoon all, Please give me your thoughts on the following procedure. 36140 and ? 75710 CLINICAL DATA: PELVIC TRANSPLANT, RENAL FAILURE PROCEDURE: Informed consent was obtained, patient placed supine on the fluoroscopy table. The left groin was prepped and draped in the usual sterile fashion. The skin was anesthetized with 1% xylocaine. Using single wall technique, the left common femoral was cannulated. A 6 french sheath was placed over the wire. Multiple retrograde arteriograms were performed via the sheath. The sheath was removed and hemostasis was obtained with manual compression. FINDINGS: There was a stent noted at the ostium of the renal artery transplant/iliac artery anastomosis. The stent is in adequate position. No stenosis was identified. The visualized intraarterial branches are widely patent. The visualized iliac artery is widely patent. IMPRESSION: Indwelling stent noted in the pelvic transplant renal artery/iliac anastomosis is widely patent. jb

AV shunt intervention

How to code this procedure- Argon cleaner thrombectomy device? Hx: AV fistula occlusion. Stenosis in existing left subclavian stent. The stent underwent balloon dilatation with a 10cm x10 cm balloon. The argon Cleaner Thrombectomy device was used to displace the visible thrombus. A 6 cm x 40 mm Bard Conquest balloon was used to dilate the venous anastomosis. At the conclusion of the device there was difficulty obtaining hemostasis. The insertion sites were closed using two 2-0 absorbable sutures. Thank you.

36832

Greetings, A patient presents with compression of a fistula due to a hematoma. The physician evacuates the hematoma. Upon evacuation of the hematoma, pulsatile bleeding was still present originating from the back wall of the transposed brachiobasilic fistula present in the mid upper arm. I think this is coded as a revision of a fistula (36832) and not a revision of a fistula w/ thrombectomy (36833). I was wondering if repair of a blood vessel (35206) is better. What are your thoughts? Lesley

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?

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