Ask Dr. Z

Getting mixed answers on this one too! PROCEDURE(S): Percutaneous Nephroureteral Stent Placement (Internal/External) Foreign Body Retrieval - Non Vascular HISTORY: Nephrolithiasis INDICATION: Urinary Obstruction MEDICATIONS: Fentanyl 200mcg; Midazolam 6mg CONTRAST: Omnipaque 350, 30 ml COMPLICATIONS: None. TECHNIQUE: Following informed consent and verification of the correct patient identity and planned procedure, the patient was placed in the prone position and the right flank was prepped and draped in the usual sterile fashion. Local anesthesia with two lidocaine 2%. Puncture of the right renal pelvis was performed using Chiba 22 gauge needle. Contrast and air was injected and spot film imaging was performed as a percutaneous antegrade pyelogram. A posterior upper pole calyx was then punctured under fluoroscopic guidance using a 21 gauge needle. A Jeffrey sheath dilator set was placed. Catheter access to the bladder was achieved using a 5-French Bernstein catheter and angled Terumo guide wire. An Amplatz super stiff wire was placed. Over the wire a 9-French vascular sheath was placed. Through this a 25-mm Amplatz gooseneck snare was advanced and used to engage the occluded internal ureteral stent. The sheath and ureteral stent were then removed intact while maintaining wire access. Over the wire, a 10.2 French x 22-cm percutaneous internal/external nephroureteral stent was placed. The distal loop was formed in the bladder and proximal pigtail was formed and locked in the renal pelvis. Post placement nephrostogram confirmed appropriate position. The catheter was sutured to the skin and placed to external drainage. FINDINGS: There is moderate right hydronephrosis, especially a lower pole calyx. There is a large stone impacted in the renal pelvis, which partial balloon partially obstructs the lower pole calyx. The internal ureteral stent was occluded. This was successfully removed. INTERPRETATION:Successful percutaneous drainage of the right kidney with placement of a percutaneous internal/external nephroureteral stent as described above.

CT-guided percutaneous drainage of a seroma anterior abdominal wall CT-guided sclerotherapy of a cyst "CT used to visualize anterior abdominal wall subcutaneous fluid collection. Using CT guidance an appropriate skin entrance site was obtained and marked and prepped and dressed in normal sterile fashion." Local anesthesia then "....19-gauge needle cyst was accessed. Approx 30 ml of serous straw-colored fluid was obtained. With needle still in place within the cyst, a mixture of doxycycline, marcaine and solu-medrol was injected into the cyst cavity for sclerotherapy." Radiologists want to code 49021 & 75989. No mention of catheters. My thoughts are 77012 and 10160. Maybe 49999 for the sclerotherapy of the cyst. My background is cardiovascular and not non-vascular IR, so I am not very familiar with this aspect. I might also mention that samples of the fluid were sent to the lab for testing. Thank you very much!!

Hi Dr. Z this is a question for the code 76937. Our physicians' practice and radiology practice are being denied payment by Medicare when billing 76937 if coded on any procedure other than central line placements/PICC placements. I did see in your database from 12-20-2006 that you answered a question on this that it is appropriate for any vascular access including dx angio. Has this changed since then? Do you know of any policy that Medicare has that would state why these claims are being denied. I can't find one. Thanks for your help, Lisa C.

How do you code the following scenerio. The doctor tried to inject the right and left common iliac arteries for a bilateral runoff but he couldn't get access into the vessels. So he did a right brachial access and injected both right and left internal mammary arteries to visulize both right and left legs. I am not sure if what he wants to charge is correct. He wants to charge for injecting both RIMA (75756-RT) and LIMA (75756-LT) and bilat runoff (75716). I'm not sure if that is the correct thing to do. This sort of thing doesn't happen very often so I need some advice on this case. Thanks

Pt. has a unruptured ophthalmic aneurysm in which we did a crani/aneurysm clipping, they also did a balloon temporary occlusion for assisting with the clipping, can we bill 61623 with the crani ?

Dr. Z..Can you please help with this endovascular repair? Right and left side common femorals were dissected out and arteries were punctured and guidewires were advanced into the aorta (34812-50 and 36200-50). At this point a retrograde arteriogram was done demonstrating that the iliac arteyr was patent and this probably represented stenosis (yes, he says patent) Patient was systemically heparinized. I made a decision to perform angioplasty of the right and left common iliac arteries to try to assist us in being able to get a device up. Next from the right side an 8 mm stent and the left a 7 mmstent was then placed. and insufflated to approx 8 atmospheres and deflated. Following this a sheath was then placed up into the external iliac artery as far as it could be passed. On the right side, I placed Amplatz wire and used the renal dilators. At this point, I obtained the main body (34802) and was able to advance up into the aorta. Next the pigtail cath was placed on the left and using a series of injections, the main body was deployed to the point that the gate was open. Next on the left side, using a banshee cath, the gate was cannulated and advanced up into the device. a balloon was then placedm, pulled down and appeared to be in good position. arteriogram again (75952-26) a 14 x 11.5 was advanced up into the gate. However, during the deployment it did come down some. therefore to bridge this we placed a 14 x 5.5 which actually fit very nicely. (extension? 34825? 75953-26) deployment was then completed on the right. I shot a retrograde arteriogram on the right and decided to place a 14 x 8.5 (34826? 75953-2659?) The graft was then angioplastied on both sides. Completion angio showed no endoleak however the left internal iliac was no longer visible. We then placed a 8 mm balloon into the left limb of the graft and pushed it up proximally and angio demonstrated the left internal iliac is now patent. Do I have all of the codes that can be charged? is the bridge an extension graft? Thank you for your help!

Our patient has a left chest fistula with a left pseudoaneurysm. The interventional radiologist performs a fistulogram and subsequent angioplasty of venous outflow stenoses. There is a sidehole within the graft which fills a very large aneurysm. The hole is repaired using a FLAIR stent graft and tacked into place using a DORADO balloon. Post stent graft deployment documents complete repair of the pseudoaneurysm. Additionally, a Yueh catheter was inserted into the pseudoaneurysm and complete evacuation of the extra blood in the pseudoaneurysm was performed. My question is how to code the catheter evacuation of extra blood in the pseudoaneurysm space? Or would this evacuation be inclusive in the stent graft placement for treatment of the pseudoaneurysm? Thanks for your advice Dr. Z.!

Hello Dr. Z, Our radiologist just recently started doing discectomies. He brings all patient's back in 2 weeks or so and has a follow up MRI done. We have been coding the follow up MRI as 76498, but medicare is saying we cannot bill this on the part B side. Do you have any input on this? THANKS

A patient comes in for replacement of dual rate responsive pacemaker change. A ventricular lead is inserted transvenous and temp. paced durinf the replacement of the dual chamber pacemaker. Is the appropraite coding on this 33213, 33233 & 33210. There was a similar question but over thre years old and I wanted to make sure this was still acurrate information.

Dr. Z; I have reviewed your book for the Av fistulogram and interventions. I would like to know if my coding is correct given this episode of care on this pt. My codes are 36120, 75790, 35476, 36147, 36148, 75978, 35476-59, 75978-59. I have the use of three catheters and three puncture sites. Under ultrasound guidance access was gained into the left brachial artery, guidewire was introduced and the needle removed. Through this 5 french dilator, a left upper ext atrteriogram, fistulogram and venogram preformed. Images reveal patency of left axillary & brachial arteries with patency of proximal radial, ulnar and interosseous arteries. An Av fistula is seen arising from the distal portion of the brachial artery at approx. the level of the elbow joint to a drainign cephalic vein. The remainder of the cephalic vein is seen to be patent. The left axillary and proximal left subclavin veins are seen to be patent however, thereis a short segmental occlusion of the mid subclavin vein at the entry of a pacemaker wire. Thid distal portion of the subclavian is patent and there is patency of the innominate vein and the superior vena cava. Under ultrasound guidance access was gained into the draining cephalic vein with the needle directed towards the arterial anastomosis. A stiff guidwire introduced and a 6 french sheath was advanced. The stenotic segment of the draining cephalic vein was traversed. Mutiple angioplasties of these segments of he proximal draining cephalic vein preformed. Repeat fistulogram reveals significant improvement in the degree of stenosis with some minimal residula stenosis. Acess was also gained into the drainign cephalic vein with needle towards the central venous circulation. A sheatlh dilator system was advanced, serial dilatiations were preformed at the entry site. Utilizing a guidwire and cath combination, the occluded segment of the subclavin vein was successfully traversed, mutliple angioplasties of the segment were performed utilizing balloon angioplasty catheters. Repeat venogram completely callous aeration of the subclavian vein with no residual areas of stenosis. All 3 catheters were removed>>>>>>>>>>

Hi Dr. Z, My question is regarding AVF aneurysm repair. Since 36834 has been deleted, is 36832 the correct code to use. However, if the vessel treated is not part of the AVF, then do we code those as aneurysm repair codes CPT 35001-35152? Please provide guidance on how to code AVF aneurym repairs correctly. Thank you.

In the 2010 Vascular and endovascular book page 313, you recommend coding a venoplasty inside the AV graft with an open thrombectomy but not with an open revision and thrombectomy. Can you explain the rationale for allowing it with an open thrombectomy but not with an open revision/thrombectomy. Thanks

Greetings. I have a pt with a bovine arch and there is also a stent placemnt. I assume the bovine arch make the LT CCA and the RT CCA ispilateral. Any imaging for these areas would be bundled with the stent placement into the RT CCA stent placement. Is this correct? Thanks, LW

Dr. Z. Which is the appropriate code to use for the injection of Yttrium-90, 77778 or 79445 during a Theraspheres embolization? The doc from Nuc Med comes up and injects the Theraspheres. The confusion stems from 77778 being a Rad Oncology code. Thanks, Judy A.

Dr. Z, I need some advice. I had always had the idea that when there is no site specific code for an abscess drainage, we should report 10160. Recently I encountered another source that advises the use of code 20000 for drainage of an abscess or fluid collection when there is no site specific code. What are your thoughts on this? Thanks, Chris McCoy

Dr. Z, Patient has perinephric hematoma. Not sure if we can code this as 10160 or 50392? Thanks Using sonographic guidance a 18-gauge sheathed needle was advanced into the right perinephric fluid collection. Aspiration revealed old blood. Samples were obtained for gram stain and cultures. Subsequently a guidewire was placed through the needle and a 8 French all-purpose drainage catheter catheter was advanced over the wire into the fluid collection under fluoroscopy guidance. Contrast was injected which confirmed satisfactory position of the catheter in the hematoma. Catheter was sutured to the skin.

Dr. Z, I love your website. I have a cardiology coding background and am gettng more involved with IR coding, so I search the question and answer database all the time. The following ? came up in a recent case of ours. If a patient comes with dialysis needles in the AV fistula and they remove the needles, insert sheaths and inject, would that be coded with 75791 rather than the 36147 since they did not puncture the graft for a direct access? As what point would that turn to a 36147? Thanks so much, Jane Schappell

Dr. Z, Our doctors performed a Left renal mass cryoablation (50593), "guided by a combination of ultrasound and CT scan guidance" (76940/76942). Can we charge for both modalities?

Would you code 2 separate nerve blocks for the Greater (64405) and Lesser (64450) Occipital Nerves done from the same puncture, or just the Greater Occipital (64405)? Report does state separate areas done with needle movement. thanks, Paige

Hi Dr Z, my physician performed an open repair of a bilobar 4.3-4.5 cm inflammatory AAA. This was a very complex case and required division of the left renal vein, control of the aorta above the renal arteries and control of both renal arteries. My question is regarding interpretation of the CPT definitions between 35081 and 35091. Is 35091 only to be used when there is aneurysmal and/or occlusive disease of the involved visceral vessels? Or is the sheer involvement of them in the repair sufficient for that code? I appreciate your insight on this matter!

Hello Dr. Z, I have yet another question for you. Our interventional radiologist did a vertebroplasty and a bone biopsy of the L1 same insertion site. Can code 22521, 20225-59 and 72291?

Dr.Z, In online Q&A 2145 posted March 25, 2010, in your answer you refer to the fact that that there are new edits preventing billing of angioplasty and atherectomy in the same vessel, effective for MD's 1/1/2010 and hospitals 4/1/2010. I had heard that somewhere else, probably a webinar and had been advising my clients of the upcoming CCI edits, however when I look at the CCI tables on CMS website there are no edits whatsoever for any atherectomy or angioplasty codes. I have read the reference in the NCCI Manual, 15.3, but your reference to them being effective Jan. 2010 for physicians and April 2010 for hospitals leads me to believe that there would have been true CCI edits as hospitals are one quarter behind physicians on CCI edit effective dates. Any additional information would be greatly appreciated. Thank you

Hello Dr. Dunn: What code(s) would be appropriate for a right external iliac artery to profunda and SFA bypass with a bifuracted dacron graft? I have 35665, however that just doesn't seem to be enough. Thank you, Jill

Hi-- I need help with a surgery my provider performed on an extracranial right internal carotid artery pseudoaneurysm. "Under roadmap conditions an Xpert device, 6 mm in diameter x 20 mm length was placed with the proximal and distal edges across the neck of the aneurysm and deployed with good coverage proximally but distally at a turn may not completely cover the distal aspect of the aneurywm. A second device 6 mm in diameter x 30 mm length was then deployed with the distal portion in the internal carotid artery distal proximal to the aneurysm with good coverage acrosss the pseudoaneurysm. Control angiograms demonstrated dramatically decreased filling in the pseudoaneurysm at this point, with patency of parent vessels." Explanation: The intent is to occlude the pseudoaneurysm, when we check the CTA in 3 months it will to see if its occluded. Whether we use a stent, coil, hammer, or nail. We can change the procedure, & add an unnecessary coil & then there is no arguement - but it then keeps us from getting a good picture on the CTA in follow-up because of artifact from the coil. Can we code an emobolization code (61624) since that is the intent or do we use one of the stent codes? 37799 since it is Medicare? Thanks for your help!

Good afternoon, Dr. Z and Dr. Dunn. I have a lot of questions about the following op report. I'm debating whether to represent the angioplasty with 35456,LT or 35459,LT, along with 75962,26,LT. I'm leaning towards 35456,LT, because the doctor says it was done in the mid thigh, but 35456,LT is considered bundled with 35566,LT, according to NCCI edits, while 35459,LT isn't. It also seems as if 36140,LT is considered bundled with 35566,LT, but would that be added with a 59 modifier if an angioplasty of the graft is done? On the other hand, does the statement, "Primary vascular procedure listings include establishing, both inflow and outflow, by whatever procedures necessary.", pertain to this situation? How about the repairs due to extravasation, during the angioplasty of the graft? Could 35226,LT be used as an additional code? If so, how many units? I decided against using 35682,LT, because the doctor basically did a resection and anastomosis of the same vein, as opposed to merging two veins from different locations. Was that the correct decision? Is there another code you'd use to describe this procedure? If not, does this warrant billing with modifier 22? The doctor also mentions several angiograms. How many units of 75710,26,LT can I use? On top of that, the doctor mentions that a Doppler was brought onto the field. Does this statement warrant the use of 93922,26,LT? I know the narrative says "noninvasive", so is there another code you'd use, like 37250,LT and/or 75945,26,LT, or is it just included in 35566,LT? I don't see any NCCI edits saying either of those codes are included in the bypass. As you can see, I'm extremely confused. Your assistance would be greatly appreciated. Your answers to this might help point me in the right direction with a lot of future op reports. Thanks, in advance. Here's the op report: DATE OF OPERATION: 03/29/2010 ANESTHESIA: General. PREOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. POSTOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. PROCEDURES: 1. Left lower extremity angiograms. 2. Left superficial femoral artery to anterior tibial artery bypass with composite great saphenous vein graft. 3. Angioplasty of vein graft. 4. Completion angiograms. INDICATION: This is an 88-year-old female who presented with rest pain and ischemia to the left foot with some mild motor dysfunction of her toes. The patient did undergo a cardiac evaluation. She was brought to the operating room for elective femoro-anterior tibial bypass after having undergone aortoiliofemoral and left lower extremity angiograms earlier in the week. The patient had this performed with composite nonreversed great saphenous vein graft from the left leg. Completion angiogram demonstrated areas of stenosis in the vein graft and angioplasty was performed. This was complicated by a linear tear with some extravasation in the mid thigh, which was directly repaired with interrupted stitches of 6-0 Prolene. There also did appear that the vein graft requiring a repair was an interrupted stitch of 6-0 Prolene. Completion angiograms demonstrated very good result with good caliber of the vein graft and run-off onto the dorsalis pedis artery in the foot. PROCEDURE: The patient was identified and brought to the operating room. She was placed in the supine position on the operating room table. After administration of general anesthesia by the anesthesia department, the patientâ?Ts lower abdomen, groin, entire left lower extremity, and right thigh were prepped and draped in the usual surgical sterile fashion. Attention was turned to the left lower extremity and in the distal third of the leg, a lateral skin incision was made approximately 8 cm in length. This was carried down through the skin, subcutaneous tissue, and fascia. The anterior tibialis muscle was retracted medially and the extensor digitorum longus retracted laterally. Dissection was carried down and the neurovascular bundle was identified as well as the anterior tibial nerve. The anterior tibial artery was dissected out. The Doppler was brought onto the field. The proximal portion was without evidence of flow and dissection was carried more distally to where collateral flow was heard in the artery. For this reason the incision was extended more distally. The artery was harder and calcified more proximally where it was occluded. The artery was softer more distally. A portion of the artery was dissected out where the vessel was soft and suitable caliber being 2 to 2.5 mm in diameter. Attention was turned to the left groin. Incision was carried down through the skin with the scalpel. Dissection was then carried down through the subcutaneous tissue and fascia and femoral sheath. The common femoral artery, profunda femoris, and superficial femoral arteries were identified and dissected out, and vessel loops placed. The great saphenous vein was identified. A bridge incision was made in the thigh and the dissection carried down through the subcutaneous tissue and the saphenous vein exposed. Continuous incision was then made along the medial leg and the saphenous vein was exposed along its length. Below the knee at about the proximal to mid calf, the saphenous vein became of smaller caliber dividing into two tributaries. The larger branch was followed. The vein was smaller and more disadvantaged at this site and in the distal leg, the vein then became larger again and was with good caliber to the medial malleolus. This was dissected out. As there was the disadvantage portion of vein measuring less than 2.5 mm, the plan was to do a venovenostomy to use the portion of the vein greater than 2.5 mm. For this reason, the dissection was carried farther down the superficial femoral artery proximally where it was still with good caliber with minimal disease based on the angiogram through the proximal thigh incision. Dissection was carried down through the subcutaneous tissue and fascia, and several centimeters, approximately 8 cm distalfrom the bifurcation, the superficial femoral artery was dissected out and vessel loops placed. Following this, a subcutaneous tunnel was made traversing to the lateral thigh with a gentle curve and then along the lateral aspect of the leg in a subcutaneous position and down to the distal wound. The saphenous vein was controlled at the saphenofemoral junction. The saphenous vein had been dissected out along its length, ligating and dividing the tributaries between 3-0 and 4-0 silk ties and clips on the tissue side. The dissection was routine, but on distending the vein through a tributary, which controlled the vein proximally, the vein did require repair of multiple small areas with 7-0 Prolene. The vein was clamped at the saphenofemoral junction taking a cuff of the femoral vein excising the saphenous vein and oversewing the femoral vein with 6-0 Prolene. Attention was then turned to performing the proximal anastomosis. The first vein valves were cut under direct vision. with LeMaitre valvulotome with two passes. The blood flow was pulsatile through the vein. The mid-distal third was smaller, disadvantaged as noted. Proximal anastomosis was performed by controlling the superficial femoral artery. About 5000 units of intravenous heparin was given under my direction. An additional dose was given as needed. Vertical arteriotomy was made in the superficial femoral artery and extended with the Potts scissors. The vein was used in nonreversed fashion, spatulated, and anastomosed, end-to-side using a running stitch of 6-0 Prolene. Prior to completing the anastomosis, the femoral artery was back bled and antegrade flushed. There was a good inflow. The anastomosis was then completed. It was then that the valves were cut with a valvulotome. The first two valves had been cut under direct vision. The remainder of the valves was then cut using LeMaitre valvulotome with two passes. Blood flow was pulsatile through the vein, although the smaller disadvantage segment of the vein was as noted in the mi-distal portion of the vein. The vein was then passed through the subcutaneous tunnel and brought out to the anterior tibial wound. The anterior artery was then controlled where the artery appeared of good caliber and was soft. This was opened with the #11-blade and extended with the Potts scissors. There was reasonable backbleeding in the artery as well as some antegrade flow via collaterals. Angiogram was performed, which demonstrated that this was a good site for the anastomosis with flow into the dorsalis pedis artery with the artery being of good caliber without significant stenosis. The vein length was then measured. The vein graft was then cut to remove out portion of the disadvantaged segment of vein. Venovenostomy was then performed over #8 pediatric feeding tube. When this was complete, the end of the vein was then spatulated and anastomosed end-to-side to the anterior tibial artery using a running stitch of 7-0 Prolene. Prior to completing the anastomosis of the vein graft, the artery was back bled and flushed. The artery was flushed with heparinized saline solution. The vein graft was flushed, and the air was released. The anastomosis was then completed. Flow was allowed to propagate down the foot. There was a palpable pulse in the dorsalis pedis artery in the foot and an excellent Doppler signal distal to anastomosis. The vein graft was pulsatile but still did not appear to distend fully, being on the smaller side despite excising the smaller portion. Completion angiogram was performed through a side branch just distal to the proximal anastomosis. This did demonstrate a couple areas of severe narrowing, the first being in the anterior thigh. The area was marked with a glow tape. A #5 French sheath was placed through the side branch, and a glidewire followed by angioplasty balloon was passed through the mid thigh and angioplasty was performed. On the post-completion angiogram, unfortunately there was some evidence of extravasation and cutdown was done in the mid thigh and a linear tear in the vein was directly repaired. It was also noted along the distal lateral incision and again evidence of a frail vein that the guidewire had transversed thru the vein wall. The wire was pulled back and this was repaired with a 3-0 interrupted stitch of Prolene. The wire was negotiated down the vein, and completion angiograms demonstrated also two other areas of narrowing, and the angioplasty balloon was applied lightly in these areas with excellent result on completion angiogram. Due to the presence of the sheath and the angioplasty balloon, intermittently the vein graft was flushed with heparinized saline solution. Intra-arterial papaverine had also been given due to some spasm of the artery distal to the anastomosis after controlling the vessel. The artery here is soft. Completion angiograms demonstrate excellent result of the vein graft and the distal anastomosis to be patent with the anterior tibial artery patent into the dorsalis pedis artery on the foot. The guidewire, the balloon, and the sheath were then removed from the vein and the branch stump was ligated with 3-0 silk. Flow was allowed to propagate down the vein graft into the foot. The patient did have a strong dorsalis pedis pulse as well as a palpable vein graft pulse along the lateral leg. Hemostasis at the anastomoses was obtained with thrombin and Gelfoam. Hemostasis of the subcutaneous tissue was obtained with diathermy. Attention was turned to closing the wounds when hemostasis was satisfactory. The groin wound was closed in two layers using 2-0 and 3-0 Vicryl. The skin was reapproximated with skin clips. Similarly over the SFA and proximal anastomosis, subcutaneous tissue was closed in two layers. The remainder of the saphenectomy site along the medial leg was reapproximated in one or two layers with Vicryl and the skin was reapproximated with skin clips. The lateral leg wound was closed using subdermal stitches proximally. Due to the thin subcutaneous tissue and some leg swelling, the distal portion of the incision was reapproximated using interrupted stitches of 3-0 nylon. The incisions were cleansed and sterile dressings were applied. The patient tolerated the procedure and was taken to the recovery room in stable condition.

When treating an ostial right renal artery lesion, the intervetionalist did angioplasty, post angiography demonstrated a dissection and recoil at the site of the lesion. A 6 x 18 x9 Express monorail balloon expandable stent was advanced across the lesion. Post deployment demonstrated stent deployment across the lesion, with proximal portion of the stent approximately 1.0 mm into the aorta. Can we report the angioplasty and stent placement when treating an ostial lesion? Another coding resource that we have access to states if treating an ostial renal artery lesion, code only for stent placement. Thank you.

Hi, Very complex case and need help with modifiers...PLEASE HELP!!! Aortography with findings of bilateral renal arteries, infra renal abdominal findings and bilateral common iliac findings. Would you code 75630 or 75625 They then IVUS the left common iliac and proceed with stenting. Next they stent the right common iliac. Then they ivus the aorta and procede with a stent. they then stent both renal arteries. Should I append modifier 59 to the additional stent and S&I codes for the four additional stents placed?

Dr Z, how would you code for a stent used to trap debris that had floated down stream after atherectomy and angioplasty? thank you

Dr. Z, Patient came for Permanent pacemaker insertion on day one and the next day (still in hospital OBservation status) return to the cath lab for repositioning of the atrial lead since this in global period can't charge 33215 separate however can we charge for fluoro time with 76000, please clarify. Thanks

Hello Dr. Z, I have a consistent issue with my docs they continuously code 36147 and 75710 together stating in their OP notes that an additional "runoff" or "reflux" arteriogram was performed. I continuously crossoff the 75710 and only bill the 36147 feeling the "runoff" or "reflux" arteriograms are included in the all neccessary imaging mentioned in he code description of code 36147. In what instance would a 75710 be billed in addition to 36147?

Your coding book and coding site are the best that I have ever found. I was unable to find an answer to this question in your book. Could you help me? Would this be coded as 32551? TECHNIQUE: The patient's existing chest tube was cut, wire was placed, and then a new 12 French APD catheter is then inserted. The chest tube was re-manipulated toward the right upper lateral lung zone. This was hooked back up to suction. IMPRESSION: Successful repositioning and re-exchange for a larger chest tube on the right side.

Can CPT code 93458 be reported for a left heart catheterization performed through the radial artery instead of femoral, brachial or axillary?

Hi Dr Z, During a dialysis catheter exchange, the physician documents a fibrin sheath treated with venous angioplasty. Do you recommend coding 35476/75978 in addition to the catheter exchange code 36581/77001? Are you familiar with the Coding Guide from the American Society of Diagnostic & Interventional Nephrology? This guide suggests this venous angioplasty is warranted and should be separately codeable. Any advice you could provide would be greatly appreciated!

A gray zone in my opinion. They definitely did not see enough to call this a bilateral lower extremity angiogram during a heart cath in my opinion. G0278 changed from iliac angiography to iliofemoral angiography at time of heart cath a year or two ago to prevent coding 75716 for obliques of the pelvis, so the proximal SFA and profunda femoral arteries are now clearly included in G0278 during a heart cath. Personally, if done during a heart cath and the catheter hooks the contralateral common iliac to visualize the iliofemoral on that side as a screening tool, then pull back into the ipsilateral for the same, I still just code G0278 and ignore the catheter placement. I suppose to be exacting per the codes, one should consider 36245-59, 75710-59 and G0278 for the ipsilateral side, however I think that 75710 is a zero edit with G0278 (so can’t be billed anyways) and the intent of the screening code G0278 is just that, screening. IF they look all the way down past the knees on both sides, then I switch to 75716-59. I remain conservative on these. Dr.z

Dr. Z., Patient has a diagnostic visceral angio and embolization of GDA for a pre- theraspheres (or any TACE procedure). Patient returns 2-3 weeks later for the actual TACE or Theraspheres injection and the doctor performs another visceral arteriogram. Can we code for the visceral angio again? Or is it included with the embolization. Or does the MD have to state that it is medically necessary to repeat the visceral angio to be able to code it. thanks, Judy A.

In the book Interventional Radiology Coding Reference on page 76 example 1 "the left and right common carotid were selected", I am sure about 36215, 36215(59). I would coded instead like 36216 (right common carotid) and 36215 (left common carotid).What type of variant is RIGHT BRACHIAL APPROACH?. Please advise. Thanks

I know this has been asked many times but still unclear for treatment of more than 1 aneurysm, if we do a coil embolization on bilateral ophthalmic aneurysm's can we bill 61624x2,75894x2,75898x2 ?

I'm trying to determine if documentation supports reporting 93620 or 93620-52 and +93621. There is no documentation for catheter placement at the high rt atrium but there is documentation for his recording and rt ventricle pacing/recording and catheter placement at these two sites. The cardiologist also documents catheter placement at the coronary sinus but there is no documentation of pacing/recording at this site. When I questioned him about the documentation for pacing/recording at the coronary sinus he responded to me, "the atrial stimulation site was the coronary sinus. I did not have a separate catheter to stimulate the atrium. All of the testing requiring atrial stimulation was done through the coronary sinus. This is always the case for my SVT ablation procedures. I will state it explicitly going forward". My question to you is can the rt atrium be stimulated at the coronary sinus or is he referring to left atrium only?

Hi Dr. Z, We had emailed a question thru the website within the last six months and have not heard/seen anything posted on the webpage. Our question was when a radiologist injects contast into a replaced prosthetic joint to look for prosthetic loosening/complications, is this considered an arthrogram? There can be a minimum of 2 views or up to multiple views obtained of the joint. This usually follows an aspiration to look for infection. How would this be coded? If this is considered an arthrogram, how should be code when a MLP injects the joint and the radiologist interprets the images? Thanks for the assistance!!

In the process of obtaining IRB approval to perform transcatheter pulmonary valve placement in our cath lab. Not sure as to the correct coding as there is no specific CPT code for this procedure. Device used is a stent/valve combination. At a recent training session, physicians were informed that CPT committees are not reviewing this procedure until the aortic valve stents are available because they feel there are not enough of these cases to warrant review, and it was recommended to physicians to report 92990/37205 to ensure reimbursement. Other centers already performing procedure stated that they were not getting reimbursement using 93799, and now also reporting the 92990/37205/75960 combination. Is it appropriate to report this procedure as a stent placement?

Is it appropriate to report code 93623 when adenosine is administered to stimulate the heart as part of an EPS study? Also, can congenital heart cath CPT codes be reported on a patient who is status post heart transplant or should we use the non-congenital codes? Can we continue to report the congenital ICD-9 codes when the patient is status post heart transplant. Thank you.

Hi Dr. Z: One of my surgeons is placing a Spider filter through a catheter and then passes an atherectomy device and performs an atherectomy and then removes the Spider filter through another catheter. Can anything be charged for the filter placement and then removing it? Thank you! Jill

Dr. Z, Question regarding AV graft access. Our physicians are stating when they say criss cross catheters used or two access done and intervenion performed the second access automaticaly is for the intervention even though it is not documented that second access used for intervention but only two access done. Per coding percepective is this safe to assume that way and code 36148? Thank you

There is still much confusion in our office on when to use 36147 or 75791. Would 75791 be used, when the doctor reports and open thrombectomy (36831), then a French Sheath is placed into venous end of graft and fistulogram was done. Thanks for your help.

Could you please tell me how I would code the following. Our radiology department thinks the guidance code is 77003, but I believe that it is 77002, but I am not sure how to complete the ablation part: Needles and electrodes were placed between the 1st and 2nd, 2nd and 3rd, and 3rd and 4th metatarsophalangeal joints. Two seperate ablations were obtained as described above and slightly more proximal with the second radiofrequency ablation obtained at both positions for a total of 4 needle placements and four radiofrequency abllations. This was done on the left and right foot. Thanks for your help.

5 mo. year old female with a history of ALCAPA and recent Heart transplant. Presents for initial RHC and Bx per transplant protocol (93530, 93505). In addition, she underwent an innominate vein contrast injection. An end-hole catheter was advanced up the IVC into the SVC and subsequently into the innominate vein (36011) near the junction of the left subclavian and left internal jugular vein. With injection we see an nonobstructed innominate vein. There does appear to be mild narrowing of the superior portion of the SVC just below the entry of the innominate vein which is best appreciated on the lateral projection. Total fluoro time was 7.5 minutes, total contrast used was 2 ml. The findings are otherwise unremarkable. What code do I report for the venography?

Dr. Z, How would you suggest coding for the AngelMed device. This is a new research project and the product supplied by the vendor for no charge. The device has an RV lead and a small generator type device inserted subcutaneouosly just like a single chamber pacemaker as it continually monitors the patient for any heart attack and alerts the patient to get help. The cath lab wants to charge this with 33207 not sure on this, please advise. Thanks

Documentation of catheter placement: if the cardiologist states "selective injection was performed in the left subclavian artery using hand injection and digital subtraction". Can I code selective catheter placement of the subclavian? In the "Procedure Log Report", its states "right subclavian artery accessed, Optiray 320 2 ml injected into the rt. subclavian artery. The information on this report is documented by an RN with CCLR certification and the report is signed by the Interventional Cardiologist. (Pediatric Congenital Heart Cath Service) thank you.

DR. Z, The patient came in for AV fistula creation and in the same setting it states 'using ultrasound, the upper extremity was mapped. Based on the findings from the ultrasound decision was made to proceed with a left basilic vein transposition.' Not sure if this is good enough to code 'G0365'along with the creation of AV fistula? Is this ultrasound mapping included in the AV fistula performed in the same setting? Sometimes we see an order stating vein mapping or pre op for AV fistula creation and the procedure is bilateral venogram, please clarify when and what kind of documentation suports 'G0365'? Thanks

I would appreciate some guidance on this scenario. I have searched the database relentlessly and cannot locate a similar case. Right CFA is accessed. catheter is advanced to the origin of the innominate artery. A stent only was initially attempted but due to the angulation and heavy calcification at the origin of the innominate, a pre-dilating balloon was utilized but the stent still could not be deployed. Therefore, angioplasty catheter was re-inserted into the right subclavian artery (36216) and a smaller, low profile stent was finally deployed at the origin of the innominate artery (37205). Subsequently, the angioplasty was performed as an assistive effort to deploy the stent due to angulation and heavy calcification. Then, the ipsilateral right EIA 80-90% lesion at its origin was angioplastied and stented (37206). The documentation for the angioplasties lack the requirement to code as a 'therapeutic' procedure in my opinion. My codes are: 37205, 37206, 36216. I did not code 36160 for the ipsilateral stenting of the EIA because I am thinking that it bundles into the 36216 (subclavian). Is this correct? Or, would it be separately coded since one selective catheter placement is above the diaphragm and the other is below it? Thank you Dr. Z as always!