Ask Dr. Z

"Nuclear cisternogram blood patch" ordered for CSF leak. Procedure report reads, "...spinal needle was advanced into the thecal sac. 1.1 mCi indium0111 DTPA radiopharmaceutical is injected into the thecal sac. Subsequently, the needle is retracted into the epidural space." Blood patch px is performed. "Impression: Under fluoroscopic guidance, nuclear medicineradiopharmaceutical placed in the thecal sac. Subsequently, blood patch performed at the L3-4 level..." I am considering coding 62273, 77003 and 78650. Any advice is greatly appreciated!

Please do NOT include any actual patient medical records with your question. A patient was brought in for an ICD implant, prior to the implant a venogram was done and it was decided not to continue with the implant, because there was too much occlusion. Would you still code 33249 with a 74 modifier since anesthesia was administered? Coding is for the hospital side and done as an outpatient surgery. And would there be a problem since no C-code was reported? Thank you.

I have a question regarding a heart cath and billing intracoronary nitroglycerin give for spasms. Is this separately billable with a basic heart cath?

93458
92980-LC
92975???? Billable?

thank you for any guidance you can give me.
 

Hello Dr. Z Could you please help us?! The procedure that was done is a contrast injection of the peritoneal dialysis catheter under fluroscopy. The catheter was not functioning properly, the doctor wanted to see where the problem was. Would 36598 be appropriate, or should we go to an unlisted code? Thanks!!! Mindi Neeley Team Leader Coding

Dr. Z or Dr. D could you please help?? If you have a doctor take over from different practices. Dr H brought pt to angiogram suite and performed an aortogram with runoff. This demonstrated a large pseudoaneurysm within the left iliac area and with blood flow into the left pelvis. I was consulted at this point (Dr F). Access to the left common femoral was performed by Dr H. An 8-French sheath was placed. Subsequently, a Jwire was inserted into the aorta. Runoff demonstrated the pseudoaneurysms that appeared to be coming off the common iliac artery. It should be noted that a LIMA catheter was used to select the left internal iliac artery to make sure that this was not the source of aberrant blood flow to the pseudonaueyrsm. This was not the source. Subsequently, a stif Amplatz wire was placed within the iliac system into the aorta. Covered atrium stents were placed. The completion angiogram was performed with a balloon 12x40 and 10x40 distally. Completion angio deomonstrated a complete exclusion of this pseudoaneurysm. There was no leaking into that or into the pelvic area. There is a slight type 1 leak into the iliac artery in the region of the distal common iliac artery. This was angioplastied again with a 12x40 ballon. There was no evidence of type 1 leak into the stent area. Can Dr. F charge for the cath movement into the iliac? 36246, 37205 and the 35473? Could you please help? I can't find in search a change of doctor. Thank you!

I do not feel this documentation supports additional coding above the currently reported (19103LT, 76942, 19295LT, 77055) Understanding 76942 can only be reported once per encounter (NCCI Manual: Chapter 9, page 10); Do the biopsies obtained at the two "linear extensions" sites and current documentation support additional coding of 19103LT-59, 19103LT-59 and 19295LT-59, 19295LT-59? HISTORY: Lump in the left lower medial breast. Mammography and ultrasound show a highly suspicious mass, and biopsy was recommended. TECHNIQUE: The procedure of ultrasound-guided vacuum-assisted core needle biopsy was explained in detail including potential risks and complications such as bleeding and infection. Informed consent was obtained in writing. On the pre-biopsy scanning, I noted the bulk of the mass is accompanied by two somewhat linear extensions away from the larger body of the mass. I decided to biopsy all three areas and place clips in the two linear extensions for purpose of helping to guide the excision later. The skin and area around the mass were anesthetized with percutaneous injection of 9 cc of 1% buffered lidocaine. We then injected another 2 cc of lidocaine 1% with epinephrine into the deeper tissues for hemostasis. Once local anesthesia was achieved, a nick was made in the skin, and the Celera 12-gauge vacuum-assisted needle was advanced to the target labeled site 1, which is the bulk of the mass. We obtained three core samples in the usual way. Because this area is easily palpable, no clip was placed. We then reoriented the needle to the proximal slightly inferior projection, which was labeled site 2. Again, a 12-gauge sample was obtained under ultrasound visualization. We labeled this site with a CeleroMark clip. We then reoriented the needle towards a slightly more cephalad site labeled site 3, again using the 12-gauge vacuum assisted device, obtained one sample, and placed an Inrad clip in this area. Manual pressure was applied for hemostasis for about 10 minutes. We then obtained two-view mammography for assessment of the clip position. It shows both clips were deployed in the areas described adjacent to the bulk of the mass. Further manual pressure was applied for better hemostasis. A pressure bandage was applied, and post-biopsy instructions were given both verbally and in writing. The patient tolerated the procedure very well and left our office in excellent condition. CONCLUSION: Technically satisfactory ultrasound-guided vacuum-assisted core biopsy left 9 o'clock position, three sites were sampled. A total of five core specimens were obtained. Pathology is pending. Two small contiguous but slightly separate-appearing portions of the mass were sampled in addition to the larger aspect of the mass.

What should we code for placing a drain in a biloma? What would you code for a tube check on the same patient?

Given: CPT 36598 - Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report. OPSI Code T (Significant Procedure, Multiple Procedure Reduction Applies) MUE: Units of Hospital Service Limit: 2 Procedure: Patient presents with a dual lumen port-a-cath where separate access is made via a Huber needle into each port septum so as to evaluate both chambers and sides of dual lumen catheter via separate contrast injections with documented fluoroscopic images. Q: Is it correct to report 36584 once for both sides of this dual chamber port injection?

Hi Dr. Z and Dr. Dunn,I have a combined procedure between surgeon and interventional radiologist for bilateral popliteal aneurysms with endartarectomy on one side. I'm unsure as to whether this is coded as open stent placements, popliteal aneurysm repair or exclusion of the aneurysm which leads me to an embolization code. The surgeon exposed the arteries via cutdown so I'm clear on this being an open procedure. The dictation describes the following: Access to the common femoral arteries was provided by the vascular surgeon, who performed bilateral cut-downs. Single-wall needles were utilized to access the common femoral arteries bilaterally directed in an antegrade fashion. Eventually vascular sheaths were advanced into the proximal superficial femoral arteries and bilateral selective angiography was performed, confirming large bilateral popliteal aneurysms (right greater than left). Additionally, there is severe stenotic disease noted in the left superficial femoral artery. Utilizing 0.035 Glidewires, 5-French catheters were advanced into the distal popliteal arteries and over 0.035 guidewires, overlapping Viabann stents were deployed at the site of the aneurysm and post-dilated using 7mm angioplasty balloons. Completion angiography demonstrated excellent exclusion of the aneurysms with preserved distal flow bilaterally. The vascular surgeon now picks up the dictation and continues: Upon completion of the endo-stenting angiograms sluggish flow to the right side was demonstrated. The superficial femoral artery on the righ had very weak pulsation. It was noticed to be due to a large plaque in the common femoral, which was partially lifted during the previous procedure. The arteriotomy was extended and a large plaque removed from the base of the common femoral and into the entrance of the profunda femoral. A patch was needed in order to establish a better flow in to the superficials and this was done with an Impra patch. The surgeon goes on to describe repair and closure of the groins. What I'm most concerned with is the IR portion of the stent placements. I initially coded as 37207/75960 and 37208/75960 X2 for the two popliteals, then saw the implant documentation indicated for all four stents as Right SFA, Left SFA, Right Popliteal and Left popliteal. I'm hesitant to code the SFA as additional vessels for stent placement since I don't have documentation of why the stents were extended into that vessel. The encoder software wants to code this as an exclusion of the aneurysm cpt 37204. I have never used the popliteal aneurysm 35151 code so not sure this is the right code either or if that requires excision of the aneurysm. I am not coding any angiography as he states this was only to confirm the aneurysm. Catheter placements from common fem to popliteal antegrade I believe would be 36246 on both sides. Any help is greatly appreciated.

What would be the correct way to enter charges for upper and lower extremity studies that are done on same day with same cpt. Medicare is dening claims if we enter both charges (upper ext study) (lower ext study) and add a 59 on 2nd charge. Should we enter charge one time and put a 2 in quanity and use modifier 59?

Please do NOT include any actual patient medical records with your question. Please consider my scenario below: A 6 french sehath was placed in the left femoral artery and a Quickcross catheter was then placed in the left anterior tibial artery, and selective angiogram was performed through the catheter. The catheter was placed distally in the left anterior tibial artery and subsequently a 0.014 Viper wire was placed and atherectomy was performed using a 1.5 Classic Diamondback Crown at low and medium speeds. Post atherectomy there was significant improvement with residual stenosis, 50-60%, which was treated with angioplasty at low pressure with a 2.4 mm long balloon catheter. Post angioplasty reduced to about 20% with much improved distal flow. In relation to the therapy performed, what would you suggest to report? Thank you for your consideration.

Dr.Z, This is pedi case. During pulmonary valvuloplasty was performed and during the procedure the MD covered the valve as well as pulmonary artery stenosis and used the same balloon inflation to dilate areas of stenosis. Since a single balloon was used and covered both areas of stenosis (valvular and supravalvular) can we charge only 92990 or both 92990 and 92997? Please advice. Thanks

How do I code for a brush cleaning of a peritoneal dialysis catheter? The physician used a 3mm ERCP brush to retrieve material and debris from the tip of the catheter. Contrast was injected during this procedure.

Question: Our physician completed a femoral angiography with an attempted PTA of the SFA. The physician made several attempts to pass several different wires. The physician also tried to pass a frontrunner catheter (a catheter used for total occlusions) but was not able to pass the lesion. No balloon was used. The patient was on the table for about an hour. Can we bill 35474 with modifier 74? Michelle Moreno,RHIT,RCC Scottsdale Healthcare

The physician wants to code a venoplasty and a stent placement in this case. I am leaning more towards a thrombectomy since the physician is describing clot not stenosis and I'm aware that mashing a clot with a balloon catheter is not an angioplasty. It seems that the underlying issue here is compression from a tumor with resulting narrowing of the vessel. Please tell me if my codes are correct: 36299, 75827, 36010, 37187, 37205, 75960. I chose the 36299 as I can't tell from his dictation where he was when he initially injected contrast but since he accessed the IJ it seems he was nonselective. Thank you very much! Patient with lung cancer and significant face and head swelling secondary to SVC syndrome. Patient is here for further evaluation and possible treatment. PROCEDURE: Using a micropuncture kit and under direct ultrasound visualization, the right internal jugular vein was accessed and an 0.018 wire advanced. The needle was removed and a 4 FR conversion sheath inserted over the wire. Wire and introducer were removed and runs were done demonstrating extensive clot and tumor burden seen within the right internal jugular vein. The right braciocephalic vein and the proximal SVC. Using glidewire, access into the right atrium was achieved. Sheath was up-sized to a 7-French vascular sheath. Angioplasty was performed using a 10X6 balloon. Using a 12X40 Smart stent, this area was then secondarily stented as there was no significant interval improvement. Follow-up runs demonstrated mild improvement with residual high-grade stenosis and using a 12X40 Atlas stent, this area was then re-angioplastied. Follow-up runs demonstrated marked improvement but with significant residual stenosis which was refractory to further angioplasty. There is, however, no relux seen up towards the head. Tumor involvement is seen within the proximal right atrium.

Is 96420 billable with this note if the physician is doing the infusion himself? thanks! PROCEDURE(S): Right Hepatic Arterial Chemoembolization HISTORY: Neuroendocrine Tumor, Metastatic to Both Lobes Liver, Status Post Right Hepatic Arterial Chemoembolization in July 17, 2009 and Left Hepatic Arterial Chemoembolization August 27, 2009. Recent CT Scan Shows New Tumor Growth in the Right Lobe of the Liver. INDICATION: Control of Tumoral Growth MEDICATIONS: Fentanyl 200mcg; Midazolam 3mg; Cisplatin 100 mg I-A; Adriamycin 50 mg I-A; Mitomycin-C 10 mg I-A; Ethiodol 10 ml I-A CONTRAST: Omnipaque 350, 90 ml COMPLICATIONS: None. TECHNICAL: Following informed consent, and verification of the appropriate patient identification and procedure to be performed, the right groin was sterilely cleaned, prepped, and draped. Via a right common femoral artery puncture a 5-French vascular sheath was placed. Through this a 5-French RC-1 catheter was advanced into the superior mesenteric artery, and superior mesenteric arteriography was performed. The catheter was advanced into the distal SMA, beyond the origin of the replaced right hepatic artery (second order), and superselective superior mesenteric arteriography including portal phase imaging was performed. Confirmation of patency of the portal vein is necessary prior to chemoembolization. This confirmed such. The catheter was advanced into the celiac artery, and celiac arteriography was performed. The catheter was advanced into the replaced right hepatic artery, which arose from the SMA (second order), and superselective right hepatic arteriography was performed. With the catheter in this position, chemoembolization was performed by the intra-arterial administration of the above-mentioned chemotherapeutic agents immediately followed by the intra-arterial administration of 4 cc of 300-500 micron Contour-SE particles. Follow-up hepatic arteriography was performed showing reduction of flow in the right hepatic artery distribution by 30%. Flow was maintained in the superior mesenteric artery and its branches. The catheter was removed and hemostasis obtained at the puncture site. FINDINGS: There are several vague hypervascular masses throughout the liver consistent with metastatic neuroendocrine tumor. Chemoembolization was performed as described. There is variant celiac anatomy with a replaced right hepatic artery arising from the superior mesenteric artery. The superior mesenteric artery and its branches, superior mesenteric vein, portal vein, and left and right portal branches are normal. IMPRESSION: Right hepatic arterial chemoembolization as described.

Hello Dr. Z, In your book you mention that a repeat EP study should not be coded â?oon a subsequent date unless there is documentation of a new arrhythmiaâ?. What types of circumstances would this include? VT vs. SVT? Same type of arrhythmia in a new location? Examples of when it would be appropriate to code an EP Study on a subsequent date due to a new arrhythmia would be especially helpful. I would appreciate any input you can provide. Thank you for your time. Jill Paul CPC-San Diego

Dr. Z, Could you tell me how you would code this ablation. CT guided radiofrequency ablation of two lesions along the right lateral aspect of the thorax. Thanks

Dr. Z, I can not find a CPT code for an exchange of a PleurX pleural catheter? Can I use 32552 for the removal, and 32550 for the re-insertion? Thanks in advance,

Hi Dr. Z! We have a question regarding online Q&A 1768 from 2008. Our office recently went through an external audit and our auditor marked one of our charges incorrect for not billing the additional endarterectomy of the iliac/femoral along with the bypass. In the procedures performed the provider listed them as 1. Right iliac and right femoral endarterectomy with patch angioplasty and 2. Right above-knee femoral to popliteal bypass with 6 mm Gore-Tex graft. As we know some coding rules change, we are wondering if something has been updated from the date this Q&A was published or if you have any other advice. I know it’s long, but I have pasted the report data below. We coded only 35656. What is your opinion about the use of 35355 as well? Thanks, TN Subscriber 9.1.10 DESCRIPTION OF PROCEDURE: A right groin incision was made. The dissection was carried out through the subcutaneous tissue down below the femoral sheath. The femoral sheath was then opened. There was a modest amount of scarring around the area of the previous puncture site where the closure device had been inserted. The common femoral artery was then dissected free along the entire length for clamping. Next, dissection was then carried up underneath the inguinal ligament as adequate retraction was obtained with a Martin Arm. The distal external iliac artery was then dissected free with the crossing vein across the external iliac artery was ligated and divided with multiple hemoclips. Next, once I had obtained adequate exposure for iliofemoral endarterectomy a skin incision was then made on the above—knee medial aspect of the leg. Next, dissection was carried down through the subcutaneous tissue down to the level of the sheath. The sheath was then opened. The popliteal space was then entered. Dissection was then carried down to the level of the popliteal artery, it was then dissected free circumferentially. Potts tie, silk ties were placed around multiple side branches of the vessel. The vessel was small in caliber, probably 4 mm. Next, a 6 mm ringed Gore-Tex graft was then obtained and tunneled subsartorially between the 2 incisions. Next, the patient was then heparinized and following an appropriate time the external iliac artery was then clamped with a Satinsky clamp. Then, the common femoral artery was then clamped with a profunda clamp distally. Next, an arteriotomy was made and extended with the Potts scissors. Next, the endarterectomy was then performed with the common femoral artery and external iliac artery. Next, the remaining debris was then removed and the distal plaque within the common femoral artery was tacked down with 6-0 Prolene sutures. Next, a Vascu-Guard patch was obtained and soaked appropriately and then subsequently used and sewn in place with a running 5-0 Prolene stitch. Prior to completion of the patch angioplasty the lumen was flushed and heparinized with saline solution. The artery was allowed to back-bleed proximally and distally by virtue of removing the clamps. Next, the anastomosis then completed. Three interrupted repair stitches were used to control some suture line bleeding. Next, the vessel was once again clamped proximally and distally. A patchotomy was made standard with the Potts scissors. Next, the graft was then cut to fit and sewn to the patch repair in an end—to-side fashion with a running 5-0 Prolene stitch. Following completion of anastomosis the proximal and distal clamps were removed. A distal graft clamp was placed. Next, there were no repair sutures needed. Next, a graft clamp was then placed proximally. Next, the popliteal artery was then clamped proximally and distally. An arteriotomy was made and extended with Potts scissors. Next, the graft was then cut to fit and sewn in place in an end-to-side fashion to the popliteal artery with a running 6-0 Prolene stitch. Just prior to completion of the anastomosis, the lumen was flushed with heparinized saline solution. The artery was allowed to back-bleed proximally and distally as well as the graft by briefly removing the clamps. Next, the lumen was once again, flushed with heparinized with a saline solution. Next, the anastomosis was then completed. Next, the proximal and distal clamps are removed. The graft clamp was then removed. There was a palpable pulse in the foot upon completion of the anastomosis. Next, protamine was given. Adequate hemostasis was obtained with Surgicel and thrombin spray. Next, all wounds were then irrigated and closed with 2 running 3-0 sutures in the above-knee popliteal incision and in 4 layers in the groin with Vicryl sutures. Skin clips were used in the skin. Sterile dressings were applied. The patient was awakened, extubated, returned to the recovery area in satisfactory condition. All instrument, needle and sponge counts were reported as correct on 3 occasions.

Dr Z, I am a bit confused on all the changes with coding of dialysis grafts. What would be the correct codes for a declot of av graft with 2 access sites with one of the caths being advanced into the svc for intervention? What if there is only one access for a shuntogram and then the cath is advanced into the svc for intervention? Thanks for your help!

Greetings, This patient has a AV graft. The physician does a open thrombectomy of the arterial and venous sides of the graft. Following this a AV shuntogram is performed. This shows irregular calcifications in the graft. A curettage of the graft was performed to remove calcifications. Follow up angio showed a stenosis at the venous anastomosis which is ballon angioplastied. Due to pt history of strictureplasty a stent was placed. I think I can code 36831-59 thrombectomy / the shuntogram with code 75791-26-59/ Angioplasty is bundled with the stent placement / Stent codes 37207, 75960-26. What about the curettage? I'm not sure about the curettage. Would I code this as a 36833 and think of the curetage as a revision with thrombectomy along with code 75791-26-59 and then the angioplasy and stent are bundled as they are completed in the same zone as the revision. Any clarification would help. Thanks, LW

We have recently started utilizing the Spinal Wand to do coablations prior to a vertebroplasy. The physician has wanted to bill as CPT 20982 (bone ablation) and CPT 22521 (Vertebroplasty) I have two questions. 1. Can we charge for CPT 20982 or is it considered part of the procedure with the vertebroplasty (basically prepping the area for the cement)? 2. Shouldn't we really be charging for a kyphoplasty since the coablation catheter "creates a cavity" allowing us to inject more cement? Thank you, Michelle Moreno

Hi Dr. Z: In your Q&A database, I found a question dated 2/14/06 about coding for interventions of the dorsalis pedis. In your answer, you weren't sure whether or not the dorsalis pedis artery would be considered part of the tibial or a separate vessel. I haven't found anything about coding for interventions of the dorsalis pedis other than the above reference. Have you come across anything since this question was submitted from the AMA or SIR that addresses this?

Hi Dr. Z. I have a central stenosis treatment question with access from an AV fistula. I know some rules changed this year and the CPT codes. I was on your call in May, but there were no real examples of treatment of central stenosis. We accessed with a micropuncture needle, wire, and sheath. The fistulograms were obtained up to and including the central venous circulation. The patient has a very large fistula. The outflow is fairly rapid. Visualization of the central circulation was difficult, but there was persistent retrograde filling into the internal jugular and other branches around his shoulder consistent with the clinical impression of central obstruction. I ended up placing a #7-French sheath and passing a guide wire. We meet obstruction about the level of the trachea in the innominate vein. We passed a Bern catheter and performed selective injections in this area which appear to confirm a stenosis just at about the level of the trachea and left of the trachea and central vessels there. With some difficulty with an angled wire, I eventually crossed this lesion. I selected a 10-mm balloon and performed 2 inflations to angioplasty the area with good resolution of a mild wasting in the area. I do not feel there was any real indication to aggressively dilate this further. Follow-up images appear to show improved outflow. Finally, there is clearly adequate outflow for this thing to function. My question is about the catheter coding and S&I for the central stenosis now. I know the 36147 now includes the visualization of the central vessels, so does this also then includes the cath placement to the central vessels as well? At what point now would you use the 36010 via AV Fistula access and do you have an example of the 75791? We coded the above as 36147 since the 36010 is a CCI edit and he only goes to the inomminate and not the SVC. We also coded the 35476 and 75978 for the angioplasty of the vein. Are we on target or totally missing this? Thanks Dr. Z. TN Subscriber 8.26.10.

What code would you use for using a 3mm ERCP brush for cleaning the peritoneal dialysis catheter? The indication was the catheter would flush but the return was poor.

Hi, Dr. Z: Our surgeon has been using some atherectomy devices that can also retrieve thrombus. He is dictating thromboembolectomy and then also angioplasty on the same case. We are not sure if we should be coding these as an atherectomy or thrombectomy. here is an example:Procedure: thromboembolectomy of the RT popliteal extending into the tibial peroneal trunk and into the peroneal artery; angioplasty of RT popliteal artery extending into the tibial peroneal trunk and also peroneal artery; angioplasty of RT popliteal artery; angiplasty of RT SFA. From the Description: A mini Pathway device was introduced over the gguidewire and multiple passes were made throught the complete occlusion of the distal popliteal artery extending into the tibial peroneal trunk and then into the peroneal artery. Post thromboembolectomy revealed residual stenosis greater that 50%. Thus a 2.5 mm x 150 mm angiplasty balloon was introduced over the guidewire, and angiplasty at the level of the distal right popliteal artery extending into the tibial peroneal trunk and into the peroneal artery was carried out. post angioplasty revealed significantly improved results. Catheter removed. A 5mm x 150 mm angiplasty balloon was then introduced over the guidewire and angioplasty of the right popliteal artery was carried out. Due to heavy calcification, the angioplasty of the distal right superficial femoral artery was carried out. Would you code the procedures: 35495, 35474x 2 or 37186, 35474 x 2? Thank you so much for your help!

When can you code 92980 and 93508, and 93556 together?

We had a case in our cath lab the other day that I had not seen before and I would like your opinion on the codes we used. The patient came in and had a left heart cath with left ventriculogram. Then the physician placed drug eluting stents in the RC and LC. During placement of the RC stent, the vessel was perforated. They placed a JoMed Graftmaster covered stent to tamponade the perforation. We coded the diagnostic cath and G0290-RC and G0291-LC for the stents. We couldn't find any code to use for the covered stent since we had already used G0290 for the RC. Are we correct on this or is there some code we are missing for the use for the covered stent? Thanks for your help.

Dr. Z, Need advice for the following. One-step needle was placed into left pleural effusion with negative pressureapplied via syringe. Once pleural fulid was aspirated, the catheter was removed. The catheter was then connected to a vaccum container and approximately 750 cc of opaque blood fluid was revmoved. Here we only code 32422? Please advice. Thanks

Dr Z can you help with this case?? The Doctors notes a type 3 aortic arch. He punctures the right common femoral artery in a retrograde direction, he goes up and does an arch angiogram. He then selectively catheterizes the left sublclavian artery. Additional images of the left subclavian artery are obtained. He then selectively caths the left subclavian artery distally and was able to advance a sheath over a stiff wire into the left subclavian artery. The shuttle sheath was advanced distal to the left vertebral artery and a atrium stent was deployed in the distal subclavian lesion. This was post dialated with a balloon to a more acceptable caliber across the lesion. He then places a genesis stent within the sheath and pulls the sheath back to the origin of the left subclavian artery where another stent was deployed across the origin of the artery. He then removes the catheters and wires from the left subclavian position and pulled down to the abdominal aorta. Additional images of the right iliac system where obtained and this demonstrated a very significant external iliac artery lesion of approx. 70% and a common iliac artery multifocal calcified lesion. He then does an angioplasy of the external and common iliac arteries with significant recoil. A Smart stent was deployed across the lesion and this stent was postdilated with a balloon. He then goes on to deploy a closure device. Can you help me code this?? Thanks

Can lysis of a valve be reported in addition to the code for creation of an AV fistula? Our surgeons are passing a Mill's valvulome and doing lyse of the valve in the vein to control the flow of blood thru the fistula.

Question: Our physician completed a femoral angiography with an attempted PTA of the SFA. The physician made several attempts to pass several different wires. The physician also tried to pass a frontrunner catheter (a catheter used for total occlusions) but was not able to pass the lesion. No balloon was used. The patient was on the table for about an hour. Can we bill 35474 with modifier 74? Michelle Moreno,RHIT,RCC Scottsdale Healthcare

A patient presents following EVAR for a AAA with a type II endoleak. There is one aneurysm sac but two embolizations were performed. One was from access via the inferior mesenteric artery and the other was from access from the fourth lumbar artery. My question is would you consider this 2 operative fields for the embolization (charge 37204 x 2 and 75894-26 x 2)? Please let me know if you need additional information on this one. Thank you so much for your expertise. Jane Schappell, CPC, CCC (jschappell@ppamail.com)

Dr. Z,  93621 is the bane of my existence! Below I have two separate excerpts which I would appreciate if you could tell me equal 93621. I can't recall any situation when I have specifically seen "LEFT atrial pacing/recording". (Well, maybe one.) Additionally, is there a specific phrase or wording I could suggest to the physician that would make it easier for everyone? Or, wording that I can specifically look for? Is coronary sinus cannulation sufficient? Because he almost always says that. He is very good about documenting comprehensive EP study. 1) Quadripolar catheter placed in high right atrium. Pacing septal and lateral to the isthmus. Rapid pacing in the atrium showed Wenckebach cycle.  Coronary sinus was also cannulated and mapped. 2) Quadripolar mapping and cryoablation catheter was placed in the right atrium and the right ventricle, and the coronary sinus.  Comprehensive EP study performed.  Patient had pacing, both septal and lateral.  Rapid atrial pacing.  Pacing in the RV. I have referred to your Q&A's from 7/30/10 and 12/28/09 as well as scrutinizing the CPT description for 93621, but I still wrestle with this. YOUR HELP IS GREATLY APPRECIATED.

Hi Dr. Z: Question from our Cardiology dept: 2 different scenerios: Pediatric patient is s/p repair of congenital defect (ASD) and having transthoracic echocardiogram. And adult pt who is s/p VSD repair as a child now having a transthoracic echo. in each of these cases--are the congential echo CPT codes used? Thank you, April Childers, RHIT, CCS West Virginia University Hospitals

DR. Z, We have a case where they ablated the VT and then proceeded to ablate the AVT (atrial Flutter) can we charge 93652 and 93651? Per NCCI edit they are mutually exclusive unless performed different session, site or encounter, can we use '59' since both performed for differnt reasons and sites? Please explain. Thanks

High grade stenosis at cephalic/subclavian junction of AV fistula; atherectomy of stenosis using Diamondback device.Fluoroscopy used, cannulation of AV fistula on arterial site, fistulogram , patent arterial side anastomosis. On the venous side of the fistula, multiple areas of stenoses seen, especially 95% at cephalic/subclavian junction. Atherectomy performed using Diamondback device, total spin time was 1 minutes. Stenosis improved to 60%;decision to perform balloon angioplasty at the same site. Subsequent fistulogram performed revealing complete restoration of the caliber of the vessel. Please verify 36147, 36148, 35494, 35476.

Greetings, A pt had a aneurysmal vein segement of a AV fistula. the aneurysmal portion was bypassed with a graft. I coded this as a 36832. One month later the aneurysmal section is sill bothering the patient. The pt is taken to surgery and the aneurysmal section that was bypassed on the previous surgery is excised. Is this coded as 36832 or 35011? Thanks, Lesley

Greetings, How would you code a open endarterectomy in the internal carotid and proximally into the common carotid, a patch graft was then placed. The patch graft was punctured a diagnostic angiogram was performed, then a genesis stent was placed in the common carotid over the storq wire. Would you use a open stent code or 0075T. and is the endarterectomy bundled. Very Confused. Thanks LW

What code(s) should I charge for the following procedure... ..on physical examination, this was a distended varix filled with coagulum. A total of five venipunctures were performed with an 18- gauge needle and coagulum was expressed. A total of 6cc of coagulum was removed.... Is it an unlisted vascular code or CPT code 36410? thank you

Pt has PSVT and is having a comprehensive EPS and procainamide challenge test done. Which code would be used for the procainamide challenge test during the EPS? Procedure dictation: Via seledinger technique, two wires were placed in the right femoral vein, over which sheaths were used to allow intravascular access. Wires wre placed into the His-Purkinje system and into the right ventricular apex where baseline intervals were obtained. Catheters were later moved into the high right atrium where further electrical stimulation was perfomed. Baseline intervals showed a normal sinus rhythm with a cycle length of 1100 milliseconds. Patient's A-H was 81 with an H-V of 52. Pt was in normal sinus rhythm. Pt's baseline EKG did show RSR prime with mild coving of the ST segment in V1 and V2with ST segment elevation. Procainamide was initiated and a total dose of 750 mg was given. This was given over a 20 minute period with EKG's being followed on every 3-4 minute basis. A final EKG was done following a total dose of procainamide. These were all unchanged from patient's baseline. A ventricular stimulation study was then performed with evidence of ventricular and atrial retrograde conduction and a V-A block cycle length of 540 milliseconds..... Would code 93623 be appropriate for the procainamide challenge test or would it be considered part of the comprehensive EPS and not charged separately?? Your assistance is greatly appreciated Thank you.

is there anything billable for the following service: injects TPA into renal artery for thrombolysis trying to perfuse the newly transplanted kidney. thanks!

When a needle biopsy is ordered of an organ because of an abnormal finding on some previous radiology work, an IR doc uses ultrasonic guidance or CT guidance to try and locate the area of suspicion but these images either show no abnormality or abnormality has reduced in size and therefore a biopsy isn't performed, what do you charge for the radiologic imaging performed? do you code the guidance code with a -52 or if there is a limited modality code such as US abdomen limited or the limited CT code 76380?

Greetings, Now that the rule has changed: Would you now use code 35485 when a angioplasty is performed on the arterial side and venous side of a AV graft (arm) when performed through the open incision instead of 35460? Thanks, Lesley

Hi Dr. Z, I've gotten better at coding the peripherals since you were here in January. This is the first AV fistula procedure that's been done in our cath lab and with the G codes being deleted, I'm hoping you can help me. Here's what the doctor documented: The patient is a 34 year old male with the following indications: abnormal fistula duplex, failure to mature AV fistula . The patient has the following Comorbidities/Risk Factors: Hypertension, On Dialysis, Renal Failure Prior to PCI. DIAGNOSTIC PERIPHERAL VASCULAR PROCEDURE Under ultrasound and fluoroscopic guidance, the left AV fistula was locally anesthetized and accessed with a micro puncture needle using the standard percutaneous technique. After injection and visualization of the brachial AV fistula anastomosis, the microsheath was exchanged over a wire a short 6F Brite-tip was placed in the AV fistula. With occlusive pressure of the distal fistula, angiography was performed in mulitple views. PERIPHERAL ANGIOGRAPHIC FINDINGS Subclavian: There was severe stenoses at proximal anastomosis and inflow segment of fistula. There was normal flow through the mid and distal portions of the AV fistula. The brachial artery was normal in size and did not have any significant stenosis. The primary indication for PVI was abnormal duplex of stenosis fistula. Additional indications include: abnormal fistula duplex, failure to mature AV fistula. INTERVENTIONAL PERIPHERAL VASCULAR PROCEDURE PVI of the left AV fistula artery was indicated for failure to mature graft due to proximal stenosis. A 6F sheath was chosen for the intervention. This sheath gave good support in the left AV fistula. A heparin bolus was given. The lesion in the left AV fistula stenosis was crossed successfully with an 0.035 inch stiff angled Glide wire and a 4F multipurpose catheter. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon at the anastomsis of left AV fistula and brachial artery two times. The maximal inflation pressure was 3 and 6 atm. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon in the residual vein in the proximal left AV fistula artery three times. The maximal inflation pressure was 3,4 and 8 atm each time. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon at the anastomsis of left AV fistula and brachial artery. The maximal inflation pressure was 8 atm. We then inflated a 6.0mm diameter of 40mm length Dorado balloon in the proximal left AV fistula three times. The maximal inflation pressure was 6, 10 and 9 atm each time. Repeat angiography revealed improved flow in the fistula with mild residual stenosis and no evidence of compromise of the left brachial artery. I appreciate any guidance you can give me. Kathy

Can you please calrify the difference between dialysis fistulas and dialysis grafts. Reviewing your coding information, it seems as though you are only discussing coding rules for dialysis grafts. How do I code for an angioplasty at the anatomosis of a native fistula. Would it be correct to code 35476 since the artery and vein are directly anastomsed to form the fistula?

How do you code a thromboendarterectomy and patch angioplasty to a bypass graft (femoropopliteal vein bypass)? Thanks for your help.

Dr. Z, My physician performed a Aortic Arch aortography with findings noted. He then placed the cath into the rt common carotid and performed intacranial and extracranial views with findings noted. A 5mm angiogaurd 7x40 stent was deployed in the distal cervical internal common carotid srtery. What codes would I use for the stent placement in this situation? Respectfully, Lesley

I know this is simple, but i've gotten varying answers on this one...75984/47525...also add the 74305/47505?? thanks 1) CHOLANGIOGRAM THROUGH EXISTING TUBE 2) BILIARY TUBE CHANGE 3) SEDATION History: 60-year-old woman with left biliary drainage tube. She has had a Whipple procedure and had an anastomotic stricture at the H-J as well as a right-sided abdominal fistula. The fistula has since sealed. She is due for routine tube change. Indications: For biliary tube change. Medications: 2 mg of Versed and 100 mcg of Fentanyl were given IV for complex conscious sedation. Unasyn 3 grams was given IV. Contrast: 10 cc of Omnipaque 350 Complications: None Technique: After informed consent was obtained and confirmation of patient identification and the planned procedure was carried out, the patient's upper abdomen including the single left biliary tube was prepped and draped in the usual fashion. Contrast was instilled via the tube and cholangiography thereby performed. Local anesthesia was instilled around the drain exit site. A Glidewire was passed through the tube. It was advanced into the small bowel. The tube was removed over the wire. A new 18 French Heyer-Schulte catheter was passed over the wire and positioned appropriately just inside the entered left duct. The wire was removed. Contrast was instilled to confirm positioning. The catheter was then secured with 2-0 Nylon sutures. The catheter was capped. A small amount of granulation tissue was treated with silver nitrate. Sterile dressings were applied. Findings: The cholangiogram demonstrates nondilated biliary ducts. The tube was appropriately within the ductal system. Contrast flows freely to the small bowel. Postop changes are again noted. There is no extravasation. An uneventful tube change was carried out. Impression: Successful left biliary tube change. Recommendations: The patient will return to CVIR in eight weeks for her next routine tube change