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EXAMINATION: Right elbow arthrogram.

FINDINGS: After explanation of the procedure and potential complications of infection and bleeding, the patient was given the opportunity to ask questions. Signed informed consent was then obtained from the patient. Patient verification and time out was performed.

The right elbow was prepped and draped in the usual sterile fashion. Buffered one percent lidocaine was used for local anesthesia. Under fluoroscopic guidance, a 25-gauge needle was used to attempt to get into the radiocapitellar joint space. We were not successful at cannulating the joint space. There were no immediate complications. The patient was instructed to observe for signs or symptoms of infection.

IMPRESSION: The elbow joint was not successfully cannulated.

The innominate artery was selected, followed by the right common carotid artery. Biplane cervical and intracranial angiograms were performed from the right common carotid artery before stenting. Measurements were made from magnified oblique projections and an 8 mm x 2.5 cm GORE Viabahn covered stent was selected. This was prepped in the usual fashion with an Aristotle 18 microguidewire. The stent was attempted to advance through the Cerebase, but the sizes were not compatible.The Cerebase was fully removed from the body. Next, a 90cm BMX96 was advanced over the 130cm Berenstein selection catheter and Terumo Glidewire to the level of the aortic arch and the right common carotid artery was selected.  The 8 mm x 2.5 cm GORE Viabahn covered stent was then advanced over the Aristotle 18 microguidewire to the distal right common carotid artery. Next, the stent system was removed and we proceeded with balloon angioplasty to ensure good wall apposition. Would this qualify as 37215, EPD not specified?

We have a physician documenting IVUS in the lower extremity like this: "We then performed intravascular ultrasound. This was necessary as the angiogram did not adequately demonstrate location of wire as well as morphology of plaque. The findings are as follows: Please note, we performed individual intravascular ultrasound, which was distinct from the pullback. In the peroneal artery, there was no significant stenosis appreciated. The tibioperoneal trunk

had no significant stenosis. We were indeed in the true lumen. The popliteal artery had 100% occlusion. There was soft plaque and what appeared to be chronic thrombus. The superficial femoral artery had mild stenosis measuring

20%-25% diffusely. The common femoral artery had no significant stenosis." Would you count each individual vessel as a separate 37253? We have still been only giving credit for 1 vessel as it still seems to be a pullback even though they are documenting it isn't.

"Limited incision was made thru subcutaneous tissue with cautery. The femoral sheath was sharply incised. A severely diseased artery was identified that was circumferentially severely calcified. Dissection extended under the inguinal ligament where the external iliac artery was controlled. Heparin was administered. Longitudinal arteriotomy was made with a #11 scalpel and then extended with a Potts scissors. Severe calcific and mixed plaque in the common femoral artery was identified. Endarterectomy was extended up into the distal external iliac artery. Separate endarterectomy profunda femoris artery was necessary due to the extent of the plaque. Good backbleeding was obtained. The SFA was endarterectomized as the saphenofemoral junction was noted to be relatively low. Primary closure of the endarterectomized vessels was undertaken with running 6-0 Prolene suture."

Would you code this as 35355 and 35372-- is "arteriotomy was extended" to bill both?

During a port a cath placement, the provider stated the guidewire was inserted through needle and confirmed to travel to the IVC via x-ray imaging intraop. Later in the note he says x-ray was utilized to confirm location of the catheter at the atriocaval junction. I was advised by the audit team to query because fluoroscopy was not mentioned and we felt the 77001 was not supported. The provider responded that "x-ray is fluoroscopic guidance". Would this be enough documentation to support 77001? There is nothing else in the note, procedure list, or findings that mentions the fluoro guidance. Would you recommend an addendum as well?

We have a physician who is performing transperineal MRI-ultrasound fusion prostate biopsies. As a preparatory step of the procedure, MRI segmentation and contouring of the prostate is required. This step is usually performed by the radiologist, but they use a different system at this site and the urologist is performing this step. He was told by a vendor this step is billable with code 76377 and that the contouring/segmenting needs to be done on a day other than the day of the biopsy. Would you agree that codes 76377 and 72197 could be billed by the urologist if the documentation supports billing the two codes?

Redo sternotomy; Cutdown of Femoral for cannulation for cardiopulmonary bypass; Extensive adhesiolysis; Inferior approach to the mitral valve with radical mitral valve debridement and preservation of the posterior mitral annulus; Mitral valve replacement (TRANSCATHETER SAPIENT 3 ULTRA 26MM

I'm confused because the surgeon describes performing a sternotomy (not a mini-thoracotomy) w/extensive lysis of adhesions. He also excises anterior leaflet and resects posterior leaflet partially. He uses a 26 Sapien balloon inflated w/saline to assess the size. He goes on to talk about using a balloon to size the annulus and selects the Sapien 3 ultra valve. Under direct vision the crimped valve was advanced antegrade through the mitral annulus. Then the balloon was deflated and deployed uneventfully. Would the 0484T, 33368 be reported? Or 33430 with 33530? Maybe the confusion is the procedure performed states TMVR Sapien, but in actuality this was open. I would appreciate any help?

According to the Shockwave IVL reimbursement guide (included link below) CPT add-on code 0715T is appropriate for physician billing only. The HCPCS Coding Clinic 2nd Q 2023 states that 0715T can be reported with codes C9600-C9608 or 92928 along with the device code C1761. However, this Coding Clinic does not differentiate the encounter type (physician billing vs. hospital outpatient APC billing). Please clarify if it's appropriate to report CPT 0715T on Hospital Outpatient/ASC claims. 

https://shockwavemedical.com/r...

I had heard in an IR webinar that for ultrasound guidance 76937 permanent recording of images didn't have to be stated if the ultrasound machine used uploaded the images to the patient chart automatically, since now most equipment used in hospitals now have that capability. Are you in agreement with this statement or do you feel they should still state the permanent recording (of course it's best to state it) but wanted to know your thoughts on this and/or if you had seen this documented anywhere?

I have a question regarding your response to Question #19449. You advised that since the physician documents "Successful ablation for slow pathway for treatment of typical AVNRT" to code 93653 even though the patient was not inducible for Atrial tachycardia or Atrial Fibrillation during the EP study and it was an "empiric" ablation? I thought we are not to code empiric ablations. Please clarify. Thank you in advance.

Patient came in for a right ventricle to pulmonary conduit replacement due to severe conduit dysfunction with stenosis and regurgitation. Patient had tetralogy of Fallot with pulmonary atresia with repair ten years ago, so would you report code 33920 for the replacement since patient did originally have pulmonary atresia, or would you report code 33608 since the pulmonary atresia was corrected ten years ago?

I am having an hard time choosing a code for this interspinous bursa injection that was done for interspinous bursa with pain. Would this be considered being coded with the arthrocentesis/injection codes? Intermediate or major joint? Please help on this one. Below is the report:

FOLLOWING THE INFILTRATION OF LOCAL LIDOCAINE AND USING FLUOROSCOPIC GUIDANCE, A 22 GAUGE SPINAL NEEDLE WAS INSERTED INTO INTERSPINOUS BURSA AT THE L3-L4 LEVEL. CONTRAST INJECTION DEMONSTRATES THE NEEDLE TO BE WITHIN THE BURSA. A TOTAL OF 120 MG OF DEPO MEDROL AND 4 CC`S OF 0.25% SENSORCAINE FOR A TOTAL VOLUME OF 7 CC WAS INJECTED INTO THE BURSA. THE NEEDLE WAS REMOVED AND HEMOSTASIS WAS ACHIEVED. THERE WERE NO COMPLICATIONS. A TOTAL OF 2.2 MINUTES OF FLUOROSCOPY WAS USED.

93297, 93298: As per CPT guidelines, to bill CPT 93297 and 93298 requires a minimum of 10 days of monitoring. Suppose the provider receives the report on the 10th day with 9 days of remote monitoring data and signs the report on 10th day. The provider has not received and signed any other reports between day 10 and day 31. Is the charges billable?

93294 and 93295: As per CPT guidelines, to bill CPT 93294 and 93295 requires a minimum of 30 days of monitoring. Suppose the provider receives the report on the 30th day with 29 days of remote monitoring data and signs the report on 30th day. The provider has not received and signed any other reports between day 30 and day 91. Is the charges billable?

Confused on documentation for the two codes, if injection by the radiologist do we code 62370 or does the report need to say the physician skill was needed and we should code 62369 if not mentioned?

Can we bill transthoracic echo limited with color flow and pulsed wave codes 93308-26, 93321-26, and 93325-26 on the same date of service as the TAVR code 33361? The TAVR IS PERFORMED by one cardiologist and the TTE is preformed by a DIFFERENT cardiologist. I know we can bill the TEE 93355 when a TAVR is preformed when a different cardiologist performs the TEE. Our cardiologist are now starting to do the TTE with the TAVRs. I had read on one of your post if they preformed a TTE the diagnosis would need to be different from the reason we preformed the TAVR. Could you please give clarification on if we can bill a limited echo 93308-26, 93321-26, 9325-26 with a TAVR with two different providers, one preforming the TAVR and the other preforming the transthoracic limited echo when the same diagnosis is being applied?

Diagnosis - Pseudoaneurysm, left femoral artery /Dehiscence of the pericardial patch from femoral artery.

Dictation: I made a left flank incision to obtain retroperitoneal control of the left limb of an aortobifemoral graft. I dissected out the left limb of an aortobifemoral graft and was able to put a spring clamp on the left limb of the aortofemoral graft. I then proceeded to remove sutures from a left groin wound. I evacuated all the clots and there was a hemorrhage. On exploration, it appeared that about 25% the pericardial patch had dehisced from the left common femoral artery. I then proceeded to re-suture it with a 5-0 Prolene and ran several sutures along that anastomosis at the site where it had dehisced several interrupted sutures. After I placed the sutures and removed the clamps, it appeared that the bleeding was controlled.

Would this procedure be coded to revision of graft 35883 or would 35141 be more appropriate. Thanks for your help.

Need correct code for procedure.....

Patient catheterized via umbilical cath channel by Urology...and needle inserted into bladder. Bladder lumen opacified. ...Then IR.....Skin of Abdomen prepped and draped and Ropivicaine infused at Venous insertion site. Urine obtained, rosen wire inserted into bladder and coiled. Tract dilated with stiff micropouncture set and secured within bladder. Care then transferred. to Urology for stone extraction. 

Is it 51702? Urology billed 51102 in addition to code for stone extraction

Our vascular surgeons have started perform the Detour percutaneous femoral-popliteal bypass graft. There is not much information regarding the billing of this procedure. What would this procedure be comparable to? What CPT code(s) would be a comparable “crosswalk”? Additionally, I understand this is a carrier priced; however, what would be the best practice as far as post op visits? Should visits after fall within a global package like they do with an open bypass?

"The graft was accessed under ultrasound guidance. Contrast was injected, confirming a focal stenosis at the level of mid humerus. A 6 French sheath was placed and a Kumpe catheter advanced into the proximal graft where contrast was injected. This demonstrates a second more proximal stenosis near the graft/venous anastomosis. Angioplasty was performed of these stenoses. Contrast was then injected more centrally where prominent collaterals are present. These seem to be related to a recurrent stenosis in the subclavian vein. Angioplasty was performed with a 12 mm balloon. The balloon ruptured and would not fit in the 7 French sheath. Unable to remove the balloon through the sheath, access was achieved in the right common femoral vein and a 10 French sheath placed. A snare was used to capture the proximal end of the balloon."

Are codes 36902, 36907 and 37197 correct? Can we also code the catheter placement from the groin?

We have an order in a hospital setting for a CT-guided abscess drainage (49406). After the patient is prepared, the radiologist is unable to drain any fluid. How should that be coded?

During EPS study, at the end of the procedure note it was mentioned as “Drug study with arrhythmia induction, Adenosine was infused and repeat arrhythmia induction was performed with no inducible sustained arrhythmias”. Is the physician trying to check the adequacy of the procedure performed? If yes, should we deny CPT 93623 based on NCCI Policy Guidelines? Or the physician is performing a diagnostic study in order to see if there is any arrhythmogenic foci left over to ablate and therefore CPT 93623 should be billed separately?

Procedure: Intracranial embolization of chronic subdural hematoma through middle meningeal artery.

Please provide confirmation, that although a CTA/MRA was performed, a catheter-directed diagnostic angiogram is reportable if the provider documents medical necessity; and, second, when a diagnostic angiogram is not reported (intervention only), that it is proper to report the catheter placement codes during intracranial embolization (referring to CPT code 61624). Have I misunderstood something? Having this guidance from you, in 2023, will resolve issues on this matter. If any changes have occurred please kindly inform. Your help is greatly appreciated.

Patient had a tonsillectomy and adenoidectomy with intraoperative course complicated by oropharyngeal bleeding. IR did cerebral angiography of internal carotid (36224), external carotid and facial artery (36227). Coil embolization was then done of the left inferior pharyngeal artery and again in the left ascending palatine artery.

Your previous guidance, question ID 18819, states to code to the highest level performed when it is a bleeding tumor, but would the same guidance apply for intracranial or extracranial arteries? Would this be 61626 (75894, 75898) or 37244?

After angiogram done -I pass an intravascular ultrasound through the right common femoral artery, superficial femoral, popliteal, tibial peroneal trunk, posterior tibial arteries. This demonstrated patent right common femoral artery, occluded right superficial femoral artery stent, 60% stenosis of the right popliteal in the P1 plus P2 segments but patent P3 segment, patent tibioperoneal trunk and posterior tibial arteries without stenosis. I see 37252 and 37253 x2 . My coworker thinks it is pull back and only gives 37252. but there are 3 separate pathologies (with tibio being patent) also if you could clarify if SFA and CFA are the same or separate vessels for IVUS imaging.

A right femoral PTFE graft was punctured, fistulagram and central angioplasty were performed due to a pseudoaneurysm along the right arterial limb and common iliac stenosis. A direct needle injection of thrombin under US guidance into the pseudoaneurysm sac was performed. Can this be coded as 36909 or 36002/76942 with modifiers? 

When a patient comes in for a G-tube placement and has dysphagia secondary to ALS or in other instances dysphagia due to throat cancer what would be the proper diagnosis coding/sequencing? Is dysphagia considered inherent to ALS and not coded at all? In patients with throat cancer would the dysphagia be coded first since that is why they are getting the G-tube? Or would dysphagia be considered a sign/symptom of the cancer and not coded? If both dysphagia and cancer should be coded, what would be the proper sequencing?

We have a procedure that took place similar to question ID 5119, since this is an older question we wanted to see if the guidance has changed. Our physician completed a new bypass where a PTFE was placed between the CFA/SFA. It did take place on the same leg (left). There was no previous bypass. Would we treat this as a FEM-FEM bypass 35661 even though that specifies right to left. Or would we go with the unlisted CPT?

Can I bill 36558 and 36821 during the same operative session? I am getting a denial as not separately payable.

Left radial cephalic AV fistula. 2. Right internal jugular tunneled hemodialysis catheter placement. 3. Removal of right femoral temporary dialysis catheter.

I did not bill for the temp cath removal, as there is no code I could find for that.

43-year-old female on peritoneal dialysis admitted with fluid overload, shortness of breath, cardiac tamponade who was not tolerating peritoneal dialysis and recommendation to convert to hemodialysis.

Is code 37243 appropriate for the following procedure?

"A 4 French Cobra catheter was advanced over the aortic bifurcation and the left internal iliac artery was selected. Angiography was performed-microcatheter was advanced into the left uterine artery. A small vessel travelling inferiorly, likely a vaginal artery, was identified and the microcatheter advanced beyond this point. Embolization was performed with 500-700 micrometer beads until there was sluggish flow. After some difficulty attempting to cannulate the ipsilateral, right internal iliac artery with a SOS catheter, Omni flush catheter was used to access the artery and then exchanged for angled glide catheter over the wire. Angiography was performed which showed a smaller right uterine artery which was quite tortuous. Numerous attempts to advance the microcatheter distally were unsuccessful. This site was abandoned. The catheters were removed and an angiogram of the right external iliac artery and common femoral artery was performed showing normal caliber and anatomy."

Patient presented for biventricular pacemaker. RV lead was placed in the RV apex. Multiple attempts made to place a lead in the CS, but continued to dislodge. A left bundle lead was placed in the RV septum and leads connected to the pacemaker generator. Would you code this as 33207 or 33207 and 33225-74?

Can you please advise if there are any billable CPT codes for CMD studies performed in the cath lab at the same time as coronary angiograms and FFR, with codes 93454 and 93571. Our provider is performing these and is asking for additional billable codes for the CMD studies.

Procedures performed: Right/Left coronary angiography. CMD Study Values. Pressure flow reserve measurement.

6F FR4 catheter was placed. Selective right coronary angiography. Contrast was injected. Images were obtained using multiple projections. Selective left coronary angiography. A 6F JL4 catheter was introduced. Contrast was injected. Images were obtained using multiple projections. Successful CMD Study Values for the LAD Mid was performed. A CMD study was performed and data was obtained. The study was Positive and the results were: RFR = 0.92, CFR = 1.3, IMR = 81, AND FFR = 0.99. Pressure derived flow reserve measurement for the mid LAD. Flow reserve was measured using a 175 CM PRESSURE WIRE X pressure-monitoring guide-wire. The flow reserve was calculated to be 0.92.

What would be the appropriate codes for this scenario? 36556, 77001, 36589?

"Procedure performed: Over the wire exchange right tunnel dialysis catheter to non-tunneled temporary catheter.

Fluoroscopic guidance: Existing catheter and skin was prepped and draped in usual sterile fashion. Lidocaine was infiltrated around exit site of the catheter. The catheter was mobilized and pulled back and an over the wire exchange was performed for a 24 cm non-tunneled temporary dialysis catheter. Catheter was positioned with the tip in the right atrium."

Transjugular liver biopsy was scheduled for the patient. Physician was unable to access the hepatic vein, so the decision to abort the procedure was made. The physician performed a percutaneous liver biopsy instead. Can I code the transjugular biopsy? I feel like I cannot because the percutaneous biopsy was completed instead.

This is a 21-day-old patient with a complex intrahepatic arterioportal fistula. The report says to apply modifier -63, which I have never used before but seems to apply. They are embolizing two arterial feeders to this AVM via an umbilical venous approach. Sounds like they went through the ductus venosus and selected both arterial feeders separately (which appear to stem from bilateral inferior phrenic arteries). My question on the catheterization is would this be two second order venous catheterizations 36012 x 2, or does it switch to arterial? If we code arterial, what order of selectivity? They're trying to assign 36247 and 36248. Also, would this be coded 37241 for venous embolization or 37242 for arterial? What would be the correct cod, and should I use a -63 modifier? 

What CPT would be best to use since the provider only replaced the valve on the pleural catheter?

Patient was positioned in the semiright lateral decubitus position and the left chest and pre-existing catheter were prepped and draped in usual sterile fashion. Preliminary fluoroscopic images demonstrate satisfactory positioning of the catheter. Ultrasound of the left chest demonstrated a large left pleural effusion. A syringe was attached to the catheter valve and aspirations were attempted. No pleural fluid was aspirated. Given these findings, the pre-existing valve was removed after which copious amounts of pleural fluid was noted to be draining through the catheter. As a result, the valve was replaced and aspiration yielded pleural fluid via the new valve. Approximately 1200 mL of yellow fluid was then removed successfully without incident.

What code would you recommend for the G-tube repair described below?

"Procedure: The existing jejunostomy tube was injected and images obtained. The tube was then removed and a new custom length 14 F EnFit jejunostomy tube was placed with its tip in the distal ileum. Attempted retraction and shortening, however, patient could not tolerate additional manipulation. Post placement injection was performed. The balloon was inflated with 4 mL of saline. Attention was turned to the leaking Kangeroo-type gastrostomy tube. The gastric port was noted to be gastric contents. A new MIC-type dual port a doctor was applied and the like he was controlled. The gastrostomy tube was injected with contrast material. 

Findings: Initial injection shows existing jejunostomy tube terminating in the cecum. After exchange, jejunostomy tube terminates in the distal ileum. Patient could not tolerate additional manipulation and thus the case was terminated. Gastrostomy tube in good position. 

IMPRESSION:

1. Jejunostomy tube exchange.

2. Gastrostomy tube repair."

How would you code for a LIMA to LAD graft and two SVG to OM1 and OM2 BUT before closing checked flow in the grafts and realized the LIMA is not a good conduit? Surgeon then creates SVG to LAD. Would you code 33512 for the three SVG, OR would you code for the LIMA 33533 and two or three SVG ( 33518 or33519)?

How would mitral valve in ring and mitral valve in MAC be coded?

I have read that you don't use code 75625 unless you were at LEAST high at the level of the renal arteries, so with that being said, if a doctor only states he was at the DISTAL AORTA (I'm thinking right above the bifurcation), and an abdominal aortography with bilateral iliofemoral angiography with runoffs was performed with the catheter tip in the distal aorta, then I'm thinking that 75630 is my code.

Now, what happens if he then advances the catheter and puts it in the left common femoral artery and does a selective angiography there? There are now two different studies (but they aren't high and low), so do we forget about needing to be high up by the renals and then go with 75625 and 75710 or what?

According to your Vascular & Endovascular Surgery Coding Reference, we can code the RS&I codes for any truly diagnostic imaging performed in the intracranial or extracranial vasculature that is the same vessel in which a balloon occlusion test was later performed during the same surgical session (61623). Since the RS&I codes of the intracranial and extracranial arteries were deleted in 2013 when the bundled codes came out, do we just code 3622X-52 if they performed diagnostic imaging prior to performing the BOT test in that same vessel during the same surgical session?

Physician performed an ICD implant dual chamber ICD insertion and indicated ICD testing. Would documentation “Ventricular fibrillation was induced with burst pacing and successfully terminated with 25 J" be enough to support ICD testing CPT 93641?

Our provider documents the following during a patient office visit in our office:

"Attempt to perform non-invasive EP study with atrial tachycardia pacing to terminate his atrial flutter due to significant symptoms with atrial flutter and high ventricular rate of 130 bpm. Atrial tachycardia pacing (ATP) was performed at 230, 220, 200, 180 ms in both bipolar configuration and unipolar configuration. Despite multiple attempts of ATP's, atrial flutter was not able to terminate."

Would we be able to bill code 93724 even though he was unable to convert the aflutter to sinus rhythm? Also, are you able to bill this in addition to the E/M code?

Does I&D and removal of infected thrombosed vein left have to be coded to unlisted, or is there a more appropriate code?

I know from previous Q&As you state when a LBB lead is placed it is coded to the location of the placement, typically in the RV septum. I'm starting to see providers state they are placing the LBB lead to the LV endocardium. Would this support reporting with 33225?

"A permanent pacing lead was advanced to the RV septum and positioned in the LV endocardium for direct left bundle branch capture where a stable position with satisfactory sensing and pacing characteristics were obtained. Successful upgrade of St Jude dual chamber pacemaker to a Bi-V PM (CRT-P) with addition of LV endocardial lead for direct left bundle capture."

Would you code this as: 33233, 33207 OR 33229, 33225? Patient does have existing RA/RV leads from previous system implant.

I have a question I hope you can help me with. Cardiologist is seeing a patient who is getting an MRI (outpatient). The pacemaker was deactivated before the MRI. Physician stayed at patient's bedside to watch for any possible problems for the duration of the MRI, and then changed the programming back to how it started (and made sure there were no changes to the pacemaker because of the MRI).

Physician's question is, in addition to billing for the pacemaker check, how can I bill for the hour spent (outside of the pacemaker check)? Patient not in ED or inpatient (this is an outpatient procedure).

Seem like no extra charge for the time spent "monitoring" this patient.

The patient was positioned supine. Initial imaging was performed w/ CT. Local anesthesia was administered. A wire was placed thru the indwelling drainage catheter and the catheter was removed. The new catheter was advanced and position within the fluid collection was confirmed. How would this be coded? Can we code 49423 with 76380?

I am wondering if we can code 76937, 76937-59 for AV fistula cases that document US vascular access like this: "Under ultrasound guidance the AV graft was accessed in both antegrade as well as retrograde direction using a micropuncture needle. Needle entry was confirmed using real time ultrasound guidance and permanent ultrasound images were obtained and stored for documentation, for both the antegrade and retrograde accesses." Also, later under "FINDINGS" documentation states: "Initial US images demonstrate a thrombosed left upper extremity AV graft from the AV anastomosis to the venous anastomosis."

I am hesitant to code 76937 x 2 due to both accesses were into the same AV graft. I am also not sure if this is preferred technique or medical necessity.

I'm new to EP coding and not sure how to code ablation of the left atrial roof line and partial left atrial posterior wall after redo PVI in this case. Any recommendation is greatly appreciated.

"After PVI was achieved for all veins with entrance and exit block, isup was then titrated and numerous PACs were noted from the posterior wall. A sinus rhythm scar map was created of the posterior wall showing dense patchy scar. A left atrial roofline was applied connecting the superior veins with bidirectional block achieved. Next an inferior posterior wall RF line was delivered from the bottom of the left inferior vein to the bottom of the right inferior vein. Further ablation was then applied to areas of the posterior wall. Despite targeting all early signals and reinforcing the radiofrequency ablation lines full isolation could not be achieved. Partial isolation was achieved of the right aspect of the posterior wall."

Can you help me figure out a report? I have a Dr that did a 93656 & 93655 but at the end of the report the Dr states that a comp EP could not be done as the patient has a pacemaker and was intermittently in both atrial and ventricular pacing. Would I then add a 52 mod to the 93656? Ablation was done for Afib with pulmonary vein isolation and A-Flutter. mapping and transseptal were done as well. 

How would we code occlusion of a Mustard baffle leak?