Ask Dr. Z

I have a question regarding Fractional Flow Reserve performed in multiple vessels. Following angiography, an FFR is performed in the LAD, and then an FFR is performed in the 1st Diagonal Branch of the LAD. Can this be reported with 93571 and 93572? or does this procedure have the same rules as PTCA/Stents and is considered just one vessel for CPT coding purposes?

Hello! I am unsure if I can bill more than 1 set of 37204 & 75894-26 for the embolization part of this procedure. Also, an Amplatzer plug was used in internal iliac. I am OK with the cath placements. Dx: Growing AAA with a type II endoleak from multiple inferior lumbar arteries from different sources. 1. Coil embolization of a lateral lumbar and pelvic artery with the source coming from the internal iliac artery branch with a shared vascular supply from the contralateral internal iliac and coil embolization of 3mm Tornado and 5mm Tornado coils for a total of 5 coils. 2. Selective cath of an ascending lumbar artery and insertion of 0.75cc of NBCA embolization glue. 3. Selection of the origin of the right internal iliac artery and deployment of a 16mm Amplatzer plug to the right common internal iliac origin. Thank you,

My question is in regards to charging for the PICC line insertion on the hospital side when the line is placed by a RN. This is both for inpatient and outpatient. On the inpatient unit the lines are placed bedside. Outpatient lines are placed in the infusion center, emergency room and recovery room. The PICC line insertion charge is a treatment room charge, but is performed bedside on the inpatient unit, recovery room or emergency room. Is it ever appropriate to charge the PICC line insertion in addition to the room charge? What about if the nurse is declotting the PICC line bedside, is this billable or bundled into the room charge? Thank you for your help,

Dear Dr. Z, This is a procedure we've been unable to locate any coding advice on thus far: CLINICAL INFO: ESRD w/left upper arm fistula that is difficult to cannulate PROCEDURE: Skin overlying the Left Upper Arm fistula was prepped/draped...Ultrasound was used to mark the course of the fistula on the skin. Multiple sterile OR markers were used. Then, 22 gauge needle was used to abraid the skin through the ink. This resulted in small tattoo dots along the course of both sides of the fistula. IMPRESSION: Successful marking of he course of a left upper arm fistula. We have considered Unlisted Skin 17999 (APC 12, SI "T") with 76942 (SI "N"), but also wonder about Unlistd Vasc. 37999 and/or Unlisted Ultrasound 76999. Your opinion and advice would be much appreciated! Thank you in advance. It was great meeting you at our facility in November!

Dr. Z, Please give me your insight on this case. I'm just not sure which codes to use - patient with a CSF fluid leak has a lumbar puncture and contrast injected. The patient is tilted head down for 20 minutes then transported to CT for a maxillofacial and cerebral scan. Would the lumbar puncture be coded -- 62311, 77003 or 62284, 77003? We are coding the CTs separately. Thanks for your help.

Dr. Z- What is the correct code for this report? The radiologist indicates 78195 but I am leaning towards 38792 because he doesn't describe any lymph node imaging: Utilizing aseptic technique, a total of 600uC of Tc99 Sulfur Colloid was injected intradermally into the right breast. Scintigraphy confirmed uptake of the radiotracer. The patient was then transferred to the operating room for intraoperative localization. Please correlate wtih the operative report. Thank you.

A physician accesses both common carotid arteries and performed both bilateral cerebral as well as bilateral cervical angiograms. He then went back (same session) and accessed the right internal carotid and performed a second cerebral angiogram. Is the 2nd angiogram (75665) billable with the 75671 (bilateral cerebral angio) w/ modifier 59? The patient has moyamoya so he only accessed the commons before deciding to go into the right internal.

Pt had a PTA with stent insertion of the left internal carotid artery. What would the approptiate CPT and ICD-9 codes for this procedure. I was told that if they are in the internal/external carotid artery this is cerebral artery (intracranial). Please verify. Thanks
 

The H&P says the patient has a Fem-Tib bypass graph. The Preoperative diagnosis on the Op report says Stenosis of the left leg anterior tibial bypass. If this is an open procedure, do I code to the vessel that was bypassed or as a vein angioplasty 35460? The operative report reads as follows:

"A 1cm transverse incision was made over the vein bypass on the lateral aspect of the patient's left knee. A pursestring sture of 6-0 Prolene was placed and the patient was heparinized with 5000 units. Seldinger technique ws used with a micropuncture set and a 5 French sheath was placed. Catheter was advanced up to the area of stenosis near the proximal anastomosis and an angiogram revealed a 90% stenosis proximally. It was crossed with a 014 wire, dilated with a 3 mm balloon and it was improved to about 30% stenosis. No stent was felt optimal in this locatin in the groin and the heparin was not reversed. The flow in the bypass was much better and the pulse distally was palpable. The sheath was removed, pursestring tied. Wound was closed with 4-0 vicryl subcuticularly. Benzoin, Steri-Strips, and Opsite dressing were applied. "

Thank you again for your help.
 

When a vascular surgeon performs an angioplasty of a femoral vein graph and documents he made a 1 cm incision above the graph prior to utilizing seldinger technique, would the incision make this an open procedure? Does any incision make a procedure open even if the vessel is entered by seldinger technique?
 

Dr. Z. Do the imaging guidance rules of one per encounter apply to 75989?

Hi Dr Z, I am hoping you can provide some clarity for the CPT coding for use of the Impella 2.5 VAD in the cath lab. Recommendations have included unlisted CPT 33999 (Per CPT Asst 11/2009 P10) and 92970. Can you please advise what you are recommending for coding of this expensive device? Thanks in advance!

Hi Dr.Z, I have a question: is this statement qualifies for use of 75898: "Successful TACE of the right lobe hepatoma."  CPT Lay Description of this follow-up study states: "... the radiologist interprets the status of the blood vessel and the effectiveness of treatment rendered." Is status of the vessel should be reported or is it enough to document "Successful TACE"  Thank you. EE
 

PLEASE EXPLAIN YOUR ANSWER TO THE RECENT QUESTION REGARDING G0393 AND G0392, DOES THIS MEAN THOSE CODES ARE DELETED FOR 2010? THANKS

Dr. Z, Please help clarify an issue we are having with IV hydration in conjunction with CT scans, general x-ray exams involving contrast and angiograms. Is it ever appropriate to separately charge for the hydration (96360) in addition to one of the exams listed above and if so under what circumstance is it justified as a separate and distinct procedure? We have two opinions, one being that we are treating the patient with IV hydration for a medical condition (dehydration, renal disease etc) and the other being this is bundled into the procedure and not medically necessary regardless. Not all patients receive IV hydration prior to their exam. Thank you!

 Dr. Z, I hope you can help us resolve this coding issue. HIM and I are coming up with different codes. I read the following as an open procedure of an AV graft including angioplasty, thrombectomy, and thrombolysis. PROCEDURE: The patient was taken to the operating room and placed on the operating room table in supine position. General anesthesia was given. The right upper extremity was washed circumferentially and prepped and draped in traditional sterile fashion. A small transverse incision was made right over the graft above the bicipital fossa. Through that incision, the graft was identified and was encircled with umbilical tape. A small graftotomy was performed and then using a 5 French and then a 4 French Fogarty embolectomy catheter, thrombectomy of the venous limb was carried out. After removal of well organized clots, we noticed that the patient will develop new fresh clots right at the same time undergoing the thrombectomy. The patient was then given 5,000 units of heparin. Then thrombectomy of the arterial limb was carried out with return of brisk pulsatile flow. The graft was clamped proximally and a 6 French sheath was inserted, directed toward the venous anastomosis, and a fistulogram was obtained. It showed a slight narrowing at the venous anastomosis and then a patent right subclavian axillary system, high-grade stenosis at the level of the right innominate vein with flow being diverted to large collaterals. Superior vena cava was patent without significant stenosis demonstrated there. A 0.035 inch Glidewire was advanced through the 6 French sheath and then sequential balloon angioplasty of right innominate vein was performed, first using a 10 x 40 mm conquest balloon and then a 12 x 40 mm conquest balloon. Then using a 6 mm Fox balloon, we gently inflated the balloon at the venous anastomosis. A repeat injection of contrast was satisfactory with no residual stenosis demonstrated. Then the sheath was removed and the angioplasty of the right innominate vein was performed through a 8 French sheath and then the 8 French was removed. The graft was clamped toward the venous anastomosis. The 6 French sheath was inserted, directed to the arterial anastomosis. An injection of contrast demonstrated a patent anastomosis, however, there was thrombus present into the radial artery and the distal brachial artery. A .035 inch Glidewire was advanced through the brachial, then the radial artery, down to the level of the wrist, and then a Fogarty embolectomy catheter was used, and embolectomy was performed of the radial artery and the distal brachial artery using a 4 French Fogarty embolectomy catheter. A repeat injection of contrast showed a persistent defect into the proximal right radial artery. Unclear whether it was a plaque. It persisted after a repeat embolectomy. Then it was angioplastied using a 4 x 40 mm balloon. A repeat injection of contrast after angioplasty showed some improvement. Intraoperative infusion of thrombolytic therapy was used. Approximately 3 mg of TPA was administered. Then a repeat injection of contrast was satisfactory with no further defects demonstrated to be present and good flow going down the radial artery into the end. We then had a palpable radial pulse present. The sheath was removed. The small opening in the graft was closed using interrupted sutures of CV-6 Gore-Tex suture. The wound was closed in two layers using 3-0 Vicryl in the subcutaneous tissue and the skin was closed using subcuticular suture of 4-0 Monocryl. Dermabond was applied and a small sterile dressing. SUPERVISION AND INTERPRETATION: Following a surgical thrombectomy of the right arm arteriovenous graft, a fistulogram was obtained and the findings are as outlined above. Balloon angioplasty was performed, first of the right innominate vein using up to a 12 x 40 mm balloon and then at the venous anastomosis using a 6 x 40 mm Fox balloon. Subsequently, injection of contrast demonstrated there was interruption of flow and thrombus into the distal brachial artery and the proximal radial artery and was it treated with thromboembolectomy and intraoperative infusion of thrombolytic therapy and also balloon angioplasty of the proximal right radial artery where there was narrowing and what appears to be a plaque present. A repeat completion angiogram was satisfactory with good flow demonstrated to the brachial artery, the radial artery to the hand. Here are the codes that I think should be assigned: 36381, 75790, 75798-59, 35460, 75798-59, G0393, 34101, 34111, 75962, 35458, 75986, 37201. I should add that this was done during 2009. We need all the education and help we can get. Thanks,

Dr Z, We have a case where there was a stenosis of the main hepatic artery treated with balloon angioplasty. Following this there was poor antegrade flow and a small amount of thrombus within the main hepatic artery. This was treated with intra-arterial TPA and Papaverine. Final injection showed excellent flow within the main hepatic artery with markedly improved perfusion of the liver. Our question is, does this constitute billing for a secondary thrombolysis (37186) along with the angioplasty codes? Thank you!

This is in regards to the status indicator for 37215. In the final rule addendum E, CMS had removed 37215 from the inpatient only list. However, in the January addendum B list on the CMS website, they have it listed as inpatient only. Have you seen this discrepancy and know which is correct? Thank you. 37215 Transcath stent, cca w/eps C http://www.cms.hhs.gov/apps/ama/license.asp?file=/HCPCSReleaseCodeSets/Downloads/10anweb.zip

If a right heart cath is performed without a left heart cath but a coronary angiogram is performed, would you use codes 93501, 93508, 93545 and 93556? Or should you not code 93508 with 93501?

What kind of documentation would we see to support medical necessity for angiograms (75716 and 75710) on the same day as an intervention? Can you please help to clarify??? THANKS!!! We have seen your previous notes specifying that the bottom line is medical necessity. And the CCI edit says documentation must support medical necessity...."to further define anatomy and pathology." Can you give some examples of what things would support medical necessity? i.e. worsening claudication i.e. abnormal ABI or doppler.
 

Lap Band Port access with aspitation. Can you please help with coding the following? THANKS!!! The patient was taken to the fluoroscopy suite and placed prone. The port was accessed under fluoroscopic guidance and 5ml of saline withdrawn. Oral contrast was administered. Under fluoroscopic guidance the stomach was evaluated. The patient was placed in several positions in order to facilitate gastric outflow. Using fluoroscopic detail evaluation, contrast was followed through the proximal small bowel to the ileum. The lap band was released on the mid-aspect of the gastric antrum. With repositioning, oral contrast was observed to extend into the pylorus and duodenum. IMPRESSION. sucessful release of the gastric band.

The intent of the procedure is to declot a left arm graft by using an angioplasty balloon. The anastamosis itself was also angioplastied using a 5mm balloon contrast injection demonstrated clearing of the thrombus within the graft. please tell me if the above statement warrants an Angioplasty CPT code or just thrombectomy code?

I have read and re-read your information so far on the new AV fistula codes as well as CPT and CPT assistant and am going to take a stab at this (no pun intended, ha ha), but would really appreciate hearing your thoughts on the best way to code, given the information so far available on the application of these new codes. PREOP DX: Chronic renal failure, failing left thigh arteriovenous fistula. POSTOP DX: Chronic renal failure, failing left thigh arteriovenous fistula, stenosis of the arteriovenous fistula, long segment, approx 12cm. OPERATION: Right groin puncture, sonographic guidance into the right common femoral artery, aortic and left lower extremity angiogram, non-selective, sonographic-guided puncture of the left thigh arteriovenous fistula, fistulogram, and angioplasty of the arteriovenous fistula and the arteriovenous anastomosis. The patient has an AV fistula of the left greater saphenous vein in the left thigh. We have dilated about three weeks before and again the fistula was failing. We thought that there was some arterial component. We decided to do an angiogram first and then possible angioplasty of the AV fistula. DESCRIPTION OF THE PROCEDURE: Both groins and left thigh were prepped and draped. We then infiltrated lidocaine in the right groin and under sonographic guidance we did a direct puncture into the right common femoral artery. We then placed a wire and a 4-French sheath over the wire. We went in with a diagnostic Omni flush catheter into L1 and then proceeded to move the catheter down to the bifurcation and do a different injection. Findings were as follows. Abdominal Aorta: The abdominal aorta was patent with no evidence of stenosis. Both renal arteries were patent with no evidence of stenosis. The SMA was patent with no evidence of stenosis. The bifurcation was patent with no evidence of stenosis. The common iliac arteries bilaterally were patent with no evidence of stenosis. The left superficial femoral artery was patent with no evidence of stenosis. We then visualized the anastomosis. It was patent with a severe stenosis of the AV fistula right at the anastomosis, and beyond that a segment of approx 12cm. At this point, then we infiltrated lidocaine in the AV fistula. Under sonographic guidance, did a direct puncture into the fistula, and proceeded to do a fistulogram directly and then passed a wire through the stenosis. After that, we placed a 5X6 angioplasty balloon and inflated right at the anastomosis and beyond that, for a long area that was stenotic. After this was done, then we proceeded to do a completion fistulogram, and it showed that there was a complete patency of the AV fistula. There was no evidence of extravasation, and the fistula at this point was patent. There was a complete resolution of the stenosis. There was no residual stenosis. We then proceeded to pull on the sheath and the patient received 2000 units of heparin. We pulled first the puncture in the AV fistula. There was no evidence of any bleeding or hematoma at this point, patient was stable. Here are my questions: My initial thought was to code 75791 for the first puncture to the right common femoral artery. However, there is no description of any venous imaging/outflow on either the initial angiogram from the right femoral access, nor of the direct puncture of the AV fistula so would either 75791 or 36147 be appropriate? I know I can't use both of these codes together, but it really seems like this would be the answer if the lack of venous outflow imaging isn't an issue. 36147 would indicate the initial access to the fistula, and although 36148 refers to access for intervention, that seems to be for an additional access into the fistula and there was only one direct access. If I think about the reference to access for intervention I could choose 36148 but then I can't use that without using 36147 first. Should this be coded as an abdominal arteriogram 36200-75625, then 36147? I'm not clear on whether this is an angioplasty in the arterial side or the venous side and the whether the 12cm segment is within the graft? So it would be either 35474/75962 or 35476/75978? And if 36147 is supposed to include all catheter placements does that wipe out the 36200 if I go that route? The direct puncture came second but does that matter if it includes all catheter placements? I am really stumped. I realize I may just have to take my best shot and wait to see as info develops for these codes, but I'm really not sure what my best shot should be! Thanks, I'm sure you will want to edit as this is long winded, but you did ask for thought process!! I am not coding the sono guidance as I have no documentation or images captured for that. I also was hesitant to code an extremity angiogram as all he described of the left leg was the SFA and profunda femoral were patent. Thanks again!!!
 

Good morning from KC,MO. My question deals with the use of 3D imaging in conjunction with angiography, specifically cerebral angiography. Q: When fluoro is used to obtain the images from which a 3D rendering is performed is that billable with 76377 or 76376?? And what UB code do you recommend being used. Thank you again for you assistance.

Dr. Z, We have been using CT and US guidance to inject india ink for tumor marking prior to surgery. Is it OK to use C9728 for this or should this be an unlisted procedure? Thanks,

Pt had a pta with stent insertion of the left internal carotid artery. What would the approptiate cpt and Icd-9 codes for this procedure. I was told that if they are in the internal/external carotid artery this is cerebral artery (intracranial). Please verify Thanks

Dr. Z, Question regarding PTA in arterial anastomosis and venous anastomosis for AV fistulas. In 2009 bcause of the CCI edits for medicare we coded G0392 when PTA done in arterial anastomosis and venous anastomosis since the 'G' codes are no longer active how do we caputre this scenario with 35476 or 35475, please explain. Thank you

Since the G-codes have been eliminated and 35475/35476 are being used does the same rule about "zones" still apply? For example, if the Dr treats a stenosis at the arterial anastamosis and then one in the axillary vein is this still just one code (35475)? Thanks for your help!
 

How do you code a true ramus intermedius intervention if one is already done on an LAD and/or circ? Scenario 1: If we do a ramus intermedius by itself, do we code this to the LAD or Circ? Scenario 2: if we do a RI intervention and then an LAD intervention? Scenario 3: if we do a RI intervention and a circ?? I was always told the RI was coded to the LAD but then others state code to whichever one it is closer to??

Hello Dr. Z, I have yet another question for you. Our radiologist does vertebroplasties and always does an epidural injection with this. The code for a thoracic lumbar vertebroplasty is 22520 and then the epidural injection code is 62311. We have been putting the 59 modifier on the 62311 as it is a seperate procedure, but on the physician side we are still getting edits saying that they can not be billed together. What is your suggestion? Thanks,
 

Dr. Z, Really need your thoughts on the appropriate codes for a dicyphor discogram. We have an IR doc performing these. His documentation has changed a little since he began and not sure if this makes a difference or not. Now he documents " Dicphor needle advanced into the disk space. Dicyphor balloon positioned in the center of the disc space. Slight amount of contrast and 0.5 milliliters of lidocaine and 1.5 milliliters of bupivacaine were instilled into the disk space.....do I use the appropriate Diskogram codes or do I use an unlisted code? Thanks for you help.

Dr Z - Wondering how to code AVF access when there is only an intervention, not an angio. In this case access venous end going directly to thrombectomy and angioplasty. A second access arterial end, also thrombectomy / angioplasty. I don't think I can use 36147 without the angio and cannot use 36148 as it is an add-on code. Thank you for your help!
 

My question is in regards to the new category III code for lipiscan = 0205T. We are doing this procedure at our facility. The code description states to code this per vessel. Since this can be done multiple times during the same event, is the charge the same per each vessel? Also, since we can charge for multiple vessels, does it matter which vessel? Example, if they do the LAD and then turn off to a side branch of the LAD does this constitute two vessels and two charges or does it have to be two main vessels (LAD - RCA) to get two charges. I haven't been able to find a lot of information on this code so any help you can give me is very appreciated. Thank you.

Dr removed thrombus from graft,did arteriogram, performed aneurysmorrhaphy and a PTFE graft along with Miller cuff was stitched on to the graft. Then had to remove thrombus from anterior tibia after doing another arteriogram. DR is billing 36140, 75710,35152,35666 and 34203. I don't think this is correct I think 75710, 35876 and maybe 34203 should be billed, but the more I read it the less sure I am. Thank you
 

Hello Dr. Z, I have another question. Our radiologist did a CT guided thoracentesis with a 12 gauge single stitch catheter in 2 access sites. Do I code it as below: 77012- CT guidance for needle placement 32422- Thoracentesis 32422-59 for the 2nd access site Thanks again for your help.

Dr.Z, question regarding pacemaker debridement. A week before Patient had pacemaker infection so pocket moved to the other side and prescribed antibiotics. A week later came back for the closure, and has lot of scar tissue. What can we charge for the closure? Thanks

Dr. Z, Please explain the rationale for new code 36148 additional access for therapeutic intervention. Sometimes our physicians access graft in 2 locations and criss cross catheters were placed, in 2009 we can code this with 36145 twice with or without intervention. With new codes can we charge 36147 and 36148 (for the second access) when they perform only diagnositic study no intervention performed or only 36147 since no intervention performed with the additional access. And also even when they perform intervention we can't tell from the report whether they used the second access to perform intervention, please explain. Thanks
 

With the new 2010 AV fistula codes I am not sure how to code a cath placement. Fistula was accessed with a needle, contrast imaging done (36147). Tapered narrowing approaching the arterial anastomosis. The arterial anastomosis itself is moderately narrowed. The entire juxtaanastomotic segment was irregular in contour with two discrete moderate foci of stenosis. Balloon cath was advanced over the wire. Angioplastied the inflow segment down to the radial artery in an overlapping fashion (35475 & 75962). Can I also charge for catheter placement in the radial artery 36140? Thanks for your help.
 

Greetings,

This site has been my life line. Here I go with another AV fistula creation.
Local anesthetic was infiltrated along the previous surgical scar in the antecubital fossa. The skin incision was made overlying the previous incision and cautery was used to dissect down to the aneurysmal portion of the fistula. This segment of the fistula was mobilized circumferentially and the arteriovenous anastomosis was identified and dissected free. The fistula was doubly clamped and divided. The stump of the fistula, which was still attached to the vein, was oversewn with a GoreTex suture. This allowed the very small stump to act as a vein patch angioplasty to the brachial artery. The remaining segment of the aneurysmal portion of the vein was excised. The wound was then closed in layers with interrupted Vicryl in the deep tissue and a running Vicryl suture for the skin. Is this a revision of a fistula or ligation?

Will there be new codes for G0393 and G0392? If so, what are they being replaced with?  (Asked 11/9/09)

When performing a Thoracentesis and Paracentesis at a single outpatient encounter can you charge for the US guided needle placement once for each procedure or a single guidance for both procedures.  thank you.

Hi Dr. Z, When the MD documents in his/her procedure report a crossed catheter technique to access an AV fistula/graft, would this always be reported with 36145, 36145-59?  Does this terminology always indicate two access sites? Thanks. (Submitted 11/09/09)

Hi Dr Z.one of our interventionalists does this procedure frequently for Liver Ca and I'm having trouble getting it coded correctly. I hope you will be able to help. I use your book when I code these but I would like some validation that I'm using the right codes. PROCEDURE: 1. Superior mesenteric artery angiogram. 2. Accessory right hepatic artery angiogram arising from the superior mesenteric artery. 3. Celiac artery angiogram. 4. Selective left gastric artery angiogram. 5. Selective gastropancreatic common trunk angiogram. 6. Coil embolization of this common pancreatic gastric trunk. 7. Selective left hepatic artery angiogram of two segmental left hepatic arteries. 8. Selective right hepatic artery angiogram. 9. Gastroduodenal artery angiogram. 10. Coil embolization of the gastroduodenal artery. 11. MAA infusion of approximately 2.5 mCi Tc 99m MAA into the accessory right hepatic artery arising from the superior mesenteric artery. 12. MAA infusion of approximately 2.5 mCi Tc 99m MAA into the right hepatic artery arising from the celiac artery. DESCRIPTION OF PROCEDURE: The patient was laid supine. The right groin was prepped and draped in the usual sterile fashion. Skin and deep subcutaneous soft tissues were anesthetized with 1% Lidocaine. A small skin nick was made with a #11 blade, and then using micropuncture technique, the right common femoral artery was accessed and a microwire advanced. Over the microwire a #5-French microsheath was placed. Through the microsheath an 0.035 3-J wire was advanced into the abdominal aorta, and over the wire a #5-French working sheath was placed. Over the wire and through the sheath, a #5-French Sos Selective catheter was placed over the wire and formed in the abdominal aorta. It was then used to select the superior mesenteric artery and a digital subtraction superior mesenteric artery angiogram was performed, and using a Progreat microwire and microcatheter, the microwire and microcatheter were used to select the accessory right hepatic artery arising from the superior mesenteric artery proximally. A digital subtraction right accessory hepatic artery angiogram was performed, which showed dominant supply to a hypervascular complex right-lobe-of-liver mass along with several satellite lesions. The accessory right hepatic artery supplies a moderate amount of the right lobe of liver, likely greater than half of it. Next, the microcatheter was removed and the Sos selective catheter was used to select the celiac artery. Digital subtraction celiac artery angiogram was then performed. This reveals a complex configuration of celiac artery with two left gastric arteries arising from the bifurcation of the common hepatic and splenic as well as a very large pancreatic gastric trunk. Using Progreat microwire and microcatheter, the wire was used to select the left gastric artery, and a digital subtraction left gastric artery angiogram was performed. Then using Progreat microwire and microcatheter, the gastric pancreatic trunk was selected. This comes off in a trifurcation fashion with gastroduodenal right and left hepatic branches. This pancreatic gastric trunk was selected and then back- coiled with 0.018 Vortex microcoils to complete stasis. Hand-injected arteriogram was performed documenting the adequacy of embolization. Next the left hepatic artery was selected. There are two left hepatic arteries, the segment two branch first was selected and digital subtraction angiogram performed. Next the segment three branch was selected and digital subtraction angiogram performed. Next right hepatic artery was selected and right hepatic artery angiogram was performed, which showed a branch vessels supply to part of the hypervascular dominant right-lobe-of-liver hepatocellular carcinoma. Next the gastroduodenal artery was selected and a digital subtraction gastroduodenal artery angiogram was performed. This was then coiled to complete stasis using Nestor microcoil as well as Azure detachable coil. The gastroduodenal artery was coiled to complete stasis and a post-coiling angiogram was performed documenting adequacy of embolization. Next the catheter was brought into the proper hepatic artery upstream to the trifurcation of vessels. 2.5 mCi Tc 99m MAA was then infused at this site. Delivery materials were then safely disposed of by the nuclear medicine technologist. A new Progreat microwire and microcatheter were placed after the Sos Selective catheter was used to select the superior mesenteric artery. Microcatheter was then used to select the accessory right hepatic artery, and the remaining dose of MAA was injected. 2.5 mCi Tc 99m MAA were injected into the right accessory hepatic artery. Infusion materials were then removed and safely disposed of by nuclear medicine technologist. The right groin sheath was then removed and excellent hemostasis achieved using manual compression for about 15 minutes. My codes are 37204 and 37204-59, 75894, 75894-59, 36245, 36246, 36247-59x3, 36248 x's3.

Thanks for your help in advance

We did a diskogram at three different lumbar levels, so I have coded 62290x3 and 72295x3 with modifiers. Our Radiologist is also wanting us to code CPT 64999 additionally for what he is calling a functional anesthetic diskography. He placed these tiny little, what he is calling functional micro balloon catheters at each level. After the conventional diskogram he left the catheters in place and stood the patient up and injected lidocaine at each level waiting 20 minutes between levels and had the patient bend forward and back and from side to side as well. All of this is documented in his dictation with pain levels from the patient. Would you suggest additional coding for this? Your help is greatly appreciated! Thank you!

Dr. Z I have a question regarding standards or benchmarks for coding of interventional radiology, cardiology &/or endovascular procedures. I am trying to gather information on the average number of cases that are coded in a day or week. I realize that each case is different and it might be too difficult to put something like that together, but I figured you would have the information if any was available. Thank you for any information you can give me

Hello guys- I have a physician who is going to perform intracranial procedures at another hospital, mostly elective coilings. We have done this at other hospitals and they coded the procedures, the entire procedure. This time, could we code for the professional services only, by adding the 26 modifier on the 70,000 series codes? Is this wrong to do or is it mandatory? Thank you

During cardiac cath on a medicare pt. the phy. documents below with one cath position. Findings are both renal and iliacs, would you code both G0275 and G0278 from just one contrast shot from the renal area? "DESCENDING AORTOGRAPHY: The descending abdominal aorta has at least moderate atherosclerotic plaquing with some aneurysmal dilation distal to the renals. The left renal artery has a cleft-like 60 to 70% stenosis. The right renal artery was not well visualized, is overlapped with the inferior mesenteric. There is mild plaquing of the left iliac artery. The left internal iliac is not well visualized. Right iliac artery is aneurysmal with mild plaquing. There is moderate plaquing seen in the right external iliac artery." Thanks! Jim H.

With the new codes for AV grafts 36147 and 75791 how do you code if via one access into the graft the farthest catheter placement is the SVC. Example is declots where via only one access into the graft a fistulogram is performed and declot of graft and SVC is performed. Code 36147 includes fistulogram and cath into graft. Code 36010 includes cath to SVC. Thanks in advance.

Dr. Z, Our interventional radiologist did a biopsy of the largest nodules in the left and right lobe of the thyroid gland (two seperate stab incisions). Do we code 60100 twice with only one guidance code 76942? Thanks for your help