Ask Dr. Z

Hello,

Is stating "aortic valve was crossed" or "LVEDP was measured" adequate documentation for billing 93452 or does the provider need to give the numeric value of the LVEDP?

Thank you!

(For percutaneous transluminal coronary lithotripsy, use 0715T). (Use 0715T in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975)

Patient had a 92920 along with 0715T. Which requires c1761 for the0715T. We are being told not to report code 92920 with c1761. But 0715T requires the c1761. Would we change the supply code c1761 to possibly c1725?

What is the CPT code for aortic root aortoplasty with Aortic valve repair with free margin plication of all 3 cusps and placement of 23 mm rigid annuloplasty ring

Is it appropriate to use the aftercare Z codes such as Z48.03, Z46.82 along with the dx code when the patient returns for drain checks with or without exchanges when the condition is still under treatment such as an abscess? Or should the return visits be coded with the diagnosis code alone with no Z code? Having trouble determining if the drain management visits are considered aftercare during the "healing/recovery phase" since we are still currently treating/evaluating the condition and adjusting the plan of care on each return visit. Also when the abscess is determined to be resolved during the visit would it be appropriate to still report the abscess as the first listed diagnosis since that is what was chiefly responsible for the services during the encounter? Or should it be a Z code alone since the most definitive diagnosis is that it no longer exists and is resolved?

Our physician performed Shock Wave balloon lithotripsy of the Lt SFA (6x60 mm) along with Drug coated balloon angioplasty LT SFA (6X40mm). We are trying to determine if this is 37224 angioplasty or 37225 atherectomy which includes angioplasty and not billing both CPT codes. Our department feels we are not coding this correctly. Does Shockwave balloon lithotripsy mean an atherectomy was performed? If you need any additional information, please let me know. Please advise since Dr. Z is the Expert to clear this up. Just waiting for an answer.

Question 18154

Would it be correct to code a tunneled pleural catheter (PleurX) placement with imaging (32550, 75989) with the same tunneled pleural catheter also getting removed at the end of the procedure (32552) for the reason of the output was too thick for patient to have benefit from home drainage of recurrent pleural effusion? The entire placement procedure (subcutaneous tunneling, PleurX catheter placed, imaging guidance used, minimal output due to thick, loculated pleural effusion) was performed in its entirely, so we are seeking guidance if it is also okay to code for the removal of the tunneled catheter during the same encounter?

TEE with no specific documentation of Right Atria (All other required elements are documented -LV, MV, TV, AV, PV all were imaged and findings documented)

My question is they documented:

Intraatrial septum:

The left atrial appendage is normal in appearance with no evidence of thrombus

Pulsed wave doppler of the left atrial appendage demonstrates normal emptying velocity

No interatrial septum shunt visualized by color doppler.

Is that sufficient to show that they are viewing both the left and right atria to report a complete study?

This pertains to the new pulmonary artery angiogram 93569 and 93573 codes during congenital cardiac catherization. If the MAIN pulmonary artery is selected with bilateral pulmonary angiograms is this a "selected" 93573 or does the selection need to be of the left and right pulmonary arteries?

If the MD orders a limited echo and the report states a limited echo was performed using colorflow and doppler AND all elements of a complete study were resulted (LV and LA, RV and RA, mitral, tricuspid and aortic valves, pericardium and portion of the aorta adjacent to the heart.....should a 93306 be billed instead? Does the order need to match the code and is it appropriate to bill a complete study when the intent is to perform a limited?

Can we code an additional stent when both the right main renal artery and right superior accessory renal artery are stented? 37236 and 37237

Coder used 36904 but I'm not seeing this. However, unsure what code should be used in this case ??

INDICATIONS: Patient had a Cimino fistula ligated due to successful kidney transplant. Now having symptoms in the hand and shown to have prominence over the left radial artery and acute thrombosis of the remaining portion of the fistula.

SURGERY: 15 blade for incision over old incision. Dissection down to the radial aneurysm. Scissors dissected the fistula from surrounding adhesions. Proximal and distal radial artery were isolated, and control achieved. Proximal artery was palpable but distal artery had no pulse and not even dopplerable. Heparin given and proximal radial artery clamped. Aneurysm was cut and thrombus cleared out. Balloon used to thrombectomize the distal radial at which point we noted backbleed. Aneurysm was excised. Arteriogram showed distal radial artery showed no significant supply for the hand and we decided to tie off the distal and proximal radial artery. Hemostasis verified and incision closed.

Percutaneous access via outflow vein close to the antecubital fossa with fistulogram + central venogram.Angioplasty along entire length of the peripheral outflow vein, however, vein was still clearly somewhat diseased.Separate percutaneous access via outflow vein closer to the shoulder with fistulogram and angioplasty of the anastomosis. Repeat fistulogram showed extravasation. Balloon was reinflated, no change on repeat fistulogram which told me that the rupture was at the anastomosis directly. Longitudinal incision was made overlying the AV anastomosis w/blunt dissection of brachial artery. No backbleeding from the outflow vein. Brachial artery was fully mobilized w/creation of end-to-end anastomosis resulting in excellent pulse in the brachial artery. I then ligated the open end of the outflow vein using medium clips. There was a seroma at the basilic vein harvest site with was drained w/needle (100ml). Provider wants to bill 36902,35206,37607. Would this be a revision, 36832-22 (for conversion to open)? Your guidance is apprecicated. Thank you.

35881 for revision w seg vein interposition (portion not shown). What code would be used for the angiography (prior noninvasive testing done)? Access was achieved by a longitudinal incision over the palpable graft pulse at the level of the knee. Sharp dissection was used to expose roughly 2 cm of the bypass graft, which at this level appeared to be of good caliber and quality and had a strong pulse. It was encircled with a vessel loop. The graft was then accessed antegrade with a 21-gauge butterfly and angiography confirmed patency of the distal graft with a focal area of critical stenosis in the graft several centimeters below the knee, but several centimeters proximal to the anastomosis. The area of diseased vein was roughly 4 to 5 cm, but the distal anastomosis appeared patent and the posterior tibial artery ran off uninterrupted into the foot. With the area of graft revision now marked after angiography. 75710-26-59?

Would this be coded 93656 vs. 93653 due to successful reconnection/re-isolation of PV's?

Presenting rhythm was atypical left atrial flutter that was LA roof dependent

The atrial flutter terminated with mechanical effect of the catheter in the LA roof (near the left PV). Repeated attempts to re-induce the atrial flutter were unsuccessful, so we decided to perform LA roof ablation with a line of ablation from the left common PV to the right superior PV along the roof. The target power was set at 40 Watts. The target flow was set at 30 mL/min. Chronic partial reconnection noted of the right superior & left common PV's - successfully re-isolated. Re-do pulmonary vein antral isolation (PVAI) was performed using RF ablation. Ablation was performed in atrial pacing. During ablation along the posterior wall and anywhere close to the esophagus power was limited to 30-35 watts. Esophageal temperature was monitored throughout ablation. Maximal esophageal temperature = 37.1 deg C. After RF ablation entrance and exit block were noted in all pulmonary veins

A provider performed angioplasty of the tibioperoneal trunk. Pre-treatment stenosis was 100%, post-treatment stenosis is documented as 50%, and is documented as follows in the report:

"We balloon dilated the right tibioperoneal trunk to 6 Atm for 2 min with a 2.5 mm by 100 mm Coyote balloon from Boston Scientific. Pre-treatment stenosis was 100%. Post-treatment stenosis was 50%. The distal most peroneal artery could not be traversed but there appeared to be improvement of flow into collaterals."

The payer is denying payment with these remarks:

"Per CPT, the clinical documentation provided in the narrative operative report does not sufficiently describe or support the requisite criteria for approval of the requested CPT code. As such, CPT 37228 is denied as "not documented." A significant residual stenosis is documented."

So, basically, they're denying payment of revascularization because he could only open this completely occluded vessel to 50%. Is there some definition of technical success that must be met in order to bill a revascularization?

Where does the guidance for the answer to Question ID: 11258 come from? NCCI Manual?

I have not been able to find this same guidance in any other coding manuals (AMA Clinical Examples in Radiology, MedLearn, SIR Coding Update, CPT Assistant, etc.)

Can you please advise if this information would be enough to charge for a 93655 for the spontaneous flutter after the initial PVI?

" Ablation was then started in the right inferior pulmonary vein, and was performed in all 4 pulmonary veins. A minimum of 2 lesions were performed at each vein. During ablation of the right sided veins, the phrenic nerve was paced and the patient was monitored for diaphragmatic excursion. Pacing in each pulmonary vein confirmed entrance and exit block. Atrial flutter with a cycle length of 320 msec noted spontaneously and a roof and floor line were done with posterior wall isolation noted and CTI line also done with use of the open irrigated Tacticath catheter using radiofrequency with use of the HD Grid showing that the lines in the LA was not re conducting bidirectional nlock noted across the CTI line and Catheters were removed and protamine was given to reverse the heparin.

Impression is only reading: Acutely successful cryoballoon pulmonary vein isolation for paroxsymal atrial fibrillation.

NAME OF PROCEDURES: CPT code needed for cath placement of umbilical vein

6.Central umbilical vein catheterization, venogram, temporary balloon occlusion, and retrograde venogram.

Then, a 5.5-French Fogarty balloon catheter was inserted via the abdominal wall sheath and navigated into the central aspect of the umbilical vein over a 0.035 inch angled Glidewire. Following catheterization, venogram was then performed, confirming catheter placement within the central aspect of the umbilical vein near the portal vein tumor thrombus as well as flow from the portal system into the abdominal wall venous collaterals. The balloon was inflated and titrated to achieve full apposition of the balloon to the vein wall. Retrograde venogram was then performed via the occlusion balloon catheter, confirming occlusion of the umbilical vein. What CPT code would be used for the cath placement of the umbilical vein during this embolization record?

Patient with repaired Tetralogy of Fallot and has a pulmonary valve implant. Noninvasive imaging demonstrated notable pulmonary insufficiency, so patient is brought to cath lab for diagnostic cath. They do a right heart cath and angiography of the main pulmonary artery. Would you agree with 93451 and 93569? Just want to verify since there are new pulmonary angio codes for 2023

Three (3) 4F micropuncture catheters were placed under real-time ultrasound guidance into the right greater saphenous vein and proximal and mid tributaries of the RT greater saphenous vein via direct puncture x2 followed by subselective catheterizatiom of the right'genicular artery to achieve the most comprehensive coverage of the lesions.

A thorough assessment of flow dynamics and deep venous connections as well as the potential for nontarget embolization due to anomalous anatomy was performed. Embolization x3 was then performed using an embolic slurry with continuous reassessment of anatomy in between doses using both color flow duplex and angiography.

I believe 37242 for one separately identifiable area with 36245. Dr. wants 3 (MUE 2). Are there multiple separately identifiable surgical areas in the leg? Groin? thigh ankle?

Thank you so much for your help and education.

We are receiving denials from CMS indicating modifier incapability when billing for Vertebral Artery Stenting (0075T). We’ve tried using various modifiers without success. You referenced this same issue previously in a Q&A for September of 2014. Do you know which modifier we should be using for this procedure? Thanks in advance for your help.

procedure code 78803 + A9538 were retired on 12/2022. I can't seem to find a replacement codes for it. Please advise.

Patient had emergency bypass due to Multiple Dog Bite wounds. 2 bypass procedures were required radial-radial & ulnar-ulnar. Would we code 35523 X’s 2 or 37799 & compare to 35525? Cut down onto the radial artery. Radial artery was dissected free from structures proximally there was obvious injury to the radial artery. Complete disruption was a through and through puncture injury on the radial artery at the antecubital fossa. No brachial artery at the antecubital fossa. Total bypass length 4 and half centimeters onto. It was a functional end-to-end anastomosis. Ulnar artery lot of tissue injury muscle tearing from the dog injury and the ulnar artery was below the biceps muscle. Dissected it free from surrounding structures. There is a crush injury I then used reverse greater saphenous vein and did end-to-end anastomosis on both the proximal ulnar artery and the distal ulnar artery for total bypass length approximately 2-1/2 cm.

Nephroureteral stent was removed, and ureteral dilation was performed. Attempts were made to manipulate the stone distally. A few smaller fragments dislodged mechanically. A new nephroureteral stent was placed.

I am not sure how to code the stone manipulation here. I am coding as 50387 for replacement and 50706 for dilation.

Please advise how to cede this part of the procedure.

Thank you

Patient had an Impella 5.5 with Smart Assist inserted during a CABG. The provider brought an 8mm graft into the field, it was bevelled and sewn end-to-side at the distal ascending aorta to use as a conduit for the direct implantation of the Impella. A small incision was made at the right side of the neck and the 8mm graft was tunnelled out of this incision. The sheath was placed in the graft and using TEE, the wire was advanced to the aortic valve. The Impella 5.5 was brought into the graft and delivered to the aorta through the aortic valve and placed in position, verified by TEE. The provider has coded 33975. I've never seen a direct aortic implant before. Would the conduit he created be an unlisted code? Compared to 34716? Thank you.

.Using fluoroscopic guidance via 9 French sheath a left bundle branch guide sheath and lead were placed into the left bundle branch position. Prior to placing the lead the his bundle was identified in order to guide positioning. Using electrocardiogram and fluoroscopic guidance the appropriate position was found and the lead was screwed into position. Once the appropriate numbers verified left bundle branch specific pacing the sheath was removed and the lead was fixated to the muscular fascia. Using fluoroscopic guidance via a 9 French sheath a Tacticath SE ablation catheter was advanced into the right atrium. A 3D electro anatomical map was created of the right atrium and the right ventricle noting the atrial signal, ventricular signal, his signal and the coronary sinus. An appropriate his signal was identified this was ablated. The doctor is wanting to bill 93619, 33208, is that proper billing? Shouldn't the 5 catheters be mentioned. I'm very confused about the LBB pacing implant. Does the 22 modifier up RVUs? HELP!!!

Dr. Z with new 2023 C codes, if a physician performs LHC (93458) WITH IVUS there is C7523. If LHC with FFR is performed there is C7524. What if BOTH FFR and IVUS are performed? It seems disingenuous to code both C7523 and C7524 and receive double payment for 93458. Do we just pick one C code? Code one C code and the other with 52? Any help is greatly appreciated? Thank you!

Open repair AAA w/right CIA attachment and left CFA as follows: Attention was then directed to the left common` femoral artery. The left limb of the graft was positioned within the previously described retroperitoneal tunnel. The left superficial femoral and profunda femoris arteries were controlled using elastic vascular loops. Using a #11 scalpel blade a longitudinal arteriotomy was made in the common femoral artery and extended using Potts scissors into the proximal profunda femoris artery. The plane between the plaque and the common femoral artery was developed circumferentially using a surgical elevator, and the plane was developed proximally and distally. The plaque was removed, and great care taken to remove all debris from the endarterectomized vessels. No tacking sutures were placed. The graft was spatulated and the femoral arteriotomy repaired in an end of graft to side of artery anastomosis using 5-0 Prolene suture in a running fashion. Would this be coded with 35081 and 35371? The left CIA, EIA and IIA were found to be occluded same session.

Approximately the sixth interspace anterior to the anterior axillary line the trocar sites was injected with local anesthetic. A port was placed intercostal space under direct visualization. Nerve blocks performed from that level through the 11th level. Tumor was then identified. Using the local needle the superior inferior lateral margins were identified. The medial margin appeared to be beyond the costal margin. Incision was then made over the mass. Skin flaps were then created superiorly inferiorly medially and laterally. We then entered the chest 1 interspace above the mass. The finger then sweep medially to identify the medial margin it was then noted that there were deposits on the diaphragm that were not previously visible. These were removed and sent to pathology for frozen section as above after an additional 5 mm incision was made laterally. The cryoprobe was then used to treat the intercostal nerve bundles from level 8 through 11. Once frozen section returned intra-op consult completed and decision to abort. How would this be coded?

My provider did a Diagnostic EP study including right atrial recording/pacing, right ventricular recording/pacing, and attempted induction of arrhythmia without the His bundle electrogram as it was "not readily identifiable from the superior approach and had been evaluated at a prior EP study". Would you still bill the 93620 or bill each component separately? If billing each component separately what CPT codes would I bill for this case?

Has there been any updated guidance for the below procedure since CPT 50395 was deleted?

Technique:

1. Fluoroscopic guided access of a posterior calix of the left kidney.

2. Antegrade left-sided nephrostogram.

3. Placement of a percutaneous nephrostomy access wire into the bladder.

Using fluoroscopic guidance, a 21-gauge Chiba needle was advanced into a posterior calix within the mid pole. A micro wire was advanced into the collecting system. The needle was exchanged for a triaxial transitional dilator. Injection of contrast confirmed position within the renal collecting system. Oblique views of the caliceal access demonstrated satisfactory positioning. A Benson wire was advanced through the transitional dilator into the bladder.

Hi Dr. Z when using the code C7516 with a Coronary Angiogram and IVUS of say the LAD, if you also did an IVUS of the CX at the same time of the procedure, would you use 93454, C7516LD, 92979LC?

Can you tell me what the difference between pleurodesis & fibrinolysis is? Also, 32561 is for the "initial" day of fibrinolysis, correct? Not the "initial" day the tube was placed, correct?

Patient was brought to the Cath Lab for extraction of CIED pulse generator and leads. Successful explant of ICD and leads 33241 & 33244., Attention was then turned to the pocket itself, we attempted to debride all relevant tissue that appeared infected. The area was flushed with hydrogen peroxide and then antibiotic flush. A wound CAC sponge was inserted in the pocket and wound VAC placed over the relevant are. (White foam 6CM x 6Cm placed submuscular, black foam 6cm x 4cm place supramuscular). Recommendation: will have wound care team see patient to arrange ongoing care of wound vac.

Question: Is it appropriate for the physician to code separate for Wound VAC placement (97607 non-DME) Durning the extraction or is this considered part of the removal extraction and would be included in the work of 33241 & 33244 which included cleaning and debridement during procedure. This is not common for our department and want to inform physician and staff if this will be done in the future cases.

Our doctors inserted a Perclose device and are charging 35226. Is this correct? Here is the note for this portion: At the right groin level, we then removed the previous sheath after rewiring it. There was an existing Perclose, and this provided some hemostasis. We added a 2nd Perclose, this gave excellent hemostasis with a good distal pulse. We applied pressure on the right groin for several minutes to obtain good hemostasis.

This seems odd to me (of note, we also billed 32551, 33990 and 34716). Thank you.

Can you please help explain what a gastrografin challenge is, and what is the correct coding? The description from the provider is "gastrografin challenge is contrast given and then a plain abd film taken." I am not sure if this is a fluoro bowel study, a 1 view abdomen x-ray, or multiple views of the abdomen x-rays.

Midline incision - trans-peritoneal exposure of R external iliac artery, SMA, common hepatic artery and Left renal artery and inferior branch of R renal artery distal to bifurcation.

2 limb Dacron graft anastomosed to R external iliac (diseased native vessel) with 1 limb anastomosed to SMA and 2nd limb anastomosed to common hepatic artery (extremely diseased native vessel) I'm leaning towards 35633 and 35632,52. Thoughts?

PTFE graft sewn from SMA limb of Dacron graft to L renal artery

 Separate PTFE graft sewn from common hepatic artery limb of Dacron graft to R renal artery inferior branch

I'm thinking unlisted for the SMA to L renal and hepatic to R renal. Maybe compared to 35636,50. Thoughts?

Patient is having debranching done prior to EVAR scheduled in the future.

Any help would be greatly appreciated.

Should I report 20100, or 37799 for Ligation of Ext Jugular Vein?

"Patient had a 6 cm oblique laceration just lateral to the sternocleidomastoid with obvious muscle belly visible in the wound. We extended this incision 1 cm superiorly and laterally for better exposure. After further inspection of this injury, there was a clear through-and-through injury to the external jugular vein, and as such, was not amenable to repair. We ligated the proximal and distal vessel using 2-0 silk ties. In similar fashion, we ligated the facial main tributary with a 2-0 silk tie. We transected the vessel to gain better exposure to the underlying structures and we palpated for a carotid pulse which was immediately adjacent to where we ligated the external jugular vein, so we decided to explore the carotid sheath and the sheath was opened utilizing blunt dissection and we were able to dissect out the distal common carotid artery. There was no evidence of laceration or contusion to the artery. Carotid sheath was intact and injured, and no violation to trachea or esophagus."

Pt sent to our facility for pelvis and transvag US. Our standard protocol is to do US with color Doppler & obtain spectral waveform ovarian arterial and venous flow. Is 93976 appropriate in addition to the ultrasounds? We did not have a provider order but it is our standard

Indication menorrhagia

Technique Routine pelvic ultrasound protocol. Transabdominal eval of general pelvic anatomy and uterine size. Transvaginal eval of the endometrium, myometrial detail and eval of ovaries and adnexa w/ doppler

FINDINGS: bladder is not adequately prepped for proper transabdominal examination of the pelvis

UTERUS: measures 7.8 x 3.6 x 5.4 cm. The endometrium measures 0.7 cm. No focal myometrial abnormality

RIGHT OVARY:measures 2.8 x 2.0 x 2.1 cm. No right adnexal or right ovarian mass. No abnormal or non physiologic cyst. Blood flow is demonstrated by Doppler

LEFT OVARY:measures 2.9 x 2.2 x 2.9 cm. No left adnexal or left ovarian mass. No abnormal or non physiologic cyst. Blood flow is demonstrated by Doppler

PERITONEUM:No ascites or mass

IMPRESSION: Normal pelvis

How would one code for a right pleural drainage catheter exchange? Should we be using 32999 with a guidance code, like ultrasound (76942) or is there a better procedure code to go with the guidance? Is 49423 an option for this scenario?

Hi Dr Z, We have a physician who is performing artificial ascites when performing ablation of a kidney mass. He is placing a cath between the kidney and liver and introducing fluid to separate the liver from the kidney to safely be able to ablate the mass, How would you code this? Do you feel that it would bundle into the ablation procedure 50592 where performed to safely perform procedure or do you feel we can charge for this separately maybe with an unlisted code where this is not always performed? I appreciate any help on this where the physician feels he should be able to charge for this and I am not seeing any information on coding for this.

Thank you for your help,

Good morning. We are coding for a professional client and came across a CTA report that clearly states the 3D reconstruction was NOT supervised by the radiologist. Can you please clarify whether supervision of the 3D reconstruction is a required element of CPT 71275? Sample section of the report below. Thank you so much!

Report Sample:

Imaging Protocol: Computed tomographic angiography of the chest with contrast.

3D rendering (not supervised by radiologist): MIP and/or 3D reconstructed images were created by the technologist.

Radiation Optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction.

Contrast material: Isovue 370

Contrast volume: 100 ml

Contrast route: Intravenous

Question ID:17880 from 10/17/22 addresses TAVR complication repaired by PV surgeon. We have similar issue but repair was done by the CV surgeon present for the case. "A linear incision was made above the insertion point of the DrySeal sheath. The artery was quite deep. Bridging veins were clipped and divided. The tissues were quite woody and indurated, but ultimately circumferential control was obtained around the right common femoral artery proximally and distally. The sheath was removed, the old proglide sutures were removed. Potts scissors were used to debride torn intima/adventitia. The residual hole was inspected, and appeared to me to be large to repair primarily. A 0.8cm x 8 cm patch was obtained, and a 1 cm circular patch of bovine pericardium was fashioned. This was sewn to the artery using a running 5-0 prolene suture. The vessels were back bled to get out any debris from under the patch, and the patch was tied down.

33361 + repair (which cpt do you suggest?) or 33362 because it was the same surgeon to do TAVR and repair?

Many thanks!

Hi Dr.Z

I am debating between 32999, 32552 and 32557.

Initially, a diagnostic abscessogram was performed through the uppermost right pleural drain. Following the diagnostic study, the indwelling drain was removed over a wire and replaced with a 16 French drain (after injection of which was placed in a more central location of the cavity.. Post placement injection was performed. The tube was sutured in place and connected to Pleur Evac drainage. This was repeated for the other two pleural drains. The other drains are also 16F. The procedure was well tolerated without complication.

DX : Bacteremia with empyema

Please let me know your thoughts on this..

LT wrist Radiobasilic transpo fully created due to concerns that the fistula would not develop it was taken down and revised to a non-transposed brachiobasilic AVF. Since the second attempt was successful and created through a separate incision would we be able to bill 36820-53 with the 36821?

Incision basilic vein to wrist. Basilic vein dissected & branches ligated/divided distally & proximately. RA was dissected. Vein was tunneled medial - lateral aspect of forearm bringing vein to RA. The vein was spatulated. Flow was established then through the fistula. The basilic vein harvest site was then closed. Noted to be no flow in the fistula. The anastomosis was then taken down and revised. Incision was made over the distal upper arm over the basilic vein made arteriotomy which was stented with Potts scissors. The vein was then spatulated using a running suture was sewn in there is a strong thrill in the fistula due to the larger size of the vein & artery. Hemostasis was confirmed. The radial artery incision and the upper arm incision were closed.

"Pt has distant history of open retroperitoneal AAA repair. Aneurysm sac has gotten larger over the years and now presents with abdominal, back, and groin pain. Surgeon is concerned the aneurysm sac enlargement is related to these symptoms. Exploratory laparotomy with exploration of the AAA sac and evacuation of contents and control of bleeding performed.

Midline laparotomy incision was made. The aneurysm sac was evident, intestines retracted appropriately, posterior peritoneum was incised and aneurysm sac dissected free. Aneurysm incised, fluid came out under pressure with blood clot component, cultures taken. Contents of aneurysm evacuated and retractors placed. Evidence of arterial bleeding from lumbar vessels, these were suture ligated. Hemostasis assured. Aneurysm sac reclosed with running Vicryl along with posterior peritoneum."

What CPT codes would you use to code this case? I was thinking 49000 (exploratory laparotomy) and 35221 (repair blood vessel), or would an unlisted procedure code be best? 

We have interventional cardiologists at our facility who are stating that the term "FFR" automatically means that pharmacologically induced stress was part of the procedure. They are using the term "FFR" in their cath reports, but are not actually documenting that a drug (such as adenosine) was administered. Is using the term "FFR" alone enough to support coding 93571 without modifier -52? Or is it still necessary for the physicians to document the drug administration?

Plan was to provide perventricular access for device closure of muscular ventricular septal defect by cardiac catheterization team. Pericardium was opened by CTS. An 18-gauge needle advanced through pursestring suture into RV. Wire from a 9 Fr sheath advanced through the needle & under echo guidance across VSD into LV. Wire was in LV, needle was removed & 9 Fr sheath was advanced over the wire across the VSD into LV. Wire & dilator were removed & sheath flushed. Tip of the loader was then cut off once the device 14 mm Amplatzer muscular VSD was fully pulled into the loader. The loader was advanced into the 9 Fr sheath. VSD device advanced through the 9 Fr sheath into VSD under TEE guidance. Device was manipulated & placed straddling ventricular septum under TEE guidance & release the device which was done by unscrewing it from the delivery cable. At this point the device appeared to be quite stable and the sheath was removed & pursestring suture was secured.

Would you code 33681-52 since no CPB used or unlisted code 33999 vs 93799?

"Left genitourinary catheter conversion. Local anesthesia was administered. The existing PCN was severed and a KMP loaded with Glidewire was advanced into the small bowel across the stricture. The KMP and wire were placed with a superstiff Amplatz and the 8 French sheath was advanced into the distal ureter. A fusion cytology brush was coaxially introduced through the sheath to obtain the specimen which was sent in a sterile cup. The brush and the sheath were then exchanged for PCNU tube. Contrast injection was performed. Genitourinary catheter placed: Boston scientific 10 French by 24 cm. Findings: Ureteral stricture at the distal anastomosis. External catheter securement: Non-absorbable suture."

I'm aware I'll be using 50434 for the conversion of the tubes, but are we still using unlisted code 53899 for the brush biopsy of the ureteral? 

Can the hospital bill C9607 for the revascularization of CTO when no DES is placed? Only a cutting balloon was used. Physician billing 92943.