Ask Dr. Z

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.

aortic arch arteriogram evaluation of the coronary origins, aortic root

How should we report CPT code +93567 when we have no documentation for a base code. Pt has Marfan syndrome with thoracic aortic aneurysm between 6 and 7 cm in diameter. He was admitted to evaluate his coronary anatomy as part of a preoperative evaluation because he has developed severe aortic regurgitation. After discussion with the cardiothoracic surgeon, it was decided the best way to evaluate his anatomy prior to surgery is to do an aortic root study which would show the origin of the left and right coronary arteries relative to the plane of the aortic root annulus and location of the tubular graft that was placed at age 13 (valve sparing aortic root replacement). Procedure: percutaneous right femoral arterial insertion of a 6F sheath after routine prep and drape and lidocaine anesthesia. Aortic root study in the LAO position with slight cranial adjustment to visualize aortic root structures including coronary arteries. At the conclusion of the study the patient left the cardiac catheterization lab in good condition with adequate right groin hemostasis and intact distal pulses. Results: aortic root pressure 101/57 mmHg. Aortogram: shows the sinuses of Valsalva are moderately dilated. The origin of the lt coronary artery is clearly seen as originating from the native sinus. The origin of the rt. coronary artery is similarly seen as to originate from the native sinus. The suture line of the aortic root graft is also clearly discernible by invaginations just above the sinuses of Valsalva. Diagnostic impression: significant aortin insufficiency. Visualization of the relative positions of the origins of the left and right coronary arteries from the sinuses of Valsalva. Based on this documentation, I would consider this service to be non-billable. Your thoughts? Claire Shumate, RHIT, CCS, CPC Washington University Medical School St. Louis

Pulse spray of thromblytics into cerebral vasculature

How would pulse spray or injection of” thrombolytics into the cerebral vasculature" be coded? It would not meet the guidelines for 37201 since it is not really an infusion. Thank you!

tube injection change

not sure if a tube injection/change (76080/49424/75984/49423) would be best for this or 51705/51710 with a mod? TECHNIQUE: Following informed consent, and verification of the correct patient identity and planned procedure, the anterior lower abdomen, including the indwelling suprapubic drain, was prepped and sterilely draped. Local anesthesia around the drain was administered using 2% Lidocaine. Contrast was injected through the tube and spot film imaging was performed as a baseline cystogram. Review the images failed to identify the bladder. A small tract was identified from the subcutaneous pocket in which the catheter was positioned, which extended toward the region bladder. Over wire the catheter was exchanged for 5-French Berenstein catheter. Additional contrast was injected in attempts at defining a tract to the bladder, but ultimately to no avail. Therefore, over wire a new 10-French MPD drain was introduced into the subcutaneous cavity. The tube was sutured to the skin and placed to gravity drainage. FINDINGS: The existing suprapubic catheter was not in the bladder, but was instead coiled in the subcutaneous tissues. The tract to the bladder could not be identified. INTERPRETATION: The existing suprapubic catheter was not in the bladder, but was instead coiled in the subcutaneous tissues. The tract to the bladder could not be identified.

renal angioplasty and stent placement

Regarding renal artery interventions, i was informed when renals are treated with a balloon angioplasty and a stent, regardless of 'recoil' or lack of improvement of stenosis only the stent placement procedure code is allowed to be billed and not the angioplasty and is considered a predilation unless the patient has a congenital condition. is this accurate for renals?

duplicated IVC with filters

hello, I have a case where a patient has a duplicate vena vaca arising from the renal vein. I am thinking of coding everything twice my only concern is if i should code the duplicated vena-cava as 36010 or 36011 since it came from a selective renal vein. codes 36010,37620x2 75940 x2 75827 (as he found the duplicate vena cava via this study)for the additional vena cava i am not to sure. Here is the example: please advise as i am at a lost..thank you for your help The patient's right neck was prepped and draped using sterile technique. 1% lidocaine solution was used for local anesthesia. Under real-time ultrasound guidance, the right internal jugular vein was punctured using a 21-gauge needle and a 0.018 wire was passed into the inferior vena cava. The needle was then exchanged for a 5 French micropuncture catheter. Through the micropuncture catheter, a 0.035 stiff shaft Glidewire was advanced into the inferior vena cava and eventually into the left common iliac vein. The micropuncture catheter was exchanged for a 5 French pigtail catheter which was placed into the left common iliac vein. Then, inferior vena cavogram was performed. The inferior vena cavogram demonstrates a patent inferior vena cava. There is, however, a duplicated inferior vena cava present extending from the left common iliac vein to the left renal vein. There is intraluminal thrombus seen within the left common iliac vein extending slightly into the inferior vena cava as well as extensive amount of thrombus within the duplicated inferior vena cava. Then, over a stiff shaft Glidewire the pigtail catheter was exchanged for a 9 French vascular introducer. The vascular introducer was placed within the intrarenal inferior vena cava and a Gunther-Tulip filter was advanced and deployed within the infrarenal inferior vena cava above the thrombus within the inferior vena cava. Then selective catheterization of the left renal vein was performed using a Cobra 2 catheter and the vascular introducer was advanced over the Cobra 2 catheter into the left renal vein and eventually into the duplicated inferior vena cava. A venogram was then performed which again demonstrates thrombus within the duplicated inferior vena cava and a patent left renal vein with no evidence of intraluminal thrombus. There appeared to be a small amount of space within the superior aspect of the duplicated inferior vena cava where a filter could be placed without protruding into the left renal vein. Through the vascular introducer, a second Gunther-Tulip filter was advanced and deployed within the duplicated inferior vena cava above the thrombus within the duplicated inferior vena cava. The filter did not protrude into the left renal vein. The vascular introducer was then removed. Complete and immediate hemostasis was achieved

36832 35045

Can you please help/guide? Patient had 2 giant pseudoaneurysms left forearm fistula: The pseudoaneurysm inflow and outflow was identified and carefully managed with isolation of the inflow vein and the outflow vein. 4 to 6 cm aneurysm was carefully opened and excised. Dissection of the entire aneurysm component tree was performed from the proximal forearm adown to the distal forearm where the inflow from the proximal forearm down to the distal forearm where the inflow from the radial artery was identified. The complex of the inflow was resected at the radial artery. This unfortunately caused a discontinuation of the radial artery. The cephalic vein was harvested and of nice caliber. Radial artery to radial artery wbypass was performed with teh reversed cephalic vein. Once that was complete, complete resection of the pseudoaneurysms was ensured. The capsules were completely resected. The distal outflow of the cephalic vein AV fistula was ligated with prolene... I am so lost.36832-22? 35045 with a 22? Would really appreciate your expert opinion. Thanking you in advance!

Embolization of kidneys

Hi Everyone, Embolization of the kidneys to we bill 37204 once or twice? Also emboliztion of an ovarian artery for abnormal bleeding should we use 37204 or 37210?

AV fistula

I have a question about your response #2884 dated 5/27/11. Why would you recommend 36011, first order selective venous. I have a similar encounter. "a 5 french angiographic catheter was manipulated into the large venous side branch arising from the middle of the patient's left radiocephalic fistula (i.e. forearm cephalic vein). This venous side branch was successfully occluded using six 5mm diameter embolization coils and standard embolization techniques. We coded 36012 for catheter placement. Claire Shumate Compliance Analyst

Same access two catheters for neuro embolization

Hi Dr. Z. Patient has a neuro aneurysm. Embolization is to be performed. Two catheters were placed via the same access as described below: Under biplane roadmapping in biplane working projections, using coaxial technique, a microcatheter (Prowler 14 LP) was coaxially introduced and navigated over a microguidewire via the internal carotid artery segments, through the supraclinoid segment and was positioned into the distal left A1, proximal to the aneurysmal neck. A second microcatheter (Echelon 10) was coaxially introduced via the same guiding catheter and navigated over a microguidewire via the internal carotid artery segments, through the supraclinoid carotid segment and the left A1 to be positioned in the lower portion of the aneurysmal sac. Question - Would you code 36217 and 36217-59 (same access but two separate catheters), 36217 and 36218 (same access but two separate catheters going to the same vascular family) or only one 36217(because both catheter placements were via the same access)? Thank you for your assistance.

35475

Please do NOT include any actual patient medical records with your question. Hi Dr Z, AV fistula is created by directly attaching the radial vein to the unlar artery w/o using a graft. We did a diagnostic study that showed results of stenosis at the anastomosis & then separate stenosis in the vein. Both of these sites were ballooned open. I say this gets coded w/ 36147, 35476 & 75978. Performing physician says the radial vein is considered an artery since it was directly attached the the ulnar artery and that it should be coded w/ 36147, 35475 & 75962. Can you help us out here please? Thanks.

37184 intracranial

Hello Again, I have a guestion on Mechanical thrombectomy: Can I use 37184 for a clot removal in the MCA artery or do I have to use an unlisted code and if yes which one. I think I read somewhere that code 37184 & 37185 is for mechanical thrombectomy of peripheral arteries. Thank you for allyour help.

Dilation of vein with sheath for PICC add -22 modifier

I researched the Q&A list. I would like to know if a venoplasty is appropriate under these circumstances? I know that in several non-vascular dilations, it is acceptable to use a balloon or a dilator. But is that true for vascular angio/venoplasty? He says, "A 7F dilator sheathe was then placed and the venogram performed via the sheath. Narrowing of the proximal subclavian vein was noted. A 7F dilator was then advanced over the .018 wire, through the level of narrowing. A 6F dual lumen PICC line, measuring 40cm in lentgh, was then advanced over the guide wire through the area of previously noted narrowing, with the tip positioned at the junction of the SVC and right atrium. Impression: Successful venoplasty, proximal right subclavian vein as discussed above. Coded as 35476,36569,75978, & 77001 Thank you for your consideration.

36818

Hello,

For this case I have the angioplasty and fistulagram 75791. Don't know if I should charge the cephalic transposition 36818 because 2 incisions were not done to tunnel a vein, just subcu tissue was closed underneath to raise the vein. And don't know if a ligation counts. Does there have to be a know problem with colaterals and a seperate incision done to charge a ligation? I think a revision was not done to code that because in a revision there is a new anastomosis created with or without thrombectomy. Do I just charge the fistulagram and pta, or is there anything else appropriate to charge? Thanks,
Jenny



INDICATIONS: The patient is status post left brachiocephalic AV fistula. The vein is deep and ultrasound shows a central vein stenosis.

FINDINGS: The cephalic vein in the upper arm was nicely dilated. Fistulogram showed a high-grade stenosis at the cephalic vein just prior to the junction with the subclavian vein. Following angioplasty with a 5 mm cutting balloon, there was significant residual stenosis. Following angioplasty with a high-pressure 8 mm Dorado balloon, there was good flow through the fistula and the subclavian, innominate vein and superior vena cava were widely patent. Following transposition, there was an excellent palpable thrill through the arm.

PROCEDURE: The patient was identified and brought to the operating room. She was placed in the supine position. Her left arm was prepped and draped in standard fashion. An incision was made along the cephalic vein from the elbow to the upper portion of the upper arm and extended down through subcutaneous tissue. The cephalic vein was dissected circumferentially. Through a large side branch, a 5-French sheath was placed and then a fistulogram and central venogram was performed. The patient was given heparin and a wire was advanced across the cephalic vein stenosis. A 5 mm x 2 cm VascuTrack balloon was advanced to the area and angioplasty was performed. Follow-up angiogram showed residual stenosis and therefore, an 8 mm high-pressure balloon was advanced across the anastomosis and angioplasty was performed. Following angioplasty, there was good flow to the AV fistula. Subsequently the sheath was removed and the side branch oversewed with Prolene. The remainder of the side branches were ligated and divided and the cephalic vein was circumferentially dissected. Subsequently, the subcutaneous tissue plane was closed underneath AV fistula elevating it to a more superficial position. Subcutaneous flaps were created on either side and then the top portion of the wound was closed in layers.
 

Direct thrombin via needle into hepatic aneurysm

Dr Z. and all, wondering if you could recommend how I would code a CT guided percutaneous thrombin injection of a right hepatic artery pseudoaneurysm? Which was un-reachable via the common femoral artery. Thanks

How to use anatomical drawing to code selective catheter placement

I am writing to request an explanation for the answer given to a test question in the Basic Catheter Selection module exam. The question was exactly as stated: Correct code(s) for left femoral access with catheter placed into the right superficial artery for angiogram is (are: 36247, 36246, 36245 36247, 36200 36247 36247, 36140 The correct answer was indicated as 36247. I cannot see how that was selected. Is the cath placement in the right superficial FEMORAL artery (femoral was not in the test question, but I assumed that was the vessel in question); if so, the access was on the left and the diagram Lower Extremity Arterial Anatomy Right Transfemoral Approach leads me to 36245 for the right leg in this diagram. 36247 is the code for the left leg. I think the left approach is starting me off on the wrong diagram and I need to choose the code based on the Order of the vessel selected (3rd order, initial, lower extremity) and the fact that it is a selective (placed) catheter. Please explain how to use the diagram to simplify Basic Catheter Selection. Thanks so very much for your extremely helpful webinars, but I do want to be sure I get the basics down pat now.

Ergonovie and acetylcholine challenge

Will you please clarify which of these instructions is the current one to go by in regard to this question posted 9/1/11: Is 93024 the appropriate code for a coronary artery spasm test using acetylcholine (acetylcholine challenge) during a heart catheterization procedure? Answer was no additional codes are reported for acetylcholine challenge tests. In AHA Coding Clinic for HCPCS Third Quarter 2009 the following coding instruction for hospital billing was given: • Do not report additional codes for performance of an acetylcholine (Ach) challenge test performed during cardiac catheterization. It is included in the cardiac catheterization procedure. Per page 505 in the Cardiac ebook: The ergonovine test - otherwise known as a "provocation test" - is not done often, but can be performed if angina is thought to be caused by coronary artery spasm. The procedure is conducted during coronary angiography.  "The artery-narrowing drug ergonovine (or, alternatively, acetylcholine) is injected to provoke coronary artery spasm.  The person's response to the ergonovine is then documented."  If the individual experiences severe arterial spasm in response to ergonovine, he or she probably has variant angina due to coronary arterial spasm. Coding Instructions: 1. Do code ergonovine provocation in addition to cardiac catheterization if documented. 2. Do not code separately for the injection of the pharmacologic agent, as it is considered part of the test and is not separately reimbursable. Thank you

Bracketing a breast lesion during needle localization

With the improved developments for image guidance, many physicians now perform preoperative wire localization by "bracketing" a lesion. Coding of a single wire versus multiple wires to bracket a radiographic breast abnormality has been discussed, as it can be inconclusive as to whether a large mass is determined to be that of a single lesion, or a more complex mass possibly composed of more than one lesion. As there is much more work involved for the placement of multiple wires in order to bracket a lesion prior to surgery, it is appropriate for this scenario to utilize CPT 19291 and more than one unit of either guidance code (77031 or 77032)?

Hypothermia 37799

Dr. Z, How do we charge intercool insertion, an invasive catheter that stays in the body for hypothermia done in cath lab? Since it is CVC can we charge 36556 77001? Thanks

36569 vs 36558

Hello Dr.Z, Hope you are doing well with good health. It would be great if you solve the coding issue on tunneled peripheral vein PICC placements. We have been coding 36569 for the reports stating tunneled catheter placement through the peripheral veins(brachial/axillary) and I believe that there is no separate code for tunneled PICC lines. Our physician states that it should be 36558 and it depends on termination point (SVC/IVC/subclavian) not by the access points & he has been placing the PICC's by tunneling. Kindly clarify asap... Regards Prabhavathi, India

Catheter placement for IVUS in same vessel as extremity revascularization

Hi Dr. Z, I am not sure what to do with cath placement for IVUS when used in the same vessel with lower extremity revascularization. Bundled?

Coronary thrombectomy must be performed with mechanical device

Is the most recent news letter that was sent this month "AMA Supports ACC Position on Use of Coronary Thrombectomy Code 92973" effective as of right now? we have a vender that is disagreeing with this and stating that it will not be effective until 2012. thanks so much!

Date of service for event monitors

Dr.Z Could you tell me what date of service should be billed for 30 day event monitors (93268)? Would it be the date the monitor was put on, or the date that the report was read. Thanks

Crossover is now atherectomy

Bard, Inc. has apparently received approval from the FDA in August to market the CROSSER Recanalization System as an atherectomy device, equivalent to the Diamondback and Turbohawk devices. Does this change your opinion that use of the crossover catheter should not be billed as atherectomy (at least for the Bard device)? Can we now bill for atherectomy when we use the Bard crossover catheter to cross a lesion? Thank you in advance.

Embolization and diagnostic angiography

Dear Dr. Z: More CCI edits- eff 4/1/2011 75726 and 75774 bundles into 37204, 75894 and 75898. Can the pre-procedure angio no longer be billed when hepatic embolization is performed? Do the guidelines for angio performed at the time of a therapeutic intervention apply to this procedure, as stated in the instructional CPT notes in the Radiology section for Vascular Procedures? Thank you. mlb

Dilation with fogarty balloon for fistula creation

The patient came for possible creation of AV graft. No prior mapping was done prior to arrival in OR. A venogram was performed via direct puncture. Venogram showed several areas of stenosis within the cephalic vein; however, decision was made to proceed with PTA of cephalic vein prior to creation of brachiocephalic fistula. Dissection was carried down to the cephalic vein and vessel exposed. A Fogarty balloon catheter was used to dilate the vein. Following successul angioplasty, the fistula creation was completed. Would it be appropriate to code the open PTA (35460) and the venogram (36005/75820) separately or are these considered part of the AV creation? Thanks in advance for your assistance.

IVUS aorta

Dr Z, If IVUS is performed in the Aortic arch, Thoracic and Abdominal aorta do you code as 3 procedures? Thanks

Myelogram and CT spine

Dr.Z,

We see lot of myelograms where they use fluoroscopy to injection contrast and then sent patient to the CT myelogram for lumbar, cervical and thoracic. For myelogram we only code 62284 and 77003-59 and then CT cervical, Lumbar and thoracic separate. Lately our physicians documenting a small paragraph describing the myelogram images
“digital images were obtained of the lumbar and thoracic spine to document the flow of contrast. There was prompt flow of intrathecal contrast surrounding the cauda equine nerve roots, conus and cord without evidence of myelographic block” then transferred the patient to CT myelogram for lumbar and thoracic regions where very clear documentation for both CTs separate. My question is can we charge complete myelogram 62284 72270 based on the myelogram images documentation besides charging separate CTs? Please advice.

Thanks
 

36589 35903 removal of HERO device

What are we using for removal of a HeRO device under fluoro?
thanks!
 

Lower extremity Duplex Doppler and Mapping

Within the PVL, a written physician order is documented within the patient chart that requests:
• Deep Vein studies/ lower extremity
• Bilateral Carotid Duplex
• Bilateral Lower extremity vein mapping
When these orders are entered from the unit and received within the Radiology order billing system; CPT 93970 is reported for both (venous mapping and Bilateral Lower Extremity Duplex) orders selected (93880, 93970, 93970). Although a distinct service modifier would pass edits, I feel that when performed during the same encounter, the venous mapping is inclusive with the bilateral duplex scan of extremity veins and should not be reported separately. I submit that both technical and professional charges for this encounter should only be reported as 93880 and 93970.
I would respect your opinion on this to support my position for what I feel could be a duplication of procedural charges.

Dictated report for all procedures are provided below:
PROCEDURE: BILATERAL SAPHENOUS VEIN MAPPING
COMPARISON: None.
INDICATION: Pre open heart surgery.
TECHNIQUE: Gray-scale imaging was performed on the bilateral greater saphenous veins with caliber measurements.
FINDINGS:
RIGHT GSV:
Thigh proximal: 2.9 mm
Thigh mid: 3.0 mm
Thigh distal: 2.7 mm
Knee: 2.4 mm
Calf proximal: 1.9 mm
Calf mid: 1.7 mm
Calf distal: 2.2 mm
LEFT GSV:
Thigh proximal: 3.8 mm
Thigh mid: 2.8 mm
Thigh distal: 2.0 mm
Knee: 2.2 mm
Calf proximal: 2.0 mm
Calf mid: 1.5 mm
Calf distal: 1.4 mm
CONCLUSION: The bilateral greater saphenous veins were imaged and measured as described above.

PROCEDURE: BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND FOR DVT WITH DOPPLER
COMPARISON: None.
INDICATION: Previous DVT.
TECHNIQUE: Gray-scale and color Doppler imaging were performed on the bilateral lower extremities.
FINDINGS:
RIGHT LOWER EXTREMITY:
CFV: Normal.
SFV: Reduced.
PFV: Normal.
POP-V: Reduced.
PTV: Normal.
PER: Normal.
ATV: Normal.
GSV: Normal.
LEFT LOWER EXTREMITY:
CFV: Normal.
SFV: Normal.
PFV: Normal.
POP-V: Normal.
PTV: Normal.
PER: Normal.
ATV: Normal.
GSV: Normal.
Normal findings indicate good phasicity, spontaneity, compressibility, augmentation response, and competence.
CONCLUSION: Chronic DVT seen in the right SFV and popliteal vein with recanalization. Remaining deep vessels show no evidence of acute or chronic DVT. No evidence of superficial thrombophlebitis.

PROCEDURE: BILATERAL CAROTID DUPLEX ULTRASOUND
COMPARISON: None.
INDICATION: Preop screening.
HISTORY: CAD.
TECHNIQUE: Gray-scale and color Doppler imaging were performed on the bilateral carotid arteries.
FINDINGS:
RIGHT:
COMMON CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar
PEAK SYSTOLIC VELOCITY: 80 cm/s
END-DIASTOLIC VELOCITY: 17 cm/s
PROXIMAL INTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous. Calcified.
SURFACE CHARACTERISTICS: Irregular.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 207 cm/s
END-DIASTOLIC VELOCITY: 62 cm/s
DISTAL INTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 188 cm/s
END-DIASTOLIC VELOCITY: 37 cm/s
EXTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 137 cm/s
END-DIASTOLIC VELOCITY: 21 cm/s
VERTEBRAL ARTERY: Antegrade.
ICA:CCA SYSTOLIC RATIO: 2.6
LEFT:
COMMON CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 87 cm/s
END-DIASTOLIC VELOCITY: 21 cm/s
PROXIMAL INTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous. Calcified.
SURFACE CHARACTERISTICS: Irregular.
FLOW CHARACTERISTICS: Turbulent.
PEAK SYSTOLIC VELOCITY: 184 cm/s
END-DIASTOLIC VELOCITY: 54 cm/s
DISTAL INTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 162 cm/s
END-DIASTOLIC VELOCITY: 47 cm/s
EXTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 157 cm/s
END-DIASTOLIC VELOCITY: 27 cm/s
VERTEBRAL ARTERY: Antegrade.
ICA:CCA SYSTOLIC RATIO: 2.1
CONCLUSION: Bilateral 60-79% ICA stenosis with irregular plaque characteristics and turbulent flow. The vertebral arteries appear patent with antegrade flow bilaterally.
 

Innominate vein to right atrium bypass with spiral vein conduit

Patient has right internal jugular vein occlusion and innominate vein occlusion with massive symptomatology head edema, saphenouse vein was harvested, median sternotomy was performed and innominate vein to right atrium bypass was performed with spiral vein conduit. Right atrial appendage was free of any lesion and was a good location for distal bypass, innominate vein was dissected, and found to be hard and filled with throbus. Innominate vein was transected , stump leading to superior vena cava was over sewn with 2 layer suture. innominate vein leading to the axillary and subclavian and jugular was explored, thrombus was evacuated. Next using the consturcted spiral vein conduit with a running polene suture, end to end anastomosis of the vein to the innominate stump was performed. Would you stil use 34502? Thanks for your help Dr. D

Fistulogram and intervention in two settings

Dr Z, we had an interesting case in which a patient with a brachio-cephalic AVF was complaining of severe arm swelling. Fistulogram was performed revealing the fistula to be widely patent, so an upper extremtiy arteriogram was performed revealing an occluded brachial (just distal to the anastomosis) and ulnar artery, as well as occlusion of a previouslly placed stent in the left subclavian. At this point the sheath is pulled and hemostatis is achieved. Vascular surgery consult is obtained. Later the same day, they re-access the AVF, but this time a diagnostic exam is not performed, just thrombectomy and restenting. How do you recommend we code the re-accessing of the AVF on the same day, should we use 36148 even though it is a separate session? Thank you

CPT code 36246 75716

Can you code 36246 and 75716 when an interventional procedure is not involved?

CPT code for injection into the symphysis pubis

Good evening Dr Z, Would the following be considered an unlisted injection? Following consent, following sterile prepping and draping and under fluoroscopic guidance 20 gauge needle is advanced into the symphysis pubis and steriod with local anesthetic injected. 20999 vs 27299 I'm leaning 20999, 77002 Appreciate your thoughts, Judy

embolization of ICA

Greetings, Pt had a coil embolization of the rt internal carotid at the cavernous and the supraclinoid. Am I correct in letting the physician know he can only code one embolization as it is in the same vessel. LW