Ask Dr. Z

Is this code billable with procedures other than tunn cath's, central lines, etc...I know it's able to be billed with other codes but it either won't get paid by insurance or it edits out in our system as being an add-on, etc...

I just wasn't sure if we're supposed to be pushing this through, if it's correct to be billing it, etc...I hadn't heard anything recently so I was curious what info. you may have.
 

I have a provider that did a radial access attempts to advance the J wire into the aorta from the right radial was not successful, therefore a JR cath was advanced to the level of proximal subclavian and an angiogram was performed. Apparent that the pt had about 75-80% right sublcavian stenosis. Glide wire was advanced into the ascending aorta and the JR-4 and AL-2 multiple angulated view of the Rt and Lt coronary performed. JR-4 was used to selective engage the vein graft to the RAMUS and vein graft to the marginal and selective angiography of these grafts were performed. LIMA was patent because of competitive flow in LAD. No attempt was made initially to engage the LIMA. At this point the provider did a common femoral arterial access was obtained, LIMA cath was selective engaged into the left internal mammary, angio performed. Pigtail cat was advanced into the ascending aorta, aortic root ang was performed. AL-6 guiding cath then selectively engaged into the the Rt coronary artery, multiple agulated views of Rt coronary artery were performed. This was performed after 300mics of IC nitroprussied. Pt given ANGIOMAX bolus and drip in .014 whisper wire dilated from distal RCA to mid RCA. Drug eluting stent was then done.

My question on this case is can I bill anything for the first access that was not able to complete the heart cath?
I have one coder that feels we should bill 93459, 93459-59 or 74, G0290,93567.

The other coder feels we should bill 93459,G0290,93567 and 36216 and 75710 for the subclavian access and angio.

Any guidance you can give use on this case would be greatly appreciated.
Thank you for your assistance.
 

For the new revascularization codes, are there any multiple procedure payment reductions we should be aware of? Like if they do stent in 2 places or even a primary and 2 add on’s in the iliac or tib/peron territory, would the 2nd add-on payment be reduced or would they get full reimbursement?

Docs are asking and I really am not sure where to find this info!
 

We come across a case where the patient scheduled for upgrade of AICD to Bivent AICD however after unsuccessful multiple attempts decided to place only a dual chamber AICD. During the procedure found to have insulation breach proximal to the suture sleeve and was repaired with silicone glue and the old generator explanted. A new atrial lead was placed which attached to the new dual chamber AICD along with the existing RV lead. There are NCCI edits for 33249 and 33220 or 33218 edits can we assign with repair codes with ‘59’? And also in this scenario if we can code the repair which one you suggest 33218/33220?

Thank you for your time.

Patient has an infrarenal AAA with type 2 endoleak. Bifurcated endograft is in place. Patient goes for a CTA abdomen for identifying the endoleak. Patient in prone position and CT fluoro used to advance the needle into the posterior aspect of the sac near the site of the endoleak. Bentson wire advanced into the aneurysm sac. After "successful placement of access system into the aneurysm sac" the patient goes to IR suite for coil embolization. Kumpe cath advanced into the aneurysm and coil embolization with follow up images obtained. I found Q&A 2182 that appears to be a similar but different sort of scenario. I don't think there is anything to code for the access in this case, but wanted to get your opinion. Very unusual access I've never seen before. Thanks Dr Z.

Can we bill for u/s guidance (permanent image on file and documentation of vessel patency is in report) when placement of TIPS is performed?

Our hospital recently purchased both the cardiology and the IVR books. I have a question on one of the examples in the book.
In the Interventional Radiology book on page 232---example no. 1, when they did a selective catheterization in the contralateral leg and an S&I-there is no catheter placement code. I see they also did a PTA in same leg. Is it because they did a PTA also on same side? If that is the reason, then-if they had did a select cath and S&I on left leg and a PTA on right leg-then could you code the selective catheter placement, S&I and PTA?
 

Dr Z, Hello! I have a question regarding percutaneous ablation procedures. In my hospital we do RFA, Cryo, and Microwave of liver, lung and renal tissue. In your January 21, 2011 newsletter, Percutaneous Tumor and other Ablation Procedures, I found the codes I was looking for to use for soft tissue masses, 17999. I had these built in the chargemaster, but in checking the reimbrusment for this code it is not in the same category as the liver, lung and renal tissue. Is there another code for soft tissue ablation that we should be using? One example that has come up is renal cancer, the kidney was removed and now there is recurring tumor in the renal fossa. The radiologist read it as a soft tissue mass that was ablated with a microwave technology. In your book on page 395 number 7 says to use "unlisted codes for RFA of soft tissue and organs not specifically listed with a code". I think that maybe I misunderstood the newletter and that I need unlisted codes for different anatomical areas, and different procedures-RFA, Cryo and Microwave. I hope you can help. Thanks, R Mercer

Dr. Z This is a CT-Guided Nephrostomy Placement question. CT is used to direct entry into the left collecting system. Left back is sterily prepped and draped. There is placement of a 17-French introducer guide and the needle is removed. Bloody urine is obtained. 0.038 Benson wire is placed through the introducer guide and the needle is removed. Over the wire a 6-French dilator is placed. That is removed. Finally there is placement of an 8-French pigtail type catheter which is coiled in the left renal pelvis and its pigtail locked. Codes 50392 and 74475 were used but the question is can we also code the 77012 for the CT-guidance? Your interventional book mentions that fluoro and ultrasound are both included but is the CT?

I had attended the 2011 Cardiology Conference in Florida in December. Dr. Dunn was one of the guest speakers and he had given us information on how to code the Ventricular assist device (VAD). He provided us with the Initial 24 hours use of transseptal VAD (0048T), Prolonged use of VAD beyond 24 hours (33999) and Removal of percutaneous VAD (0050T). I had asked Dr. Dunn if there was a code for the Management of the VAD. He wasn’t sure if we were to bill 33999 so he had asked me to contact your office. He stated that Dr. Z performs this procedure more often than he does.

Any information would help.

Should 2011 CPT code 93460 be used for R/LHC even if Left Ventrigulography is not performed? The coronaries were injected.

Thank you,
 

Hello - If an open thrombectomy of an AV graft was performed in the OR and took care of the thrombus, and the patient was then transferred to the CATH lab immediatley after open procedure and angioplasty and stenting was also performed of the AV graft to treat the stenosis causing the thrombolysis. Can we code for all the procedures?

36831 open thrombectomy of AV graft
35476 Angioplasty of AV graft
75978,26
37205 Stenting of AV graft
75960,26

Shouldn't the Dr. have to state that after the angioplasty flow there were suboptimal results therfore they proceded with stenting in order to bill for angioplasty and stenting? Also, can we code for the open thrombectomy with the percutaneous angioplasty and stenting?

Thank you for your help!

We found this in the CMS NCCI guidelines:
7. If a failed percutaneous vascular procedure is followed by an open procedure by the same physician at the same patient encounter (e.g., percutaneous transluminal angioplasty, thrombectomy, embolectomy, etc. followed by a similar open procedure such as thromboendarterectomy), only the HCPCS/CPT code for the completed procedure, which is usually the more extensive open procedure may be reported. If a percutaneous procedure is performed on one lesion and a similar open procedure is performed on a separate lesion, the HCPCS/CPT code for the percutaneous procedure may be reported with modifier 59 only if the lesions are in distinct and separate anatomically defined vessels. If similar open and percutaneous procedures are performed on different lesions in the same anatomically defined vessel, only the open procedure may be reported.

 

What is an EKOS considered? We infuse TPA and use ultrasound to break up the clots. We bring patient back between 6 and 24 hours for a recheck. Is it a mechanical thrombectomy because of the ultasound or infusion for thrombolysis?

I have two questions:

1. Patient came for nephrostomy tube and the following day scheduled for nephrolithotomy. Nephrostomy tube was placed by IR physician accessing the renal pelvis and nephrostogram performed and there are findings for the collecting system. Then inserted a nephrostomy tube. Coded 50390-59, 74425, 50392, 74475, however, since scheduled for nephrolithotomy we can only code 50395, 74485?
2. How do you suggest coding when nephroureteral stent was placed for PCNL. Patient came and the IR physician performed nephrostogram and nephroureteral stent was inserted. Same as nephrostomy tube?
    

Do you have any material published or available that explains how the procedures need to be documented? Is there specific verbage necessary? Are there any CMS guidelines stating specifically what they are looking for in a cath lab procedure report? Thank You

I was at your recent seminar. I want to thank you for a great experience. I’ve learned so much and can’t wait for next year’s seminar. One of the many things that I’ve learned is that we should not bill for a chest x-ray on the same date as any line or tube placement. I’ve also tried to research and googled this information but was unsuccessful. Please forward the document to support this so I can properly educate the radiology department.

Physician inserted 3 indwelling chest tubes on the left with radiological guidance for treatment of hydropneumothorax. Can we code 32551, 32551-59, 32551-59, 75989?

Is there an additional charge for sclerotherapy performed of the pelvic varices at the same time of the embolozation?

Dr. Z, Our radiologist does Discectomies, vertebroplasties, and kyphoplasites quite a bit. He always has a follow up CT/MRI in 2 weeks to 1 month. These procedures have a 90 day global, can I charge for the follow-up CT/MRI? Thanks

Dear Dr. Z, Would the use of the "Pipeline Embolization Device" for treatment of carotid wide-mouth aneurysm be considered 61626 / 75894? No coils are placed so I'm wondering if it is still considered an embolization. Thank you. mlb

This patient was brought in for repair of iliac aneurysm and AAA. A bifurcated graft was placed and in addition, a stent was placed inside of the iliac limb of the graft due to vessel tortuosity. CPT book indicates that 37221 iliac stent is for occlusive disease. We have 34803, 75952, 36200 x2. Main body stent graft 32 x 96 was advanced from a right approach into the abdominal aorta. The contralateral limb was oriented anterolaterally. Proximal 2 stents were deployed and position adjusted to just below the level of the renal arteries. Contralateral limb was deployed. The suprarenal stent was deployed and catheter was pulled back to the distal abdominal aorta. Catheter was exchanged to a Kumpe catheter and later a Vanshee catheter. Contralateral gate was cannulated using the Vanshee catheter. Intraluminal position was confirmed by injecting a small amount of contrast within the graft. Lunderquist wire was advanced to the upper descending thoracic aorta. The catheter was removed. Left iliac arteriogram was performed to evaluate the common iliac bifurcation. A left limb 14 x 90 was advanced from a left approach to about 1-1/2 stent overlap. The stent was deployed proximal to the common iliac bifurcation. Due to tortuosity of the common iliac artery, it was decided to place a self expanding stent to increase radial force. A 14 mm x 60 mm SMART stent was deployed within the left iliac limb. The remaining 2 stents from the main body were deployed and nose cone was retrieved. Right iliac arteriogram was performed. Right limb 12 x 107 was advanced from a right approach to the right iliac limb. 2 stents overlap proximally and distally. The stent was deployed in the proximal right external iliac artery covering the origin of the right hypogastric. The infrarenal neck areas overlap and distal limbs were dilated using compliant balloons. The stent on the left was dilated using a 12 mm angioplasty balloon. Completion arteriogram was performed through a pigtail catheter from a left approach.

I need some help coding the following. The patient was brought to the heart catherization laboratory and draped in the usual sterile fashion. Consent was obtained prior to the procedure. IV conscious sedation as given using Versed and fentanyl thoughout the case. Next we attempted to cannuulate the left subclavian vein.We then took a venogram of the left subclavian vein and it was found to have diffuse collaterals and no good discrete subclavian vein to proceed with the implant on that side. Therefore, we went to the right side of the patient and we took a venogram and this time there were good images seen of the right subclavian vein. Next approximately 15Ml of lidocaine were used to anesthetize the planned pacemaker pocket on the right side of the patient.Next using Seldinger techinique two subclavian access sites were obtained and then the pacemaker pocket was created using a scapel and cautery. At this point over a 7-French introducer sheath the right ventricular lead was positioned into place near the lower RV septum. This sheath was torn and peeled away and another 7-French introducer sheath was inserted and the lead was then placed at the right atrial appendage. RV pacing leads were kept on the patient due to the fact that he had a baseline left bundle branch block. Next the coronary sinus sheath was inserted and a specific sheath for the right-sided coronary sinus was inserted and using a J-tipped guidewire we able and contrast we were successfully able to cannulate the coronary sinus. Tehre was found to be a mild lateral vein though small which was used as our planned placement for the LV lead. At this point the LV was positioned over a coronary guidewire into the mid lateral vein and successfully wedged into that position. The sheath was then slit appropriately and the lead was kept in place. At this point pacing thresholds were also checked here and they were within normal limits. Next the sheath was torn and peeled away and all 3 leads were sutured using 0 silk to the left pectoral muscle. Next antibiotic solution with consisting of Bacitracin and gentamicin was used to flush the pocket at this point. At this point 2-0 and 4-0 Vicryl sutures were used to close the pocket. Steri-strips were applied on the skin level. The estimated fluoro time would be 25 minutes. Implanted Device: Boston Scientific Guidant Contact Renewal CRT pacemaker. the patient had a heart cath with grafts: 93459-26 ICD Insertion: 33249 33225 71090-26 Is this correct codes to use?

Is there a reference or resource available for when it is and is not appropriate to separately report an EKG with cardiac cath or EP procedures? Thank you!

A patient comes in on day one and has an aortogram and right lower extremity angiogram. Doctor starts TPA infusion in SFA, then later in the day does a follow-up. Day two, he does a follow-up and left lower extremity angiogram. My codes are 37201, 75896-59, 36247-RT, 75625, 75710-RT and 75898 for day one. Day two 75898 and 75710-LT. Should I code for two separate lower extremity angiograms or combine them using 75716 since it was a continuing procedure. Thanks, Cynthia Boyer

Dr. Z, Sorry if this has been covered already. I checked your IR reference and SIR's reference, MedLearn's reference, etc. ad nauseum. Forgive me if I'm reading too much into this, but I was wondering if a physician indicates symptoms only in one leg does that mean that there is only medical necessity for a unilateral extremity angiogram (75710). Or is it common practice and acceptable to perform and charge bilateral extremity angiogram (75716) even if there are no documented signs and symptoms in the contralateral leg? We have many interventionalists who perform bilateral angiograms but have only indicated signs/symptoms in one of the legs in their report. I am grappling with whether medical necessity supports bilateral imaging when only one leg is indicated. Is there some unspoken rule that a bilateral extremity angiogram is standard and acceptable for documented PVD in only one leg? Your help would be greatly appreciated!

Dr Z, if the pt is having existing crt-d replaced and existing RV pacing and RA leads are reattached to the new generator with a new left Bi-ventricular lead placed, would we code that to 33249, or 33240,33241 and 33225?~thanks!

Can you please help with this report? I'm not sure how you would code this. History: Patient with a postoperative left pelvic lymphocele here for transperitoneal drainage and laceration of lymphocele wall.. Procedure: -CT guided transperitoneal puncture of lymphocele -angioplasty of lymphocele wall and a transperineal direction -exchange of the patient's transabdominal lymphocele drain Informed consent was obtained. Risks and possible complications were described in detail. Please note the patient did receive intravenous moderate sedation for which she was continuously monitored for one hour and 40 minutes using 5 milligrams of Versed and 400 mcg of fentanyl. She was also given Zosyn and Benadryl. The patient was first brought to the CT scanner. Using CT guidance a 15-cm 22-gauge needle was advanced through the peritoneum avoiding bowel into the left pelvic lymphocele via an anterior transperitoneal approach. A 0.018 Bentson wire was coiled in lymphocele. The patient was transported then to the fluoroscopy suite. The indwelling tube this transabdominal lymphocele was exchanged and contrast was injected showing contrast in the lymphocele. We then upsized the 018 Bentson wire that is transperitoneal with an INRAD needle and advanced the wire. We upsized and over two wires dilated the wall of the dilated the wall of the lymphocele with a 16-mm balloon and an 8-mm balloon simultaneously. Upon injection of the lymphocele clearly we could see this drain into the peritoneum. We then advanced a Kumpe catheter into the lymphocele from the transperitoneal approach for access and sutured this to the skin. The plan is to maintain this and bring the patient back in a few days. We then exchanged the transabdominal lymphocele drain for a 14-French drain and will keep this to external drainage as well. Plan: Patient will return in 72 hours for further work/investigation of the lymphocele. Successful laceration of the wall with clear leakage of lymph and contrast into the peritoneum. A follow-up CT scan did demonstrate complete decompression of the lymphocele. Thanks for your help!

Hello Dr.Z, I believe your are the only one to answer this scenario. When the AV fistula is accessed using two crossing sheaths, which is followed by AV fistulogram, and followed by any other therapeutic procedures such as thrombectomy/angioplasty. Our coders are coding 36147 alone, but I believe it should be 36147/36148 since two access were obtained one for AV Imaging and the other for therapeutic interventions. Regards Prabhavathi, India

I'm getting conflicting information on when we can charge for CPT 93623 (Programmed stimulation and pacing after intravenous drug infusion). Even the Case of the Month was not clear to me because at one point the article states "in some cases the drug study is performed post-ablation instead of prior to ablation. When performed post-ablation it is still a separately billable study." Then at the end of the article, it states "post-ablation testing is included in the ablation and not coded separately. If the only drug testing performed is post-ablation, code 93623 can be reported for the drug testing." Our doctor's usually state "postablation testing on IV Isoproterenol infusion" is this enough to pick up code 93623? Thank you!

Hi Dr. Z, Could you please help me with this procedure? Our interventional radiologist reason is PermCath insertion for hemodialysis. In his impression he says it was a successful right subclavian dual port dialysis catheter insertion via skin tunneling on the right. It was a 14.5 French dialysis catheter. Thanks for your help!

Good afternoon Dr. Z. We need to know if performing an abdominal angiogram is standard protocol when doing peripherals. Is this considered a medical indication for doing them? Our docs are performing 75625 on a regular basis with only claudication or peripheral artery disease as an indication. As always, thanks for your guidance.

Pt had RHC with pulmonary artery angiogram, bilat selective pulmonary vein angiogram and lt atrial angiogram. The next day had ASD repair. We billed 93451-26 and 93568 for cath and angio and for ASD billed 93580. We were told you could not bill congenital codes for PFO but according to your book if diagnostic cath is done prior to PFO closure device placement you can code w/congenital codes. It also states an isolated PFO is not considered congenital. What is an isolated PFO? Also, our physician states the ASD repair was much more involved than the PFO, it was a hole in the heart rather than a "flap" but the diagnosis code is the same (745.5) so don't see how you can get around it. Would appreciate any help you can give in clearing up the confusion.

If the posterior tibial and the tibioperoneal trunk are both angioplastied, is that just 37228? thanks!

Hi, It seems I am asking a question every other week now. I thought I had a good grasp on the the new Cath codes for 2011, and for the most part I still do. However I have had some Medicare denials when billing a coronary stent placement (92980-RC) in the same setting as the left heart cath (93458-26) I know as of last year when we billed a STENT or PTCA, at the same time as the cath codes, we would have to put a 59 modifier on the 93555-26, and 93556-26, otherwise Medicare would deny those two codes as included with the intervention. Would billing 93458-26 with a 59 modifier be the way I should be billing? or would this be improper. The only other code that was billed the same day was a critical care E&M code 99291. What am I doing wrong, can you please help. Thanks Jene Anderson Central Fla Heart Center.

We have a question we were hoping you might be able to help us with:

Scenario: a non-covered procedure is performed on a Medicare patient (i.e. Intracranial PTA/Stenting; Carotid Stenting without distal embolic protection).

1. Do you identify and move all related non-covered procedure and supply charges to the non-covered column of the UB-04? Or do you delete all related non-covered procedure and supply charges from the itemized bill?
2. These patients are statused as inpatients, should the corresponding ICD-9 procedure codes (i.e. 00.62 & 00.65; 00.61 & 00.63) for the non-covered procedures performed, continue to be coded/reported on the UB-04?
    

We are performing many Thrombectomies on patients that have severe thrombus or embolism over a period of two or more consecutive days. I cannot see how the angioplasty is not bundled in with the thrombectomy code 37187. I understand that a balloon has to be inflated to perform the thrombectomy, but wouldn't that be bundled? If not, can an agioplasty be charged the second day or third day in conjunction with 37188?

Can you verify a vertebroplasty question for me? What is the proper way to code a vertebroplasty performed on T12, L1 and L2? In an article I read, it states you can only bill one initial vertebroplasty code even if the procedure is performed on different levels. There is a CCI edit when you bill 22520 and 22521.

Should the correct coding be 22520, 22521-59, 22522 or 22520, 22522 x 2?

 

If a pt comes to the cath lab with a IABP in place and it is taken out and Impella is put in and then in the same setting the Impella is taken out and a IABP is put back in, can I code for IABP removal and another insertion?

If intervention is done on a fem-pop graft and the MD states where in the graft it corresponds to the native artery location, can I code it the same as the native or because it is a graft I only get to code intervention once? In other words he talks about stenting graft corresponding to SFA and to POP. I have tried to find documentation of how to code but can find nothing.

Where can I find documentation guidelines on performing biopsies? For example, does the body and/or impression need to state whether a core biopsy or and FNA was performed? Can the decision to code either a core or FNA be determined from the size of needle used? If you can reply asap, I would very much appreciate it!!

Thank you for the assistance!!
 

In your book it says to use code 10160 for inguinal lymphocele drainage catheter placement. Is the tx perirenal lymphocele considered inguinal? What else would you charge for it? Its not really an abcess. Thanks,

If a true incision is made with dissection performed to expose the artery and requires closure of the subcutaneous tissues and skin at the conclusion of the procedure, then it is considered an open procedure. It is not dependent on an actual arteriotomy so they may access the closed artery with a needle/sheath but via an open incision and it is still considered an open procedure. Thanks, Dr. D

From the NCCI Manual:
3. A number of diagnostic and therapeutic cardiovascular procedures (e.g., CPT codes 92950-92998, 93501-93545, 93600-93624, 93640-93652) routinely utilize intravenous or intra-arterial vascular access, routinely require electrocardiographic monitoring, and frequently require agents administered by injection or infusion techniques. Since these services are integral components of the more comprehensive procedures, codes for routine vascular access, ECG monitoring, and injection/infusion services are not separately reportable. Fluoroscopic guidance is integral to diagnostic and therapeutic intravascular procedures and is not separately reportable. HCPCS/CPT codes describing radiologic supervision and interpretation for specific interventional vascular procedures may be separately reportable.

Our recommendation is NO as it appears that you would absolutely be trying to get around correct coding per NCCI, CCI edits, and everything else that CMS has put into place to prevent you from coding that.

We have a patient that came in for a gastrostomy tube removal and they used flouro.  We know that with chest tubes, gastrostomies there isn't a code for removal and they normally just pull these out. What if they use flouro, are we able to charge for these? Either with a low E&M or the flouro time? Below is the report that we have. Thank you so much for looking at this.

Thank you,


HISTORY: Removal of a percutaneous gastrostomy tube as it is no longer
required for feeding.

PROCEDURE: Fluoroscopic guided removal of the gastrostomy tube.

FLUORO TIME: 0.2 minutes.

PROCEDURE DESCRIPTION: The retention balloon was deflated and the
gastrostomy tube was removed. An image was obtained to document complete
removal.

IMPRESSION:

Fluoroscopic guided removal of the indwelling gastrostomy tube.
 

Can a diagnostic unilateral mammogram be charged after a breast cyst aspiration was done with ultrasound guidance? The mammogram was done to assure that the cyst was completely evacuated. Thank you.

My question concerns selective catheter placement during inferior vena cava filter placement. No contrast is used for the procedure due to the patient's renal status. Selective caths of the renals and iliacs are done and a looped wire is used to measure the IVC between these vessels prior to deploying the filter. Are all the cath placements reportable?

On the following procedure we are questioning if we can code the stent and the angioplasty and also would you code abdominal aortogram and iliac? In your opinion did he do an angioplasty of the iliac? Another question?? Is this an Inpatient only procedure since he did cut down? DESCRIPTION OF PROCEDURE: With patient lying in a supine position on the operating table, a #16 Coude catheter was used to place in the urinary ostomy. Prior to the procedure by myself, I modified this catheter to cut the tip of it off very short since palpating the urinary bladder, it was only about 3 cm in depth. I placed a 5 mm balloon catheter in the stoma, by holding pressure on it and then cutting the end of this in 3 different places,I was able to get urine and irrigant with saline through this area from the stoma. This was then excluded from the field with an loban drape, and then the abdomen was sterilely prepped and draped. Another loban was placed over the entirety of the abdominal prepped area, after towels were placed and then a full draping. The operation was begun with a transverse incision right over the inguinal ligament. This basically was the same incision as previously, it is approximately 8 cm in length, and since this was exactly in the groin crease, I dissected upwards after dividing through the subcutaneous tissue and actually divided about 1 inch of the inguinal ligament in order to get control of the distal external iliac artery, which had not been dissected out preVioUsly. This was a small artery about 5 mm in size and so went ahead and dissected it out, and then dissected back on the extensive scar tissue over the common femoral, and in so doing, I was able to get control of about 2.5 cm of the distal external iliac and proximal commoril'emoral. There was 1trip branch that I had to tie off that was about a 2 mm collateral that took off laterally from the external iliac vessel and this was closed over with a figure-of-eight•.5-0 Prolene suture. Then, the patient was heparinized with a total of 7000 units of heparin. Seldinger needle was used to access the vessel and a .f-wire was placed through this and then a short 6-French sheath was placed over that into the vessel. Arteriogram revealed that the wire hung up at the distal stent graft'and th;tihe iliac was of narrow caliber. It appeared to be about a 5-6 mm vessel all way up to the common iliac. At any rate, Iwent ahead then and because the f-wire would not pass up through the stent, I went ahead and got a angled glide catheter (a Berenstein catheter) and then using this was able to advance the j-wire through the midportion of the stent. It went smoothly up into the distal thoracic aorta, and then the Berenstein catheter was rernoved'Ieavinq the J-wlre in place and then a 4-French angioplasty ealloon catheter was inflated and passed through this and then passed up with it being already inflated up the wire and it went smoothly through the stenotic lesion of the aorta and therefore I felt that the wire was through the midportion of the graft and had not gone underneath 1 of the stents. Then, the balloon catheter was advanced to the distal thoracic aorta and through this, I passed a Lunderquist wire to obtain stiff wire access through the lesion and then once that was accomplished, the Berenstein catheter was removed and then a 16-French long sheath was exchanged for the 6-French sheath, which was in the groin. This was passed up with some difficulty and went very slowly and with push-pull maneuver, was able to advance it through some areas, which felt like a stenosis but ifl fact this performed probably a Dotter dilatation of the iliac and once it was in place, it was advanced up to the distal to the level above the renal arteries. Then, a 40 diameter Palmaz stent approximately 3 cm in-lenqth was placed on a Coda balloon and then advanced through the long sheath and I neglected to say that an aortogram ha'd been accomplished through the sheath. A glow tape had been placed on the abdomen and I precisely identified the stenosis, which was right in the mid portion of the previously placed stent graft. I then pulled back on the long sheath, exposing the Palmaz stent, which was loaded on the Coda balloon and then deployed it by inflating the Coda balloon. Unfortunately, the Coda balloon was.not strong enough which with a low pressure balloon to dilate the lesion. The Coda balloon was removed leaving the stent in good position, and then a 14 mm diameter and 4 cm in length angioplasty balloon was exchanged for the Coda and placed in so that it extended on either side of the Palmaz stent and insufflated. There was an obvious waist on this where the in-stent stenosis had been, but it dilated nicely and dilated the Palmaz stent very successfully. This is a nice 14 mm lumen and a confirmatory arteriogram by hand injection through the long sheath, confirmed that the lesion was nicely dilated. Then, I removed the long sheath, slowly and pulled it back into the iliac and performed 3 hand injections as I pulled this back to confirm that there was no leak from the iliac artery, since I had felt that this had dilated the iliac considerably when it went in. Once it was back to the external iliac, and no leak from the iliac vessel was seen on the 3 arteriograms that I did and there was good flow all the way down and up across the bifurcation. The stent was then removed. Tapes were pulled up on the distal external iliac and common femoral vessel and then I closed the common femoral vessel with interrupted stitches of 5-0 Prolene and 6-0 Prolene suture. I used an interrupted closure so as to not create any stenosis of the femoral at that level. Once that was accomplished, a Doppler signal and palpable pulse was much stronger since the initial pulse was barely palpable in the groin and it was not palpable through the skin, but was barely palpable when the artery was exposed. It was much stronger and when hemostasis was felt to be secure, I closed the groin incision with 2 layers of running 2-0 Vicryl suture and skin clips were applied to the skin. An occlusive dressing with Betadine ointment and 4x4s were placed over the incision and then lastly the Foley catheters removed from the urinary stoma and an occlusive urinary stoma dressing was applied with Stomahesive and a small flange was placed over this and then attached to urinary drainage bag. The patient had a triphasic dopplerable signals in the foot at termination of procedure, and both right and left foot indicating much a very good result. The patient tolerated the procedure well and was extubated in the operating room, transferred to the recovery room in good condition.

In reveiwing the two Echo interps below, I don't see documentation to support that the pericardium was evaluated. Per CPT guidelines, that is the only thing I see that is lacking in order to bill each of them as a complete Echo. Am I missing it? Thanks so much for your help! 1st Patient Example Indications for Study:TETRALOGY OF FALLOT. 745.2, F/U Procedures:CONGENITAL COMPLETE W/ DOPPLER AND COLORFLOW, Congenital Echo, Doppler and Color, Ekg, Colorflow Mapping, Echo Congenital Limited, Intracardiac Doppler Race:Caucasian Session ID: ************************************ SUMMARY: ************************************ Poor acoustic window. s/p repair of Tetralogy of Fallot, pulmonary atresia. with unifocalization. S/p bilateral branch PAs stent. H/o para-aortic abscess. s/p RV to PA conduit replacement. Stable paraaortic abscess pouch, unchanged from the previous study. Mild aortic regurgitation, stable. No residual VSD. No RVOT Doppler interrogation. Trivial regurgitation. Unobstructed flow through the steneted branch PAs. Mild dilatation of right ventricle with qualitatively normal systolic function. Normal LV systolic function. Atria: Situs: Solitus. RA Size: Normal. LA Size: Normal.Septum: Normal Defect sz. None. Shunt: None. Ventricles: D-looped LV size: Normal. LV function:Normal. Rv size: Dilated. RV function: Normal. IVS: Motion: Normal. Defect Type/Size: None./None. Shunt: None. ___________________________________________________________________________________________________ Grt Vessls: Normal. Aortic Root: Normal. MPA: RV-PA conduitLPA: StentedRPA: Stented Coarctation: No. PDA: No. Shunt:None. Coronaries: NOT VIEWED Systm Veins: SVC: Normal. IVC: Normal. Pulm Veins: Visualized: 2/4. Connections: 2/4 visualized ___________________________________________________________________________________________________ Mitral Valve: Structure: Normal. Stenosis: No. Regurgitation: No Tricuspid Valve: Structure: Normal. Stenosis:No. Regurgitation: Mild , estimated RVSP 40 mmHg+RAp. Pulmonary Valve: Structure: S/P HOMOGRAFT Stenosis: Not interrogated Regurgitation: Trivial. Aortic Valve: Structure: Normal. Stenosis: No. Regurgitation: Mild ************************************ MEASUREMENTS: ************************************ MMODE Left Ventricle LVIDd 5.29 cm (3.81-4.63)* LV%fs 37.8 % (28-40) LVIDs 3.29 cm (zsc -0.08) 2nd Patient Example ************************************ SUMMARY: ************************************ Limited subcostal views LV normal size and systolic function Atria: Situs: Solitus. RA Size: Normal. LA Size: Normal.Septum: Limited views Defect sz. None. Shunt: None. Ventricles: D-looped LV size: Normal. LV function:Normal. Rv size: Normal. RV function: Normal. IVS: Motion: Normal. Defect Type/Size: None./None. Est. LV-RV Press. Gradient:____mmHg. Shunt: None. ___________________________________________________________________________________________________ Grt Vessls: Normal. Aortic Root: Normal. MPA: Normal. LPA: Normal.RPA: Normal. Coarctation: No. Type: _____. Est. Pressure Gradient: _____mmHg. PDA: No. Shunt:None. Coronaries: Normal LCA, RCA origin not seen Systm Veins: SVC: Not viewed IVC: Not viewed Pulm Veins: Visualized: 2/4. Connections: Normal. ___________________________________________________________________________________________________ Mitral Valve: Structure: Normal. Stenosis: No. Regurgitation: No. Mitral 1/2 time____. Tricuspid Valve: Structure: Normal. Stenosis:No. Regurgitation: Trivial Est. RV pressure_____.+ RAp. Pulmonary Valve: Structure: Normal. Stenosis: No. Mean ___mmHg, Peak___mmHg. Regurgitation: No. Aortic Valve: Structure: Normal. Stenosis: No. Mean ___mmHg, Peak___mmHg. Regurgitation: No.

Good afternoon, My interventionalist is exchanging bilateral ureteral stents via suprapubic access (pt has suprapubic foley). I'm going to assume this will be an unlisted code 53899 along with 74480 x 2 as it is not via ileoconduit, transurethral or percutaneous access. Am I on the right track? Judy

Good Morning Dr Z! My question has to do with documentation of IVUS. If the physician states that he passed the IVUS catheter thru the right common femoral vein, external iliac vein, and inferior vena cava and took images,but only reports what was found in the common femoral and external iliac, should I report 37250, 37251, 75945,75946 or 37250,37251 x2, 75945, 75946 x2?