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Intraprocedural ECMO

Our facility is starting to perform ECMO during procedures. Within the session, the cannulae are being placed, ECMO started, and cannula removed at the end of the procedure. Is it appropriate to bill for all components of ECMO in addition to the procedure?

Biliary Stent removal

"Successful placement of 12 French, internal/external, locking pigtail biliary drainage catheter using a right anterior intrahepatic biliary duct. Successful placement of 12 French, internal/external, locking pigtail biliary drainage catheter using a left intrahepatic biliary duct. Successful removal of a right hepatic and left hepatic biliary stent into the small bowel. Successful cytology brushing of the tumor. PLAN: Bag to drainage. Monitor output Flush catheters every shift with 10cc normal saline. See Dr. X in clinic in late September with follow-up LFT and possible biliary stent placement."

What would you code for the biliary "stent" removal? 47534x2 for the int/ext cath placements(new punctures) and 47532 for the brush biopsy. The only thing we can come up with for the biliary stent removal is unlisted?

REVASCULARIZATION: FEMORAL/SUPERFICIAL FEMORAL ANGIOPLASTY

The provider couldn't cross the lesion in the right superficial femoral artery. The question is, can I still code for 37224 or not??

"Ultrasound-guided left radial percutaneous arterial access. Iliac and right leg angiogram, catheterization of aorta and femoral artery, supervision and interpretation. Intra-arterial administration of nitroglycerin and verapamil, ultrasound-guided right dorsalis pedis percutaneous arterial access, catheterization of right anterior tibial artery, and percutaneous closure utilizing TR band."

Coronary atherectomy with lithotripsy and stent

How will the following be reported? Coronary orbital atheterectomy was attempted but unable to cross a lesion in the left circumflex artery. Shockwave lithotripsy then performed successfully with delivery of a drug eluting stent. C9602 -LC or C9602-74-LC are being considered, but it is not included in the 2 codes, C9600 or 92928, that CMS listed for receiving pass-through-payment when reported with C1761. Please advise, including rationale. Thank you!

Aortic arch angiogram and angioplasty of coarctation

Can you tell me what CPT I would use for the aortic arch angiogram that is done with a congenital heart cath and balloon angioplasty of coarctation of the aorta? I am unsure if the 93567/75605 are the correct codes.

CPT 49465 with regular films instead of fluoroscopy

For CPT code 49465, we have patients who have the service done without fluoroscopic guidance. Instead, a portable x-ray machine takes a series of about ten films within a few seconds of each other. How would this be coded? Although normally provided with fluoroscopy, the code description simply says image documentation.

Use of 77001

During a tunneled CVC, angioplasty was done of the right innominate vein. The catheter was then placed; however, the physician does not state that a final image was taken (CPT states radiographic documentation of final catheter position). He does state a fluoroscopic radiation summary in the report, so with all this work, can we report code 77001?

Pre-TAVR Aortic Valve Calcium Scoring

The cardiologist is requesting a pre TAVR CT without contrast for a calcium score of the aortic valve. The exam will need to be gated and post processing to provide the calcium score. Only the aortic valve will be scanned. I'm wondering what the correct code would be. Code 75571 specifically states coronary, so I don't think we can use that CPT. I'm thinking a CT limited (76380) or an unlisted CT (76497) code. What are your thoughts?

93460 billing

My doctor states he did a left and right cath with coronary angiography only, no ventriculogram. By description of the code it states "including intraprocedural injection(s) for left ventriculography when performed". Can I bill code 93460 with the understanding that it can be with or without the ventriculography?

Foley catheter exchange w/contrast injection

"External genitalia was prepped and draped. Contrast was injected through the existing Foley catheter. His urinary bladder is free of evidence of extrinsic mass effect and debris. No contrast was seen to travel in a retrograde fashion to the distal ureters. The balloon was deflated, and the catheter was removed. I immediately replaced it with a 20 French catheter. It was inflated with dilute contrast and remained well in place. The catheter was attached to a urine bag, and free flow was noted." 

What would the correct codes be for this report? I think the injection would be 51600 and 74430. What code would you use for the Foley catheter exchange?

DES Balloon used for PTCA

Can we charge for a PTCA in the RCA (92921) when a DES balloon is used for the PTCA? Patient had a DES in the RPL and PCTA in the proximal RCA using the DES balloon. 

US insert Pleural Catheter w/cuff and paracentesis

Our doctor inserted a tunneled Pleurx catheter for malignant ascites (49418). After the catheter placement he connected to the drainage tube, and 1 liter of ascites was removed (49083). I was told before not to code the paracentesis 49083 at the same time as 49418 when the tunneled catheter is what he is using to describe 49083. He says because 49418 description is just for placing "insertion" of the intraperitoneal catheter, that we can bill the paracentesis during the same session. What is your expert advice on this? There is no CCI between the two codes.

36556 vs 36561

"Under sterile conditions the skin above the left clavicle was prepped with chlorhexidine and covered with a sterile drape. Local anesthesia was applied to the skin and subcutaneous tissues. Using anatomical technique, the finder needle was inserted under the clavicle at an appropriate angle and venous appearing blood was obtained. Needle was removed and an 18-gauge needle was then inserted into the same location and angle. Venous appearing non-pulsatile blood was obtained and a guide wire was then passed easily through the needle. The needle was then withdrawn. An incision was made and a dilator was subsequently passed over the guide wire then withdrawn. A 7.0 French triple-lumen catheter was then inserted into the vessel over the guide wire. The guidewire was then removed. All ports aspirated and flushed without difficulty. The catheter was sutured into place. A chlorhexadine biopatch and Tegaderm dressing were both placed." Is this CPT 36556 or 36561 since ports were mentioned? However,  there is no two incision, no tunneling, no pocket done. 

COMPLICATION OF BYPASS GRAFT vs ATHEROSCLEROSIS OF BYPASS GRAFT DX CODE

"CTA IMPRESSION: Occlusion of celiac and proximal/mid SMA, second to severe atherosclerotic plaque. Moderate/severe atherosclerotic burden of abdominal aorta, distally occluded. Occlusion of bilateral common/external iliac arteries. Occlusion of aorto-bi-femoral graft. Occlusion of bilateral common/superficial femoral arteries. Occluded left common iliac to popliteal graft. Occlusion/severe stenosis of bilateral popliteal arteries. Stenosis/complete occlusion of left anterior tibial artery."

Question one: How would you code the occlusion of the bypass graft? T82.898A or I70.312? The physician was queried for the cause of the bypass graft occlusion, and this is what he would document. What would be the default diagnosis in general (if more documentation can't be obtained)?

Question two: If the same was documented, but PTA was performed in the OR at another setting, would that default the diagnosis to a complication code as intervention was required?

Septostomy and stent to decompress the LA

7-year-old female status post cardiac arrest thought to be secondary to dilated cardiomyopathy. Patient presents to cath lab for "septostomy to decompress the LA".  Procedures performed: RHC, ASD creation, and stenting under TEE guidance. Septostomy was performed. She had a "thinned out appearance of her ventricle", so the cardiologist felt a more stable decompression by placing a stent was in order. I don't see that this patient had a previous history of congenital heart disease, but would the "dilated cardiomyopathy" in such a young patient be considered something she might have been born with, or is that something that happens from an injury to the heart? What would my CPT codes be? 33999?

bypass with ipsilateral reverse greater saphenous vein

How do you code this? "Right below-knee popliteal to distal posterior tibial artery bypass with ipsilateral reversed greater saphenous vein. Completion angiogram was not performed due to limitations."

Right atrial thrombectomy

Physician removed a large vegetation from the right atrium due to an infected pacemaker lead. Diagnosis code is the root operation extirpation of matter or revision.

Y90 and chemo given during tumor embolization

If Y-90 and chemo are both given in the same surgical site, I know we can only get 37243 for the CPT, but can we show both S&Is (96420 and 79445?) Do they have to be separate tumors to use both?

Can ICE cpt 93662 and tandem heart cpt 33991 be billed together?

Is ICE code 93662 bundled with 33991? Or can it be billed together?

PICC exchange with port

What CPT code would you assign for an exchange and conversion of a right basilic vein PICC line to a tunneled right basilic vein infusion port?

Perm to temp. pacer with pocket infection

Please let me know if this is correct coding on this unusual case. 

"Patient has infected pacemaker pocket (dual chamber). Removal of generator with debridement of pocket with swab sent to lab. I was unable to access left axillary vein using approach that did NOT involve the pocket. So instead, right atrial lead was freed up, and guidewire used to obtain new access to the left axillary vein. Using this access, new lead placed in RV. Using pacing through the pacing system analyzer to avoid asystole and then removed the old RA and RV leads. Irrigated and packed pocket. I attached the same pacemaker to the lead and placed it on the skin and programmed to VVI at 60 paces per min."  

I'm thinking: 11042 pocket debride, 33216 new RV lead, 33233 removal generator (looks like used now as temp. external) and 33235 for removal two leads?

RHC Repeated Post Sublingual Nitro Spray

Would you add 93463 if a right heart catheterization was repeated in full after sublingual nitro spray?

Additional Information on FFRct 0503T

I am looking for additional information on code 0503T. It appears there is only one diagnosis code allowed for medical necessity and that would be R93.1.  I looked in your book about this code (0503T),  and it does mention there is payment for this code under APC. Is that if it has the R93.1 only? I don't see a lot of information on the FFRct.

Removal of Active Fixation Lead Used for Temp Pacing

Patient had an active fixation lead that was attached to an external generator being used for temporary pacing. When the patient had a DC PPM implanted, the active fixation lead was "unscrewed" from the RV and removed from the patient. It was not used in the newly implanted DC PPM. So, 33208 is coded for DC PPM insertion. Can the active fixation lead removal be coded (33234)? Or is it considered bundled into the PPM insertion procedure?

Fluoroscopy with a lumbar puncture

Our RADS have new lumbar puncture templates. Is this enough to bill 62328? Or where it says "under imaging guidance,"should they state fluoroscopy was used?

"PROCEDURE DETAILS: Diagnostic lumbar puncture with fluoroscopic guidance. 

Total intra-service sedation time (minutes): Not applicable. Lumbar puncture: The patient was placed in prone position. Local anesthesia was administered. Under imaging guidance, a spinal needle was advanced into the subarachnoid space using a midline interspinous approach."

Shouldn't they state, "Under fluoroscopy, a spinal needle was advanced..."?

37242 with EVAR

I am in a debate with my physician. He placed an EVAR (34705), then used a catheter to go between the EVAR graft and the blood vessel wall to access the AAA sac and deploy embolization coils. He thinks we should bill codes 34705 and 37242, while I think we should bill code 34705-22. His reason is the EVAR does not include embolization. My reason is I believe the AAA sac is in the treatment zone. He did not access the internal iliac, but used the common iliac to slide up the outside of the EVAR graft to access the sac. What do you think we should bill and why?

Excision of Aneurysm of Nonusable AV Fistula

Patient with an aneurysm of non-functioning fistula that hasn't been used since 2018 due to clotting. Procedure was coded as 37799, but insurance is denying. Is this the correct coding, and if so, is there any suggested information that can be sent to help fight this claim?

"Longitudinal elliptical incision around the existing aneurysm down to the level of the elbow was made. I identified the brachial artery in the AV fistula aneurysmal anastomosis. I clamped just above the anastomosis on the fistula after dissecting around it to get complete control. After complete proximal control I extended the elliptical incision around the entire aneurysmal portion of the fistula. Using electrocautery I dissected the entire aneurysmal dilated fistula out all the way to the occluded area in the mid upper arm. I ligated this off with a silk tie and then excised the aneurysm in its entirety. I tied off the fistula just above the anastomosis with a 5-0 Prolene suture in a running horizontal mattress fashion followed by running locking outer layer."

Intra Op ICD Lead and Generator Evaluation

I am question how to code this procedure for an intra-operative ICD lead and generator evaluation.

"Patient was taken to the EP lab with moderate sedation. The RV lead was inspected radiographically and physically. There was no obvious abnormality. The pin was inserted to the appropriate position past the electrodes. There was no change in the lead position radiographically. The interrogation intra-operatively at the time of surgery was within normal limits. Given this we took out each of the leads and re-inserted the leads in the header and re-secured the set screw, though this was also done previously. Interrogation of the device and leads revealed normalized function, as it was intra-operatively and post operatively previously."

I was thinking of code 93624 with a modifier -52 or option 93642 with modifier -52 since he did not induce or attempt induction of arrhythmia, or simply 93283 with the place of service as OP?

32608 vs 32666: Intraoperative Pathology

The procedure performed was diagnostic VATS LUL wedge resection for a nodule. Intra-operative pathology confirms clear margins. The final diagnosis is adenocarcinoma of the LUL.

Would this be coded as diagnostic 32608 because the intent of the procedure was to biopsy the nodule? Or would this be coded as therapeutic 32666 because the final diagnosis is adenocarcinoma of the LUL and intra-operative pathology confirmed the margins were clear?

AVF revision vs aneurysm repair

I am not sure if this would be an aneurysm repair (35011) or a revision (36832). What are your thoughts?

"The skin over the left arm distal to the aneurysmal portion was instilled with lidocaine. The skin was cut with a 15 blade and deepened with electrocautery. The fistula near the arterial anastomosis at the antecubital crease was controlled with clamp. The fistula near the arterial anastomosis was ligated with 5-0 Prolene in double layers. The aneurysmal portion of the fistula including the overlying skin was resected sharply with scissors. The vein in the proximal arm was also ligated with 5-0 Prolene suture in double layers. Hemostasis was achieved. The incision was closed in layers with 3-0 PDS sutures, and the skin was now closed with 4-0 Nylon sutures and staples. A sterile, occlusive dressing was placed."

Staged cases for lower extremity revascularization

If a patient is being treated with intervention in the right tibial vessels for a CTO, and the patient is then brought back in one week to intervene on the right femoral/popliteal, does this require modifier -58 for the second procedure? Or bill "normally"?

Y-90 arteriography

On a first account, the patient has pre Y-90 mapping arteriography. On a second account, the patient has the Y-90 treatment with arteriography. On this second account, would the arteriography be considered guidance and not coded separately since it was just performed a few days earlier on this first account if no changes have happened in the meantime?

Endovascular Repair Internal Iliac Aneurysm

We are have difficulty determining the correct CPT code(s) to use for this right iliac aneurysm repair. Could you help us decipher if this is a stent, stent graft, endograft, embolization, other? What CPT codes are assigned?

"Left common femoral access. Anterior and posterior divisions of the internal iliac artery were cannulated and then embolized with 8 mm and 12 mm Amplatzer plugs respectively. A 12 French Gore dry seal sheath was introduced and advanced into the right iliac system. A pigtail catheter was used for measurements, and a 18mm x 11 1/2 cm Gore iliac extender was used to occlude the origin of the internal iliac artery extending from the distal external iliac artery to the proximal common iliac artery. It was post-dilated with a balloon. Completion angiogram demonstrated no filling of the internal iliac artery aneurysm. The Amplatzer plugs placed in the anterior and posterior divisions were noted to be occlusive."

MRI brain for cancer treatment planning

If the physician orders an MRI of the brain for cancer treatment planning, one of our insurance plans suggests we bill with the unlisted code 76498 instead of the site-specific code. I'm not sure I agree, and I can't find any specific guidelines from CMS or the AMA on this. Should we use code 70552 with a -52 modifier or the unlisted code 76498?

Open Impella Insertion

How do I code for an open approach for Impella insertion? Should I use the unlisted code or use what the device rep states (33975)? I don't feel an open Impella should be coded as an extracorporeal LVAD.

36832 or 37799 IJ vein to Cephalic Vein bypass of AV Fistula outflow tract

Patient with brachiocephalic AVF has a crushed stent in the subclavian vein, which is causing issue with outflow. The physician performed a bypass of the subclavian vein by placing a PTFE graft from the cephalic vein at the level of the shoulder to the internal jugular vein. The AV fistula venous anastomosis was not recreated or altered in any way. Would the below be considered a revision of the AV fistula (36832) or a vein-to-vein bypass (37799)? 

"The dorsal surface of the cephalic vein was incised with a #15 blade scalpel, and this was extended proximally and distally with Potts scissors. The 8 mm PTFE graft was spatulated. We performed an end-to-side anastomosis with 5-0 prolene suture. We turned our attention to the distal anastomosis within the internal jugular vein. Again, a #15 blade scalpel was used to incise the skin. The jugular vein was exposed and skeletonized. A venotomy was performed to construct an end-to-side anastomosis. The bypass graft was again spatulated in order to fit the venotomy."

Q9967 with 49450

Is it appropriate to report the contrast separately (Q9967) in addition to CPT 49450?

Documentation requirements for 93657 after PVI

When a patient comes in for a PVI ablation, and additional ablative lines are performed after PVI, does the physician need to state that the patient remained in Afib in order to report 93657?

In regards to CFAE ablation after PVI, CPT Assistant, September 2019, seems to say that the physician does not have to document that the patient remained in Afib in order to report 93657. Is that correct?

We want to make sure we are clear in what needs to be documented in order to capture 93657.

28805 vs 28820

"Pre and Post Diagnosis: Severe right foot diabetic infection with abscess and osteomyelitis. Procedure: Transmetatarsal amputation of right third toe; transmetatarsal amputation right second toe; partial resection right first metatarsal. Description: Using a 15 blade scalpel, the base of the right second toe was incised all the way to heathy bone. The toe was amputated and using a ronguer debrided all the way to healthy bone. This involved resection of the metatarsal head of the second toe."

He also resected metatarsal head of previously amputated right first toe. He amputated and resected metatarsal head of right third toe in the same manner as he did the second toe.

Can you please advise if this is coded as two 28805's with a 28122 for the resection of the right first metatarsal head, or do you code as 28820 for the toe amputations with a 11044 bone debridement?

Please let me know if more information is needed for you to be able to answer us appropriately.

TCAR procedures

Do TCAR procedures need to be in registry? Unable to find if Z00.6 is a requirement.

ligation radiofrequency ablation and excision of portion of GSV aneurysm

"MD identified aneurysmal segment of greater saphenous vein. He dissected proximally and distally, then using silk ties he ligated the proximal saphenous vein near the junction. He ligated the greater saphenous on the causal side of the aneurysmal vein segment. He advanced radiofrequency ablation catheter to the proximal thigh until the tip hit the end of the ligated vein at the distal end of the incision by direct palpation, then infiltrated tumescent solution around the vein from the catheter tip to the sheath insertion site. He performed radiofrequency ablation on the vein. Each segment was doubly ablated."

We are coming up with 37700 for ligation and 36475 for radiofrequency ablation. Is the aneurysm resection included with the ligation?

VATS Diverticulectomy

When coding a diverticulectomy via a VATS approach, would you code this as 43135 or unlisted? I thought about 43180, but that didn't seem correct either.

Epicardial pacemaker system insertion

How would you bill an epicardial pacemaker system insertion with open insertion of LV and RV leads?

"The bipolar epicardial steroid-eluting leads were then placed on the lateral wall of the LV, and each lead was secured with 4-0 prolene suture... As the heart was reperfusing, an RV epicardial steroid-eluting lead was then placed on the diaphragmatic surface of the RV and on the anterior surface of the RV and secured with 4-0 prolene. Both leads were brought out through the intercostal space. A left subclavian pocket was fashioned, to which the leads were brought and eventually hooked to the bipolar pacemaker."

Greater than 12 french MUE edits

CPT instructions are to bill for bilateral 34713 on two separate lines utilizing -RT/-LT modifier; however, the MUE is 1 with a MAI of 2. So how exactly are we supposed to bill for bilateral 34713? Is this an error in CPT? Done with 34848 FEVAR.

33990 with 33995

If an Impella CP is placed in the LV from the RT CFA and an Impella RP is placed in the main PA from the RT CFV, are both CPT codes 33990 and 33995 to be reported together? There is an edit with this code pair. Should modifier XS or 59 to be appended to one of the codes?

US guided LT Breast Localization and US guided RT Breast Cyst Aspiration

If ultrasound guidance was used to perform a left breast wire localization, and then US guidance was used to perform a right breast cyst aspiration, what are the hospitals charges? Would I report 19285 for the left breast and 19000 and 76942 for the right? Since US guidance is included in the left breast wire localization, I was unsure if it can be reported on the right side separately if an aspiration is performed.

LE lithotripsy with IVUS

Can we report intravascular ultrasound codes 37252 and 37253 with new lithotripsy codes C9764-C9775? They are not on the list of primary codes. As I understand, catheter placement is bundled into lithotripsy code, so we are not reporting it. There is a recent diagnostic angiogram, and we are not able to code for it either.

Wound Vac During Surgery

We have surgeons who use the incision wound vac system on surgical wound incisions placed during the surgical encounter (disposable). There are no wound measurements noted due to the incision is already closed when the vac is placed. Our question is when the wound vac is placed on a closed surgical wound, is this bundled with the surgical procedure? Some have NCCI edits that do bundle the vac; some do not. Would that be inclusive to the surgery, or is there an additional code that should be reported? Since this is closed and there are no measurements of an open wound, does this support 97607?

Attempted Induction during EP testing

"The CS catheter was inserted through the access & placed in the coronary sinus. Standardized diagnostic EP testing was performed with atrial pacing & recording, ventricular pacing & recording, and His recording with attempted induction of arrhythmia: Next we started decremental pacing starting at 600 msec from CS 7-8. AV block was obtained at 430 msec. Next we started decremental pacing from the RV catheter starting at 700 msec. VA block was obtained at 580 msec with VA prolongation during pacing. Next we paced from CS 7-8 with extrastimuli: AV block was obtained at 650/350 msec. No echo beats or AH jumpe were obtained during pacing. Next, we started isuprel 2 mcg with gradual increase to 5 then 10 mcg. We repeated the same pacing protocols without being able to induce any SVT."

How would this study be coded? I also have a question regarding the CVC lines placed for study. Our HIM codes them. Can they be charged?

VATS w/ Chest wall mass excision

"Incision made in the 8th intercostal space and camera inserted. Additional ports placed and robot docked. ID area of concern on chest wall. Cautery used to completely excise nodule. Not adherent to bone and freely dissected away. Mass removed in Endo Catch bag." I can't find any VATS codes that meet this, but if it goes to unlisted does it go to the MS section since that is where the chest wall procedures are or to the VATS unlisted section?

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