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Tortuous Coronary Graft

What would be the proper diagnosis code for a tortuous coronary graft? Would I77.1 be considered? "RIMA graft to 2nd marginal. Graft is angiographically normal, but the vessel has significant tortuosity."

Occlusion Vs Thrombosis

I have a case where the physician is performing a thrombectomy (37184) with a Penumbra catheter as well as an atherectomy/balloon angioplasty (37229) in the right anterior tibial artery. Anterior tibial stenosis is documented as well as an "occlusion" in the same artery. Is it okay to capture the thrombectomy even though he is only naming it an occlusion?

CPT 93295, 93296 in skilled nursing facility

If a patient is in a skilled nursing facility, what codes get billed to the SNF vs. Medicare, 93295 and 93296?

congenital vs. non-congenital cath codes

It is my understanding that certain cardiac conditions, such as ASD and VSD, can technically be congenital or acquired. The ICD-10-CM classification assumes these conditions to be congenital (when not otherwise specified, of course). The CPT codebook does not include ASD and VSD in its list of diseases for which only the non-congenital cath codes may be assigned. When a patient with a known ASD or VSD undergoes a cardiac cath, and the physician has not indicated whether the disease is congenital or acquired, can we automatically code from the congenital family of cath CPTs? Do we need to query the physician? (All of our cath lab patients are adults.)

Ruptured arch IMH post Zone 3 TEVAR

LT carotid-subclavian bypass PTFE. Then to endovascular component of the case. US guidance and Perc fem access, 18 french to aorta. Direct puncture LT CCA w/cath to ascending aorta for diagnostic ascending, arch, and descending thoracic aortic. Advanced a cook alpha proximal into the proximal aortic arch. Through the left common carotid artery sheath we advanced a 8 mm x 79 mm Gore VBX stent and aligned this with leading edge of device. Incised over RT brachial artery, punctured & advanced 7 French into ascending aorta. From RT brachial advanced 8 mm x 79 mm Gore VBX at the proximal edge of the graft. From LT CCA 8 mm x 59 mm Gore VBX to extend given the location of the thoracic endograft. Dx ascending and arch angio showing gutter leak. Direct access to LT subclavian artery did angio define vertebral then deployed Amplatzer plug to Subclavian. Withdrew and closed, cut down on LT CFA for acute thrombus dx angio down extremity closed groin. Looking at 35606, 37242, 37236, 36200x3 and could use help on the rest. Welcome any advice. Thank you

50432, 50080

When a urologist places a nephrostomy tube (50432) prior to a percutaneous nephrostolithotomy (50080), can both codes be coded? If the tube is taken out at the end of the procedure, is it appropriate to append a -52 modifier?

AVM Surgical Field

Could you please define what a surgical field is considered in the case where you have multiple AVM's in the neck? LT paratracheal, RT supraclavicular & RT Submandibular were treated.

Temporary Uterine Artery Balloon Occlusion

Preop uterine myomectomy in OR, but had balloons placed in IR suite prior to procedure. Physician placed bilateral temporary uterine artery balloons. Balloons were removed after myomectomy. Is there a code for placement of temporary uterine artery balloon placement?

93571-52

Can you advise of the percentage reduction in physician work given an iFR /DFR is less time/less intensive than FFR? Also how it is documented correctly?

Is this coded 64400x 2 or 64400 x 3?

Is this injection coded with 64400 x 2 or 64400 x 3? Do we code per branch or nerve? "The supraorbital, supratrochlear, and auriculo-temporal nerve regions were identified by manual palpation. The overlying skin was prepped with an alcohol pad. At this point, after negative aspiration, a total 1.5 mL volume of treatment injectate, consisting of 0.75 mL of 1% lidocaine and 0.75 mL of 0.25% Bupivacaine, was injected easily at each area. Needles were withdrawn, and the patient was monitored for 15 minutes with no ill effects."

Is an "evolving STEMI considered acute?

Patient presented to ER with CP @ 21:19PM; first troponins were negative. Patient left AMI before second troponin results came back. ER staff called patient to return to the hospital. Patient returned next morning at 7:53 with CP, jaw pain, sweating. EKG showed ST elevation V3 and aVF, ST depression V2 and aVL. Patient taken to cath lab emergently. Would 92941 be appropriate in this scenario?

Intravascular lithotripsy performed on external iliac artery and SFA

The provider performed intravascular lithotripsy of left superficial femoral artery, left common femoral artery, and left external iliac artery. Do we code C9764 x 2?

33285 and 33286 via new channel and different plane

If the old implantable cardiac monitor is removed, and the insertion tool is used to form a new channel and insert the new monitor in a slightly different plane (but using the same incision), can codes 33285 and 33286 both be reported? I know previous guidance states if performed via same incision then we only report insertion, but I want to confirm about the "new channel" and "different plane".

LVAD driveline debridement & omental wrap

Is there a cpt code for LVAD driveline debridement and reconstruction of the driveline exit site and wound? An omental wrap was performed. CPT code 49904 may not be the appropriate code to bill.

PM Lead Removal with PVI RFA & LAA Exclusion

"PROCEDURE: Infected cardiac pacemaker lead removal, pulmonary vein isolation, left atrial appendage exclusion. FINDINGS: Two leads fully removed via right atriotomy and opening of the innominate vein + SVC junction. Dr. T of Electrophysiology inspected all parts of the extracted leads. The innominate/SVC was then repaired, and right atrium was closed with suture. (CPT 33243???) // Bilateral pulmonary vein isolation with RFA AtriCure. Left atrial appendage excised and closed. Next, bilateral pulmonary vein isolation with RFA AtriCure was performed with three burns on each side until evidence of transmural lesions. The left atrial appendage was then clamped, resected, and oversewn with 4-0 prolene suture. A small residual appendage remained, however, was felt to be too close to the circumflex artery for further resection." Can PVI RFA and LAA reconstruction can be coded separately? Because EP was there, would this be 93656, or would 33256 be appropriate due to sternotomy? (The add-on codes are not applicable to 33243.) Or, is this bundled into 33243?

CPT 61645

Is 61645 used for both mechanical and aspiration thrombectomy? If not what code do we use for aspiration thrombectomy, unlisted?

Subsequent Thrombolysis 37213

On the second day of thrombolysis, the patient is transferred to the suite for a relook angiogram--CPT 37213. Six hours later on the same date of service, the patient is returned to the suite for another relook, without intervention performed. Is CPT 37213 allowed to be billed again?

TAVR Echo Billing

For MD billing only, if a patient has a transthoracic echo performed on the day of a tavr procedure usually hours before and after their procedure, is this a billable service to report? Patients have one during their "tavr work-up" months before the procedure. But when they come in for tavr procedure, they repeat and do a limited transthoracic echo. The dx of the echo prior to and after tavr procedure is either aortic stenosis or checking placement. The MD interpreting the echo report often times is the same MD who performs tavr procedure. Please advise.

non/delayed healing wound

The patient has peripheral artery stenosis with non-healing wound. May the non-healing wound be coded (ICD-10-CM) as an ulcer?

Takedown of infected axillary-fem-fem bypass; axillary only

"A patient has an infected left axillary-fem-fem bypass. The surgeon creates a right axillary PTFE graft and attaches it to the existing fem-fem bypass, thereby creating a new axillary-fem-fem bypass. Surgeon then proceeds to take down the left axillary bypass, which is infected. But, only the axillary graft is removed." Surgeon wants to report 35654 for new PTFE axil-fem-fem and 35907 for removal of axillary graft. Is this appropriate since the fem-fem portion was not removed, only a new anastomosis from the axillary to the right femoral graft was added?

Hemodynamic Stress Echo

Is there a specific CPT code or add-on code that should be used when a "hemodynamic" stress echo has been performed? This test is more involved than a conventional stress echo.

Trauma Patient Vessel Repair

"Trauma patient had injury to an upper extremity. Axillary artery was repaired with harvested GSV interposition. Cephalic vein in same extremity was injured and bleeding, so vein was sutured."  I came up with 35236 for repair of axillary artery with vein graft and 35206 for suture repair of cephalic vein. There is an edit against 35236 when coded with 35206, so I am looking at 35236-XS (59), 35206-51 (billing pro-fee and 35236 has higher wRVU). Can I not code for both even though two separate vessels repaired in two different ways?

Follow-up Ultrasound (76970 - deletion)

For venous ablation procedures, the plan of care often includes a duplex ultrasound to diagnose (93970/1) the venous insufficiency, then the procedure (e.g., 36475), and then a follow-up ultrasound at a later date. With the deletion of 76970, what would the recommended code be for this follow-up? It was my understanding that the duplex ultrasound codes are used for diagnosing the condition.

Aorto-pulmonary Collateral Imaging without Heart Cath

How would you handle selection and imaging of aorto-pulmonary collaterals when no heart cath or intervention performed?

Hello~ would this be an unlisted code?

"Cryoablation of recurrent painful left lower rectus intramuscular endometrioma. 2) Post ablation contrast-enhanced CT scan demonstrated adequate coverage of the ablation zone." Would this be reported with an unlisted code?

central or peripheral circuit?

Focal area of stenosis in patient's fistula in the chest at the junction of the cephalic vein and subclavian vein responding to 8 mm balloon dilatation. Is this the central or peripheral circuit?

CT GUIDED L5-S1 ANESTHETIC DISC INJECTION

What CPT code we use for the following procedure,

PROCEDURE:

 1. CT guided anesthetic injection of L5-S1 disc space

The planned entry site at the L5-S1 level was selected based on the presence of bone marrow edema adjacent L5-S1 disc space.

The location was marked on the skin surface confirmed in the left posterior lumbosacral region.

A skin entry site was anesthetized with 1% lidocaine. A 22-gauge 3.5-inch spinal needle was advanced into the collapsed L5-S1 level using a CT guiding scan with 22 degrees of cephalad to caudad angulation,

Due to the collapsed nature of the disc entry only into the posterior lateral one-third of the disc space is possible.1.8 cc of 0.5% bupivacaine were slowly injected into the disc space at the needle withdrawn

Findings,

CT planning images of the lumbar spine demonstrate the severe collapse of the L5-S1 disc space with the vacuum phenomenon.

Intermittent CT guiding scans confirmed appropriate placement of a 22-gauge, 3.5-inch spinal needle in the region of the targeted L5-S1 disc space.

Indiana Pouch

How would you code a retrograde Indiana pouch drain exchange? I only find information for ileal conduit, which is not the same.

AVF, lligation followed by AVG same session

"Patient had a left brachiocephalic AVF created. After completion there were multiple leaks at the suture line. The anastomosis had to be taken down, and attempts to redo the suture line led to disintegration of the vein making it unusable. The cephalic vein was ligated with silk tie. Then a left brachial-axillary AVG was created." Can both the AVF and AVG be coded? How about the ligation?

Access of an EVD with aspiration and injection

Would I use 61070 or 61026 for the following? "Proximal EVD port accessed and cleaned with betadine. 3 cc of serosanguinous CSF fluid aspirated gently from EVD at proximal site. 4 mg of Cardene administered intrathecally slowly over one minute without any complications or fluctuations in hemodynamics and 2 cc of sterile NS flushed slowly behind. ICP post-administration was 13 with an adequate waveform and EVD clamped successfully for 30 minutes without complications."

Fasciotomy Closure

Doctor performs a four compartment fasciotomy through two incisions and is left open. A few days later the incisions are closed. We are billing 13160 for the closure. However, since there are two incisions, would you bill with two units? Or since it was one surgery would you bill as one unit? What if the surgery extends multiple body areas such as an ax-fem-fem? Would you bill one unit as it was one surgery or multiple units as it was multiple body areas?

Can I code endarterectomy with a bypass?

Is it allowable to code a right common femoral endarterectomy, right common femoral to left common femoral bypass, and a right external iliac angioplasty? If so what are the codes?

Billing for the drugs used during a surgical procedure?

When the place of service is an office (POS 11), can all drugs that are injected or administered by IV be coded in addition to the surgery? I am clear drug administration service codes can't be coded in addition to the surgery, but can at least the HCPCS for drug get coded such as the drugs used for pain and prophylactic antibiotic use? Example: Could Dilaudid and Ancef be additionally coded with a tunneled dialysis catheter replacement?

Can we report CPT 25020 with 29848 in this scenario?

The endoscope was then introduced. The transverse carpal ligament was released from distal to proximal making sure it was completely released about the entire course of the transverse carpal ligament.  I was careful to use a probe and a rasp to delineate the distal edge of the transverse carpal ligament and to clear any of the underlying synovial tissues and also to protect the arch and potentially the motor branch of the median nerve.  Care was taken to ensure complete division of the transverse carpal ligament by probing the defect.  I also followed the  release from distal to proximal, making sure the release was complete throughout the entire course.  At this point, the median nerve was identified at the wrist flexion crease and there was compression on the nerve secondary to a thickened forearm fascia.  At this point, the distal end of the forearm fascia was carefully released using tenotomy scissors being careful to avoid injury to the palmar cutaneous branch of the median nerve. The median nerve appeared completely decompressed.

Coding of Operative report

I have a limited vascular background and started working denials. I was wondering if I could submit a op report to have coded to confirm what was coded is correct as my one question? From the reading I have done I do not agree with what was coded but need confirmation. I also need a superior source like yourself that the coder and provider would be less likely to argue the recommendation. Thanks!

hypothermic arrest 33866

Is hypothermic arrest another technique to achieve total circ arrest and/or cerebral perfusion? The report states: "Hypothermic circulatory arrest, blood flow was discontinued and hypothermic arrest instituted. The cross-clamp was removed." Does this meet the requirement of either total circulatory arrest OR isolated cerebral perfusion? Would 33866 be billable by this documentation?

multiple abscess drains

If more than one abscess drain is placed within a large, loculated abscess, can you code 49406 and 49406-XS, or can you just code for one abscess drainage?

Retrograde urethrogram, urethroplasty and exchange of a Foley catheter

How would you code this procedure: Utilizing the dislodged transurethral drainage catheter, a retrograde urethrogram was performed. This identified a stricture within the prostatic portion of the urethra. A guidewire was directed across the stricture allowing for re-entry into the urinary bladder. A 6mm balloon was used to perform a urethroplasty to facilitate placement of 14-french Foley catheter. Following urethroplasty, the Foley catheter was advanced over the guidewire into the urinary bladder. A cystogram was then performed. The Foley catheter retention balloon was then inflated with contrast. Urine was flowing freely from the bladder.

Findings: The indwelling transurethral urinary bladder drainage catheter has retracted into the penile urethra and is no longer within the bladder. The bladder is markedly distended as noted on fluoroscopy. The Retrograde Urethrogram showed a urethral stricture at the junction of the penile urethra and prostatic urethra and prostatic urethra. Urethroplasty was performed and the Foley catheter was placed.

Figure of Eight Suture on AVF

Patient comes to ED after dialysis due to bleeding after completed dialysis. TXA was tried by ER physician along with 30 min of pressure. patient still had arterial bleeding from dialysis access site. Second attempt of TXA and Surgicel and more pressure dressing was tried and still unsuccessful in getting bleeding to stop. At this point a "figure -of-eight" stitch with a noncutting needle was preformed by the ER doctor until IR could get patient in. The next day IR got the patient into the IR lab and found stenosis in innominate vein and the venous AVF anastomosis and both were angioplasited (36902 36907). I am wondering how you code the "figure of eight" stitch done by the ER doctor? My supervisor feels since it was a bleeding artery it is ok to use 35206. I am leading to 12001. What are your thoughts on this? Thank you

RHC with Biopsy

Routine surveillance endomycardial biopsy and right heart catheterization for diuretic management. Would you code the right heart cath with the biopsy?

36221 documentation requirements

I am trying to nail down the documentation requirements for 36221, so any specific advice would be greatly appreciated. I am assuming that mention of the origins of the great vessels is adequate, according to the code book. But, what about indications? Does the intention to perform the arch study need to be on the order? In one recent problematic example, all concern was for injury to vessels of the arm in patient with ischemic symptoms. No CTA, but prior US shows occlusion of the brachial artery. There is no order for an arch study, or mention of a problem with the innominate, vertebral, or carotid arteries. Dr selects the RT axillary artery and performs angiography. Under ‘Procedures Performed’ he notes “arch aortogram.” Under findings he wrote “Type 1 arch with no significant stenoses.” To me, this documentation seems weak, and more like a guiding shot than anything... particularly since there was no separate indication for the arch study. What do you think? Is 36221 justified?

36221 w/ upper extremity- how would you code the following?

Hi! I know you've answered on this before, but there's still a lot of back and forth between cath lab and coding staff for when 36221 is appropriate w/ an upper extremity. Do you need documented clinical necessity separate from the upper extremity concerns to justify 36221? How specific do the findings need to be? If a physician states, "Type 1 arch. No significant stenoses." Is that enough? Pt with a significant PMHx for HTN, CKD3, polysubstance abuse and DM2 presenting w/ R hand coolness, pain, weakness and numbness x 3 mos since several surgeries relating to arm abscess. Suspect RUE symptoms are multifactorial. Art US does suggest poss brachial artery injury w/ reconstituted flow downstream. Pt has decent doppler signals in the arm, but very asymmetric from the easily palpable LUE pulses. Procedure: A 5 Fr pigtail catheter was advanced to the ascending aorta and an arch aortogram was performed. RUE angiography was performed w/ selective catheter in the axillary. Findings: Arch: Type I arch w/ no significant stenoses RUE findings documented as well.

93463 Documentation Requirements

What type/degree of exercise is required to support code 93464, and what are the documentation requirements for this code? It appears that 93464 and 93463 are achieving the same results; should these be reported together? If so, what is the clinical significance in the outcome/result between the two?

Inpatient only procedures for Physician reimbursement

Are there any IR procedures where the patient must be in an inpatient status for physician reimbursement?

India ink injection post biopsy

FNA of a suspicious lymph node in the axilla. Total of 3, 20 gauge aspirate samples were taken. 2cc of India ink were injected into the lymph node. Is the India ink coded with an unlisted (38999) or considered inclusive?

RT & LT HEART CATH WITH SELECTIVE ANGIORAM WITH COIL EMBOLIZATION

I am a new pediatric cardiology coder. What CPT codes are used to code the following? "Right and left heart cath with selective angiogram with interventions: coil embolization of aortopulmonary collateral arising superiorly from the right subclavian artery."

On the fence as how this should be coded

Would the unlisted code be appropriate, or would modifier -22 be added to primary code 33405? "Debridement of aortic root abscess with pericardium patch provider also performed replacement of aortic valve 33405 or would the debridement be included in valve replacement code

93621 and 93622

We have EP doctors that would like to charge for 93621/2 with allowed ablation procedures. However, I do not feel like the documentation is appropriate enough to bill either 93621 nor 93622. Plz note below:

"All vascular access sites were prepped and draped in the usual sterile fashion and the Seldinger technique was used to catheterize right and left femoral vein with multipolar electrode catheters, which were placed in the appropriate intracardiac sites under fluoroscopic guidance. During the procedure right atrial pacing and sensing, His bundle sensing, RV pacing and sensing, and left atrial sensing and pacing, left ventricular sensing and pacing were performed."

I feel like this is not descriptive enough. Should the doctor(s) say where the catheters were placed and then what was performed from each location? For example: "A decapolar cath was inserted into the CS and left atrial (and or ventricular) pacing and recording performed." Please advise. 

Aortic coarctation gradient interrogation

When interrogation of the gradient in the coarctation of the aorta is performed (gradients measured and recorded), can we use code 93571-26-52 for professional coding, as we do for RFR? Documentation: "Next we proceeded with interrogation of the gradient in the coarctation of the aorta. We exchanged for a JR4 guide catheter and advanced the catheter over a Versacore into the descending aorta. Next, a BMW coronary guide wire followed by a ACIST NAVVUS microcatheter was equalized in the aorta. The JR4 guide catheter was pulled back into the ascending aorta-right subclavian artery juncture. Simultaneous gradients were measured and recorded. Finally, the microcatheter was then pulled back to the ascending aorta to confirm absence of drift."

0439T for professional claim

Should 0439T be submitted on professional claim since it has PC/TC indicator 0 associated with it?

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