Ask Dr. Z

Intra-operative billing for interventional radiology procedures

I need some clarification on intra-operative billings…vasc. surgeons sometimes do arteriograms in the OR and then a radiologist or CVIR phys. will also interpret the findings.  Here are some questions from one of my cvir physicians…I just want to make sure I'm telling them the correct thing.  should cvir/rad be billing a technical chrg. only for interpreting their findings since the vasc. surgeon did the supervision and interpretation?  Since I don't normally see the radiology part but I do see and bill the vasc. surgeon, we're afraid of duplicate billing.

thanks!

So, here are my questions:

1.  If we provide an appropriate dictation for the images, what would we be billing for?  We may be providing an interpretation, but what about the "supervision" part?
2.  If we provide an appopriate dication for the images, would we be double billing (ie we and the vascular surgeon?).  In reality, I doubt that can happen.
3.  If we are providing a dictation to bill for the "techincal" aspects of having radiology techs go up there, is it sufficient to say, "Please see  findings reported on operative report."
4.  Is it the norm for radiology techs to provide this service in the OR?  I know the CVIR techs used to go up there, but don't any more.

Revascularization of a bypass graft

I have a question that I hope you can help with.  Our surgeon did a bypass graft with cadaver vein about 2 years ago.  Last week he did an atherectomy in the graft (femoral to posterior tibial). Would I code the revascularization codes 37225 and 37229 for the atherectomies?

Thanks so much!!

Thoravent

Dr. Z, Would you code a thoravent procedure the same as you would a chest tube placement??

Aspiration of trapped blood

Hi Dr Z, The diagnoses in this case are incompetent lower extremity veins and bilateral LE venous malformations with pain and swelling. The GSV was treated with radiofrequency ablation. Then the physician says "Using direct stick technique, thrombectomy was performed on priviously sclerosed veins of bilateral lower extremities." This was followed by direct sclerotherapy on multiple veins of the right thigh. The questions is how do I code the "thrombectomies". Would 37187 be appropriate? Would it be coded twice for bilateral procedures? Thanks again.

35013 35881 35621

Greetings, A patient had a axillary bifemoral graft. It develops a ruptured aneurysm at the axillary anastomosis. The physican removes the axillary graft from the right side and creates a new anastomosis on the left then takes the new graft across the chest wall and transects the distal rt femoral anastomosis and attaches a new graft to the end stump of the old graft. He also performs a bovine patch to the right axillay artery where the original graft was attached. The physicaian coded 35013 and 35881. Im thinking this should be a 35621 as it was moved to the left side, and 35013. What do you think? LW

33264

The question we have is regarding an ICD upgrade to a Bi-V ICD. The patient had a dual chamber ICD. The generator was removed, a LV lead was placed, along with a new Bi-V ICD generator. What would be the correct coding for the above situtation with the new 2012 CPT codes? Thank you!!

Bleeding after hysterectomy

Dr. Z, At your Nov. 2011 conference, you said that we should not code for an angiogram with an embolization when the bleeding site was known. Specifically, you cited embolizing the uterine arteries post partum. Would that same thing be true for an embolization of the uterine arteries following a vaginal hysterectomy?

Billing for cystografin

when performing 51600 (cystography) contrast 250 ml cystografin was injected would this be included in 51600 or would you bill the contrast and if you would bill it what would the hcpcs coded be?

Deployment of septal occluder right pulmonary artery/pulmonary vein fistula

Deployment of septal occluder for right pulmonary artery/pulmonary vein fistula. This was performed by IR radiologist and cardiologist. I am not sure about catheter selections and what imaging studies I can charge for the IR lab. I am going to condense the actual report below. Lt. common fem venous access obtained, Grollman cath and wire utilized to gain access to rt. superior pulmonary vein cath removed for exchange length wire that was left in place. Rt. common fem venous access obtained, Grollman cath utilized to gain access to rt. pulmonary artery. Cath exchanged by sheath and the sheath positioned in rt. main pulmonary artery with AP and lat PA-grams performed. Additional angiography of rt. lower lobe pulmonary artery performed. Could not identify definitively the fistula and used wire and catheter to negotiate the fistula tract and gain access to left atrium. Lt. atrial angiography confirmed access in the lt. atrium. At this point the cardiologist entered the procedure and you have already answered my coworkers question regarding the occluder. I was thinking of using 75741, 36015, 36015, and 75774? Thank you for your help on this unusual case!

LVL attempt 33225-53 (or -74)

I found a Q&A dated 6/3/11 that partially relates to a procedure I am trying to code, but still need clarification. This is regarding a Bi-v ICD and coronary sinus angioplasty. In my case, the dr made quite a few attempts to place the LV lead. There was stenosis encountered and a separate cardiologist was brought in to help angioplasty this area. Angioplasty was able to be done, but the LV lead was still not able to be advanced and was not placed. Is there any code I can use for the CS angioplasty work that was done? Sure seems to me that since there was a separate reason for this being done that I could pick up something. Or is all this extra work just part of the ICD placement(dual chamber was done)? Thank you for your time.

Drainage of Bakers Cysts

Under ultrasound guidance, a 18-gauge needle was advanced into the cystic collection (Baker's Cyst). 6 mL of highly viscous straw-colored fluid was aspirated. There was marked collapse of the cavity. We then proceeded to inject 3 mL of a 1:1:1 solution of 1% Lidocaine, Depo-Medrol, and Kenalog. Please help. I thought 20612, 76942. Thanks

37233

Please do NOT include any actual patient medical records with your question. hi dr. z please help. we need clarification on how to use cpt code 37233.

37201

Dr Z or Dr Dunn: My question is around 37201 In the CIRCC study guide there is a notation on page 29 that this code is for a "continuous catheter-directed infusion of a thrombolytic agent." I do not have that directive in the actual code and can not find a CPT assitant on this. Can you give me other source documentation for this coding "rule". I have a patient whom recieved 10mg of TPA being injected at the level of ICA for an M1 occlusion.

TAVR 0256T, 33300

Good afternoon Dr. Z: We need your guidance. When doing an Implantation of catheter-delivered prosthetic aortic heart valve; endovascular approach (CPT 0256T), there is a complication and the LV is punctured. The thoracic surgeon, who is standing by, cracks the chest, repairs the LV and then the cardiologist finishes the deployment of the valve. What does the cardiologist bill for in this situation (0257T?)? How does the surgeon bill? As always, thanks for all your help.

37186 37215

Dr Z or Dr Dunn: I have a question regarding stenting of the right internal carotid for stenosis just above the bifurcation and then mechanical thrombectomy of the M1 and M2 arteries. I have 37215 for the stenting and this code includes diagnostic cath and the placements of the cath. I have two questions on the thrombectomy. This was performed after follow-up injections from the stenting still showed "some reopening of the right M1 segment and thrombus located within the M2 branches." Since the thrombectomy is after the stenting this would be considered secondary is that correct 37185 and is the M1 and M2 considered the same vascular family since access was through the rt internal carotid? Also the cath placements and diagnositic are still not able to be coded because of the stenting correct? thanks for patience and explanations in advance.

35523 or 35525

I love your site! my Physician asked that i send this to you. he is not sure of the codes for this procedure. he had on his list 37799 or 35525. thanks for your help. PROCEDURE IN DETAIL: The patient was taken to the operating room and placed in the supine position. Following smooth induction of general anesthesia, the right arm, hand and upper arm were prepped with Chloraprep Solution and draped with sterile linens. A longitudinal incision was made through the middle scar on the medial side of the upper arm, and with some difficult dissection, the brachial artery was mobilized over about 2 cm and retracted with a vessel loop. A second incision was made transversely just below the elbow through an old scar, and because of the scar the dissection was quite difficult and it was tedious, but ultimately the brachial artery was identified along with the ulnar and radial. It appeared that the ulnar branch was occluded from a previous anastomosis as there were Prolene sutures there. The artery would only have a pulse when the fistula was occluded. The vessels were small and were retracted with a vessel loop. A tunnel was then made between the two incisions, and a 5 mm, 30 cm. long Artegraft was placed through this tunnel after it had been flushed with heparinized saline 8 times with saline. The patient was given 3000 units of Heparin intravenously, and a Martin bandage was placed across the forearm, and a tourniquet was placed just above the elbow and inflated to 250 mmHg pressure. A longitudinal incision was made over the deep artery just below the wrist. An end-to-side anastomosis was fashioned with running 6-0 Prolene. The clamps were released and there was some bleeding through the graft, and the graft was flushed with saline and clamped. The brachial artery above the elbow was clamped and opened longitudinally over about a centimeter and a half, and a tapered vein was sutured end-to-side using running 6-0 Prolene. The clamps were released, and there was a good pulse in the vein and a much improved Doppler signal at the wrist. The two incisions were closed with 3-0 Vicryl and steri-strips.

Repeat cardiac catheterization for staged procedure

I have a cardiologist that is requesting documentation of reasoning for non-coverage/payment of 2nd diagnostic heart cath at time of "staged intervention". He strongly stresses that when a patient had a MI and "rescue intervention"(on thrombosed and stenotic RCA) and then scheduled for staged intervention(stenting) of qualified lesions in the LAD and Cirx, that a repeat LHC is the "standard of care" and should be charged. Timing between "rescue" cath and "staged" intervention was approx. 3 weeks. Per physician's H&P, procedural dicatation and discharge summary I cannot locate any additional documentation of change in patient status. In discharge report on this patient he states..."is 59-year-old gentleman who was admitted for straight stenting, and recent history of acute coronary syndrome, and RCA stent placement by Dr. in January of this year. He was admitted for planned PCI of the LAD and circumflex."  If possible would prefer reference sites/links to provide "offical" documentation to cardiologist. Thank you.

76937 and 36251 - 36254

Do the new renal angiography codes include US guidance, 76937?

33225, 33224, 33264

Dear Dr Z, Thank you for all of the help you have given us in the past! We are having difficulty reaching a consensus for this particular situation and would appreciate your guidance. The procedure preformed is stated below: PROCEDURE PERFORMED 1 Removal of the old ICD 2 Positioning of left ventricular pacing lead in the coronary sinus 3 Replacement with new ICD generator Several of us think it should be coded 33241, 33225, & 33230 based on the part of the code description that says "insertion of pacing electrode...with attachment to previoulsy placed generator". Others believe it should be 33224 based on the part of the code description that says "including revision of the pocket, removal, insertion, and/or replacement ofexistion generator" Thank you in advance for your help. Debra Patterson, RHIT

33264

How do we code a patient who has a dual chamber ICD in place and comes in for an upgrade to a Bi-V ICD? We would be removing the dual chamber ICD, inserting a Bi-V ICD device along with inserting the LV lead (the RA and RV leads would remain in place from the old ICD and just get hooked up to the new Bi-V ICD deice along with the newly inserted LV lead). Thanks! Sarah C.

Lower extremity venous revascularization

Good Morning, When a stent and or angioplasty of the lower extremities are performed on the venous side do we use the new lower extremity intervention codes (37220 -37239). I would say not.  Please advis.

venography 75860, 75820, 75827

Hello, Would the codes 36010/75827/75820 be incorrect based on the documentation below? I thought the unlisted code 36299 for the jugular access because it is not documented that the catheter is in the vena cava. Should this be 75860 or is there enough to bill 75827/75820? Thank you in advance. PROCEDURE: LIMITED CENTRAL VENOGRAM. CLINICAL DATA: 46 YEAR OLD FEMALE STATUS POST ORTHOTOPIC HEART TRANSPLANT. INABILITY TO PASS GUIDEWIRE INTO RIGHT ATRIUM FOR CARDIAC BIOPSY THROUGH RIGHT INTERNAL JUGULAR VEIN. OPERATORS: AMULURU, MOLVAR. MODIFIER GC - THIS SERVICE HAS BEEN PERFORMED IN PART BY A RESIDENT, DR. AMULURU UNDER THE DIRECTION OF A TEACHING PHYSICIAN. DETAILS: AFTER DISCUSSION OF THE PROCEDURE, INCLUDING ITS RISK, BENEFITS AND ALTERNATIVES, INFORMED CONSENT WAS OBTAINED. PATIENT WAS PLACED SUPINE ON THE FLUOROSCOPIC IMAGING TABLE. THE RIGHT NECK WAS PREPPED AND DRAPED IN USUAL STERILE FASHION. THE RIGHT INTERNAL JUGULAR VEIN WAS ACCESSED WITH A 5-FRENCH MICROPUNCTURE KIT UNDER ULTRASOUND VISUALIZATION. CONTRAST INJECTION OF THE 5-FRENCH SHEATH DEMONSTRATED PATENT VISUALIZED RIGHT INTERNAL JUGULAR VEIN AND RIGHT BRACHIOCEPHALIC VEIN, WITHOUT SIGNIFICANT STENOSIS. WIDELY PATENT SVC. THE 5-FRENCH SHEATH WAS REMOVED AND HEMOSTASIS ACHIEVED WITH MANUAL PRESSURE. A STERILE DRESSING WAS APPLIED. THE PATIENT TOLERATED THE PROCEDURE WELL WITHOUT IMMEDIATE POSTPROCEDURAL COMPLICATION. IMPRESSION: PATENT RIGHT INTERNAL JUGULAR VEIN, RIGHT BRACHIAL CEPHALIC VEIN AND SVC.

75822

I am having difficulty coding a case for a left and right common femoral vein angiogram. The op states the groin was prepped and draped. Using 1% lidocain and micropuncture needle, access was obtained in the right common femoral vein, however the wire could not be advanced and therefore contrast was injected. This showed complete occlusion of the right femoral vein with collaterals across the abdominal wall. Access was obtained on the left. A 4 French micropuncture needled was used to access the vein, however the wire could not be advanced and therefore contrast was injected. This showed left femoral vein to occluded as well with collateral. The suggested codes was 75716 and 36140. I don't agree with codes selection, but unable to come up with anything else. Thanks in advance for your help.

Ultrasound of soft tissue mass of back

Would it be correct to code 76775 (US, retroperitoneal, limited) for soft tissue mass of the lower back? If not, what code would you recommend?

35571 35671

Greetings, This site is great and I appreciate all the work that goes into the publications. I also appreciate the quick turn around time with questions. KEEP UP THE GOOD WORK!!! I hope you can help with the following. PT. has a fem -pop bypass. The proximal anastomosis is patched angioplastied with an accessory saphenous vein. The distal anastomosis has a stent right before the anastomosis that was not functioning correctly. The surgeon then does a bypass around the stent to restore proper blood flow. Code 35897 and 35881 are mutually exclusive. Should I just bill the 35881 with a 22? Any advice. Thanks, LW

34900 versus 37221

Pt is brought to IR lab for treatment of left common and external iliac artery stenosis with lifestyle limiting claudication. The patient was also noted on recent MRA to have left common iliac artery aneurysmal dilatation. He used a 8x100 mm Viabhan stent to dilate the stenosis and exclude the aneurysm. He notes excellent exclusion of the aneurysm and 0% residual stenosis following placement and dilatation of the Viabhan stent. What would you code for this procedure? 37221 LT or 34900

50394 versus 50390

Can you please clarify your instruction on page 283, point 3 of the Interventional coding book regarding the use of code 50394? "Use code 50394 for the injection of a newly placed or pre-existing nephrostomy tube" Is newly placed referring to the same encounter? Thanks for your help.

36200 with 37221

I think I have read all of the Q&A's regarding coding catheterization with the lower extremity revascularization codes and haven't seen this one. Pt has catheter access into left common femoral artery with advancement to the abdominal aorta for lower extremity run-off = 75716 (abd angio was not done). Catheter is advanced into the aortic arch for arch angiogram = 75650 then pulled down into the left common iliac for insertion of stent = 37221. My question, can 36200 be billed since the catheter was inserted into the aortic arch from the same access site? I know that if the catheter is inserted into the carotid, renals etc I would be able to bill for the selective cath and if the catheter were only advanced into the abdominal aorta then I wouldn't bill for it. I'm just not sure about the non-selective cath into the aortic arch since the angiogram is of the carotids and subclavians. Thanks for your help.

37226 and 75625

Dr Z I have had two denials for 75625/26 from two different insurance companies saying this code is bundled with 37226. I thought this could be billed or has something changed? Thank you,

Upgrade of a dual chamber device to a bi-ventricular

We have a coding question regarding the upgrade of a dual chamber to Bi-V generator, this applies to both a pacemaker and ICD. We have two patients that had an upgrade generator and LV lead placed. Per CPT, page 170, under “When the battery of a pacemaker or ICD is changed”. Does the upgrade from a dual to Bi-ventricular count as the upgrade? Are thoughts are that we code 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) Because we didn't replace any of the exsisting RA and RL leads. Is this thought correct? OR do we code 33225 in additon to what?? We keep hitting edits because we are not submitting any other device codes.

33870

Please do NOT include any actual patient medical records with your question. I have a surgery that I have never coded before and I am lost on this area. patient has Subclavian Steel syndrome with significant stenosis of left common carotid and innominate artery. Surgery performed was Resection of the aortic arch and head vessels with debrancing of the head vessels. resection of left subclavian artery with graft, resection of left common carotid artery origin with graft, innominate resection of origin with graft. Patient was cooled and circulartory arrested, placed on bypass. carotid and subclavian endarterectomized. Resected aortic arch in a patch fashion and resected the head vessels. we selected out a trifurcated 30 mm branch graft and created a nice patch with the head vessel branch grafts intact. 30 mm and 10 mm innominate, and 8 mm left cartoid and left subclavian branch graft. With the arch anastomosis completed we placed bioglue around to seal all suture lines. I think the 35301 for carotid endartectomy would be correct and 35311 for the subclavian and 35311-59 for the inominate. I am totally at loss for the Aortic resection and the debranching. Can you guide me. I may be totally off on this one. Thank you.

Attempted ICD

Dr. Z, This help clarify the correct coding for the following 2 part question: Pt has an AICD that is nearing ERI but would benefit from an upgrade to BiV ICD as she has wide QRS complex, RBBB, shortness of breath, as well as functional Class and EF of 15-20%. History: Ischemic cardiomyopathy, CHF, VT, CAD with CABG and AICD. Procedure: Planned upgrade of a dual-chamber implantable cardioverter defibrillator to biventricular implantable cardioverter defibrillation. Pt was brought back to the cath lab. Informed consent obtained. On examination of the skin, there appears to be active cellulitis of the back and the procedure was cancelled. I coded 33249-73; is that correct? Secondly, when pt is readmitted for the upgrade to BiV would codes 33249 and 33225 be appropriate and how do we bypass the edit for the QO modifier as this is not a new preventative AICD placement? Thanks very much for your help.

35583, 35682

Hello... not sure how to code for a left insitu fem-pop bypass with harvested cephalic vein (because of insufficient length of left saphenous vein). Would this be coded 35583 and 35682 or would 35556, 35682 be more appropriate? Would 35500 be appropriate to use for the cephalic vein harvest? Thank you, Lara

Pacemaker to ICD 33249

Please do NOT include any actual patient medical records with your question. The patient had a biventricular implant AICD with removal of permanent pacemaker generator and right ventricular lead. The pacemaker and leads were carefully dissected out. Modifierd Seldinger techniques was then used to place two 9-Fr sheaths in the left subclavian vein. Therough these sheaths passed the endocardial leads. Right ventricular lead was positioned under fluoroscopic guidance in the right ventricular apex. Attempts were made to cannulate the coronary sinus with an Attain guide - cannulation was difficult. Using combination of catheters he was able to tie down the coronary sinus os. Once this was identified a deflectable-tipped catheter and a extra large curved Attain guide was used to cannulate. balloon tip catheter was placed in the coronary sinus. Coronary sinus venogram was performed in the LAO position. I was unable to pass the balloon catheter past the thebesian valve, but the coronary sinus venogram demostrated small lateral and anterolateral branch and a moderate size posterolateral branch. Initially, the left ventriculat lead was placed in the anterolateral branch, but after removal with Attain sheath there was evidence of dislodgement with elevated pacing threshold. Because of this, this was not felt to be a viable branch and the coronary sinus was recannulated and using Attain Select II catheter posterolateral branch was cannulated. The left ventricular lead was placed over a guidewire into the posterior lateral branch. After appropriate sensing and pacing parameters were confirmed, leads were secured. Once the leads were secured, the existing right ventricular lead was freed up and this was removed under fluoroscopic guidance with gentle traction w/o any resistance. The pacemaker was disconnected from the pacemaker leads and the pacemaker generator was removed from the pocket. The leads were connected to the defibrillator. Defibrillator was then placed in the packet. Defibrillation threshold testing was performed. I coded as follows: 33249, 33234, 33233, 93641 should I also charge for the fluroscopy as well as the venogram? Thanks, margie.clarkrn@yahoo.com

Pacemaker upgrade

Hi Dr. Z - We can't wait to see you in Boston this year but until then we are confused as to how to code this scenario using the 2012 CPT codes. What are the CPT codes for upgrade of a dual chamber pacemaker to a biventricular pacemaker with insertion of an LV lead? (Patient retains RV and RA lead with removal of Dual chamber generator, insertion of new Biventricular generator and insertion of new lv lead). Thanks so much!

62270, 62311

Patient with stroke/tia, evaluate for NPH. LP was performed with 4 vials submitted and additional 6ml for cytology. Opening pressure was normal. Then, the patient was injected with I 111 for nuclear med study, cisternogram. 62311 and 78630 seems like you are missing revenue for the initial LP.

MADIT II and Medicare NCD

Good Morning, We are having some difficulty with medical necessity for an ICD. Our facility has created a form based on the Medicare NCD to ensure patients are meeting the criteria for implant. We have a patient that is falling out based on class I heart failure. The physician has stated the patient still meets medical necessity because they are meeting the MADIT II criteria. The patient has ischemic cardiomyopathy, h/o MI, and EF of 25% and class I heart failure. Can you please help us determine if patients that are meeting MADIT II criteria automatically meet the Medicare medical necessisty criteria for implant? Thank you for your assistance!

Declot with Trellis, 36870

Hello: I am hoping you can verify my coding and using code 37201 for Thrombolysis of AV loop graft, total of 15 mg of TPA used in isolated system. I am looking at coding 37201,35476,36147,75896-26 & 75962-26 A small incision was made to expose graft. there was no pulse in the looop graft at all. Access was accomplished through a pursestring and wire was passed up the venous end and then venou end fistulgram was performed showing the vein stopped right at the venous anastomosisi and it appeared that there was some stenosis at the venous anastomosis. Trellis 6 sytems was performed on the venous end for 2 treatments of each 10 cm long. Then Trellis of the arterial end was performed by micro puncture through the skin. Again, an additional 5 mg of TPA for total of 15 and arteriogrm showd fairly good resuts. There was one area in the very proximal end that showed stenosis, this was done with a 6 mm x 4cm balloone at 5 atmospheres of pressure for 3 minutes. Thanks for your assistance!!

62272

Dr. Z, My question to day is, Radiologist using fluoro placed a drain in the subaracnoid space to monitor the CSF pressure for a patient going to surgery for an endovasc thoracic procedure. I looked at the codes and guidance for epidural drains in your book, but could not find what I am looking for. Anesthesia provided a tray that we used, so I have checked the CPT book under anesthesia codes, but did not find the answer. I would appreciate your help! Thank you, R Mercer

X-ray of abdomen showing contrast in stomach and duodenum

How would you code the following? RESULT: Portable supine view of the abdomen shows contrast in the stomach and duodenum, injected via the gastrostomy tube. The bowel gas pattern is unremarkable. Scoliosis is again noted Thanks

Modifiers 76 and 77

Dr. Z, I bill for a hospital. Is modifier 76 and 77 based on whether the same or different radiologist reads the film? Example: Two hip x-rays done on the same ED visit for dislocated hip. The first one shows the dislocation and the 2nd one confirms that it was reduced. Some of the coders thought the modifier is based by the ED doctor and not the reading radiologist. Thanks for you guidance. Michelle,

37201

Hi Dr, If a patient has a CTA which demonstrates a Thrombosis in the aorta and one in the CFA. Radiologist and the vascular surgeon have a discussion to transfer the patient and do a Thrombelytic therapy and the Radiologist does an angiogram which shows the Thrombosis in the same locations as the CTA before starting the TPA, can we will a diagnostic angiogram. I would think not, your thoughts.. Thanks

75630

Hello Dr. Z I have a question when it comes to cpt code 75630 vs. 75625 and 75710. In the case below i am more inclind to use 75625 and 75710. one of the things holding me back from using this is no catheter movement documented (75630). But un the other hand i dont have medical necessity or finding for a bilateral extremity study. all that mentioned for is the Lt CFA and SFA. thanks, ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Procedure: pelvic angiogram Both groins prepped and draped in the usual sterile fashion. 5F micropuncture set and USG used to access both CFA. 035 bentson wire was advanced from the CFA through the iliac artery and into the abdominal aorta. 5F vascular sheaths placed. 5F Pigtail catheter was advanced over the wire from the L access into the abdominal aorta used for aortogram and pelvic arteriogram. This showed infrarenal aortic thrombus and thrombosis of the L CFA, SFA. 5F Cobra catheter used from the R groin access to advance access into the contralateral CFA and SFA. 100cm MTI catheter with 20cm infusion length inserted across CFA and proximal SFA. L access pigtail catheter exchanged for 5F MTI with 5cm infusion length placed across aortic thrombus. Imp: 1) aortic thrombus and L CFA, SFA thrombosis, s/p initiation of TPA

35654 and 3556 or 35656

Question: We have a patient who has severe peripheral vascular disease in which the docotor performs axillary-femoral-femoral bypass graft other than vein, which we are looking to code 35654. But they physician also places a femoral-popliteal bypass graft which the proximal anastomosis is attached to the axillary-femoral-femoral graft then to the distal popliteal artery. Would this be billed separately? Or would a unlisted code be more appropriate? Any help on this code would be a great help!

venous embolization 37204

Please verify if these codes for this procedure are correct. 36011, 76496, 37204, 75894,75898 Thanks! Report History: 18-year-old male with chest wall vascular malformation status post embolization in August of 2011. He notes worsening symptoms of chest pain since the embolization. The procedure was performed using general endotracheal anesthesia. After obtaining informed consent, the patient was placed on the interventional table and placed under general anesthesia. Percutaneous catheterization of the internal mammary vein was performed a under ultrasound guidance and a sheath placed into the feeding vessels supplying the venous malformation. Diagnostic study of the venous malformation was compared to previous study of August which demonstrated more thrombosis but persistent flow. Superselective catheterization of the more lateral compartment of the malformation was performed and multiple coils placed within the large central vein. Follow-up after embolization showed persistent flow and the remainder of the malformation was treated with a embolization with 100% ethanol. A total of 15 mL was injected in 4 to 5-mL aliquots x 3 with each injection followed by 10 minutes of observation and repeat injection. At the termination of the procedure, follow-up injection showed complete thrombosis of the lesion. The patient was awakened from general anesthesia and the catheter was removed sent to the recovery room. He tolerated the procedure well. Impressions: 1. Superselective catheterization of the chest wall malformation via the right internal mammary vein. 2. Venography of the chest wall malformation showing persistent flow 3. Embolization of the chest wall malformation as noted above. 4. Follow-up injection showing thrombosis of that portion of the treated malformation.

heparinization and 93458 and not 93463

Good morning, After checking national CCI edits we have a question. When billing for a cardiac cath 93456 is the heparinization inclusive (CPT 93463) or billable separately? We ask because the description of 93456 says includes contrast imaging. Thank you, Jackie

33264, 33225, exchange of dual generator to multilead generator with LVL pl

how do we code replacement of ICD generator with attachememt to existing right atrial and right ventricular lead and insertion of new CS lead using 2012 codes. Doesn't 33249 still include insertion or replacement of one or more right leads? Currently 33225 can't be used with 33262, 33263 or 33264. Medtronic and Boston Scientific and 3M all tell me that they are waiting for clarification from AMA on this particular coding scenario. I'm hoping you have more insight because we seem to be doing a flurry of these at the moment. Thanks

50395

I have been reading the recent Q@A responces to questions about procedure 50395 and have another question on this subject. In the cpt book under code 50395 it states to see 74475,74480 or 74485 for RS&I. Would it be appropriate to bill 74475 or 74480 along with 50395 when the radiologist is placing a sheath or catheter in the kidney or bladder for preparation for nephrolithotomy that is being done by urology immediately following this procedure by the radiologist? I'm not understanding when 74475/74480 would be used with 50395. Thank you for your help.

Thrombin injection with balloon occlusion

Hi, We have a question about a thrombin injection of a right SFA pseudoaneurysm with the use of a ballon to blcok the vessel. We understand code 36002 and 76942 is assigned for the injection. However, should we also add 36247, 75710, and ?37799 for the balloon blocking portion? Thanks! "We felt lower extremity angiography with balloon blocking of the neck would assist with the procedure and prevent thrombin from migrating into the native vessel. Access was obtained via the left femoral artery. We crossed over using a rim catheter with angled Glidewire. We then were able to exchange for an Amplatz wire. We then placed a Destination sheath. We used a 5 x 40 balloon to block the neck of the pseudoaneurysm, which was visualized under digitally subtracted images. Using ultrasound guidance, we injected the pseudoaneurysm. Ultrasound color Doppler showed no flow afterward. All equipment was removed, a runoff of the right lower extremity was taken. A selective angiogram shot of the left femoral access was taken and a 6-French Angio-Seal was deployed to obtain hemostasis."

Reporting medical devices packaged in a kit

Dr, Z Some of our facilities are going to start using the Medtronic Revo MRI SureScan pacing system. Out dilema is this. The company packages and bills for this as a complete system including the Revo MRI SureScan IPG and 2 CapSureFix MRI leads. On the invoice there is only 1 price for the complete system. The patients are usually outpatients and therefore we need HCPC codes for the generator and the leads. Is it appropriate for us to split up the package price and designate part of the cost to the generator and each of the leads? If not, how do you suggest we code/bill for this pacemaker system? Thanks! Judy