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Accidental access with imaging

Our MD accessed the femoral vein instead of the femoral artery by accident. While he was in the vein he shot images and charged for it. Since this was not part of his original intent, would we allow those charges?

IVUS

IVUS was done for a patient in the fem/pop, AT, and pedal loop. Would coding 37252, 37253 x 2 be correct? If not, what are the guidelines for coding IVUS below the ankle?

Intervention below the ankle

Patient had atherectomy in AT, angioplasty in dorsalis pedis, arch and lateral plantar. In this situation, would we code an additional 37232 for the angioplasty below the ankle along with the 37229 for the AT?

SMA stent placement through laparotomy

"1) Exploratory laparotomy. 2) Retrograde superior mesenteric artery recanalization, angioplasty, and stenting with 6 mm x 29 mm VBX stent graft. Yesterday, I performed a brachial artery attempt at mesenteric recanalization in an antegrade fashion, which was unsuccessful due to the dense calcification and occlusion of the origins of the vessels. Brought back for laparotomy and retrograde approach today. A longitudinal midline incision was made through skin and subcutaneous tissues. SMA was accessed retrograde with a micropuncture wire and needle, followed by a 4 French microcatheter. We were able to traverse the area of occlusion into the abdominal aorta. A 5 French sheath was then placed over the Glidewire into the SMA. We then were able to bring a 7 French sheath across the occlusion, then brought a 6 mm x 29 mm VBX stent graft and delivered it through the stent and pulled the stent back into the residual SMA."  Do I report code 37236 with modifier -22 or report an unlisted code?

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?

Pressure Wire 93571

If the documentation only documents the intravascular Doppler velocity pressure derived coronary flow reserve measurement for coronary vessel, do you bill 93454 with it?

Balloon compression of trigeminal nerve

In your Question ID 3027, you suggest to use 64999 for a trigeminal balloon compression w/o neurolytic agent. My question is , what do I cmpared to. Maybe the series 64600-610 wityh modifier 52? Please advise

Why did Medicare deny CPT code 37252, Intravascular Ultrasound (IVUS)?

Cerebral angiogram was performed on patient with high grade stenosis of right ICA. The right internal carotid, left vertebral, and left common carotid arteries were all selected and catherized we billed 36224-RT, 36226-LT and 36223-LT. During the catherization of the right internal carotid artery a microwire was loaded into the guide catheter and the IVUS catheter was navigated into the petrous segment of the right ICA and it was insonated. We coded 37252 for this procedure. Medicare denied CPT 37252 for the following reasons: Remark Code: M20 Description: Missing/incomplete/invalid HCPCS. Remark Code: N56 Description: Procedure code billed is not correct/valid for the services billed or the date of service billed. Is there an issue with billing 37252 with 36223-6? Is IVUS considered a separately billable, valid procedure acc. to Medicare? Would appreciate an explanation for why this code was denied? Thank you.

DOS for Device Checks

The clinic we do billing for hired a device company that monitors PPM and ICD devices. We are having concerns because the physician signs the notes late and we are trying to be compliant. The device company is telling us that even though the physician signs the notes late we are still able to bill it on the date the service was completed. For example, CPT codes 93297, G2066, and 93295 were all completed on 10/01/2020 and the doctor then reviews the notes and signs them on 10/12/2020. From my understanding the date the physician reviews the note and signs would be the DOS that we would bill on, can you clarify this? Also, they want us to bill the remote technical G2066/93299. Per, biometric telemonitoring state that "remote device evaluations" (93926 and 93299) require "general supervision" by a physician. Since it's a device company we are not supervising. Therefore, I am not sure whether we could bill the technical. Can you provide any guidance on this matter?

Fiducial Marker Placement

How would I code a guided fiducial marker of the hepatic lesion? "Using aseptic technique, a 17 gauge fiducial deployment needle was advanced into the lesion under CT guidance. A total of two markers were placed in the lesion margins (superior and inferior)."

Diagnostic Right Gonadal Venography

When a catheter is placed in the right gonadal vein that is directly off the IVC and diagnostic venography is done, what is the CPT code for the venography? Is 75831 permitted?

Wound Debridement and Bone Biopsy

I always question myself about what CPT codes to use for the procedure below. Thank you for your help!   The wound was located on the posterior aspect of the heel as well as a second one on the lateral aspect. The one on the posterior aspect was sharply debrided using a 15 blade. There was necrotic subcutaneous fat that was completely excised. This seems to extend to the calcaneal bone. Biopsy of the calcaneal bone was performed using a rongeur. Culture of the necrotic fluid was also obtained. On the lateral aspect of the heel there was a second wound that had purulent drainage. Sharp excision of the overlying skin was performed with a 15 blade and the wound was obtained. Copious irrigation of both wounds was now performed. There are both Bactroban to form packing and dressing was applied. Of Note: TISSUE SUBMITTED:     BONE, LEFT FOOT GROSS DESCRIPTION: Received in formalin labeled "left foot bone" are two tan to focally hemorrhagic, irregular, roughened portions of bone measuring 0.3 x 0.3 x 0.1 cm and 0.5 x 0.4 x 0.2 cm.

Coding for unspecified acute on chronic anemia

We have physicians who indicate a patient has acute on chronic anemia (without a specification of anemia due to chronic disease/CKD/etc.). There's some debate on how to actually code it, though the consensus seems to be D64.89 for the other specified anemia. Can you verify D64.89 as a valid option, or would some other code be more appropriate?

Holter less than 24 hrs

We have had some issues with our Holter monitors that stop recording before 24 hours. Sometimes we only receive 4 hours of recording. Should we append a -52 modifier to 93226? This is for hospital outpatient dept.

Would this support 35371 and 35372? I think 35355

Would this support 35371 and 35372? I think 35355. "We performed a linear incision overlying the common femoral artery and dissected down onto the artery without difficulty. As expected, the external iliac, common femoral, and superficial femoral were densely calcified. We then proceeded to expose the deep femoral and dissected it down to the third collateral branch. In the process, we had to ligate the deep femoral vein to give additional distal exposure. We reached a soft spot on the deep femoral. All the side branches were looped. We prepared for clamp application on the external iliac and at this point we administered heparin, dose 100 units per kilogram. Clamps were applied. We made an arteriotomy beginning at the distal deep femoral and then running the arteriotomy onto the common femoral. We also extended the arteriotomy onto the superficial femoral. We performed aggressive endarterectomy of the distal external iliac, common femoral, and deep femoral."

Pacemaker Interrogation Documentation

The day following a dual chamber pacemaker implant, my provider drops a charge for the interrogation of the pacemaker, but the only documentation he provides is the following in his progress note:
Interrogation: P- 4.8 Imp- 513 A- 0.25 @ 0.4 R- 9.9 Imp- 627 V- 0.5 @ 0.4". Is this enough documentation to bill for an interrogation? My feeling is that it is not proper documentation to warrant a charge for the interrogation.

Coding 36410 for US IV starts

Our facility is considering coding 36410 when one of our nurses goes to do an US-guided IV for diagnostic (CT, MRI) procedures, or for cancer patients receiving therapy and a regular IV cannot be started. This is the same code we charge for midlines done by our IV nurses that are used for medicines being administered. Is this an allowable code for this? The CPT Codebook says by physician or other qualified healthcare professional. A similar question has been asked before but over a year ago. What is the newest recommendation?

Superficial Cervical Plexus Block

How would you code this? "Procedure done under US guidance. Posterior border of sternocleidomastoid muscle identified. Scalene muscle identified. Injection posterior to the sternocleidomastoid muscle identified. No paresthesia was noted. No blood was aspired. Good local spread. Trigeminal neuralgia is being treated."

Replacement of a midline

What do you use if the doctor replaces a midline? "INTERVENTION: The collateral venous network was unable to be successfully negotiated with a wire, and the decision was made to replace the patient's midline catheter. The catheter was cut to an appropriate length of 11 cm and advanced through the peel-away sheath into the vein. The tip was fluoroscopically positioned in the left axillary vein. The catheter was able to be aspirated and flushed easily. It was secured to the skin with a StatLock. IMPRESSION: Left upper extremity venogram demonstrating stenosis at the level of the upper arm with multiple venous collaterals. Technically successful exchange of left upper extremity midline over a wire under fluoroscopic guidance."

LVAD left open subsequent day closed trying to bill subsequent E/Ms

We have a dilemma. My doc inserted an LVAD 33979-52 left open "0" global days. Closed chest 21750 on a subsequent day with 90-day global. Now this bundles any E/M services they performed subsequently. We were wondering if appending a -58 to the 21750 would make a difference. Any directive is appreciated.

AAA repair with graft

"Diagnosis: AAA with bilateral large renal accessory arteries emanating from the aneurysm and include extensive iliac occlusive disease, as well as ectasia of bilateral common iliac arteries. PROCEDURE: Aorto-bi-femoral bypass with 16 x 8 Dacron Hemashield graft and bilateral reimplantation of accessory renal arteries to the body of the Dacron graft." AAA that involves both visceral and iliac vessels? Do I report 35091 with 35697 X2 or 35102 with 35697 X2?

Is nerve blocking ever reported by the provider?

It is my understanding that the provider should not bill for the nerve block performed immediately prior to the Ellipsys procedure. Is the nerve blocking ever reportable by the provider? I have a case in which the provider describes successful right brachial plexus nerve block immediately prior to the basilica vein banding procedure he performs. Reportable? Or bundled?

Fibrin glue clot patch

Code 62273 states injection of blood or clot patch. Would you consider fibrin glue to be a "clot" patch?

Left Radial Approach to Left Subclavian

When using a left radial approach to place a catheter in the left subclavian, would that be 36215 or 36216?

Precise Stent Placement

Would codes 37238, 36012, and 75820 be appropriate for the following? "The left internal jugular vein was catheterized. We used a Synchro 2 microwire, which we advanced past the stenosis in the superior sagittal sinus. The 3 Max catheter was tracked along this to the superior sagittal sinus. The wire was removed, and the system was flushed. Contrast injection was performed utilizing DSA in multiple views, which re-demonstrated the stenosis at the transverse sigmoid junction. it was decided to advance the 8 x 30 mm Precise stent over the wire, which passed easily. Once in place the stent was positioned in the optimal location based on the roadmap images and deployed under fluoroscopic visualization."

Corpak feeding tube placement

Please advise on correct coding for this procedure. Examination: FL enteroclysis tube perc. Clinical History: Image-guided postpyoloric corpak placement. Intra-Procedure Meds: Contrast agent omnipaque 300 50 ml bottle 50 milliliter. NASOGASTRIC Using fluoroscopic guidance a 10 French Corpak feeding tube was placed without difficulty. Result: Position was confirmed with a small injection of barium; the tip is in the third portion of the duodenum. The tube was then flushed with a small volume of water. Impression: Uneventful placement of Corpak feeding tube." Should this be coded with 43752 or 49440 or 74355?

HIS LEAD PLACEMENT WITH PACEMAKER UPGRADE

"The pacemaker was explanted. Atrial and ventricular leads assessed. New subcutaneous pocket created. His mapping, recording, and pacing performed under fluoro. Three positions attempted. Final new lead position - His. Device connected to all three leads." His lead not stated for LV pacing. Diagnoses are chronic diastolic heart failure, new nonischemic cardiomyopathy from RV pacing, chronic atrial fib, complete heart block. LVEF is 40-44%. Would you consider 33225 for placement of His lead with 33229 as primary code? Position for His lead is HBP per registration.

Cpt 35102-50, 34201-RT, not 35647, 35637 for AAA, Iliac arteries aneurysms?

Infrarenal aorta incision aneurysm neck was cleared and clamped. 16 x 8 Hemishield graft sewn in an end to end fashion to the Aorta.Graft was tappered aortobi-iliac bypass anastomoses made to LEIA and the RCIA in an end-to-end fashion anastomoses.RIIA ligated. RT side no iliac or femoral pulses we took down the anastomosis,REIA had plaque flap, did Endarterectomy, redid the anastomosis still very weak pulse.Decided to do an aortofemoral bypass. Longitudinal arteriotomy in RCFA, end to side anastomosis between the dacron graft and the CFA. Once hemostasis had been obtained, the AAA sac was closed using a running 3-0 Vicryl suture over the graft, fascia was approximated, the skin was closed. RT groin incision closed in layers.RT no pedal pulses. Re-opened RT groin,took down anastomosis,large clot burden in graft limb, Femoral a.,fogarty thrombectomy of the dacron graft, RSFA and RPFA a with large clot burden retrieved. RLE angio large clot burden in the SFA and Popliteal a.,repeated thrombectomy till no more clot was removed x2 passes.Excellent flow.

76932

May code 76932 be billed for use of "fluoroscopic guidance" of an endomyocardial biopsy? Or do you recommend another CPT code to capture the service? This is the documentation in the report: "Right ventricular endomyocardial biopsy was then carried out using a 7 French St. Jude bioptome under fluoroscopic guidance. A total of four biopsies were sent for analysis."

PROCEDURE MED DOCUMENTATION

Not sure if you can answer this. We regularly used contrast, heparin NS, 2% lido and lido w epi during our IR procedures. Our techs document these items. It came to my attention that they were documenting these after they left the procedure room, which wouldn't be a problem, except they were using the present time and not the time while in the procedure room. I did some research and in my mind if it's procedure med it should be documented as being used before the procedure is finished. Sometimes the patient is in the room from 800 to 845 and I will see the med documentation is 840 but the procedure ended at 830. Is this ok? The patient is still in the procedure room but the actual procedure ended earlier. So basically, should meds be documented between start and finish of procedure or it is ok as long as the patient is still in the procedure room? Thanks.

Aspiration of Thrombus from Graft

What CPT code is used for the aspiration of thrombus along 36902/76937? "The 70% stenosis at the edge of the stent, as well as the intrastent stenosis, were maximally dilated using an 8 mm x 8 cm Gladiator angioplasty balloon. Prolonged balloon inflation was performed. Repeat angiography demonstrates wide patency at the treatment site with minimal recoiling. A non-pulsatile thrill was palpated within the graft at this time. In order to allow easier access to the venous graft limb, it was decided to aspirate thrombus from the thrombosed pseudoaneurysm of venous graft limb. After administering local anesthesia to the overlying skin using 1% Xylocaine solution, an 18-gauge needle was advance into the pseudoaneurysm. Approximately 15 mL of liquified thrombus was aspirated. Hemostasis was achieved using manual compression. The sheath was then removed and hemostasis was achieved using manual compression. Liquified thrombus was aspirated from thrombosed venous limb pseudoaneurysm in order to make it easier to access stents within the venous limb during hemodialysis."

Double Lumen PICC

The provider placed a double lumen PICC in the right basilic vein. Would 36573 only be charged once regardless of how many lumens were inserted at the same site? "Using ultrasound guidance for vascular access, the RIGHT basilic vein was accessed, and a 0.018 inch wire placed through the needle under fluoroscopy. The needle was removed and exchanged for a peel-away sheath-dilator. The 0.018 inch wire was placed into the atrial-superior vena caval junction under fluoroscopy and the catheter cut to measure. The 5 French PICC line catheter was placed with the tip in the atrial-superior vena caval junction under fluoroscopy. Spot radiograph was obtained for documentation. The peel-away sheath was removed. Both lumens aspirated blood easily and then were flushed and locked with heparinized saline."

AngioVac Procedure

What would be a good comparison CPT to build an unlisted code to bill using unlisted 33999? See procedure list below PROCEDURES: 1. AngioVac procedure with suction evacuation of large volume of right atrial and right tricuspid valve vegetations. 2. Insertion of 26-French sheath into superior vena cava using C-arm guidance. 3. Insertion of 18-French sheath into inferior vena cava using radiographic guidance. 4. Utilization of ECMO without oxygenator. 5. Radiology S and I for catheter insertion.

35881

My physician does the following on a previous common femoral to peroneal bypass using saphenous vein. Due to the vein graft stenosis a previous covered stent was placed in the distal portion of the bypass graft. The patient presented with exposure of the covered stent. My physician performed the following procedures: Revised the proximal saphenous vein anastomosis with interposition of a cryosaphenous vein graft at the anastomosis to upper thigh saphenous graft due to intimal hyperplasia of the proximal several inches of the saphenous vein graft. Revised the distal saphenous vein anastomosis with removal of the penetrating stent and interposition of cryosaphenous vein graft at the anastomosis up to the distal thigh saphenous vein graft with removal via catheter of thrombus from the peroneal down to the level of the ankle. I considered codes 35881 or 35876. Would I code it twice? Would I code removal of the stent separately and if so what code would I use? Since the thrombus removal was down to the ankle, would I code separately for that?

MRI Whole Body

Is code 76498 still the correct code for a whole-body MR?

Open PD Cath Removal Non-Tunneled

While I am aware there is no CPT code for the removal of a non-tunneled intraperitoneal catheter, usually what we see for this is that they just kind of pull it out. For this procedure, the physician actually cut out the catheter. Is there anything we can pick up for this? "An incision was made along the previous insertion site of the catheter, just on the right lower abdomen. Local anesthetic was injected along this incision as well as along the tract of the catheter exit site. We made an incision with a #15 blade and dissected down with Bovie electrocautery down to the level of the peritoneal dialysis catheter. We placed proximal and distal clamps and transected the catheter. We used this clamp on the catheter to allow for traction. We were able to pull the catheter up. The fascial cuff was identified, and this was circumferentially dissected and the catheter was removed intact from the abdomen. The fascial area was then irrigated well and was closed. With gentle traction, we pulled and did blunt dissection, and we were able to remove the second cuff."

CPT code 37241

When coding for a right face lymphatic malformation, how would the following be coded: 1st site: direct puncture from a posterolateral approach into a right preauricular macrocyst was accessed, 2nd site: direct puncture from a anteromedial approach into a separate and discreet anomalous macrocyst of the right cheek?

Imaging included in 77001

Does CPT code 77001-26 include imaging for the SVC if done from the same access? "Wire could not be advanced into the IVC, therefore contrast was injected through 4 French catheter, and superior venacavogram was done." This was done during a placement of a tunneled perm cath placement from the catheter access. My doctors insist the IVC or SVC should be separately reported. Please deny or confirm so I can get back to them.

Nerve block injection following procedure

"A bilateral uterine artery embolization is performed for uterine fibroids. After the procedure is concluded, but prior to the patient leaving the OR, a superior hypogastric nerve block was performed after the embolization was completed. A 22 gauge 20 cm Chiba needle was advanced under fluoscopic guidance, and a solution of 20 mL of 0.5% bupivacaine and 40 mg of triamcinolone was injected." Is the nerve block injection billable since it was not performed prior to the intervention?

Dual ppm downgrade to single ppm

Physician removed dual chamber pacemaker device and capped of the the atrial lead and replaced with a single pacemaker device. We are tossed up on the codes 33227 or 33233 and 33212.

Drug-coated balloon for dialysis

Will there be a CPT code down the road for drug-coated balloon for dialysis?

Double crash stent technique

My physician carried out stenting of LM, LD, and LC. Stent in LC was crushed with stent from LM into LD. It was followed by multiple kissing balloon angioplasties. Can I code three separate stents 92928-LM, 92928-LD, and 92928-LC?

Stenting post EVAR

Patient has previously had aorto-bi-iliac EVAR and TEVAR. Comes in for TEVAR extension. Extension of TEVAR performed that ends up going down to the top of the previously placed aorto-bi-iliac endograft. Physician placed a stent in the previously placed aorto-bi-iliac limb of the endograft to treat the perviously placed but now free-floating undersized stent: "To best treat this, so as not to embolize this free-floating undersized stent, a Gore Viabahn VBX 11 mm x 59 mm balloon-expandable stent was positioned at the proximal iliac endograft adjacent to the undersized stent. This was then fully expanded and deployed in essence leading that prior undersized stent as endotrash." Do we code for the stent placement in the iliac?

Modifier 26 for hospital-based procedures

We are an IR group contracted by the hospital and perform procedures in the hospital setting. If a physician does not append a CPT code that is eligible for a modifier -26, will this code get denied by insurance? For example, if a paracentesis is planned, but limited ultrasound shows no fluid and images were permanently stored, would we get reimbursed for code 76705, or would it need to be 76705-26? Is there a list of procedures that require modifier -26 for reimbursement?

Repair of ruptured left popliteal artery and tibial peroneal trunk mycotic

aneurysm with vein interposition reverse saphenous vein graft to anterior tibial artery and distal tibial peroneal trunk and Debridement of infected hematoma and surrounding soft tissue.Incision was made in the medial calf pseudoaneurysm or aneurysm cavity was entered and a large hematoma was encountered.Dissection was then carried out to identify the popliteal artery tibial peroneal trunk anterior tibial artery origins. Hematoma was removed and the obviously infected or inflammatory tissue removed as much as possible. Further inspection revealed that the pseudoaneurysm involves the posterior wall of the tibioperoneal trunk as well as the distal popliteal artery at the origin of the anterior tibial artery and tibial peroneal trunk. This areas was resected as a vein graft was harvested from the right groin.Patient was systemically heparinized prior to arterial clamping. The anterior tibial artery was debrided to a point where a adequate sewing ring for anastomosis was created. The saphenous vein was gently dilated and then reversed.

33228 and 93286

Can you bill codes 33228 and 93286 together? If so, what would be the appropriate modifier?

Exchange of an NG Tube

Could I get your advice on how to code an exchange of a Corpak tube? This is how the report reads: "The existing tube is removed completely, and the right nare is anesthetized. A new Corpak tube is then advanced through the nose into the stomach, then manipulated out of the stomach and into the jejunum. Position verified with injection of contrast. Successful fluoroscopically-guided placement of a new Corpak after unsuccessful attempts at declogging the existing tube."

CT guided steroid injection of right ischium nonunion fracture

"Under CT guidance, a 22 gauge needle was advanced into the right ischium and right pubic bone nonunion fracture. Then 40 mg of depo-medrol and 5 mm of 0.5% bupivacaine was administered at each site." Are the correct codes 77012 and 2099 for this since the injection is of a nonunion fracture?

pre-op vein mapping (ERFA)

I am hoping for your feedback regarding pre-operative vein mapping for ERFA. Patients presents to general surgeon for initial visit with subsequent diagnostic Duplex performed by vascular specialty (i.e. 93970). Based on findings the patient is then scheduled for ERFA 1-3+ months later by the general surgeon with pre-procedure vein mapping performed by the vascular specialty. Question surrounds the allowance to bill for the vein mapping. Per Medicare one pre-procedure Doppler/Duplex is allowed. Would this refer to the diagnostic study initially performed? There is no specific vein mapping code allowance for ERFA nor do I believe the vein mapping supports billing for a Duplex (93970/71). We want to be sure to capture what is supported in this case while ensuring we are payer compliant. Your guidance surrounding appropriate billing for the pre-procedure vein mapping in this case scenario is much appreciated.

Bleeding ulcer and thrombus of AV graft

"Patient came in with a bleeding ulcer and thrombus of AV graft. Via transverse incision, ulcer and elliptical portion skin and AV graft was resected. The graft was freed from the skin and subcutaneous tissue circumferentially. Thrombus was noted and removed. A 4 Fogarty was passed proximally and distally, removing thrombus, and the tourniquet was deflated confirming inflow and back bleeding. Then there was stenosis in the AV graft and MD performed angioplasty. The skin was closed with multiple vertical mattress ethilon sutures. Sterile dressing was applied." What should we report? 36833 for thrombectomy and angioplasty does that included resection of the ulcer as well since it was performed via one incision? Thanks!

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