Ask Dr. Z

Extracardiac Fontan Stenting

I have abbreviated the report to submit... Right heart catheterization was performed. Left heart catheterization was performed. Conduit angiography was performed. A super-stiff wire was navigated into the innominate vein. The 8-French venous sheath was exchanged for a 14-French x 65 cm Gore Dry Seal Flex sheath. A 5-French MultiTrack catheter was advanced into the conduit. Using the Medrad Power Injector, angiography was performed. Again, the conduit was seen to be diffusely small with a focal narrowing in the middle (possibly at the site of a previous fenestration). I proceeded to conduit stenting. The following stents were placed in the conduit: P4010 x 2 P5010 x 2 These stents were post-dilated with 18, 20, 22, and eventually a 24 mm high-pressure balloon up to rated burst pressure. The conduit appeared significantly larger. Final angiography showed patent stents with no extravasation. Report states this as an Extra-cardiac Fontan with 18 mm Gore-Tex conduit performed 20+ years ago. Recommended codes? 33745? 37236 and RHC/LHC?

Code 38382

Is code 38382 appropriate for percutaneous embolization of thoracic duct, or should I use an unlisted code? The procedure is described as follows:

left: 30px;">Abdominal percutaneous approach. After reconfirming the intraductal location of the catheter, 6 fibered platinum embolization coils were deployed from the distal chest down to the cisterna chyli in the proximal abdomen. Subsequently, a 2:1 Ethiodol and N-butyl cyanoacrylate glue mixture with tantalum powder was injected through the catheter to complete the embolization of the distal thoracic duct and cisterna chyli. The catheter was removed while aspirating to minimize extravasation. Final spot radiographs of the chest and abdomen were then obtained to document the position of the embolic implants. Findings: Coil embolization of the thoracic from the distal chest down to the cisterna chyli. Distal thoracic duct and cisterna chyli sealed with N-butyl cyanoacry liquid embolic glue.

PPM gen removal and replace- add new deep septal /left bundle lead

Patient had RA RV leads. Physician placed a deep septal/LV lead.

"Using the glidewire, a steerable His sheath and dilator were advanced past the tricuspid valve and extended towards the septum just distal to the tricuspid valve. A passive fixation 3830 His lead was advanced and using pacing morphology guidance, a suitable deep septal site was identified. The lead was advanced using passive fixation but failed to achieve appropriate pacing morphology (rsR in lead v1) and the lead was withdrawn and repositioned further proximally towards the septal tricuspid valve. A second appropriate site was identified using pacing morphology. The lead was advanced and appropriate narrowing with acceptable pacing morphology was identified. Adequate pace/sense parameters were obtained. We now have RA, RV and a Deep septal / LB lead WITH NEW GENERATOR. Analysis and programming of a biventricular PPM at implant."

How would this be coded? Is it 33229 and 33225? Or 33229 and 33216? He's calling it a biventricular placement.

93657 vs 93655 for CAFE

Indication was Afib and Aflutter. "PVI was completed and exit block confirmed for each vein. After PVI, isuprel was started and burst pacing was performed from the CS catheter. Patient was induced for Aflutter, and subsequently an activation map, Ripple map, and coherent map were performed that showed an area of slow zone conduction in the septum of the left atrium; areas were targeted with ablation. Aflutter organized with proximal to distal activation in the CS catheter. Multiple areas in the septum were targeted for complex fractionation. A few areas of complex fractionation noted in the posterior wall as well. These were targeted as well. The catheters were taken to the right atrium, and ablation of the CTI was performed. The flutter was terminated during the ablation in the CTI." One coder thinks this should be coded as 93656, 93655 x 2, and 93623, while the other coder thinks it is 93656, 93657 x 2, 93655, and 93623. What is the correct coding please? Second question, is CAFE always coded as 93657?

Retinoblastoma via extended ophthalmoscopy and fluorescein angiography, etc

"Selective catheter placements and angiographies of the patient's left internal carotid artery, external carotid artery, and ophthalmic artery via a right CFA access. Angiography reveals both extracranial and intracranial internal and external carotid arteries and their branches are of normal course and caliber without atherosclerotic disease, aneurysm, focal area of stenosis, or early draining vein. Ophthalmic artery and its branches reveal a chorodial blush. No significant washout of contrast is noted into the supraclinoid internal carotid artery. 1 mg of topotecan was injected into the ophthalmic artery with follow-up angiography performed with no changes from initial angiogram. 5 mg of melphalan was injected into the ophthalmic artery with follow-up angiography demonstrating no change from initial angiogram. Follow-up internal carotid artery angiography was performed with no changed from initial angiogram. No branch occlusions are seen." Is this coded 61624, 36217, 36218, 75898 x 3, 75894, and 96420 (hospital only)? There is no example of this in your database.

36825 or 36830

Could you please clarify if this procedure is reported with 36825 or 36830? "Left upper extremity brachial to axillary AV graft creation with 4 x 7 AcuSeal graft. Transverse incision was made across the brachial artery pulsation just proximal to antecubital fossa. Longitudinal incision was then made over the axillary groove in the upper arm just before the armpit. The axillary vein was identified and was circumferentially dissected. Once proximal distal control was obtained a tunnel was anesthetized in the skin between the 2 incisions in the shape of a Nike symbol. Using a curved Gore tunneler the 2 incisions were tunnel between with and a graft of the AcuSeal 4 x 7 was brought through the tunnel. Potts scissors were used to make 4mm brachial artery arteriotomy. The vein anastomosis was then performed.Using 7-0 Prolene suture after the graft was spatulated and Cobra it a large anastomosis was performed with 7-0 Prolene in a running parachute fashion. The axillary fascia layer was closed over the graft using interrupted 2-0 Monocryl sutures."

Simultaneous procedures by two vascular surgeons, same group

"Patient with left LE critical limb ischemia with gangrenous 2nd toe. Vascular surgeon A performs the upper extremity vein harvest of the cephalic and basilic veins while simultaneously vascular surgeon B performs fem-pop bypass with the spliced veins. Physician A documents the vein harvest procedure indicating that simultaneously Physician B has already started with arterial exposure of LE and then finalizes the procedure once the harvested veins are handed over by Physician A." Physician B also had an assistant (PA-C). Reason for both physicians is reduction of OR time and improved patient safety (documented by Physician A). Since each procedure is distinct and has its own CPT code, how would we capture this, as the vein harvest, performed exclusively by Physician A, is and add-on code and requires a base code which in this case was exclusively performed by Physician B? This scenario does not look to support a true co-surgery (based on 2 distinct procedures/codes and same physician specialty); however, is there a way to capture both physician services appropriately? 

Dual Pacemaker implant with HIS lead in RV port and RA lead in RA port

"Surgeon mapped the bundle of His, located a satisfactory signal and fixated the lead onto the HIS and checked thresholds. The sheath was slit, removed, and lead fixed to the cephalic vein and pectoral muscle. Surgeon then advanced 7 French pacing lead into the RA. Lead tip was placed into the lateral RA wall and screw deployed. The sheath was removed and lead secured to pre-pectoral fascia. Pocket formed, dual pacer inserted, RA lead placed in RA port, HIS lead placed in RV port." Summary is: "Uncomplicated implant of a dual chamber pacemaker with non-selective His bundle pacing achieved with the RV lead via a left cephalic vein cutdown and axillary vein puncture." What is the correct CPT code to report? MD wants to charge 33208 because the His lead was placed in RV port. Medtronic vendor coding information states to code 33206 and 33999. Based upon my experience, I think code 33206 is appropriate. Please provide rationale that I can present to the surgeon.

37184 vs. 37186, Primary vs Secondary Arterial Mechanical Thrombectomy

"A patient has PVD with no pulse in the left leg and goes for a diagnostic angiogram with IVUS of the SFA, popliteal, and proximal tibial vessels. Physician finds extensive thrombus and performs a thrombectomy in the SFA and popliteal arteries, followed by placement of a stent in the popliteal artery, atherectomy and stent in the anterior tibial artery, and atherectomy and angioplasty in the posterior tibial artery." Can you clarify whether we'd use code 37184 or 37185? The reason for the visit was not of a known thrombus; however, once the angiogram/IVUS was performed the treatment was for the thrombectomy, with the other treatments for the additional stenosis in the anterior and posterior tibial arteries. Do you recommend reporting codes 37184, 37185, 37252, 37226, 37231, and 37233? Or do you recommend coding thrombectomy with 37186, 37252, 37226, 37231, and 37233?

Indirect Portal Venogram vs Direct Portal Venogram

Is this indirect portal venogram billed with 36481 in addition to the hepatic veins selection?

"US-guided RIJ vein access, hepatic fourth order vein selection. Transcatheter venous pressure measurement, indirect portal venogram. RIJ vein was accessed under continued US guidance. A single US image of access was obtained for documentation. A wire was advanced into a fourth order branch of the right hepatic vein, and a 5 French catheter was passed. The wire was removed and pressure measurements taken, both wedge and free. Right atrial pressure was measured. The catheter was wedged, and multiple indirect portal venograms were performed. The catheter was repositioned into the left hepatic vein, and then the middle hepatic vein and fourth order branches were selected. Multiple indirect portal venograms were performed in both these branches."

CS Catheter

Dr. Z,  93621 is the bane of my existence! Below I have two separate excerpts which I would appreciate if you could tell me equal 93621. I can't recall any situation when I have specifically seen "LEFT atrial pacing/recording". (Well, maybe one.) Additionally, is there a specific phrase or wording I could suggest to the physician that would make it easier for everyone? Or, wording that I can specifically look for? Is coronary sinus cannulation sufficient? Because he almost always says that. He is very good about documenting comprehensive EP study. 1) Quadripolar catheter placed in high right atrium. Pacing septal and lateral to the isthmus. Rapid pacing in the atrium showed Wenckebach cycle.  Coronary sinus was also cannulated and mapped. 2) Quadripolar mapping and cryoablation catheter was placed in the right atrium and the right ventricle, and the coronary sinus.  Comprehensive EP study performed.  Patient had pacing, both septal and lateral.  Rapid atrial pacing.  Pacing in the RV. I have referred to your Q&A's from 7/30/10 and 12/28/09 as well as scrutinizing the CPT description for 93621, but I still wrestle with this. YOUR HELP IS GREATLY APPRECIATED.

Direct punture sclerosis of a vastus lateralis fatty infiltrate

Patient has left thigh pain with fatty infiltrate of vastus lateralis muscle, here for direct puncture sclerosis, treating like a vascular malformation. "Sequentially accessed different points w/in malformation w/21 gauge needle injecting contrast to determine anatomy of lesion. Sotradecol foam injected to spread w/in lesion. Skin cleaned & dressed. Then RT CFA accessed, wire passed centrally, 5 F4 C2 cath passed over wire to select LT ICA anterior division (36247) w/imaging (75736-LT), Cath then pulled back &selected LT CFA (36248) w/ imaging (75710-LT) which showed no abnormal vascularity. Final was LT vastus lateralis focal fatty infiltration being treated as a vascular malforamtion. No evidence of AV malformation." This sounds like a direct puncture varicose vein sclerosis, but there was no vascular findings or location treated. How will this procedure be coded?

gelfoam slurry mixed with thrombin into retroperitoneal hematoma

Would this be unlisted? No catheterization due to extensive atherosclerotic disease. Agent: Packet of Gelfoam mixed with 5000 units of recombinant thrombin. fluid portion of the hematoma was accessed with a 5 French Yueh catheter directly. Under ultrasound guidance, Gelfoam slurry mixed with the recombinant thrombin was administered into the retroperitoneal hematoma. Via the 5 French Yueh catheter, other parts of the hematoma was also injected with Gelfoam slurry mixed with recombinant thrombin. A total of 50 mL of Gelfoam slurry mixed with recombinant thrombin (5000 units) was administered directly into the liquid portion of the hematoma. Catheter was removed.

Impression: Ultrasound-guided percutaneous administration of Gelfoam slurry mixed with the common and thrombin into the left retroperitoneal hematoma.

Any help would be appreciated!

EPS/Ablation pre-proc DX: paroxysmal atrial fib/paroxysmal atrial flutter

May we report codes 93656/93655 for the following?

"Cryoballoon ablation with PVAI, RF ablation CTI. Four femoral venipunctures/sheaths placed. ICE cath to right atrium, low normal EF/trace pericardial effusion noted. Ablation catheter to right atrium, 3D map created. CS cath advanced to CS. Baseline conduction taken. RF of CTI delivered. Bidirectional block confirmed. Ablation catheter removed. ICE-guided transseptal puncture, trace pericardial effusion noted. Cryoballoon advanced to left atrium. 3D map created. Pulmonary veins identified. Voltage mapping. Four pulmonary veins targeted with cryoablation. Entrance and exit block documented. Comprehensive EP study with R/L atrial pacing/recording and His bundle recording. AH and HV intervals noted to be 120 ms and 54 ms respectively. ICE noted baseline trace pericardial effusion. All catheters removed."

Modified Lymphangiography for Chylous Leak

Is unlisted code 38999 appropriate for the following case? "Sterile prep of the chest, abdomen, and bilateral groins was performed with patient under general anesthesia. Using ultrasound guidance, a 25 gauge needle was advanced to the cortical medullary junction of a right inguinal lymph node. This was repeated on the left side. Approximately 5 ml of lipiodol and 10 ml of saline flush were injected into both lymph nodes over 30 minutes using intermittent fluoroscopy to opacify the lymphatic system. Lymphangiogram clearly demonstrated the lymphatic channels of the pelvis ascending into the abdomen with two large lumbar lymphatic channels. Overlying the upper right L5 vertebral body, just inferior to the L4-L5 disc space, there was a focal area of contrast extravasation into the right peritoneum and retroperitoneum. This was confirmed by fluoroscopy and Dyna CT, demonstrating free lipiodol in the right retroperitoneal space collecting along the right psoas muscle and posterior abdominal wall. Additional lymphangiography demonstrated drainage of the cisterna chyli and ascending to the thoracic duct."

Discontinued Bone Marrow Aspiration

I am questioning the use of a -74 modifier for an unsuccessful bone marrow aspiration during a bone marrow biopsy/aspiration procedure. The report states: "After informed written consent was obtained, the patient was brought to the fluoroscopy suite and placed in the prone position. The patient's right posterior pelvis was prepped and draped in the usual sterile fashion. 2% lidocaine solution was used to anesthetize the skin and subcutaneous tissues, and a dermatotomy incision was made. Initially, a 15 gauge needle was advanced into the posterior left iliac bone under fluoroscopic guidance. Marrow aspirates could not be obtained. Per protocol, three separate 11 gauge core needle biopsy specimens were obtained under fluoroscopic guidance. The samples were submitted to the pathology technologist. The 11 gauge needle was removed and hemostasis achieved following two minutes of manual compression." Would the correct codes be 38221, 77002, and G0364-74? Or would you only code the completed procedure of the biopsy with 38221 and 77002?

PV ablation in WACA fashion

"Patient entered room in persistent AF. Polaris was placed into CS for LA stim/recording. ICE cath was placed into RA. Soundmap of LA was created. Transseptal access was obtained. PentaRay was used to create LA FAM. Thermocool STSF unidirectional D cath was placed into the LA. Ablation was done around the bilateral PVs in WACA fashion with 20W along post wall and 30W everywhere else. A roof-and-floor line was created to attempt to isolate post wall; however, at the post aspect of the right inferior PV the esophageal temp rose, so ablation was limited here. The bottom right corner of the post wall box was left partially ablated. Another vertical line was created throught the mid post wall, so it was partially isolated. Entrance and exit block confirmed with pacing along the lines at 10mA/2mS and with PentaRay for valiation map." Can code 93656 be billed for WACA? Since the report does not state PVs isolated, can code 93656 be billed? If remaining AF after PVI, can code 93657 be billed if only partial isolation?

3D Rotational Angiography with Ventricular Pacing

When is it appropriate to bill codes 76377 for 3D and 93612 for ventricular pacing when performed during rotational angiography along with pulmonary artery angioplasty (92997)?

"Example: Patient presents for a diagnostic cardiac cath and possible intervention on the conduit. Complete right heart and retrograde left heart cath was performed. 6 French Berman angiographic cath was placed in the right ventricle. A 4 French pacing cath was inserted in the LFV sheath and placed in the right ventricle. Right ventricular pacing was performed at 180/min with breath hold, and rotational angiography was performed. Rendering and post-processing of the rotational images was performed. After post-processing, the image was used for overlay on the fluoroscopy. Angioplasty was then performed within the RV-PA conduit and the right pulmonary artery. There was adequate arborization bilaterally. Post angiography demonstrated adequate relief of the stenosis. Improved angiographic appearance of the RPA post balloon angioplasty with no evidence of vascular injury."

Upgrade of a dual chamber defibrillator to a biventricular defibrillator

Hi Dr. Z I looking for a clarification from a question posted from March 8, 2012 "Question: Upgrade of a dual chamber defibrillator to a biventricular defibrillator. Remove and replace generator, insertion/addition of left ventricular lead and attachment of generator to previously placed atrial and right ventricular leads. How would you code this utilizing the new 2012 cpt codes? Thank you! Answer: I would code the removal of a dual chamber generator and replacement with a multi-lead ICD generator (as the final device placed is a multi-lead) as a multi-lead generator replacement, along with the LV lead at time of generator change. So the codes are 33264 and 33225. Dr.z" My question according to 2012 CPT manual 33225, in the parenthetical note, 33264 isn't listed as a CPT code to use in conjuction with 33225. I apprciate any clarification to this matter. Thank you!

AFX Stent Graft for Aortic Stenosis

Please code the following procedure done for aortic stenosis: "Stent graft repair of the patient's abdominal aorta and common iliac arteries and then address residual disease in the external iliac arteries. We utilized the AFX stent graft system. We then used two 8 x 40 mm Armada balloons to perform kissing balloon angioplasty of the aorto-iliac bifurcation, as well as the right and left common iliac arteries. There was still some concern about a possible stenosis or dissection in the distal right common iliac artery and proximal right external iliac artery. IVUS revealed an area of dissection or residual thrombus in the distal right common iliac artery beyond the right limb of the endograft. There was also an area of dissection seen in the proximal to midportion of the right external iliac artery. We placed a covered stent across the distal right common iliac artery immediately above the takeoff of the right hypogastric artery. To cover the area of dissection in the right external iliac artery, we used an Absolute stent."

Code 33881 vs 33886

Placement of catheter in the aorta x 2; endovascular thoracic aortic repair without coverage of the left subclavian artery. Use of non-coronary IVUS, graft used 42 x 42 x 150 proximal main graft, extension of 46 x 42 x 150. Patient had a rupturing thoracic aneurysm. The patient had previous stent grafts, and the components had separated. The decision was made to bridge the separation of the components as well as extend past the aneurysm to cover the aneurysm. It was felt that we would bridge the components with a 42 x 42 x 150 graft. This was passed over the wire. Pigtail catheter was utilized to confirm position using LAO picture view, and the bridging component was placed. Angiogram was again obtained, again localizing the celiac artery, and a second distal extension was placed. The grafts and attachment sites were ballooned. Would the bridging of the prior thoracic components be reported with code 33881 or 33886 since the patient had prior stent grafts? I know we can't use both 33881 and 33886. The physician states that 33881 is the correct code.

MD stented an LVAD graft with a VSD Occluder device?

What would you bill if physician put a stent in an existing LVAD graft using a VSD occluder device? "A 9 French x 80 cm Amplatzer delivery sheath was advanced through the 12 French sheath over the Amplatz SS wire into the outflow graft. Sheath was aspirated and flushed. Wire was removed, and a 14 mm muscular VSD occluder device (after being prepped) was advanced into the outflow graft. Together with the sheath, the device deployment tool was partially retracted, and the VSD occluder was deployed such that the distal half was situated in the proximal outflow graft and the proximal half in the ascending aorta. The deployment tool was removed, and the delivery sheath was removed over wire. A 5 French pigtail catheter was then advanced to the left ventricle where a power injector was used to perform a ventriculogram, which showed complete exclusion of the LVAD outflow graft by the VSD device. Catheter was then removed over J wire."

Catheter selection

Dr. Z -- I would appreciate your interpretation of the procedure description below as to the code/charge for selective catheterization. “The 6-French sheath was placed in the right femoral artery. The right lower extremity angiography was performed through the sheath. Following this, the sheath was exchanged out for an AccessPro which was advanced TO THE CONTRALATERAL COMMON ILIAC.” (Angio findings are documented.) Then says, “An intervention was performed on the LEFT INTERNAL ILIAC. An 0.014 Stabilizer Plus WIRE was advanced out INTO THE INTERNAL ILIAC and balloon angioplasty…etc., etc.” (Stenting followed the angioplasty.) I do not have any problem with the procedure codes. However, as far as selectivity, should we code/charge 36245-LT (first order to common iliac) OR 36246-LT (second order to internal iliac)? Does the WIRE placement described above equal selective catheter placement? Is the "default" that the vessel is selectively engaged/cathed if it is treated?? MANY THANKS FOR YOUR ASSISTANCE!

36252 and renal stents

For the following, would codes 36252 and 36245 be correct? "Procedure: selective and non-selective renal artery angiogram and direct stent to ostial proximal segment of the right renal artery. Description: A 4 French sheath was placed in right common femoral artery. A 4 French JR4 diagnostic catheter was used to perform selective and non-selective renal artery angiography. With following findings, the abdominal aorta showed no evidence of abdominal aortic aneurysm. Left renal artery had proximal 30% stenosis, large 4.5 to 5 mm vessel. Right renal artery had an ostial proximal 90% stenosis. A 6 French sheath was exchanged for a 4 French sheath. 70 units/kg of heparin given. ACT was 271. A 55cm JL4 guide and 0.01 Prowater guidewire place distal right renal artery. 5.0 x 14 mm EV3 Paramount mini GPS stent placed ostial proximal segment of right radial artery with approx 2 mm of the proximal edge located inside the abdominal aorta. Stent was deployed, and stenosis went from 90% to 0% with TIMI-3 flow." 

Cardiac Cath Documentation

I was wondering if there are specific requirements for what needs to be in the documentation of a cardiac cath. An outside resource disagrees with documentation requirements, and we are asking for your help to clarify. The physician includes the pre-procedure diagnosis, the findings and plan, contrast used, blood loss, fluro time, etc. This is an example of the main part of the procedure dictation: "Catheter: JACKY, JL4, PIG, 3DRC Sheaths: 5 FR, right radial artery Closure device: TR Band Dominance: right Pressures: Aorta: 136/75/101 LVEDP: 21 Coronaries: Left Main: Large caliber. Free of obstructive disease. LAD: Heavy proximal calcified plaque but no significant obstructive disease. Moderate caliber Diagonal. Free of obstructive disease. LCX: Moderate caliber, nondominant LCx. Moderate caliber OM. Free of obstructive disease. RCA: Moderate/large caliber. Dominant. No obstuctive disease. Moderate caliber PDA. Free of disease LVG: EF: 65% Findings: Calcified but nonobstructive coronary atherosclerosis Normal LV systolic function. EF 65% Mildly elevated LVEDP."

Aortogram and run-off 75710

Dr Z, With so many ways to code abdomen and runoff studies, I'm finding it more difficult because of the wording "pelvis" and rt lower extremity. Heading reads "Right extremity arteriogram possible PTA stent" PVD with wounds. The report reads "pelvic with rt lower extremity angiogram, PTA rt SFA with attempted recanulization of rt SFA" FINDINGS: Aorta/Pelvis:There is mild ectasia of the infrarenal aorta. No aneurysmal disease, dissection or flow limiting stenosis exists.Iliac arteries are unremarkable. Both internal iliacs are patent. Common femoral segments are patent.  Note, on the left supreficial femoral artery is occluded. Then goes on to Right leg findings:....(the rt leg is injected at the external iliac) I feel the intent of the study was rt leg as stated on the very top of the report. In order to evaluate the iliacs you would need to inject at the bifurcation (that's a given). I also feel the "Note" is an incidental. I would greatly appreciate your thoughts on this. Your examples for claudication both have high and low injections which this does not. Injection bifurcation and rt external.

Infected left axillary artery Dacron graft conduit stump 35905 w 35572?

"Excision of the infected axillary Dacron graft. The axillary artery was exposed proximally and distally to the graft anastomosis. Once branch was ligated using silk ties and clips. Infected axillary Dacron graft. We decided to use a bovine pericardial patch for axillary artery repair. IV heparin weight-based was administered and ACT was allowed to come above 250. The axillary artery was clamped proximally and distally using clamps. Sidebranches were clamped using Vesseloops. 11 blade was used to transect the graft off of the axillary artery right at the suture line. The graft was sent to microbiology. We then debrided the vessel wall back to healthy tissues. Inflow and outflow was confirmed. We then washed the wound with 3 L of normal saline via cystoscopy tubing. A bovine pericardial patch was then trimmed to shape and length and sewn onto the axillary artery using a running 6-0 Prolene suture. Prior to completion flush was done." 

35905 & 35572 or only 35905?

35216

Please help with coding this report. Would codes 33320, 36010, and 75827-26 be appropriate? I was also thinking about codes 36597and 76000 since they had to reposition it back in place. Do I separately code for thoracotomy? I am really lost on the coding for this one! "Fluoroscopy was used, demonstrating that the proximal port was in the SVC and the distal port was within the pleural space. Completion venogram showed distal port was now in the right atrium. Once the cath was originally determined to be in the pleural space, the patient was placed in the left lateral decubitus position, sterilely prepped, and sterilely draped. A thoracotomy incision was made. Entry was through the fifth intercostal space. Lung was retracted and cath identified. Purse-string suture in position, and cath was then pushed back into the SVC and placed into the right atrium. Suture was tied. There was no hemorrhage from suture, and the chest was closed. Chest tube in place. Fluoroscopy was brought back into position and distal tip in the RA."

Contrast Injection with Resting Echocardiogram

Is 96374 reportable with resting echo? Per CPT Assistant: "A contrast agent may be administered with a stress echocardiogram to improve the delineation of the left ventricular endocardial borders in a patient whose non-contrast echocardiography study is inadequate or suboptimal, and for whom the LV function information is essential to the management of the patient. Neither the CPT code 93350 nor 93351 includes the administration of a contrast agent. If the physician performs intravenous administration of an echocardiographic contrast agent in conjunction with a stress echocardiogram (code 93350 or 93351), report the add-on code 93352, which is reportable only on a global basis. To further clarify, contrast material may be used during performance of resting echocardiography (codes 93306, 93307, and 93308). In this circumstance, the injection of contrast media for imaging code 96374, Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug, may be reported." CPT Asst Jan. 2010, Vol 20 pg 8

AVG patient w./ radial artery thrombectomy - 34111 vs. 37186

A patient with an AV graft undergoes open thrombectomy of the graft, along with balloon angioplasty and stenting of the axillary vein. Selective cath and thrombectomy of the radial artery are also performed as follows: "....Fistulogram was performed, which showed evidence of persistent thrombus in the proximal AV graft. There was also evidence of thrombus at the origin of the radial and interosseous arteries. Wire was then directed in the radial artery under fluoro guidance. A Fogarty balloon was then passed into the proximal radial artery, and a thrombectomy was performed until all clot was evacuated. A completion angiogram was performed of the left forearm and hand that showed no residual thrombus and improved flow through the radial, interosseous, and ulnar arteries." We have 36833 for the open thrombectomy with axillary angioplasty and stenting. Is the radial artery thrombectomy to be reported with 34111? 37186 and 36215? Would we also need code 75710?

33210 with 92980

Per the Q&A below code 33210, should not be billed when done with an intervention. Is that because the TVP was removed at the end of the intervention? Has this guideline changed since 2010? The doctor states that it takes additonal work and time to insert the pacemaker and he should be getting reimbursed for it. If we cannot bill 33210, when done with an intervention, should we append modifier 22 to 92980/92982 etc? Also, what if only a diagnostic heart cath/coronary angiogram is being done and the pt has episode of bradycardia. Can 33210 be billed? Date: Friday, April 30, 2010 Question: Please advise when to report temporary pacemaker with modifier -59. The Q & A's that I reviewed (#325 & 1554) do not match my billing scenario. Patient is admitted for complex percutaneous coronary intervention on three vessels (third redo). LVAD is inserted into the left ventricle which caused a complete heart block. Temporary pacemaker was then inserted. At the completion of the complex procedure, the LVAD was removed along with the pacemaker. Can 33210 be reported with modifier -59? Thank you Answer: Again, we would not recommend using 33210 as it is considered part of any coronary artery intervention. The use of a Percutaneous non-transseptal LVAD, such as Impella, is 33999. Dr.z Thank you for all of your help.

Contralateral right internal iliac and right common femoral coding

I'm unclear if I can code both right internal iliac and right common femoral catheter placements from a contralateral approach. How would you code the following? "A 5 French sheath was introduced over a guidewire along with an Omni flush catheter, which was advanced into the infrarenal aorta. Pelvic flush angiogram was performed. Catheter was then used to select the contralateral right internal iliac artery. Arteriogram was performed. Selective catheterization of the third order branch of the posterior region was then performed with angiogram. Three additional third order branches were selectively catheterized with additional views. Catheter was then used to select the right common femoral artery. Right lower extremity arteriogram was performed. Cobra catheter was then introduced and used to select the ipsilateral left internal iliac artery with arteriogram. Upon completion of the procedure, catheter, sheaths, and guidewire were removed. Hemostasis was achieved using Angio-Seal closure device."

AAA EVAR w bifurcated stent graft and bilateral iliac limb extensions

Main body was a 26 mm ALTO graft. Positioned and deployed just below the renal arteries with the covered portion of the graft. It was then per instructions filled with palmar. We then used a 3.0 x 140 mm with maximal overlap into the main body graft on the left side, we placed a 22 x 140 mm Ovation iliac extension limb, which was landed just proximal to the hypogastric excellent positioning and then mimicking the procedure on the right side with oblique imaging and iliac retrograde injection. We had trouble identifying the hypogastric takeoff, so I used an SOS Omni catheter to selectively cannulate the hypogastric perform injection and pelvic selective angiogram, and locate the position of the hypogastric. We then used a 3.0 x 140 mm with maximal overlap of the main body, positioned and landed just proximal to the hypogastric. We per instructions used 14 mm balloon to lock in iliac limb into the gate of the main body, we used a compliant balloon to iron out the proximal extent and overlap portions of the graft into the iliac vessels. 34705 with 34709 x 2?

Charge for balloon tamponade post Impella removal?

"Patient had an access from the left groin previously. We advanced an Omni Flush catheter and crossed over to the right common femoral artery, advanced a Supra Core wire beyond the level of the sheath into the right SFA, and advanced a 7 French sheath into the right external iliac artery. We then advanced a wire through the side port of the 14 French sheath, through which Impella device had been placed, and we removed the Impella CP device successfully out of the body. We placed a 12 French sheath into this access site, and continued bleeding around the sheath was noted. We advanced an 8.0 x 40 mm balloon into the right external iliac artery and inflated it to 10 atmospheres to achieve balloon tamponade. Following that, through the wire that has been placed in the right CFA, we performed the Perclose using a ProGlide device. We then advanced the balloon into the common femoral artery access site and performed balloon tamponade for 20 minutes." After Impella removal 33992, I'm not sure what else we can code. Thoughts?

Endovascular repair 33881 or stent placement 37236?

The hospital coded 33881, but I see 37236, followed by embolization of a pseudoaneurysm. Am I missing something? M.D. mentions proximal end of stent extending to the takeoff of the left subclavian and stent "flared proximally". HELP! "CATH REPORT: 18 y.o. has history of coarctation with pseudoaneurysm formation, presents for stenting of coarctation and pseudoaneurysm. After informed consent, the patient was brought to the cath lab and prepped and draped in the usual fashion. The RFA was entered and a 6 Fr sheath introduced. Aortic arch angiography was performed. The sheath was upsized to a 12 Fr long sheath for stent placement. The aortic arch was stented with 3.9cm premounted CP covered stent with proximal end extending to the takeoff of the L subclavian artery. No residual gradient. Due to tiny amount of residual flow into the pseudoaneurysm above edge of the stent, an AVP-4 device was used to occlude the ductal ampulla which communicates with the pseudoaneurysm. Stent was flared proximal with 18mm Tyshak balloon. No residual flow." Is this 33881?

Ligation of Internal Jugular Vein

"Patient has a self inflicted stab wound to left neck. Incision was extended along the sternocleidomastoid. Internal jugular vein was completely transected, and both ends were able to be identified and ligated. (I did verify with the surgeon – he ligated both ends, not sutured/repaired.) Sternocleidomastoid was nearly completely transected and was repaired with a series of U stitches. Platysma and skin were approximated with sutures incorporating the initial stab wound." My coworker and I are going back and forth with coding this surgery. She feels that repair of blood vessel of the neck is accurate. I don't feel like this is a "repair" since it is only being ligated. She is leaning towards 35201, and I am leaning towards 37565 ligation of neck vein. (Also code 24341 for the muscle repair.) We also discussed code 20100, which includes repair of minor blood vessels, but the IJ vein seems more important than "minor". What specifically makes a blood vessel "major" vs. "minor"? And how would you code this? 

Therapeutic Aspiration with Biopsy

Can we report a therapeutic drainage with a biopsy of the same lesion? Would this be reported with 49180, 10160, and 77012? Or just 49180 and 77012? "Imaging guidance for biopsy: CT access location: Left lower quadrant. Needle gauge: 18 gauge. Technique: Image guidance was used to identify the biopsy site. A total of 10 cores were obtained. In addition, approximately 50 mL of foul-smelling dark red material was aspirated from the lesion during the procedure. Hemostasis was achieved before withdrawing the introducer needle. In addition to autologous blood clot, the needle tract was embolized with Gelfoam slurry. Intraprocedural or immediate post-procedural complications: None. Findings: Preprocedure CT imaging showed a large intra-abdominal mass appearing to arise from the sigmoid colon and containing a central hypodense component as well as gas, suggesting fistulous formation with the colon. No drain was placed at this time due to historically poor healing when drains traverse masses. Impression: CT-guided pericolonic mass biopsy and aspiration."

Supporting documentation of continued Afib for 93657

Based on the CPT description, code 93657 is used for an additional ablation of the left or right atrium for treatment of Afib remaining after completion of pulmonary vein isolation. Clarification is needed if continued Afib must be documented after the PVI is complete to code 93657. Can the following documentation of the roof line and floor line ablation performed resulting in posterior wall isolation be coded as 93657 in addition to 93656?

"Wide antral circumferential ablation was performed around the LSPV and LIPV, resulting in electrical isolation. Wide antral circumferential ablation was performed around the RSPV and RIPV, resulting in electrical isolation. Roof line and floor line ablations were performed, resulting in posterior wall isolation. The patient remained in Afib after ablation, so DCCV with 360J was performed, resulting in conversion to sinus rhythm."

Disc Aspiration Biopsy

Are disc aspiration biopsies coded with 64999 and 77003? This is what I have seen the last few years. Is this still the current way to code these type of cases? "Examination: IR disc aspiration percutaneous x 2. History: Imaging findings concerning for discitis. Summary: Uncomplicated L1-L2 and L2-L3 disc space biopsies. Multiple 18 gauge core needle specimens were sent from each disc space for cultures. Procedure: The left flank was prepped and draped using maximal sterile barrier technique. Using fluoroscopic guidance, a 17 gauge coaxial introducer needle was inserted into the L2-L3 disc space after appropriate local anesthesia with 1% lidocaine. Multiple 18 gauge core needle specimens were obtained as above. Using fluoroscopic guidance, a 17 gauge coaxial introducer needle was inserted into the L1 to disc space after appropriate local anesthesia with lidocaine. Multiple 18 gauge core needle specimens were obtained as above. The needles were removed. Total fluoroscopy time 4.7 minutes."

36556 vs 36561

"Under sterile conditions the skin above the left clavicle was prepped with chlorhexidine and covered with a sterile drape. Local anesthesia was applied to the skin and subcutaneous tissues. Using anatomical technique, the finder needle was inserted under the clavicle at an appropriate angle and venous appearing blood was obtained. Needle was removed and an 18-gauge needle was then inserted into the same location and angle. Venous appearing non-pulsatile blood was obtained and a guide wire was then passed easily through the needle. The needle was then withdrawn. An incision was made and a dilator was subsequently passed over the guide wire then withdrawn. A 7.0 French triple-lumen catheter was then inserted into the vessel over the guide wire. The guidewire was then removed. All ports aspirated and flushed without difficulty. The catheter was sutured into place. A chlorhexadine biopatch and Tegaderm dressing were both placed." Is this CPT 36556 or 36561 since ports were mentioned? However,  there is no two incision, no tunneling, no pocket done. 

Surgical Package with a device insertion

Patient with chronic afib. Patient went into cardiac arrest and had a biventricular ICD inserted. EP physician wanted to initially do ablation for the afib with insertion of device prior to cardiac arrest as part of a previous plan of care. Next day EP physiscian sees patient - wound check, interrogation, chest x-ray, and EKG performed. Per operative note on this visit: "Patient did well with biventricular ICD implantation yesterday. I reviewed her chest x-ray, ECG, and device interrogation. These are all stable from my perspective. I have left her at VVIR 75 to 120 beats per minute. Atrial lead is in place in case we elect to pursue a rhythm control strategy after she improves clinically. No AV node ablation performed, as her rate control was good and I felt this was not urgently necessary. Her CHF appears to be much improved, though she continues to have some rales. I agree with ongoing diuresis. From my perspective she can be discharged whenever Dr. X and the team feels this safe. I will follow-up with patient in the office in 1-2 weeks as an outpatient for her afib." The physician believes this isn't a post op visit. Please confirm.

LV/CS lead functioning alone with plugs into RA and RV ports

We need some guidance, not sure if we should just report 33207 here? Or 33207/33225? Or unlisted? This was an initial implant with RA and RV ports plugged.

"The Seldinger technique was utilized to access the left axillary vein. A Wholey wire was positioned in the SVC. Due to recent tricuspid valve surgery for severe tricuspid regurgitation and concerns of recurrent tricuspid valve regurgitation if pacing lead is placed through the tricuspid valve, decision was made to place ventricular pacing lead in the coronary sinus. A 9 French peel-away sheath was advanced over the third guidewire. The CS was successfully cannulated using a Medtronic MB2 diagnostic catheter, deflectable QUAD catheter, and the Wholey wire. A venogram through the MB2 sheath showed a large size posterior lateral CS branch terminating at 3:30 o'clock on MA. A quadripolar, pace/sense lead was positioned in the lateral cardiac vein initially using a Choice PT wire. The RA and RV ports were plugged. Generator St Jude model PM3562 LV Lead St Jude 1458Q/86."

How would you code this procedure? The Swan was already in place.

How would you code this procedure? The Swan was already in place. "The externalized portion of the Swan-Ganz catheter within the sheath was thoroughly sterilized. The tip of the catheter was in the main pulmonary artery. Pullback samples to evaluate oxygen saturations were done from multiple sites in the right heart with the patient on room air. A pigtail catheter was then placed in the ascending aorta, and an aortic root saturation was also done.The Swan was then removed as was the pigtail. All saturations were done with the patient on room air, and he was put back on 4 L of oxygen postprocedure. The radial sheath was removed, and a TR band applied. The Swan was removed and the indwelling triple-lumen sheath was left in. Saturation data: Main pulmonary artery 58.7%, RVOT 55.0%, right ventricular body 57%, RV inflow tract 52%, low right atrium 48.6%, mid right atrium 50%, high right atrium 50.7%, SVC 51.7%, ascending aortic saturation 80%. Ascending aortogram: This was done with a pigtail above the aortic valve, which is a #21 Trifecta valve. The valve appeared competent."

93653 unsuccessful ablation

Can I use code 93653 when ablation was attempted but not successfull? "Physician states ablation was attempted however the pathway was too deep. All component for 93653 were performed but ablation was just not possible. Based on the EP findings, the pt was determined to have an antegrade only, low risk WPW pathway.Mapping was performed during preexcited sinus rhythm and atrial pacing. The earliest ventricular electrogram and atrial electrogram were mapped to the right posteroseptal AV groove. Extensive mapping and attempted ablation was attempted utilizing mulitple strategies, however there was no effect on accessory pathway conduction inspite of excellent temperatures, catheter stability, and early ventricular electrograms that preceded the surface delta wave by 25 - 50 ms. Strategies used: Approach from the IVC with a standard and large curve catheter within an SR0 sheath, a Mullins sheath, and an Agilis sheath; Approach within the coronary sinus and middle cardiac vein; SVC approach & Transeptal mpping of the left posteroseptal AV groove. WPW due to a right posteroseptal accessory pathway,therefore not at risk for SVT."

PICC vs. Venoplasty

Do you recommend codes 36573 and 37248 for the following? "The left arm was prepared and draped in sterile fashion. The brachial vein was shown to be patent by ultrasound. A spot image was stored. The vein was punctured under direct sonographic guidance and local anesthesia. A wire was advanced to the SVC. The tract was dilated. The wire did not pass centrally. Contrast was injected to confirm a stenosis at the level of the thoracic outlet. Ultimately, a catheter wire was associated across the stenosis. 4 mm balloon angioplasty was performed to facilitate passage of the PICC line. The catheter was measured and cut to length. A dual lumen PICC line was placed through a peel-away sheath. The final tip was confirmed to be in the lower superior vena cava with a spot fluoroscopic image. The catheter was secured, flushed with Heparin, and a sterile dressing was applied. FINDINGS: Central venous stenosis at the level of thoracic outlet protruding wire passage. Area treated with 4 mm balloon angioplasty to facilitate PICC line placement."

Stent placement RVOT - open chest

"Patient's chest was prepped and draped, and the CV surgery team opened the chest and placed a 5 French sheath into the RV apex under direct visualization. At that time, we took over advancing a .014 wire through the sheath into the left pulmonary artery. Pulmonary arteriogram was performed. Sheath position was then adjusted by Dr. M. Ventriculogram was then performed. Measurements of infundibulum, pulmonary valve annulus, and main PA were obtained. A 4-15 Multi-Link Vision coronary stent system was advanced over the wire and into place across the infundibulum and proximal main PA under fluro guidance. Further angios were performed to check device placement. The stent balloon was then inflated to 16 atm. Angiogram showed stent position. The balloon was removed over the guidewire. Follow-up ventriculogram revealed satisfactory stent placement in the RVOT with no residual narrowing. At that time we turned care back over to the surgery team who removed the sheath and closed the chest." Would unlisted code 33999 best describe this procedure?

Coding for EVAR Case perform with fenestration dissection plane

"Patient admitted for EVAR for iliac aneurysm on the back drop of an aortic dissection where a steel core wire was advanced to the thoracic aorta and through the false lumen in right lower extremity. A 31 gooseneck snare was used to capture the steel core wire and externalized through the right femoral sheath. A pair of 6-French Raabe sheaths were advanced to top of wire crown then proceeded to fenestrate dissection plane by pulling the sheaths and wire distally from just below the left renal artery to iliac bifurcation. Wires were then directed to the true lumen from both fem sheaths to thoracic aorta where a 31 mm x 14.5 mm x 13 cm Gore ipsilateral trunk device was deployed through right femoral sheath at a position below the renal arteries and extended with 14.5 mm x 13 cm iliac limb extender down to right external iliac. Through contralateral sheath a 23 mm x 10 cm contralateral limb was deployed in over lapping fashion." How would you recommend coding this case?

glue embolization of the gallbladder remnant and cystic Duct

I have not seen this procedure performed before by the IR physicians, and I am not sure what codes would be correct for it and would appreciate your thoughts. "Patient with post-operative bile leak from the cystic duct. Liver was accessed, right hepatic bile duct was injected, and cholangiogram was performed to opacify the remaining right lobe bile ducts. Needle was used to target an opacified right segmental hepatic duct. This duct was cannulated, and then a glidewire and glidecatheter were used to select the small bowel. The sheath was exchanged and tip was positioned in the proximal hepatic duct. Cholangiogram was performed, demonstrating the cystic duct stump. Cystic ductogram was performed, which demonstrating an active leak from the gallbladder remnant. The microcatheter system was positioned in the mid cystic duct, and the duct and gallbladder remnant were glue embolized, which showed significant residual flow. Embolization was repeated, and post-embolization cholangiogram demonstrated no residual leak. Catheter was left in place in case further intervention is required."

Heparin Infusion

Would heparin infusion be considered a continuation of infusion therapy (37213) even thought it’s not a thrombolytic agent? On 2/7 patient’s thrombolytic infusion catheter was injected, removed, and replaced with a sheath, in which heparin infusion was initiated. On 2/11, sheath was injected for follow-up venogram and heparin infusion continued. Should we report code 37213 or 37214 for the 2/7 exam? And for the 2/11 exam should we report code 37213 or 75898? Patient undergoing thrombolytic therapy. Infusion catheter injected, catheter removed, AngioJet placed with several passes, and angioplasty performed. Sheath left in placed and heparin infused through this access (35476, 75978, 37187)... but what I'm not clear on is 37214 or 37213 (does heparin infusion qualify for continued therapy?) - A report a couple of days later reads sheath injected, stent placed, heparization continued (37238). Again, not clear on this, 37213 or 75898 (because heparin is not thrombolysis?)?

50837 verse device dependent supply help

We are unsure how to code this situation, we think it maybe 50387 but they used drain catheters and that will not match the device dependent list. Can you advise?

Bilateral retrograde nephroureteral catheter exchange

Obstructed right retrograde nephroureteral catheter.

The patient was placed supine on the IR table. Contrast injection into the left retrograde nephroureteral catheter demonstrates pigtail formed within the renal pelvis. This catheter was exchanged over a Glidewire advantage for a new Cook 10.2 French x45 cm pigtail catheter with pigtail formed within the renal pelvis and contrast injection confirmed appropriate position.

The right retrograde nephroureteral catheter was occluded. This was removed over a Glidewire advantage and replaced with a new resolve 10 French x40 cm pigtail catheter with pigtail formed within the renal pelvis and contrast injection confirmed proper position.

Catheter ends outside the urostomy.

IMPRESSION: Successful exchange of bilateral retrograde nephroureteral catheters.