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Vein mapping with additional duplex scan

When performing a duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access (93985/93986), if you were to perform a duplex scan on the entire radial and ulnar artery as well as the palmar arch, would you be able to bill for the additional studies (e.g.,  93930/ 93931)?

In know code 93930 is a column 2 code for 93985, but you may use an NCCI-associated modifier to override the edit under appropriate circumstances, so I just wanted to check whether the use of a modifier would be appropriate.

LE Angioplasty

When angioplasty is performed in the posterior tibial/ lateral plantar and dorsalis pedis arteries, would we code 37228 and 37232, or only 37228?

VAD Impella Insertion exceeding MUE

These insertions were performed on the same DOS. Patient was released from the cath lab and was brought back 5 hours later. See documentation below. How would we code the second insertion, 33990?

"The Impella is seen to have migrated to the arch of the aorta. Despite multiple attempts, we were not able to prolapse the Impella CP across the patient's aortic valve. Our next plan was to use a snare through JR4 guide and use it to snare the tip of the Impella pigtail and push it across the aortic valve. However, we noted that there is spasm in the radial artery and did not resolve with nitroglycerin. Hence, we decided to proceed with Impella removal and insertion of new device."

35102 with modifier 50

Code 35102 allows a -50 modifier. If both iliacs are involved and bypassed, would you use a -50 modifier? If not, is there a case where you would use a -50 modifier? A Carrier is insisting on an anatomic modifier; however, -LT or -RT does not feel correct because both sides were equally involved and the -50 would modify the price, so I wanted to see your thoughts.

Post biopsy clip removal

We have a patient who previously had a breast biopsy and biopsy clip placed. Now the clip needs to be removed. Should we use 10120 for this procedure?

loop recorder inplants/removal in office setting

My doctor is wanting to do loop recorder implants and removals in the office instead of the hospital. He is planning on purchasing the devices from St. Jude. How do I find out if this is okay to do in the office and figure out cost?

93018

My provider is documenting limited findings for stress tests performed in the hospital setting. His documentation will at times only have "normal". Must the provider document all of the following: starting and ending hemodynamics, arrhythmias, symptoms ST segment changes, and functional capacity? Can you please tell me what are the minimal requirements that the provider must document to support 93018?

Post-operative epicardial echocardiogram performed in OR

Please advise how to code for an epicardial echo. I’m baffled because the procedure has been around since the 1970s, and in 2007 ASE published an article on the growing importance of them, so epicardial echos are well-established yet I cannot find any mention of it in CPT or your reference books.

The case: A baby is in the OR for surgery to correct ASD. Before closing the chest, a pediatric cardiologist (not a surgeon) performs a limited epicardial echocardiogram with spectral and color flow Doppler. How do we report this service appropriately? Unlisted, 93799? Or is there a better code? I do not believe 76998 is appropriate here because it is not for guidance; it is done at the end of case to evaluate function after surgery. Or does that count as guidance?

If we must use unlisted, how does the work compare to TEE? Not sure how to go about pricing it, we didn’t have to place a probe down a throat so that seems like less work, but carefully probing over the surface of the heart might be more work? I don’t know.

Brachial Vein Resection and Debridement

Our surgeon performed a basilic vein resection due to thrombophlebitis with an extensive arm debridement. We cannot locate a code for the resection. Can you suggest one?

CT Sternoclavicular Joint

Is it appropriate to submit CPT code 71250 for CT of the sternoclavicular joints? Would a -52 modifier need to be appended?

Additional ablation 93655

"Patient has AF and atrial flutter. After completion of successful PVI, the physician performs a typical atrial flutter ablation. Three-dimensional mapping and conventional catheter mapping were performed using this ablation catheter and the left atrial coronary sinus decapolar catheter. Multiple radiofrequency lesions were administered, resulting in gradual slowing of the atrial flutter with eventual termination. The ablation catheter was then placed in the lower lateral right atrial wall, and pacing was performed from the coronary sinus catheter from coronary sinus. Conduction times across the caval tricuspid isthmus were noted to be [135] ms in both directions confirming a bidirectional block across the isthmus."

We were going to bill 93656 for the PVI and 93655 for the atrial flutter ablation, but the physician is thinking we should bill an additional 93655 for the CTI. Would you please review and see if we should add the additional code?

jump graft common femoral to profunda artery

Would we code anything for profunda jump graft in addition to CPT code 35646?

"Procedure(s): Aorto to left iliac and right femoral bypass 18 x 9 and ligation of right femoral artery aneurysm, profunda bypass with 6 mm graft, profunda endarterectomy.

Dissection included dissecting out the femoral artery aneurysm, which was ligated, profunda bypass with a 6 mm graft. Aorta endarterectomy and stent removal were performed, and then an 18 x 9 Dacron graft was sewn into side. I then turned my attention to tunneling the right limb of the graft through the inguinal canal, and my assistant started the anastomosis to the common femoral after ligating proximal femoral aneurysm forming endarterectomy at the SFA and profunda and was performing common femoral anastomosis along with his profunda jump graft, I performed the left limb to the proximal common iliac artery end-to-side anastomosis."

75573 or 75574

When a patient has an anomalous origin of the coronary arteries and you perform a CT with contrast, would you report code 75573 or 75574?

Petticoat cook aorto-aortic tube graft with bilateral iliac VBX stents

Patient underwent TEVAR with coverage of the take-off for the left SCA using TX2 Cook endograft (33880) with Petticoat Cook graft in the perivisceral aorta to infrarenal aorta (tube graft) with bilateral iliac limbs using VBX stent grafts as follow: "Next, to treat the abdominal aorta, we advanced a Cook Petticoat Bare endograft and deployed it an aorto-aortic tube graft across the perivisceral aorta to the infrarenal aorta above the aortic bifurcation. This was done using a 36mm/36mm x 180 mm Petticoat Cook Bare endograft. Next, we advanced VBX stent graft 11 mm x 79 mm in bilateral common iliac arteries, which were deployed successfully with about 2 cm into the distal aorta. They were post-dilated with a 16 mm x 4 cm balloon for distal seal with excellent results." For the Petticoat and bilateral iliac stents, do we report 34705? Or 34701, 37236-50?

MINCA

Please help! I have a case where the patient was diagnosed with MINCA (MI with normal coronaries). I have no clue whether to code it as ACS or NSTEMI or something completely different. 

AngioJet Thrombectomy, Unanticipated

Patient presents for planned atherectomy about one week after percutaneous angio. Spider distal protection device was placed. Injection of contrast revealed string sign. SilverHawk device is advanced, “which went though the lesion very easily. For this reason, I decided against initiating the procedure with atherectomy and instead I proceeded with mechanical thrombolysis to remove any soft material or thrombus that may be present... The AngioJet device was then used through the SAME popliteal lesion removing a significant amount of thrombus.” After another injection of contrast, SilverHawk is used for atherectomy in the same vessel. Would you code this thrombectomy as primary 37184 because an AngioJet was used for a significant amount of thrombus? Or, would you code it as secondary 37186 because it was unanticipated and removal of clot was needed before the planned atherectomy?

Ligation branch with fistula creation via 2 different incisions

Procedures: 1) Hemodialysis access, autogenous fistula, branchiocephalic, left antercubital crease. 2) Ligation of large accessory branch via small separate incision, left extremity.

The surgeon performed creation of arteriovenous fistula. Also performed closure commenced after making a small separate stab incision, closing an obviously large and a clearly visible cutaneous tributary.

Is code 36821 (arteriovenous creation) included with ligation (37607) when both are done at the same encounter via two different incisions? Or do we code both separately?

TAVR Intraoperative LV perforation

Patient was undergoing transcarotid TAVR, which will be billed with unlisted CPT 33999. Intraoperatively, there was an LV apical perforation requiring emergent sternotomy and primary repair with pledgeted sutures and then a superimposed patch with Dermabond impregnated valve bovine pericardial patch overlay. Is the sternotomy with LV repair separately reportable?

35102 or 35102/50

I have noticed that the -50 modifier is allowed on open aneurysm repair involving iliacs. Does that mean if a patient has a AAA and also an aneurysm in both iliacs that the 35102 should be coded with a -50 modifier? I always thought that the 35102 is a bifurcated graft, therefore you only code once if the repair also involves the iliacs.

Carotid stenting - confirmation of stenosis by angiography

Per the NCD for carotid stenting it states: "The degree of carotid artery stenosis shall be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the patient's medical records. If the stenosis is measured by ultrasound prior to the procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. If the stenosis is determined to be < 70% by angiography, then CAS should not proceed." Does confirmation by angiography include CTA or just catheter placed angiogram?

Date of Service for Remote Device Checks

For professional services, what should the date of service be on claims for remote device checks? CMS released an article "Guidance on Coding and Billing Date of Service on Professional Claims" that outlines rules for cardiovascular monitoring services that outlined: "When the service includes a physician review and/or interpretation and report, the date of service is the date the physician completes that activity." However, the company we have partnered with for remote device interrogations has stated that on the CMS 1500 claim form for physician services we have to use the date on their reports so that it will show every 30/90 days for reimbursement. What is your opinion on the correct date of service for reporting remote device checks for professional services? Ex: CPT code 93294.

Cath Placement for Segmental Arteries of Liver for y90

Please answer this, as we are getting mixed messages from your older answers (Oct.  1, 2013).

REPORT READS:

"Vessels selected: 1) Celiac artery. 2) Right hepatic artery. 3) Segment 5/8 hepatic artery.

Cath into celiac with angiogram then to RHA with angiogram done. This catheter was then advanced into segment 5/8 with angio and y-90 embolization done."

Is it correct to code 36247 for RHA and 36248 for the Segment 5/8 (this is based off your answer from Oct 1 2013)? Or is it just 36248 since the segment 5/8 normally is off the RHA?

What is normal anatomy for SEGMENTAL arteries off the LHA and RHA and does documentation have to state the segmental arteries came off the RHA or LHA?

Transthoracic Echo with Definity

What is the proper CPT code for a TTE, 2D, M-Mode, complete, with spectral/Doppler, with contrast for non-Medicare patients?

Billing 33508-59 for Surgeon and 33508-59-AS for PA

Would it be appropriate to bill 33508-59 twice: once for the surgeon and once for the assistant who is a PA or NP? We have been billing for both and now starting to see denials. Should we just be billing 33508 for the assistant with 59-AS?

Re-Amputation vs Secondary Closure following a Guillotine Amputation

If a patient has a guillotine amputation (27882) of the lower extremity, would it be appropriate to use the secondary closure CPT code (27884) as the book suggests, or would it be more appropriate to use the re-amputation code (27886)? This question has arisen due to the description of the re-amputation states that bone is resected, and this is not in the description of the secondary closure. If the guillotine is at the ankle, would it be more appropriate to bill a straight below-knee amputation code (27880)?

SFA to BK Pop Gortex bypass graft with GSV Taylor Patch

Patient was undergoing a fem-pop bypass with a 6 mm Gore-Tex graft. Following completion of the proximal anastomosis, the physician went down to the below-knee popliteal space and took the GSV and sewed it on as a patch, then made an arteriotomy in the vein patch and sewed the distal end of the Gore-Tex to the vein patch. Is this still coded using 35656, or would there be a different or additional code added for the vein patch?

What is the logic for billing 74022 when 74019 & 71045 are performed?

Are the studies only combined if ordered as an acute abdomen series? Or do they require separate technical scans and medical necessity?

VAD Delayed Chest Closure Global

Sometimes our providers insert a VAD, which has no global period, but then delay chest closure, which does have a 90-day global period. When they come back to see the patient the follow-up is focused on the VAD and reason for the VAD and not the chest closure itself. Is it appropriate to append modifier -24 to the E&M in this situation?

HIM Coders and OR room time charge dilemma. Who should do what and where?

I am a CIRCC coder for HIM. I enter the facility CPT codes for the Hybrid room. I enter these codes where the supplies and room time charge is entered. -HIM also has outpatient coders who would enter the CPT codes (only up to the 70,000 series) on a billing side, the side staff would not see. These coders do not code any CPT codes for IR/CV/EP/Hybrid cases; I code and enter them. -The OR billing staff enters their room time charge and says I should not double bill the patient by entering CPT codes; the OR says they “want the HIM outpt coders to enter them” instead on a side not seen. 1) Does it matter who enters the code? This creates a problem in HIM. To keep consistency I want to enter the codes, and the outpt coders want to enter their DX codes. 2) Is there double billing since there is no CPT code for room time? your Q&A #5257 reads “Since the operating room charges time for the surgical procedure performed, all surgical procedures are included in the OR time charge. I don't think that is correct. Please clarify.

SECOND REQUEST-BARD ROTAREX ATHERECTOMY/THROMBECTOMY

We are still having debates on the compliant coding of the Rotarex device. According to the NCCI this should be atherectomy only (37225 see example) - in the beginning the Rotarex coding team told them to report code 37184 with 37225, and now they are telling them to code 37186 instead with 37225. I interpret the NCCI edit to clearly state if in same vessel as intervention only the atherectomy should be coded? Example: DX; multiple areas of atherosclerosis/significant stenosis: "A Rotarex device was then prepped per routine and advanced to the lesion over a 0.018" wire. Primary mechanical atherectomy and secondary mechanical thrombectomy were performed in multiple passes in the SFA and popliteal arteries." (Then they stented.) Am I correct in coding only the atherectomy and not to bill secondary thrombectomy with a modifier? Since the start of the use of the Rotarex and their suggested coding, I can get no one from Rotarex to respond to discuss their suggested coding with me.

64445 or 64446

Is it appropriate to report code 64445 if a sciatic nerve block is performed using a catheter, but the catheter is not specified as being indwelling or that the infusion was continuous?

Arterial Stenosis

For ICD-9, arterial stenosis was coded 447.1, which crosswalks to I77.1 for ICD-10. In the ICD-10 index, "Stenosis, artery NEC" indicates "see also Arteriosclerosis I77.1", which seems misleading since the Arteriosclerosis section appears to only have I70.XXX codes included. Is this a typo in the index? To confirm, extremity artery stenosis is coded as I70.XXX (as the index routes you to Arteriosclerosis, extremities when looking up Stenosis, artery, extremities)? If yes, what diagnosis term/condition is represented by I77.1?

Peritrochanteric fluid Colleciton

"Using ultrasound guidance, left peritrochanteric collection was identified. A 5 French centesis catheter was inserted into the left peritrochanteric bursitis/collection. 10 cc of dark red-colored fluid aspirated and sent for analysis. FINDINGS: There is a complex septated collection overlying left peritrochanteric region, either represents hematoma, complicated seroma or bursitis."

Since catheter into peritrochanteric fluid collection, can we report code 20611 (US requirements met) though diagnosis not confirmed?

Nasojejunal Tube Exchange

"TECHNIQUE/FINDINGS: A spot image of the existing nasojejunal tube was obtained. A Roadrunner wire was advanced, the old tube was removed, and a new weighted nasojejunal tube was placed. Postpyloric positioning was confirmed with Gastrografin injection." How is this procedure best reported? UPC 44799 + 76000 or 44500 + 74340?

Pacemaker Upgrade

We recently encountered an upgrade.

Old device: Manufacturer: St Jude Medical. Model: Assurity MRI 2272 Pacemaker

New device: Manufacturer: St Jude Medical. Model: Quadra Allure MP 3562.

St. Jude quadripolar left ventricular pacing lead.

The two old leads (RA and RV) were disconnected from the old PM device that was removed, cleaned, dried, and connected to the new device generator.

My question is, should this be coded with 33249 or 33229? I was confused when your coding tips said, "Report 33229 when existing system has multiple or more than two leads." In this case, the existing PM was a dual system. Our cath lab charged 33249, but medical records coded 33229.

Cerebral Venogram and pressure measurements

Our physician did catheterization of bilateral internal jugular veins, bilateral sigmoid sinuses, bilateral transverse sinuses, torucla, right straight sinus, and left superior sagittal sinus with local venography and pressure measurements. I am getting: 36012 (x4), 75860, 75860-59, and 75870? Is this correct?

51705 vs 51702

"Suprapubic catheter was injected with contrast. Catheter was occluded. Catheter was removed and a new catheter placed. Contrast injection demonstrated appropriate positioning in the bladder. Successful replacement of occluded pre-existing Foley catheter with a new 14 French catheter."  Would this be 51705 suprapubic catheter change or 51702 Foley change?

Coding and billing of supplies

The patient is having a right shoulder joint injection for a subsequent MRI at an imaging center. Can the physician bill for all of the medications listed, specifically epinephrine, Marcaine, lidocaine, etc.?

"Medication supplies: 13 ml Omnipaque 180, 0.1 ml epinephrine, 5 ml lidocaine, 7 ml bupivacaine, 0.05 ml Gadavist. Discarded: 7 ml Omnipaque 180, 0.9 ml epinephrine, 2 ml lidocaine, 3 ml bupivacaine, 1.95 ml Gadavist.

Lidocaine 1% was used for local anesthetic. Under fluoroscopic guidance, a 27-gauge needle was placed into the right shoulder joint. A small amount of non-ionic contrast was injected into the joint to document intraarticular placement of the needle. A solution of gadolinium, saline, non-ionic contrast, Marcaine, and epinephrine was injected into the right shoulder joint."

Dual PM upgrade to BiVen PM w/Insertion of Additional RV & LV lead

If a patient comes in for an upgrade of a dual chamber pacemaker to a biventricular pacemaker with retention of the RA and RV leads (will be attached to new generator), insertion of a NEW additional RV lead and LV lead, how do you recommend coding this encounter? We are receiving conflicting information between coding as 33229 and 33225 or coding componently as 33233 (removal PM generator), 33207 (insertion new PM with new RV lead - prior RA and RV leads attached to new generator), and 33225 (insert LV lead). Can you please clarify with rationale?

Device Checks, pacemakers, ICDs

Can an office visit and EKG be billed with a device check?

Attempted Biliary Drain Injection x 2

Would you code 76000 or 47531 x 2 with attempted modifiers for this case? "A scout image was obtained of the indwelling catheters. Fluoro time 1.4 minutes. Despite several attempts with multiple types of syringes and catheter tips, neither tube could be injected to obtain an adequate study. IR offered to exchange the tubes to perform the study, though this was declined."

Bypass Graft attached to AV Graft

Patient has a LUE brachiocephalic AV fistula but due to repeated issues with subclavian vein stenosis a bypass graft was inserted that went from the cephalic vein to the internal jugular vein. Since the subclavian vein is completely occluded, would the peripheral portion of the dialysis graft be from the brachial artery anastomosis to the internal jugular anastomosis with the central portion being the left internal jugular vein through the superior vena cava? Reason being they performed an angioplasty and stenting of the left innominate vein from the AV graft access (36908) and internal jugular angioplasty via the femoral vein access (37248). I know the CPT Codebook 2021 page 309 states if angioplasty or stenosis is performed via a non-AV graft access it is coded with normal CPT, but what if both the stenting of the innominate and angioplasty of the internal jugular were performed via the AV graft micropuncture? Would it be just 36907? Or would it be treated as a regular bypass graft with 37248?

32557 & 32555

My IR doctor did a diagnostic CT-guided aspiration of left thoracic fluid (32555), and then through a second puncture (same fluid collection) he placed a catheter under CT guidance and the catheter was secured to the skin and left in (32557). I'm confused because he's saying since 32555 was diagnostic and 32557 is therapeutic they can both be billed, plus 2 separate entry points. (I don't think that really counts.) There are no NCCI edits between 32555 and 32557, but I thought we could only bill one procedure per operative site. This was all one fluid collection even though two separate entry points. Can you please clarify for me (and my IR doctor) which is the correct way to bill this scenario?

Venogram of Basilic vein with Brachial artery Basilic vein avf graft

"A venotomy was made in the basilic vein, and a 0.035 Bentson wire was placed. A 6 French sheath was then placed in the left basilic vein over the wire using Seldinger's technique. A venogram for the LUE was then performed. The LUE venogram revealed: widely patent SVC, left brachiocephalic, left SCV, left axillary, and left basilic veins."

This procedure was done after dissection of artery and vein, but before arteriotomy and venotomy for PTFE graft anastomosis. Can we bill 36830 with 36005 and 75820?

IVUS -same vessel different times

Is it appropriate to code IVUS (non-coronary) when the catheter remains in the aorta for diagnostic purposes prior to the endograft, and then again after one graft has been deployed, and then at the end after an additional graft is deployed and the procedure is complete? So this would be 37252 and 37253 (x2)?

Should 36228 be coded with 36223?

Should 36228 be coded with 36223? "Selective catheterization, left common carotid artery, cerebral angiography with radiologic supervision and interpretation. Findings: The left common carotid artery fills normally. Both internal and external carotid arteries are patent. Intracranial segments of the internal carotid artery are patent. The posterior communicating artery is a moderate size vessel. There is filling of the left PCA but no reflux into the basilar artery. The anterior and middle cerebral arteries are patent. Capillary and venous phases are unremarkable."

MR guided Focused Ultrasound Ablation

Our practice is performing MR-guided focused ultrasound ablation to treat primary prostate cancer. I'm not getting an NCCI edit on the facility side with codes C9734 and 77022. However, the HCPCS reads "...with MR guidance", so it seems inappropriate to code for the 77022 in addition to the C9734. Should the two codes be reported with one another?

Hospital E&M visits

Can a physician bill an E&M code on a patient that was not seen face-to-face? When rounding on patients, there are times where the patient is off the floor having a test done. The physician documents a note and reviews labs, testing, and makes changes to medication. All aspects of the E&M note are completed, except for the physical exam. Would the physician be able to bill this service out on a time based manner?

Suprapubic Catheter exchange when tube has fell out

What do we report for the hospital for the placement of a suprapubic catheter through an existing tract? Patient came in due to dislodged suprapubic catheter, and under fluoro the physician injected contrast to confirm the fistula and just used a catheter and wire to navigate through the existing tract back into the bladder. He then was able to place a new drainage tube into the bladder. My thoughts are to report just a simple catheter exchange (51705 and 75984), but I am not sure since the catheter was not actually still in the patient and I don't think a new insertion (51102) would be appropriate either.

Savi Scout Placement - Different date of service as OR Procedure

Would SAVI scout placement that is a different date of service than a lumpectomy or lesion excision be separately reimbursed / separate co-pay for patient if performed, say, 2-3 days prior to the OR procedure? - Hospital Billing

Is this allowed?

e.g. 19281, then two days later, a 19125.

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