Ask Dr. Z

Node biopsy and 19295

Can I charge 19295 for clip placement when a internal mammary lymph node was biopsied and a clip placed to mark the biopsy site for future reference? I also charged 49180 and 76942. Thank you for your assistance.

Pacemaker pocket revision

Dr Z, Could you review the below procedure and advise how you would code? The patient had a pacemaker inserted two months ago and was complaining of pain at the generator site. The pocket was opened and the generator removed. Thresholds were tested and noted to be within normal range. The pocket was flushed and the generator was then reinserted but with pacemaker wires repositioned on top of the generator instead of the bottom. If I understand correctly, this would not be a lead repositioning since the leads were moved in the pocket and not at the heart so was leaning toward unlisted 33999. However, in reading the Q&A from November 22, 2011, should this be considered a pocket revision although only the leads were "revised" within the pocket? Please explain. Thanks.

Nurses performing PICC line placement

Hello Dr. Z. Your response to this question is very important to us. We are receiving many reports describing PICC line placement for inpatients by a nurse supervised by a physician who is available if the nurse needs help. A physician reviews films before and after the procedure, makes suggestions to the nurse, and sometimes evaluates the patient. Is it OK for the physician to charge 36569? If he cannot code for the PICC placement, is there another more suitable code? Thank you very much for your help.

Fontan Fenestration dilation

Dr Z, What is the appropriate code for balloon angioplasty of a Fontan fenstration? " we then turned out attention to the Fontan fenestration. We crossed the Fontan fenestration with a coronary wire and glide catheter. We then exchanged the Glide catheter for an Apex RX 4.5 mm x 20 mm balloon. We advanced the balloon over the wire, across the Fontan fenestration and made a total of 3 inflationsfor a total of 6 seconds each. We then repeated the IVC angiogram and this revealed much improved shunting throught the Fontan fenestration and a slight drop in arterial saturations." Cath lab is using 92992, however I don't think that's correct. Is this an unlisted 93799 or would it code to a valvuloplasty code? Thanks!

Code G0448

Dr.Z Your recent conference in Vegas was great-- so helpful in understanding the new codes for 2012. Thank you again. My question is would you please explain the new G-code G0448.

Breast wire localization each additional

I have a quick question regarding breast wire localization.

I am looking for clarification on the use of CPT 19290 and 19291.  Can 19290 be used for a lesion per breast or does the second lesion in the opposite breast default to the 19291? I attached a link to the newsletter I found with a reference as the examples of 19290 in the Q & A are limited. If so would you use -50 or -59 on the 19290?

Any help would be awesome.

Arteriograms in the OR

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

Venous Sampling

Hello,
Is the parathyroid glands considered one gland or can we code times four if blood was sampled from all four gland. Thanks,

RF ablation for sympathetic renal denervation

Dr. Z, One of our facilities is going to participate in a clinical trial for the radiofrequency ablation of the renal sympathetic nerves for the treatment of resistant hypertension. I have not found much information on the coding of this procedure so I am hoping that you can help. What do you recommend? Thanks! Judy Den Herder

Charges for bilateral renal angioplasty

Regarding bilateral renal angioplasty 35471-50. Following renal angiography: “An intervention was initially performed on the superior left renal artery, which represented in-stent restenosis. A LIMA guide utilized. A Whisper wire advanced distal and balloon inflation with a 5 x 15 balloon at 12 atmospheres. Final angiogram: No residual stenosis. Attention was then turned to the right renal artery. Guide engagement 0.014 Whisper wire advanced distal and balloon inflations with a 4.0 balloon. There was significant recoil and it became obvious that stenting would be required. A 6.0 x 18 balloon-expandable stent was deployed at 10 atmospheres. Final angiogram: No residual stenosis.  Would you charge 35471-50 or 35471 times two (that is, two separate line items)? Of course, also charge for stenting of right renal artery. My belief is that we need to have a separate charge in the CDM for 35471-50 and that it is not correct to charge either 35471 (unilateral) and append a -50 OR to charge 35471 times two. In the first situation, I don't think we'd be reimbursed properly for the physician's extra risk, work, skill, and time and in the second situation, I think it could be construed as overcharging. I REALLY APPRECIATE YOUR HELP.

37205 vs 37221

Hi Dr. Z. could you help us out with this senario? Patient presents with clinical characteristics of Lerich syndrome. Pt. was denied MRA. Initail Lt. radial approach. Catheter placement in AO above the renal arteries. Abd AO with Bi-Lat Runoff. There was a 3.5cm occlusion of the abd ao to the aorotoiliac bifurcation. Since the equipment in stock might not reach, due to the distance, both fermoral arteries were cannulated. Kissing balloon angioplasty followed by kississing stent placement. Comments and Conculsion: Leriche syndrome distal abdominal occlusion extending into both cmn iliac arteries, successfully recanalized and stented with visis-pro stents. Would this be??? 36200-59, 75630-59 and 37221-50???? Or would you just code 36200 x3 w/59's 75630 -59 37205 and 75960??? Thank you very much!

Discontinued vertebroplasty

The patient was positioned for the procedure on the scanner, and scout images obtained for CT-guided vertebroplasty.After establishing pulse oximetry, BP and EKG monitoring by the radiology nurse, moderate sedation with Tordal and Fentanyl was administered. My intra-service time was less than 30 minutes. Despite the administration of IV pain medication as above the patient could not tolerate the positioning for the procedure. He demanded that we stop the procedure. It was therefore terminated, before any steps of the vertebroplasty were initiated. This is an outpatient. Could we use a modifier 74 for this?

Reposition PICC line during AV fistulogram

Please do NOT include any actual patient medical records with your question. I have a question about a internal reposition of a PICC line done during an AV fistulogram. The patient has a right forearm radial artery to cephalic vein fistula. The fistula is punctured, imaging done. Catheter is advanced across the right innominate vein, SVC, into the left innominate and subclavian vein and venogram done of the left arm to look at the possibility of creating an AV shunt on this side. Here is the part of the procedure I am questioning:..."The vertebral glide catheter was removed. We then partially inflated the 9 x 4 P3 balloon at the coil in the PICC line and gently pulled the balloon back in order to resolve the coil. The coil flipped as the balloon passed across this area and we then used the balloon to drag the tip back into the lower SVC. Postprocedure imaging showed the coil to be completely resolved and the PICC line tip was in the low SVC." Should I use 36597 for this reposition or the unlisted vascular 37799? Any guidance from you is appreciated. Thank you.

76937

Please do NOT include any actual patient medical records with your question. Dr. Z, Percutaneous sclerosant injection multiple focal venous malformations of right thigh. This procedure was done by an IR physician by injecting sodium tetradecyl sulfate foam followed after a few minutes and by one amount of absolute ethanol. However before IR physician stared the procedure the US department provided sonographic guidance for cannulation of multiple malformations in the right quadriceps muscle. The ultrasound department wants to charge this with 76998 along with IR phycian charges for sclerosis. Is this a appropriate charge for guidance here? Thanks

75989 more than once

A patient with renal infection and at least 3 separate abscess cavities. Post abscessogram, 3 separate drainage catheters were placed using Seldinger technique. How many times do we assign 75989? Thank you

Radiopharmaceutical injected but scan never done

Can we attach a modifier 52 to the study below to recoup some of the cost? Inpatient had blood drawn for a white blood cell study on Tues Dec 6th and the radioactive tracr was reinjected that same day. We were to obtain delayed images after a 24hr period, but on Wed the pt was tired and refused to come down to dept for scan. The pt was contacted on Thurs Dec 8th for 48hr delays to complete the study, but once again the pt refused the scan portion of test and was discharged. My question is "Should I cancel the study and eat the cost of the medication, or is pt responsiblee for dose charge?

Valvuloplasty and cardiac catheterization

Does 92986 include a cardiac cath 93531?

36252, renal stents, renal catheter placements

The following procedure was perform in the Cath Lab. A Heart Cath procedure was not performed. Abdominal Aortogram, Selective Bilateral Renal Artery Angiogram Angioplasty and stent of the Right Renal Artery Angioplasty and stent of the Left Renal Artery Description: Access was obtained in the right femoral artery and the abdominal aortogram Selective LT renal artery angiogram was performed. The proximal renal artery had a 90% stenosis and a lower pole branch that came off right at the stenosis.Angioplasty was performed stent was employed. There was no residual stenosis and the branch was saved. Attention was next turned to the right renal artery. The 99% ostial stenosis was pretreated with angioplasty and stent . Final results showed no persistent stenosis and no embolization. Would codes 37205, 37206 and 36245-50 be correct for this procedure?

AV shunt intervention 35475 35476 36148

I haven't had an AV fistulagram w/3 accesses in a long time. Would you please review the codes and let me know if I'm close? "Using US guidance access was gained in the left brachiocephalic vein fistula & directed up the arm centrally for a cephalic venogram, central venogram, & fistulagram (36147) followed by US guided access of the cephalic vein directed down the arm through which a sheath was placed & the catheter placed into the brachial artery for a brachial angiogram & fistulagram followed by angioplasty of the cephalic vein in several locations due to severe stenoses as well as angioplasty of the severe stenosis of the arterial anastamosis (36148, 34575, 75962) followed by a brachial angiogram & fistulagram followed by access of the cephalic vein directed up the arm for venoplasty of the cephalic vein subclavian vein junction followed by a fistulagram (36148-59, 35476-59,75978-59).

75774

We often had multiple sclerosis patients with chronic cerebrospinal venous insufficiency that present for venous interventions the internal jugular veins, subclavian veins and the azygos vein. We have no problems coding the procedures and cath placements except for the S & I code for the venography of the azygos vein (additional vessel. In the past the coders have been instructed to use 75774. I did not agree and now with your answer to question number 1 in the December newletter I know that we have been coding these incorrectly. I suggested that we use 76496 - unlisted fluoro procedure (eg diagnostic, interventional. Is this the appropriate code to use in this instance or is there a better code? Thanks for your help with this matter. Judy Den Herder

Definition of subselective angiogram versus superselective

Hello, If you can please explain for me what Subselective angiogram actually means. Does subselective mean higher than first order? In the example provided below do I have enough documentation to support anything higher than a first order? Codes 36245 or 36247, 75726 and 75774 Thank you in advance for all your help and feedback.. Here is an example: The catheter was again used to gain access into the IMA and an angiogram revealed the vasospasm had been relieved. The microcatheter was again placed and a GT 018 wire was now used. Several other bouts of vasospasm slow progress however subselective angiogram of all the LEFT upper quadrant arterioles revealed no active extravasation.

G0269 with 36251-36254

Hello Dr Z! I was wondering regarding the renal codes for 2012, 36251, 36252, 36253 and 36254, all thou it does not say it in it's description, but is the closure device to be included in the charge as they were for the cardiac cath /endovascular revascularization codes for 2011?

Cutting balloon

Greetings! Maybe you could clear things up with a quick question. If a cutting balloon is coded in the coronary arteries as Percutaneous Transluminal Coronary Atherectomy(92995) Can't you code a cutting balloon used within a dialysis graft as Atherectomy Brachiocephalic(0237T)? Thanks, Melissa

75710 vs 75716 obliques of pelvis

Dear Dr. Z: Via rt fem access catheter is placed into the lower abdominal aorta. Pelvic angiogram and left lower extremity angiogram was performed. Pelvic angiogram discusses right and left common femoral arteries, internal iliac arteries and right external iliac artery. Lt extremity angiogram discusses profunda femoris, superficial femoral, popliteal, anterior and posterior tibial funoff to the foot. Is it correct to assign 76716 for the angiography or must only 75710 be assigned since the right superficial femoral is not mentioned? SIR IR Coding Users' Guide, pg 293, Q24 indicates "The entire leg does not need to be imaged for the bilateral extremity angiography code (75716)to apply. One does not need to use reduced services modifier -52 if imaging is only done to the knees." Thank you. mlb

Direct needle stick into a non-vascular lymphatic system for treatment

Hi Dr Z, I need help with coding this case. The diagnoses are Lymphatic leak/cholothorax. Bilateral cutdowns were done on the dorsum of each foot, lymphatic channels were cannulated and Ethiodol was slowing injected for 1 hour with fluoroscopy used to observe lymphatic flow. Diagnostic lymphangiogram under fluoroscopy of the pelvic, abdominal, thoracic and neck areas was done. Extravasation was noted at the L1/L2 level. The abdomen was prepared. Using direct stick technique under fluoro guidance the area of extravasation was directly studied. Embolization was then performed using nBCA. Is 37204 appropriate here or should an unlisted lymphatic code be used?

IV adenosine administration to check for atrial flutter pre EP

I haven't run across this before and I'm not sure how to code it on both FAC and PRO side. Pt was brought in for possible DC cardioversion for possible atrial flutter. Anesthesia was provided by anesthesia colleagues. In order to evaluate whether or not the patient had underlying atrial flutter the patient was given IV Adenosine 6mg at 10:04 and 12mg at 10:06 (by the cardiologist). With ensuing bradycardia no underlying atrial futter was noted. Response consistant with sinus rhythm. In summary, pre-op and post-op diagnosis were normal sinus rhythm with cardioversion being cancelled. Do I code 92960-74 or 96374 (IV push) for the FAC side and just 96374 on the PRO side? Thanks for you assistance.

Open thrombectomy with a Fogarty catheter

Dr. Z, Doctor makes incision in leg and does thrombectomy(34201).Then places catheter in aorta,does aortagram multiple areas of thrombus. Removes thrombus from right renal(37186), removes thrombus from left renal(37186), catheterizes the celiac(36245 75726)cannot remove thrombus, catheterizes the SMA (36245 75726)no thrombus found. Dr. then opens arm and removes thrombus(34101. Dr. marked his bill 36245, 36245,36245,75625,75710, 37186 x 2,34101 and 34201. How would you bill this? Thank you

76000 for lead check

Hi Dr.Z, We need your help. There are at least 6 case reports of failure on a lead that we have used on many ICD patients, not an official recall (yet). We want to do prophylactic lead checks on these patients. Can we bill 76000 in this scenario? As always, thanks for your help and guidance.

Valvuloplasty and dx heart cath 92986

Dr Z, one of our commercial payers is denying payment for 93531, 93567 and 93565, stating it is included in 95986. They state: "Coding guidelines for valvuloplasty state: 'Do you code for heart catheterization if performed during the valve intervention to document pre- and post-intervention findings. All catheter placements, contrast injections, imaging and S&I to perform the valve replacement are bundled.' The business office and cath lab are requesting I persue this further. Part of my problem is I am not certain the H/C is reportable. I don't see it dictated as a separate diagnostic procedue I would really appreciate your opinion on whether or not we can report 93531,93564 and 93565 in addition to 92986. Thank you JM Technical Procedure(s): 1.Procedure(s) (LRB): CD COMBINED RHC & LHC RETROGRADE (CHD) (N/A) 2. CD VALVULOPLASTY AORTIC (N/A) INDICATIONS/BRIEF CLINICAL HISTORY who has been followed for a aortic valve stenosis. has been healthy with no significant cardiovascular complaints except new onset fatigue with activity. presents for cardiac catheterization and balloon aortic valvuloplasty. PROCEDURE NOTE Upon arrival to the catheterization lab, was placed under general anesthesia and was endotracheally intubated by the staff anesthesiologist. He was secured to the cath table and was prepped and draped in a sterile fashion. 1% Lidocaine was infiltrated into the skin and soft tissue around the right and left femoral vessels in order to achieve local anesthetic effect. A modified Seldinger technique was used to obtain arterial and venous access. A 5F sheath was placed in the right and left femoral vein. A 5F sheath was placed in the right and left femoral artery. 100 Units/kg of heparin were given through the venous sheath. Antibiotics were given. A 5F wedge catheter was placed through the venous sheath and was advanced to the level of the SVC. The 4F pigtail catheter was advanced to the level of the descending aorta. A full right and left heart catheterization was performed and all appropriate chambers and vessels were entered including SVC, IVC, RA, RV, MPA, LPA, LV, AAO and DAO. Oxygen saturation and pressure measurements were obtained by standard catheterization technique. After the hemodynamic data were obtained, an aortogram was performed using a 4F Pigtail catheter in the standard PA/LAT projections and the aortic valve was assessed for sized and degree of aortic valve regurgitation. The appropriate measurements made. The aortic valve measured approximately 21-mm at the annulus. Using a modified 3F pigtail catheter, the valve was crossed with an 0.018 Torque wire. This process was repeated from the LFA as well for the use of a double balloon technique. Due to the presence of a PFO, we parked Berman angiographic catheter in the LV by way of the LFV and an LV angiogram was performed. We also placed a pacing catheter in the RV via the LFV for rapid RV pacing during balloon inflation. Once double wire position was obtained across the valve, a 10 mm and 12 mmballoons were selected and advanced across the aortic valve. Inflation was then performed during rapid RV pacing until the waste on the balloons resolved. Repeat hemodynamic and angiographic data were then obtained. The catheters and sheaths were removed and hemostasis was obtained by application of local pressure. A pressure dressing was placed and Hunter was transferred to the recovery unit in stable condition. post-procedure course was unremarkable. HEMODYNAMIC DATA Pre-balloon: PSEG = 36 mmHg Post-balloon: PSEG = 9 mmHg SUMMARY successful balloon angioplast of his aortic valve. We were able to drop the gradient down to 9 mmHg without a significant change in the amount of aortic valve regurgitation. He will be observed for several hours post procedure and likely discharged later the same day. Routine follow up was recommended in 4 weeks.

Lead removal and placement

Please do NOT include any actual patient medical records with your question. Have cardiologist that wants to charge 33216(lead replacement,33233(PM removal), 33234(lead removal) and 33222(pocket revision) on patient that required replacement of chronic RA lead due none capture. Per patient's report generator removed, leads tested (noise defect reproduced with pressure on part of lead entering cephalic vein), Chronic RA lead removed, new lead placed, connected to generator, pocket washed with gentamycin saline and pocket closed. Per report no new generator placed and no revision of pocket. My understanding is that 33216 bundles the chronic PM removal and replacement. And documentation not adequate for charge of revision of pocket.Do you have avialable clear instructions on what is included in lead repair/replacement procedures. Thank you for your help. Rick

Drainage of chest wall collection

History: Patient with left chest wall collection here for drainage Procedure: Left chest wall fluid collection drainage with 10-French tube Informed consent was obtained. Risks and possible complications were described in detail. The patient's left chest wall fluid collection was identified and drained with a 5-French needle. We then advanced over wire and placed a 10-French tube. 30 cc of purulent material were removed and sent for testing. Repeat ultrasound confirmed residual fluid and septations. The drain was secured to the skin and we placed some TPA with one hour dwell time in the holding room. The patient will receive one week of antibiotics and will follow with Dr. Gates in pulmonary clinic. Please note the patient was sedated for 30 minutes using 4 mg of Versed and 200 mcg of fentanyl. Impression: Successful left chest wall abscess drainage.

EKGs and cardiac catheterization

I am auditing the CCL of one of our smaller system hospitals that hasn’t been audited since before I joined the audit department a few years ago.  I have discovered that they are CPT 93005 (with and without modifier 59) performed with CPT codes 93458, 93459 & 93460.  The EKGs are ordered as part of the standard pre-procedure routine.  From my understanding, charging for the EKG is not allowed because it’s an NCCI edit.  I discussed this issue with other auditors who agreed that the hospital should not be charging, as our other hospitals that I have regularly audited do not charge for them; but I pulled the “National Correct Coding Initiative Policy Manual for Medicare Services” from the CMS website and in Chapter 11, Section I, Point #14 it states:
This makes me think that the diagnostic EKG that is performed prior to the cardiac catheterization IS billable/reportable as long as it has modifier 59.  What is not billable is any EKG taken during the procedure.  If this is the case, then I need to instruct all of my hospitals to start reporting/billing this charge.  Do you agree?  I looked in your Cardiology reference guide but it only referenced that EKGs should NOT be billed with EP studies and doesn’t address cardiac catheterizations.

Thank you,

Vascular studies performed with vascular surgeon and radiologist

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.

Bilateral needle localization of the breast

I am looking for clarification on the use of CPT 19290 and 19291.  Can 19290 be used for a lesion per breast or does the second lesion in the opposite breast default to the 19291? If so would you use -50 or -59 on the 19290?

Any help would be awesome.

CTA or MRA with catheter based angiography

Is a CT angiogram now considered an equivalent study to a catheter based angiogram?

Why am I asking this question?  Well, each year I print out the NCCI written instructions, place it in a binder in the MD reading room.  I highlight and flag the different practice areas for my physicians here. This is the version that releases in Oct."XX.3."  I was looking last week for this year's release, it is not being released until December this year.  I happened to glance through it and it stated that diagnostic angiography cannot be billed if the patient has had a CT angiogram or prior diagnostic catheter based angiogram.  (Unless of course those were suboptimal images or change in patient status/symptoms).  Has this changed then in the past year or so?  I attempted to find a clarification in your 2011 Diagnostic & Interventional Cardiology Coding book, but was unsuccessful. (I trust your guidance over others!)  Recently, I am seeing more patients coming in having had a CT angio now that suggested stenosis or aneurysm.


NCCI Version 16.3 Chapter 9 CPT 70000-79999- D. 4.--
4. Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59. If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier 52 to the angiogram CPT code. If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure.

It appears that I am not able to charge for a diagnostic catheter based angiogram when  a  patient comes in for a diagnostic study and possible intervention if they have already had a CT angiogram that was a complete study and they have not had any changes in their symptoms.  Do you concur?

Thank you so much for your time,guidance and patience.  Every day is a new day of learning!!!

Canceled paracentesis

Hi Dr Z, I work for a hospital and we have received some conflicting advice on how to code for a cancelled paracentesis. The pt is scheduled for an outpatient paracentesis and taken to the room. A limited ultrasound of the abdomen is done to see if there is enough fluid to perform a paracentesis. Due to limited fluid, the procedure is cancelled. Should we bill for the intended procedure - CPT 49083 with modifier 73 appended or just bill for a limited US with CPT 76705? Your help with this is greatly appreciated. Thank you.

Transgluteal embolic

Dr. Z please advise on the coding for this case. Here are the codes I came up with but I am not sure about the catheter placement for the direct access to the superior gluteal and whether the imaging can be coded as 75736 since that has to be selective and this was a direct puncture. I am coding for the physician.Thanks so much for your feedback. 36200, 36140-59, 75625-59, 37204, 75894, 75898, 75736-59. Hx of left internal iliac artery aneurysm/pseudoaneurysm. Inflow internal iliac artery previously treated with covered stent. Continued enlargement of the mostly thrombosed sac, pt remains symptomatic from mass effect. CT evidence of continued sac pressurization from the superior gluteal artery retrograde flow. Left common femoral artery was accessed with ultrasound guidance. A 5-French straight flush catheter was positioned at the aorta bifurcation to left common iliac artery. Pelvic angiogram redemonstrates the ulcerated plaque with pseudo aneurysmal dilatation of the distal abdominal aorta and diseased but widely patent common and external iliac arteries bilaterally. The left common to external iliac artery covered stent is widely patent and the left internal iliac artery origin is well occluded. The right internal iliac system is widely patent. The targeted gluteal branch is seen to reconstitute via numerous tiny presacral cross pelvic collaterals. No collateral vessel reconstituting the embolic target is navigable to achieve access from an antegrade endovascular approach. Therefore, the patient was rolled prone oblique, left buttock up. The terminal bifurcation of the left superior gluteal artery was accessed just external to the sciatic notch outside the bony pelvis using ultrasound and fluoroscopic guided micropuncture. An angiogram was performed which demonstrates access in the patent superior gluteal artery, and evidence of a short branchless proximal segment culminating in a pulsating pouch of perfusion within the larger thrombosed aneurysm sac. Using a renegade microcatheter, the sac perfusion and the branchless segment leading up to it were successfully coil embolized using numerous 3 to 6 mm coils. Post embolization angiogram was performed from the directly accessed superior gluteal artery demonstrating excellent occlusion, no further retrograde supply to the aneurysm sac.

Hepatic biopsy with pressures

Hello, Could you please tell me if a first order or second order should be billed when doing a liver bx with pressures? The catheter is in the selected Right Hepatic Vein. Contrast is injected. The catheter is put in the Wedge position for pressures. Then core bx is performed. Also, can the venogram w/pressures be billed 75889.59 with 52 for the pressures? Thank you so much.

Canceled biopsy procedure

This question is about canceled procedures. The patient was scheduled for a CT-guided lung biopsy as an outpatient. The radiologist performed an H&P and pre-sedation assessment. A noncontrast CT of the chest was then performed. After multiple attempts at positioning as well as trying different breathing techniques, the biopsy could not be performed because of the inaccessible position of the nodule. Therefore, the biopsy was canceled. A report was dictated for the noncontrast CT scan and includes a description of the events that transpired. There will be a separate claim for the interpretation of the CT chest. Our radiologist wants to know if it is appropriate to also bill an E&M for the H&P in this case. Thank you.

Open ablation procedures performed in the OR by radiology and a radiologist

Dr. Z, In your book there are codes for Open RFA and Cryo Ablations. Am I correct in using this code for when the Radiologist goes to the OR suite and does an ablation with ultrasound guidance, after the surgeon has opened and exposed the liver-- 76940/47380 or 47381? We ususally do the ablations in our department, but I think that these codes should be built in the chargemaster for these types of procedures in the OR. Our department provides the ultrasound guidance and the supplies for the ablation. Thank you, R Mercer

AV fistual revision

Q. My physician has "revision" of brachiocephalic fistula, but i think that this is a new creation. how would you code this? a incision was made over the course of the vein from the old scar just across the elbow. the vein was mobilized over about 4 to 5 cm. there was a large deep branch that was identified, ligated and divided. it was thought that the vein was small in that last 2cm segment and that it could be improved by making a new anastomosis to the brachial artery just above the elbow. the deep fascia was incised and the brachial artery was mobilized ovver about 2 cm. the vein was ligated and divided distally. the pt was given 3,000 units of heparin intravenously. the artery was clamped and opened obliquely. an end-to-side anastomosis was fashioned with running prolene. the clamps were released and there was an excellent thrill. the vein was somehat thick and it was thought large clips would be too big for the smaller size artery. the incision was closed.

Coding for revision versus creation of a fistula

Q. is this a revision or a creation? My doc says a revision I think a new fistula. PROCEDURE IN DETAIL: The patient was taken to the Operating Room and placed in the supine position. Following smooth induction of general anesthesia, the left arm, hand and upper arm were prepped with Chloraprep solution and draped with sterile linens. The incision at the elbow was opened, and a small amount of serosanguineous fluid was evacuated. The vein was identified, and there was no intraluminal clot and there was no pulse when it was totally occluded. The vein was clamped and divided just at the level of the previous vein anastomosis, and there was good backbleeding. The vein was flushed with heparinized saline and clamped. The deep artery was located at the base of the incision and mobilized for about 2 cm. The patient was given 3,000 units of Heparin intravenously. The artery was clamped and opened obliquely. An end-to-side anastomosis was fashioned with interrupted #6-0 Prolene and medium AnastoClip staples. The clamps were released, and there was an excellent thrill and minimal pulse. There was a palpable pulse at the wrist. The incision was closed with #3-0 Vicryl and steri-strips after the stump of the vein had been oversewn with #6-0 Prolene. The patient tolerated the procedure well.

Axillofemoral angioplasty 37224

Wouldn't PTA revascularization of an axillo-femoral bypass graft at the anastamosis inflow of the diatal graft code to 37224? If not, what would it code to? Cath tech is trying to use 35475, but wouldn't the distal graft code to lower extremity revascularization? Thanks for your advice.

Hard copy documentation for ultrasound

Hello, I recently heard a rumor that the Radiologist has to state within the report that hard copy sonographic images were obtain for us to be able to bill out 76942. Is this correct? Your feedback is greatly appreciated.. Thanks so much for all your help....

Sclerotherapy of AVM of lower extremity

DR. Z, Sclerotherapy of AVM for lower extremity. Needle used to access the 3 venous sites involved in the AVM, scleorsed with Sodium Tetracyclic Sulfate infusion. This is done for all 3 areas. We are charging this with 37799 76496 36299. Then bilateral superficial spider veins were sclerosed with STS. Can we also charge 36468 with '50' for this additional procedure? Thanks

DynaCT coding

Greetings, Dr. Z, I have couple of questions regarding coding for this imaging devices; Dyna CT study and 180 degree Rotational angiogram. We have more and more procedures performed with using Dyna CT imaging. Our physicians asking if we can use code 3-D imaging codes (76376/76377) for the time and effort it takes to perform this kind of study including interpretation documented in the report. The following procedures are case examples we need coding clarification please:

1) Fluoroscopically-guided sacral mass biopsy and Dyna CT study was performed to delineate the position of the marker needle in relationship with the sacral mass. Once the position was established, biopsy needle was introduced and advanced toward the lesion. Confirmation of biopsy needle placement in the mass was performed by obtaining a second Dyna CT. (20225, 77012, 76377 Dyna CT post process is always on a separate workstation).

2) Fluoroscopy guided Lumbar kyphoplasty L4 and confirmation of bilateral cannula positioning was performed by obtaining a Dyna CT study. (22524, 72292, 76377)

3) Bilateral renal vein sampling and Dyna CT study (36500-50, 75893, 75893-59, and 76377)

4) Intracranial vessel angiogram, status post clipping communicating artery aneurysm now here for follow-up imaging. Selective left common carotid artery catheterization and angiogram with findings documented, a 180 degree rotational angiogram was also performed during injection of the left common carotid artery with findings documented (36216, 75665, 76377). Greatly appreciate all your recommendations and guidance.

Diagnostic nephrostogram

I have a guestion as to when a study is diagnostic in nature. We currently have a disagreement as to when to code for 47500 and/or 50390.The patient is referred to the radiologist for either a neprostomy catheter placement or a internal/external transhepatic stent placement . The report states that the patient has a stricture and needs a tube placement. The radiologist performs a 47500 or 50390 prior to placing the catheter with I want to code. In the sample below I am coding to 50390 as I see this diagnostic (Findings) and not just for localization. Any feedback would be appreciated.Would this be a diagnostic in nature? I guess my question is if the patient is scheduled for such procedure is any finding not codable? Will give an example: My CPT codes would be: 50390-59, 74425-59, 50392, and 74425 CLINICAL HISTORY: Reason: recurrent cervical cancer s/p posterior exenteration on 7/12/11 at LAMC, progressive right hydro with acute renal insufficiency, please place right percutanous nephrostomy tube, thank you OTHER MEDICATIONS: 1% lidocaine,1mg of Versed and 2mg of Morphine. CONTRAST: 20 ml of Visipaque 320. FLUORO TIME: 78 Seconds PROCEDURE TIME: 30 minutes of conscious sedation monitored by the radiology nurse J. Rigo, RN. FINDINGS: Following careful explanation of the potential risks and benefits of the procedure with the patient and/or family member , oral and written informed consent was obtained. The patient was placed prone on the angiographic table and RIGHT flanks were prepped and draped in the usual sterile fashion. Local anesthesia was achieved with 1% lidocaine. Under ultrasound guidance, a permanent image was recorded, a 22-gauge AccuStick needle was advanced into the lower pole calix of the RIGHT kidney. The stylet of the needle was removed and clear urine returned. Contrast was injected which demonstrated mild hydronephrosis. An 018 wire was inserted and the needle was exchanged with a 5-French dilator. The 018 wire was exchanged with a 035 wire. An 8-French nephrostomy catheter was inserted. The catheter was secured to the patient and connected to a drainage bag. Patient tolerated the procedure well and was discharged from the department in stable condition. IMPRESSION: Successful insertion of RIGHT nephrostomy catheter without apparent complications.

Visceral aortic debranching with gastroduodenal artery to replace hepatic

I'm getting hung up on this one…not quite sure about the debranching and hepatic to gda bypass.
I'm looking at 33881-51/33883-51/34812-51/36200-51/75957 and 35633-22 right now.
am I on the right track?
thank you!

PREOPERATIVE DIAGNOSIS:  8-cm descending thoracic aortic aneurysm.

POSTOPERATIVE DIAGNOSIS:  8-cm descending thoracic aortic aneurysm.

OPERATION PERFORMED:
1.  Thoracic endovascular aneurysm repair with a 32 mm x 32 mm x 160 mm Medtronic Captiva graft with a 36 mm x 36 mm 159 mm Captiva extension piece.
2.  Multiple aortograms
3.  Visceral aortic debranching with a gastroduodenal artery to replace right hepatic artery bypass.
4.  Right external iliac artery to replaced right hepatic artery bypass graft with an 8-mm Dacron.
5.  Left common femoral artery cutdown.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  600 mL.

RADIATION:  765 milligray (19.9 minutes photo time).

CONTRAST:  57.5 mL of Visipaque.

INDICATIONS:  This 79-year-old female with descending thoracic aortic aneurysm, who is being worked up for possible endovascular intervention with Dr. Michael Lazar and myself.  Aortic debranching of the celiac artery and superior mesenteric artery was necessary for being able to perform this in an endovascular fashion as the aforementioned vessels came off the distal aneurysmal segment of the aorta.  I discussed with the patient that given her given her overall health that the least invasive option would be to utilize her replaced right hepatic artery anatomy and use this vessel via the gastroduodenal artery to connect the replaced right hepatic artery.  The superior mesenteric artery was while not in a particular aneurysmal section of the aorta would likely be necessary to debranch in order to gain distal seal zone.  Bypass and debranching was recommended.  The patient understood the risks and benefits and wished to proceed.  I recommended proceeding through her previous open cholecystectomy right upper quadrant incision.  All questions were answered and she agreed to proceed.

OPERATION:  Patient was brought to the hybrid operating room, placed in supine position.  After adequate general endotracheal anesthesia was achieved, the abdomen was prepped and draped in a sterile fashion.  The prior right subcostal incision was entered and peritoneal cavity slowly entered as there were significant adhesions present.  Because of the amount of adhesions present, this necessitated an additional 1 hour of operative time.  Ultimately, we were able to identify the colon at the hepatic flexure.  The white line of Toldt was mobilized and colon mobilized medially.  The gastrohepatic ligaments were divided and the space entered where I was able to gain control of the right hepatic artery and identified gastroduodenal artery.  This was a tedious procedure as well, but ultimately the vessels were able to be looped with vessel loops.  At this point, while with reflection of the ascending colon, I was able to palpate the celiac artery.  It was difficult to gain exposure for the use of the common iliac artery for a donor vessel.  At this point, I did then perform a right lower quadrant transplant incision and gained access into the retroperitoneum where the iliac bifurcation was encountered.  The distal right common iliac, internal iliac, and external iliac arteries were looped with vessel loops.  The artery was soft with an excellent pulse.  The patient was systemically heparinized with 5000 units of heparin.  An 8-mm Dacron graft was then anastomosed in end-to-side fashion to the iliac bifurcation.  This graft was then brought along the right gutter in the retroperitoneal space and brought up to the replaced right hepatic artery.  The anastomosis was then constructed also in end-to-side fashion.  During this point of heparinization, the gastroduodenal artery was divided and also anastomosed to the more proximal portion of the replaced right hepatic artery.  At one point, there seemed to be some slight tension on this anastomosis.  Wanting this to be tension-free, I tried to further mobilize the gastroduodenal artery, however this still did not provide a tension-free anastomosis and thus a small piece of bovine pericardium was used to patch this area to allow this to be tension free.  At this point, the hemostasis was achieved.
At this point, the patient was prepared for the endovascular stent placement.  I chose to perform a right common femoral artery cutdown  I chose to advance the endograft via the the left common femoral artery as I did not want the large graft sitting across the 8-mm Dacron graft anastomosis, which had just been created.  An oblique incision was made over the left common femoral artery and vessel dissected free from the surrounding structures and looped proximally with umbilical tape and distally with vessel loops.  Percutaneous access was gained here with a 5-French sheath followed by advancement of an 035 Bentson wire and pigtail catheter into the proximal descending thoracic aorta.  The pigtail catheter was then used to exchange out the Bentson wire for a curled 035 Lunderquist wire with the tip positioned near the aortic valve.  In a similar fashion, a 5-French sheath was then placed in the previous left right lower quadrant transplant incision where the 8-mm Dacron had been anastomosed.  I gained percutaneous access just distal to our anastomosis and a 5-French sheath was placed.  In addition, the 035 Bentson wire was advanced into the proximal descending thoracic aorta and a 5-French pigtail catheter placed.  A left transverse arteriotomy was then created after the 5-French sheath was removed.  The 32 mm x 32 mm x 160 mm Medtronic Captiva endograft was then advanced and positioned just proximal to the sole left renal artery.  A 36 mm x 36 mm x 159 mm extension piece was then used to build the graft proximally to cover the aneurysmal segment.  This landed several cm distal to the left subclavian artery.  At this point, completion aortogram showed no evidence of endoleak.  The bypass graft and debranching was visualized.  There was flow noted into the superior mesenteric artery, however this did not appear to be causing an endoleak and thus I did not feel that the superior mesenteric artery needed to be ligated.  We had previously gotten a 0 silk tie around the origin of the celiac artery and ligated this.  At this point, the patient had received 57.5 mL of contrast.  All sheaths and wires were then removed from the left common femoral artery cutdown and the arteriotomy closed with interrupted 5-0 Prolene suture, followed by running 3-0 Vicryl suture and 4-0 Monocryl to the skin.  The right lower quadrant transplant incision was then closed with looped PDS on the fascia followed by 3-0 Vicryl and 4-0 Monocryl to the skin.  The subcostal incision was closed in a similar manner with looped PDS on the fascia followed by 3-0 Vicryl and 4-0 Monocryl to the skin, followed by Dermabond.  At this point, the patient remained hemodynamically stable making urine and had received 57.5 mL of contrast.  The patient had palpable dorsalis pedis pulses.  I was present for the entire portion of procedure.

Aortofemoral bypass graft angiography during left heart cath

Dr. Z, Our physician did a aortofemoral bypass graft angiography during a left heart cath. He introduced a 4-French sheath over the guidewire using modified Seldinger technique in the aortofemoral bypass graft before engaging the left main coronary. He does have findings of angiography. Is there an appropriate CPT for the angio of the aortofemoral bypass graft? We are having difficulty in finding one. Thanks.

CTA prior to catheter based intervention

Am I correct in thinking that if the patient had an outside CTA of extremities and then presents to our lab for intervention, we shouldn't report 75716 in addition to 33221? Thanks~