Ask Dr. Z

For the first time, the physician used 3-D angiography during the EP study.... "In order to get better delineation of the RVOT we used 3-D rotational angiography technique" After injection 60 cc of diluted contrast while V pacing to decrease cardiac output we were able to obtain good 3-D representation of the structures of interest with 3-D rotational angiography." Since angiographies during EP studies are not separately billable, I presume I cannot code the 3-D, 76377. Is that correct? Thanks so much for your help. I just want to make sure that I am not missing billing opportunities.

I know that the standard stress test includes a segment while at rest, standing, and exercising. In the 2011 edition of the "Diagnostic & Interventional Cardiovascular Coding Refernce", it states "do not code separately for a resting 12 lead ECG and rhythm strip as they are considered part of the stress test, and are not separately reimbursable." My question is what is considered the "resting 12 lead ECG". We had a case where the patient returned for continued chest pain with added shortness of breath. A 12-lead ECG was done 20 minutes prior to the start of the stress test for diagnostic purposes. Can we bill separately for this ECG? Thanks so much for your help!

Dr. Z I am having an issue with medicare dening procedure code 93567 when billed with the left heart cath. 93458. My doctor is performing these procedures at the hospital so we bill with a 26 modifier. I have attached a 26 modifier to 93567,also the 59 modifier, then both 2659. And have even tried billing with no modifier. Medicare continues to deny. No matter how I bill. What am I not understanding when reading the CPT description of this add on injection procedure code, do you have any suggestions on how we can get this paid when billed? thanks Jene, Central Fla Heart Center

Greetings, For post embolization code 75898 what needs to be documented to bill? Can they just state in the report that this was completed? Thanks, LW

If a mechanical thrombectomy of an AV fistula is done...right femoral vein punctured, cath. passed to the right upper arm access, not quite to the arterial anastomosis. Angiojet cath passed and TPA was pulse-sprayed for 20 min. Then a secondary puncture made on the venous side. this end was thrombectomized as well. would this be a 36870, 36147 (direct puncture of the fistula), and 36012 (access from femoral vein) thoughts? thanks!

Dr. Z, One of our neurosurgeons performs percutaneous balloon compression of the trigeminal nerve with use of 2-plane fluro. I have no idea of the correct code for this. He wants to use 64610, destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring. Would a 64999 unlisted be more appropriate? Thanks very much

Dear Dr. Z, Is it appropriate to code 19295 for clip placement after a breast cyst aspiration, or must the unlisted CPT be billed? Thank you. mlb

Is the code CPT 93462, for the puncture itself, and billed in addition to the left heart catheterization?

Hi, I'm not for certain how this would be coded? Would you suggest the unlisted spine code(22899) for this procedure? Thanks! PROCEDURE: Fluoroscopic guidance provided for baclofen pump access INDICATIONS: lower extremity spasticity CONSENT: The procedure was explained, risks/benefits/alternatives explained, questions answered and informed consent obtained from the patient. TIME-OUT:A pre-procedure time-out was performed to confirm patient identity and procedure. GUIDANCE: Fluoroscopic guidance TECHNIQUE: The patient was placed in supine position on the fluoroscopy table. The patient's right lower quadrant over the region of the baclofen pump implant was prepped and draped in standard sterile technique. A 25-gauge needle was used to access the baclofen pump implant, with the assistance of fluoroscopic guidance. No cerebral spinal fluid could be aspirated from the baclofen pump, suggestive of catheter dysfunction. Needle was removed and hemostasis obtained with manual compression. The patient returned to the recovery area in stable condition, and was subsequently discharged. FLUOROSCOPY TIME: 0.2 min IMPRESSION: Fluoroscopic guidance provided for baclofen pump access.

What diagnoses are covered under 36215-LT?

Dr Z How would you code a bypass with graft from the aorta to the hepatic and the sma? The doctor coded 35631 x 2, is that correct or should it be 35631/22? Thank you so much for your help.

Dr. Z, I am being told that when coding ICD implant (33249)and DFT testing (93641) to use a diagnosis code of 427.41 for 33249, because during DFT test the patient was induced into V-fib. My understanding of NCD 20.4 number 1, is that v-fib is used when the patient has a documented episode of cardiac arrest due to V-fib not due to a transient or reversible cause.No where in the medical record can I find where the patient has had cardiac arrest due to V-fib and there fore I have been using what the report says and assigning 414.8 with QO mod and assigning 427.41 for the DFT test (93641). Is it appropriate to assign 427.41 to 33249 because the patient was induced into v-fib for the DFt test? Thankyou

Dr Z, When we provide a duplex scan of extremity veins(CPT 93970), how should we be charging for the following exams? Case #1 Bilateral upper and lower extremity Case #2 Unilateral upper and lower extremity Thanks for any help you can give me.

Greetings, I have three questions on two cases. 1. Patient has a AAA graft placed in placing the graft flow is diminished to the renal artery. A stent is placed in the renal artery after the deployment of the stent to fix the problem. Can we code the stent placement separate from the AAA graft or is it bundled. 2.A patient has a radial cephalic fistula and come in for arm swelling from the shoulder down. The patient has a stent occuluded in the braciocephalic artery. Would you code this as a 36147 or a 75710, for a diagnostic angiogram.I would code the interventions as well but I'm thinking I would not use the fistula thrombectomy code as thrombus was not removed from the fistula but from the bracialcephalic vein. Any help would be great Thanks, LW

During an EP study, an MD crosses the atrial septum via the foramen ovale. He uses a transseptal needle to cross it with light pressure. Left atrial pressures are recorded. Should 93462 be billed for left heart cath via transseptal puncture, even though the septum was never actually "punctured"?

Hi Dr. Z, What is the correct icd-9 code for: steal syndrome not for subclavian artery. Thank you.

Hi Dr.Z, Can you please help me to locate a code for: resection occipital artery aneurysm? Thank you so much, Ginie

Dear Dr. Z, A patient with a pre-existing single-chamber ICD who had recently had ablation for atrial flutter was brought in for upgrade to a dual chamber ICD, for better monitoring of his atrial arrhythmias. Currently this is coded with 33216, 33240, 33241, 71090. However, A Nov. 1999 CPT Asst. says: "33216 & 33217 do not describe initial insertion, but rather a circumstance requiring subsequent insertion or repositioning occurring 15 or more days later." There's a 1/25/08 Q&A in your Q&A database which further clarifies this instruction, saying "33216/7 describe placement of 1 or 2 leads respectively to an existing, old pacer or defib. generator, without replacing the old generator with a new one." Would 33249 + 33241 be more appropriate? We were not sure if 33249 would capture the work of the additional lead. There are several Bi-V AICD revision questions in the database, but not this particular scenario. Thanks so much!

Greetings, A patient has a brachiocephalic fistula that is not functioning. The pt is taken to the OR and a thrombectomy is attemped. No dialator could be passed so the dialysis fistula is abandoned. A new graft is placed higher cephalic vein and tunneled with a end to end anastomosis on the arterial end. Is this a 36832 or a 36830? I'm thinking 36832. Thanks, LW

Hi Dr. Z, Often when performing a thoracentesis, we start with an ultrasound. If no fluid is found, the thora is not done. Is it appropriate to charge for an attempted thoracentesis (32421-73)with US guidance (76942) even though then didn’t stick a needle? We have been charging a Chest US ONLY (76604). Thanks,

Would surgeon get any credit for placement of Palmaz stent placement during a AAA repair see dictation below AAA repair proceedure, Unibody graft placed along with proximal aortic cuff. "Angiogram was performed and demonstrated small type I endoleak with the rest of the graft widely patent with good flow into both iliac arteries. Therefore the 10 mm x 40 mm Palmaz stent was placed onto the CODA balloon and advanced back up into the proximal portion of graft" Using cpt 37204, 34825 for graft placement, code 37205 bundles according to coding rules. I have not been giving credit for 37205 Palmaz stent placement. Is this correct? Surgeon would like confirmation.. Thanks for any insight... Julie Breedlove Surgical Care Associates 502-638-5115

I have a question on how to code a lower extremity venoplasty and subsequent stent placement on 3 vessels. My documentation states angioplasty of the left common iliac vein, left external iliac vein and the left common femoral vein. Flow limiting elastic recoil with virtually no antegrade flow. Then 4 stents were placed in overlapping fashion. The diagnostic venogram showed that the common femoral vein is moderately narrowed and has a large web in it. Common and external iliac venous stents are occluded. Can I use 35476/75978 three times? How about the stent placement- can I use this three times 37205/37206x2/75960x3? Thank you for you help.

Hi Dr. Z, Would you use 397.0 rather than 424.2 for the tricuspid regurgitation when there is no mention either way about rhuematic endocarditis? Or is 397.0 only used when there is multiple involvements of valvular diseases and 424.2 used when tricuspid regurgitation is dictated with no mention of other valvular diseases? Thank you for your assistance.

DR Z MD does CFA endarterectomy and the places stent in the external iliac for stenosis both are same side. Can he bill both?

Hello Dr. Z, Are there other products besides Kyphon, such as the Carefusion "AVAmax" system, that would meet the kyphoplasty cavity creation CPT code definition (22523, 22524)? Thanks so much!

Under what circumstances can I bill 93580 ASD closure with 93531 Right and left heart cath? I code/bill for hospital and I get NCCI edit 0020 when I put the two codes together, however the physicians office coder tells me that she has billed the two together without any problems. I would certainly like to code/bill the heart caths because they are definately done. Thanks

Dr Z, What is the appropriate code when TPA is injected into a vessel for the treatment of clot without the use of any "thrombectomy device" or prolonged infusion? Is it ok to use 37184 for only pharmacological thrombectomy? Thanks

Dr. Z, we are seeing an increase in the use of "crosser" catheters for CTO use in peripheral vessels. We now have a plethora of such catheters being brought in by various vendors (Flowcardia Crosser, CTO Frontrunner, Quick-Cross Spectranetics, etc, etc). The physicians and the techs want to code the use of these catheters as angioplasties. Last year we had discussed with ZHealth and we had been advised that these are "glorified" catheters and not to code anything additional for their use. Today I happened to be in the IR Suite and one of the reps was telling the physicians that they recommended the use of unlisted cpt 37799. Have you any updated information on these catheters and their use? What would your recommendation be? Thanks for your insight, we breathe easier knowing we have ZHealth resources to help us!

Hi Dr. Z, Since the Jetstream device is approved for both thrombectomy and atherectomy, if BOTH procedures are performed during the same session, can BOTH procedures be coded along with BOTH C-codes? Thanks in advance!

My physician performed a left heart cath with a lima which I coded with a 93461-26 but he also performed an "aortic root gram"? what code would I use for the aortic root gram

Dr. Z -- Thanks for all your past assistance. This question is about ablations and whether or not, in this unique situation, would be appropriate to charge TWO 93651's (one appended with modifier -59). Physician dictation states, "She had complex ablation because there were TWO arrhythmias treated with different techniques. Two SVT's: AV node reentry with cryo and atrial flutter with externally irrigated RF." Cryoablation was performed in the posteroseptal region. RF performed in the right atrial isthmus. That, to me, says two separate sites were ablated. For the RF says, "The line was completed with the RF catheter documenting complete line of block..." This statement does not equal "complete heart block" (in which case 93650 would be charged), but rather an ablation for which 93651 would be charged...right?? I hope the last part of this question makes sense and that you agree with my recommendation to the department to charge two 93651's. THANKS VERY MUCH!

I am struggling with the coding on this one and not sure I coded correctly as: 37221 37221-59 37223 37223-59 35372-RT 35371-50,59 75716-26,59 Bilateral common femoral and right profunda femoris endarterectomy with bovine pericardial patch angioplasty, aortic catheterization from open right common femoral access, second order right external iliac artery catheterization from left common femoral access, aortogram with bilateral runoff, bilateral common iliac artery stent placement (Smart 7X60 mm), bilateral external iliac artery stent graft placement (Fluency 6X80mm bilaterally, also right Smart 6X40 and left Smart 7X40) Thank you Carol

Could I get your opinion on this one please? I just wanted to see how many extensions you come up with for this one...here's what i'm thinking 34802 34812-50 36200-59-51-rt. fem punc. 75952 75953 x3 34825-51 34826 x2 36246-51-int. iliac cath (I was thinking maybe 1st order?) Embo (75894/37204/75898) was done by cvir phys. do you agree with 3 extensions? thanks! OPERATIONS PERFORMED: 1. Endovascular repair of abdominal aortic aneurysm using a Gore excluder device. 2. Left side ipsilateral 28.5 x 14.5 x 180 mm main body device. 20 x 95 mm distal extension into left common iliac artery. 14.5 x 120 mm distal extension into left external iliac artery. 3. Right side contralateral 20 x 115 mm contralateral limb. 26 x 33 mm aortic cuff (distal extension into right common iliac artery). 28.5 x 33 mm aortic cuff (distal extension into right common iliac artery). 4. Bilateral femoral artery cutdowns for exposure. 5. Second order catheterization of branches of left internal iliac artery from left femoral approach. 6. Transcatheter embolization and occlusion of left internal iliac artery (performed by Dr. Peter Waybill). ANESTHESIA: General endotracheal with supplemental local. DRAINS: None. TOTAL CONTRAST USED: 144 mL. INDICATIONS: Mr. Kettering is a 79-year-old gentleman with a 6.1-cm abdominal aortic aneurysm, which has been growing. He is brought to the operating room for endovascular repair. The risks, goals, and alternatives were discussed with the patient who understood and gave consent to proceed. OPERATION: A time-out was performed, the patient identified and procedure verified. General endotracheal anesthesia was induced without incident. The abdomen and both groins were prepped and draped in the usual sterile fashion. The patient received preoperative antibiotics within 1 hour of incision time and preoperative steroid and Benadryl administration was performed given the patient's known history of intravenous contrast. The common femoral arteries were then exposed through bilateral oblique groin incisions. These were performed a little bit higher than usual because of the heavy calcification of the femoral bifurcations. The inguinal ligament was identified and elevated cephalad. The distal external iliac artery was prepared. The crossing circumflex iliac veins were divided bilaterally. Soft spots were identified bilaterally for use. Single wall puncture technique was used on both sides, and a Bentson wire was inserted up into the abdominal aorta. 7-French sheaths were placed on either side. On the right, a marker pigtail catheter was inserted up in the perirenal aorta. On the left, a Lunderquist wire was inserted and over this the 7-French sheath was up sized to an 18-French DrySeal sheath. An aortogram was then performed, demonstrating the location of the renal arteries with approximately 150 mm of distance from the renal arteries to the aortic bifurcation. Based on this, a 180 mm length device was chosen with the left side used as the ipsilateral side. It was oriented such that the contralateral gate would be anterior. The device was then passed up through the sheath and was deployed just below the renal arteries without any complication. The C3 deployment system was used and only the proximal portion of the device was deployed. With a series of wires and catheters eventually requiring a C2 catheter and an angled glide wire, the contralateral limb gate was engaged and a pigtail catheter inserted and spun within the graft to confirm intragraft positioning. The pigtail was then advanced up and given that the device had been in position but not anchored for quite some time while the contralateral gate was engaged, I shot another aortogram demonstrating that the graft is still in good position. The remainder of the graft was then deployed and via the left side a 32-mm Coda balloon was inserted and the proximal attachment site ballooned to profile. The pigtail catheter had been exchanged at this point for a Lunderquist wire on the right. This side was also up sized to an 18-French sheath. Prior to this, a sheathogram was performed locating the right iliac bifurcation. We knew we are going to have to place a larger cuff on this side and so a 20 x 115 mm device was chosen to land us just into the right common iliac artery and allow room for distal cuff. This was placed via the left-sided 18-French access and deployed uneventfully. Another injection via the right sheath was done to locate the iliac bifurcation and a 26 x 33 mm aortic cuff was used as a distal extension on this side to obtain seal. The Coda balloon was then inserted, and all junction points and the distal attachment site were ballooned to profile. Injection via the left sheath was then performed to identify the iliac bifurcation. Based on preoperative measurements, it appeared that a 20-mm device would obtain seal and so a 20 x 95 mm device was inserted up the left side access and deployed uneventfully. The Coda balloon was inserted here as well, and all junction and distal attachment sites were ballooned to profile. An aortogram at this point was obtained, which showed a fairly extensive type 1B endoleak from the left side. It did not appear that a further ballooning of the limb would achieve seal, and so I chose to extend. At this point, I had a choice of either extending into the external iliac artery or placing a larger cuff. There was not a lot of room here between the end of the extension piece and the iliac bifurcation and so I reviewed the films with Dr. Waybill from Interventional Radiology, and we agreed that embolization of left internal iliac would be appropriate. The left internal iliac artery was then accessed by inserting an angled glide wire and the C2 catheter up the left-sided 18 French sheath as a buddy wire type system, so that we did not lose access across the device. The left internal iliac artery was cannulated successfully and the wire was inserted into the distal branches of the internal iliac artery. The catheter was able to follow and a Rosen wire was inserted to achieve a little bit more stiffness of the wire into the internal iliac artery branches. The catheter was then removed and a 7-French sheath placed into the distal internal iliac artery branches. The embolization of the left internal iliac artery was performed by Dr. Waybill and is dictated separately by him. Briefly, an 18-mm Amplatzer device had been chosen and was placed under fluoroscopic guidance with additional injections of contrast to confirm placement at the left internal iliac artery origin. This was deployed uneventfully, and the 7-French sheath was then removed. A 14.5 x 120 mm length extension was then chosen and placed up the left side and deployed about 3 cm into the left external iliac artery uneventfully. The Coda balloon was used to balloon this to profile as well. Another completion arteriogram was performed revealing a type 1A and type 1B leak from the right iliac attachment site. The proximal endoleak was addressed by reinserting the Coda balloon and ballooning the proximal attachment site to profile. Several additional images were performed with various obliquities on the right side, and I chose to extend a little bit farther with a 28.5 x 33 mm cuff on the right. This was inserted uneventfully and ballooned to profile. A completion arteriogram at this point revealed resolution of the type 1A endoleak a much slower flow into what was thought to be a type 1B endoleak but on further review, it appeared that it may have been a type 2 endoleak causing this puddle of contrast at about the midportion of the infrarenal aorta on the right. At this point, I did not feel that further extension along the right would be appropriate given that I had already sacrificed the left internal iliac artery, and I chose to terminate the procedure. All wires and catheters were removed with a good pulsatile blood flow noted, and both arteriotomies were repaired with interrupted 5-0 Prolene suture. Backbleeding, forebleeding, and flushing maneuvers were performed prior to closure, and all wounds were checked and made hemostatic. The wounds were then closed with interrupted Vicryl with Monocryl for the skin. Dry sterile dressings were applied. The patient was awakened and extubated and taken to recovery room in stable condition and tolerated the procedure well without immediate complication. Intraoperative autotransfusion was not used.

Does the new code 93463 include adenosine?

Good Morning Dr. Z, Yet another question, Our physician did a Fox Hollow atherectomy of the distal superficial femoral artery. There was a significant amount of atheramatous debris in the spider EX filter device. The filter was retrieved. Does this constitute a thrombectomy also??? Thank you and Happy Friday!! Tina Pihlainen

Hi Dr. Z, My question is basically, Is a cephalic subclavian junction angioplasty considered a central vein intervention? Thank you, Tina

Dr Z please help! Pigtail cath was taken up into the abdominal aorta. Abdominal aortogram and plevic angiogram showed a normal infrarenal abdominal aorta with normal right iliac system. On the left side, a previous left ocmmon iliac stent was completely occluded with thrombus extending into the internal iliac and proximal external iliac. Surgeon was able to get thru the occlusion with a contra catheter. Angiogram performed of left lower extremity showed thrombotic occlusion of the distal external iliac and common femoral with reconstitution of the profunda and superficial femoral arteries... 7-mm Angioguard placed in the SFA to prevent any distal embolization. Xpedient catheter to Angiojet the common iliac and the common femoral artery. Repeat angiogram showed complete thrombus resolution, and there seemed to be a high-grade stenosis in the left common iliac artery which was angioplastied using an 8-mm balloon. Repeat angiogram showed complete resolution of the thrombus and stenosis both in the common iliac and common femoral artery. A wire was passed all the way into the anterior tibial artery. However, despite Angiojet thrombectomy, no resolution of this thrombus. At this point, the procedure was terminated. The codes selected were: 37220, 37184, 37185. Would the iliac thrombectomy bundle into the angioplsty? or would the angioplsty bundle into the thrombectomy since there were 2 interventions in the same artery? and thrombectomy of femoral artery and anterior tibial artey (37184, 37185). Should modifier 59 be appended to thrombectomy codes? Sincere thanks for your help.

During an EP study and ablation, on the physician side, can 93623 only be charged prior to ablation? I have seen dictation where the physician only mentions it after ablation and not sure if it can be charged at that point.

Dr. Z, Please help clarify the correct coding for the following: a left heart cath was performed with selective coronary angiography, selective internal mammary artery angiography, aortic root injection for saphenous vein graft angiography but the SVG were all found to be occluded, left heart pressures and left ventriculogram. I feel 93459 would be the only code appropriate. Do you think 93567 should also be coded? I think 93567 would be inappropriate. Thank you

Can we bill 75670 arch angio when done to evaluate BT shunt in addition to billing 93567 ascending aortogram when done? I'm still trying to figure out the catheter placement on this one but I'm leaning to 36215x2. "After ascending aortography we then advanced the pigtail catheter over a wire into the aortic arch to better delineate the BT shunt anatomy. There is a right aortic arch with an aberrant left subclavian artery. We then advanced the pigtail catheter into the left subclavian artery and performed an angiogram. The BT shunt was not arising from this vessel. We then manipulated the catheter into the left common carotid and performed an angiogram. The BT shunt was profiled with a power injection. As the BT shunt was widely patent, it drained into the left pulmonary artery. Aortic arch angiogram demonstrates a right aortic arch with an aberrant left subclavian artery, therefore, the first branch off the ascending aorta of the arch is the left common carotid followed by the right common carotid followed by the right subclavian followed by the left subclavian. The catheter was then manipulated into what ended up being the left subclavian artery and angiogram was performed. It demonstrated normal left subclavian artery with a large vertebral artery arising off the left subclavian artery."

Hi Dr. Z. We have a case in which we want to know if the PTA that is done after an open graft revision and thrombectomy (36833) is coded open 35460 or not reported per the information after the op note below. I am assuming the venogram is not reportable. OPERATIVE REPORT Occluded left arm arteriovenous graft. POSTOPERATIVE DIAGNOSIS: 1. Occluded left upper arm arteriovenous graft. 2. Pseudo-aneurysms times two. PROCEDURES PERFORMED: 1. Aneurysmectomy times two. 2. Thromboembolectomy and balloon angioplasty of the venous anastomosis. 3. Intraoperative venogram. ANESTHESIA: General anesthesia. BLOOD LOSS: About 100 mL BACKGROUND: The patient is a 64 year old African American male who has been undergoing dialysis for some time secondary to his end stage renal failure. He had developed two aneurysms on an arteriovenous graft; one proximally and one distally, resulting in occlusion of this graft. He was taken to the operating room at this time. DESCRIPTION OF PROCEDURE: With the patient prepped and draped in a standard fashion, incisions were established over each of the aneurysms by blunt and sharp dissection. The aneurysms were isolated from the graft, opened and then resected down to opening the graft proper. There was sufficient graft to establish a primary resection of the defected graft and complete and end-to-end anastomosis using 5-0 Prolene suture. Prior to securing the suture line, a 4 Fogarty catheter was passed proximally and distally removing both arterial and venous thrombus, resulting in both forward flow and back flow. The suture line was then secured. A venogram was then performed. This indicated a stenotic area in the venous anastomosis. Using a 7 mm x 4 cm balloon angioplasty catheter, this was inserted across the anastomosis, inflated to 12 atmospheres, and allowed to remain in position for approximately five minutes. The balloon was then deflated, withdrawn, and a second venogram performed indicating excellent resolution in the stenotic region. The catheter was then removed and the access site was closed with a single Figure 8. 5-0 Gore-Tex suture. There was excellent pulsatile flow through the graft at this point. There was no evidence of active bleeding. The wounds were irrigated with warm saline solution with 1 gram of Amikacin. The wounds were then closed in a subcutaneous fashion using 3-0 Vicryl suture. Sterile dressings were applied. COUNTS: The sponge and instrument counts were correct. The patient tolerated the procedure well and was taken to the recover. VASCULAR CODING BOOK: 8. If an open surgical declot and surgical revision of the graft or anastomosis is performed, use code 36833, and do not code for additional angioplasty/stent within the graft (anastomosis to anastomosis). If an additional angioplasty or stent is performed outside of the graft, code for the additional intervention as well. This would be codes 75978 and 35460 (open) or 35476 (percutaneous) for angioplasty. Utilize codes 75960 and 37205 (percutaneous) or 37207 (open) for stent placement if performed. Dr. Dunn Q&A: ZHealth Online Q&A 2618 Date: Tuesday, March 15, 2011 Question: Hello, I need help :) The surgeon did a Graft Thrombecomy with revision (36833). He then did a fistula gram (36147) and because of stenosis in the venous outflow did an PTA (35476 & 75978-26). And a segmental incisiion of graft & overlying skin with primary closure??? Separate incision and closure.. Diag: End-stage renal disease, thrombosed graft fistula with recurrent bleeding from the false aneurysm of arterial limb of the graft with skin erosion. After revison/thrombecomy proc; The inflow was then tapered due to the incision..sheath removal of the graft was clamped proxiamally and distally, sheath withdrawn and sheath hole closed with sutures. Clamps released and palpable thrill was present along the graft, hemostasis was obtained. Counts ere correct x2. The wounds were closed in layers with Vicryl & Monocryl for the skin Dermabond waa applied to seal wounds. This is what I am not sure about: Incision was then made to excise the sutured skin at the site of graft bleeding. The skin was excised as well as the underlying graft. No evidence of infection. The wound was reapproximated with nylon suture. Because this was a separate incision and it was done after the revision was completed, he feels he should get credit for the work. Since the graft was no infected, I am thinking this is still a part of the revision but not 100% sure. Your advice would be so appreciated! Thanks you! Answer: I would code as one revision only as you suggested. When we do thrombectomies, we often open the arterial as well as venous anastomosis with separate incisions but can only code one thrombectomy. Lastly, when we do angioplasties via an open incision like here, would use the open venoplasty code 35460 instead of 35476. Thanks, Dr. D David Dunn, MD, FACS

Dr. Z., I could use some advice about this procedure. I have only charged/coded for a LHC for this procedure, but after reading this report I am wondering if I should be adding 92982. The report: He was found to have a total occlusion of the mid to distal posterior descending artery. Then through the guiding catheter was passed a 0.04 high-torque floppy guidewire, which was used to traverse the area of stenosis. Upon doing this apparently there was a clot that was dislodged or broken up and this reestablished flow to the distal vessel. Upon repeat angiographic views there was no significant stenoses and, therefore, this did not require ballooning or stenting of the vessel and he was administered 200 mcg of intracoronary nitro to the right coronary system and repeat angiographic views were obtained and after a waiting period it was elected that no further intervention would be necessary. Selective coronary cineangiography was performed of the left coronary system. CONCLUSION: 1. Percutaneous coronary intervention of the distal RCA with essentially doddering technique of the distal RCA with reestablishment of flow, and no significant atherosclerotic stenoses. What is your opinion? Thanks, Chris McCoy

If a coronary sinus venogram during an EP study reveals that the patient has an abnormal takeoff or other anatomical abnormlaity of the coronary sinus, is there a set of codes that should additionally be billed to describe these services in conjuntion to the EP study codes (ie. 93620/93621)?

Are there any additional charges that could be billed in a BIV ICD replacement case to describe a pta of a coronary sinus that was stenosed due to scar tissue buildup from multiple LV lead revisions/replacements?

Dr. Z, I feel like I'm always having trouble determinig the right CPT code when it comes to angioplasty of fistula. Please see the example of Op note that I need help on. Thanks! The patient's left arm and right groin were prepped and draped in the usual sterile fashion. Initially 1% plain Xylocaine was infiltrated over the course of the left arm fistula just above the AV anastomosis. This area of the fistula was accessed percutaneously using a micropuncture set and a 6-French short sheath placed. A left arm fistulography was then performed from the level of the antecubital fossa to the right atrium and revealed a moderate stenosis of the cephalic vein at the level of the humeral head which was then balloon dilated using an 8-mm x 40-mm Conquest balloon with good result. At this time, the sheath was removed from the left upper arm and we tried to redirect our puncture toward the antecubital fossa but were not able to get into the fistula at this point despite trying multiple attempts. At this point, the percutaneous right femoral artery access was obtained and a 5 F short sheath placed. A retrograde right iliofemoral sheath angiography was performed and revealed a good caliber right common femoral artery at site of puncture. The patient was then given 4000 units of Heparin IV. An angled Glidewire was then passed through the 6-French sheath placed in the groin and passed to the level of the aortic arch and exchanged for a vertebral catheter, which was used to selectively cannulate the left subclavian artery followed by cannulation of the left brachial artery. Left brachial angiography was performed and revealed a severe stenosis of the fistula at the AV anastomosis. The vertebral catheter was exchanged for a 90-cm Shuttle sheath through which wire crossing of the area of stenosis of the fistula in the antecubital fossa was done followed by balloon angioplasty using 8-mm and 10 mm balloons with good result. There was still a residual stenosis noted to be present of about 20% just above the AV anastomosis.

If a surgeon performs a SFA angio/atherectomy/pta/stent, then proceeds to catheterize the anterior tibial and just shoots a diagnostic angiogram, can you code that catheterization separately from the bundled code for the SFA intervention as an additional 3rd order cath?

Hi Dr. Z I have questions regarding multiple access sites. I understand for access sites with interventions the catheter placements are included but I have had two cases that I have questions. The first is right femoral access, the catheter is placed in the aorta and a high low is performed. With a diagnosis of left iliac stenosis, a second puncture site is performed on the left with subsequent angioplasty and stent. Bilateral common femoral artery StarClose deployed. I have coded 37221, 75625, 75716-59. My question, should I have coded 36200 and G0269 for the right access with diagnostic aortogram and closure given there was not intervention performed from the right? The second case is right femoral artery accessed with catheter placment into the external iliac, obstruction was identified, catheter was pulled and StarClosed deployed. The physician then punctured the left side performed diagnostics, identified two areas of obstruction and stented them. Of course I coded the diagnostics and stent placements for the left but once again the question of should I have coded the 36140 and G0269 for the right side?

Dr Z - Patient has a lower extremity AV fistula. The physician performs fistulogram (36147). He documents stenosis/occlusion in the common iliac artery (stents); external iliac (angioplasties); arterial portion of the graft (angioplasties). Here are my questions: 1. Would the new codes apply to the graft arteries or do the preexisting guidelines for AV fistula/grafts also apply to the lower extremities? 2. According to the "zones", the adjacent artery is included in the graft so both the external iliac artery and the arterial portion of the graft would be considered one vessel, correct? 3. If the new codes apply, how do we capture the fistula access and imaging? Would we then capture 75791 for the imaging since catheter placement is now included in the lower extremity interventions? Feel free to add any other advice you'd like to give! Thanks in advance.

Hi Dr. Z - I have a case in which the MD is calling a revision of an AV fistula (36833) but I think it is a creation of a new fistula (36830). Additionally, I am not certain if the diagnostic venogram performed via cutdown at the cephalic vein would be reported as 36147, 75791 or 75820. The H&P indicates that the old fistula is a left radial cephalic AV fistula which has occluded. The procedure is as follows: "Findings: 1. a newly created graft was constructed with good flow noted…findings of the upper extremity cephalic vein showed it to be a short course vein with occlusion. INdications: This patient presented with ESRD and underwent AV fistula which failed. He presents for revision…Procedure: …US was used to find the patients old AV anastomosis…I could not find any portion on tracking that was not clotted. In light of that I made a cut down over the cephalic vein at the antecubital fossa, dissected out for a short distance, and then cannulated this…venogram showed cephalic vein occlusion but a reasonable upper extremity brachial vein for access. Central venous runoff was w/o occlusion. With this in mind, I elected to convert to a new graft and continued the incision up into the upper arm to expose the brachial artery. With dissection the brachial artery carried out and the brachial vein was dissected through an upper arm incision in the deep fascia and mobilized for anastomosis. A tunnel was created and a flixene graft passed through the tunnel. The venous end of the graft was cut a venotomy was performed and the graft spatulated and sewn end to side to the venotomy…the arterial end was then approached. The brachial artery was opened…the end of the graft was sewn end to side to the artery...". Thanks in advance for your help!

Dr Z, Pt had right subclavian aneurysm, MD did right common carotid to right subclavian artery bypass,ligated the right vertebral and placed a stent in the innominate to cover the subclavian.He gave me the codes 35606, 37615 and 37215. Would the stent in the innominate be included or should I bill 37207? Thanks for all you help, I need it when these cases come up.