Ask Dr. Z

EP Lab wants to charge 93657 any time ablation is performed on the posterior wall (roof and floor lines).

"He had significant scar on the posterior wall. I then exchanged for the ablation catheter. I then made the following PFA lesions on the veins: LSPV/LIPV 8, RSPV 10, RIPV 10, Posterior wall 20. Total PFA lesions: 56. After ablation was complete, the ablation catheter was exchanged for the PentaRay and a repeat map was created showing no evidence of voltage gaps. Entrance block was confirmed and exit block performed with differential pacing with PentaRay catheter and showing persistent exit block. Back wall signals were also gone. Conclusions: Successful PVI + posterior wall isolation ablation utilizing PFA for persistent Afib."

I am focused on the CPT description stating ...additional ablation after completion of PVI.

Can code 93657 be reported for posterior wall ablation performed at any point in the procedure or should it be reserved for after PVI is documented as complete and remapping performed?

Right common femoral access. Angiogram findings: multiple areas of severe stenosis, estimated 60-70 of proximal right common carotid artery with hourglass appearance in mid segment with area of stenosis estimated to be 90%, Widely open external and internal carotid artery on right side. Decision to go ahead with intervention.

Cannulated innominate artery w/NaviCross & Glidewire. Passed wire to right subclavian, then right axillary. Exchange over wire to 7-Fr, parked in innominate artery. Profiled takeoff of right common carotid artery, navigated through the area of severe stenosis and multiple segmental stenosis of right common carotid. Passed to right external carotid artery, confirmed intraluminal position with angiogram. Calibrated the lesion, deployed 8 x 59 mm VBX balloon-expandable and stented the right common carotid artery. Complete angiogram showed widely open right common carotid artery. Good flow through the external and the internal carotid arteries. Thanks so much for your review and recommendation.

"Generator was removed from pocket and leads freed from underlying scar tissue. LV lead was in brachiocephalic vein at the level of the SVC junction. LV lead was extracted. RA lead appeared to be damaged and was extracted as well. RV lead was left in with no issues. A quadripolar LV lead was inserted in midlateral branch. RA pacing lead was inserted. All three leads (RV, RA, and LV) were connected to new CRTD generator and placed in pocket." 

Is this reported with codes 33249 (generator and new RA lead), 33241 (generator removal), and 33244 (removal of single/dual chamber defibrillator electrode)? I would not report code 33225, as that is only for use at time of insertion of implantable defibrillator or PPM generator. How do I capture the replacement of the LV lead?

Would the following embolization be reported with code 37244 or 37242? Our provider performed an angiogram and embolization of the anterior division of the right hepatic artery. The findings state no pseudoaneurysm or focal hepatic arterial disruption; however, there was a subtle arterioportal shunt arising from the anterior division or the right hepatic artery near the site of biliary access, which was successfully embolized. Indication for procedure is "recurrent hemobilia, blood loss anemia".

Can you help identify CPT codes for placing a new stent within a previously placed flow diversion device? 

"Patient with history of left internal carotid artery aneurysm previously treated with flow diversion and adjunctive coil embolization. 6-month surveillance angio two days prior showed severe neointimal hyperplasia within the flow diversion device.

Findings: Selective left internal carotid arteriogram demonstrates a flow diverter device extending from the cavernous segment to the carotid terminus with an adjacent coil mass. There is very marked neointimal hyperplasia within the flow diverter construct resulting in estimated 95% stenosis and significant refilling of the aneurysm. Angioplasty was done within the neointimal hyperplasia. Arteriogram after PTA shows residual 30% stenosis and contrast stasis in the aneurysm. Stent was deployed within the region of the neointimal hyperplasia in the flow diversion device. Arteriogram after stenting shows no residual stenosis and no distal thromboembolism with complete occlusion of the aneurysm."

Aided by the mapping system, PFA was performed at ostial level of both left and right pulmonary veins. Multiple PFA applications were delivered in both basket and flower configuration. Additional lesions were delivered over the posterior wall, connecting the lesion set over the left and right pulmonary veins posteriorly.

Next, HD Grid was positioned in each of the PVs and entrance block was confirmed. High output pacing was performed to assess for exit block and exit block was confirmed. Of note, dissociated potential was noted in the LSPV and the RIPV. A post-ablation voltage map also confirmed the presence of ablation related scar along the wide area antral lesion set without any evidence of residual viable myocardial tissue.

Provider have not documented that AFib is remaining/present after PVI. Can we still code 93657 for posterior wall ablation.

If/when is endarterectomy separately reportable in the setting of an artery repair (direct and/or EVAR)? Are there any guidelines/resources I can provide my provider regarding this?

Can we take a second LHC after patient has refused having bypass surgery? Patient has LHC on 12/6 and refused bypass surgery and then has PCI on 12/20 with a second LHC. Can we charge for the second LHC with no other changes in condition?

What code do you suggest for RVOT stent angioplasty? In 2019 you suggested 93799. Is the advice still the same?

"Next, we turned our attention to stent angioplasty. This was accomplished by advancing a 0.035" glide wire, 4 French glide catheter, and 6 French x 55 cm JR guide catheter from the venous sheath into the RV and across the RVOT stent. A 0.035" Rosen wire was exchanged for the glide wire and secured in the left lower lobe. We then performed stent angioplasty with a 7 x 20 mm Evercross balloon inflated to 14 atm. Post angiography revealed nice expansion of the RVOT stent and continued coverage of the subvalvar muscle bundles with robust flow into the branch pulmonary arteries and all lobar segments. No vascular injury nor contrast extravasation was seen. Final angiography of the RVOT stent/MPA post-stent angiography demonstrates expansion of the stent to 7 mm without vascular injury or contrast extravasation."

Transcatheter Liver biopsy - a.m. procedure - access obtained in the right internal jugular vein. Catheter advanced into IVC, and cavogram was performed. Hemodynamics were obtainded with pressures measured in IVC , Rt atrium and hepatic veins, along with hepatic venogram. Power surge in equipment caused physician to abort procedure prior to biopsy. All catheters and sheath removed, hemostasis achieved. Pt was brought back in the afternoon and repeat access, venogram and hemodynamics performed, along with biopsy. Physician is dictating on both a.m. and p.m. procedures.

Can we charge for 37200 and 75970 with -53 modifier (inpatient) for a.m. procedure, and then again with -76 modifier in the afternoon?

Patient presented for carotid stent. Stent was placed, and upon removing the stent deployment system it broke off and was not able to be retrieved percutaneously. Provider then took patient to OR and removed the deployer and the stent and then completed carotid endarterectomy. Can we report both codes 37215 and 35301 in this instance, or would this be considered a failed percutaneous procedure resulting in open procedure and we can only report code 35301 (per the Chapter 5 of the NCCI Manual, only code the open procedure)?

Patent comes in for hip joint steroid injection under fluoroscopic guidance (no ultrasound): 20610, 77002. CDR for 77002 indicates fluoroscopic guidance produces x-ray images shown on a screen to assist in visualization of the anatomy, instrument insertion, and/or contrast.

There is a separate report for XR hip 2 or more views bilateral, FL guidance only for needle placement.

Findings: Two intraoperative fluoroscopic images of right hip and two of left.

The department charged 20610, 77002, 73521. I feel the 73521 should be removed, as the documentation clearly states intraoperative fluoroscopic images. I can't find anything in NCCI or CMS manual to confirm.

Do you agree the appropriate codes would be 20610 and 77002? Or 20610, 77002, and 73521?

"Physician replaced the aortic valve with an Epic Supra tissue prosthesis size 23, He also enlarged the aortic root using Manougian technique. This is the Dr. verbiage for the root enlargement " Resection of the valve was carried out. Calcium deposits were removed with routine loose debris care. The aortic root was measured and was not suitable to admit a size 19 prosthesis. Manougian reconstruction was accomplished by extending the incision into the commissure between the noncoronary and left coronary cusp into the dome of the left atrium across the anulus of the aortic valve. Hemashield Finesse graft patch was utilized to enlarge the root by creating a teardrop fashion patch that was sutured to the sub annular surface of the aortic valve using running suture technique of 5-0 Prolene." 

33405 with 33999?

The CPT codebook does not specify a code for SFA to ATA artery bypass with PTFE. Therefore, would I use unlisted code 37799 comparable to 35666? Coding for bypass would the SFA and profunda be the same as common femoral? I have also looked at comparable to 35671. Any extra guidance be appreciated.

I have read many of your questions regarding deep vein arterialization for limb salvage. I understand currently we use unlisted code 37799. However, in this particular case the doctor not only PTA vein to artery, the doctor placed a stent from the peroneal artery into the right peroneal vein and also from the right peroneal artery to the common plantar vein. This was also salvaging the limb. How would I bill those stents, as there is no stenosis given?

My doctor performed an arteriotomy at the above-knee popliteal with proximal embolectomy. He then performed an arteriotomy at the ankle for tibial access with additional embolectomy. Is the popliteal separately billable with code 34201?

Dictation states, "Catheter was advanced up into the pararenal aorta, and aortoiliac angiogram was performed demonstrating no significant inflow disease." Does this finding meet the criteria for a full aortogram without specific mention of the aorta? No renals or viscerals are described either.

Can you provide your expertise on this PICC placement?

"Procedure was non-emergent, patient identity verified. Universal protocol time out was performed. A disinfected ultrasound probe with sterile cover was used for vessel evaluation and real-time access guidance and a permanent record of the image has been stored. The PICC was inserted through the peel-away sheath and advanced without resistance or issues. ECG based tip navigation technology was used and steady bulleye range was 34 cm to 37 cm. All wires and stylets used were inspected upon removal and found to be intact and were accounted for at the end of the procedure." 

Coding department coded this with 36573 because of the ultrasound guidance. IVR department states it should be 36569 because nurses use a navigation system and not RS&I. Thoughts?

During the live chat (February 22, 2023) I asked "Our physicians are using the term 'attempted angioplasty' differently...If they did the angioplasty and it failed treating the lesion, I code angioplasty without 74. If they cannot even advance the angioplasty balloon to even attempt it and I can bill the diagnostic imaging, I code no angioplasty code and bill diagnostic imaging only. If I can't bill diagnostic, I code angioplasty with 74 since that was planned and my only primary code. Is this correct for these different scenarios?" You confirmed yes. However, our team is now debating again based on Q&A ID 18350. Can you explain why you answered ID 18350 differently? Is it because the angioplasty balloon entered the body? The balloon was not inflated, and I thought it had to be inflated to code both diagnostic and angioplasty with -74.

Is there a separate code for the MitraClip removal done prior to TMVR, or would this warrant modifier -22 being appended to 0483T?

1. Successful removal of a MitraClip using electrosurgery and retrieval with an OnO basket

2. Successful transcatheter mitral valve replacement (TMVR) with Edwards 29 mm M3/ENCIRCLE Docking system

-Residual PVL s/p closure with 14 mm AVP 2

3. Normal LA pressure and LVEDP

4. Successful closure of iatrogenic ASD with a 30 mm Gore cardio form device

Provider performed the following procedures:

• Shockwave IVL; left common femoral and external iliac artery
• Ranger drug-coated balloon angioplasty of left CFA and external iliac artery
• Stent of left external iliac artery

On the facility side, should we only submit one unit of C9765 since two IVLs were performed in the same "above the knee" territory even though one artery (CFA) was not stented? As for the angioplasties, my understanding is this is included as part of C9765.

On the professional side, would it be 37221, 37224, & 37799 x 2 (for IVLs)?

We currently have an issue with a specific denial for angiograms when we perform diagnostic and interventional in the same surgical session. The diagnostic portion is performed bilaterally, and the intervention is unilateral. The surgeon needed to evaluate bilaterally to locate the problem, then intervened on the side where the issue was located. We get a denial because the anatomical location of the diagnosis code is mismatched to the anatomical modifier of the diagnostic portion. Do you have any advice on how to approach this situation? Currently, we get the denial and must go through the appeal process for all these charges. We would like to decrease the amount of these denials but cannot seem to find a way to bill these without getting a denial. We have reached out to payers without much success. We have also reached out to Novitas, but they were not able to assist either. Any help would be appreciated.

"History: Left Lower extremity, foot, gangrene. Status post LLE bypass and anterior compartment fasciotomy. Procedure: Exploration, washout, and closure of LLE anterior compartment fasciotomy. Description: The anterior compartment fasciotomy incision was entered, and the muscle was found to be pink, reactive, and viable. We irrigated with Irrisept. The skin was then closed using sutures, leaving fascia open. A Pevena skin VAC was applied."

Everybody has a different idea of how to code this, from VAC application only, to coding for layered repair code for closure of fasciotomy. Please give us your thoughts.

What is the documentation requirement for a Swan-Ganz insertion?

This patient had IR percutaneous cholecystoduodenostomy lumen apposing metal stent placement. The procedure involved placing an NG tube to the duodenum, obtaining direct access into the gallbladder and then using those two sites to create a direct access between the gallbladder and the duodenum, and then passing a flanged metal stent between the gallbladder and the duodenum for bile drainage due to bile duct obstructions. The bile ducts were not accessed. This does not seem to fit the descriptions of percutaneous biliary stent procedures and was not performed using endoscopy. How should this be coded?

Can you please clarify if this procedure would be reported with code 33016 or 33017 for facility? Patient had a pigtail sutured in place, but the description of code 33017 states "indwelling catheter", so I am not sure if this procedure can be coded as 33017.

"Procedure: Using micropuncture needle we accessed the pericardial space. Using echo, we confirmed position in the pericardial space with agitated saline. We exchanged micro wire for J wire and dilated track with 6 French dilator then 8 French dilator. We then placed 8.3 French pigtail and aspirated 350 cc bloody fluid. Post ECHO showed resolution of pericardial effusion. Pigtail was sutured in place."

For hospital billing, is there anything that can be reported when a CTA coronary is canceled when patients that need to have their heart rates lowered, do not, even after diltiazem / metoprolol administration? Can the facility report a low-level E&M at this point?

I have a few providers who perform coronary angiographies 93454 for pre TAVR purposes with a dx of I35.0. I35.0 is not a payable dx. Should these be billed with the Q1 modifier and Z00.6 since they are related to the TAVR? I know the LCD states that a dx of R93.1 can be used for billing 93454 in patients undergoing a non-coronary surgical procedure, however, the providers only document aortic stenosis I35.0.

I need some guidance for this case. Background, the patient does not have a previous endograft in place they are presenting with blue toe syndrome and aortoiliac disease with tissue loss but findings show an embolized aortoiliac with focal dissection associated with a plaque/thrombosis. Kissing aortoiliac stents were placed... I'm going back and forth over using 37221-50 vs using 34707-50. Am I on the right track? Which of these would you use, or do you have another suggestion. Unfortunately, the doctor does not describe a stenosis with measured percentages which is another frustrating layer which has me leaning more towards 34707-50.

"The patient came in with history of PE and bilateral lower extremity DVT and presents with IVC filter removal and venoplasty and reconstruction of the IVC and bilateral iliac veins. The physician removed the filter from the right internal jugular and left femoral access. Under US guidance he then accessed the right femoral vein, placed the catheter in the IVC, and placed a stent in the IVC and kissing stents in the bilateral iliac veins."

Would you be able to report code 36010 for the separate right fem access? If so, I don't know which X modifier would fit, or would it be just use a -59? Or would I just code the stents plus IVC filter removal?

The bilateral groins were prepped and draped in normal sterile fashion. Under ultrasound guidance a micropuncture kit was used to advance a 5 French sheath into the right common femoral artery Mickelson catheter was introduced over a Glidewire. Diagnostic spinal angiography was then undertaken of the left T6, bilateral T7, bilateral T8, bilateral T9, bilateral T10, bilateral T11, bilateral T12, bilateral L1, bilateral L2, bilateral L3, bilateral L4, bilateral iliac and median sacral arteries.

Do I code for additional 36245 for the contralateral catheterization of the LT iliac since the initial access was in the RT common femoral artery? I don't see medical necessity and looks like done for comparison only.

What exactly is a recalibration of the cardioMEMS device? Maybe if we understood what this procedure entails then we wouldn't be questioning how to code for it! Previous response (#13824) has advised not to use 93290 for this, and to use 93799 instead. So, what is the difference between performing an in-person interrogation of the cardioMEMS with 93290 and a recalibration of the cardioMEMS during a RHC with 93799?

What do I code when the only procedure performed was left atrial 3D mapping? The only documentation I have is, "We went transseptal with the Baylis sheath and needle into the left atrium add we exchanged over stiff pigtail for the Agilis sheath through the Agilis sheath we used the HD grid 3D anatomic mapping catheter and mapped out the entirety of the left atrium left atrial mapping demonstrated continued isolation of pulmonary veins and posterior wall and the lateral mitral isthmus we found significant fractionation along the anterior roof and the anterior septum and the floor we loaded the patient with IV amiodarone we are able to cardiovert him to sinus rhythm we removed the catheters back to the right atrium no pericardial effusion we removed catheters."

The EP lab wants to charge 93613, but I cannot find a primary CPT code to use. 

Atrial pacing lead extracted and not replaced during biventricular ICD generator change. RV ICD lead and LV lead remain.

Would the atrial pacing lead extraction be coded as 33235 or 33244?

Our thoracic surgeon billed code 33213 for generator insertion. In the same setting our EP physician did testing and programming in the operating room. Can the EP physician report code 93280 for his services?

Our physician documented: "Using a Seldinger technique and peel-away sheaths, the defibrillator lead was placed under fluoroscopic guidance. Once testing showed adequate and stable function, the ICD lead was secured using the suture sleeve. The pocket was liberally irrigated with antibiotic solution. First the ICD lead was connected to the ICD generator, then the existing RA and RV (LBB) lead were separated from the permanent pacemaker generator and secured/connected to the ICD generator. The permanent pacemaker generator was removed. The ICD generator and leads were then placed within the pocket. Fluoroscopy confirmed stable lead position" Since there is no LV lead I was coded 33233 and 33249, the hospital was added 33225. Can you please help with this scenario? Thank you

REMOVED/EXPLANTED: PM GENERATOR

IMPLANTS:

ICD GENERATOR

RV

RETAINED:

RA

Left Bundle

Has there been any updated guidance in regard to coding angiograms for Angio-seal placement? The most recent article I could find was from 2013. (Question ID: 4836 from April 30.2013)

Our vascular surgeons express that angiograms are a medical necessity for proper placement of Angio-seals in order to ensure proper function of the device.

Would it be appropriate to code the angiogram and Angio-seal together and if so what type of documentation would be required to support coding the angiogram? We normally see a brief statement like 'View of the left groin revealed that Angio-Seal could be utilized.' Would this be adequate?

At the start of a transvenous extraction of a dual chamber pacer system, including leads, with the insertion of a leadless pacemaker. Under ultrasound guidance and using micro puncture technique, 4 femoral venous access (12 French, 9 French, 9 French, 5French) and 1 femoral arterial access (4 French) were inserted. The super stiff wire was inserted under fluoroscopy guidance to left brachiocephalic vein. Bridge balloon was prepped and inserted into the level of SVC/RA junction. Balloon was inflated and the location of the balloon was marked on the Super Stiff wire. The volume of contrast injected was marked on the syringe. The balloon was then deflated and pulled back into the IVC. The balloon was inflated for medical necessity as there was concern for high risk of SVC tear given the lead location and dwelling time. The provider wants to bill 37244-52, as instructed in a 2018 document from Phillips Corp. We aren't familiar with this procedure and want to use 33999 (unlisted code) for 33370 (Embolic protection). Who is correct?

Would you code 37618 with 20103?

"The patient then underwent general anesthesia with endotracheal intubation. The patient was then repositioned in supine position with all pressure points padded in the standard fashion.

The patient was then prepped and draped in the standard fashion. Final time out was performed prior to incision. Patient's wound was irrigated and diffuse oozing from the base of the hematoma cavity. Significant hemostasis was achieved using electrocautery. Additional hemostasis was achieved with figure-of-8 stitches using 3-0 Vicryl. The wound was irrigated and found to be hemostatic. The wound cavity was fulgurated, and packed with Surgicell and Gelfoam. A Kerlix roll was then packed into the wound, and the wound was dressed with 4x4 gauze and silk tape. Patient tolerated the procedure well, with no immediate complications. She was extubated and taken to PACU in stable condition."

When would you anticipate using 76018 in addition to device peri-procedural code 93286 or 93287?

Patient comes in for an ERCP. The IR physicians are doing the S&I for the ERCP. They are assessing this patient's stricture at the anastomosis. The other providers may balloon the anastomosis and replace the stent or remove the stent if no longer needed.

• If they need to replace the stent, would the stricture at the anastomosis be considered a transplant complication - T86.49?
• If the stricture has resolved and they remove the stent, would this be Z48.23, Aftercare following liver transplant?
• If the transplant was within the global period and they insert or replace the stent, would we use K91.89, Other postprocedural complications and disorders of digestive system, or do we still use T86.49 or Z48.23?

Would this procedure be coded with 64999 or 62362? 

"The site was injected with 0.25% bupivacaine with epinephrine for local anesthesia. Incision was made first over the pump pocket site. Using electrocautery, pump pocket was opened. Anchoring sutures were removed. The pump was removed from the pocket and examined. It was intact. Reservoir was drained with corresponding value as reported on point of 1.2 mL. Pump was then refilled with 20 mL of 1 mg/mL morphine.

A 0-0 Prolene stitch was passed at the 11:00 7:00 and 4:00 positions deep in the pocket for anchoring of the pump. All wounds were irrigated with antibiotic saline solution. The pump was placed over the pocket incision and x3 prolene stitches were tied to 3 of the 4 anchoring loops on the pump. The pump was placed in the pocket at this point with the rest of the catheter tucked behind the pump. All incisions were closed with a deeper layer of simple interrupted and superficial layer of buried 2-0 vicryl stitches and skin staples. Dressing applied."

I recently started at a new facility and came across this documentation for moderate conscious sedation: "Under my direct supervision, intravenous moderate sedation was administered during this procedure with continuous monitoring of hemodynamic parameters by trained nursing staff. Sedation time commenced at 1259 and terminated at 1317. Moderate sedation was achieved with Versed and fentanyl, and dosages were recorded in the patient's medical record." This seems close to meeting the requirement for an independent observer, but I’m unsure if it’s sufficient. Perhaps I’m being too black-and-white in my interpretation. Would you consider this enough to support coding 99152?

Per provider report- Esophageal varices arising from the portal vein/splenic vein were selected more centrally, and further coil embolization was performed with detachable coils. The more dominant esophageal varix contributing branch arose from the main portal vein, around the level of the portal end of the stent and required access with a reverse curve Contra catheter. Further access with 2.4 French microcatheter was obtained, followed by coil embolization with detachable coils. The splenic vein was again selected with a marking pigtail catheter, and splenic venogram was performed demonstrating satisfactory embolization of varices and preserved brisk flow through the patent TIPS stent to the right atrium. In this case patient has existing TIPS- is this TIPS revision? Patient also had a gastric varix from the splenic vein, so 37241 would be coded for this regardless. My documentation frequently states the varix arises from the portal vein- if placing TIPS or doing a revision in this case, would 37241/37244 in addition to 37182/37183, be coded?

"Right common femoral access was obtained using micropuncture system and sheath. Angiographic images were performed, and there was noted to be diffuse ulnar artery calcification with two areas of stenosis distal to the fistula. The fistula anastomosis looked patent and without disease. Catheter was used to advance past the area of stenosis. Distally POA was performed with balloon extending into the ulnar artery to the proximal metacarpal joint. More proximally, a 2.5 x 100 mm was used to perform POA. Completion angiogram showed adequate results. The radial artery was evaluated, and our decision was not to perform POA, as there was no significant disease, and contrast washout now preferentially occurred in the ulnar artery prior to the radial making us feel satisfied with our results. Subsequently, a perclose device was used for closure of the arteriotomy."

Do I report code 36902-LT or 37246-LT for the POA of the ulnar artery? The diagnostic angiogram is 75710-LT.

Is 90472 reported per line or in units? For example, if a patient received four vaccines at an encounter, would we bill Vaccine, 90471, Vaccine, 90472, Vaccine, 90472, Vaccine, 90472. Or would we bill Vaccine, 90471, Vaccine, 90472x3?

I have an external iliac artery to distal anterior tibial bypass with cryopreserved vein. I'm not finding a CPT code for this combo. How should I code?

Which embolization CPT code do you report for pre-operative embolization prior to Whipple procedure?

What codes are supported for this coiling of the left circumflex to coronary sinus fistula? RFA was accessed. A fine cross microcatheter was then advanced to the previously placed plug and a whisper wire was used to access one of the micro channels into the upper third of the AVP2. Once the microcatheter was advanced past the disc we deployed a 3 mm x 8 cm Azur CX 18 detachable coil. Repeat angiography showed significant flow through the area and we felt there were multiple micro channels contributing. We then placed a second 3 mm x 4 cm Azur CX 18 detachable coil with significant flow. A third 3 mm x 8 cm Azur CX 18 detachable coil was then deployed prolapsing into a very small obtuse marginal branch. After 3 coronary deployments there was still significant flow therefore a fourth 6 mm x 20 cm Azur CX 18 detachable coil was packed tightly into the mid left circumflex avoiding the major obtuse marginal branch. The guide cath was exchanged for a pigtail catheter which was used to perform left ventricular manometry. Thank you!

Are there any guidelines for picking which level is primary when the physician performs kyphoplasty in the thoracic region and the lumbar region? I have seen documentation that states the first performed is the initial and the other the additional code, but I am not sure if that is current advice, and there was not a reference to where this information was found.