Ask Dr. Z

Neck Ultrasound Procedure

"Transverse, longitudinal, and oblique ultrasonic sections of both neck were performed. Color Doppler evaluation also was performed. Entire study was real-time with no images. Right lower neck and left lower neck level VI lymph nodes are localized on the overlying skin. Right neck level III and level II jugular chain of lymph nodes are identified and localized on the skin. Findings were demonstrated and discussed with physician on real-time images. FINDINGS: Bilateral lower neck level VI and right level II and level III nodes were identified and localized on the skin for surgical planning."

I'm not sure what the appropriate CPT code to use would be. I'm thinking of maybe unlisted code 38999 for lymphatic system. Any suggestions?

Cutdown to Remove Balloon

One of our physicians had a complication during a venous intervention, and I'm just wondering if it can be billed and, if so, what the correct codes would be. "The patient had stents placed in the bilateral common femoral veins, external iliac, common iliac vein, and a double-barrel stenting of the IVC. The complication occurred during the ballooning of the last stent in the left common femoral vein. The balloon ruptured and would not deflate fully; it appeared to get stuck on the stent and pull it in a more caudal position. After multiple attempts to remove the balloon it was decided he would have to do a cutdown. The physician opened the femoral vein, removed the balloon and stent, explored the vessel, and closed." He is billing 35860 and 37197, and I'm pretty sure they are not correct. Can this complication be additionally coded, or is this included in the primary codes? If it can be coded, what would the correct codes be?

Transnasal Sphenopalatine Block

I could not find a CPT code for this px. Is code 76000 sufficient? "Transnasal sphenopalatine block. Clinical history: 35-year-old female with chronic headaches, referred for a Sphenocath procedure. The patient's nostrils were first anesthetized with 2% lidocaine via an atomizer. A Sphenocath catheter was then inserted in the left nostril with the patient in supine position with the head tilted back and in Trendelenburg. 1.5 mL of a mixture of Visipaque and 4% lidocaine was injected in the right nostril with the spheno-catheter in appropriate position. Fluoroscopy confirmed that the mixture of contrast and lidocaine accumulated in the sphenoethmoid recess. The catheter was removed and placed in the right nostril. The procedure was repeated as above. Conclusion: Successful injection of transnasal lidocaine and contrast into the sphenoethmoid recess. Fluoroscopy time 1.1 minutes Air Kerma 1 Dose area product of 0.21 cm square."

Endovascular Repair Internal Iliac Aneurysm

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

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

62311 bilaterally

Dr. Z, Good morning! Radiologist will dictate "Left L5-S1 interlaminar epidural steroid injection", I charge 77003/62311. Radiologist dictates "Bilateral S1-2 interlaminar epidural steroid injection", I charge 77003/62311-50. I spoke to my radiologist, he says usally it is a bilateral injection, but ocassionally if the patient has had previous surgery or injury only one side is done. I asked that a bilateral charge be built in our chargemaster for the bilateral injections. They are getting challenged with this request, they say this code should not have a 50 modifier. What are your thoughts on this issue? I thought I was doing the charges correctly, no edits, but now the challenge from the the charge master software auditor. In your Interventional Radiology Coding book I find that 50 modiifers are to be used for the facet joints/64493, page 451, and nerve root blocks/64483, page 455. So I need help with the Epidural Injections. As always, thank you for your help, R Mercer

BREAST ASPIRATION WITH POST MAMMO AND CLIP PLACEMENT

The skin site over the targeted lesions was prepped and draped. Lidocaine with infiltrated into the deeper tissues around the lesion. under direct sonographic guidance, aspiration was performed using a 22 gauge spinal needle. Lesion completely collapsed upon aspiration and approx. 2 cc of yellowish fluid was removed. A ring shaped biopsy marking clip was placed at the former site of the cyst.

Compression was held until hemostasis was achieved. The specimen was sent t the lab for analysis.

Post procedure digital CC and lateral mammograms were obtained which show resolution of the mammographic finding and the biopsy marking clip in the expected location

Impression: successful ultrasound-guided aspiration of 2cm cyst in the 4-5:00 position of the left breast.

Since this is a breast aspiration, would that clip placement be considered unlisted? I got codes 19000, 76942, 77065 but unsure of the clip placement. Thank you- DM

Thrombectomy of AV graft with fistulogram and removal of AV graft

This patient had a thrombectomy of his AV graft with a fistulogram that showed an occlusion higher up in the arm at the axilla. Decision was made to take down the AV graft. Do you code this to a thrombectomy of the AV graft (36831)? Or is this an unlisted procedure of the vascular system (37799)? "Graftotomy was made in the arterial limb of the graft, and patient was given heparin. A thrombectomy was performed with a #4 Fogarty, clearing the graft material of clot. A fistulogram was performed, demonstrating a total occlusion higher up in the arm at the axilla. After multiple attempts, we still could not clear the total occlusion in the left upper extremity vein. At this point, because of the presumed contact in the outflow obstruction, it was elected to remove the graft material in the forearm loop. Next, a counter incision was made in the distal forearm, the graft material was dissected free of surrounding tissue with the scissors, and then the loop of the AV graft was removed."

Biventricular ICD pocket infection with extraction

Incision extended to pre-existing pocket. Device was freed from the pocket. There is pus coming from the pocket which was irrigated & culture sent. Leads disconnected from old generator. All 3 leads were able to be easily removed with placement of stylette and retraction of the screws with gentle traction. The upper pocket incision was then. Access obtained to left IJ under ultrasound guidance with placement of guidewire. A 6 French peel-away sheath was then advanced over which a Boston Scientific pacing lead was advanced to the right ventricular apex and secured with active fixation. The explanted generator was then cleaned and attached to the lead and the atrial port. The RV and LV port were then plugged with pin plugs. Externalized device and lead used to continue backup pacing for a few days.

I am new to EP I currently have 33244, 33241. Would I also add 33234 since there were 3 leads removed, or since there was a new lead attached for the external device leave the 33234 off of the claim?

IR Myelogram Followed by CT Myelogram

Confusion over how to code. IR dept does IR myelogram followed by CT myelogram. Order "lumbar puncture for cervical myelogram". IR physician report: "L5-S1 inerspinous region localized using fluoro. Spinal needle introduced. 10cc of 300 strength contrast injected with free flow within thecal sac. Contrast seen to upper thoracic level. Further imaging CT cervical region. CT Report: Axial images were obtained from the posterior fossa through the cervicothoracic junction with sagittal and coronal reconstructions in bone and soft tissue. There is good filling of the thecal sac with contrast with visualization of the posterior fossa cisterns and fourth ventricle. There is retrolisthesis of C5 on C6 of 2 mm with otherwise normal alignment. Vertebral body height is preserved. There are multiple anterior osteophytes from C3 through C7. At C2-3, there is a small right marginal osteophyte encroaching on the neural foramen with mild nerve root displacement. Facet arthropathy is present on the left. At C3-4, there are no significant abnormalities..."

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?

35371 & 35302

"Incision was placed in the left groin and taken down through subcutaneous tissue. We then carefully dissected the common femoral, the superficial femoral, and profunda femoris. The lateral circumflex femoral vein was doubly ligated and divided. I then dissected distally on the profunda, and two large terminal branches were circumferentially controlled. The patient was given full heparinization. At this point, we performed an arteriotomy in the common femoral. This was extended to the profunda all the way to the distal terminal branches. We then performed an endarterectomy on the common femoral and profunda and extensive eversion endarterectomy of the superficial femoral. I had to make a counterincision to get the plaque out of the proximal superficial femoral artery. After this was done, the shards of intima and media were circumferentially removed. A bovine pericardial patch was then placed on the common femoral to the distal profunda. This was sutured with 6-0 Prolene."

Does the counter incision mean that both codes 35371 and 35302 are billable?

36252, renal stents, renal catheter placements

The following procedure was perform in the Cath Lab. A Heart Cath procedure was not performed. Abdominal Aortogram, Selective Bilateral Renal Artery Angiogram Angioplasty and stent of the Right Renal Artery Angioplasty and stent of the Left Renal Artery Description: Access was obtained in the right femoral artery and the abdominal aortogram Selective LT renal artery angiogram was performed. The proximal renal artery had a 90% stenosis and a lower pole branch that came off right at the stenosis.Angioplasty was performed stent was employed. There was no residual stenosis and the branch was saved. Attention was next turned to the right renal artery. The 99% ostial stenosis was pretreated with angioplasty and stent . Final results showed no persistent stenosis and no embolization. Would codes 37205, 37206 and 36245-50 be correct for this procedure?

Unsuccessful Recanalization of the SFA with Crosser Catheter

My question on the case that follows is regarding the unsuccessful recanalization of the SFA with a Crosser catheter. The physician was able to pass the Crosser catheter through the occlusion of the SFA, but was not able to proceed with any other interventions due to not be in the true lumen. Based on the documentation in the operative note below, would code 37225 be reportable?

left: 30px;">Operative report: PROCEDURES PERFORMED: 1. Abdominal aortogram. 2. Right lower extremity distal runoff, third order catheter placement. 3. Percutaneous transluminal angioplasty and stent placement, right external iliac artery. 4. Crosser atherectomy, right superficial femoral and popliteal artery. INDICATIONS: Woman who presented to the office with ischemic rest pain of the right lower extremity. Physical examination as well as noninvasive studies confirmed the atherosclerotic etiology, and she is, therefore, undergoing angiography with hope for intervention and limb salvage. PROCEDURE: The patient is taken to the Special Procedures Suite and placed in the supine position. After adequate sedation is achieved, both groins are prepped and draped in a sterile fashion. 1% lidocaine is infiltrated in the soft tissues overlying the left common femoral impulse, and access to the left common femoral artery is obtained with ultrasound guidance. Ultrasound is placed in a sterile sleeve. Ultrasound is utilized secondary to lack of appropriate landmarks to avoid vascular injury. Under direct visualization, the common femoral artery is identified. Image is recorded for the permanent record. The artery is noted to be pulsatile and homogeneous indicating patency. Micropuncture needle is inserted into the anterior wall with direct ultrasound visualization. Microwire followed by micro sheath, J-wire followed by 5 French sheath and 5 French pigtail catheter are then inserted. Pigtail catheter is positioned at the level of T12, and AP projection of the abdominal aorta is obtained. Pigtail catheter is repositioned to above the bifurcation, and an LAO projection of the pelvis is obtained. Previously placed stents in the common iliac arteries are identified, and both are patent. Occlusion of the right external iliac artery is identified with reconstitution of the common femoral. 5000 units of heparin is given and using a combination of VS-1 rim, and the pigtail catheter and a stiff angled Glidewire the aortic bifurcation is crossed. Initially the VS-1 is successful. The Glidewire and VS-1 catheter are then negotiated across the external iliac and into the common femoral artery. Hand injection of contrast demonstrates patency of the common femoral and intraluminal placement. The catheter is then advanced into the profunda femoris, and the 5 French sheath is exchanged for a 7 French Balkan sheath. Balkan sheath is positioned in the mid common iliac on the right, and a 6 x 10 Rival balloon is used to angioplasty the external iliac artery. Follow-up angiography demonstrates it is patent. There is a significant intimal flap; however, this does allow advancing the Balkan in so that the tip is now in the common femoral. Additional heparin is given. The S6 crosser with an angled Usher catheter is then positioned at the small cul-de-sac, and Crosser catheter is used to advance down to the popliteal. Ultimately, however, we were not able to re-enter the true lumen in the mid popliteal, and further attempts at treating the SFA were abandoned. The Crosser catheter and Usher catheter were then removed. There was an exchange for a 0.035 Magic torque wire, and a Life Star 7 x 80 stent was deployed across the external posted with a 6 mm balloon. Follow-up angiography demonstrated the iliac system is now widely patent flowing into a common femoral and profunda femoris, which were widely patent. The sheath was then pulled into the external iliac on the left side, oblique view obtained, and subsequently the sheath was exchanged for a 7 French 11 cm sheath. ACT was checked, which was noted to be 200, and the sheath was later then pulled and pressure held. There were no immediate complications. INTERPRETATION: Initial views of the abdominal aorta demonstrate diffuse atherosclerotic changes. However, there are no hemodynamically significant stenoses. The aortic bifurcation is diseased but patent. There are bilateral common iliac artery stents. They do not extend up into the aorta. They are both patent. The right external iliac artery appears occluded. Internal iliac artery is patent. There is reconstitution of the common femoral and profunda femoris. Superficial femoral artery is a flush occlusion. The popliteal is reconstituted in its midportion at the level of the femoral condyles, and there appears to be single vessel runoff to the foot. Following angioplasty there is a flow-limiting dissection in the external iliac. This was later treated effectively with a Life Star stent and postdilated to 6 mm. Attempts at crossing the SFA using a crosser atherectomy catheter were successful at achieving the catheter and negotiating down into the popliteal; however, we could not re-enter the true lumen and, therefore, no further interventions were performed at this time. SUMMARY: 1. Successful recanalization of the iliac system. 2. Unsuccessful recanalization of the SFA.

CABG x 6

"Left radial artery graft was carefully anastomosed side-to-side to the ramus and then end-to-side to the OM1 in standard vascular anastomotic fashion. A separate vein graft was placed onto the acute marginal side-to-side and then end-to-side onto the PDA, which was then interpositioned anastomosed to the RIMA in standard running vascular anastomotic fashion. An SVG was placed end-to-side to the D1. LIMA was carefully anastomosed to the mid LAD in standard running vascular anastomotic fashion. The proximal SVG was carefully anastomosed to the ascending aorta in standard running vascular anastomotic technique. The hood of the radial artery graft was placed onto the hood of the SVG off the ascending aorta." I'm a bit lost... is this reported with 33535, 33519, 35600, and 33508? I'm very confused as to the meaning of the last sentence.

Sclerotherapy of fluid collection with Drainage from existing drain

"Patient has a cystic pelvic mass that needs frequent draining, and drain is already in place. When patient comes to the radiology suite, contrast is injected under fluoro, and multiple images are taken and stored in PACS. The cystic mass is completely drained by approximately 470 mL of yellow fluid via the existing drain, then 35 mL of Betadine was injected through the drain tube to perform sclerosis. The tube was capped for one hour, then the Betadine was drained. The drain was left in place." In addition to the 49185 sclerotherapy procedure, are we able to code for the drainage procedure that proceeded the sclerotherapy since the drain was already in place and a new drain was not placed? Can we report codes 49406 and 49185-59, or should we only report code 49185 for this scenario with the drainage procedure being included?

Endoloop

Is there a code for Endoloop, or is it included? "A 5 mm incision was made in left upper quadrant, and under direct camera vision a 5 mm trocar was placed in the abdomen. Belly was insufflated. There was no trocar site injury. There was ascites present, which was drained around 1 liter with clear yellow ascites. After this, a 5 mm incision was made above the belly button, and under direct vision 62 mm dual cuff pigtail peritoneal dialysis catheter was pushed into the pelvis. A separate stab incision was made in the pelvis in the midline, and under direct vision an Endoloop device was used to tack the catheter to the belly wall. Hemostasis was confirmed. Belly was desufflated. A tunneler was used to tunnel the catheter from the incision site to the trocar site and brought out. Attachments were applied to the catheter. Incisions were closed. A liter was instilled into the belly without any difficulty in 3 min and drained in 3 minutes."

RT femoral artery removal of sheath

My provider wants to bill the following as a repair indication for procedure: "Patient was having thrombolysis and was noted to have decrease in hematocrit and hemodynamic decompensation. Patient was found to have a retroperitoneal hematoma and has a right femoral sheath that had been upsized to a 6 French sheath to avoid further potential bleeding. Description of procedure: Patient was prepped under sterile and controlled condition. Incision was made in the right groin and dissection carried down to expose the area where the sheath has entered the femoral artery. Sheath was removed. The sheath insertion site and femoral artery were repaired by means of 5-0 prolene. Hemostasis was obtained and wound was irrigated thoroughly with irrigating solution. Platelet gel was applied on the wound. The wound was subsequently closed in a double layered fashion with absorbable suture and skin approximated in subcuticular fashion. Dermabond was applied, and patient left the OR to be monitered in ICU." How would this be coded. Just a removal or a repair?

Fem-peroneal bypass with jump graft to distal peroneal artery

"Left fem-peroneal bypass using reversed ipsilateral greater saphenous vein. After patching the femoral artery with a portion of the greater saphenous vein the vein was then anastomosed and tunneled to the level of the peroneal artery. It was diseased in the more proximal segment, so a patch was placed with a segment of the GSV, and then the graft was anastomosed end-to-side into the patch. Angiography confirmed poor outflow fromt he peroneal segment. Provider then harvested a segment of the contralateral GSV and created an end-to-side anastomosis within the prior bypass and an end-to-side anastomosis between the jump graft and peroneal artery." We feel that code 35566 is supported for the initial bypass graft. We are not sure about the jump graft in this case. Is there a separately reportable code option for this additional work?

Code 37210

Original Question: How would you code a uterine artery embolization for dysfunctional uterine bleeding where the end of the report states: "Right uterine artery injection outlines large round mass consistent with leiomyomata. This was succesfully embolized." This patient had congenital absence of the left uterine artery (determined after doing angiography.) Would you use code 37210 or 37204, etc.?

Follow-Up Question:  The issue is that the IR doc says "consistent with leiomyomata", so it is not definitive and this is for professional fee billing.  I coded the dysfunctional uterine bleeding instead, and it was denied. However, I felt using the selective catheter placement, angiography, and regular embolization codes would be over-coding.  Any thoughts on this?

2nd request-Discography/FAD

Is this coded with an unlisted for FAD or 62290/72295 for discography each level or both? 

Provocative discogram of L2-3, L3-4, L4-5, L5-S1. (4 separate levels). Technique: The patient was prepped and draped in usual sterile fashion. Local anesthesia was achieved with 1% lidocaine. The L2-3 disc space was accessed with a 22g Chiba needle introduced coaxially through a 18g spinal needle from the left. The L3-4, L4-5, and L5-S1 levels were similarly accessed. Injection of contrast was performed at each level, blinded to the patient. Findings are listed for each level similar to this: Level L2-L3: Opening Pressure: 30 psi CC's of contrast: 1 End Pressure: 100 psi Pain Severity: moderate Pain Classification: Concordant Moderate concordant pain elicited at L2-3, L3-4, and L5-S1. No pain elicited at L4-5. Endpoint for each level is as follows: 1) 3cc total contrast volume, or 2) pain level of "severe" or 3) pressure of 100 PSI in a normal disc or 4) pressure of 50 PSI over the opening pressure if there is grade 3 degeneration or higher.

Melody Valve

We have a physician who in the H&P says under plan the intent of the procedure is "cardiac catheterization and percutaneous pulmonary valve placement" and then in the operative note says, "...presents for cardiac catheterization, stent placement across the pulmonary valve, and possible percutaneous pulmonary (Sapien) valve placement. We may elect to place a stent today and have the patient return in 4-6 weeks for placement of the percutaneous valve to allow for stent endothelialization." In the operative note he also lists the technical procedures as right and left heart cath/stent placement RVOT. For coding this should I go by the stated intent of the procedure in the H&P and use 33477-74, or should I code what he said was done in the operative note? In both of these cases we will have another account coded and billed with the Melody valve procedure once they return to complete the procedure. We do not want to code the valve replacement with a modifier if he wasn't planning on doing that. Is this a staged procedure? What would be appropriate in this situation?

Neuroprotective Device to Prevent Stroke During TAVR

Would placement of the Claret Medical Sentinel neuroprotective device under clinical trial be considered inclusive in the TAVR procedure codes for ICD-9-CM and ICD-10-PCS? Or should we be assigning a separate code for it? If it is to be coded separately additional information as to location of the device will be requested. "Using, micropuncture technique the right and left femoral arteries and right femoral vein were accessed. Heparin was given. A sheath was placed, and a Claret neuroprotective device was placed. Then, a 26 mm SAPIEN 3 was passed through the sheath into the descending aorta. The balloon was docked on the valve, and the valve was then passed across the aortic annulus and positioned using aortic root angiogram, fluoroscopy, and transesophageal echo. We deployed the valve under rapid ventricular pacing. Post deployment there was excellent hemodynamics, trivial regurgitation, and minimal gradient. We then removed the Claret neuroprotective device and then protamine was given. The patient will be returned to CICU in stable condition." 

S&I with lower angioplasty

"The left femoral artery was accessed under fluroscopic guidance with a micropuncture needle, wire, then sheath. A 4 French sheath was inserted over a wire. A wire, then catheter was inserted into the aorta. An aortoiliac arteriogram was performed. A bilateral lower extremity arteriogram was performed. The right iliac, then common femoral artery was selectively catheterized, and an arteriogram was performed. The right superficial femoral artery was selectively catheterized and angiography performed. Two severe stenoses were identified in the right popliteal artery, in the P1 and P2 segments. An up-and-over 5 French sheath was inserted over the wire into the right superficial femoral artery after 3000 units of intravenous heparin was administered and three minutes allowed to elapse. Balloon angioplasty of the right popliteal artery was performed using a 5 mm cutting balloon." How would you code the S&I: 75630 or 75625, 75716?

Trauma Pelvic Fracture with Hematoma

Since the inferior epigastric artery comes off the external iliac, would codes 75716 and 36247 along with 75898, 37204, 75894, and 75774 be appropriate?

"5 French catheter is advanced into abdominal aorta via left femoral, followed by abdominal-pelvic arteriography. Next, catheter is advanced across aortic bifurcation, followed by more focused angio of right iliac vessels. Extravasation arising from muscular branch of medial inferior epigastric artery. 3 French microcatheter advanced selectively into right inferior epigastric artery. Repeat angio confirms acute hemorrhage. Gelfoam is injected until no demonstrable flow within distal inferior epigastric vessel. Lastly 3 mm microcoil placed immediately proximal to the vessels previously supplying area of hemorrhage. Dedicated angiography of contralateral iliac system is unremarkable."

PVI and Additional Lines

We are debating a case and need your expert advice. Our EP physicians are saying we should be able to bill code 93657 x 2 for both of the additional ablations, and they indicated the medical necessity in their dictation. Due to the allowed space, I have only sent you their conclusion. "Successful EP study with successful ablation of the mitral isthmus line, anterior line, and septal line. Successful ablation guided by 3D mapping. Left atrial recording successful. Uncomplicated transseptal puncture assisted by intracardiac echo. EP study after Isuprel infusion with induction of typical right atrial flutter. Successful ablation of cavotricuspid isthmus with bidirectional block demonstrated. Successful cardioversion out of atrial fibrillation at the start of the procedure to determine whether the previous lines were blocked." We billed codes 93656, 93613, 93622, 93623, 93655, and 93657 x 2. Is there any time that you can bill 93657 x 2? We don't see this very often and would appreciate your advice and direction.

popliteal femoral artery embolectomy,tibial artery thrombectomy left side

Would this just be 34203? "Clamps were placed on the legs to make a transverse arteriotomy in the common femoral, and we first identified the profunda femoral, passed a #3 Fogarty balloon to 15 cm, and then brought it back with a small amount of clot and excellent backbleeding. A second pass revealed no further clot, and so we placed a bulldog on that and turned our attention to the SFA. A 5 mm Foley balloon was advanced down the SFA and into the anterior tibial to 60 cm. The balloon was inflated and brought back with return of clot. A second inflation did as well and the third revealed nothing further. Clot was removed There was some spasm and the anterior tibial had some spasm in it The peroneal was essentially occluded as was the posterior tibial. We used a TrailBlazer catheter and an angled Glidewire to get into the posterior tibial and we were able to get down to the level of the foot and placed a catheter, embolectomy balloon into the posterior tibial artery brought the clot back into the artery with no futher debris."

75630 vs. 75716 and 75625

Would codes 36200, 75716-26, and 75625-26 be correct for the following case? Or would codes 36200 and 75630-26 be correct? "Patient placed in supine position. Bilateral groins prepped and draped in usually sterile fashion. Patient had easily palpable femoral pulses. The left common femoral artery was carefully anesthetized with 1% xylocone. The common femoral artery was punctured. A glide wire was placed under fluoroscopic guidance, and a 5 French sheath was placed over the glide wire. We then did an abdominal aortogram using 10 milliters a second of half strength contrast. The catheter was pulled down the aortic bifurcation, and we did a non-selective run-off of the bilateral lower extremities. We were concerned about the integrity of the right common femoral artery, so we did an RAO and LAO projection to look specifically at the common femoral artery. At completion all catheter wires and sheaths were removed."

Dilation of Aorta for Impella advancement

"A pre-existing RFA IABP was exchanged over a wire for sequential dilation of the RFA access site, followed by insertion of a 14 French Impella sheath. A 6 French sheath was inserted in the LFA via modified Seldinger technique. The Impella wire was then advanced into the LV, but the device could not be advanced beyond the level of a distal aorta calcified plaque. Accordingly, the sheath was removed from the RFA and exchanged for a long sheath, with subsequent dilation of the distal aortic plaque over a 035 wire with a 10 x 40 Bard Ultraverse balloon, followed by successful advancement of the Impella device over the Impella wire across the aortic valve and into the apex of the left ventricle with initiation of LV support with a good and stable hemodynamic tracing." Can we charge for the dilation of the aorta because there was plaque, or is it included because it was for advancing the Impella device? Would that be 37246 with 33990 and 33968 (IABP was removed)?

62267 & 77012 or 10009

"The patient was placed in the prone position upon the CT fluoroscopy table. The skin overlying the mid thoracic spine was prepped and draped in the usual sterile fashion. The overlying skin was anesthetized with 10 cc 1 percent lidocaine. After obtaining IV access and during continuous vital sign monitoring by a registered nurse under my direct supervision, monitored conscious sedation was performed using 4 mg of Versed and 250 mcg of Fentanyl. 13 minutes of face-to-face sedation time was spent with the patient (99152). Under CT fluoroscopic guidance a 13 gauge bone cutting needle was advanced into the T6-7 disc via a costovertebral approach on the left. Needle was advanced into the affected disc. Through the trocar, a 22 gauge needle was advanced into the disc. Three fine needle aspirates were obtained. Aspirate was then obtained with the trocar. There are no complications." Is there enough documentation to report codes 62267 and 77012? Or would code 10009 be more appropriate?

93657

"Voltage mapping confirmed that a line of block had been created across the LA roof and also mid-posterior LA to connect the LIPV and RIPV. There was also a semi-vertical line that traveled from this horizontal line to the mitral annulus by passing posteriorly and centrally reaching the midposterior mitral annulus.  From a posterior view this was a somewhat diagonal-shaped line slanting from right to left as it traveled from the posterior LA to the mitral annulus.The roof line seemed to be intact, but there were some locations with more amplitude and fractionation, and these were targeted. The mid-posterior line from LIPV to RIPV was mostly intact but had a few sites with moderate voltage that were also targeted. The line from posterior LA to the mitral annulus definitely had breakthrough; these breakthrough sites were targeted. All posterior wall ablation was done with 20 watts and FTI of 200 g-s. Most other atrial sites were ablated with 30 watts." Are these breakthrough ablations considered 93657?

dual chamber pacemaker

Does this support a dual chamber insertion?

"Using fluoroscopic guidance a lead was inserted into the area of the left bundle via guide sheath. Pacing and sensing parameters were appropriate with LV activation time of 71 ms. The guide was slit. The lead was anchored in position using sutures around the anchoring sleeve. Next, another sheath was used to place an atrial lead in the area of the right atrial appendage. The lead was anchored in position using sutures around the anchoring sleeve. The leads were then connected to generator and the pocket was irrigated with saline.

The device and leads were placed in the pocket and the pocket was closed with a combination of subcutaneous absorbable sutures and Steristrips. Pacing and sensing parameters were checked through the device and were appropriate, there was no phrenic stimulation with high outpatient pacing from both atrial and ventricular leads."

RVOT stent extending across pulmonary valve

"Prograde right and left heart cath was done. Diagnostic catheter was positioned in the RV apex, and a right ventriculogram was done. Using this image as a guide, 5 French JR 2.5 catheter was positioned in the right ventricular outflow tract and selective angiogram done here. 018 roadrunner wire was advanced through the catheter and across the pulmonary valve in the pulmonary artery. The 018 guidewire was advanced to the right lower lobe pulmonary artery and a 5 French sheath advanced over the guidewire, and the main pulmonary ateriogram was done. After careful assessment of the anatomy 12 mm long Palmaz blue stent pre-mounted on a 6 mm balloon was advanced over the guidewire into the sheath. The balloon was inflated across the pulmonary valve, and the stent was implanted extending from the RV outflow tract and across the pulmonary valve and into the main pulmonary artery." What code best describes placement of the stent? 33999 or 93799?

Lower extremity Duplex Doppler and Mapping

Within the PVL, a written physician order is documented within the patient chart that requests:
• Deep Vein studies/ lower extremity
• Bilateral Carotid Duplex
• Bilateral Lower extremity vein mapping
When these orders are entered from the unit and received within the Radiology order billing system; CPT 93970 is reported for both (venous mapping and Bilateral Lower Extremity Duplex) orders selected (93880, 93970, 93970). Although a distinct service modifier would pass edits, I feel that when performed during the same encounter, the venous mapping is inclusive with the bilateral duplex scan of extremity veins and should not be reported separately. I submit that both technical and professional charges for this encounter should only be reported as 93880 and 93970.
I would respect your opinion on this to support my position for what I feel could be a duplication of procedural charges.

Dictated report for all procedures are provided below:
PROCEDURE: BILATERAL SAPHENOUS VEIN MAPPING
COMPARISON: None.
INDICATION: Pre open heart surgery.
TECHNIQUE: Gray-scale imaging was performed on the bilateral greater saphenous veins with caliber measurements.
FINDINGS:
RIGHT GSV:
Thigh proximal: 2.9 mm
Thigh mid: 3.0 mm
Thigh distal: 2.7 mm
Knee: 2.4 mm
Calf proximal: 1.9 mm
Calf mid: 1.7 mm
Calf distal: 2.2 mm
LEFT GSV:
Thigh proximal: 3.8 mm
Thigh mid: 2.8 mm
Thigh distal: 2.0 mm
Knee: 2.2 mm
Calf proximal: 2.0 mm
Calf mid: 1.5 mm
Calf distal: 1.4 mm
CONCLUSION: The bilateral greater saphenous veins were imaged and measured as described above.

PROCEDURE: BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND FOR DVT WITH DOPPLER
COMPARISON: None.
INDICATION: Previous DVT.
TECHNIQUE: Gray-scale and color Doppler imaging were performed on the bilateral lower extremities.
FINDINGS:
RIGHT LOWER EXTREMITY:
CFV: Normal.
SFV: Reduced.
PFV: Normal.
POP-V: Reduced.
PTV: Normal.
PER: Normal.
ATV: Normal.
GSV: Normal.
LEFT LOWER EXTREMITY:
CFV: Normal.
SFV: Normal.
PFV: Normal.
POP-V: Normal.
PTV: Normal.
PER: Normal.
ATV: Normal.
GSV: Normal.
Normal findings indicate good phasicity, spontaneity, compressibility, augmentation response, and competence.
CONCLUSION: Chronic DVT seen in the right SFV and popliteal vein with recanalization. Remaining deep vessels show no evidence of acute or chronic DVT. No evidence of superficial thrombophlebitis.

PROCEDURE: BILATERAL CAROTID DUPLEX ULTRASOUND
COMPARISON: None.
INDICATION: Preop screening.
HISTORY: CAD.
TECHNIQUE: Gray-scale and color Doppler imaging were performed on the bilateral carotid arteries.
FINDINGS:
RIGHT:
COMMON CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar
PEAK SYSTOLIC VELOCITY: 80 cm/s
END-DIASTOLIC VELOCITY: 17 cm/s
PROXIMAL INTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous. Calcified.
SURFACE CHARACTERISTICS: Irregular.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 207 cm/s
END-DIASTOLIC VELOCITY: 62 cm/s
DISTAL INTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 188 cm/s
END-DIASTOLIC VELOCITY: 37 cm/s
EXTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 137 cm/s
END-DIASTOLIC VELOCITY: 21 cm/s
VERTEBRAL ARTERY: Antegrade.
ICA:CCA SYSTOLIC RATIO: 2.6
LEFT:
COMMON CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 87 cm/s
END-DIASTOLIC VELOCITY: 21 cm/s
PROXIMAL INTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous. Calcified.
SURFACE CHARACTERISTICS: Irregular.
FLOW CHARACTERISTICS: Turbulent.
PEAK SYSTOLIC VELOCITY: 184 cm/s
END-DIASTOLIC VELOCITY: 54 cm/s
DISTAL INTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 162 cm/s
END-DIASTOLIC VELOCITY: 47 cm/s
EXTERNAL CAROTID ARTERY:
PLAQUE MORPHOLOGY: Heterogenous.
SURFACE CHARACTERISTICS: Smooth.
FLOW CHARACTERISTICS: Laminar.
PEAK SYSTOLIC VELOCITY: 157 cm/s
END-DIASTOLIC VELOCITY: 27 cm/s
VERTEBRAL ARTERY: Antegrade.
ICA:CCA SYSTOLIC RATIO: 2.1
CONCLUSION: Bilateral 60-79% ICA stenosis with irregular plaque characteristics and turbulent flow. The vertebral arteries appear patent with antegrade flow bilaterally.
 

93656 or 93653

"Patient comes in for pulmonary vein ablation but has typical Aflutter instead of atrial fib. This confirmed the diagnosis of mitral isthmus dependent atrial flutter. In order to create adequate flutter ablation lines, I elected to isolate the left pulmonary vein. It was a large common vein. Ablation was then performed, connecting the mitral valve annulus back to the common pulmonary vein. With ablation, there is change in tachycardia cycle length. Remapping of the atrial flutter showed that this was now a different atrial flutter circuit, new roof dependent atrial flutter. This was confirmed with entrainment mapping. Linear ablation was then performed around the right pulmonary veins. Esophageal temperature was monitored throughout the ablation procedure. Entrance and exit block were confirmed in all pulmonary veins following ablation."

Would you report code 93656 or 93653 with add-on codes 93462 and 93621?

Balloon Tamponade of Perforated Inferior Epigastric Artery

"Complications: After completion of left heart catheterization, a right iliac angiogram was done for closure device deployment. A small perforation was noted from needle stick in the inferior epigastric artery, which was successfully sealed off/tamponade by 7.0 x 20 Mustang over the wire balloon, with two inflations of 10 min at nominal pressures. Angiogram was repeated, which showed normal inferior epigastric artery with extravasation of contrast." This was recently performed in the heart cath lab. My question is how would you code this to reflect the procedure performed? The first iliac angio was done for closure device evaluation. The second was done to evaluate the perforation. A balloon was used to seal the perforation until hemostasis was achieved. I spoke with the cardiologist, and the balloon was inflated in the femoral/iliac artery area, and at no time did he enter the epigastric artery. Are codes 36245, 75710, and 37244 appropriate?

93462

Dr Z. I have one question and how it would be coded in 2010 and today. Comprehensive EP Study 93620 & 93527 I receive an edit that the 93527 is a component code of 93620. My understanding was that a transpetal puncture was a part of the comprehensive EP because of placing multiple caths. I do not get an edit with 93620 & the new code 93462. The Cath Lab is stating it was always and still is seperatly reportable. This is the below statment that I received from them. "Transpetal has always been a seperate procedure. Futhermore, when this type of procedure is preformed in EP we are not doing any cath like procedures, we are usually performing an ablation that most likely has a pathway on the left side of the heart. The transpetal procedure although high risk puts the ablation cath in a position that is much easier for the Electrophysiologist to work with. My question was some patients have a patent foramen ovale/PFO (this should close aswe get older - it is a hole in the heart, it actually makes the transpetal easier if you have one) there was a code last year for transpetal 93527 w/o PFO and transspetal w/PFO. Is there just one code now no matter what?"

37229 documentation help

a 0.014 wire was passed into the peroneal artery, which was single vessel runoff and intravascular us was performed of the peroneal artery, tib trunk, popliteal artery, and the sfa. the pt has 72% stenosis in the peroneal, 67% stenosis in the tib trunk, 70% stenosis in the popliteal artery & 73% stenosis in the sfa.

a laser atherectomy was performed across the sfa, pop, tib trunk & peroneal artery followed by balloon angioplasty using 2.5 mm balloon in the peroneal artery and tib trunk & a 5mm balloon in the pop artery and sfa.

findings: pt's aorta and iliac vessels appear widely patent. the pt has a stent in the rt sfa with intrastent stenosis. also evidence of popliteal stenosis & single vessel runoff via ant tibial artery. left sfa stenosis including intrastent pop, tib trunk, & peroneal artery stenosis which was single -vessel runoff.

we billed 37229 lt, 37225 lt, 37252, 37253 but uhc isnt paying 37229 based on this doc. does anything look like 37229 should NOT be paid

ASD Closure-Device removed after AV block

Would this be 93580-74, 93580 or cath only? "A prograde right and left heart catheterization was performed with a 6 French GL. The GL was advanced across the atrial septum to the LUPV and exchanged over a wire for a 20 mm ASD sizing balloon, which was advanced over the wire and across the ASD to straddle the atrial septum. The balloon was inflated during real-time TEE color Doppler, and the stopflow diameter of the ASD was found. This was found to be 12 mm by TEE and 13.4 mm by fluoroscopy. The balloon was deflated and removed. A 30 mm Gore/Cardioform was selected, prepped, flushed, and loaded. The device/delivery catheter were advanced via the RFV to the RA and across the ASD to the LA. The LA disc was deployed and pulled to the atrial septum, and the RA disc was deployed. Device position was assessed by fluoroscopy, TEE, and gentle push-pull. The mandril was popped deploying the RA locking loop. The patient went into 2:1 AV block with a heart rate of 70 and a normal blood pressure. The device was recaptured with the retention suture and removed."

10180 or 35860?

Patient had femoral embolectomy and returned for postop infection. Can you also give any guidance as to what is required for 35860 instead of 10180? "A 10 blade was used to incise the previous incision in the left groin. This was carried through the subcutaneous tissue with electrocautery. A large cavity of old hematoma was encountered. In order to completely evacuate the hematoma of the incision was extended distally. The majority of the cavity was unroofed. Once all gross hematoma was evacuated, the wound was copiously irrigated with normal saline. The area of necrotic skin was sharply debrided. Sharp debridement then continued to necrotic subcutaneous fat, muscle, and fascia. This was an excisional debridement of necrotic skin, subcutaneous tissue, muscle, and fascia measuring 100 cm2. Hemostasis of the subcutaneous tissue was then achieved with electrocautery. There was necrosis of some of the muscle fibers of the sartorius muscle. These were manually debrided. The wound was then packed..."

BIV-ICD Pocket Hematoma Evacuation/Cautery

How do you suggest this be reported? "Patient underwent implantation of biventricular ICD system. On the day following procedure, there was evidence of a large hematoma with worsening pain despite the use of analgesics. Lidocaine 1% was infiltrated in the left subclavian region along the incision, and the incision was opened, removing sutures. A moderate amount of blood and clot was removed from the pocket. The pulse generator was removed from the pocket and irrigated with copious saline solution. Inspection of the pocket showed no clear source of active bleeding, but moderate diffuse bleeding. Very careful hemostasis was performed by quadrants in the pocket with extensive use of cautery. Persistent diffuse bleeding was observed in several areas, and more continued use of the cautery and suture with 2-0 silk was performed until adequate hemostasis was obtained. Surgicel was inserted in areas of diffuse bleeding in the pocket, and the generator was inserted in the pocket." 

50688 vs 50387

For the following case, I am being advised that this is not 50688 but should be 50387. Can you clarify? "Clinical indication: Hematuria. Tube pulled back. Informed consent was obtained. The patient was prepped and draped in the usual sterile fashion. The existing nephroureteral catheter was injected with iodinated contrast. It shows opacification of the pyelocalyceal system and proximal to mid ureter. The intrarenal pigtail has pulled back into a lower pole calyx. The distal pigtail has uncoiled partially. Contrast is not seen extending into the ileal loop. A 0.035 guidewire was advanced through the existing catheter, and exchange was made for a new 8.5 French x 26 cm nephroureteral catheter. The proximal pigtail was coiled in the renal pelvis, and the distal pigtail was coiled in the ileal loop. Contrast was injected showing flow of contrast through the catheter into the ileal loop. There is minimal left-sided pyelocaliectasis."

CRTD Generator Replacement

I have a portion of the surgery documentation below, and am wondering, based on what I have provided, if this would be CPT 33264?

PROCEDURE: CRTD generator replacement. CRTD interrogation and programming.

After local lidocaine infiltration, a 4 cm incision was made along the left deltopectoral groove. The subcutaneous pocket was opened with blunt dissection, and local hemostasis was obtained with cauterization. The CRTD generator and the leads were extracted from the pocket. The leads were disconnected from the generator. The underlying rhythm is AF. Sensing P wave 1.5 mV, impedance 400ohms. Sensing R wave wave 14.5 mV, pacing threshold 0.75 V and 0.4 ms, impedance 360ohms. LV epicardial lead pacing threshold 1.5 V and 0.4 ms, impedance 265 ohms.

A new CRTD generator was connected to the leads and into the pocket after antibiotic irrigation. An antibiotic envelope was used for prophylaxis. The wound was closed. Pacemaker interrogation showed stable RA, RV and epicardial LV lead measurements.

Pericardial Drain Manipulation

I'm unsure how to code the following scenario: "Rate of pericardial drainage noted to be minimal over last 48+ hours. Drain clamped for nearly 24 hours, and opened this morning with no significant output. Echocardiogram with small global pericardial effusion, with inability to express fluid via drain. Drain disconnected from pigtail catheter. Attempts made to unclog by flushing saline, which flushed easily, with inability to briskly garner return from pigtail catheter. On three occasions, attempts made to unclog catheter tip with 0.035" j-tip and then 0.035" striaght wire under sterile conditions, with no change in drainage. Total of approximately 10-12cc saline flushed in and not returned. Trace amount pink-tinged serous fluid returned with aspiration. New drainage bag hooked up and left to gravity. Patient tolerated exchange and attempts to unclog wire well."

33240 or 33262 with 33202

Would this be 33240? Or 33262 with 33202? "17-year-old status post AICD for primary prevention in 2013 via small left anterior thoracotomy with generator in right upper abdomen who now presents with v-lead fracture requiring new ventricular lead. After sternotomy was performed, 25 cm epicardial bipolar leads were brought onto the field and held in place in what appeared to be good locations. The old pacemaker generator incision was re-entered, and we dissected down to the old generator itself. This was carefully excavated from the pocket, and we could see an area of insulation fracture at the spot where the lead inserted into the device. The new generator was brought onto the field. It was wider than the other generator at its base, but tapered in terms of width and thickness more distally. The pocket was therefore widened to accommodate the new generator. The old ventricular leads were capped. The new v-leads were tunneled from the inferior aspect of the pericardial well into the old pocket. These leads and the AICD leads were then inserted into the new generator and secured."

Repeat ablation by Extension of Line of Isolation of PVI

This is another persistent afib patient returning for repeat ablation.

" A voltage map revealed pulmonary vein isolation from prior ablation procedure. In this context we decided to extend the line of isolation. Radiofrequency applications with 25 to 45 watts were delivered around the left and right pulmonary veins to achieve wide antral circumferential isolation. Entrance and exit block was confirmed bilaterally. High esophageal temperatures were noted while ablating the posterior aspect of the RPVs. Applications were interrupted once the temperature reached 38.5 C in the esophagus. After pulmonary vein isolation was achieved, pace capture at 10 mA x 2 ms was performed along both lesion sets. Additional radiofrequency energy was applied at the areas of capture."

If the pulmonary veins were identified as isolated from a prior ablation is the extension of the line of isolation in the presence of persistent afib still reported as 93656?

ECMO & Distal Perfusion Cannula

What is the proper code for the scenario below? The patient is a middle aged man with a witnessed cardiac arrest. He was in V-fib, taken to the cath lab, placed on AV ECMO, and underwent PCI. "A 19 French cannula was placed in the right common femoral artery and a 25 French cannula in the right femoral vein. An Impella was placed in the left common femoral artery over a 14 French sheath. I was asked by Dr. X to place a distal perfusion cannula. The micropuncture wire was advanced under fluoroscopy, and a 4 French sheath introducer was placed. The wire was exchanged for a J wire, and the 6 French antegrade perfusion cannula was placed under fluoro visualization. Of note, the SFA appeared to be calcified in fluoro, and an SFA stent was visualized. The wire and cannula were advanced without any complications. The perfusion cannula was flushed and secured to the right groin, then connected to the ECMO circuit, achieving antegrade perfusion of the right lower extremity." Would 33952 or 36140 be the best code, or does it bundle to the ECMO placement?

51600/74430 vs. 51610/74450

Could you advise on CPT codes that should be used for this procedure? What do we need to look for in a retrograde cystourethrogram? "Retrograde cystourethrogram was performed via indwelling Foley. Scout imaging and fluoro images of the urethra and bladder were obtained during and following instillation of contrast through indwelling Foley. Fluoro cystogram was performed with contrast instilled in the bladder lumen via gravity flow through patient's indwelling Foley. Total of 225 mL of contrast was instilled into bladder lumen. No extraluminal contrast was visible to suggest postop leak. There was irregularity of the bladder dome near the reimplantation site during filling, which improved but did not resolve on further distention. Large volume reflux of contrast was seen in the left renal collecting system, and small volume reflux was seen into the right renal collecting system. Following evacuation, small post void residual was seen. No residual contrast seen."

Epicardial Lead Removal Only

"In 2012, patient had left mini-thoracotomy and placement of epicardial pacing system; however, the place where these leads were attached to the pacemaker generator was infected. In view of this, in October 2014, the leads were truncated at the point where they were entering the pericardial space, removing the remaining part of the leads towards the pacemaker generator as well as the generator itself. This admission, patient was temporized with a transvenous pacemaker system from the neck and was sent to Cardiothoracic Surgery for placement of epicardial leads. Upon performing median sternotomy, we noted significant adhesions inside of the pericardial space from the previous opening of the pericardium. These adhesions were carefully taken down to the point where I was able to identify 3 epicardial leads that were placed before and were truncated at the level of the entry into the pericardial space. These were carefully released and removed and sent to the pathology." The only code I am coming up with is 33999 (in addition to 33202/33221-51, implant report not attached).

Medically Necessary Cholangiogram

A medically necessary question! Patient had a bilary stent placed with external drain left in on January 11th. Patient came back on February 13th to evaluate and check patency of the stent.  There was no output from catheter for a week. Choli was normal and external biliary tube was capped. Radiologist dictated in report to have patient return in a few days for a check and to see if the patient's biliary tube can be removed. Patient comes back on February 15th, and cholangiogram is done again and biliary cath pulled. Since there is a big crack down on doing procedures that are not medically necessary, I just wanted to make sure I can charge for the second cholangiogram.  Was it really needed after one just performed two days ago (no new problems or pain reported)? Is this normal practice accepted as medically necessary?  If I shouldn't charge the choli code, what can I charge, or what modifiers can I use with the choli charge to bill it?

Advised by MD, At PVI redo is ok to bill Afib ablation 93656?

Is he correct?

The MD did a redo of Atrial fibrillation ablation. Since the veins were silent I told him we were advised to bill as SVT 93653 not Afib ablation 93656.

His response was this is not exclusively PVI. At redo AF ablation one can do other ablation such as CFAE ablation and posterior wall isolation which is what we did.

Summary:

1. Symptomatic persistent atrial fibrillation

2. Symptomatic roof dependent atrial flutter, termination to sinus rhythm with roof line

3. All pulmonary veins were isolated from prior ablation

4. CFAE ablation targeting posterior wall non-PV triggers

5. Left atrium ablation with floor line creation and posterior wall isolation targeting posterior wall non-PV triggers