Ask Dr. Z

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

CPT CODE FOR OPEN LIGATION OF RT UTERINE VEIN

Would the unlisted vascular surgery CPT be used? "DX: intraoperative hemorrhage. The patient was undergoing a TAH, and significant bleeding was encountered deep in the pelvis that proved difficult to isolate and control. The provider was called to the OR to assist in isolation and control of the source of the hemorrhage. The patient was already under general anesthesia with her peritoneal cavity exposed via a midline laparotomy incision. The peritoneum was copiously irrigated and examined. Several small areas of bleeding were controlled with cautery. The area was carefully examined, and better exposure was achieved by ligating and dividing several small bundles of tissue. A 2-3 mm diameter thin-walled vascular structure was identified and noted to be bleeding steadily. The vessel was then oversewn with 0 vicryl suture. Hemostasis was excellent. The peritoneum was again inspected and copiously irrigated, and no further bleeding was evident. At this time, the provider scrubbed out and left the abdominal closure to the OBGYN team."

CPT code 55874 and 55876 with 76942

A skin block was performed. A peri-prostatic block was performed by placing a spinal needle on each side towards the prostate base and injecting 10ml of 1% xylocaine for a total of 20ml. Under ultrasound guidance 3 gold markers were inserted into the prostate (right apex, mid-gland, and left mid-gland) placed at the appropriate depth and avoiding the urethra. A long spinal needle was then used to hydro-dissect the perirectal space with sterile normal saline. Separation was confirmed in both the transverse and sagittal planes. The needle was aspirated slightly to ensure the needle was not intravascular. While keeping the needle in place, the hydrogel applicator was attached. The hydrogel was then injected over 5 seconds. The placement of the hydrogel was evaluated and the ultrasound probe was removed. After 15 minutes of observation the patient was released. Would you code 55874 with 55876 and 76942 or is the ultrasound guidance included in 55876 because you used 55874?

Is this 33017 if the Dr instilled fluid in pericardial space during VT abl?

Is this reported with 33017 if the physician instilled fluid in the pericardial space during VT ablation? "40 mL of fluid was instilled within the pericardial space, then 3D mapping of the pericardial space was performed and the earliest breakout on the endocardial surface was identified. It was decided to do more extensive endocardial mapping with both the aortic approach, as well as the mitral approach with the HD grid was performed. The endocardial spot was much earlier than any of the epicarial spots. It was decided to give a single burn at this location, and following the burn, the patient still had inducible VT. It was clear that the VT focus was mid myocardium and was not accessible via the pericardial space or the endocardial space. A long guidewire was placed, and a standard pericardial drain was placed and the Agilis sheath removed. Then, 40 mL of blood-tinged fluid was removed and then 10 mL were injected back with 150 of Solu-Cortef. The pericardial drain was left to gravity drainage. It was sutured in place. The patient was then taken to the ICU in good condition."

Selective vs Non Selective pulmonary artery angio

Would this be a non selective PA angio from the RV or a bilateral selective PA angio due to this additional note? RV: Antegrade RV angiogram shows normal systolic function with mild to moderate

TR. The RV-PA PECA conduit is widely patent. There is to an fro flow across the

valveless conduit. Well-developed, dilated bilateral pulmonary arteries are present. The

RPA measures 20 mm and the LPA measures 23 mm. Levophase demonstrates

unobstructed bilateral pulmonary venous return to the left atrium. No discernible atrial

level shunting is present.***Due to her anatomy and atrial baffling, the RV was difficult to enter using the

conventional wedge catheter. A 5Fr AR1 over an exchange length glide wire was used

to enter the RV then pulmonary arteries. The AR1 catheter was exchanged over the

glide wire for a 0.035 Quick Cross catheter. An 0.035 Amplatz ES wire was used to

exchange for pressure measurement with a glide catheter and 5Fr pigtail for angiogram.

Biventricular ICD Generator Change with Capping of LV Lead and Insertion of New LV Lead

A patient presents with biventricular ICD pulse generator change due to ERI along with LV malfunction. The provider removes and replaces the generator and decides to cap the malfunctioning LV lead and then inserts a new LV lead, all at the same session. Would it be more appropriate to report codes 33249 and 33241, as CPT only indicates lead (table on pg. 177) without clarifying which one(s)? Or would it be appropriate to bill as you would for an upgrade with codes 33225 and 33264? Also, per CPT Assistant June 2012, Vol. 22, Issue 6, there is a tip indicating that code 33225 can be used with 33264, yet indicates this is for generator upgrade... and goes on to say for code 33264: "Codes 33262-33264 should be reported when the sole procedure is the replacement of a pacing cardioverter-defibrillator pulse generator and the procedure does not include the insertion or replacement of a right atrial and/ or ventricular electrode(s)." It does not clearly indicate if the ventricular electrode(s) are right or left. How would you recommend coding the above scenario?

Code 33866

Would this disqualify a 33866 since a cross-clamp was used with a 33860? "The arch of the aorta was then explored. A tape was placed around the innominate artery. The origins of the left carotid and subclavian were identified, and they were not involved with the intramural hematoma. The intramural hematoma did extend proximally to the level of the aortic root, but could not be well visualized while the patient was still being perfused in a normal antegrade fashion. Once this had all been completed, a #30 Hemashield graft was obtained, and a beveled cut made. This was then sewn endtoend to the aortic arch utilizing running 40 Prolene suture. Once this had been completed, the graft was allowed to fill with blood, and the aortic crossclamp placed on the graft after first measuring the graft for length to the proximal anastomotic site. Once the aortic clamp was in place, the clamp on the innominate artery was removed, and rewarming commenced as well as standard antegrade cardiopulmonary bypass. The graft was cut to length then sewn endtoend to the proximal aorta."

Hello. For outpatient surgery, we append the Q0 modifier on CPT 33249 with 33225 for Medicare patients with necessary diagnoses for primary prevention. Our business office requested V707 for participation in a clinical trial in association with the Q0 modifer. Is this correct? Is this a clinical trial? My understanding is that all participants are entered in the registry, but is the registry a clinical trial? The basis for appending the Q0 modifier is Dr.Z's coding referece. Medicare patient with ischemic cardiomyopathy, documented prior MI, NYHA class II and III heart failure, and EF less than or equal to 35% OR Medicare patient with non ischemic cardiomyopathy greater than 9 months, NYHA class II and III heart failure, EF less than or equal to 35%. Is my coding correct for a biventricular AICD placement with left coronary sinus lead = 33249-Q0 and 33225? is this a clinical trial? should we append the V707 diagnosis code? thank you for all your help, Aileen

Right Heart Cath (93451-59) with Biopsy (93505)

Can a right heart catheterization (93451-59) be coded with biopsy (93505) in this case? "A patient with history of orthotopic cardiac transplant, now with mildly reduced ejection fraction and complaining of easy fatigue. Based on patient's mildly reduced EF and fatigue, she was brought to the cardiac catheterization laboratory to evaluate for possible entiology with endomyocardial biopsy and right heart catheterization (RHC). Five endomyocardial biopsies were taken from the right ventricle and intraventricular septum and sent to pathology. Right heart cath was performed with a 7 French Swan-Ganz catheter. The usual pressures were measured along the way. Thermodilution technique was used to obtain cardiac output. HEMODYNAMICS: 1) RA: 11/13, with mean of 10.; 2) RV: 28.5, with EDP of 1-.; 3) PCWP: 16/5, with mean of 13.; 4) PA: 30/16 with mean of 21.; 5. Thermodilution cardiac output: 3.4 L/min with cardiac index of 1.91 L/min per m2. Summary: Normal right and left filling pressures with decreased cardiac index at rest. Result of endomyocardial biopsy pending."

Fistulogram with Arterial Anastomosis Balloon Angioplasty

I am very new to IR coding, so I am not real sure on how to code this report, which reads as follows: "Under ultrasound guidance the left upper arm dialysis access graft was catheterized. Images of the graft were recorded. Subsequently under fluoro guidance a catheter was placed in the graft, and fistulogram was obtained. A questionable stenosis at the arterial anastomosis was dilated with a 5 mm angioplasty balloon. FINDINGS: Ultrasound shows markedly thickened wall of the graft consistent with mural thrombus. The fistulogram shows very slow flow through the graft with very small lumen. There was a questionable stenosis at the arterial anastomosis, but there was really no change with the angioplasty. The distal anastomosis at the venous end is unremarkable. Central veins are patent." I was going to report codes 36147, 35475, and 75962 because he stated "at the arterial anastomosis". However, another coder thinks we should only code for fistulogram (36147) because the doctor did not give the percentage of the stenosis. What is your opinion?

thrombus breakup. 93799

Dr. Z., I could use some advice about this procedure. I have only charged/coded for a LHC for this procedure, but after reading this report I am wondering if I should be adding 92982. The report: He was found to have a total occlusion of the mid to distal posterior descending artery. Then through the guiding catheter was passed a 0.04 high-torque floppy guidewire, which was used to traverse the area of stenosis. Upon doing this apparently there was a clot that was dislodged or broken up and this reestablished flow to the distal vessel. Upon repeat angiographic views there was no significant stenoses and, therefore, this did not require ballooning or stenting of the vessel and he was administered 200 mcg of intracoronary nitro to the right coronary system and repeat angiographic views were obtained and after a waiting period it was elected that no further intervention would be necessary. Selective coronary cineangiography was performed of the left coronary system. CONCLUSION: 1. Percutaneous coronary intervention of the distal RCA with essentially doddering technique of the distal RCA with reestablishment of flow, and no significant atherosclerotic stenoses. What is your opinion? Thanks, Chris McCoy

Fluoroscopy of mechanical heart valve at time of cardiac cath

My provider performed coronary angiography, bypass graft angiography, and cinefluoroscopy of mechanical prosthetic aortic valve as follows: "Left wrist catheterized with 11F. Diagnostic coronary angiograms performed in multiple projections....(findings then delineated). Cath used to cannulate LIMA graft to LAD for angiograms....(findings then delineated). I performed cinefluoroscopy of mechanical prosthetic aortic valve and was only able to visualize one leaflet moving as expected. Second leaflet was not mobile or visualized in any view. I became concerned that he had partial prosthetic thrombosis...." As this point, another provider entered the cath lab to perform TEE, and the procedure continued on from there. Am I able to submit 93455 with 76000 for the prosthetic valve fluoroscopy, or is the 76000 included in the 93455? CodeCorrect says it is billable with a modifier, but I do not know whether this would constitute a situation where that would be appropriate.

Severed radial artery with end-to-end anastomosis

What CPT code for severed radial artery with end-to-end anastomosis? "This patient arrived to hospital following a bow accident. The patient was induced under general endotracheal anesthesia. He was then prepped and draped sterilely following a tourniquet being placed on his right upper arm. In addition, his left lower leg was shaved and prepped and draped as well. A 7 cm incision was made over the radial artery and the radial artery was explored. It was found to be transected and thrombosed proximally and distally along with the radial vein. No major neural structures were found and no foreign bodies were visualized. The radial artery was then freed approximately 3 cm proximally and 3 cm distally to allow approximation of the artery without undue tension. Approximately 1 mm debridement was performed of the radial artery in the proximal and distal section due to necrotic and torn edges. The vessel was then spatulated proximally and distally. Interrupted 7-0 Prolene sutures were then utilized, following embolectomy of the distal segment. Flushing is performed, and the end-to-end anastomosis was completed."

75630 vs. G0278 and 75625 with heart cath

Could you please clarify some confusing verbiage from your Diagnostic & Interventional Cardiovascular Coding Reference? Patient is having right and left heart cath (93460) and aortic root angiography for aortic stenosis (93567). Patient also has PVD with diffuse iliofemoral disease, renal artery stenosis, and disease of the distal aorta, so they did an abdominal aortogram and bilateral iliofemoral study from one catheter position in the aorta. Your guidelines state to use code 75630 if there is no catheter repositioning and if it is medical necessity for AAA. Your notes also state not to use 75630, but rather to use codes 75625 and G0278, if done during cath for "screening". Well this isn't a screening, and if it were just a screening with no medical necessity, we wouldn't code it anyway, correct?? So are we using code 75630 since there is medical necessity, even though it's not an AAA, or do we use codes 75625 and G0278?

FEVAR and TEVAR combined procedure

Patient previously treated with infrarenal aortic endograft and followed by TEVAR for ruptured thoracic aortic aneurysm. He now returns because aorta has degenerated between the thoracic endograft and the infrarenal aortic endograft to a max diameter of 7 cm thoracoabdominal aortic aneurysm. Patient is taken to surgery for FEVAR for repair of visceral aorta with stents into celiac, SMA left, and right renal (which is CPT 34844). Also thoracic aneurysm repaired with Zenith graft deployed with adequate overlap of existing thoracic graft and the new fenestrated endograft. What coding can the thoracic graft get? Technically it's a delayed distal extension of the TEVAR 33886 or proximal extension of FEVAR, which there is no coding as it's bundled into 34844. Or the other possibility is a new TEVAR of 33881 not covering the subclavian. He did treat two different problems, so I feel additional coding is warranted, but wanted expert advice on the correct way to go about it. There is no bundling issue with either scenario.

IVC draining to LA, repaired with prior ASD patch adjustment, how to code?

Background: Newborn with supracadiac TAPVR and ASD had surgical repair by anastomosing common pulmonary vein confluence to the LA. Residual malaligned atrial septal tissue was resected, and ASD was closed with a patch, very carefully aligned along the ridge of the resected septal tissue. Two days later echo showed IVC draining into the LA. Surgeon explored the anatomy very carefully and determined that the IVC to LA was truly a congenital anomaly and not an iatrogenic redirection from the previous ASD patch. Second surgery: “I removed the suture line from the ASD patch, excised the lower part of the atrial septum all the way down to the IVC opening, and then excised the residual separation between the IVC and the right atrium all the way down below the level of the coronary sinus. Then, I sutured the ASD patch posteriorly onto the left atrial wall using 7-0 Prolene continuous suture. With this, the IVC was clearly now on the right side, and then I closed the right atrium with 6-0 Prolene continuous suture in two layers.” How would you code the second surgery?

Evaluation of Drains in 2014

It is my understanding that billing for contrast injection/evaluation of drains is discouraged in 2014. There are instances in which our doctors evaluate these because of rising bilirubin (biliary), obstruction (urinary, biliary), etc. We are a cancer center; therefore, there is quite often obstruction. In what instances are we allowed to bill for these? This is an example: "Bilateral biliary catheters were removed over a wire and bilateral cholangiograms performed from the skin surface, demonstrating poor opacification of biliary tree, worse on the right than left. Plans were discussed with patient for possible need for a third biliary catheter in future. New bilateral 10 French internal/external biliary catheters were placed over the wires and sutured to the skin." In this example would you bill for these bilateral evaluations? Am I correct in billing codes 47505/74305 twice for these (injection was performed "from the skin surface")? There are also times when a cholangiogram is done in order to determine whether internal/external drain can be internalized. Would this also justify?

Robotic assisted Left Hemidiaphragm Plication

What CPT code would you recommend for robotic-assisted hemi-diaphragm plication?

"Landmarks were identified for robotic port placement, daVinci Xi robotic surgical system docked to camera port and robotic endoscope placed in pleural space, examination performed to facilitate subsequent port placement. Under direct endoscopic visualization instrumentation was placed via the ports and the intra-thoracic procedure initiated.2.0 ethibond double armed pledgeted mattress stitches were used and I started at the dome of the diaphragm performing a plication and a medial to lateral direction. After the first stitch was placed the diaphragm naturally formed pleats which were elevated taking great care not to allow the passage of the needle to involve the abdominal viscera beneath the diaphragm. Gradually the diaphragm was lowered and additional areas were then identified for the placement of mattress stitches. Pledgeted mattress stitches were required to achieve a satisfactory plication."

37236 or 33881

Real-time visualization of the common femoral artery and vein were identified as the artery was accessed. At this time the Neurosurgery team expose the T10 screw and transected the upper segment of the rod and prepared the screw for removal. Under the protection of a Kumpe catheter a Lunderquist wire was placed into the aortic arch. We upsized to a 16 Fr DrySeal sheath via the left groin. A 28 x 33 mm Gore cuff was advanced to the area where the screw was. Under fluoroscopic visualization the screw was slowly backed out and the stent graft was deployed over the area where was located. The screw was then ultimately removed with no signs of bleeding. We exchanged for a flush catheter and two views demonstrated patent stent graft with no extravasation. Perclose devices were tightened over a stiff wire after the sheath was removed with good pedal pulses. Protamine was given. The remainder of the spine closure was performed by Neurosurgery. 

Would you consider this 37236 or 33881 for the stent graft?

36831 or 36904

Is this considered an open or percutaneous procedure? "Left upper extremity prepped and draped. 3000 units heparin given IV. Small transverse incision was made over the graft 3 cm distal to the arterial anastomosis. Graft was exposed. Opened transversely with 11 scalpel blade. #4 Fogarty thromboembolectomy balloon catheter was utilized proximally with recovery of thrombus twice, but not the third time, and recovery of the arterial. With torrential inflow obtained. The graft was clamped on that side. 4 Fogarty was then used through the venous end and went through the venous anastomosis without any resistance. Pulled back twice without any resistance through the venous anastomosis and thrombus removed. Not the third time. Distal end of the graft flushed easily with heparin saline and clamped. Graft was closed with a running double layer closure Blalock style 6 0 Surgipro. Air vented prior to tying the knots. Clamps were removed. Wound was irrigated with some Betadine and closed in layers."

Billing for 77001

In the 2017 edition of the Interventional Radiology Coding Reference, example 2 in the "Vascular Access Device Placement" section of chapter 7 states: "Patient presents for central catheter. Ultrasound is used to determine suitability of the jugular veins. The right jugular vein is determined to be too tortuous to use. The left jugular is suitable for the placement. Ultrasound is used as guidance for needle placement (76937). Hard copy images (permanent recording) and reporting are documented. The non-tunneled central venous catheter is placed without difficulty and secured with suture (36556). After catheter manipulation and injection of contrast, confirmation of tip placement in the superior vena cava (77001) is documented on a stored image." In this example, how do you know that tip placement was confirmed by fluoroscopy? In this same section you state, "Some catheters may be placed without any guidance. The use of these guidance codes requires specific documentation to support utilization of the access guidance codes." If they do not state fluoroscopy was used, how can you code 77001?

TAVR with coronary angioplasty

Would it be appropriate to code 92920 with TAVR? Patient has a patent LM/LC stent protruding into aortic root.

"Via the right femoral artery, a 6F XB 3.5 guide catheter was advanced to the aortic root and BMW Universal 2 coronary guidewire was used to wire the LM stent into the distal LCx artery. A 3.5 x 20mm non-compliant balloon was then prepositioned into the LM/LCx artery stent. The aortic valve was crossed using a 6F AL-1 catheter. An Amplatz Extra Stiff wire with a broad distal curve was positioned in the left ventricle. A 23 mm Edwards Sapien 3 Ultra valve and Commander deployment system were prepared and inserted into the introducer sheath; final assembly was performed in the descending aorta; and the valve was advanced to the aortic annulus. After confirmation of valve positioning, the NC balloon was partially withdrawn with the proximal segment protruding into the aortic root and inflated to 18 ATM. The valve was then deployed in the aortic valve annulus under rapid ventricular pacing at 180 bpm."

Graft and Native Interventions

We are having difficulty determining whether we should code both C9604-LD for the drug-eluting stent and 92928-LD for the bare metal stent. Can you help? Report follows: "Saphenous vein graft to diagonal was selectively engaged with the left coronary artery bypass graft catheter. A 0.014 filter wire was advanced through mid body lesion of the graft. There is a 90% lesion with what almost looks like a dual tract. After crossing the lesion, a 3 x 12 mm stent was advanced and deployed at high pressure. There is an 80% to 90% lesion in the diagonal below the graft as well. At this point, filter wire was retrieved, and a 0.014 All Star wire was used to cross the diagonal lesions. A 2 x 23 mm Vision mini stent was deployed with no residual stenosis. The patient tolerated the procedure well, and there were no immediate complications. IMPRESSION: Successful drug-eluting stent deployment to mid body of saphenous vein graft and also a bare-metal stent deployment to diagonal downstream."

Cryoablation of lung 32999

Dr. Z, In the area of cryoablation of the lung, I have suggested 32999 as the appropriate code, others are stating that microwave, radiofrequency and cryoablation would use the same code: 32998. Could you please clarify this as our hospital uses your guidelines but we do not have anything in writing on this issue. Another issue that has led to some confusion is that the physician used the RFA equipment but changed the needles on the equipment to perform the cryo? Documentation reads: Two 24L cryoablation needles were subsequently inserted into the lesion. Multiple adjustments in the position of the needles were made followed by limited CT scans in full expiration were performed until correct positioning was obtained. During this process, the patient developed a moderate volume pneumothorax for which an 8 French APDL pleural catheter was placed. Intermittent hand aspiration was performed to maintain lesion targeting. One run of 30 minutes was performed to ablate the lesion. The ablation needles were then removed and the tract was ablated. A sterile dressing was applied and the pleural catheter was left in placed to 20 mm Hg of wall suction. Thanks in advance for your help with this problem, Rhonda, Ancillary Manager

Is this a 0644T, and if not what codes should be assigned? Thank you.

Is this reported with code 0644T? If not, what code(s) should be reported? "Catheter was advanced into SVC and sheath positioned into internal jugular vein. An Inari Triever 24 was introduced to evacuate a large thrombus from the right atrium, as well as a curved 20 Triever catheter to perform mechanical thrombectomy of the right ventricle. Aspirated blood was reintroduced through the sheath. A repeat cardiac echo was performed, as well as non-selective bilateral pulmonary arteriography, as the patient had no prior imaging of the pulmonary arteries and they could not be well seen by cardiac echo. Catheters were removed and hemostasis achieved with perclose device. A successful thrombectomy was achieved from the right atrium and right ventricle. Pulmonary arteriography shows no evidence of a saddle embolus, there is non occlusive embolus in the descending left pulmonary artery trunk as well as thrombus in the medial basilar segmental branch. Successful mechanical thrombectomy of right heart."

Long Complex AAA Repair

I code for both the primary and assistant surgeons. The primary surgeon from the first procedure was the assistant for the second and visa versa. How do you code one procedure that turns into two, that stretches from 7:45 am to after 4:30 pm on a patient that exceeded 400 lb? They did a bilateral femoral artery cutdown, with attempted deployment of aortobiiliac unibody graft. They added a micropuncture to the left brachial artery for additional access. In addition to the patient’s size he also had severe tortuosity of both iliac arteries with at least two 90 degree bends. They had difficulty unsheathing the right limb, and after many attempts to unsheathe the limb and a broken wire, they decided to move to the OR where they performed an open AA aneurysmorrhaphy with aortobiiliac bypass. After thoughtful research I feel that the following is correct, but I would like a second opinion. Surgery 1: 34812-50, 36200-RT, 36200-59LT, 34804-53, 75952-26. Surgery 2: 35102-2278. One of my concerns is that code 35102 will be bundled into code 34804 due to NCCI edits.

Coil Localization

How would you code coil localization? "Indication: 1.1 cm nodule rt lung (near the fissure rt middle lobe) preop coil localization requested. A pleural catheter is placed and secured (this was coded with CPT 32557). From a separate antral lateral approach site for coil localization was sterilely prepped all the way down to the pleura at the intercostal space. Unfortunately the lesion is deep to the patient's breast tissue requiring an approach through the breast . A 20 gauge Chiba needle was inserted and advanced to the periphery of the lesion. The localization coil was then partially deployed with the central aspect immediately adjacent to the lesion at the ant/sup/medial margin of the sm nodule. Needle Cobb off including the remainder of the long coil, was then withdrawn, pneumothorax enlarged with pleural air injection, and the remainder of the coil was deposited within the pleural space. Ndl removed. Pneumothorax aspirated and final CT images performed. Pleural cath left in place in case pt develops visceral pleural leak before entering OR."

Ductus Arteriosus Stent Open Chest

I'm not sure how to capture the stent insertion by the interventional cardiologist below. "The chest was open by the surgical team. Pulmonary artery band were placed by the surgery team. A 6 French sheath was positioned in the proximal main pulmonary artery. An angiogram was performed for aorta/Pulm arteries. Measurements were made of the ductus arteriosus. The ductus was crossed with an angled glide catheter and a 0.035 rosen wire was positioned in the descending thoracic aorta. Over this wire a 7 mm x 2 cm protege self expanding stent was positioned across the ductus arteriosus. It was deployed in the standard fashion. Flwup angiography demonstrated good positioning of the stent with retrograde flow in the arch. The entire ductus appeared to be covered with good flow into the left pulmonary artery. The surgery team removed the sheath and proceeded with chest closure." Is this unlisted CPT 93799?

PFO Closure Not Done

"Patient with recurrect CVAs. Hypercoagulable workup negative, TEE with postive bubble study, thought to have PFO. Presents for closure. PROCEDURE: 10 French venous sheath was placed in left femoral vein, and 8 French Lamp catheter was advanced with wire into SVC. Bolton catheter was used, and intra-atrial septum was interrogated with ICE catheter. We were unable to cross septum with multiple catheters. Lamp catheter was advanced and demonstrated tenting. Agitated bubble study x 3, 2x with Valsalva maneuver, and we saw no bubbles across septum. Detailed interrogation of septum showed no evidence of PFO. Agitated bubble study negative, and septum couldn't be crossed. Procedure was discontinued. Impression: No intra-atrial septal defect, no PFO identifed."

Not sure how to code 93462-74 and 93662, but these are add-on codes with no base code. No pressures were taken. What are your suggestions on how to code?

36005 with 37241 for venous malformation

Regarding the use of codes 37241 and 36005 for venous malformation. "PRE-EMBOLIZATION ANGIOGRAM #1: Direct puncture in the posterior left leg is performed with a 23 gauge needle. Access in the malformation is accomplished. Contrast is injected an angiogram is performed and the study is reviewed to determine treatment of that malformation compartment percutaneously accessed. (The above is repeated sometimes up to 8 times – each puncture into the same part of the leg, pre and post angiograms are being performed, with 36005 reported for each pre-embolization angiogram.) After injecting 4 mL of ethanol contrast is injected an angiogram is performed the study is reviewed and thrombosis of this compartment is now noted." Also, if the malformation is found in the chest area, utilizing direct puncture, is there a more appropriate code to use other than 36005, or is 37241 the only code reportable? The provider is reporting the codes as noted above. We feel code 36005 is not appropriate to report for the cases and would appreciate your expertise.

35371, 35372, 35741

Would it be appropriate to code 35371, 35372, 35741 for this case? Incision left groin, exposing the distal external iliac artery, entire common femoral artery, several centimeters of superficial femoral artery and well down into the profunda femoral artery as well- extensive endarterectomy of the entire common femoral artery extending well down into the profunda femoral artery. The superficial femoral was totally occluded - We divided that beyond its origin, the SFA, about 6cm distally and divided it, over sewed the distal SFA. The proximal and then the 6 cm stump was opened on its inferior surface, endarterectomized and this was used as the patch for the profunda endarterectomy. We then opened up the profunda femoral artery for several centimeters, did extensive endarterectomy of the profunda. The vessel of course was opened here and we did an extensive endarterectomy of the common femoral artery through this same access. He also did an exploration of the popliteal artery for possible by-pass but found that it was a non-bypassable vessel

Complicated gastrostomy placement

Pt w/peritoneal carcinomatosis. With fluoro guidance, an angled glide catheter and stiff Glidewire were advanced thru the nose and into the stomach. A 24mm x 4cm angioplasty balloon was advanced into the esophagus over the guidewire. The balloon was inflated and US of the left neck showed a safe window of access for percutaneous transesophageal gastrostomy between the thyroid gland and LT carotid. With US guidance, an 18-g trocar needle was advanced between the thyroid gland and LT carotid. The needle was used to puncture the angioplasty balloon. Through the needle a J-wire was advanced/coiled within the angioplasty balloon. A 2nd operator then advanced the angioplasty balloon and wire into the stomach. Once in the stomach, the wire was separated from the angio balloon and the balloon was removed. Over the wire, after serial dilatation, a 12Fr x 60cm drainage catheter was advanced. The pigtail portion was formed within the stomach. Position was confirmed with contrast and catheter was secured to the skin. 

Would this be 49440 or unlisted 43999? 

93975 vs. 93978

Our physicians are documenting the following for an abdominal aorta duplex: "CONCLUSIONS: 1) Mild atherosclerosis of aorta demonstrated, no evidence of stenosis or aneurysm formation. 2) Patent IVC with unremarkable flow. Study Data-Mid abdominal aorta duplex evaluation. Complete study, duplex scan, and Doppler flow study including spectral analysis, color and gray scale imaging. A vascular evaluation was performed. Image quality was good. ARTERY MAPPING: Measurements of the suprarenal aorta, juxtarenal aorta, infrarenal aorta, right common iliac, left common iliac. FINDINGS: There is a mild atherosclerosis." Is the comment on the patency and flow of the IVC along with the comments on the abdominal aorta enough documentation to report this as a 93978? Are we looking for iliac vasculature documentation in order to report 93978? Does the lack of documentation of the iliac vasculature indicate we should report as 93975?

Impella VAD Insertion

What CPT code(s) is the most appropriate for this procedure: 33990, 34716, or 33975? "PROCEDURE: The patient was induced with general anesthesia, and the neck, chest, abdomen, groins, and legs were prepped and draped in the usual aseptic manner. An incision was made in the right infraclavicular space and dissection carried down to the subclavian artery. After heparinization, a partial occlusion clamp was applied, and a 10 mm Dacron graft was sutured to the subclavian artery in an end-to-side fashion using the 6-0 Prolene suture. The patient had extremely poor vessel tissue that easily dissected away from the wall of the vessel. Once the anastomosis was complete, the end of the graft was tunneled out subcutaneously to a more lateral position to the right shoulder, and the Impella 5 L left ventricular assist device was inserted under fluoroscopy in standard fashion. We shortened the graft down to the level of the skin at the exit site and anchored the device in position. The infraclavicular incision was irrigated and then closed with sequential layers of Vicryl suture."

37236 vs. 33881

Which CPT code, 37236 or 33881, would used for the following intervention? "Given the unexpected finding of the aneurysm, it was necessary to perform a covered stent angioplasty of the proximal thoracic descending aorta. This served the dual purposes of endovascular repair of the aneurysm as well as treatment of the residual coarctation. The right femoral artery was noted to be stenotic, and not large enough to accommodate the required sheath. An 8 French sheath was therefore placed in the left femoral artery under ultrasound guidance. After serial dilation, a 12 French sheath was advanced through the LFA without any resistance and positioned in the transverse arch. Next, an Amplatz super-stiff wire was positioned in the right subclavian artery. A 2.8 cm long CP covered stent was mounted on a 12 mm BIB balloon. The covered stent was advanced to the proximal descending aorta, within the previously placed stent and spanning the broad-based aneurysm. The stent was implanted without difficulty and post-dilated with a 12 mm x 2 cm Opta balloon. The aneurysm is completely excluded."

Microcystic Lymphangioma Embolization

Please provide the CPT codes with an explanation. "12 month old with large dominant macrocyst. Sclerotherapy of the left neck lymphatic malformation. In supine position, using ultrasound guidance, a 20 gauge angiocath needle was initially directed into the lobular posterolateral collection. Only a small amount of fluid could be aspirated, likely due to collapse of this smaller cavity. The catheter was removed. Using direct ultrasound guidance, a 20 gauge Angiocath needle was then used to access the large anechoic cyst more anteriorly. The needle was removed and a total of 10 ml of amber colored fluid was aspirated. The pocket of fluid again collapsed around the Angiocath, and access to the cyst was lost. After aspiration, on ultrasound, the large cyst was noted to be significantly smaller in size. No additional fluid was aspirated. The needle was removed from the sheath. Through the Angiocath, 100 mg of doxycycline (10 mg/mL) was injected under fluoroscopic guidance. Even filling of numerous adjacent microcysts. Sheath was removed."

Selective Cath Coding for Variant Hepatic Artery Anatomy

What are the correct select cath codes for the following? I believe the correct codes are 36245-59 (celiac) and 36246 (RRHA). "Vessel catheterized: celiac axis. Findings: The celiac axis was catheterized with a 5 French Simmons 1 catheter. Angiography demonstrates the left hepatic artery arising from the celiac trunk perfusing hepatic segments 2, 3, and 4. Vessel catheterized: superior mesenteric artery. Findings: The superior mesenteric artery was catheterized. Angiography demonstrates a replaced right hepatic artery. Vessel catheterized: replaced right hepatic artery. Findings: The replaced right hepatic artery was catheterized. Angiography with rotational cone beam CT demonstrates multifocal hypervascular tumor throughout the right hepatic lobe. Technetium MAA was administered to the right hepatic artery."

93975 with 76856

I have a claim that is editing for NCCI of 93975 with 76856. I would put a -59 modifier on 76856. Is this correct and why or why not? "Reason for Exam: Lower ABD/Femal Reproductive Organs lower abdominal pain, RLQ or LLQ Exam: Transabdominal Pelvice Ultrasound with Doppler Technique: Transabdominal real-time Duplex scan was performed using B/Mode/gray scale imaging, color flow and spectral Doppler analysis to include bilateral Evaluation of arterial and venous flow. Findings: Uterus 8.0 x 3.9 x 2.8cm No myometrial mass to suggest Leiomyoma. Endometrium: 7 mm Ovaries: Right ovary 4.2 x 2.3 x 2.3cm. Normal arterial and venous flow. No focal lesions Left Ovary: 3.7 x 2.3 x 2.9 Normal arterial and venous flow. No focal lesions small amount of cul-de-sac fluid Normal uterus, Normal Ovaries without evidence of torsion. Trace amount of cul-de-sac fluid, nonspecific."

Thrombosed Dialysis Leg Graft

"Thirty minutes prior to the procedure, I placed 2 mg of tissue plasminogen activator into the graft. This was allowed to dell. We then accessed the graft initially near the arterial limb, but I could not be sure if I was in. Therefore, I went further distally and accessed antegrade towards the venous limb. We were able to successfully place a 6 French sheath. I was able to aspirate thrombus. Imaging revealed a high grade stenosis at the saphenofemoral junction and the previously stented area. We then treated the outflow with a 7 x 40 mm balloon. An arterial sheath was placed in the opposite direction near the same area, and a wire was able to be advanced up into the left external iliac artery through the common femoral artery. We then treated the first segment of the arterial limb of the graft with a 7 x 40 mm Dorado balloon. Finding stenosis at saphenofemeral junction, proximal portion of venous outflow and first segment of the AV graft near the arterial anastomosis." I reported this with codes 36870, 372220, 35476, 75978, 36147, and 36148.  Am I correct?

Discontinued TIPS procedure

I am not sure how to code this discontinued TIPS procedure. When I look at valid modifiers for 37182, I do not see -73, -74, or -52 modifiers as being okay to use. Should I code this as a diagnostic study and use codes 36011, 75889, 36481, and 75887? Condensed version of procedure: "Approach from right internal jugular. A 5 French multipurpose catheter was placed used to obtain pressures in the right atrium, after which it was manipulated into the hepatic IVC where another pressure was obtained, and then into the right hepatic vein for free and wedged pressures. Several passes into the liver were made with a needle wire and 5 French catheter. The right portal vein branch was entered, but the wire could not be manipulated peripherally into the left lobe. After exchanging multiple caths a stiff glidewire was placed into the more central right portal vein but was not able to cross into the main portal vein. Contrast injection showed filling defect within the main portal vein. Wire, catheter, and sheath were removed, and hemostasis was obtained."

Open Aorta-bifem bypass graft w/ indication of Aortoiliac claud 36246?

"Left/right common femoral SFA and profunda were isolated and dissected. Retroperitoneal tunnels created LT/RT a 14 x 7 step graft limbs. Clamp on the aorta below renal arteries. Arteriotomy within the aorta and extended. Significant clot in the aorta removed. Graft was tailored to fit. LT common SFA and profunda are placed on vessel loop. Made arteriotomy within the common femoral and extended. The graft was tailored to fit. SFA and profunda placed under traction on the right. Significant atherosclerotic disease within the common arteriotomy extended to the proximal SFA. Endarterectomy common femoral and the proximal SFA. Plaque in the proximal SFA had eaten through wall of the vessel. Bovine pericardial patch was tailored to fit. Still some bleeding from the repair of the wall of the SFA common region. This was reinforced with a piece of felt. Aortobifemoral limb on the right was tailored to fit."

Would this be 36246 only? Or 34832 due to an open procedure? The indication does not specify AAA.

Percutaneous Fem-Fem Bypass for femoral occlusions.

Is code 35661 for open proc or can it be used for percutaneous bypass? "The interventional radiologist performs percutaneous accesses in RT internal jugular and LT SFV then performs small suprapubic incision and performs a needle access in each femoral vein through the incision. He places Ensnares through each percutaneous access (RT IJV/LT SFV) then performs through and through access from the lright internal jugular to the left femoral vein through the subcutaneous tissues in the suprapubic area. That area is dilated with balloons, the distance is measured with marking catheter. Long sheath placed the RT IJV through suprapubic soft tissues into the LT femoral vein. Through this sheath, percutaneous bypass was created using 8mmx15cm Viabahn stent. Two additional 8mmx10cm Viabahn stents were deployed to cover the complete segment between the two femoral veins with balloon dilitation. Successful percutaneous LT fem vein-RT fem vein bypass creation." Should this be an unlisted code (37799)?

Acute GI Bleed

When a patient has an embolization due to a GI bleed (because of tumor), and bleed is not located but embolization is done, would the embolization code for hemorrhage be used (even though they did not locate the bleed)? I see this frequently, as we are a cancer hospital and tumors frequently cause hemorrhage. Here is an example: "Multiple attempts to access right gastric artery were attempted without success. Splenic artery was accessed with microwire and renegade catheter, which was placed distal to area of irregularity. 3 mm coils were placed. Findings: Tumor encasing splenic artery without active bleeding identified. Right gastric artery originates from tortuous left hepatic artery, and multiple attempts were made to access right gastric without success. No active bleeding identified from right gastric." Would cases like this be coded as hemorrhage (since reason was GI bleed), tumor (since the tumor is the cause of bleed and it states "tumor encasing splenic", which was embolized), or non-tumor? Please advise.

Is RVOT stenting_pre-stenting or can we code 33477 and 33745?

Can we report both codes 33477 and 33745? Is the RVOT stent placement in the valve deployment zone, or is it considered pre-stenting (33477)?

"Status post bioprosthetic pulmonary valve replacement with an enlarging right ventricular outflow tract pseudoaneurysm, which has been causing worsening sub-pulmonary stenosis. There has been concern that when his anticoagulated and in the setting of significant RV hypertension, the RVOT pseudoaneurysm continues to enlarge, worsening his sub-pulmonary stenosis and the strain on his right heart. I noted that he had a severely reduced cardiac index at 1.86 L/min/m2 and a 40 mmHg gradient from the right ventricle to just above the bioprosthetic valve due to the sub-pulmonary obstruction and compression by the RVOT pseudoaneurysm. The procedure included diagnostic right and left heart catheterization with oximetry hemodynamics and angiography. Intervention included stent placement in the right ventricular outflow tract and transcatheter pulmonary valve implantation."

Iliac Stents at Time of TEVAR

"Patient presented for TEVAR for thoracic aortic ulcer. Bilateral femoral cutdowns were done (34812-50). On the right, pigtail was passed for diagnostic angio (36200). Device sheath could not be advanced due to iliac disease. Common and external iliac stents were placed (37221/37223). Still could not advance device sheath. Right side was abandoned. Device sheath couldn't advance on the left either, so an iliac conduit was placed (34833). Catheter was advanced into arch through conduit (36200-50). TEVAR not covering subclavian was placed (33881/75957). Conduit was then converted to a ilio-common femoral bypass (35665)." Since the right side was abandoned and the stents were placed to facilitate passage of device, can I still code the stents? Can I code the conversion of the conduit as a bypass and as a conduit? Can I report code 36200-50 since the catheter was for the TEVAR, not the stents? Your expertise is greatly appreciated.

Popliteal to Popliteal Bypass

"Right saphenous vein harvested for use in both legs. Right: The popliteal space was opened below the knee. I could see the area of obvious contusion at the proximal aspect of the popliteal below the knee. The thigh incision above the knee was then deepened into the popliteal space. Popliteal artery was identified. A tunnel was bluntly created between these two. Vein was brought onto the field reversed and marked oriented. It was spatulated and anastomosed end-to-end to the popliteal artery. Vein was then passed back into popliteal space. The vein was trimmed at the proper length and an end-to-side anastomosis was created. Left: The incision was made below the knee. I was able to identify the tibial/peroneal trunk. A longitudinal incision was made above the knee overlying the popliteal space. Vein was then anastomosed end-to-side to tibial/peroneal trunk and then run subcutaneous around knee to popliteal space. Anastomosed end-to-side to popliteal artery above knee." I'm not sure how to code: unlisted, fem-pop bypass, or popliteal-distal vessel bypass?

93640

Could you please clarify the use of code 93640? "Patient here for biventricular generator change due to ERI. Patient was brought to the lab; all of the leads worked well. The old device was removed. The leads were inspected, and they all worked well. They were attached to the new device and placed into the pocket. Three layers were used to close the wound. High voltage resistance was checked. Patient left in stable condition. Patient was in complete AV block. No shocks on previous device." We are told the physicians test the leads when they place/change/upgrade an ICD and we should therefore report code 93640. We report code 93641 when they test the generator and the patient is induced into an arrhythmia and joules back into sinus rhythm. Can you clarify on implantation/change/upgrade regarding what the report has to indicate to report code 93640? Or is code 93640 considered inherent to the procedure and not coded if the report doesn't document an arrhythmia being induced? Does the report have to indicate that an arrhythmia was induced, or can it be assumed? We (hospital) reported the above with codes 33264 and 93640.

Which is correct CPT 34201 VS 37184 and 37211

Which is correct 34201 vs. 37184 and 37211?

"Using a glide catheter and Glide Advantage wire, we advanced the Glide Advantage wire to the level of the proximal to mid superficial femoral artery. This was followed by placement of a 45 cm, 6-French sheath from the left common femoral artery access. Heparin 4000 units were given intravenously. Serial ACTs were performed and additional heparin given to maintain an ACT of greater than 250. At this point, we used a Glidewire and a Rubicon catheter to traverse through the occluded SFA stent. We were able to navigate the Rubicon catheter to the popliteal artery contrast injection, revealed a patent TP trunk artery, anterior tibial artery, posterior tibial artery as well as peroneal artery. The peroneal artery, however, is diseased. TPA 4 mg was given through the sheath intra-arterially. We then used an AngioJet device and sprayed tPA solution in the entirety of the popliteal artery and the stented SFA. After 15 minutes had elapsed, mechanical thrombolysis was performed in two passes."

RT atrial and bilateral pulmonary artery thrombectomy

For this abbreviated report for rt atrial and bilateral pulmonary artery thrombus, are 0644T, 36015-50-XS, 37184-50 correct? "CTA chest was done prior to this IR procedure. Catheter was advanced into the SVC. Dilated with 12 French and 22 French dilator. A 24 French Inari sheath was advanced over the Amplatz wire and positioned in the IVC. The dilator was removed, and an additional 22 French Inari suction sheath was advanced to the SVC. Suction thrombectomy was performed. Catheter was retracted immediately adjacent to thrombus in the eustachian valve. Repeat suction thrombectomy. Catheter was advanced to the main pulmonary artery. 22 French suction thrombectomy cath was advanced into the inferior right segmental pulmonary artery. Thrombectomy was performed. Repositioned into the inferior left segmental artery where suction thrombectomy was performed."

Central Venous Access-Newborn Temporal Access

How would you report the following central venous access procedure? Would this be central or peripheral due to temporal access? Also, why might the provider consider this unsuccessful if the tip terminates in the SVC? "Central Line Procedure Note. Patient Age: 7-weeks-old. PICC - PEDIATRICS. The patient was positioned supine. This procedure was performed under sterile conditions. The catheter was cut to cm. The 26 gauge catheter was inserted into the right temporal vein. We advanced the single lumen PICC catheter to cm at skin entry level and secured in place. All ports were flushed with saline at the end of the procedure. Blood return was noted. A sterile dressing was applied. Line placement was not successful. Tip location terminates in the inferior vena cava (line insertion unsuccessful). Ultrasound was not used during this procedure. Additional Details: Results: Line unsuccessful. Both right and left temporal veins accessed, but unable to pass the catheter. Recommend escalation of PICC line placement to IR."