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Aortic root replacement, cut down and LAA

If the following procedures listed below were performed during the same operative session, would the LAA be considered bundled with the aortic root replacement? Also, how would you code this scenario? 1) Aortic root replacement with 27 mm freestyle with ascending aortic aneurysm repair with 26 mm tube graft. 2) Right femoral artery cutdown for arterial cannulation. 3) Ligation of left atrial appendage with Atriclip. 

thrombectomy at time of AVF creation

"A patient underwent creation of a brachiocephalic AVF. After construction, thrill in the fistula was noted to be weak. The anastomosis was taken down and fresh thrombus was seen at the anastomotic site. This was removed and flushed away with heparinized saline. Then thrombectomy of the brachial artery was performed with a Fogarty catheter. The artery was flushed. A Fogarty catheter was passed into the cephalic vein and a small amount of thrombus was extracted. The vein was flushed. The anastomosis was redone." How would this procedure be coded? Would the thrombectomy be considered part of the AVF creation, or is it separately reportable?

CPT code for Innominate to left common carotid artery bypass with 8 mm dagr

CPT code for innominate to left common carotid artery bypass with 8 mm Dacron graft and 8 mm Dacron graft cannulation of innominate artery. These two procedures were done with aortic valve replacement (David procedure): 33864. Can't find codes. 

ICD pocket debridement

Patient with CRT-P came in with pocket infection. Opened pocket and just did debridement of pocket with tissue cultures sent to lab. Placed original device back in pocket and closed. What would be the correct billing code for this procedure?

Thoracotomy drainage lung parenchymal&pleural abscess

What is the code for the procedure above? and here is the note. Thank you in advance, I performed a standard posterolateral left thoracotomy, shingling the rib in about the fifth intercostal space. The lower lobe was very inflamed and matted down and the upper lobe was relatively adherent as well. With difficulty, I was able to mobilize the lower and upper lobes. There appeared to be 2 abscesses of the lower lobe that are perforated into the pleural space and there were multiple collections of thick yellow pus. There was approximately 1200 mL or more of purulence in a rather small hemithorax. I was able to mobilize the lung and wash the entire space out. The chest wall was rather raw as anticipated and oozy, so we did give him DDAVP. We irrigated with multiple liters of saline. I did obtain cultures. I placed a posterior right angled 28 at the base of the thorax and a more anterior access tube to the apex of 28.

Multiple attempted, unsuccessful line placements

My provider attempted to place a central line in four different vessels with US/fluoro, but was unsuccessful. The op note states, in summary, "Inability to thread wire through vein once vein accessed. Attempted at right subclavian, right IJ, left subclavian, and left IJ." Ultimately, the provider was unable to place a central line and abandoned the procedure. Do I code each attempt with a -53 modifier?

Modifiers LT/RT on Dialysis circuit codes

Is it correct to add -LT/-RT site modifiers on dialysis circuit codes 36901-36909 or creation/revision of the graft/shunt codes 36800-36861?

93463

Is CPT code 93463 billable for the physician side? A doctor had performed a dobutamine challenge for aortic stenosis assessment during a heart cath. In his documentation, he stated the resting peak and mean gradients along with his findings. Hospital/facility side is saying it's only a technical charge whether he administered it or not. Please advise.

Follow up on Holter question ID: 8872

Code 93225 is a code that does not have a physician component. Can this code be billed without the device being returned for scanning and analysis?

How to obtain proper reimbursement for unlisted procedures 37799?

I verify with the surgeon a comparison code and we send letters to the insurance companies. I have also suggested management involvement on a contracting level. However there are payers out there that deny unlisted procedures as investigational. I don't understand that, as some of the procedures have been performed for years. Some examples of unlisted procedures that come to mind are stab phlebectomy of varicose veins less than 10 incisions, median arcuate ligament release, and bypass revisions that don't have a code in CPT like revision of arterial bypass that are not lower extremity or hemodialysis grafts. What do you suggest?

Correct coding for a "Florida sleeve " for aortic root dilation & AV insuff

Our doctor's short description of what was done is: "Transesophageal echocardiography; total cardiopulmonary bypass; Florida sleeve aortic root reconstruction using 30 mm Dacron Hemashield graft and reduction aortoplasty of aortic root above the midportion of the noncoronary cusp." We are back and forth between 33864 and 33860-22. Since the Florida Sleeve procedure is new to our facility, I'm asking what the most appropriate code would be. Since the surgery was similar yet a different procedure with the root than the "David Procedure".

Coding for 93623

Is the following documentation sufficient to report code 93623? Would you please explain why or why not? "Bidirectional block was demonstrated in and out of all four pulmonary veins post ablation. Adenosine was administered in 9 mg boluses to check for dormant pulmonary vein reconnections, and additional ablation was administered as needed to eradicate these connections."

93623 Post Ablation

I believe 93653, 93655, and 93609 are documented here, but I wonder about 93621 and 93623? Is the coronary sinus location for 93621 and key word 'induced' enough to support 93623? "We first mapped and ablated the left slow pathway, mapping the retrograde sequence during atypical AVNRT with retrograde left slow pathway. After ablating this pathway, the sequence in the coronary sinus showed only retrograde right slow pathway activation. The right slow pathway was then ablated. Junctional beats were seen both with left and right slow pathway ablation. After this, no sustained tachycardias were inducible with and without the use of isoproterenol. After waiting period of about 30 minutes, repeat testing was done, and no tachycardia was inducible. The patient was recovered from sedation. Catheters were removed. There were no recognized complications."

Update on convergent or hybrid cardiac ablation?

A question about how to code for hybrid approach EP ablations was asked back in 2017 (question ID 8968). Recommendation was to use an unlisted code for this investigational procedure, and to check with specific payers. Also, use 93656 for A-fib ablation if done at separate encounters. Are there any more current recommendations on how to code these procedures now (2019/2020) from Dr. Z?

Large French cath placement with Impella joint case

The vascular surgeon was called into the cardiology case for a placement of the Impella (33990), requiring placement of a 14 French for the cardiologist to be able to place the Impella in a high risk patient. Code 34713 is only allowable with TAVR, EVAR, FEVAR, and TEVAR procedures. It would not be an allowable separately reportable service for the vascular surgeon, or as an add-on to the Impella. Would they both share code 33990 with either an -81 or -82 modifier for the vascular surgeon for the placement of the 14 French sheath, or would the vascular surgeon not be able to bill for the Impella at all?

DFR during heart cath

We have been seeing some of our heart doctors say they are doing a DFR during heart cath. I have seen the FFR but have not been able to find enough information to get a code for the DFR procedure. Physician says EX: "We then did Comet wire interrogation of the LAD and left main Distal to the LAD lesion the DFR was 0.85, significant. Next EX: Diagnostic cath was done then a DFR determination RCA with Mach1 6 French FR4, unfractured heparin weight adjusted." Some coders are using the 93571 FFR, but Im not sure there is enough documentation for this. Do you have any information on the DFR procedure? 

KX modifier on device codes

I am getting a denial back from our billing office stating that the required modifier on C1785 is missing. The primary diagnosis was I48.1, and CPT 33208 was coded with a -KX modifier appended. Is the -KX or -SC modifier also required on the device codes?

Fluoroscopic guided bilateral pedicle marker using Hilal marking coils

Could you tell me if C9728 would be the appropriate charge for the scenario below? Due to the fact they are placing coils, the attending feels 76000 would be the correct charge. "Using fluoroscopic guidance, a 20 gauge spinal needle was advanced toward the left T12 pedicle. Three 3 mm Hilal marking coils were placed overlying the pedicle. Placement was confirmed with fluoroscopy. The procedure was repeated at the right T12 pedicle, and again coils were placed overlying, then confirmed with fluoroscopy."

His Bundle Recording

I'm confused about what exactly is needed to bill 93600. Is just notating an HV interval enough?

When is it ok to bill for non-pv triggers post PVI ablation?

"We isolated all pulmonary veins using wide area circumferential ablation. The right carina was ablated. External cardioversion was not performed. Pulmonary venous conduction block was demonstrated using entrance block (adenosine) and exit blocked (pacing). Posterior wall isolation was not performed, but an anterior roofline was ablated." Are codes 93656 and 93657 correct?

Coding for 93566 vs. 93566, 93567, 93568

"HX: 1-day-old with HLHS on prosteaglandins. Cath and placement of flow restrictors in bilateral PAs, stent PDA, atrial septostomy in order to allow growth before Norwood proc. PROC: antegrade RHC using 5 French end-hole wedge catheter was performed & DSAO & RV pressures obtained & baseline oximetry. Power injection performed in RV. Measurements were made in RPA & LPA. ANGIO: Power injection performed in RV w/berman catheter and contrast shows no catheter related TR. The RV is moderately hypertrophied w/adequate systolic function. There is no angiographic obstruction of main PA. There is a large duct which is opacified & the descending aorta. There is retrograde faint opacification of ascending aorta. Both branch PA's appear of normal caliber. There is normal distal arborization." Would you code 93566 since injecting RV, or 93556, 93567, and 93568 based on angio description?

CTO 92943 Clarification use Mod 52 or 53

For physician billing, if the intent of procedure is CTO but only angioplasty is performed, is a modifier -52/53 required? Or since 1 of the 3 components is performed would no modifier be required?

Atherectomy of Non-coronary Arteries

How many times can code 37225 be billed if two femoral arteries are treated?

Diagnostic LP with chemotherapy

Is it appropriate to bill code 62270 (diagnostic lumbar puncture) with 96450 (intrathethcal chemotherapy) if the CSF is sent to pathology for diagnostic testing? Documentation EX: "A 3.5 20 gauge spinal needle was advanced with the stylet in place using an oblique approach at the level of L3-L4. 5 mL of clear CSF was removed and divided across 4 collection tubes. Intrathecal chemotherapy (methotrexate) was administered as per hematology/oncology order."

Segmental liver artery catheterizations

I'm wanting clarification regarding liver segmental artery catheterizations. In the dictation, it sounds like the physician accessed a single artery versus two segments. Here is a sample of his wording: “with the catheter in position within the 5/8 hepatic artery,” “with the catheter in position within the 6/7 hepatic artery,” and “the microcatheter was advanced into the segment 4A/4B hepatic artery.” I coded this 36247 and 36248 x 2. Please advise.

Diagnosis for cardiac monitors

My educators and I are having a discussion. Maybe you can help us on this. "Event monitor was placed. There were 7 events including baseline. Events showed sinus rhythm, sinus bradycardia, and sinus tachycardia. Symptoms includes shortness of breath, dizziness, and racing heart. Conclusion reads: Event monitor with 6 events recorded, symptoms were reported for sinus rhythm, sinus tachycardia." Would R00.0 be an appropriate diagnosis, or would the indications be a better choice since there really isn't an abnormal finding? My thought is that the sinus "rhythms" are just the rhythm the patient was in at the time they had their "symptoms." Sinus tachycardia isn't an abnormality to code here is it?

Code 76376

Is the following documentation sufficient to report code 76376, or does it need to state acquisition scanner? "With a 5 French vertebral catheter, the right internal carotid artery, left internal carotid artery, and left vertebral artery were selected in turn. Standard angiographic runs were performed from each location; rotational acquisitions with 3D reconstructions were performed from the left vertebral artery. The images were reviewed."

93619 or 93620?

Is this reported with code 93619 or 93620? "Indication: Persistent atrial flutter with symptoms of congestive heart failure and slow ventricular response. An octapolar catheters and placed in the coronary sinus and quadripolar catheters were placed in the RV and His bundle region. A 20 pole catheter was then placed around the tricuspid annulus and baseline measurements were made revealing an AA interval of 280 ms, and R-R interval 950 ms and HV of 52. Pacing was performed from the coronary sinus and demonstrated a PPI minus TCL interval of approximately 55 ms. Pacing from the right atrium however demonstrated PPI minus TCL of over 200 ms suggesting this was not typical CTI flutter. The cardioversion was then performed to restore sinus rhythm and with further pacing maneuvers, we were able to demonstrate the continued presence of both clockwise and counterclockwise block. Significantly, the patient developed AV Wenkebach at cycle length 710 ms in sinus node recovery times were performed at 500 ms resulting in an SNRT of 3090 ms with a corrected CNS RT of over 1700 ms which was blatantly abnormal."

Geniculate nerve ablation with Coolief system

We have a physician using the Coolief system to perform geniculate nerve ablation. Procedure: Ultrasound-guided nerve ablation of the following nerves: Superior lateral geniculate branch from the vastus lateralis, Superior medial geniculate branch from the vastus medialis, Inferior medial geniculate branch from the saphenous nerve Ultrasound confirmed that needles were 50% depth of the femur and tibia and at the correct anatomic locations for all 3 needles. Motor stimulation was tested at 2.0 V with no leg movement. An additional 2 mL of 1% lidocaine without epinephrine was slowly injected at each of the 3 previously mentioned locations. Then a thermo-radiofrequency ablation of each of the geniculate nerves was done at 80°C for 2 minutes and 30 seconds each. The needles were then withdrawn. Is it appropriate to report 64640 or should it be an unlisted 64999? In addition, can we report our code per nerve or is each knee 1 treatment area, so 1 CPT?

Can you code 92997/92998 and 37236/37237 same session/same vessel?

Can you please clarify whether it would appropriate to code both pulmonary angioplasty codes (92997, 92998) and arterial vascular stent placement codes 37236, 37237 for pulmonary artery stent placement at the same session and in the same vessel? MD performed right heart catheterization, pulmonary artery angiography, LPA/RPA angioplasty – due to LPA,RPA narrowing bilateral stents were deployed. Of note the intent was not initially for stent placement but to determine why there was pulmonary stenosis. Please see reference below from Dr Z’s Medical Coding Series -Interventional Radiology coding Reference. Pg 278 #17. Separate cardiac codes for pulmonary artery angioplasty (92997,92998). Use established arterial vascular stent placement codes 37236/37237 for pulmonary artery stent placement(s). These procedures included catheter placements at the time of cardiac catherization.

What code would you use for the palcement of an Alfapump?

Would you use 49419 for the following?
Sequana Medical’s alfapump is a fully-implanted, programmable, wireless, CE-marked system that automatically pumps ascites from the peritoneal cavity into the bladder, where the body eliminates the ascites naturally through urination. The potential of the alfapump to address the unmet medical need in patients with recurrent or refractory ascites has been demonstrated in multiple clinical studies showing a significant reduction in the need for large volume paracentesis, which is paracentesis where at least 5 litres of fluid is removed (i.e., the current standard of care), and a significant improvement in patients’ quality of life."

Code 0296T - External electrocardiographic recording

We receive many denials on code 0296T. Can you provide any guidance or suggestion for resources on required documentation and billing guidelines for this procedure both alone and in conjunction with other codes such as 93458, 92928, stress test codes, and ECG with pacemaker interrogation?

37226 or 37236?

Can we please pick your brain? Would the below procedure qualify as occlusive, or should it be used with 37236? "The left external iliac artery is patent with minimal atherosclerotic disease. The SFA is patent for about a centimeter, and there is a total occlusion of the SFA along about 8 cm length and appeared there is reconstitution via collaterals. There is some filling defect in the proximal aspect of the reconstituted SFA, which is now about mid femoral level consistent with thrombus and probably the cause of embolic debris. The popliteal artery is patent with minor irregularities, but no evidence of aneurysm or stenosis." Physician "felt that recannulization of the SFA was indicated because of the concern of embolization and thrombus that a stent was indicated". Stent was placed in this area.

Percutaneous Fem-Fem Bypass for femoral occlusions.

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

Appropriate Use Criteria Modifiers

I was hoping you could expand on two of the HCPCS modifiers that relate to Appropriate Use Criteria (AUC). 1) Modifier QQ - ordering professional consulted a qualified clinical decision support mechanism. Considering that there are more specific modifiers that will be available for CY 2020 (MA through MH), will this modifier have any relevance next year? 2) Modifier MG - the order for this service does not have appropriate use criteria in the clinical support mechanism consulted by the ordering professional. Can you explain when this modifier might be appropriate?

FFRs and IVUS codes

How is everyone billing for FFRs and IVUS codes? We get a lot of denials for FFRs and IVUS codes. Are we applying a -59 modifier or not? Or just a -26 and branch modifier or not? These codes have me so confused.

62264 or 62321

Is the appropriate code for this procedure 62264 or 62321? "The patient was brought to the fluoroscopy suite, and monitors were applied. The patient was placed in the prone position on a carbon fiber fluoroscopy table. The skin was prepped, wiped, and draped in the usual sterile fashion. Lidocaine 1% was used for skin and subcutaneous anesthesia. A Coude needle under fluoroscopy in PA/lateral position was used to enter the caudal epidural space. No CSF, blood, or paresthesia was noted. Epidurography: 5 ml of Omnipaque 240 was injected to confirm the epidural placement of the needle with real time fluoroscopy. No intervenous or intrathecal diffusion was noted. Poor lumbar and sacral diffusion and filling defects corresponding with patient’s pain distribution were noticed. A catheter was advanced towards the L4-5 level. Following multiple gentle mechanical manipulations contrast was injected, which showed some improvement in the lumbar and sacral diffusion. Then a solution containing lidocaine mixed with betamethasone was injected without problem, needle removed."

LD and LM separate vessels for IVUS/IFR/FFR

There are times whe our cardiology docs will pull back into the LM to verify the adequacy of the test when there is a lesion in the LD. In this case, we would just charge for the LD study. However, if they need to look at the LM for stenoses or a lesion as well, can both the LM and LD or LC be coded in that instance? My thought was yes, but one of our physicians told me he was told not to bill separately. Could you please advise?

92997 for PTA of embolus?

A patient presents to IR with bilateral main pulmonary artery emboli. The provider performs PTA of both arteries in an effort to create a channel for perfusion, and then initiates TPA bilaterally. There is no underlying, chronic cause for the PE; this was an emergent event. Is the PTA billable with 92997/92998? I am getting hung up on if its a true stenosis or not, and if the PTA was only a means to place to TPA catheters.

DORV - TOF Type

The physician documents "double outlet right ventricle - Tetralogy of Fallot" type. Would you recommend coding both Q20.1 and Q21.3 to accurately capture the condition/diagnosis? Our CDI department recommends capturing both, but I would like to have your input. 

Does a venogram with PM or ICD require separate access to be billable?

Would this be guiding or diagnostic? "He was brought to the EP lab in a fasting state, ECG and OX monitoring were initiated and sedation was administrated. He was prepped and drapped in the usual fashion, the skin and the soft tissues in the left infraclavicular region were anesthetized with lidocaine. A 3 cm skin incision was made, electrocautery was used to dissect down to the prepectoral fascia. I attempted to obtain axillary venous access from within the pocket using fluro, I encountered the artery on 2 separate occasions. I was suspicious that there may be some venous anomaly or venous variant anatomy and a left upper extremity venogram through a separate site (the left antecubital vein) was performed. The venogram revealed slow filling of the axillary vein with brisk filling of the cephalic. I did not appreciate any stenosis, I was able to obtain vascular access after completing venography and 2 spring wires were placed." 

Axillary AV chest wall loop graft

How would you code this? Is this just 36830? "Transverse incision in the infraclavicular fossa using a 15 blade; dissected down to subcu tissue. Identified the pectoralis fascia, divided that & split the pectoralis major muscle to enter into the axillary sheath. Identified pectoralis minor, divided at tendinous portion. Identified axillary vein and artery;dissected free from surrounding attachments and isolated vessel. Made a counter incision, created loop configuration. Occluded axillary artery proximally & distally; longitudinal arteriotomy w/ 11 blade extended w/ Potts scissors; end of graft to side of artery anastomosis. Flushed antegr & retrograde; graft clamped. Focused attention toward the venous end. Longitudinal venotomy made; tailored graft to the approp size; end of graft to side of axillary vein anastomosis. Strong palpable thrill noted."

Percutaneous CT guided diagnostic and therapeutic coccyx injection

Question ID: 9960 revisited with CT guide. I wanted to see if you have any update to your answer from October 2017, which you had indicated at the time there is not a consensus of opinion on how to report this procedure. Our scenario indicate under imaging guidance the 20 gauge 3.5 inch spinal needle was advanced to the target. Kenalog was injected about the coccyx under CT guidance without complication. 

Endarterectomy: 35302 vs. 35355

According to Question ID 6907, the CFA, PFA, SFA, and iliac are one since there is one arteriotomy so it is reported with iliofemoral code 35355. We brought this example to our provider, but he disagrees and would like to report 35302 since in his words, “This was extended into a very long segment of SFA.” Could you tell us which code you would report for this service? Any rationale you can provide would be very helpful. Thank you. "An arteriotomy was made and extended with Potts scissors. Endarterectomy was performed including in the distal external iliac artery. The endarterectomy was extended all the way to the superficial femoral artery where the plaque was divided. I did place a 7-0 Prolene tacking sutures at the origin of the profunda as well as the distal intimal shelf on the superficial femoral artery. All loose debris was removed. Then, using a 1 x 14 CryoLife PhotoFix bovine pericardial patch, I sutured this into place with a 6-0 Prolene suture beginning at the superficial femoral artery."

can you bill 33340 with 93653 or 93656

I have an EP MD asking if during a scheduled Watchman procedure can he charge for left atrial appendage ablation?

Aborted EP Study

The intended procedure was an EP study with an ablation for atrial fibrillation. The physician had just completed the 3D map of the right atrium and then advanced the catheter into the coronary sinus. While making their placement for a transseptal shealth, the physician noted a significant amount of arterial bleeding. When the bleeding could not be controlled the decision was made to terminate the procedure and remove the right-sided sheaths. There is some debate as to whether we can report code 93619 with a -53 modifier, or if we need to report with an unlisted code, seeing that 93613 is an add-on code that needs a primary procedure.

Billing 36415 for ISTAT prior to MR or CT with contrast

Is it appropriate to bill 36415 for venipuncture when blood is drawn for an ISTAT creatinine test via the same access used for IV contrast administration prior to an MR or CT study with contrast?

Fiducial marker placement during hepatic embolization

Right hepatic artery was catheterized with the microcatheter. DSA and cone beam CT confirmed tumor hypervascularity in the lateral aspect of the right hepatic lobe. Transcatheter embolization was performed with PVA particles. The microcatheter was advanced more distally into the treated vessel and an additional two 1 cm hilal microcoils were deployed intravascularly to serve as fiducial markers for stereotactic beam radiation. Can we pick up fiducial marker placement code 49411 even though the markers were placed intravascularly and not percutaneously?

Pt in for Redo PVI and CTI Ablation

Is this 93656 or 93653? "The patient presented to the EP lab in atrial flutter (CL 300ms). An ICE catheter was inserted via the left femoral vein to image the transeptal puncture. A 10 pole catheter was advanced into the CS. The activation of the atrial flutter was linear along the CS catheter (earliest at CS 5,6). Next the Lasso and ablation catheters were used to generate an activation map of the clinical atrial tachycardia. This was consistent with a left atrial roof dependent atrial flutter. After mapping, the Lasso was positioned in the large common left PV ostium - when the tachycardia changed in activation and CL (280ms) -- activation distal to proximal along CS. Linear ablation from 10 o'clock on the mitral annulus to the septal aspect of the RSPV was performed with initial slowing then termination of the atrial flutter #2. Short bursts of tachycardia was seen (similar activation pattern to AFL #1 - roof dependent). When ablation just posterior to the LSPV (area of slow conduction), salvos of AFL terminated.All PVs were confirmed to be isolated."

Left internal mammary harvest not used

Left IMA was harvested for coronary bypass surgery; however, the artery was not suitable for grafting so he ended up just doing bypass x2 using only veins. Since this is included in 33533-33536, and I am now billing 33511, how can I bill for the harvest of the IMA?

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