Ask Dr. Z

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~

Attempted intervention -74 modifier

I have a scenario that is frequently encountered in our IR department. A patient with a prior diagnostic lower extremity angio (75716) comes in for revascularization. Due to the occlusion the guidewire is unable to cross and any revascularization attempts are aborted. All that is performed is another angiography. Based on the coding rules, I cannot capture another diagnostic exam. However, since the plan was for intervention, can a PTA be charged with a -74 modifier or should the diagnostic 75716/75710 be charged with a -59 or is there a better option in this case? I am inclined to think that if the doctor is only able to get a wire in then 75716/75710-59 should only be billed, however I still question if that is appropriate. Thank you for your help.

IV placed in IR for CT scan with contrast

If a patient comes in for a CT scan and requires an IV access to be placed by IR due to "poor venous access", is the 36000 and 76937 seperately reportable? Typically the 36000 is bundled, but due to the poor access and the fact that they are taken to IR for the procedure, does that warrant the charges? The fact that is performed for the sole purpose of administering the contrast, regardless of the reason they have poor access, does that void charging the 36000/76937 seperately?

Injection of pain pump catheter with intrathecal imaging

Dr. Z, In reference to an earlier coding question that you answered on July 6, 2011 we have a similiar coding question but need clarification if we should also use the CPT code 61070 and 77003. Our exam reads: (possible baclofen pump malfunction) The catheter access of the pump was punctured with a 24 G needle and aspiration retrieved 3 cc of clear fluid. Under flouroscopic control a total of 5 cc of contrast was injected into the pump catheter. Intrathecal subarachnoid spread of contrast was noted at the tip of the catheter in the thoracic spine. Spot films to document the course of the pump catheter were taken and there was no evidence of rupture. IMP: baclofen pump catheter contrast study and myelogram w/o complications. Aspiration of CSF was successful. They have been previously coded as myleograms?? Thanks

MRA of the heart

What is the appropriate code for MRA of the heart?

Nuclear Medicine myocardial perfusion study performed by two physicians

Lexiscan Cardiolite tests are often done at the hospital, of course using their equipment and their radiologist reports the xrays. The cardiologists read the EKG's and look at the xrays. I think the proper codes are 93016, 93018 and 78451 or 78452 depending on the rest or stress part being done. Will you verify these codes and tell us if the inclusion of EKG's as Status B for HOPPS will have any effect on these charges? Thank you, Sharon

Nephroureteral stent removed through nephrotomy

Hello from KC,MO--Have a situation that has both IR & HIM stumped. Briefly patient had cystectomy secondary to bladder CA. Approximately one month post-op the stent placed at that time migrated causing spasm VS ureteral stricture. IR was requested to place a left flank nephrostomy. Patient seen several times for check & exchange of nephroeueteral stent. Patien now returns for nephrotomy check & possible removal of nephroureteral stent. The neproureteral stent is removed & the nephrotomy capped. Our questions are: is the nephrostogram billable separately & is 50389 correct for the nephroureteral removal? Appreciate you help.

Pacemaker pocket revision

Dr Z, Could you take a look at the below case and advise how you would code it? I am thinking 33999 as leads were only repositioned in the pocket and pocket revision was performed. Thanks. The pocket was opened and generator removed. Pacing thresholds of both the ventricular and atrial leads were checked and found to be acceptable. The pocket was then flushed with antibiotic solution and the generator was replaced with the leads being moved on the top of the generator instead of the bottom. Pocket was closed.

Carotid angioplasty

Hi Dr Z, one of our Rad techs is asking how he should code pta of a PREVIOUSLY placed carotid stent with distal embolic protection. I'm not sure what to tell him and am hoping you can offer advice. Thanks

Humana denying catheter placements

Greetings Dr. Zeilske or Dr.Dunn, We have lately started receiving denials from at least Humana, Cigna, and Tricare, maybe others, when reporting 36140, 36200, 36245-36248 when submitted with 75710 or 75716. We have recently found on the Humana website that on June 24, 2011 Humana has published an edit that "36140, 36200, 36245-36248 will not be separately reimbursed when submitted with 73706, 75635, 75710 or 75716". Are you familiar with any such edit or coding change that would support the insurance denials not to pay the cath placement with the diagnostic study? Our surgeons regularly perform the diagnostic angiograms and we of course report the catheter placement as well as the radiological supervision and interpretation. (of note, no cath is reported with interventions, of course. Cath only reported with the diagnostic studies). Thank you for any insight you may have to how / why the insurance carriers have developed this edit to deny the catheterization with 75710 / 75716. Thank you

Atherectomy and thrombectomy in same vessel

Hello Dr. Z. I would like to kow your thoughts on coding for the JETSTREAM CATHETER. I see a lot of reports that are reporting atherectomy done in blades up position, and thrombectomy performed with blades down position. My thoughts were that only one code would be used for a specific vessel. What would appropriate documentation be in order to code for both in a SFA for instance? thank you as always for your guidance. Brenda B.

FFR in renals

Hi Dr Z, One of our physicians recently performed a bilateral renal angiography, and placed a FFR wire in the left renal artery. It is my understanding that the FFR is not separately billable with a non coronary angiography. Thank you

Reamputation versus debridement

Greetings, A patient has dehiscence of a amputation stump with infection. The pt is taken to the OR and 4 inches of femur were removed with the saw. Is this a reamputation or a debridment? Thanks,LW

EP and echocardiogram

Dr Z I would really appreciate your assistance in the EP case below. The intended procedure was EP ABL w/ 3D mapping for A-fib. However all that was done was 93662 intracardiac echocardiogram which is an add on code with 93651 which did not take place. I have searched your database extensively and the only example I can come up with is for a PFO in which you suggested to use a 74 modifier for the intended procedure along with the add on code. Based on this would I charge 93651-74 and 93662. Or charge for possibly TEE 93318 as a completed procedure? Thank you for your expertise, Terri DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the electrophysiological laboratory in a fasting state. The patient's oropharynx was anesthetized using aerosolized lidocaine spray. Once sedation was achieved, I manually advanced the echo probe passed the oropharynx into the lower esophagus. Limited echocardiographic images were obtained in multiple views. FINDINGS: Left ventricle size is grossly normal. There appears to be left ventricular hypertrophy. Global left ventricular systolic function is normal. Ejection fraction is visually estimated to be 60-65%. There are no regional wall motion abnormalities. Right ventricular size and systolic function within normal limits. The mitral valve is morphologically normal. The tricuspid valve is grossly normal. The left and right atria both appeared mildly dilated, both measuring approximately 4.5 cm. The intraatrial septum is intact to 2-D imaging. There is a mass in the tip of the left atrial appendage thrombus highly suggestive of thrombus. Doppler velocities in the left atrial appendage are less than 0.4 meters per second. CONCLUSIONS: 1. Normal left ventricular size and systolic function. 2. Biatrial enlargement. 3. Left atrial appendage thrombus. PLAN: Based on this study, we will defer on left atrial ablation. His anticoagulation will be restarted and we can consider restoring sinus rhythm in approximately 1 month.

Right sind M1 and M2 vessels

Hello, Are the Right side M1 and M2 considered two different branchees when it comes to catheter placement guidelines. By this i meand do i code 36217 for M1 and 36218 for M2.. Please advise.. thank you..

ICD-9 for follow-up angiogram post placement of coils

DR. Z or Dr. Dunn: I have a follow-up arteriogram post placement of coils. Diagnosticly speaking would we use the V58.73 and the current disease process that necessitated the placement of coils for this follow-up exam? Such as V58.73 and V12.59 or V58.73 and 437.3 Thanks for your in put.

repeat 75710

We have a patient who had an ischemic left lower extremity. He was taken multiple times to the angio lab for multiple angioplasties and stents within 2 days time and at one point and open thromboembolectomy. Due the urgent nature of each trip to the lab, the surgeon did a re-look lower extremity angiogram. With the new coding rules, is that angiogram billable? Thank you so much for your advice!

Co-surgery 0256T

Dr Z When doing Core Valve the cardiologist performs the cath part of the procedure and the surgeon does the actual valve replacement. Should BOTH docs be billing for the Core Valve (temporary code 0256T modifier 62) or should the cardiologist be billing as assistant to the surgeon (256T,mod 80) OR should the cardiologist be billing for the cath only? thanks Jean

35903 35907

Hello~ Is the appropiate to code 35907 for the removal of an infected aortobifemoral bypass? Now, if that is correct... how should it be coded if it is removed in stages? Example: 1st the right & left limb and at a later date the remaining portion from the aorta? Thank you!

IVC with heart catheterization

Hi Dr. Z, The physician performed a right and left heart cath with left Vgram and coronary angiography and aortic arch angiography. Because the patient had a history of IVC ligation, the physician performed a hand injection through the venous sheath in her right groin in an effort to identify her venous anatomy to faciliate the right heart cath. This revealed a narrow venous structure region with continuous flow present into a more normal appearing inferior vena cava adjacent to the entrance of the right atrium. He suspected that this is a well developed collateral that has developed as a result of ligation. He was able to navigate the right heart catheter through this vessel into the heart. My codes are as follows - 93460, 93567, but I question if I should use 75825-59. I decided against 36010 first because there is an edit, and I didn't feel that was distinct from the catheter placement used for the cardiac cath portion. I'm thinking the 75825-59 is in fact appropriate but would greatly appreciate your fine wisdom!! Thanks!

36821

Dr Z, I am not sure if the procedure described in the below op report would be considered a revision or new creation and whether or not the ligation of the collateral vein can be reported separately. Any clarification you can provide is appreciated. A patient has a nonmaturing distal radial AV fistula who came for evaluation. The fistula was cannulated and shuntogram performed (36147). The vein immediately after the anastomoses showed significant stenosis with flow through through collaterals with no flow through the main fistula. Arterial anastomosis was found to be adequate but the radial artery was small in caliber. Ligation of fistula performed and a portion of the cephalic vein more lateral and superior in location is found to be adequate and dissected proximally and distatlly with the side branches of the same being ligated. The vein is then cannulated and venogram of the upper extremity as well as central venous and SVC performed. Other than the cephalic vein being small, no stenosis or obstruction noted on studies. Dissection of radial artery was then performed and a longitudinal arteriotomy wsa performed. An angioplasty in the proximal portion of the artery was performed followed by angioplasty of the cephalic vein. (No codes as I believe angioplasties were done due to the finding they were small vessels and would be considered part of the revision or creation of the fistula.) The anastomosis of the two were performed in an end-to-side fashion (36821 or 36832 - creation vs revision). Once completed, flow was obtained. Incision is closed. There is a collateral branch arising from the cephalic vein that was visualized on angiogram. A separate incision was performed and vessel ligated (37607?).

Interventional radiologist consults

My physician is an Interventional Radiologist. He is the only one on call for one of the area hospitals. He will get called in at all hours of the night for a "consult", which I bill a 99222. During that consult he will usually find that a procedure needs to be done of some sort. The procedure is scheduled for the next day. Medicare will pay my procedure but deny the 99222 as "pre-op or post-op care". Not only is my physician being woken up in the middle of the night, I can't even get him paid for his services. Is there a way around this? Is there a modifier I can use that would help? Thank You, Shannon Dr. Stephen K Liu

Declot with venoplasty AV shunt 36870

Dr. Z Please tell me if I'm on the right track with the following code: 36147 1st access 36148 2nd access 36870 Mechanical Thrombolysis 35476 Angioplasty 75978 S&I for angioplasty thanks, :) The venous side of the patient's hemodialysis access graft was then cannulated in an arterial direction using a 21-gauge needle and a 0.018-inch guidewire is introduced in the graft. Over the guidewire, a Cook micropuncture system is used to place a 5-French catheter in the graft. The catheter is then steered in the left brachial artery. A left brachial arteriogram is then performed. A total of 70 mL of Visipaque-300 was used during the exam. Nonionic contrast media was used because of the patient's history of renal failure. 30 mL was wasted. The graft is seen to anastomose to a high takeoff of the radial artery. There is no evidence of stenosis in the radial artery. There is no flow identified from the radial artery into the graft. This is consistent with complete thrombosis of the graft. The arterial side of the graft is then cannulated in a venous direction using a 21-gauge needle and a 0.018-inch guidewire is introduced in the graft. Over the guidewire, a Cook micropuncture system is used to place a 5-French catheter in the graft. The catheter is then steered to the region of the venous anastomosis of the graft. A small amount of contrast media was then injected. This shows 90% venous anastomotic stenosis. There is also 90% stenosis in the venous side of the graft. Thrombus is seen to extend to the level of the venous anastomotic stenosis. A metallic stent is identified across the venous anastomotic stenosis. Both catheters were then exchanged for 6-French sheaths. The patient then received 5,000 units of intravenous heparin. Mechanical thrombolysis is then performed on the graft using the Arrow percutaneous thrombectomy device. A 6 mm diameter angioplasty balloon was then placed across the arterial anastomosis of the graft and gentle balloon embolectomy and angioplasty was performed of resistant thrombus and stenosis at the arterial anastomosis of the graft.This occurs within a previously placed metallic stent. An 8 mm diameter angioplasty balloon was then placed across the intragraft stenosis in the venous side of the graft and the venous anastomotic stenosis. Balloon dilatation was then performed at several levels. A left arm arteriovenous fistulogram and left upper extremity venogram were then obtained. There is no residual thrombus at the arterial anastomosis of the graft after angioplasty and balloon embolectomy. There is no evidence of intragraft stenosis. There is no residual venous anastomotic stenosis after angioplasty. There is no stenosis identified in the left axillary vein, subclavian vein, brachiocephalic vein or superior vena cava. Both catheters were then removed and hemostasis was achieved at both puncture sites using silk suture.

ICD diagnosis coding

Hi Dr. Z, I am having a problem with coding an ICD case. The paient had a single chamber ICD put in for primary protection in 2003. He is back for replacement of his depleted generator, and also an upgrade to a Bi-v ICD due to his worsening CHF (class 111), EF of 29% conduction delay on ekg, with QRS duration of greater than 120. He is an out patient. He received a Bi-v ICD generator, atrial lead and a bi-v lead. I coded 33249, 33241, and 33255. I did not use the Q0 modifier because of the existing ICD and I thought the Q0 was only for new ICD inserts. MR coded 428.22 as the diagnosis code. 33249 hit an edit for a modifier, or addd't diagnosis code. " 33249 requires a modifier, or a diagnosis (per CR3604) must be present if the AICD is for secondary prevention of sudden cardiac arrest. I was told that V53.32 could not be used because of the upgrade. Should I use Q0 to bypass the edit? Thanks, Dr. Z Diane

Vessel repair hole in av fistula

Greetings, How would you code a(one)suture repair of a puncture hole of a AV fistula ? It doesn't seem complex enough to code repair of a blood vessel. thanks, LW

Documentaion for left atrial pacing and recording

When billing for left atrial pacing and recording (93621) what documentation should be present? Is the mere mentioning that the wire is placed in the coronary sinus enough to bill this code, or should there be mention of the findings of the left atrium stimulation be present in the documentation? Thank you, Ana

Placement of infusion wire beyond location of LE revascularization

Patient was brought to IR suite with an ishemic foot. A pelvic angiogram was performed and the catheter was advanced to the right external iliac and a lower extremity angiogram was performed. The catheter was advanced into the fem-pop graft an angiogram was performed showing thrombosis. Catheter advanced to the above knee jump graft to below knee angiogram showed a 90% stenosis. Angioplasty was performed at the jump graft anastomosis. Next an infusion catheter was placed in the fem-pop graft and an infusion wire was then advanced through the infusion catheter to the peroneal artery. Overnight thrombolysis was performed. I know catheter placements are bundled into angioplasty codes. Can we code 36247 for placing the infusion wire in the peroneal artery since it is past the location of the angioplasty?

32551

Dr. Z Can I code both 32422 and 32511 with guidance or is 32422 and 76942 more appropriate. If I can code both 32422-59 & 32511 do I code only one guidance 75989? Under real-time ultrasound guidance an 18-gauge Yueh needle was inserted into the right pleural space and approximately 10 mL of amber colored fluid was removed from the pleural space. Then a 0.035-inch wire stiff Glidewire was advanced through the Yueh catheter into the right pleural space. The tract was dilated to 8-French and an 8-French pigtail drainage tube was advanced into the right pleural space. The pigtail was formed and locked into position. The pigtail was left to external suction drainage. thanks, :)

Right femoral vein sheath with cardiac cathterization

Dr.Z, I have a physician that placed a Right Femoral Vein Sheath(RFV) in order to administer IV Fluids during a cardiac cath. He documented "RFV inserted d/t peripheral IV access infiltrated on arrival." He also accessed the RFA for the procedure. The venous sheath was pulled at the end of the procedure and a 22g placed to the right wrist. Would the placement of the Venous Sheath be considered a PICC line placement and CPT 36569 be appropriate to use in this situation based on the physician documentation?

75625 and renal artery

Could you please list the documentation requirements to bill for an abdominal angiogram? 75625-26. I thought I had seen in your questions or in some of your training that renals were required. I have several doctors that are leaving out mention of the renals. Hope you can help! Thanks, Kim

35141

Dr Z MD does AAA repair 34802,75952,34812/50 36200 after this is completed. He does repair of bilateral common femoral aneurysm he turned in 35141x2 but is that the code he should use? He placed graft on resected CFA and anastomosed to the PFA on the right side. He placed graft on resected CFA and anastomosed to PFA/SFA common origin. In reading the section before the AAA, I am wondering if he can bill 35141x2 or if he should use 35286 x 2. Should I bill what he used, not bill at all or use 35286 x 2? Would be nice if these were cut and dried, wouldn't it? Thank you,

CPT codes for embolectomy and iliac angioplasty

Hello Again, I am having a hard time with this case. I am debating between cpt codes 32401 with 75710-59,37220 or 35371,37184, 37220 and 75710-59. I am helding more on 32401 codes as i see the incision and repair and a catheter is also used. for the second pair of codes i really dont see the andarterectomy 35371 done as the surgeon states. Please help as the more i read it the more confused i get. Thanks for your help.... PROCEDURE: 1. Right common femoral artery exploration with endarterectomy. 2. Right SFA embolectomy. 3. Right common femoral embolectomy. 4. Right external iliac embolectomy. 5. Right iliac angiogram. 6. Right common iliac embolectomy with over the wire Fogarty, 4 French. 7. Right common femoral angioplasty with 8 millimeter x 60 millimeter balloon. 8. Right common femoral artery repair with patch angioplasty. - SURGEON: Kin-Man Lai, M.D. - ASSISTANT: John Beemer, Physician's Assistant. - ANESTHESIA: General endotracheal anesthesia. - ESTIMATED BLOOD LOSS: 50 cc. - ESTIMATED FLUID: A liter of normal saline. - COMPLICATIONS: None. - DISPOSITION: To the recovery room in stable condition. - BRIEF DESCRIPTION OF PROCEDURE: This is a 52-year-old gentleman with known peripheral vascular disease status post right common iliac angioplasty and stenting with double stent in the past and status post left common femoral artery endarterectomy and patch angioplasty repair 2 years ago who presented to the emergency room today with a four day history of right lower extremity numbness. The patient's symptoms progressively worsened with inability to walk and pain. - The patient was immediately evaluated with bedside ultrasound which noted there was little to no flow in the common femoral artery. The patient has flow in the SFA and profunda femoral artery via collateral. The patient also has no flow in the external iliac artery. Due to these findings and history of peripheral vascular disease and stenting, the patient was deemed to have evidence of acute on chronic ischemia. The patient was then given the option to go to the operating room to have this repair emergently. The risks and benefits of this procedure were carefully explained to patient and wife in full detail who wished to proceed. - The patient was then brought to the operating room, placed on the operating room table. After adequate anesthesia was achieved, the patient was appropriately prepped and draped. We made an incision approximately 3 inches above the groin crease. The subcutaneous tissue was then dissected with cautery device. With Weitlaner in place we dissected all the way down to the common femoral vein following the epigastric branch. We also ligated the epigastric branch and saved it for patch angioplasty repair at the end of the procedure. - We isolated the common femoral artery which has no pulse. A vessel loop was then placed around each one, the distal aspect of the common femoral artery. The patient was given 5000 units of heparin. When the heparin had been in for five minutes we opened up the arteriotomy with an 11 blade, extended it with Potts scissors. We then performed a Fogarty angioplasty with #3 Fogarty down the SFA and then #4 Fogarty at the common femoral and external iliac. We were not able to pass the Fogarty retrograde past 15 millimeters. Due to these reasons, I suspected a possible occlusion or stenosis of the previous atrium stent. We therefore placed a 6 French sheath in place and used 4 French over the wire Fogarty to open up a small passage. Under fluoroscopic guidance we were able to gain access to above common iliac artery on the right side. - Angiogram with Kumpfe catheter revealed no flow into the right limb of the iliac artery. We therefore proceeded to perform over the wire Fogarty with a 4 French system. We removed a small amount of clot. At this point we did not have good flow under completion angiogram. We therefore used an 8 millimeter x 60 millimeter Admiral balloon and performed angioplasty of this stent. This was performed successfully. Post procedure we had an open channel in the common iliac. We had good flow into the right iliac and retrograde flow into the aorta and the left iliac system. - At this point, after multiple angioplasty was performed, we elected to remove the sheath and proceeded to irrigate the arteriotomy and then we paired this arteriotomy with the epigastric branch saphenous vein. This was repaired with a 6-0 Prolene. This was repaired without any difficulty. We backflushed and foreflushed the conduit and irrigated the repair area with heparinized saline. The patient has good pulse at the end of the procedure. - We then proceeded to apply thrombin soaked Gelfoam for hemostasis. We then proceeded to close the wound with 2-0, 3-0, and 4-0 Vicryl and then Biosyn. The patient's wound was then carefully cleaned off and local anesthesia was infused. DermaFlex was then used as a sterile dressing. The patient tolerated the procedure well. No complications. The patient was then taken to recovery in stable condition. - -

Ethiodol

If Ethiodol is injected during a visceral angiogram on a patient with a hepatic mass, is it correct to charge for an embolization?

Venoplasty with dilators

DR. Z, Patient came in for atrial lead fracture (dual chamber Pacemaker, performed a left subclavain venogram noticed stenosis both in Subclavian vein and SVC then dilated the stenosis with 7-French, 8-French and 9-French dilators then placed the atrial lead wihtout difficultly. Can we charge 36005 75820 35476 75978 along with 33216 and 71090? Please advice. Thanks

Injection of adenosine during cardiac catheterization

Hello~ I am asking for clarification of your answer below. Q uestion: Does the new code 93463 include adenosine? Answer: Yes, if given and a repeat heart Cath is done. Code 93463 is for repeating the heart cath after infusion of a drug, not just giving a drug. Dr.z So if adenosine is given as part of the FFR, which includes pharma stressing, and the report reads: resting FFR across lesion is .9x following maximal adenosine infusion this jumps to .8x, showing no evidence of hemodynamically significant stenosis". We would not code 93463 additionally, but can you provide a situation that adenosine is used that we could? Thanks, Eileen

35371

Dr Z, I think I am correct but here is the question. Dr opens both the left and right common femoral arteries performs endarterectomies on both, then does endarterectomies of the left and right external iliac arteries. Then places a stent in both the left and right external iliac arteries because of documented stenosis. I think we can only bill for one endarterectomy on each side and one stent on each side, but which code 35351 or 35371? Thank you, Suzan

Selective catheterization of protal vein

Hello!! In regards to your on line Q & A #1693 2008 re: Portal system coding...fast forward to 2011, do you still agree with your answer? I have heard in the past that all catheter movement within the Portal vein is still coded 36481 yet I have other coders stating that if the RT or LT portal vein is catheterized it makes it a selective code. I can not find it in writing anywhere either. thank you

AV shunt intervention 36147, 36148, 35475, 75962, 36870

I have a case that is giving me some trouble, and it comes up frequently. Following is the report.

INDICATION: The patient has a clotted AV graft that is used for dialysis. The patient is referred for thrombectomy.

CANNULATION OF THE AV SHUNT: An 18-gauge needle was used to cannulate the graft. A guidewire was placed under fluoroscopy. An angiographic catheter was inserted for venous access.

SVC VENOGRAM: A diagnostic angiographic catheter was inserted into the subclavian vein, to rule out a central lesion. The superior vena cava, brachiocephalic vein, and the subclavian veins were well visualized. The left subclavian vein was obstructed by the pacer wires.

PULL-BACK VEOGRAM OF AV SHUNT AND UNILATERAL EXTREMITY: The preferential draining vein was the basilic vein, which was of moderate caliber. Site and description of stenosis: The vein was collapsed at the elbow.

INTRO OF NEEDLE FOR ARTERIOGRAM/EMBOLECTOMY: An 18-gauge needle was used to cannulate the graft. A guidewire was placed under fluoroscopy. A 6-French sheath was used to cannulate the graft for arterial access.

THRMOBECTOMY OF AV SHUNT: Under fluoroscopy a Fogarty thrombectomy catheter was passed across the arterial anastomosis and using a sweeping motion, the clot was aspirated via the side port of the 6-French sheath. Number of sweeps: 4 Amount of clot aspirated: Large.

ANGIOPLASTY # 1:
Lesion location: basilic vein
Lesion length in cm: 1 cm
Balloon size: 7x6
Atmosphere inflation: 20
Time for angioplasty: 15 secsx7; <5secsx3
Results: Successful

ANTEGRADE ARTERIOGRAM: Under fluoroscopy, a guide wire passed across the arterial anastomosis. A 4 FR angiographic catheter was passed over the guidewire into the brachial artery in order to visualize enough of the native artery to be certain the graft had adequate arterial inflow, and to exclude stenosis of the arterial anastomosis and arterial inflow of the graft. 4 cms of the native artery were visualized. There was a stenosis at the arterial anastomosis.

ANGIOPLASTY # 2:
Lesion location: arterial anastomosis
Lesion length in cm: 1 cm
Balloon size: 6x6
Atmosphere inflation; 10
Time for angioplasty: 15 secsx5; <5secsx2

FOLLOW UP VENOGRAM OF THE AV GRAFT AND UNILATERAL EXTREMITY: The exit venogram showed blood flow determined using angiography was good. There was no residual stenosis.

RESULTS: Successful thrombectomy of the AV graft.

 

Exchange of Rt femoral CVC with bilat upper extremity selection same access

We did an exchange of existing right femoral CVC with the selectively of both the RT and LT upper extremity veins and a bilateral venogram was done. I’m thinking that we can not bill for the selection of the bilateral upper extremity nor the venogram because it is done via the CVC exchange access site and it is encompassed into the exchange code. The physician also accessed the lt ext jugular vein and angioplastied the Lt Brachiocephalic vein (occlusion) and placed tunneled CVC.
Your thoughts,

Endoleak treatment with 37205

Please do NOT include any actual patient medical records with your question. Hello again, If a patient returns for endoleak a few days after AAA repair, and two Palmaz stent are deployed in the AAA neck and two more additioanal extensions in the common iliacs can I charge for the stents (37205 & 37206). I am heading more for a "NO" as this were done for anchoring purposes not for stenoses.. Please Advise...

Aborted vena cava filter removal

Dr. Z, In your online question (this is an old one OCt 13, 2005 )when filter removal attempted however unsuccessful your advice code only the completed procedures 36010 75825. The online book page # 197 Instruction # 6 if filter not removed, only code the catheter placement and cavagram. For our scenario patient schduled for filter removal after venogram no clot noticed proceeded to removal after an hour of multiple different maneuvers (snare) the decision was made that the filter was positioned such that removal would be very diffcult. Procedure abonded. Since hospital charged for snare not sure if we can also code 37204-74 to justify the attempted filter removal along with 36010 75825-59? please advice. Thanks

Vertebral stent inpatient procedure coding

I hope we can reach out to you once more for your expertise. We have a newly credited stroke center and one of our interventional radiologists is treating vertebral occlusions with stents. Cases are coded with 00.61 and 00.64. We are getting MCR rejections; our edits state 00.61 (plasty) needs to be billed in conjunction with 00.63 (carotid stent). The only reference I find is NCD 20.7 which seems to indicate only carotid stenting (w/ or w/out EP) is covered and verbebral remains non-covered. Our doc insists this is the only treatment indicated for the patient symptoms/ presenting problems. He also indicates the procedure can be described as a “Mechanical thrombectomy / revascularization of the vertebral artery” In the end, the stent is the therapeutic procedure performed and thus, coded.

Would you know if there is MCR coverage for vertebral stents (perhaps we are not coding them correctly) or if there is any other treatment alternative for these symptomatic patients with confirmed vertebral obstructions?

As always, your comments are greatly appreciated!
 

50382 vs 50387

Dr Z, Please tell me if this situation can be coded with more than just 50387. Patient had an int/ext nephroureteral stent for an anastomotic stricture. Has a neo-bladder and ostomy bag. Patient's wife cut the external portion of the NU stent at the level of the skin and it retracted almost to the kidney. Using contrast and glidewires access was regained posteriorly through the existing tract. Ostomy bag was removed and with contrast and hemostats, the 'ureteral foreign body' was removed anteriorly. A new stent was then placed posteriorly across the ureteral anastomosis and contrast confirmed proper placement. This is not a simple replacement of a stent but we are at an impasse on the coding. Thanks so much for your help.

Nuclear Medicine vascular catheter patency.

Dr Z, Hello, I have a client that checks vascular catheter patency using radionuclide in Nuc Med department. History:Left neck pain with flushing port-a-cath "Immediately after radionuclide injection images were obtained at 2-second intervals during the radionuclide phase. During the first 8 seconds, the port-a-cath was not opacified. radionuclide promptly opacifies at 10 seconds. The superior venacava is patent. Radionuclide promptly opacifies the right atrium, right ventricle, pulmonary outflow tract and lungs. Impression: no reflux into the left internal jugular vein was seen. I appreciate any suggestions, Judy

35907

Dr. Z, I need your expertise. This is a first for me and I looked up potential CPT code 34831 and there is no information in your data base. Patient w/ infected Zenith aortic endovascular stent graft. My Physician performed exploratory Lap w/ excision of the infected Zenith graft w/ an in situ replacement with a cadaveric aortic homograft (aorta to left common iliac and aorta to right external iliac)-aortobiiliac homograft. Thinking of using the excision of infected graft CPT and the CPT 34831 but concerned w/ the description referring to "plus repair of associated arterial trauma, following unsuccessful endovascular repair". It seems the previous endovascular repair was successful but now it's infected along w/ infected lumbar spine which Ortho is taking care of.. Greatly appreciate your help Tammy B Morgantown, WV

49080 vs 49021

Dr. Z, What would you suggest for the following procedure? 49418 or we can charge both 49418 and 49080? Thanks Using ultrasound guidance, a 5 French sheathed needle was placed in the right lower quadrant. A guidewire was then advanced through the sheath and into the peritoneum. An 8 French all-purpose drain was then advanced over the guidewire and placed within the peritoneum.Approximately 2500 cc of clear straw-colored fluid was aspirated. The fluid was sent for laboratory evaluation. The patient tolerated the procedure well, and there were no immediate complications. IMPRESSION: Ultrasound-guided paracentesis with aspiration of 2500 cc of fluid. Placement of an 8 French all-purpose drain for subsequent chemotherapy.