Ask Dr. Z

Dr. Z - please clarify whether the arterial angioplasty or venoplasty takes precedence when both are performed on an AV dialysis graft or fistula. This guidance has changed a few times recently and last week during an audioseminar we thought we heard you mention arterial but we also found a Z health book errata dated 9/23/10 that states venous (and a 6/8 errata that states arterial). Thank you in advance for this clarification.

How would you code a ligation of the anterior branch of the greater saphenous vein?

We have a difference of opinion among our coders regarding the correct coding of certain interventional procedures. The following is an example: "Percutaneous coronary intervention was carried out on a totally occluded saphenous vein graft. Initially a balloon was used but failed to open the vein graft. Next an Export extraction atherectomy catheter was used. Provider was able to suction out some of the clot. A balloon was used to pre-dilate a lesion in the distal vein graft allowing placement of a bare metal stent." Some coders coded an atherectomy while others coded an angioplasty. Apparently the physician's use of the term "atherectomy catheter" is prompting some of the coders to code an atherectomy. Can you provide our coders with some guidance regarding the appropriate codes for the procedure described?

In 2010 I would code 93539 to check IMA for suitability for CABG. What would be used in 2011? Thank you. Becky

Hi Dr.Z I am at a loss as to how to code this Arteriovenous fistula pseudoaneurysm case. I am hoping this is enough information. The plan is for an open repair but instead of proximal distal control, get control with an angioplasty balloon placed by our Endovascular surgeon first. Then the surgeon came in and incised the skin over the aneurysm , evacuated the blood and clot which identified the 1 x 0.5 cm oval defect. A Bovine pericardial patch was selected and cut to fit and sewn over the defect. Bleeding points were over sewn with sutures and a completion fistulagram was obtained which showed flow through the psoric into the radial and ulnar arteries. My first thought was to code 36832 or 36833, but now am thinking more like a direct repair code. I do not see a code that fits this, would this be unlisted 37799? I am also thinking that any imaging and placement of the balloon done before the open procedure by the vasc surgeon would be included in the open procedure and not coded seperately, is that correct?

In your book Vascular & Endovascular Surgery Coding Reference on page 240 example # 4 you use 35286 along with 34802 but when I put all the codes in I come up with that code as bundled. I thought you could not do anything else with the AAA repair. Can you help me to understand? Also can you do and endarterectomy of the common femoral when doing a AAA?

Dr, Question for pressure wire during coronary intervention. After diagnostic angiogram which 70% stenosis noted in LAD and proceeded to evaluate the LD and a pressure wire was advance through teh guidewire into the left main but could not be manipulated or advanced into the left LD due to tortuosity below, as well as the sharp angle of the LD. After several attempts, it was decided to go ahead with PTCA and a DES was placed. Can we code 93571-74 here they used the supply and several attempts made even though the procedure unsuccessful? Thanks

Hello Dr Z, I have a complex case which the physician spent an exorbitant amount of time on due to complications. My coding conflicts a great deal with what the physician wants billed, so I was hoping you could provide some insite. The procedure performed states "resection of AAA, AAA to right common iliac and left common femoral bypass using a 14x7 knitted Dacron Hemasheild graft. Left Common iliac and ext. iliac endartectomies. Reimplantation of left renal artery, reimplanation of IMA". The physician wants to code: 35540, 35351,35351-59,35697,35697-59 I coded - 35091-22 My question is: The graft did come past the iliac on the left side, but I am unable to locate a code for an extension prosethesis other than for endovascular repair. Based on this, should I code 35102 with 35697 to cover the visceral work? Also, CCI edits state 35091 and 35697 can be billed together, in what case would you do so? Any insite would be appriciated. Thank you.

Dr. Zielski, We only treat adults in our Cardiac Cath lab. What kind of congenital defects will merit the use of the Congenital Catheterization codes in an ADULT? I went the Las Vegas meeting in November, and there is slide where some congenital defects are listed. Can I go by that list? I thought of using it, but I remembered that you mentioned that PFO is not an indication to use the congenital codes. Should we exclude any others?

DR Z, This may seem like a simple question but I have a physician that wants to charge a Selective Bilateral Renal Angiogram (36245-50) based on the following Documentation. What do you think? PROCEDURE PERFORMED: Aortic angiogram and bilateral selective renal angiography. INDICATIONS: History of PTA of the renal arteries bilaterally in the past along with resistant hypertension. PROCEDURE: After the patient was prepped and draped in a sterile fashion the left groin was infiltrated with 10 cc of 2% lidocaine. Access into the LSFA was done using 6-French arterial sheath. After images were obtained and hemodynamics were measured, an attempt was made to place a 6-French Angio-Seal. The artery was felt to be too hard and we had a little bit of trouble pushing the Angio-Seal so this was stopped. Manual pressure was applied. The patient tolerated the procedure well and left the cardiac catheterization laboratory without complications. FINDINGS HEMODYNAMICS: AO is 180/80. AORTOGRAM: An aortogram was done in an AP position. Diffuse atherosclerosis was noted. Both renal arteries were seen. LEFT RENAL ARTERY: The left renal artery shows moderate 30-40% proximal stenosis. RIGHT RENAL ARTERY: Right renal artery shows a 20% mild renal artery stenosis. SUMMARY: 1. Mild right renal artery stenosis. 2. Mild to moderate left renal artery stenosis. RECOMMENDATIONS: Medical treatment I only coded this as a non-selective aortogram (36200) and he says there is documentation based on the "Procedure Performed" listing. Please Advise.

Hello! (again!) We have this scenario, the procedure was removal of ICD, revise the ICD pocket, added a new ICD, tested the defibrillator threshold, and added a subcutaneous anterior chest coil array was added to the vector after the new ICD and old leads weren’t providing optimal results. This is what we coded – 33249, 33241, and 93641 with device codes C1894, C1721, and C1896. Is there something else that you would suggest? Thanks for your continued advice!!! Melinda Neeley Nebraska Methodist Hospital

Hello Dr Z, I actually have a question regarding the new cath codes for 2011. In using the current codes 93510, 93543, 93555, 93545, and 93556, what would be the new codes (2011) that would replace these for a cath procedure Thank you, David Kouba CPC Meriter Heart & Vascular Hospital 202 S. Park Street Madison, WI 53715 dkouba@meriter.com (608) 417-5857

Does time have to be listed when Nicardipine is infused for vasospasm? this is what the doctor has dictated:to improve the vasospasm a total of 8mg Nicardipine was infused.A control run after the infusion showed persistant vasospasm with prolonged transit time.Pt. was given high dose pressors to maintain the target BP.at this point we decided not to give more Nicardipine. Thanks for all your help.

Dr. Z-- Have been pouring over resources on the 2011 cardiac catheterization codes to get my chargemaster in order. And as I was doing a powerpoint presentation outlining the new codes, I realized, I can't find a 2011 code that describes a Left Heart cath (for pressure measurements only) + graft(s) catheterization. All the pairs I see include coronary angiography and don't have any with or w/o verbiage for the coronary angiography. In 2010 I would have coded this situation as 93510, 93545, and 93556. Do you know what we should code starting 2011 for this scenario?? Help! I have a lab full of hungry cath lab staff!

Hello! We listened to your 2011 IVR Updates webinar last week and heard that we cannot code diagnostic angios if the patient has had a prior catheter based angiogram. Our question is since CTA, MRA and vascular ultrasound are not catheter based, we're assuming that we can code for diagnostic angios even after these procedures. Would this be correct?

Need some help please. We have a patient that came in ER in cardiac arrest, brought back and then taken to the cath lab. Cardiologist #1 did coronary angio only and then Cardiologist #2 attempted PCI of ostial RCA (which was subtotal occlusion) but was unsuccessful. The patient arrested during cath and had to be cardioverted along with CPR several times. Once patient was back in sinus rhythm a ballon pump was placed and the patient was transferred. The Cardiologist documents 2 hrs of critical care spent with this patient. My question is should we use 92982-74 for the unsuccessful PCI along with 33967 and 93508? I know we can't charge for the cardioversions. Appreciate any help you can give. Thanks.

I know that we cannot code angiograms if the patient has had a prior catheter based study to determine the need for intervention. We are doing more CTAs and MRAs in our institution. These images are obtained with a power injection into a IV. We have not been considering this catheter based, so if the patient is in the IR suite and angiograms are done to determine the need for intervention, we have been coding them. Is that correct?

When our Radiology department scans for possible DVT, they scan the patient's abdomen, pelvis, and both lower extremities. Currently they are charging codes 74160 and 72193. Can they also charge 73701 for the extremity portion of the exam, and can they charge 73701 twice to account for the bilateral extremity exam? Thanks.

Hello Dr. Z, can you please advise on how you would code the following? Pt came in with left brachiocephalic fistula with a hx of cephalic arch stenosis with a stent and central innominate stenosis where previous innominate PTA was required from a femoral approach because the wire would not pass from the AVF. RFV was cannulated. Angio of SVC and RA were normal and L innominate vein was not seen due to complete occlusion. The L innominate vein was selectively catheterized from the SVC. Angio of the central veins revealed a 90-100% stenosis of the innominate vein. Central venous angioplasty was carried out with <10% residual. An attempt was then made to pass a wire into the cephalic arch from the subclavian which was unsuccessful due to the presence of occlusion at the junction of the stent in the cephalic arch with the subclavian vein. Therefore, decision was made to cannulate the AVF. Left upper brachiocephalic fistula was cannulated and an angiogram was performed that showed 90% stenosis in the stent in the cephalic arch vein extending into the subclavian. Venous angioplasty was carried out showing 10% residual stenosis. Would the following codes be correct since there are 2 separate accesses? 36011, 75827-59, 35476, 75978 36147, 35476-59, 75978-59 ...or would the 36147 need to be changed to 75791? Thanks - a little confused.

Hi Dr.Z, After Overnight thrombolysis in SFA, the patient comes in for evaluation and diagnosed for peroneal artery thormbus using thrombectomy & angioplasty for the stenosis in anterior tibial artery. I am not sure whether we need to code the catheterization as 36247-52 for this case..Please clarify when we need to code the catheterizations along with therapeutic treatments on the following day of the treatments. Regards Prabhavathi, India

Good morning! Our cath lab is going to be using the Impella Device in a case today and we were woundering how to go about coding it. We have seen a lot of different ways to go about coding it but are not sure what to go with. We saw where the website said to use 33999, 93799, 92970 but the actual package for the device says to use 33975 or 33975-52. Also is there HCPCS code that goes with it? Any help would be greatly appreciated! Thanks!

ZHealth Online Q&A 1779 Date: Tuesday, November 04, 2008 Question: We had a patient who had no venous access because of long term central lines. Our doctor placed a PICC line transhepatic with the tip placed in the IVC. What do you suggest to code? Answer: This is still a central venous access, non-tunneled. I would code for any guidance and the non-tunneled central venous access (as the liver is in the trunk of the body, centrally, like the subclavian, jugular and femoral veins). I would use code 36558. Dr.z My question is; would you still code it this way in 2010? 36556? non tunneled

Hi Dr. Dunn, I need help with a code for lower extremity bypass graft segmental resection. This was done prior to an above knee amputation. Can I code this seperately? Thank you so much, Ginie

DX is retinoblastoma,some lesions in the eye were inoperable,was brought in for intra-arterial chemotherapy. Angiogram done: Left internal carotid artery injection,superselective left ophthalmic artery injection. Endovascular Procedure-intra arterial chemotherapy,intra-arterial Nicardipine infusion for vasospasm. To prevent vasospasm.3mgNicardipine was slowly infused into the opthalmic artery.Melphalan was then slowly infused into the opthalmic artery over 20min. Should I only code for the angiogram? control run showed no evidence of thromboembolic occlusions or vasospasm.

Dr. Z -- I would appreciate your interpretation of the procedure description below as to the code/charge for selective catheterization. “The 6-French sheath was placed in the right femoral artery. The right lower extremity angiography was performed through the sheath. Following this, the sheath was exchanged out for an AccessPro which was advanced TO THE CONTRALATERAL COMMON ILIAC.” (Angio findings are documented.) Then says, “An intervention was performed on the LEFT INTERNAL ILIAC. An 0.014 Stabilizer Plus WIRE was advanced out INTO THE INTERNAL ILIAC and balloon angioplasty…etc., etc.” (Stenting followed the angioplasty.) I do not have any problem with the procedure codes. However, as far as selectivity, should we code/charge 36245-LT (first order to common iliac) OR 36246-LT (second order to internal iliac)? Does the WIRE placement described above equal selective catheter placement? Is the "default" that the vessel is selectively engaged/cathed if it is treated?? MANY THANKS FOR YOUR ASSISTANCE!

I have searched and cannot find a similar question. Could you please help? I have an angiogram: right common femoral artery was accessed and the sheath was inserted and placed in teh suprarenal aorta (36200) 10 for 20 visipaque contrast was used for a suprarenal aortogram was taken. The dr. then addes the patient's creatinine was etc. and patient was prehydrated before the procedure. Then the dr continues with earlier dication stating: The lower extremity runoff was taken with 7 for 70 Visipaque contrast. The results are as follows: aorta was.........sfa occluded and anterio tibs ect. Dr. doesn't dictate cath movement...just the injections of 75625 and then the 75716 with complete results. Would no cathether movement withstand an audit for 75716 and 75625. Or are we stuck with 75630? Thank you for your opinion!!

Please do NOT include any actual patient medical records with your question. Dr Z, two questions regarding av fistula coding I haven’t seen addressed yet. First, how would we code under the most current guidelines, for angioplasty of the arterial inflow (arterial anastomosis is patent) with additional angioplasties within the fistula and outflow vein. Would we consider the inflow part of the fistula and code this as one venous angioplasty or would it be considered arterial and override the venous code? (Don’t think I have enough documentation to consider it a separate stenosis considerably away from the fistula.) Second, I have a case where the fistula is accessed and a fistulagram was performed (36147). Then from a direct access into a collateral an embolization was performed (37204/75894). How should the collateral access be coded? Thanks so much for your help.

Dr Z, During a thoracic endovascular aortic aneurysm repair with left subclavain artery coverage 33880 75956/26 the physician places an intravascular ultrasound catheter and performes an intravascular ultrasound of the thoracic aorta from the arch all the way down to the celiac axis in the abdominal aorta. This was done to confirm diameter measurements proximally and distally. Is the IVUS 37250 75945/26 a billable service with the placement of the thoracic graft in this case? Thank you, LaVonn

Hello Dr. Zielske. I need your help again. We have an ongoing discussion regarding code 75984. In your IR book and website I found “if the use of contrast is not documented, do not code 75984”. Our doctors would first inject contrast for a nephrostogram (50394, 74425), then exchange existing tube (50398) without documentation of another contrast injection, saying that replacement was successful or an image was obtained to document position. I was told, since contrast remains in the patient’s system, it is ok to use 75984. Is this statement correct? Thank you. Always appreciate your help.

Hello, I have a question for you. Could you please tell me when and if it is appropriate to charge for a Chest x-ray after a NG tube is placed? Most of the time the nurses place this, but there are times where the physician places it.

Dr. Z - This question is in regards to modifiers 78 and 79. The patient has an internal/external biiary drain, 47511, placed on 7/30. The drain was "pulled back by the patient" on 9/2 and the radiologist replaced it, 47525. Since this falls within the global period of the 7/30 procedure would the appropriate modifier be 78 or 79? Then 4 days later the drain "fell out" and the radiologist placed a new one int/ext, 47511 - 78 or 79? Thanks so much for any advice you can give on these modifiers!

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?

Thank you for all the help you've been. I do know your a very busy man.
 

Got a question for you¦ I have a case here where the patient is coming in for angioplasty/stenting of the right common iliac artery (DOS 1-14-2010). The patient had a prior CT angiogram 11-13-2009 which was mentioned in the H&P and I did review the actual report. Essentially the same findings are seen in the prior study as what is seen in the current study; and there is nothing said by the MD that really gives medical necessity for a repeat study. I do believe that this is pretty cut and dry that the repeat study cannot be reported. However, my question is can the selective catheter placement still be reported even though the angiography is not going to be reported? In this case the right femoral was the puncture site. He takes the cath to the abdominal aorta for aortogram, then up and over to the left common femoral artery for left lower extremity angiography. At this point the cath placement is at 36246-LT. Then, he comes back to the right side, does injection for run-off, and performs angioplasty and stenting of the right common iliac artery. (If there had not been any angiography performed (or angiography of the right leg only), there would be no selective catheter placement; as the right side was the puncture site, and the right common iliac was the vessel intervened upon. The catheter placement code would be 36140-RT just for the puncture.) I am confused about whether to report the 36246-LT. Should this still be reported (even though the diagnostic study is not being reported)? I canâ?Tt find a specific resource to back that up. I looked in the Dr Z book and on the Q&A site. What do you think? Any guidance would be greatly appreciated! Pat

Have you heard of the Hero Device? Can we bill 36558 and 36830 for implanting the device? I don't think so but I need clarification. Thank you,

Hi Dr. Z This is a general question about carotid stenting. Is there a code that you would use other than 37216 for carotid stenting with a proximal protection device ( Mo Ma)instead of a distal protection device?? I have seen this on a few reports and I am holding them trying to decide the best way to code them..? Thank you in advance for your help.

Greetings, I have a pt that has a axillary sxillary bypass at the same time he has a stenosis in the subclavian artery treated with stent. Would the stent be coded as a open or percutaneous stent placement? I thought it would be coded as a open stent placement as the vessels are the same selectivity. Would I also code a cath placement? Please help, Lesley

HI Dr. Z, My doctor did: left superficial femoral vein transposition av fistula. I can't find the code for this. In the past we used 37799 but the reimbursement was very low. Please advice. Thank you.

Hello Dr. Z! Could you please tell me how to code a peroneal PTA and stenting from an antegrade lt popliteal approach???? Please???? Most wondering about the catheter placement. Thank you!

Hi Dr Z, I would like your input on an aborted EPS that has hit an audit. The Pt was to have an EPS w/ ablation for PVC. "The patient was taken to the electrophysiology laboratory in a fasting state. Noninvasive ECG monitoring was notable for one isolated premature ventricular complex that was strongly suggestive of a right ventricular outflow tract focus. More specifically, there was a left bundle branch block morphology with a late transition and an inferiorly directed axis. The patient's bilateral upper legs were prepped and draped in the usual sterile fashion, and the patient was monitored. With no further spontaneous ectopy, the patient was given increasing doses of intravenous isoproterenol up to and including doses as high as 20 mcg per minute. She was also given intravenous Aminophyllin up to 200 mg in a bolus fashion. Varying levels of sedation as well as beta-blockade with 10 mg of intravenous metoprolol in divided doses; however, no further ectopy was noted. After two hours of observation, decision was made to abort any attempt at electrophysiologic studies and/or ablation. The patient was returned back to the day patient area in stable condition." I coded for the intended procedure 93620-74 EPS w/induction and for the add on code 93623 drug infusion. How would you have coded this. Thanks for your help.

Hello Dr Z, Thank you for your quick response last time. I have another interesting question. Pt comes in for Left Heart Cath and has DES to mid LAD only 92980. The Dr dictates the diagonal with 80 to 90% stenosis. However he decides not to intervine "Plan: The patient will be given Effient 60 mg in the cath lab, continue 10 mg a day. HE IS NOT TOLERANT TO ASPIRIN, we will therefore place him on dipyridamole as well. We will consider percutaneous intervention to the diagonal at a separate setting depending on how he responds, etc. and this could be done as soon as tomorrow if required." The pt. was brought back the very next day and had a DES to the diagonal. Can I charge for another DES to the LAD 92980? Thanks

Dr. Z, Following is the most recent answer to a question on code 96420. "We do not use code 96420 for the chemo aspect of an infusion or embolization with chemotherapeutic agents. This is only billable by physicians in the non-facility setting, and most chemoembolizations are not performed outside the hospital. We would code the diagnostic angiography, catheter placements, embolization and follow-up if documented. Dr.z" Also in the reference book you indicate to not code 96420. My question is does this guideline which was also indicated in the Clinicial Examples in Radiology Summer 2008 only pertain to profee billing? When I check addendum B for OPPS code 96420 continues to be assigned status indicator "s" and remains with payment. So can OP facilities still bill this code for chemoembolizations on a UB04? Thanks.

Through an existing nephrostomy, brush biopsy and cutting biopsy needle were advanced to the ureter and brush and cutting biopsies were taken. Then a neph. tube change. I have the 74425/50394 for the initial neph. thru the tube and the 75984/50398 for the tube change...i'm not quite sure on the biopsy parts...for the biliary, 47552 is used for the biliary brush biopsy...would 50555 be appropriate for the biopsy of the ureter? would that include both types of biopsies? thanks!

When performing a coiling of a side branch in an AV fistula, can you code separately for the selective catheterization of the side branch? i.e. 36147-59, 36011, 37204, 75894 and 75898? The physician did a complete diagnostic study followed by selective catheterization of the side branch, coiling and follow up angio. Thank you.

Hi Dr Z, I have an interesting question. I had a pt who already has a pacemaker come in for an AV Node ablation 93650. Three hours later the AV node condution returned. Pt was brought back to the EP lab for another AV node ablation 93650. Can or would you charge for the second AV node ablation? Thank you,

if a phys. does an arch and upper extremity arteriogram with selection of the brachial artery...catheter is placed in the artery and then the pt. is sent to ICU to have TPA initiated...i'm looking at 75650/75710/36217...I don't need the 75896 since they were sent to ICU for the TPA correct? thanks!

On july 9, 2010, someone asked what to charge for placement of wires in the ureter prior to nephrolithiasis. In your answer you stated that we should use CPT 50395--"introduction of guide into renal pelvis and/or ureter with dilatation to establish nephrostomy tract, percutaneous." We are doing this same procedure here, but we are not dilating the tract at all. The urologist is doing that in the OR. We simply place an angio catheter and wires into the distal ureter. This may be done one or days before the actual tract dilatation and nephrolithiasis. Can you tell us why we would be allowed to use CPT 50395? Thanks.

Just curious what you come up with...thanks! PROCEDURE(S): Peritoneal Dialysis Catheter Repositioning HISTORY: End Stage Renal Disease INDICATION: Catheter Malfunction MEDICATIONS: Fentanyl 200mcg; Midazolam 4mg CONTRAST: Omnipaque 350, 3510 ml COMPLICATIONS: None. TECHNICAL: Following informed consent, and verification of the appropriate patient identification and procedure to be performed, the abdomen, including the indwelling peritoneal dialysis catheter were sterilely cleaned, prepped, and draped. Contrast was injected via the peritoneal dialysis catheter. A stiff Terumo wire was advanced through the catheter until the tip of the peritoneal dialysis catheter was redirected into a different portion of the peritoneal cavity. Post repositioning contrast injection confirmed free flow into the peritoneal cavity. The catheter was flushed with saline and sterilely dressed. FINDINGS: The existing peritoneal dialysis catheter was in a small contained space. Contrast flowed back along the distal 10 cm of the catheter until instilled into the open peritoneal space. The peritoneal dialysis catheter was repositioned from the contained space into the open peritoneal cavity. IMPRESSION: Peritoneal dialysis catheter repositioning as described.

Good Morning Dr Z, once again I need your help in determining the correct way to code/bill this procedure. We coded 93799, 93544, 75774, 36215,75898 and 37204. Can we code 36215 for the selective catheterization for the AP collateral off of the aorta? I attended one of your Webinar's (which was wonderful) and you addressed the issue of collateral catheterization, but I cannot remember just what you said about these when a HC is done. ~thanks Catheterization for PDA occlusion. Procedure Note: A complete right and left heart cardiac catheterization was performed. All the appropriate chambers and vessels were entered, including SVC, RA, RV, MPA, LPA, LV, AAO and DAo. Oxygen saturations and pressure measurements were obtained by standard catheterization technique. After the hemodynamic data was obtained, a pigtail catheter was advanced to the base of the distal aortic arch and a descending aorta gram was performed. The PDA was identified. There was a moderate-sized PDA that tapered to approximately 2mm at the pulmonary artery insertion site. The geometry was suitable for a ductal occluder. We also noticed a very prominant bronchial collateral supplying the right lung which was felt to be hemodynamically significant and also likely require intervention. We then proceeded with the occulsion of the PDA usinga 6-French delivery sheath. By way of the right femoral vein, over a wire, we positioned the delivery sheath in the descending aorta. We loaded a 6/4 ductal occluder in the usual fashion and deployed the device. We then performed an angiogram with the device still attached to the delivery cable. It was in excellent position fo released in the usual fashion. We then turned our attention to the AP collateral. Using a 4-French angled Glidecatheter, we engaged the collateral which was just to the right of the PDA. We then performed select hand injection in the collateral. There was a very prominent collateral that supplied both the right middle and right lower lobes of the right lower lind. Measured 2 mm in diameter. We selected a 2x3 diamond shaped Vortex coild with the microcatheter positiioned deep in the AP collateral we depolyed in the usual fashion, followed by a 3mmX6cm.

I am new to cardiology coding and need some help with two echocardiography codes. 93303 and 93304 are echocardiography for congenital cardia anomalies, complete and limited respectively. The guidelines in CPT do not identify what needs to be included to be considered complete and when you should use the limited code. Any information you can provide would be most appreciated. Thanks!

Is the following documentation enough to bill for 76937 during an AV fistulogram and Angioplasty of the venous arm of the graft. And also would we need a 59 modifier on this procedure. Under ultrasound guidance, a 21-gauge micropuncture needle was used to access the graft near the arterial anastomosis but central to the aneurysmal segment. The documentation then goes on to discribe the AV Fistulogram part of the procedure. Another question on IV acess. My understanding is that it is not acceptable to code multiple unsucessful attempts at iv access is this correct.