Ask Dr. Z

Correct coding for wedge resection of blebs 32655 or 32666, 32656

Correct coding for wedge resection of blebs 32655 or 32666, 32656? 

"Procedure details: the patient was brought to the operating room and placed supine on the table. General anesthesia was induced and patient intubated with double lumen tube. Perioperative antibiotics were given. Bilateral lower extremity sequential compression devices were placed before induction. He was then placed in left lateral decubitus position. He was prepped and draped in usual fashion. 3 thoracoscopic ports were placed and the chest explored. He had blebs visible in RUL apex. This area was resected with purple load stapler. The superior segment of the RLL also had irregularity of the edge, thus this area wedge resected as well with purple loads. Pleurectomy was then performed from the 6th rib cephalad, sparing the apex where the subclavian vessels lie. The remainder of the pleura was scratched with a bovey scratch pad. A 28F chest tube was placed apically, and a 24F blake placed at the base. Patient was awakened from anesthesia and taken to recovery in good condition. There were no apparent complications."

can we bill a pulmonary vein isolation during a CABG (33533 & 33257)

The procedure is a CABG x3 (33533; 33518), PV isolation with RF clamp ablation (33257), and LAA ligation.

The patient is a 74-year-old female who presents with atrial fibrillation and severe CAD on angio.

"PROCEDURE: Patient was systemically heparinized. Right and left pulmonary vein isolation was performed with atrcure system clamp ablation. Pt had bradycardia to 50 and conversion to NSR during right side PV isolation. LIMA was carefully anastomosed to the proximal LAD with 7-0 prolene. De-airing was performed. Sidebiting clamp was placed on the proximal ascending aorta and the proximal SVG was carefully anastomosed to the ascending aorta us 6-0 prolene in standard running technique. Ascending aorta and SVG were carefully de-aired and the sidebiting clamp was released. Heart was then lifted and the SVG was carefully anastomosed side-to-side to the D1, followed by end to side to the D2 using 7-0 prolene sutures. Careful deairing was performed and SPY angio imaging was used to visualize all grafts. Hemostasis was confirmed."

Port Removal, 36590

Are codes 36011, 36590, and 77001 correct for the following case? If not, what do you advise? "Known thrombus associated with the central line of port. RUE prepped amd draped. With ultrasound guidance, a small caliber needle was directed into the right basilic vein. Guidewire was directed centrally, needle was removed, and dilators were passed until a 5 French cath could be directed into right subclavian vein. Contrast was injected under fluoroscopy with digital images recorded. Cath was then directed into upper aspect of SVC and advanced into the left innominate vein. Repeat injections of contrast agent performed. Cath was removed and hemostasis achieved. The right anterior chest wall was prepped and draped and anesthetized with local anesthesia. A transverse incision was made over the port and was then removed in its entirety with the attached central line. Pocket was closed, as was skin. Findings: Superior vena cava is chronically occluded with reversal of flow into the azygous system, which is now capacious. A port, which is no longer functional, was removed."

Antegrade Ureteral Stent Placement

At the risk of sounding stupid, I just have to ask because I'm still not grasping the difference between the twp separate sets of stent codes when they are not clearly spelled out in the report (that I can tell). How do you know which this is, 50695 or 50433? My guess is 50433? "A 5 French coaxial introducer was placed the dilated left renal pelvis using micropuncture technique. A nephrostogam was done. Antegrade ureteral stent placement: A 0.035 wire successfully advance into the bladder . A 5 French Angiocath then was advanced over the guide wire in the bladder. The glidewire was exchanged with super stiff guidewire. The needle tract was dilated to 9 French . A 6 French x 22 cm was inserted over stiff guidewire under fluoro into the bladder. The guide was pulled back out of the upper end of the stent but was kept in the renal pelvis. An 8.5 French nephrostomy catheter inserted into the renal pelvis and the stiff guide wire removed. The nephrostomy catheter was secured on the skin with adhesive tape. The final image showed a good position of the stent and nephrostomy catheter."

Previous tube graft repair aneurysm, now doing 34705 for infrarenal AAA

Patient had previous tube graft repair of AAA, now presents with infrarenal AAA and iliac aneurysm. Can this be coded as 34705, 34713-50, or 34710/34711?

"Subsequently a universal flush catheter with guidewire guidance was passed up from the left femoral access and bolus angiography was performed visualizing the level of the renal arteries the infrarenal aorta as well as the aortic bifurcation and iliac anatomy. With these landmarks identified a stiff wire was passed up from the right femoral access. The 11 French sheath on this I was now exchanged out with a 16 French sheath. This was passed up into the aorta. Through this sheath and over the stiff wire a Gore-Tex bifurcated IBE endograft was passed. This was specifically a 23 x 14 x 100 device. This was now deployed extending up into the previously placed aortic tube graft. The bifurcation of this device was placed just above the native aortic bifurcation and the right limb of the graft extended down into the distal right common iliac artery just prior to the origin of the internal iliac artery."

Aborted electrophysiology study with ablation

Hi Dr Z, I would like your input on an aborted EPS that has hit an audit. The Pt was to have an EPS w/ ablation for PVC. "The patient was taken to the electrophysiology laboratory in a fasting state. Noninvasive ECG monitoring was notable for one isolated premature ventricular complex that was strongly suggestive of a right ventricular outflow tract focus. More specifically, there was a left bundle branch block morphology with a late transition and an inferiorly directed axis. The patient's bilateral upper legs were prepped and draped in the usual sterile fashion, and the patient was monitored. With no further spontaneous ectopy, the patient was given increasing doses of intravenous isoproterenol up to and including doses as high as 20 mcg per minute. She was also given intravenous Aminophyllin up to 200 mg in a bolus fashion. Varying levels of sedation as well as beta-blockade with 10 mg of intravenous metoprolol in divided doses; however, no further ectopy was noted. After two hours of observation, decision was made to abort any attempt at electrophysiologic studies and/or ablation. The patient was returned back to the day patient area in stable condition." I coded for the intended procedure 93620-74 EPS w/induction and for the add on code 93623 drug infusion. How would you have coded this. Thanks for your help.

93975 and 96976 Documentation

Related to pelvic, abdominal, and retroperitoneal ultrasounds, we understand that code 93975 or 93976 should not be reported in addition to the base ultrasound code when used for a quick assessment of blood flow or to simply identify a structure. Could you help us clarify for our physicians what elements should be seen in the report in order to substantiate these codes? This is an example of what we often see: "Technique: Transabdominal and transvaginal imaging, 2D gray scale, color Doppler, spectral waveform analysis. Findings: Uterus measures XX, uterine fundus circumscribed hypoechoic structure measuring XX. Another located in the posterior fundus measures XX. Endometrial measures XX. No endometrial fluid seen. Overlying bowel gas structures obscures right ovary. Left ovary measures XX. It demonstrates normal color flow Doppler and spectral waveform analysis. No free fluid seen." Could you please review and clarify if there is sufficient documentation to report codes 93975/93976 in addition to pelvic and transvaginal ultrasound codes?

Can E/M code be billed when diagnostic procedure is determined not needed?

Can a radiologist bill an E/M visit for a report such as the following?

"The patient presented today for diagnostic follow-up of a focal asymmetry marked in the posterior lower inner quadrant of the left breast on screening mammograms of 3/14/2022. However, in review of prior studies, this area is a stable chronic findings consistent with a previously demonstrated sebaceous cyst, demonstrating no appreciable change in size or appearance dating back to mammograms of 9/23/2015, and also seen on multiple earlier studies dating back to 2003. In 2013, this area was notably larger in size and underwent ultrasound-guided aspiration on 5/24/2013 with cytology indicating only inflammatory changes and no malignant cells. I discussed today with the patient the benignity of the previous work-up and the chronic appearance of this lesion over numerous prior studies, and I advised that additional diagnostic work-up was not necessary today, but still offered diagnostic work-up if she desired. The patient was satisfied with no diagnostic work-up."

PROCEDURE: Ultrasound guided abdominal musculature Botox injection

Is code 64647 correct for the following?

"Informed consent for the procedure was obtained, and time-out was performed prior to the procedure. Prophylactic antibiotic administered: Not administered. Position: Supine. Preparation: The site was prepared and draped using maximal sterile barrier technique including cutaneous antisepsis with 2% chlorhexidine. Local anesthesia was administered. The bilateral internal and external oblique musculature was sonographically identified. Real-time ultrasound was used to visualize needle entry into the bilateral internal and external oblique musculature and a permanent images were stored. Sites of access: Right internal and external oblique (three separate sites), left internal and external oblique (three separate sites). Technique Summary: 300 units of Botox were combined with 6 mL of sterile saline. 1 mL of this solution was administered at each of the sites described above. A dressing was placed at each access site. Contrast agent: Omnipaque 240. Contrast volume: 0 mL."

Abdominal Debranching

Midline incision - trans-peritoneal exposure of R external iliac artery, SMA, common hepatic artery and Left renal artery and inferior branch of R renal artery distal to bifurcation.

 

2 limb Dacron graft anastomosed to R external iliac (diseased native vessel) with 1 limb anastomosed to SMA and 2nd limb anastomosed to common hepatic artery (extremely diseased native vessel) I'm leaning towards 35633 and 35632,52. Thoughts?

 

PTFE graft sewn from SMA limb of Dacron graft to L renal artery

 Separate PTFE graft sewn from common hepatic artery limb of Dacron graft to R renal artery inferior branch

I'm thinking unlisted for the SMA to L renal and hepatic to R renal. Maybe compared to 35636,50. Thoughts?

Patient is having debranching done prior to EVAR scheduled in the future.

Any help would be greatly appreciated.

Total Body MRI

How would you code for a whole body MRI with a diagnosis of Li-Fraumeni syndrome? The provider wants to bill unlisted. Our coders want to bill each body area. What are your thoughts? "FINDINGS: Neck: Non-enlarged cervical lymph nodes bilaterally. No suspicious mass lesion identified. Thorax: Minimal left basilar atelectasis, likely related to sedation. No pulmonary nodule is identified. This a small area of T2 hyperintensity in the right paraspinal region in the chest (series 401, image 20), which was partially imaged on the prior study, unchanged. This is of uncertain clinical significance and could represent a lymph node.   Abdomen and pelvis: Postsurgical changes of right adrenalectomy. No suspicious mass in the right suprarenal fossa to suggest recurrent tumor. Liver, spleen, pancreas, and kidneys are normal in contour and signal intensity. No mass lesion identified. Trace amount of free fluid in the pelvis, physiologic. Lower extremities: Bone marrow is normal in signal. Muscles are normal in bulk and signal intensity. No abnormal fluid collection." 

Poor MD Documentation

In reviewing charges for a procedure, I came across a case coded 75625, 75716, 37228. The operative report states selective right leg angio and PTA to anterior tibial. Procedure portion states, "LCFA accessed and wire into aorta with use of Omniflush catheter to access left iliac. Omiflush catheter exchanged for 65 cm sheath. Selective angiogram with multiple views performed. PTA to anterior tibial performed." The physician's report is finalized with an impression, which dictates findings of an abdominal aortagram and findings of only the right side extremity and angioplasty. Due to the difference in charges and report I viewed the x-ray films. These show Omniflush catheter just below renals and abdominal aortagram imaging; next I see bilateral lower extremity imaging from bifurcation to toes. The selective right angio and PTA imaging. I queried physician to verify clarify op report and filming. I suggested including catheter position in their report to assist in proper coding. Physician says will not dictate maneuvers not performed. How can this be coded 75710, 37228?

33010 vs 33015

Would you use code 33010 or 33015 for the following example? "Sheath Introducer Kit was inserted into the Pericardium. The sheath kit was removed. Pericardial tap performed & cath inserted into the pericardium. Removed fluid 600cc. Cath sewn in with JP drain. I'm confused because your 2017 book states Use code 33010 when pericardiocentesis is performd through a catheter and left in place for conintuous drainage., but encoderpro's lay terms for 33010: physician places a long needle below the sternum and directs it into the pericardial space.; When fluid is aspirated, the physician may advance a guidewire through the needle into the pericardial space and exchange the needle over the guidewire for a drainage cath. Lay terms 33015 ;When pericardial fluid flows back through the needle, the physician passes a guidewire through the needle into the pericardial space. The physician exchanges the needle over the wire for an indwelling drainage catheter. The physician attaches the catheter to a drainage bag, sutures the indwelling catheter into place on the chest wall, and dresses the wound."

Lymphatic Malformation

Is it appropriate to code 49185 or 37241? "PROCEDURE: Lymphatic malformation sclerotherapy. Ultrasound mapping confirmed the presence of lymphatic malformation within area of concern, comprised of 3 dominant large macrocysts and multiple smaller macrocysts. The largest macrocyst was accessed using ultrasound guidance and a 20 gauge Angiocath needle. The cyst was aspirated to completion and injected with a dilute solution of Sotradecol 3%. The Sotradecol was left to dwell for approximately 5 minutes and then aspirated. The cyst was then injected with a smaller volume of the contrast-opacified doxycycline solution than was initially aspirated. The two remaining dominant macrocysts were each treated in a similar fashion. The remaining smaller macrocysts were accessed under ultrasound guidance, aspirated, and then injected with a slightly smaller volume of doxycycline solution. Post procedure ultrasound and radiograph confirmed the presence of contrast opacified doxycycline solution within the region of concern."

Facet and Nerve Root Injection at Same Time

Our physicians state they are performing a facet joint injection and a nerve root block. If both of these procedures were performed at the same session, are we allowed to report both codes 64483 and 64493-50? "Utilizing sterile technique, fluoroscopic guidance, and local anesthetic, 22 gauge spinal needles were advanced into the bilateralL4-L5 facet joints. After injection of dilute contrast into the joints, confirming the needle position, 1 ml mixture of 0.25% bupivacaine and 20 mg of Kenalog were injected into each joint space. Utilizing sterile technique, fluoroscopic guidance, and local anesthesia, a 22 gauge spinal needle was advanced into the perineural space of the left L4 nerve root. After injection of dilute contrast into the perineural space, confirming needle position, 1 ml mixture of 0.25 bupivacaine and 20 mg of Kenalog was injected."

Code for TEVAR or EVAR be used for repair of endoleak with previous EVAR?

Placement of Chimney for previous EVAR with endoleak by vascular surgeon. Per note: "Open left subclavian access, percutaneous right brachial access, percutaneous bilateral femoral access with only right side using larger than 12 French sheath. Selective cath and stent placements in right renal, SMA, and celiac arteries. Decision to continue with the extension of the infra-abdominal endograft and ends stenting of the aforementioned arteries. A 6 mm x 79 mm was placed in the right renal artery. A 6 mm x 59 mm stent was placed in the SMA. The right groin sheath was removed and the artery was dilated serially to 18 French size. A Medtronic Navion endograft was then placed over the Lunderquist wire and deployed into the abdominal aorta just below the celiac artery takeoff. The balloon-expandable stents in the right renal artery and SMA were then deployed. Abdominal aortogram showed inadequate overlap of prior endograft. Another Medtronic endograft was deployed." Provider wants to use code 33881. It seems this is in abdominal aorta and not thoracic; however, Navion device is used for TAAA. What are your thoughts?

We are unsure of how to code Amplatzer plug deployed into Ductus Venosus.

We are unsure of how to code Amplatzer plug deployed into ductus venosus: "Following sterile preparation and draping and infiltration of local anesthesia, a 21 gauge micropuncture needle was inserted into the right internal jugular vein. A 0.018 wire was introduced. A 4 French transitional dilator was used to exchange the 0.018 wire for a 0.035 Bentson wire. Over this wire, a 4 French Kumpe catheter was introduced. The catheter and wire were guided through the right atrium into the inferior vena cava. The ductus venosus was successfully catheterized. Hand injections of contrast were made, which demonstrated a markedly enlarged main portal vein and left portal vein and a small, but patent right portal vein. The catheter was removed, and over the wire, a 4 French delivery sheath was introduced. Through this sheath we introduced and deployed an Amplatzer 2 plug, 4 mm in diameter by 6 mm in length. Final radiographs appear to show the occlusion device in good position within the ductus venosus. Ultrasound images of the deployment device were also obtained and are retained within the patient record."

Neck venous malformation sclerotherapy

Procedure coded as 36299, 76499, 37204, 75894, not sure if this is correct. Physician not clear as to where in the neck the patient was accessed. Thanks! Indication: Right neck venous malformation Procedure: Right neck venous malformation embolization Findings: After obtaining informed consent, the right neck was prepped and draped in normal sterile fashion. Sedation was provided by the anesthesiology service in the form of general endotracheal anesthetic. Sonographic guidance was used to direct needle access to a vascular structure within the malformation. Contrast material was injected for malformation venography. There is a complex vascular structure with what appears to be irregular venous as well as lymphatic component. Via this access, a total of 4 cc of 3% STS was foamed and administered in 3 separate sessions with interval dwell time for the purpose of malformation venous scleroablation. Needle access was removed. A compressive dressing was placed. The patient tolerated this should well and left the department in stable condition. Impression: 1. Right neck vascular malformation venography demonstrates a complex venolymphatic lesion 2. Technically successful scleroablation of the lesion utilizing foamed STS with excellent result

Radial to Ulnar transposition w/thrombectomy via separate arteriotomy

Hello,

I’m thinking the below procedure would be coded as 37799 but I’m hoping there is/are actual procedure code(s) I could assign instead.

Patient came into the OR w/ palmar arch injury w/intraluminal thrombosis. No inflow or proximal stumps of lacerated thumb vessels identified. Distal stump of the thumb ulnar digital artery was

identified dissection performed to obtain additional distal length. Artery was debrided back to normal healthy intima. The radial artery to the index finger was open w/ pulsatile flow. We elected to use the radial artery to the index finger as our inflow to revasc the left thumb. Dissection was performed to release the artery, it was clipped distally & cut & rotated to be utilized for micro anastomosis. Next, a 9-0 Nylon suture was used to perform the anastomosis in standard microsurgical fashion. The clamps were removed. Next arteriotomy over proximal radial aspect of the superficial palmar arch was performed and catheter was used to evacuate all clots and restoration of antegrade and retrograde pulsatile flow.

Transverse Sinus Stenosis Stent Placement

How would I code the following stent placement?

left: 30px;">A 5 French terminal angled glide catheter was advanced over a Glidewire through the right femoral sheath into the right internal jugular vein. Right internal jugular venogram was performed. This confirms the placement within the normal-appearing jugular vein. The 5 French angled glide catheter was then advanced through the femoral arterial sheath into the right internal carotid artery. Cerebral angiogram was not performed. This shows a normal appearance of the internal carotid artery as well as the anterior and middle cerebral arteries. The parenchymal phase is normal. The venous phase is normal aside from the severe stenosis of the right transverse sinus. The microcatheter was exchanged over an exchange length Synchro 2 microwire. A Precise stent 9 mm x 30 mm was advanced over the wire into the internal jugular vein. By advancing the guide catheter into the sigmoid and transverse emesis, the stent was delivered across the stenosis and deployed.

Renal Angiography

"Right common femoral artery was accessed utilizing micropuncture technique. A Bentson wire was advanced into the abdominal aorta, over which a 5-French vascular sheath was placed. A 5-French Contra 2 catheter was then used to select the right renal artery and digital subtraction angiography was performed in the PA and RAO projections. The catheter was repositioned into the left renal artery and digital subtraction angiography was performed in the PA and LAO projections. Decision to intervene was made based of these images. The vascular sheath was exchanged for a new 6-French sheath. A 6-French guiding catheter was then advanced into the proximal renal artery. A 0.018 inch McNamara wire was advanced into the upper pole artery of the kidney, and a 0.016 inch fathom wire was advanced into the lower pole. Angioplasty of the proximal aspect of the upper pole renal artery was then performed utilizing a 5 mm x 2 cm balloon. The balloon was deflated and post angiography angiogram was obtained." Unilateral or bilateral renal angiogram? Which is correct: 36254 OR 36251-RT, 36253-LT with 35471/75966?

BM aspirate > stem cells>...PCS Root term?

CPT was previously addressed. This refers to the PCS codes: Patient had chronic, nonhealing leg ulcer and deemed a stem cell candidate. H&P states: "The only option is stem-cell injection to facilitate neovascularization." Operative report: "Procedure: Bone marrow aspirate with injection and delayed primary closure of left distal leg wound. We accessed the right anterior superior iliac spine with a bone marrow aspirate and aspirated 240 mL of bone marrow from the right iliac bone marrow. We spun this down to stem cells and then implanted the autograft proximal to the wound in healthy tissue to effect late closure or delayed closure, closure by secondary intention. The procedure was staged in two parts. The bone graft was removed and created a bone autograft to seal, fill, and replace lost tissue. This was injected at multiple locations around the wound and proximal to the wound in healthy tissue in order to facilitate neovascularization and facilitate healing of the wound." What is the PCS code for aspiration? For placement, is it Introduction or Supplement?

Attempted Atherectomy with Embolization

Can I code for laser atherectomy, coil embolization, and follow-up angio? "Diagnostic angio showed subtotal/total occlusion distal right superficial femoral artery. Procedure during intervention: Over guidewire 5 French Rhabie sheath placed from the left common femoral artery to the right common iliac artery right external iliac artery right superficial femoral artery. We chose a 0.9 mm diameter eczema laser catheter, power settings 45/25 flushing heparinized saline through the tip of the catheter over CT 2 guidewire. I could not identify site of occlusion having small collateral type collateral vessel. We proceeded with multiple laser runs. Heavy calcification obvious, progress poor. In multiple projections we attempted to traverse to the distal vessel ultimately unsuccessful. We did penetrate vessel wall, contrast extravasation obvious. A 2 mm diameter 5 mm length microembolization coil then placed through the renegade catheter into the path before extravasation, complete occlusion defined on multiple follow-up angiograms."

peripheral dialysis stent from remote access

"Arterial limb of graft accessed antegrade towards the venous outflow. Thrombectomy & angioplasty of arterial limb performed. Attention was then turned to the recurrent basilic vein outflow stenosis. A fluency stent delivery device could not be introduced to bare back. Right common femoral vein accessed. Glidewire utilized to select the innominate vein and cross the left basilic vein stenosis retrograde. Exchange length Magic torque wire then placed across the basilic outflow vein stenosis from the common femoral access. 10 x 60 mm fluency endograft on long delivery then advanced across the basilic outflow stenosis and deployed under guidance. The Magic torque wire was pulled back to the innominate vein, allowing advancement of the 8 x 60 mm for in-stent angioplasty. Final angiogram via the sheath demonstrated excellent result with brisk forward flow through the basilic outflow and no residual stenosis or venous injury." Is this 36906 only? Or is the remote access separately reportable?

37225, 37229, 75630

Dear Dr.Z Good afternoon I am your student through webinars. I was able to code most of charts confidently after listening to your webinars. But, following is the case where I am feeling little chalenge. Please help. Patient doesnâ?Tt have any prior catheter based angiogram of Lower Extremities. Now, the patient with Peripheral vascular disease. Planned angiogram to evaluate Lower extremity PVD and Intervention as necessary for Limb salvage procedure. Right femoral arterial sheath placement and Right common femoral angiography done. Then, Aortobiiliac angiography was performed. Followed this Left common femoral and popliteal angiography with runoff done. Then the wire was in the dissection plane. Then, an ultrasound re-entry device was used to re-enter into the distal SFA. Then, TurboHawk Atherectomy and angioplasty done in superficial femoral artery. Following this Atherectomy of Tibioperoneal Trunk was done. My coding 36247-59, 75625-59, 75716-59, 76937-59, 37225 & 37229 Q) 1) As patient doesnâ?Tt have the prior catheter based Angiogram, I coded 36247-59 for Angiogram (based on this angiogram only physician decided to do intervention). Am I Correct? Q) 2) Is it appropriate coding 76937 (ultrasound guidance for re-entry) here? I appreciate your help

PDA Occluder procedure. I was going to use CPT code 93582 yet I don't know if this correct as the device was deployed and removed in same operative setting.

Attempt to access right femoral vein was unsuccessful, left femoral vein and right femoral artery were accessed instead. Guidewire into atrial sheath advanced to ascending aorta, blood gas obtained in ASAO and pullback pressure from ASAO and DSAO. Aortogram performed in proximal descending aorta. Measurements of PDA obtained and decision to close with Amplatzer Ductal Occluder-II. Guidewire placed in venous sheath, advanced across ductus, catheter exchanged over wire and Occluder advanced through delivery catheter until tip of device was at tip of sheath. Aortic disc exposed and pulled back against aortic ampulla. Rest of device then exposed so central pug was contained within PDA, proximal disc against PDA-PA junction. Small residual shunt with good device position. Device released and PA disc reoriented. Pressure obtained from LPA and MPA, significant gradient was found, decided to remove device. 5 mm Snare was inserted but device couldn't be pulled. Changed to 10 mm Snare and device was removed through the sheath.

Venous Catheter Placements When It Comes to Access Site, Catheter Course, and Exit Site

My question to you is regarding when the physician starts at the access site internal jugular vein (36012) and moves the catheter through the heart down towards the superior vena cava and places the catheter and also images the superior vena cava (36010, 75827), and also performs a congenital right and left heart catheterization (93531), and the exit site of the catheter is back through the internal jugular vein (the access site). Also, while using the access site as the same exit site, the physician decides to perform a selective injection and also image the internal jugular vein (36012, 75825) as he exits the body.  I'm thinking that the codes that need to be selected would be the following: 93531, 75827, 75825, and 36012.  I'm thinking that you would not report code 36010 because it's a major vessel that leads to and from the heart, but can also pick up the image code for the superior vena cava.  Is this correct thinking for facility billing?

Charges for bilateral renal angioplasty

Regarding bilateral renal angioplasty 35471-50. Following renal angiography: “An intervention was initially performed on the superior left renal artery, which represented in-stent restenosis. A LIMA guide utilized. A Whisper wire advanced distal and balloon inflation with a 5 x 15 balloon at 12 atmospheres. Final angiogram: No residual stenosis. Attention was then turned to the right renal artery. Guide engagement 0.014 Whisper wire advanced distal and balloon inflations with a 4.0 balloon. There was significant recoil and it became obvious that stenting would be required. A 6.0 x 18 balloon-expandable stent was deployed at 10 atmospheres. Final angiogram: No residual stenosis.  Would you charge 35471-50 or 35471 times two (that is, two separate line items)? Of course, also charge for stenting of right renal artery. My belief is that we need to have a separate charge in the CDM for 35471-50 and that it is not correct to charge either 35471 (unilateral) and append a -50 OR to charge 35471 times two. In the first situation, I don't think we'd be reimbursed properly for the physician's extra risk, work, skill, and time and in the second situation, I think it could be construed as overcharging. I REALLY APPRECIATE YOUR HELP.

correct code for spinal angio's & embolization fo L2 hemangioma

What is the correct code for spinal angios and embolization for L2 hemangioma? 

"Once we were satisfied with our diagnostic images, we removed the HS1 cath and introduced the Mikaelsson cath with a 0.035 wire. This was then introduced into the LT L-3 radicular feeder going into tumor. We then proceeded to connect this to a flush line and introduced an Echelon cath with a Synchro 2 standard micro wire into a copilot sys through the Mikaelsson cath into the radicular vessel. We then deployed our first 4 x 2 Tornado coil and then proceeded to use a mixture of particle embolisate of 100 PVA and 200 PVA under direct fluoro visualization into the radicular feeder going into the tumor blush. There was no reflux. Once satisfied with this embolization, we removed our microcath and then used the Mikaelsson to access the right L-3 radicular feeder. We then used a similar sequence of steps using our Echelon and Synchro 2 standard to access into left radicular feeder and deployed a 4x2 Tornado coil. We then proceeded to use our Echelon to subselect into the vessels going into the tumor feeder and deployed our mixture of 100 & 200 PVA particles."

32666 for VATS wedge

Would you bill more than the 32666 for VATS wedge resection upper lobe with enbloc removal chest wall mass including deep tissue? Maybe a -22 modifier, or would this all be bundled under 32666? "Procedure: LEFT VATS wedge resection upper lobe with enbloc removal chest wall mass including deep tissue. An incision was made in the 7th intercostal space, and a camera was inserted. The mass was identified on the lateral chest wall with multiple adhesions of the lung overlying the mass. Most were loose adhesions. A working incision was made in the 4 ICS. The adhesions were taken down with use of electrocautery until the tumor appeared to be coming from the lung. Multiple firings of a stapler were used to perform a wedge resection of the mass with a negative margin. The mass was then dissected off the chest wall to obtain a wide margin to include soft tissue and intercostal muscle. A ICS neurovascular bundle was divided. The mass was then completely free and was placed within a glove and brought out through the working incision. No other pleural masses were seen."

Dear Dr.Z A very good morning Could you please answer my coding question, where I am feeling difficult. PROCEDURES PERFORMED 1. Peripheral angiogram of the right extremity with selective engagement of the catheter in the right superficial femoral artery. 2. PTA of the right anterior tibial lesion. 3. Infusion catheter placement in the right anterior tibial artery due to thrombus at the end of the procedure. INDICATIONS: 1. Nonhealing ulcer on the right lower extremity in the right over the ankle. 2. Severe claudication symptoms in the right lower extremity. 3. Severe peripheral vascular disease by CT angio of the lower extremity arteries. PROCEDUER DETAILS: A-5 French sheathe was introduced into left common femoral artery under local anaesthesia using Seldinger technique. After inserting a 5-French sheath I took a J-wire with 5-French catheter. Then, I brought to the catheter and wire over the iliac bifurcation in a retrograde fashion to the superficial femoral artery and placed the catheter there and took pictures of the right lower extremity. The angiographic results revealed the right distal superficial femoral artery shows disease. The right popliteal artery shows about 60% to 70% lesion. The right anterior tibial artery shows total occlusion in the mid portion with reconstitution above the right ankle. The right tibioperoneal trunk shows mild disease. The right posterior tibial artery shows mild disease. The right peroneal artery shows mild disease in the proximal mid segment with distal portion showing totally occluded and reconstitutes right above the foot. I used a 6 French 45 cm length destination sheath brought over the iliac bifurcation placed in the right common femoral artery. Then I used a 20 cm exchange length J wire and placed in the SFA. I brought the glide catheter and took the J wire out. Then, I used an Angiomax bolus drips as per weight-based protocol and creatinine clearance protocol. This is a Quick-Cross catheter. I took the guide catheter out and replaced the Quick-Cross catheter. Then I used a 0.014 guidewire, which is a length prowater wire. Then I used the wire and crossed the lesion in the anterior tibial artery and placed all the way at the end. Then, I used a balloon to inflate across the lesion. The balloon is 3.0x150 sleek balloon and inflated anterior tibial artery at about 10 atmospheres of pressure. Then I used a 5-French sheath tempo echo catheter, took the wire out and took good pictures. It showed there a good flow in the anterior tibial artery with a focal 95% stenosis in the mid portion. Then I went back with the Asahi Prowater wire used a 4.0x150 mm balloon and tried to dilate the entire tibial artery, especially across the lesion at about 6 to 7 atmospheres of pressures. Then I got good flow with good flow all the way to the foot but considering the severe calcification throughout the artery, to get better result, I went with 3.0 mm balloon again and dilated. After that last flow in the anterior tibial artery. Also I see the flow to the posterior tibial artery and the peroneal artery got slow and finally the flow became very faint in the distal portions of the posterior tibial artery, as well as the peroneal artey, which was not intervended at all, and never had a write placed in the artery. Then I realized that there was some thrombotic situation, likely from the Angiomax issues. Either not being given enough or the Angiomax given was not enough anticoagulation. We re-bloused the Angiomax at that point. Then I tried to reverse the leak over the wire balloon and tried to dilate many times, giving intra-arterial nitroglycerin and verapamil. Still the flow was less with thrombus. The flow is was scant. Then I used Activase intra –arterial with catheter placed in the anterior tibial artery area. Then I used a 10 mg IV bolus given initially and then I started infusion. I then inserted an ev3 infusion catheter. The catheter placed in the anterior tibial artery extending into the popliteal artery. At that time I left the catheter in the popliteal artery and left the catheter in place and gave another 2 mg IV push of Activase and started a drip. This lasted for 6 hours with plan to bring him back for repeat angiogram and possible PTA. The patient tolerated the procedure, hemodynamically, stable without any issue from respiratory or cardiac point of view. Also, another procedure was performed, which was PTA of the popliteal artery. There is a 70% lesion in the popliteal artery. I used a 4.0 balloon to do the PTA of the popliteal lesion at about 8 atmospheres of pressure. The balloon extended from the proximal ED into the popliteal artery. CONCLUSIONS: 1. 70% lesion in the right popliteal artery 2. Total occlusion of the anterior tibial artery in the mid portion. 3. Thromboembolism of the infrapopliteal arteries during intervention leading to poor flow into the foot, requiring Activase bolus and infusion using the infusion catheter. The infusion catheter is ev3 infusion catheter. 4. At the end of the procedure, the patient is to have posterior tibial Dopplerable and anterior tibial Dopplerable pulses. Recommendations: 1. Continue the infusion with Activase for 6 hrs. 2. Repeat angiogram after 6 hrs of Activase infusion. My coding is 37228, 37224, 75710-26, 59 & 36247(Infusion catheter placement not for Angiogram). Repeated procedure on same day: INDICATIONS: 1. Thromboembolic phenomenon in the infrapopliteal arteries to PTA of the right popliteal lesion, as well as the totally occluded anterior tibial artery. 2. Status post Activase infusion over 6 hours to see how the thrombus burden in the infrapopliteal arteries and the right lower extremity, and possible intervention. HISTORY: This is a 73 year old white male with a history of significant peripheral artery disease, with nonhealing ulcer on the right lower extremity above the ankle. He was found to have significant infrapopliteal disease. The patient had a PTA of the popliteal artery lesion, as well as intervention of the anterior tibial artery of the right lower extremity during which the patient developed thromboembolic phenomenon leading to a good flow in the infrapopliteal arteries with poor circulation to the foot. An infusion catheter was placed and infusion of the Activase was done over 6 hours. The Patient was brought for a repeat angiogram an possible PTA. Again, a 6 French destination, placed in the right superficial femoral artery beginning proximal portion on the right side. The infusion catheter was already in place which was in the popliteal artery extremity, anterior tibial artery. Then we cleaned this in a sterile fashion and changed the gloves, took an angiogram of the right lower extremity. RESULTS: 1. Angiogram of the right lower extremity showed the popliteal artery lesion was less than 30% 2. Anterior tibial artery flow was again not seen well. 3. Peroneal artery also showed good flow with distal reconstitution after occlusion in the distal portion. The distal portion of the reconstitution was right above the foot. Then I gave him 4000 units of IV heparin. Then, we used the same catheter. Through the same infusion catheter I inserted a Benston wire and placed in the anterior tibial artery all the way to the foot. Then, I used an angioplasty with a balloon which is 4.0x100 balloons. After PTCA the flow is slightly improved but not greatly. Considering his recent complication of thromboembolic problem in the lower extremities, we compromised with results and had partially successful results regarding opening the anterior tibial artery. The posterior tibial artery and peroneal artery were left as they were in the beginning. No complications. My Coding is: 37228-76 & 75710-26,76 I appreciate your help. Thanks & Regards Ronald

Conventional Myelogram vs. Digital Subtraction Myelogram

"First day, spinal needle was placed in thecal sac under fluoroscopic at L2-L3. A needle was placed over left pedicle of T10 vertebra. Omnipaque was injected to confirm subarachnoid position. 12 mL intrathecal Omnipaque was administered for biplane digital subtraction myelography centered at the thoracic level. Normal saline was then administered. Cervical, thoracic, and lumbar conventional myelographic images were then obtained. FINDINGS: Biplane fluoroscopy confirms appropriate position of the needle at the L2-L3 level. Digital subtraction myelography of the thoracic spine demonstrates no findings specific for CSF leak. Conventional myelographic images of the cervical, thoracic, and lumbar spine exhibit no findings specific for CSF leak (62305). CT post myelogram follows. Next day, repeat complete spinal myelogram (62305)." The conventional myelogram is documented as complete for both days, but the digital subtraction myelogram is thoracic (on first day), then cervical (on second day). Does this documentation warrant coding two complete myelograms for two sequence days?

Aortic Repair

Can/should the procedure to repair intraoperative dissection be coded? "Mitralplasty with cardiopulmonary bypass was performed. Left atrium was closed with 3-0 Prolene running suture. Patient was cardioverted to sinus rhythm and came off bypass. Blood pressure was allowed to rise, venous line was removed, and ascending aorta was found to have bluish discoloration. Patient had an intraoperative aortic dissection. Right femoral artery cutdown was performed and Fem-Flex cannula inserted. Patient cooled to 20 degrees centigrade. Ascending aorta was transected proximally, and tube graft was sewn, two layers for posterior wall and one layer for anterior wall. Adentitia was preserved. Clamp was removed from ascending aorta. Aorta was transected distal to cannulation site. There was 2 cm linear cut in the aorta at the cannulation site from an extension of the cannulation orifice. We then did distal anastomosis with two layers posteriorly and one layer anteriorly. Patient was rewarmed. There was bleeding from proximal anastomosis and tear found in the intima. We redid suture line with pledgets and biological glue." 

36140 versus 36200

"Procedure done was flush aortogram and bilateral lower extremity bolus chase angiograms. StarClose left common femoral artery: Ultrasound-guided needle access used to access the LF common femoral artery. A Storq guidewire was passed up into aorta, over which a 6 French brite tip was passed. Through the sheath and over the wire, a 4 French universal flush cath was passed to the suprarenal level of the abdominal aorta. Universal flush cath was passed to the suprarenal level of the abdominal aorta. Flush aortogram was done using 20 ml bolus for a total of 20 ml, after which the universal flush cath was withdrawan to the bifurcation of the aorta to the iliac arteries. Bolus chase angiogram of both lower extremities was done simultaneously using total of 70 ml boluses all the was down to the foot. StarClose placed in the LF common femoral artery."  Would the code used for this procedure be 36140 or 36200? I'm having a hard time trying to figure out if cath entered the iliac artery from the right side also.  Will I need to use G0269?

Left neck exploration with aborted carotid endarterectomy

Should I report code 35301 -53, or just the neck exploration with node excision?

"Dissection carried down through subq tissue and platysma to the level of the internal jugular vein with cautery. Facial vein was then identified and ligated with 2-0 silk ties proximally and distally along with medium clips; vein was transected with Metzenbaum scissors. Large reactive lymph node was noted overlying the ICA and mobilized and transected. It were passed off the field to be sent to path. Additional smaller veins were ligated distally with 3-0 silk and small clips. Internal jugular was then reflected laterally. Common carotid was then visualized & dissected circumferentially; red vessel loop was used to encircle. The internal, external, and the superior thyroid arteries identified and controlled with vessel loops. After dissection of the ICA, it was palpated gently and lesion was noted to be high. Maneuvers for more distal exposure were performed such as mobilizing the hypoglossal nerve, taking down part digastric muscle & ligating associated veins. Lesion still to high, proc aborted." 

Pocket Relocation

After prep bilaterally, sharp & blunt dissection w/incision carried down to pectoralis fascia on LT side PG pocket site. Chronic LT ventricular & atrial leads uncapped & tested, adequate pacing/sensing confirmed w/ventricular lead & sensing in the atrial lead. 10 volts applied w/no observed diaphragmatic stimulation in the ventricular lead. Copious abx solution used to irrigate LT side pocket. Boston Scientific Model K173 device was connected to chronic leads & sewn into pocket, lead placements again verified, pocket closed. Using a combo of sharp & blunt dissection, incision carried down to level of pectoralis fascia on RT side PG pocket site. Existing RT side PM model K1783 removed from leads. Existing ventricular lead unable to be extracted due to fibrosis, left in place in RV, capped. Existing atrial lead extracted. RT side pocket debrided, irrigated w/abx solution, pocket closed w/deep & subcu Vicryl & Dermabond. Pt tolerated px well, returned to floor in stable condition. Would you would report this with 33222-59, 33228, 33234?

Would like an opinion if this would be reported as 96356 or 93653

Should this be reported with code 96356 or 93653? "Persistent A fib; A Flutter, Typical; Prior PVI; Here for endocardial portion of convergent. High density mapping catheter advanced into left atrium. 3D mapping to assist with catheter manipulation/construct cardiac geometry. Patient had 4 veins with normal anatomy. Esophagus midline, lesions monitored with esophageal probe directly posterior to ablation catheter. A small reconnection near LSPV toward the roof. Some fractionated signals high and posterior near the roof. For atrial fibrillation and/or substrate modification remaining after PVI, the ablation catheter was used to perform a roof line, achieving complete posterior wall isolation. LSPV was reisolated upon completion of the roof line. No evidence of recurrent atrial fib. Isoproterenol infused up to 6 mcg/min. Short nonsustained bursts of typical CTI dependent flutter. CTI ablation line performed at 40W beginning on ventricular aspect, toward IVC. Bidirectional block achieved/confirmed on differential pacing. Double potentials seen >110ms. Rapid burst pacing failed to induce an arrhythmia."

Persistant atrial flutter Is this coded 93656 or 93653?

Persistant atrial flutter Is this coded 93656 or 93653?

"Procedures performed: 

Confirmed Durable Pulmonary vein isolation from prior ablation

Lateral mitral isthmus line, anterior to LAA

Posterior scar and inferior posterior wall ablation

Posterior septal scar ablation

Atrial pacing was performed to reinduce atrial flutter. Initial pacing from the distal CS down to 240ms induced atrial fibrillation. Reentry formation in AF were seen along the posterior septum. AF terminated spontaneously. REpeat pacing (atrial double extra stimuli from the lateral LA appendage successfully reinduced the clinical flutter. Activation mapping confirmed a left atrial flutter circuit around the LAA, through the scar at the anterior base of the LAA and through the coumadin ridge. RF ablation lesions were performed at this site, with a line created from superior-anterior base of LAA, adjacent to the LSPV to the lateral wall scar with termination of the flutter. Pacing from HRA identified persistent conduction and further ablation lesions were applied until pacing identified bidirectional conduction block across the anterior."

Right atrial Fontan conduit catheterization and pressure measurement coding

"Congenital heart disease status post extracardiac Fontan procedure now with chronic hyperbilirubinemia and lesion seen on CT. Concern for hepatic cirrhosis. Anatomy is not favorable for a transjugular liver biopsy. IR consulted for hepatic venogram with pressures. Left femoral vein access. Catheter used to select second order branch of right hepatic vein with subsequent venography that demonstrated a normal patent hepatic vein without stenosis. Catheter was exchanged for occlusion balloon catheter that was utilized to obtain free (14 mmHg) and wedged (16 mmHg) hepatic venous pressures. The catheter was then withdrawn and advanced into the right atrial Fontan conduit. Angiography showed antegrade flow, and pressure (15 mmHg) was also obtained. Finally, the catheter was withdrawn into the intrahepatic inferior vena cava, and venography showed antegrade flow with pressure measurement (15 mmHg) performed. Catheter was removed and hemostasis obtained." Is this procedure reported with codes 36012, 75889, 75825, 36013, and 76496? Or should I report codes 36012, 75889, 75825, and 93530?

Definition of ICD Replacement Codes 33262, 33263, and 33264

I think I have been misinterpreting the definition of ICD replacement codes 33262, 33263, and 33264. My understanding of these codes was that the number of chambers explanted had to match the number of chambers implanted. In the case of a dual chamber ICD generator only being explanted and a multi-chamber ICD being implanted with use of two existing leads and implantation of a left ventricular lead, we are being instructed to use code 33264. I thought it should be reported with codes 33241, 33230, and 33225. However, I see that the CPT parenthetical notes under code 33230 for implant generator only with existing dual leads instructs us to NOT report code 33230 with 33241 for removal and replacement of the ICD pulse generator and to use codes 33262-33264 when pulse generator replacement is indicated. Code 33241 is for removal only not replacement.  Is this a misprint in the parenthetical notes?  If we are to use codes 33262-33264 in this instance, am I understanding that it doesn't matter what we are explanting, we only code by what we are implanting?

Clamshell Incision w/ bilateral explant and reimplant of breast prothesis

A clamshell incision for chest and mediastinal exploration (bilateral anterolateral thoracotomy with transverse sternotomy) and intrapericardial pneumonectomy with resection of large tumor mass are performed along with bilateral explant and reimplant of breast prosthesis because of where the anterolateral incision had to be made for exposure. Are the explant/reimplant of breast prosthesis procedures separately billable, or are they bundled into the mediastinal exploration with intrapericardial pneumonectomy procedures?

"Due to size of tumor and extension into mediastinum, clamshell incision was performed. The breast prosthesis pocket was extended and was actually opened bilaterally because of where the anterolateral incision had to be made for exposure. Pocket was opened, and breast prosthesis was removed and re-implanted at the end of the clamshell incision for left chest and mediastinal exploration (bilateral anterolateral thoracotomy with transverse sternotomy) and intrapericardial pneumonectomy with resection of large tumor mass procedures."

37202, 75896, 96420, chemoinfusion

Please do NOT include any actual patient medical records with your question. Patient admitted for follow-up intra-arterial chemotherapy.(first IA chemo done 9/26/12) Diagnostic Cervical and Cerebral Angios done at that time) Access site RCFA Catheter placements LCA, Bilateral Internal Carotid arteries Angiogram runs LT Cervical angiogram via LCA,catheter advanced to LICA-angiogram LT Cerebral Angio Chemo infused via catheter in Left ICA Catheter flushed and Follow up angio performedCatheter repositioned to Right Common Carotid-Angiogram performed, Catheter advanced into RICA for Cerebral Angiogram.. Chemo infused via Catheter in Right ICA -catheter flushed and follow up angio performed. Codes used to bill services.75680, 75896 x2, 75898 x2, 96420 x2, 36216 My argument is that the intra-arterial injections 96420 is the injection and therefore 75896 even without 37202 is wrong. It should be noted they were charging 96420, 75896 & 37202 in prior case and I told them they were charging the patient twice for the same injection which has been remedied by the above. So if my argument holds and 96420 is the appropriate charge vs 75896 & 37202 is it appropriate to bill follow up angiograms for the images taken post chemo? And lastly, if there is not change in the patient's status should she be charged for the diagnostic procedures again? Thank you for any assistance you can provide. Sincerely, Melinda Martino,R.T.R.,CIRCC

Catheter Placement via PDA

Hi, I have researched your Q&A and found that it is appropriate to bill 36015 when selective catheter placement in a PDA via the aorta is done. However, I am not sure what to do with a catheter placement in a PDA via the pulmonary artery with angiography. Can you please review the attached documentation an let me know if I can bill for the catheter placement into the PDA and which angiography code I should use, 76496, 75774, or perhaps since the aorta was described can I use 93567? A RHC & LHC was also done. Thanks so much for the help!! 1. Cameras are in the straight AP and lateral position. There is a Berman catheter placed across a femoral venous sheath with the tip into the right ventricle. With injection of contrast, the right ventricle is dilated and heavily trabeculated with preserved systolic function. There is no evidence of significant tricuspid regurgitation. The patient is status post hybrid Norwood procedure. The PDA stent appears to be widely open. There is good retrograde flow into the native ascending aorta. The distal right pulmonary artery appears to be normal in size. 2. Cameras are still in the same position. The Berman catheter is now placed across the main pulmonary artery with the tip into the distal PDA stent. With injection of contrast while the balloon, at tip of the catheter, is inflated, there is good flow into the native ascending aorta. The distal left pulmonary artery also appears to be of normal size. 3. The Berman catheter is now pulled back to the proximal portion of the PDA stent. With the balloon inflated, there is flow into both branch pulmonary arteries that appear to be filling very faintly. The narrowing at the proximal pulmonary artery is at the level of the previously placed band.

EPS Study with Cardioversion

For the following report, can the cardioversion be coded along with the EPS study and injection of Isuprel?

Patient was brought to the EP Lab in the fasting state, sedated by the Anesthesia Team. The right and left groins were prepped, and the right neck was prepped. A catheter was advanced. Patient had atrial fibrillation that was seen with catheter manipulation. This had to be cardioverted back to sinus rhythm. Patient had an EP study done and had no inducible SVT, no evidence for dual AV node physiology, and no evidence for an accessory pathway. VA conduction was not present. We started Isuprel, and the patient went into A-fib again, so we had to discontinue the Isuprel, and the patient received another cardioversion once the Isuprel was discontinued and went back to sinus, but then degenerated back into A-fib again. The patient also had an episode of atrial flutter that appeared to be typical flutter. Procainamide was ordered and was about to be hung, but the patient went back into sinus rhythm just as we were about to start the Procainamide. The patient was awake at this time with a baseline heart rate about 100. The EP study was repeated and again no VA conduction was seen during the awake state. The patient did have occasional episodes of a very short three to ten beat runs of nonsustained SVT that may have been an atrial tachycardia earliest in the high atrium, and it is possible that this may be the patient's clinical diagnosis. All catheters were removed. No ablation was performed. IMPRESSION: EP study significant for inducible atrial flutter, which was typical, atrial fibrillation and also a short atrial tachycardia that was nonsustained. Hard to know what is her clinical tachycardia. It may be the nonsustained atrial tach. The patient felt better on the Digoxin. We are going to resume Digoxin.

EKGs and cardiac catheterization

I am auditing the CCL of one of our smaller system hospitals that hasn’t been audited since before I joined the audit department a few years ago.  I have discovered that they are CPT 93005 (with and without modifier 59) performed with CPT codes 93458, 93459 & 93460.  The EKGs are ordered as part of the standard pre-procedure routine.  From my understanding, charging for the EKG is not allowed because it’s an NCCI edit.  I discussed this issue with other auditors who agreed that the hospital should not be charging, as our other hospitals that I have regularly audited do not charge for them; but I pulled the “National Correct Coding Initiative Policy Manual for Medicare Services” from the CMS website and in Chapter 11, Section I, Point #14 it states:
This makes me think that the diagnostic EKG that is performed prior to the cardiac catheterization IS billable/reportable as long as it has modifier 59.  What is not billable is any EKG taken during the procedure.  If this is the case, then I need to instruct all of my hospitals to start reporting/billing this charge.  Do you agree?  I looked in your Cardiology reference guide but it only referenced that EKGs should NOT be billed with EP studies and doesn’t address cardiac catheterizations.

Thank you,

Good afternoon, Dr. Z and Dr. Dunn. I have a lot of questions about the following op report. I'm debating whether to represent the angioplasty with 35456,LT or 35459,LT, along with 75962,26,LT. I'm leaning towards 35456,LT, because the doctor says it was done in the mid thigh, but 35456,LT is considered bundled with 35566,LT, according to NCCI edits, while 35459,LT isn't. It also seems as if 36140,LT is considered bundled with 35566,LT, but would that be added with a 59 modifier if an angioplasty of the graft is done? On the other hand, does the statement, "Primary vascular procedure listings include establishing, both inflow and outflow, by whatever procedures necessary.", pertain to this situation? How about the repairs due to extravasation, during the angioplasty of the graft? Could 35226,LT be used as an additional code? If so, how many units? I decided against using 35682,LT, because the doctor basically did a resection and anastomosis of the same vein, as opposed to merging two veins from different locations. Was that the correct decision? Is there another code you'd use to describe this procedure? If not, does this warrant billing with modifier 22? The doctor also mentions several angiograms. How many units of 75710,26,LT can I use? On top of that, the doctor mentions that a Doppler was brought onto the field. Does this statement warrant the use of 93922,26,LT? I know the narrative says "noninvasive", so is there another code you'd use, like 37250,LT and/or 75945,26,LT, or is it just included in 35566,LT? I don't see any NCCI edits saying either of those codes are included in the bypass. As you can see, I'm extremely confused. Your assistance would be greatly appreciated. Your answers to this might help point me in the right direction with a lot of future op reports. Thanks, in advance. Here's the op report: DATE OF OPERATION: 03/29/2010 ANESTHESIA: General. PREOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. POSTOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. PROCEDURES: 1. Left lower extremity angiograms. 2. Left superficial femoral artery to anterior tibial artery bypass with composite great saphenous vein graft. 3. Angioplasty of vein graft. 4. Completion angiograms. INDICATION: This is an 88-year-old female who presented with rest pain and ischemia to the left foot with some mild motor dysfunction of her toes. The patient did undergo a cardiac evaluation. She was brought to the operating room for elective femoro-anterior tibial bypass after having undergone aortoiliofemoral and left lower extremity angiograms earlier in the week. The patient had this performed with composite nonreversed great saphenous vein graft from the left leg. Completion angiogram demonstrated areas of stenosis in the vein graft and angioplasty was performed. This was complicated by a linear tear with some extravasation in the mid thigh, which was directly repaired with interrupted stitches of 6-0 Prolene. There also did appear that the vein graft requiring a repair was an interrupted stitch of 6-0 Prolene. Completion angiograms demonstrated very good result with good caliber of the vein graft and run-off onto the dorsalis pedis artery in the foot. PROCEDURE: The patient was identified and brought to the operating room. She was placed in the supine position on the operating room table. After administration of general anesthesia by the anesthesia department, the patientâ?Ts lower abdomen, groin, entire left lower extremity, and right thigh were prepped and draped in the usual surgical sterile fashion. Attention was turned to the left lower extremity and in the distal third of the leg, a lateral skin incision was made approximately 8 cm in length. This was carried down through the skin, subcutaneous tissue, and fascia. The anterior tibialis muscle was retracted medially and the extensor digitorum longus retracted laterally. Dissection was carried down and the neurovascular bundle was identified as well as the anterior tibial nerve. The anterior tibial artery was dissected out. The Doppler was brought onto the field. The proximal portion was without evidence of flow and dissection was carried more distally to where collateral flow was heard in the artery. For this reason the incision was extended more distally. The artery was harder and calcified more proximally where it was occluded. The artery was softer more distally. A portion of the artery was dissected out where the vessel was soft and suitable caliber being 2 to 2.5 mm in diameter. Attention was turned to the left groin. Incision was carried down through the skin with the scalpel. Dissection was then carried down through the subcutaneous tissue and fascia and femoral sheath. The common femoral artery, profunda femoris, and superficial femoral arteries were identified and dissected out, and vessel loops placed. The great saphenous vein was identified. A bridge incision was made in the thigh and the dissection carried down through the subcutaneous tissue and the saphenous vein exposed. Continuous incision was then made along the medial leg and the saphenous vein was exposed along its length. Below the knee at about the proximal to mid calf, the saphenous vein became of smaller caliber dividing into two tributaries. The larger branch was followed. The vein was smaller and more disadvantaged at this site and in the distal leg, the vein then became larger again and was with good caliber to the medial malleolus. This was dissected out. As there was the disadvantage portion of vein measuring less than 2.5 mm, the plan was to do a venovenostomy to use the portion of the vein greater than 2.5 mm. For this reason, the dissection was carried farther down the superficial femoral artery proximally where it was still with good caliber with minimal disease based on the angiogram through the proximal thigh incision. Dissection was carried down through the subcutaneous tissue and fascia, and several centimeters, approximately 8 cm distalfrom the bifurcation, the superficial femoral artery was dissected out and vessel loops placed. Following this, a subcutaneous tunnel was made traversing to the lateral thigh with a gentle curve and then along the lateral aspect of the leg in a subcutaneous position and down to the distal wound. The saphenous vein was controlled at the saphenofemoral junction. The saphenous vein had been dissected out along its length, ligating and dividing the tributaries between 3-0 and 4-0 silk ties and clips on the tissue side. The dissection was routine, but on distending the vein through a tributary, which controlled the vein proximally, the vein did require repair of multiple small areas with 7-0 Prolene. The vein was clamped at the saphenofemoral junction taking a cuff of the femoral vein excising the saphenous vein and oversewing the femoral vein with 6-0 Prolene. Attention was then turned to performing the proximal anastomosis. The first vein valves were cut under direct vision. with LeMaitre valvulotome with two passes. The blood flow was pulsatile through the vein. The mid-distal third was smaller, disadvantaged as noted. Proximal anastomosis was performed by controlling the superficial femoral artery. About 5000 units of intravenous heparin was given under my direction. An additional dose was given as needed. Vertical arteriotomy was made in the superficial femoral artery and extended with the Potts scissors. The vein was used in nonreversed fashion, spatulated, and anastomosed, end-to-side using a running stitch of 6-0 Prolene. Prior to completing the anastomosis, the femoral artery was back bled and antegrade flushed. There was a good inflow. The anastomosis was then completed. It was then that the valves were cut with a valvulotome. The first two valves had been cut under direct vision. The remainder of the valves was then cut using LeMaitre valvulotome with two passes. Blood flow was pulsatile through the vein, although the smaller disadvantage segment of the vein was as noted in the mi-distal portion of the vein. The vein was then passed through the subcutaneous tunnel and brought out to the anterior tibial wound. The anterior artery was then controlled where the artery appeared of good caliber and was soft. This was opened with the #11-blade and extended with the Potts scissors. There was reasonable backbleeding in the artery as well as some antegrade flow via collaterals. Angiogram was performed, which demonstrated that this was a good site for the anastomosis with flow into the dorsalis pedis artery with the artery being of good caliber without significant stenosis. The vein length was then measured. The vein graft was then cut to remove out portion of the disadvantaged segment of vein. Venovenostomy was then performed over #8 pediatric feeding tube. When this was complete, the end of the vein was then spatulated and anastomosed end-to-side to the anterior tibial artery using a running stitch of 7-0 Prolene. Prior to completing the anastomosis of the vein graft, the artery was back bled and flushed. The artery was flushed with heparinized saline solution. The vein graft was flushed, and the air was released. The anastomosis was then completed. Flow was allowed to propagate down the foot. There was a palpable pulse in the dorsalis pedis artery in the foot and an excellent Doppler signal distal to anastomosis. The vein graft was pulsatile but still did not appear to distend fully, being on the smaller side despite excising the smaller portion. Completion angiogram was performed through a side branch just distal to the proximal anastomosis. This did demonstrate a couple areas of severe narrowing, the first being in the anterior thigh. The area was marked with a glow tape. A #5 French sheath was placed through the side branch, and a glidewire followed by angioplasty balloon was passed through the mid thigh and angioplasty was performed. On the post-completion angiogram, unfortunately there was some evidence of extravasation and cutdown was done in the mid thigh and a linear tear in the vein was directly repaired. It was also noted along the distal lateral incision and again evidence of a frail vein that the guidewire had transversed thru the vein wall. The wire was pulled back and this was repaired with a 3-0 interrupted stitch of Prolene. The wire was negotiated down the vein, and completion angiograms demonstrated also two other areas of narrowing, and the angioplasty balloon was applied lightly in these areas with excellent result on completion angiogram. Due to the presence of the sheath and the angioplasty balloon, intermittently the vein graft was flushed with heparinized saline solution. Intra-arterial papaverine had also been given due to some spasm of the artery distal to the anastomosis after controlling the vessel. The artery here is soft. Completion angiograms demonstrate excellent result of the vein graft and the distal anastomosis to be patent with the anterior tibial artery patent into the dorsalis pedis artery on the foot. The guidewire, the balloon, and the sheath were then removed from the vein and the branch stump was ligated with 3-0 silk. Flow was allowed to propagate down the vein graft into the foot. The patient did have a strong dorsalis pedis pulse as well as a palpable vein graft pulse along the lateral leg. Hemostasis at the anastomoses was obtained with thrombin and Gelfoam. Hemostasis of the subcutaneous tissue was obtained with diathermy. Attention was turned to closing the wounds when hemostasis was satisfactory. The groin wound was closed in two layers using 2-0 and 3-0 Vicryl. The skin was reapproximated with skin clips. Similarly over the SFA and proximal anastomosis, subcutaneous tissue was closed in two layers. The remainder of the saphenectomy site along the medial leg was reapproximated in one or two layers with Vicryl and the skin was reapproximated with skin clips. The lateral leg wound was closed using subdermal stitches proximally. Due to the thin subcutaneous tissue and some leg swelling, the distal portion of the incision was reapproximated using interrupted stitches of 3-0 nylon. The incisions were cleansed and sterile dressings were applied. The patient tolerated the procedure and was taken to the recovery room in stable condition.

Billing heart catheterization with 59 modifier

I have a provider that did a radial access attempts to advance the J wire into the aorta from the right radial was not successful, therefore a JR cath was advanced to the level of proximal subclavian and an angiogram was performed. Apparent that the pt had about 75-80% right sublcavian stenosis. Glide wire was advanced into the ascending aorta and the JR-4 and AL-2 multiple angulated view of the Rt and Lt coronary performed. JR-4 was used to selective engage the vein graft to the RAMUS and vein graft to the marginal and selective angiography of these grafts were performed. LIMA was patent because of competitive flow in LAD. No attempt was made initially to engage the LIMA. At this point the provider did a common femoral arterial access was obtained, LIMA cath was selective engaged into the left internal mammary, angio performed. Pigtail cat was advanced into the ascending aorta, aortic root ang was performed. AL-6 guiding cath then selectively engaged into the the Rt coronary artery, multiple agulated views of Rt coronary artery were performed. This was performed after 300mics of IC nitroprussied. Pt given ANGIOMAX bolus and drip in .014 whisper wire dilated from distal RCA to mid RCA. Drug eluting stent was then done.

My question on this case is can I bill anything for the first access that was not able to complete the heart cath?
I have one coder that feels we should bill 93459, 93459-59 or 74, G0290,93567.

The other coder feels we should bill 93459,G0290,93567 and 36216 and 75710 for the subclavian access and angio.

Any guidance you can give use on this case would be greatly appreciated.
Thank you for your assistance.
 

Code 36870

For the following case I reported codes 36831, 36147, 35475, 75962-26, 37205, and 75960-26. I was told I should use code36870, but embolectomy appeared to be open not percutaneous. I also questioned the two sheaths that were placed...can I bill for both??

"Patient presented with malfunctioning AV graft. DESCRIPTION OF PROCEDURE: The patient's left arm was sterilely prepped and draped after he received general anesthetic. Over the old graft on the distal part of the arm, a small incision was made approximately 1.5 cm. The graft was identified. An arteriotomy was performed of the graft and a 4 Fogarty was passed proximally. There was some resistance with the brachial artery anastomosis and there was poor inflow. Also, it was passed into the graft, into the subclavian vein and much thrombus was removed. After this was done, I now repaired the arteriotomy with a 5-0 interrupted Prolene. A sheath was placed in an antegrade and retrograde fashion so that crossing sheaths were in place. With the first sheath, a wire was passed over into the brachial artery. A KMP catheter was passed to prove that it was in the true lumen and then a 6 x 40 was gently insufflated across this area. A fistulogram had been previously performed that showed that there was a large amount of thrombus still present at the brachial artery anastomosis and this was softly/gently dilated. Now, there was good inflow into the graft. Through the other crossing sheath that was in place through the arteriotomy, a venogram was performed through the arm and followed centrally. The flow was very slow and sluggish. There was a high-grade stenosis at the venous anastomosis at the axillary vein within the chest. At this time, a 5 x 40 balloon was insufflated as this was a 6-mm graft. A 6 x 40 balloon expandable stent was then placed across the high-grade stenosis at the venous anastomosis. A venogram was now performed and showed that there was good flow through the graft and this was followed centrally and there was good flow into the SVC into the right atrium."

Direct Puncture Therapy

Here is a procedure that was performed that I need some assistance in correctly coding. These unusual procedures can get very confusing. 

DEVICES UTILIZED: Two separate 21 gauge micropuncture needles were utilized. PROCEDURES: 1. Ultrasound and fluoroscopically guided percutaneous access into the venous malformation in two separate areas. 2. Percutaneous venography of the venous malformation, times two. 3. Injection of Sotradecol into the lesion, three separate times, ten minutes apart. Using sterile technique, local anesthesia, general anesthesia, ultrasound and fluoroscopic guidance, two separate 21 gauge needles were placed within the lesion. Injection of contrast material was performed, demonstrating the extent of the filling of the lesion. The contrast material was then allowed to drain and the volume was replaced with Sotradecol. The Sotradecol was allowed to stand for ten minutes before attempting to remove it and reinjecting the same space with Sotradecol. This was performed twice from the first needle position and once from the second needle position. At the termination of the procedure the needles were removed, and band-aids were placed over the skin puncture site(s). The patient tolerated the procedure well, and no complications were encountered during or immediately following the procedure. FINDINGS: The first injection from the first needle placement demonstrated excellent filling of the lesion, representing the majority of the lesion, with a multi-lobulated appearance. The venous drainage was into an external jugular branch draining inferiorly. The second injection was in the most superior part of the lesion, filling the superior third. Venous drainage was as outlined above. IMPRESSION: Good filling of the lesion was achieved with Sotradecol, for purposes of sclerotherapy of the venous malformation within the substance of the left masseter, as described above.

tibial/peroneal trunk

Hi Dr. Z. I saw the errata regarding the tibio-peroneal trunk for vascular interventions: CODING INSTRUCTIONS 18. The tibial/peroneal territory includes three vessels that are separately coded: the anterior tibial, posterior tibial, and peroneal arteries. The tibial/peroneal trunk is considered part of any distal vessel intervention in the posterior tibial and peroneal arteries (similar to the left main coronary artery). The tibial/peroneal trunk is considered a separate vessel from the anterior tibial artery. The dorsalis pedis is considered part of the anterior tibial artery, and the medial malleolar artery is considered part of the posterior tibial artery. However, the SIR 2011 updates state this: 3 Tibial/peroneal territory: subdivided into anterior tibial, posterior tibial and peroneal a 37228–37235 b Report the initial vessel treated as the primary code for the highest level of service provided within the tibial-peroneal territory with addon codes for additional vessels treated (not additional lesions or procedures in the same vessel) c The tibioperoneal trunk is not considered a separate vessel So now I am confused. The CPT books says: “The common tibio-peroneal trunk is considered part of the tibial/peroneal territory but is not considered a separate, fourth segment of vessel in the tibio-peroneal family for CPT reporting of endovascular lower extremity interventions. For instance, if lesions in the common tibio-peroneal trunk are treated in conjunction with lesion sin the posterior tibial artery, a single code would be reported for treatment of this segment.” Is this where you are getting the information in your errata....and counting the tibioperoneal trunk lesion as a separate vessel from an anterior tibial vessel lesion? I just want to be sure where it came from as my staff are going to want to know given the SIR advice. Thanks again. I know if anyone has the answer it is going to be you!