Ask Dr. Z

ICD generator exchange with lead movement subcutaneously (33263)

Good morning DrZ...I was wondering if you could help with this case. Procedure Performed: 1)Explant of a BiV ICD, 2)Tunneling of the right ventricular ICD and a left ventricular paciong lead from the left subclavian to right subclavian 3)Placement of a new biventricular cardioverter defibrillator. I coded it, 33241, 33215, 33226, 33240. However, 33226 includes removal and insertion and moving the pacer to the right was more work then just repositioning LV lead. Can you help me? Thanks, Melissa

CPT code 93432 and 93581

Can 93463 be reported with 93581? Catheterization codes (93531, 93565) are included in 93581 but our cardiologist is repairing the VSD and then doing a nitric trial with documentation of R/L heart hemodynamics. Thanks

35661

Please do NOT include any actual patient medical records with your question. We utilize a coding company to help with our coding. For procedure: Removal infected PTFE femorofemoral bypass; Caraderic vein patch angioplasty of right femoral artery; Redo right to left femorofemoral (common femoral to common femoral) bypass (subfascial) with cadaveric deep femoropopliteal vein; Thrombectomy of right superficial femoral artery, popliteal and tibial vessels The coding company responded with 35558, 34201, 34203, 35903. I had previously learned that cadaver vein was coded with 35661 and not considered as a vein bypass graft. Is this still correct? Also, isn't 34201 part of establishing inflow/outflow and not billable? Thanks for your help.

Baylis wire perforation for pulmonary atresia treatment -22 modifier

HI Dr. Z, thanks for the opportunity to be able to ask coding questions. I have a question regarding the coding of a "radiofrequency perforation of the pulmonary valve via a Baylis wire" just prior to pulmonary valvuloplasty, 92990, for a 3 day old infant with pulmonary valve atresia. Would the radiofrequency perforation be separately billable? If so, would you suggest 93799? Thanks for your help!

Suturing a Hohn Catheter CPT

would you code this with an e/m? pt. presents to Day Infusion for suturing of his Hohn catheter. His skin was cleansed with Chloraprep. Under sterile field, he was anesthetized with 1% lidocaine. The catheter was sutured to the skin using 3-0 Ethilon sutures. He tolerated the procedure well without any complications. thanks

Billing for atherectomy supplies in a physician office setting

Does anyone bill supplies for arthrectomy procedures at an office location? I am having difficulty finding HCPCS codes for the following supplies and wondering what other sources I could use to locate the appropropriate codes, just unable to locate in the HCPCS: Tegaderm, Non-rebreather mask, dermabond, celero biopsy gun, d-stat, inred 18g biopsy gun, plavix, effient tab, nitroglycerin, perclose, starclose, medline angio pack. Is there anyone out there I could contact? thx!

Arctic Sun CPT

Please do NOT include any actual patient medical records with your question. How do we charge Arctic Sun for hypothermia performed in cath lab for hopsitals both procedure and supply charges? 99186 deleted and there is no replacement code. Thanks

I am uncertain how to code single chamber EP studies.---A crd catheter was placed in the RV. Using double extra stimuli with a drive cycle length of 450, he was paced down to 450-220-220.There was a 8 beat run of VT. Impression No inducuble VT. Do I code 93603, 93612 and 93618 for this? Thanks Diane

34502

Dr. Z I need help coding Innominate vein to right Atrium bypass with a spiral vein conduit

35011

Greetings, I have a repeat patient that I emailed for coding advice before. The pt had 3 grafts excised on one arm. The pt is back and now has a mycotic pseudoaneurysm at the repair. The brachial graft was infected. They removed the graft(35903). They also performed a axillary-brachal bypass (35522) and also removed the aneurysm when they removed the graft. Are these two codes that you would code? I would not code the aneurysm removal as it was removed with part of the infected graft. LW

Cryoablation of lung 32999

Dr. Z, In the area of cryoablation of the lung, I have suggested 32999 as the appropriate code, others are stating that microwave, radiofrequency and cryoablation would use the same code: 32998. Could you please clarify this as our hospital uses your guidelines but we do not have anything in writing on this issue. Another issue that has led to some confusion is that the physician used the RFA equipment but changed the needles on the equipment to perform the cryo? Documentation reads: Two 24L cryoablation needles were subsequently inserted into the lesion. Multiple adjustments in the position of the needles were made followed by limited CT scans in full expiration were performed until correct positioning was obtained. During this process, the patient developed a moderate volume pneumothorax for which an 8 French APDL pleural catheter was placed. Intermittent hand aspiration was performed to maintain lesion targeting. One run of 30 minutes was performed to ablate the lesion. The ablation needles were then removed and the tract was ablated. A sterile dressing was applied and the pleural catheter was left in placed to 20 mm Hg of wall suction. Thanks in advance for your help with this problem, Rhonda, Ancillary Manager

37210 Fibroid embolization

If complete, bilateral uterine artery embolization is unable to be accomplished, should CPT 37210 be modified (maybe with a 53 or a 52) to represent that? In our case, the left UE was completed. Attention turned to the right UE which spasmed with wire placement, was treated with nitro, and despite that, occluded so we weren't able to embolize the RT side and the procedure was terminated.

75774

Dr Z, I would like to clarify the use of 75774.MD does arteriogram of the leg he describes the 75710 occluded proximal SFA stent noted all the way down to popliteal. Then he places catheter in SFA and describes as arteriogram shows occlusion of the SFA completely and SFA stent. I don't feel this should be coded as a 75774 because he just repeats what he saw with the 75710, am I right or wrong? Thank you,

Intra operative imaging

Dear Dr. Z: Is it appropriate to bill intra-operative views with findings which appear to be only confirmatory of the procedure which was performed? Imaging is often included in the surgical codes now (i.e., spine injections) or in the radiological S&I code billed with the surgical component. If the view is for QA purposes, confirmatory only, or not diagnostic shouldn't it be a no charge? Thank you. mlb

Acetylcholine challenge test

Is 93024 the appropriate code for a coronary artery spasm test using acetylcholine (acetylcholine challenge) during a heart catheterization procedure?

93501 and 93505

Catheterization codes are included with biopsy. General this is for a patient with a transplated heart. My question is, for a non routine biopsy on a native heart, can we charge for both the cath and the biopsy. Example: A Right heart catheterization and a biopsy, on a native heart, was done when they suspect a patient with amyloidosis.

Diagnostic angiography at the time of an intervention

My docs have asked me two specific questions after I forwarded the latest Dr Z newsletter to them: “Diagnostic Angiography at the Time of an Intervention -- your ZHealth Online Newsletter for August 15, 2011”.

1) Does this apply to all interventions equally – Lower extremity, visceral, head & neck, etc.?

2) Does this apply to Part A and/or Part B or both
 

EKG with cardiac catheterization

Hi Dr Z. I have a question on basic EKG's. As a general practice all doctors order the standard pre /post EKG along with one view chest x-ray for standard cardiac procedures (LHC/ cardiac intervention/ EP / device implants PPM ICD etc) The billing office has always just added 59-74 or 76 to all 93005. In the pt's record I can't find documentation that the interpretation of pre /post or sequel ekg is referred to in any dicision making plans for the patient (I always think of doctors document from CCL - ex. from the angio findings, further intervention needs to be done etc.) I have also found that many times the EKG tracing are not signed and have no written interpretation from the doctor only the printed interpretation from the EKG machine, never any formal written report. Please let me know if you think the practice of adding 59/74/76 to all ECK codes 93005 is appropriate. Thanks According to the LCD from Trail Blazer L26535 - for a service to be paid the follow information need to be present in chart. Documentations Requirements Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request. Documentation should demonstrate that services are provided according to all requirements of this LCD. In this respect, the record should demonstrate the following: Evidence of recent, past, ongoing or suspected cardiac disease or symptoms. For patients in whom the ECG is performed as part of the evaluation of chest pain or symptoms that are atypical for cardiac ischemia, the record must substantiate that the ordering clinician has a valid concern that the etiology of the chest pain or other symptoms is cardiac in origin. Conversely, the record may show that the ECG is being used to exclude cardiac origin for symptoms (including chest pain) for which cardiac origin cannot be excluded by history or physical examination. For serial ECGs, information supporting the medical necessity for repeating the studies at the given interval should be present. Sequential ECGs, either short-term for an acute condition or long-term for a chronic condition, are often appropriate. Documentation must demonstrate that the findings of the test affect management of the condition. The report of the professional component (the interpretation) for the ECG must be a complete written report that includes relevant findings and appropriate comparisons. The interpretation may appear on the actual tracing or with a progress note or other report of an E/M service when the ECG is performed in conjunction with performance of an E/M service. An interpretation reported in the latter fashion, when billed as a separate service from the E/M service, should contain the same information as a report made upon the tracing itself. A simple notation of “ECG/EKG normal,” without accompanying tracing, will not not, in this circumstance, suffice as documentation of a separately payable interpretation. Preoperative ECG studies must indicate the underlying cardiac condition or risks, as well as the proposed operation for which cardiac evaluation is being performed. The ECG must be performed reasonably proximate to the proposed surgery to be considered medically necessary. Appendices N/A Utilization Guidelines Serial ECGs performed over both the short term (as for an acute condition) or over the long term (as for chronic conditions) may be appropriate when performed at a reasonable frequency. However, such ECGs will not be covered by Medicare unless it is clear that the tests are necessary for monitoring an evolving pathologic process for which the therapy will be altered based on the findings of the ECG. The interval between ECGs should be determined by the physician responsible for the patient’s care upon consideration of factors such as natural history and severity of the underlying condition, recent changes in the condition or onset of new symptoms relating to the condition, and/or the specific patient’s historical responses to therapy for his condition.

Microphlebotomy of vericose veins

Would you code this as an unlisted 37799? I wasn't sure if microphlebectomy was the same as 37766? thanks MICROPHLEBOTOMY OF VARICOSE VEINS BOTH LOWER EXTREMITIES History: 60-year-old female with previously injected symptomatic large varicose veins of the both lower extremities. She has painful areas of entrapped blood. Indications: Symptomatic previously treated bilateral varicose veins. Medications: None Contrast: None Complications: None Technique: Confirmation of patient identification and the planned procedure were obtained. The courses of the large thrombosed varicosities along the anterior and posterior aspects of both legs were noted. The patient was then placed prone on the stretcher. Both legs were cleansed with alcohol from the buttock to the ankles. Microphlebotomy was performed as described below. Dressings were applied and she was turned supine. After additional alcohol cleansing, a total of more than 40 (including those on the back) small (2 mm) incisions were made in the various marked areas of each leg. Old blood was manually expressed from the various sites. Manual pressure was held. Gauze pads were placed over each incision. She tolerated the procedure well. Findings: The multiple large varicosities with entrapped blood from previous sclerotherapy in both legs were treated with microphlebotomy as described above with a very good early result. She tolerated the procedure well. Impression: Successful microphlebotomy of entrapped blood from previous sclerotherapy in both legs.

Therapeutic needle drainage of gall bladder with 10160

Patient has a history of accute cholecystitis. A hawkins needle is placed in the gallbladder under ultrasound guidance. 100 cc of fluid is aspirated. Is this coded as 10160?

Epinephrine challenge

One of our EP doctors did a provocative testing drug study on a patient with recurrent syncope using Epinephrine and Procainamide. I have no idea what the code would be for this! When I checked my CPT book, it led me to 95078 which appears to have been deleted. Would I use the unlisted code 95199 instead?

36246 with cardiac catheterization

Please do NOT include any actual patient medical records with your question. Drs Z and D: Confused by this: When a diagnostic heart cath is performed and then a selective contralateral external iliac (36246) is additionally performed (diagnostic only), do we code the catheter placement code or is it considered inclusive? thanks, Denise

37799-GZ vertebral angioplasty

what cpt code would be appropriate for selective cath placement into the vertebral artery? medicare guidelines does not cover for head and neck vessels for PTA. the pt had 70 to 80 % stenosis at the origin of the proximal left vertebral artery.

Attempted procedure

How do we report a planned PTCA on a CTO (chronic total occlusion) when we were not able to get a guide wire past the lesion and are not able to place a catheter to do the angioplasty. The patient had a diagnostic LHC with cors which identified 100% stenosis in the proximal RCA, mid LAD and 70% stenosis in the 1st diagonal.

“014/300 Straight Prowater wire was unable to cross the lesion.
014/300cm Persuader 3 wire was unable to cross the lesion.
7FrAL.75 with side holes Wiseguide guiding catheter was used to cannulate the vessel and angiography was performed in two orthogonal planes.
014/300cm Persuader 3 wire was unable to cross the lesion.
A percutaneous intervention was attempted on the 100% lesion in the proximal RCA. Following intervention there was a 100% residual stenosis. This was not a bifurcation lesion. This was an ACC/AHA type C “high risk” lesion for intervention. There was no evidence of the transient no-reflow phenomenon. There was TIMI O flow before the procedure and TIMI O flow after the procedure.”

I reviewed questions in your data base but could not find any that address physician billing for incomplete PTCA. Do we report this service with modifier 52 on 92982 in addition to the diagnostic cath codes?

How would we report a PTCA if the guidewire is advanced into the vessel but the balloon catheter could not be expanded.

Thanks for your help.
 

61624

Dr Z, Our Physician is coding for giant Left ICA Aneursym. He is coding a 61630 61624 36216 75665 75898. Is he able to code the 61630 with the 61624. I thought the 61630 was bundled with the 61624 and all catheter/angio's are included into the 61630? Thank you in advance. G

35206, 35761, 35860, 37799

Dr Z: My physician performed: Preoperative and Postoperative Diagnosis: Septic thrombophlebitis of the left cephalic and vasiic veins. Procedure: Excision of distal left cephalic vein at the wrist. and Excision of the left basilic vein at the antecubital fossa. Descrption: Following discussion with the patient regardig the risks, benefits, and expectations, signed consent was obtained. The patient was brought to the operating room, placed in supine position. His left arm was prepped and draped in sterile fashion. I made an incision over the cephalic vein of the wrist with a knife. Dissection was performed to free the vein proximally and distally in the zone of cellulitis. The ends were tied off with 3-0 vicryl sutures. The wound was irrigated and closed with nterrupted 3-0 vicryl followed by 4-0 Monocryl. The basilicc vein at the antecubital fossa was excised in a a similar fashion and closed. The ony CPT descrition I can fine is unlisted 37799. Is this correct. thanks for your help.

35876, 35875

little confused on this one...pt has had tpa infusion done on the 11th, a follow-up and cath. change on the 12th, and now back again on the 13th...following this procedure on the 13th the pt. was taken for open graft thrombectomy in the OR...for this portion below I was thinking 75898/75900/37209. Not 100% though...i'm not quite sure if the cath. was actually exchanged or not. When the OR surgeon gets the pt. to the OR he mentions in his note that the infustion cath. was removed prior to the thrombectomy. your thoughts? thanks! PREOPERATIVE DIAGNOSIS: Thrombosis of left femoral-to-posterior tibial bypass. POSTOP DIAGNOSIS: Thrombosis of left femoral-to-posterior tibial bypass. OPERATION PERFORMED: 1. Angiogram of left lower extremity. ANESTHESIA: Local plus sedation. ESTIMATED BLOOD LOSS: Less than 5 mL. INDICATION: Mr. XXX is a 72-year-old gentleman who initially had presented with thrombosis of his left femoral-to-posterior tibial bypass graft. An angiogram of left lower extremity was obtained and catheter directed thrombolysis was initiated. 24 hours later, repeat angiogram revealed patent bypass graft, but distal posterior tibial artery remained occluded. Thrombolysis was continued. Today, he was brought again to the operative room for the reevaluation of his left lower extremity. OPERATION: After informed consent was obtained, the patient was brought to the operating room and placed in the supine position. Conscious sedation was achieved by anesthesiologist. Patient's bilateral lower extremities were prepped and draped in a standard surgical fashion. At this point of time, the wire of the Infusi-Catheter was removed. It appeared that there was a significant amount of thrombus attaached to the wire of Infuse-A-Catheter. Manual aspiration was done on the Infuse-A-Catheter which also revealed clotted blood. At this point of time, decision was made not to give any dye through the Infuse-A-Catheter because of the risk of showering emboli into distal perfusion. The Infuse-A-Cath was then removed. Aspiration was done on the sheath which revealed good arterial blood. It was flushed adequately with heparinized saline. A diagnostic angiogram of the left lower extremity was performed through the sheath which showed that the previously open femoral-to-pop bypass was thrombosed again. There was no blood flow into the bypass at all. The angiogram also revealed that there was a significant collaterals both in the thigh and calf which were patent. At this point of time, an 0.35 Glidewire was passed through this sheath successfully into the bypass and across distal anastomosis into the native posterior tibial artery. A Quick-Cross catheter was then placed into the native posterior tibial artery. Aspiration revealed good arterial blood. Repeat handheld contrast was given which showed that the distal posterior tibial artery was patent. At this point of time, the options were either to continue thrombolytic therapy through this graft or to do an open cut down and thrombectomy of the bypass. Since the patient has already received about 48 hours of thrombolytic therapy with re-thrombosis a decision was made to proceed with open thrombectomy. Dr. XXX was present inside the operating room and open thrombectomy was performed under guidance of Dr. XXX. This procedure will be dictated separately by Dr. XXX. here's the beginning of the surgeon's note: OPERATION: The angiography portion of the patient's care is being dictated separately by Dr. Aziz. I was called to the operating room to consult on the patient. Patient was receiving light conscious sedation and monitored anesthesia care. He was prepped and draped in the supine position on the fluoroscopy table in OR 25. Angiography done minutes earlier had shown that the graft was rethrombosed. However, an angiogram done through the tip of the infusion catheter showed that the runoff vessels were in fact patent, at least to the ankle. At this point, I scrubbed into the case. The cause for rethrombosis of the graft was not clear, but we were concerned that perhaps the infusion catheter had malfunctioned. Earlier in the morning, the patient had a palpable pulse and signals in the graft, but in the OR, the graft was thrombosed. Rather then reinitiate or continue the thrombolytic infusion, I felt that it would be appropriate to cut down on the graft and do a catheter thrombectomy. If this did not work, there really was nothing else surgically that could be done. We asked anesthesia team to induce general anesthesia, which was done with an endotracheal tube. The entire leg was already prepped and draped. A short transverse incision was made over the distal thigh portion of the graft. This did not provide adequate exposure of the graft and so we made a separate longitudinal incision just at about the level of the knee joint. The graft was pulseless, but was palpable because of the infusion catheter in it. After an appropriate length of graft had been isolated, we removed the infusion catheter from the right-sided 5 French sheath. At this point, the graft was soft and compressible but pulseless. The patient was bolused with heparin to achieve an ACT over 220 seconds. Control of the pulseless graft had been obtained. We made a small transverse arteriotomy in the graft. We passed a #3 Fogarty catheter proximally. The catheter passed without resistance well up into the external iliac artery. We extracted a large amount of fresh, red thrombus and this was followed by a pulsatile inflow. An additional pass of the catheter did not yield any further thrombus. We instilled heparin saline liberally into the upper part of the graft. The distal thrombectomy was done with a #2 Fogarty catheter, which again passed without resistance, all the way to the ankle and slightly beyond. We withdrew the catheter and again retrieved fresh, dark thrombus. This did not appear to be platelet fibrin thrombus. Two more passes were done with minimal additional material retrieved and we now had bright red backbleeding. Heparin saline and low-molecular weight dextran were instilled distally.

Yueh needle 32422

Dear Dr. Z: This may be an easy one for a physician, but please provide clarification. Thoracentesis is being performed. "Yeuh needle was advanced into the collection. A total of 1500 cc was withdrawn. Material was sent for multiple assays. The needle was removed and puncture wound dressed appropriately." Is a "Yeuh needle" always considered a catheter device (32422)? Is it possible to use only the needle component for the thoracentesis procedure (32421)? Thank you and have a good day. mlb.

Brain chemo infusion

Dr.Z: My physician wanted me to contact you as he is going to start doing procedures for intracranial chemo and wanted to know the specific codes that we should use. any help would be appreciated. thank-you.

Ultrasound guidance for marking the skin for subsequent needle placement

I don't know if you can help on this or not. But some of our doctors want to charge 76942 for skin markings as opposed to using wire placement or needle localization. Any help would be appreciated. Thank you for whatever help you can give. Suzan

Conscious sedation billing for hospital and physician

Hello, I have a question when it comes to conscious sedation facility vs. professional billing. If the physician performs conscious sedation on a procedure that does not have a bullet, can cpt code 99144 be added to both the hospital claim and the cm 1500 form. New to hospital billing and not sure if I can add the code to both claims. I do know that modifier 26 or TC do not apply. Thank you for your help.

Axillary puncture

I have a question on cath charges. From a right axiliary approach, the right vertebral, right internal cartoid and left common carotid arteries were selected (with proper documentation for the S/I charges). As the most selective cath off this branch of the aorta is the right internal (36216), can you also charge 36215-59 for the right vertebral artery? I know 36218 is inappropriate, because while an additional cath, it isn't a 2nd or 3rd order cath placement. So for this exam, would 36216 and 36215-59 (x2) be correct or would we lose right vertebral cath and only charge 36216 and 36215-59? Thanks in advance for your help with this!

Neck venous malformation sclerotherapy

Procedure coded as 36299, 76499, 37204, 75894, not sure if this is correct. Physician not clear as to where in the neck the patient was accessed. Thanks! Indication: Right neck venous malformation Procedure: Right neck venous malformation embolization Findings: After obtaining informed consent, the right neck was prepped and draped in normal sterile fashion. Sedation was provided by the anesthesiology service in the form of general endotracheal anesthetic. Sonographic guidance was used to direct needle access to a vascular structure within the malformation. Contrast material was injected for malformation venography. There is a complex vascular structure with what appears to be irregular venous as well as lymphatic component. Via this access, a total of 4 cc of 3% STS was foamed and administered in 3 separate sessions with interval dwell time for the purpose of malformation venous scleroablation. Needle access was removed. A compressive dressing was placed. The patient tolerated this should well and left the department in stable condition. Impression: 1. Right neck vascular malformation venography demonstrates a complex venolymphatic lesion 2. Technically successful scleroablation of the lesion utilizing foamed STS with excellent result

Sclerotherapy of vascular malformation

Docs: Have you heard of anything like this? I came up with 75989-26?? Could this be an alcohol embolization 37204?? Appreciate your opinion! Arterial venous malformation right medial thigh. POSTOPERATIVE DIAGNOSIS: Arterial venous malformation right medial thigh. PROCEDURES: 1. Percutaneous drainage of a right thigh arteriovenous malformation. 2. Scleral therapy of right thigh arteriovenous confirmation with 98% alcohol. 3. Ultrasound-guided access to right thigh arteriovenous malformation. DRUGS GIVEN DURING THE CASE: 1. Versed 1 mg IV. 2. Fentanyl 50 mcg IV. 3. Distilled 98% alcohol 40 mL into the arteriovenous malformation. COMPLICATIONS: None. INDICATIONS: The patient is a very pleasant, but unfortunate, 52-year-old male. He has a very large arteriovenous malformation of the right medial thigh. Multiple attempts have been made to secure this. He underwent his first bout of sclerotherapy last week. PROCEDURE: On 08/05/2011, the patient was brought to the Interventional Suite. He was prepped and draped in sterile fashion. A timeout was made for safety. Using the ultrasound, I was able to guide an Angiocath catheter into the arteriovenous malformation. I directly visualized my needle entering the AVM under ultrasound. There is permanent record of this ultrasound in the chart. Once my catheter was in place I drained approximately 1 liter of blood from the arterial venous malformation. Once the arteriovenous malformation was appropriately drained, I instilled 40 mL of alcohol solution into the AVM. The catheter was removed.

C-codes for angiographic catheters

Good morning, Dr. Z, A question has come up regarding C-Codes for a diagnostic angio catheters. We had a C-Code attached in our charge master for diagnostic catheters in the Cath Lab, but we did not have it attached in the Angio charge master. I checked your book for device codes and there is not a C-code listed for them. The sales reps say no, that there is no C-code for them. With the confusion between the charge masters I have been tasked with writng to you for advice. Thank you, again for all your help! R Mercer

CT and CTA of the chest

Dr. Z Can I code a CT of the Chest w/contrast 71260 with a CTA 71275 if the reports evaluates the lungs as well as the non-coronary vascular structures of the chest?

Congenital heart cath without ASD closure

Dr.Z, Question for ASD closure. During a routine echocardiogram, found to have a small left to right shunt across the atrial septum for which she was offered to have closure of ASD. After obtaineing pressures, ICE was performed and showed a small ASD near the foramen ovale. Then with transcranial Doppler in place, injectged several times the agitated saline of bubble contrast and there was no right-to-left shunting. After confirming that there is no right-to-left shunting and study was negativ e, concluded the cardiac catheterization and patient did not receiv e any closure for her defect. Our cath charges these with 93530 93662 and the order is for Right and left heart cath ASD closure with Helex TCD/ICE. Please advice. Thansk

Diagnosis coding for left and right heart catheterization

Please help with this HTC. Here is what I was thinking: 416.8, 746.89, 424.0, 93531-26. Is there anything else I can code for this? What about the mention of congential heart? or what about "both by Fick and dermal dilution multiple times"? Thank you, PROCEDURE: 1. Insertion of 7 French sheath in right femoral vein. 2. Right heart catheterization with saturations and cardiac output check. 3. Based on the results of the right heart catheterization, we did put a 4 French sheath in the right femoral artery and did left heart catheterization with a pigtail catheter. 4. Simultaneous recording of left ventricle and right ventricle for the indication of suspected constriction. 5. Simultaneous recording of left ventricle and wedge pressure for the suspicion of mitral valve stenosis. 6. Fluoroscopy of the mitral valve done in the LAO position. PREPROCEDURE DIAGNOSIS: 1. Congenital heart disease. 2. Suspected Eisenmenger syndrome. 3. Persistent hypoxemia. 4. Mitral valve disease, status post a St. Jude mechanical mitral valve replacement. POSTPROCEDURE DIAGNOSES: 1. Moderately severe pulmonary hypertension although with severely elevated left ventricular end-diastolic pressure. 2. Evidence of a 20 mm or greater resting gradient on the mitral valve. Mitral valve area calculated to 1.35 sq cm consistent with severe mitral stenosis functionally. 3. Moderate elevation of right heart filling pressures appropriate to her degree of pulmonary hypertension. COMPLICATIONS IMMEDIATE TO PROCEDURE: None noted. MEDICATIONS: Medications given during the procedure include Fentanyl and Versed. The patient was taken off and put back on her oxygen by nasal cannula during this procedure. PROCEDURE IN DETAIL: The patient was informed and consented. She was brought to the cath lab in a fasting state. Her right groin was prepped and draped in a normal sterile fashion. Her Coumadin had been held and her last dose of low molecular weight heparin was well over 12 hours ago. INR was subtherapeutic. She received some conscious sedation. It was noted that hen we turned her oxygen off to do a saturation run she promptly drops her pulse oxygenation down to the range of 84 to 87% on room air. The patient received infiltration to the right groin after it was prepped and draped in a normal sterile fashion. A 7 French sheath was introduced in the right femoral artery and a Swan-Ganz catheter was introduced from this approach. Although she is a pulmonary hypertension workup patient, I was not able to go from above due to the presence of a dialysis catheter which we did not want to disturb. Although I was prepared to leave the Swan in, the findings were not consistent with isolated systolic pulmonary hypertension but rather with secondary pulmonary hypertension due to elevated left heart pressures. Therefore the Swan-Ganz catheter was not left in at the end of the procedure. Due to the finding suggesting that she has either constriction or mitral valve disease, we went ahead and put a 4 French sheath into the right femoral artery without difficulty and introduced a 4 French pigtail catheter into the left ventricle. Left heart pressures including simultaneous recordings during wedge pressure tracing and during right ventricular tracing with dual transducer system was performed. Cardiac outputs had been performed with a right heart catheter and cardiac index was obtained both by Fick and dermal dilution multiple times. At this point in time we did a fluoroscopy of the mitral valve from the LAO position and demonstrated what appeared to be reasonably good excursion of both leaflets to fluoroscopy. Results were reviewed, sheaths discontinued and pressure applied for hemostasis. RESULTS: 1. Hemodynamic findings: Again, the patient had severely elevated biventricular filling pressures. Right atrial pressure was 35, right ventricular pressure was variable with respiration ranging between 45 and 65 over 16 to 30. Pulmonary wedge pressure was a 45 aortic the left ventricular pressure was 92 over an end-diastolic pressure that ranged between 30 and 35. Again, PA pressure ranged between 65 and 75 systolic with diastolics in the 38 to 250 range. 2. Normal mitral valve leaflet excursion to fluoroscopy. 3. Dual transudate transducer measurements do not support constriction. The patient did have repeatedly splitting of the diastolic pressures between the right ventricle and left ventricle with gentle inspiration. 4. The dual transducer measurements did suggest that the patient has functional mitral stenosis with a mean resting gradient of 20 mmHg and a calculated mitral valve area of 1.35 sq cm. CONCLUSION: Severely elevated biventricular filling pressures, left greater than right, which suggests that the patient would benefit from volume reduction and possibly may benefit from further evaluation of her mitral valve function. I would like to see if with the use of a pressor we cannot effect more aggressive volume reduction with dialysis and otherwise consider a transesophageal echocardiogram. There certainly is some pulmonary hypertension but I suspect given the magnitude compared to the magnitude of left heart filling pressure elevation this is primarily secondary pulmonary hypertension. Pulmonary will be consulted and additional contributors to pulmonary hypertension such as sleep apnea, hypoxia and anemia should be addressed, as well.

Coronary angiography 93454 with left ventricular electrophysiology ablation

HI Dr. Z, I have a case in which the patient had an EP study with 3D mapping and ablation of V-tach. However, prior to beginning the ablation a LCA angiography was done "to outline the course of the coronaries on the epicardial surface to ensure the ablation spots were safe distance away from these vessels." Can I bill 93454 or is the angio included in the EP study and ablation? Thanks so much for your help!!!

Venoplasty of AV fistula stenosis related to plasmapharesis, NOT dialysis

Good morning all, my question pertains to 36147, my patient has an A-V fistula for plasmapheresis for a dx of CIDP. My interventionalist does a fistula study and finds stenosis and thrombus, we are doing everything 36147, 35476 and 75978 these codes are used for except for the word dialysis. The term dialysis means separation, but all reasearch still adds the word renal to it. Would this have to be coded 36299 for the injection and can I still code 35476 and 75978 for the angioplasty? Appreciate your thoughts. Judy

37220 and 37224 for iliac and SFA angioplasty

would you do 37220 and 37224 for this one? PROCEDURE IN DETAIL: The patient was brought to the Angio Suite and placed in supine position. After a time-out was performed, the bilateral groins were prepped and draped in sterile fashion. Ultrasound guided access was attempted in the right common femoral artery. However, we could not advance the wire. The patient did have a known external iliac artery stenosis. However, despite multiple attempts, we could not get the wire to traverse proximally. In order to treat the left external iliac artery and superficial femoral artery occlusive disease, I needed to establish access from the left brachial artery. This was performed under ultrasound guidance with a micropuncture kit. A 5 French sheath was ultimately placed and the 90 cm pigtail catheter placed in the distal infrarenal abdominal aorta. Aortoiliac angiogram should distal external iliac artery occlusive disease bilaterally as was depicted on the arterial duplex. The 0.035 angle tip stiff glidewire was then used to carefully select the left common iliac, common external iliac and common femoral artery. The short 5 French sheath was exchanged for a 90 cm 6 French sheath with the tip positioned in the left iliac system. Iliac and left lower extremity arteriogram was then performed to the extent of the knee due to the reach of the table from the brachial position. There was approximately 60-70% stenosis of the left external iliac artery and occlusion and approximately 20 cm occlusion in the left superficial femoral artery. I was able to traverse the external iliac artery stenosis as well as the superficial femoral artery occlusion to the mid thigh. However, this was the extent of the length of the balloon at 135 cm. A 5 mm x 10 cm balloon was then used to angioplasty the origin of the left superficial femoral artery as well as the upper third of the superficial femoral artery into the mid thigh. I did over-inflate this balloon to angioplasty the left external iliac artery with good results. Completion arteriography showed excellent flow through the proximal superficial femoral artery and the known residual distal stenosis which we could not reach from the arm. There was reconstitution of the above knee popliteal artery which continues relatively disease free below the knee. The trifurcation shows only runoff through the peroneal artery. A total of 58 ml of contrast was utilized. The 90 cm 6 French sheath was exchanged for a short 6 French sheath to be removed once the ACT was less than 175 seconds. I was present the entire portion of the procedure.

35102

Greetings, A patient has a infected aortobifemoral bypass graft that is excised. They debbridement of the end of the aorta. A crypopreserved aorto illiac graft is placed. End to end anastomosis to the aorta,the right side was end to end anastomosed to the femoral bifurcation , on the left a end to side anastomosis was formed to the superficial femoral artery. Is this truly a bypass or a graft placement even though this was not completed for a aneurysm. Would you use 35646 or 35102. I was even looking at code 34832. Any help would be great. Thanks, LW

74425, 50394, 50684

In your Interventional Radiology 2011 Coding manual, pp 277-278, you indicate that codes 50684 and 50688 are retrograde procedures performed via an ileal conduit. The CPT Tabular instructs that the supervision and interpretation(S&I) code to report with 50684 is 74425. A similar note is included under code 50690 in CPT Tabular. Code 74425 is the S&I code for an antegrade procedure. Can you please clear up my confusion whether the S&I code for 50684, 50690 should be 74420 vs 74425? Thank you.

Non coverage of 3D rotational angiography

What exactly needs to be stated in the report for the use of Rotaional angiogram with 3-D? Pt. had a stent assisted endovascular coiling done. The dictation states Rotational angiogram with 3-dimensional reconstruction with postprocessing on a separate work station. The payor denied 76377 stating related or qualifying service not paid or identified on claim. I'm not sure how to appeal this? thanks for your help.

Thoracic stent graft

I was wondering if 33889/33891 was the right way to go with this one...this is the first one i've had like this. the endograft placement was dictated separately. i'll attach that note in another question. thanks!! PREOPERATIVE DIAGNOSES: 1. A 9-cm aortic arch aneurysm. 2. Need for aortic arch revascularization. POSTOPERATIVE DIAGNOSES: 1. A 9-cm aortic arch aneurysm. 2. Need for aortic arch revascularization. OPERATION PERFORMED: 1. Right-to-left carotid-carotid bypass with 8-mm Dacron and retropharyngeal tunnel. 2. Left carotid-to-left subclavian artery bypass graft with 8-mm Dacron graft. 3. Ligation of proximal left common carotid artery. 4. Ligation of proximal left subclavian artery. ANESTHESIA: General endotracheal anesthesia. Estimated blood loss is 300 mL. IV fluids were 2700 of normal saline and 2 units of packed red blood cells. Urine output was 450 mL. COMPLICATIONS: None apparent. INDICATIONS: This 77-year-old male had been seen by Dr. XXX approximately 2 years ago with an arch aortic aneurysm. He has underlying dementia and confusion and because of the need for likely circ arrest for repair of the aortic arch, Dr. XXX did not feel that the patient was a good open operative candidate. We were consulted for a possible endovascular repair. In reviewing the images, we would need to debranch the aortic arch and reroute for the left common carotid and subclavian arteries. I have recommended a carotid-carotid bypass as well as a left carotid-to-subclavian artery bypass graft. They understood the risks and benefits and wished to proceed. OPERATION: Patient brought to the Hybrid operating room and placed in the reverse Trendelenburg position. After adequate general endotracheal anesthesia was achieved and time-outs performed, the bilateral neck and chest were prepped and draped in a sterile fashion. Cushions had been placed to the heels as well as to the sacrum as well. A supraclavicular incision was made in the left supraclavicular fossa approximately 1 handbreadth proximal to the clavicle. This was carried down through the platysma, anterior scalene fat pad, and through the anterior scalene muscle. The subclavian artery was identified and looped distally with a vessel loop. There was a moderate amount of inflammation in this area felt secondary to the aneurysm. We were ultimately able to get a 0 silk tie proximal on the left subclavian artery, which was proximal to the vertebral artery takeoff. Branches of the thyrocervical trunk were then ligated in order to facilitate exposure. Next, the right common carotid artery was dissected free from the surrounding structures via a lateral neck incision along the anterior border of the sternocleidomastoid. The internal jugular artery is reflected laterally and the common carotid artery looped proximally with an umbilical tape and distally with vessel loop. A retropharyngeal tunnel was then begun, which was posterior to the esophagus and right over the vertebral bodies. This was deepened toward the left carotid artery. Next, the left common carotid artery was exposed in a similar fashion and a retropharyngeal tunnel obtained. The patient was then systemically heparinized with 5000 units of heparin and the right common carotid artery clamped proximally and distally. A arteriotomy was created on the medial aspect and an end-to-side anastomosis constructed with an 8-mm Dacron graft using 6-0 Prolene suture from the heel and the toe. Prior to completion of anastomosis, the collateral graft was clamped and antegrade and retrograde flushing performed. Next, the anastomosis was secured and appeared to be hemostatic. The graft had previously been brought through the retropharyngeal tunnel and was now anastomosed to the distal right common carotid artery in a similar fashion as the proximal anastomosis. Once this was complete, flow was restored to the brain. At this point, the left common carotid artery was looped proximally with a 0 silk tie and a retrojugular tunnel created and the 8-mm Dacron graft passed through the tunnel. A end-to-side anastomosis was created on the lateral aspect of the left common carotid artery with a 6-0 Prolene suture. The graft was then clamped and then the end-to-side anastomosis created to the subclavian artery using 6-0 Prolene suture. Prior to completion of anastomosis, antegrade and retrograde flushing was confirmed. The anastomosis was hemostatic. The 0 silk ties were then used to ligate the left common carotid and the proximal left subclavian artery. At this point, the wounds were inspected for hemostasis and the right common carotid artery incision closed with 3-0 Vicryl suture followed by 4-0 Monocryl and Dermabond. At this point, attention was then turned to the thoracic endovascular graft, which will be dictated separately. I was present throughout the entire portion of the procedure.

35903

Greetings, I have a physician excise a infected A V fistula. The pt had 2 PTFE segements attached (two different fistulas) to the brachial artery. 35903 has a MUE of 2. I assume this means one for the Rt side and one for the Lt side. Both of these were removed on the same side. Would you code for two excision of infected grafts (35903 and 35903-59). Also the brachial artery was two friable so he had to place a graft to connect the proximal and distal end of the brachial artery code (35266). 35266 is bundled per CCI but it can be bypassed but its not a different area or different session. The best I can come up with is a 35903-22. How would you code this? LW

36140 with 37229 atherectomy anterior tibial artery

OH help! I know you have coverd this in your webinars, but I can't seem to find it, and a co-worker has come to me for the answer on this>>>> Anterior tib is subtotally occluded at its origin and then occluded in the mid portion. RCF access with anterior tib atherectomy of the origin. MD was unable to pass the wire or catheter past the occluded mid portion. Pedal access was obtained wires were used without success to cross the occluded mid portion. The question is can 36140 be used for the pedal access. I coded only 37229 (there was a previous diagnostic study.) not the 36140. I want to make sure I give her the correct info! Thanx!

aortic aneurysm repair with multipel extenders

We had an abdominal aortic aneurysm repair case in which the MD used a main body (trunk with ipsilateral leg endoprosthesis; W.L. Gore) and placed one iliac extender, two contralateral leg extenders, two aortic extenders and one iliac extender.

My question is how many times can we use the code 34826?

We coded 36200x2, 34802, 75952, 34825, 75953, 34826x2 and 75953x2.

Please advise. Thank you!
 

MRI and MRA on the same site

Dr Z the radiology managers asked me if they need to create two accession #'s when the physicians are asked to dictate separate reports for MRI/MRA same anatomical site. The Radiologists say there must be two accession #'s and I agree but the managers have asked me to verify this. The business office has been bundling MRI/MRA together instead of reporting each with modifier 59 on second code for a composite APC, thus potentially losing the hospital money. The Radiologists have been billing both procedures with 59 and mostly get paid, particurlarly by Medicare. CMS indicatd these can be submitted if two separate dictated reports are created. Thanks J

Pipeline reconstruction device

What code do you suggest for endovascular treatment of an aneurysm using the Pipeline reconstruction device?