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36590 Port Removal without immediate closure

The radiologist removed an infected port (36590) and packed the pocket with iodoform gauze and loosely closed with interrupted 3-0 Vicryl sutures and steri strips. The patient returned two days later for packing removal and full closure of the site. Can we bill 36590 with a -52 modifier for the first procedure and 36590 with a -58 modifier for the second procedure, or is the second procedure included in the first?

35226

At the end of an atrial flutter ablation a vascular closure device is deployed but cannot be removed by the EP physician. A vascular surgeon is consulted who then performs a cutdown, removes the device, and suture repair of the femoral artery. Is this reportable with 35226?

Vascular Access ICD 10

Would Z45.2 (encounter for adjustment and management of vascular access device) be an appropriate ICD-10 code for the placement of central line (36556) or arterial line (36620)? One source says that these are appropriate, while another one does not define this diagnosis as including placement.

Hepatic artery aneurysm repair with interposition vein bypass graft

"No pulse in the right hepatic artery. Gastroduodenal artery clamped, aneurysm was entered, resection of aneurysmal tissue was performed. Saphenous vein was harvested and then anastomosed to the gastroduodenal artery in a reverse fashion. I then redirected my attention to the left hepatic artery. I extended the arteriotomy approximately 1/2 cm to widen the artery. I then fashioned the vein graft to fit this arteriotomy. A functional end-to-end anastomosis between the vein graft and the left hepatic artery was performed."  It has been suggested that I code this with code 35121; however, in my opinion, this is should be coded with an unlisted code 37799, as this was a hepatic artery - gastroduodenal bypass (no current CPT code for this procedure) and not a repair of an hepatic artery aneurysm. It is my understanding that code 35121 is for repair of aneurysm with graft insertion, not an actual bypass. Please advise which would be the more appropriate coding and the rationale behind your opinion.

Reporting T82.855A vs. T82.855A + Z95.5 for two different arteries

Per Chapter 21 guidelines in ICD-10-CM, c., #3: “A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code.” Therefore: if stenosis is present in a coronary artery stent, T82.855A only would be reported; however, what if there is one patent stent in a distinctly separate coronary artery? Would this not warrant reporting both codes, and is it permissible?

NCD 20.33 TEER update

Regarding NCD 20.33 TEER update: when is this effective, and will it be retroactive?

E/M data points / 1997 guidelines

We need clarification regarding review of image, tracing, or specimen under the old E/M guidelines (prior to 2021). Can a cardiologist receive credit for personally reviewing the images and documenting a finding of their own services? Can this be done if their group are the ordering physicians and have billable CPT code? And are there any limitations? For example, re-reviewing the same records at each visit?

Right transmetatarsal amputation

The right posterior tibial artery was chronically occluded with collaterals in its place noted all the way down into the foot. The right peroneal artery was patent without significant stenosis although artery is small. The right anterior tibial artery is patent into the dorsalis pedis providing collaterals into the foot however the pedal arch and digital arteries do not enhance with contrast. To further assess viability of the vasculature and tissue within the foot, 3 mg of indocyanine green green were administered intravenously and a intraoperative fluoroscopy seen vascular arteriogram was performed of the right foot. Healthy tissue and skin were noted to enhance throughout the foot with the exception of all 5 digits. It was just determined at this point the patient was appropriate for transmetatarsal amputation. is the Intraoperative fluorescence vascular angiography using SPY technology and indocyanine green included?

TEE during pacemaker/ICD procedures

Is it appropriate to separately code a TEE during a pacemaker/ICD procedure? One example we have seen is a TEE done during a pacemaker upgrade. The TEE was performed to evaluate the pericardial space and the cardiac structures during lead extraction. This question is for both the facility and the physician coding.

Indications for 36221 arch study

Hoping you can help us resolve a dispute over medical necessity for use of arch study code 36221. Because the code describes diagnostic imaging, I assume that we need documentation of indications and findings to use it. Without an indication, I assume it is just a guiding shot to find the orifice of the subclavian or innominate for angiography of the arm. Cath lab staff wants to apply this code without indications (i.e., trauma to the arm only). Is a history of PVD enough? What if there is no history of PVD or problem with the arch vessels? Could you please provide some examples of indications?

New E/M Guidelines

Regarding the new office E/M guidelines, what list of conditions fit the definition of "1 acute or chronic illness or injury that poses a threat to life or bodily function" or "1 or more chronic illnesses with severe exacerbation, progression, or side effects of treat" for cardiology? In particular, considering unstable angina can come in a rainbow of different grades (some requiring hospitalization, some can be managed with outpatient LHC or a stress test), would this justify a level 5 for dx criteria? Please advise.

global period modifier use 58,78, 79

I'm needing some help with understanding proper coding and modifier use within a surgical global period.

Patient has fistula placed (36821) as well as tunneled catheter (36558) placed. Two months later, superfistulization (36832) is performed. Two weeks after that (still within 90-day global period) the tunneled catheter is removed in the office. What would be the proper modifier use in this scenario? Can catheter removal code 36589 be reported within this period in the office setting?

Or in the case where a fistula is placed in the LEFT arm, but fails in two months and a new one is placed in the RIGHT arm within the 90-day global period, would this be reported with modifier -79 because it's different arms or -78 because it's related, but not anticipated?

For PVI/CTI

"Patient with AF burden 5-10% on most recent event monitor, also atrial aflutter (recent EKG), presents for PVI/CTI. The left pulmonary veins were circumferentially encircled as a pair. Adenosine was given within the left superior vein, and a PV reconnection was seen, suggesting breakthrough at the carina. Additional lesions were given in the carina and on the posterior aspect of the left superior vein. Adenosine was given again in the left superior vein and no PV reconnection was seen. The right superior and inferior veins were circumferentially encircled as a pair. Pulmonary vein isolation was performed until there was no further evidence of atrial activation within the veins. Adenosine was given and no PV reconnection was seen. The catheter was withdrawn into the right atrium into the cavotricuspid isthmus. A CTI line was created. Pace-testing confirmed block." Aside from 93656, should I report also 93655 (since atrial flutter was mentioned on history), 93657 (breakthrough at the carina), and 93623?

TEVAR with Petticoat stent

Unsure of coding Pt s/p Debakey type 1 dissection repair with Renovascular HTN

Rt femoral artery percutaneous access to thoracic aorta. IVUS identified that we are in the true lumen & found severely compressed SMA. A thoracic aortic arteriogram demostrated false lumen with multiple intercostals, lumbars & rt & lt renal stenosis. We elected to proceed by placing Cook petticoat stent to open the true lumen & preserve flow into the lumbars & intercostals. We selected a cook petticoat 36mmx18cm TEVAR stent vis 16Fr heath & deployed it from the mid descending thoracic aorta to below lt renal. Post stent deployment IVUS showed resolution of SMA compression. We proceeded by interrogating rt renal & were able to go thru struts & delivered a 7x39VBX stent & angioplasty with complete resolution of stenosis & stent was then taken into the petticoat stent. Same catheter was used to catheterize the lt renal & 6x29 stent was deployed & angioplasty with resolution of stenosis. The renal stent was taken into the petticoat stent.

evacuation of pericardial effusion

small 10 mm anterior incision at approximately the fifth intercostal space, right parasternal region. Intent was to gain access of the right pleural space using a different site in hopes that no further adhesions were identified. However, upon entering the right pleural space, it was evident that there was severe adhesions within the entirety of the pleural space. The 10 mm incision was extended medially to create a 2.5 cm working incision, similar to Chamberlain procedure. The pericardial and anterior mediastinal fat were divided with electrocautery. The pericardium was identified and carefully opened using electrocautery. A bloody effusion was then evacuated, with a total amount removed at 550 mL. A portion of this was collected within a trap and submitted for routine cultures.

Impella removal via an open approach

The CPT book now states to report an additional code if the Impella is removed via open approach. So if the provider takes the patient back to the OR to do an open removal and sutures the femoral artery, do you think we should report 33992 and 35226-XU?

Scout CT prior to US guided biopsy

Is the scout CT separately reported prior to US-guided liver biopsy: Code 74150?

"The lesion was difficult to initially identified on ultrasound. Therefore, a scout CT was performed. This demonstrated that the lesion was present behind one of the ribs. A second look with ultrasound was able to demonstrate the lesion using breathing techniques. The skin was marked. The patient was prepped and draped in the usual manner. The liver lesion was again identified with sterile ultrasound.  The skin and subcutaneous tissues were anesthetized with 1% lidocaine. Under direct ultrasound guidance a 17G coaxial guidance needle was advanced to the margin of the liver lesion. Three 18G core biopsies were then obtained."

Aborted Hysterosalpingogram

A hysterosalpingogram was attempted on a patient but the procedure was terminated. What would be the correct code/s to report for this situation? "Patient was placed on the IR fluoroscopy table in the lithotomy position and the perineum prepped and draped in the usual sterile fashion using maximum sterile barrier technique. Preliminary scout radiograph of the pelvis is unremarkable. Duplicated speculum was inserted. Cervical os was never identified. Patient complained of moderate pain and procedure was discontinued. Collaboration with OB/GYN he will be required to complete the hysterosalpingogram."

Removal of fem-pop PTFE bypass grafts x 2

There is a code for removal of an infected graft in the lower extremity, but I can't seem to find the code for removal of a graft that is not infected. The patient had a removal of a fem-pop PTFE bypass graft x 2.

ICD 10 DX Code

What is the correct code for degeneration of the pubis symphysis? And can you give your rationale for the code selection?

Embolectomy ileal femoral bypass graft

What is the correct CPT code for embolectomy of the ileal femoral bypass graft?

LV lead implant, only functioning lead

Patient comes in for a dual PM @ ERI. Generator removed (ERI), RA lead capped (non sensing), RV lead removed (does not clearly state why). Then a NEW LV lead was placed, and a new generator.

How exactly would we code this? 33225, 33229? With a -52 modifier on 33229? Or 33207, 33225, 33233, 33235? With a -52 on 33207? LV lead is the only functioning lead.

Debridement and repair of AVF

Would this be a simple debridement CPT or a specific AVF CPT?  "Patient placed supine. Left arm prepped and draped. Patient given antibiotic. We examined arm with US (images stored). We had tourniquet in room in case proximal. We removed scab and discovered 4 mm pseudoaneurysm at the site of retained suture of previous access for thrombectomy. We established proximal/distal control with digital compression. We examined 4 mm defect in skin. It was degenerative without signs of infection. I debrided edges to healthy tissue and repaired defect primarily with 4-0 Prolene running suture. We now had thrill and pulsation in AVF. We examined repair with US (images stored) and confirmed patency. Dressing applied."

Code 93655 with PVI

Are distinct/discrete mechanisms of atrial flutter supported here? If so, is 93655 reported once or twice? Have PVI, 93656, the CFAE 93657.

"PAF: Pulmonary vein isolation; connecting lesions of Pappone; CFAE; second mechanism. Each pulmonary vein was encircled with lesions. Chronic fractionated atrial electrograms were identified. Direct pulmonary vein potentials were identified. These were targeted. Hence, not only was pulmonary vein isolation performed, but also target of certain trigger mechanisms for their atrial fibrillation. Lesions delivered at 30 to 50 watts with lower energies and shorter durations in the posterior and inferior regions and longer durations and higher energies at the superior and anterior regions. Adenosine given without ectopy, reconnection, or AF. SN: csnrt<500; AVN: WB 300; HV: 50; No VT. Typical flutter in lab, TV isthmus lesions with block. Inducible flutter maps to IVC area and lateral areas, ablation terminates rhythm, no further inducibility. The patient underwent AF, flutter and lower loop type flutter ablation."

77063 and 77065

Is it appropriate to charge 77067, 77063, and 77065 for the following report?

"Screening with CC and MLO full field digital views of each breast was performed in combination with digital tomosynthesis( DBT). Standard mammographic views were supplemented with additional views for further evaluation of a mammographic abnormality. The mammogram was additionally reviewed by a CAD system.

Findings: The breast tissue is heterogeneously dense, which could obscure detection of small masses (50-75% glandular). Scattered, benign appearing calcifications are seen. The questionable asymmetry in the inferior right breast, seen on the MLO projection. However this does not persist on spot compression view.

The study demonstrates no mass, microcalcifications or areas of architectural distortion that are suspicious for malignancy.

Impression: No evidence of malignancy. Dense breasts."

Post heart transplant annual/routine heart catheterization and biopsy

Any guidance on annual cath/biopsy for transplant patients... does this documentation support medical necessity? Using Z48.21, Z94.1 for ICD-10 codes.

"PROCEDURES PERFORMED: Selective coronary angio, LHC, RHC, US-guided access of the left axillary vein, IVUS LAD and LMCA, right ventricular endomyocardial biopsy.

HISTORY: Male with a history of stage D non-ischemic cardiomyopathy. The patient underwent BTT-H VAT. He had a very complicated and prolonged postoperative course. He developed right ventricular failure. He required prolonged temporary right ventricular mechanical circulatory support. He required LVAD pump exchange. He ultimately recovered and underwent cardiac transplantation in December 2019. Patient has a history of HTN, type 2 DM and HLD he presents today for his annual invasive transplant evaluation.

CONCLUSIONS: ISH LT CAV 0, intravascular ultrasound demonstrates stable donor derived atherosclerosis, low right and left heart filling pressures, normal cardiac index, normal pulmonary pressures, successful right ventricular endomyocardial biopsy."

TAVR with Shockwave Lithotripsy

We are seeing more of our doctors perform shockwave lithotripsy ballooning during the same session as a TAVR. I have read that having calcified iliacs does increase the risk of serious complications during a TAVR. It seems to me that this is only being done to help facilitate the transfemoral access safely. Are we correct in not coding separately when we see this? Would there be a situation when we should be coding separately for the shockwave of the iliacs when done in conjunction with a TAVR?

RHC with biopsy

Have there been any updates on billing for a full right heart catheterization at the same time as a biopsy? Some physicians feel that these are done for two different reasons, one for rejection and one for appropriate therapy in these transplant patients.

CG modifier bypass Edit for device dependent procedures

On your 1/31/2020 Newsletter you mention the CG modifier to bypass the edit for certain procedures when no device is used. I have searched high and low for the list of procedures that would be applicable to use the CG modifier but to no avail. The only CPT/HCPCS I find are on the OCE quarterly updates which adds the codes to the "List". Going through Medicare links is a maze I never seem to get out of or find what I am looking for. Do you have any idea on where that list of procedures might be found or can you provide that list? Thank you .

STEMI X 2 VESSELS

Angiogram was performed, which showed distal right coronary artery 100% occlusion. Patient continued to have chest pain and therefore it was decided to intervene the left and descending artery, which had 90% stenosis. Angioplasty to both with placement of DES. In these instances and based on the information provided in your book 2017 Diagnostic and Interventional Cardiovascular Coding Reference, we code the highest level of intervention performed in each major coronary artery and branch separately, C9606 x 2? Is this correct?

coronary ectasia

Would coronary artery ectasia (or ectatic coronary) be I2541, Q245, or something else?

supraspinatus calcifications and bursa injection

Hi, I have an US guided access to supraspinatus calcifications with pulsation using a total of 4 syringes of saline. Attention was then turned to the subacromial subdeltoid bursa where an US guided injection of kenalog and lidocaine was injected. would this be 20611 once or twice for the different area or should the calcifications be an unlisted code in addition to 20611? Thank you!

Trial verses nontrial cpt codes

I was told that billing two separate claims for the same date of service for 0569T (trial procedure) and 33477 (non-trial procedure) would be considered unbundling. I disagree. Please advise.

Pediatric Congenital RHC and Arterial Line Insertion

The PEDs congenital providers will occasionally place an arterial line during a congenital RHC for continuous monitoring due to patient safety concerns for some of their population. Because this (arterial line) is not routinely performed for a RHC, there has always been some question as to if this should be billed. They feel it should be billed. Below is an excerpt from the latest op report:

"For safety, it was deemed that an arterial monitoring line was needed to monitor blood pressure continuously and obtain blood gasses during the case. Accordingly, a 2Fr arterial monitoring line was inserted into the right femoral artery, under ultrasound guidance, using standard Seldinger technique, and connected to pressure transducer for continuous monitoring." 

Your thoughts are appreciated on billing code 36620 along with 93530 for both the facility and pro fee sides.

Nitroglycerin given after an iFR. Is this an FFR instead?

Our physicians utilize structured reporting, and certain phrases are made up to select to insert into the cath report. We have a phrase that says “iFR/FFR”, which indicates that one or the other was performed. Then it’s supposed to clarify which one was performed with the appropriate documentation. The question we have is in regards to the use of nitroglycerin, as we know that this can be used possibly for FFR per Q&A #14476. Would the verbiage in italics be an iFR and an FFR, or is it only an iFR? “Mid LAD lesion is 60% stenosed. The lesion is eccentric. The lesion is moderately calcified. iFR was measured. iFR ratio: 0.93. Other iFR .94 Nitroglycerin was given by intracoronary injection. The pressure wire was then advanced and appropriately normalized. After IFR/FFR was assessed, with the transducer in the distal vessel well beyond the area in question, the wire was withdrawn and there was no drift. There was TIMI 3 flow and no evidence of dissection on repeat injection.”

Creating an unlisted code for a LVAD ramp study

I see you answered the question last month about how to code for a LVAD ramp study and RHC. You suggested 93799 for the LVAD ramp study, and the RHC can also be coded. My question is when requesting an unlisted code (93799) I need another CPT code that the LVAD ramp study would be comparable to for RVU purposes. In example: I am requested the following unlisted code 93799 comparable to 93451.

right external iliac artery

I am needing clarity as to coding the catheter placement in right external iliac. The provider accessed from the right common femoral artery and catheterized SMA and then he catheterized right external iliac. Would we code 36245 (SMA) and 36140 for external iliac?

MR Lymphangiography

Would codes 75807, 38790-50, 71550, 74181, 72195, and 76377 be used for the following report? "Three plane localizer imaging of the chest, abdomen, and pelvis followed by 3D steady state free precession (SSFP) imaging in the sagittal plane of the upper abdomen and chest and precontrast 3D THRIVE of the chest, abdomen, and pelvis acquired in the coronal plane were performed. The groin lymph nodes were then slowly injected with a total of 5.4 mL of the contrast/saline mixture described above while obtaining serial 3D THRIVE imaging during and following injection in the coronal plane over the next 20 minutes to evaluate lymphodynamics. Post-contrast 3D steady state free precession images were obtained in the sagittal plane 9 minutes following the initiation of contrast administration. The access needles were removed. The patient tolerated the procedure well and was transferred to the recovery area for extubation and further management. Postprocessing of the 3D THRIVE and SSFP sequences was performed by the attending physician on a separate 3D workstation."

Dosimetry

What documentation is required for 77300?

Bilateral Common Iliac Artery Intravascular Lithotripsy & Stent

We performed the IVL and stent placement in both common iliac arteries. We coded C9765-50 and have received a denial by the payer. Have you come across this issue before, and would you suggest we use separate C9765-RT and C9765-LT?

61630 and 61650

My provider is doing balloon angioplasty for atherosclerotic disease in the left common artery (61630). He is also treating pre-existing vasospam in the left vertebral and left ICA. Would he be allowed to bill the left ICA 61650 when he has treated the left common with 61630 during the same session? With these being the same vascular family, I'm unsure if we can use modifier -59 to bypass the NCCI edit. The following is the proposed coding: Left common 61630, left ICA 61650, and left vertebral 61651.

PerQ AVF branch ligation with stenosis PTA

I understand that OPEN AVF branch ligation (36832) bundles PTA in the same segment, but what if documentation only supports PerQ branch suture ligation with stenosis PTA? Would it be 36902 and 36909? "Outflow stenosis at cephalic arch was ballooned. Cephalic vein branch was ligated with less pulsatile at completion. Transverse skin incision... sheath inserted... Fistulogram with stenosis of outflow... Glidewire tracked into position and ballooned.. Two more silks were then wrapped around the outflow portion of the isolated cephalic vein branch and then tied down. As the sheath was removed, the vein was then transected, and three interrupted 3-0 vicryl deep dermal stitches were used to close the skin."

where to get ICD

What are the coding rules for where we can get ICD for IR procedures? Our new educator only wants us to use ICDs off the IR report and/or the order. Are we not allowed to use notes from the ordering provider like H&P or long-term facility notes sent with the patient for the radiologist to review? If the H&P states PAD with claudication and the order and final IR report only state PAD, we end up coding only PAD, which is not covered. This also happens a lot with fistulograms for dialysis. The report and order state only ESRD. BUT the H&P have HTN, DM, heart failure as part of patients history. Seems like the more detail we code the more accurate the coding, so do we need to query for all details, or can we use H&P when coding IR? I realize this is an education of provider issue, but we are sending out way too many queries and all that does is irritate the provider.

Attempted TEVAR

"Bilateral ultrasound guidance CFA. Right side was heavily calcified. Cutdown was made on CFA. Cath advanced into SMA for distal landing zone for TEVAR. Entire right iliac system treated with shockwave lithotripsy (right common, external, internal heavily calcified with near occlusive stenosis). Patient became hypotensive, suggesting rupture of iliac artery. We expeditiously placed 16 French in CFA to plug it and then 8 French sheath placed and two VBX stents placed in external iliac. Agram showed no further extravasation. We decided not to perform TEVAR. SMA sheath pulled into distal aorta. Sheath pulled out right CFA, and there was significant trauma, repaired with artegraft. Due to heavy calcification, CFA endarterectomy was performed."

Our physician coded this as: 34708, 35371, 37220, 36245, 36140-59, 76937 x 2. What codes do you suggest?

penile duplex examination with injection

A patient had a penile duplex examination performed after injected with alprostadil (prostin VR). Does this documentation support CPT 93980 and also CPT 54235? Does the actual injection administration need to documented?

“A penile duplex examination was performed pre and post injection. In the resting state, the cavernosal arteries were high resistant with low velocity flow. The immediate post injection images demonstrated medication microbubbles appropriately within the cavernosal compartments. The post injection cavernosal arterial hemodynamics during tumescence were low resistance with increased velocity (>25-30 cm/sec). The cavernosal Doppler waveform resistive index increased to >0.90 and was maintained for 10 minutes. Systolic rise times were within normal limits (<100 ms). The dorsal artery was patent with a normal Doppler profile. The dorsal vein flow during maximal response was absent. There were no dorsal to cavernosal perforators identified. Conclusions: Patent bilateral cavernosal arteries with normal response to injection.”

Dobhoff inserted by a nurse

When a nurse inserts a Dobhoff tube, is it appropriate to report 44500 on the technical side? I know that 43752 can't be reported when performed by a nurse, but code 44500 does not specify "requiring physician's skill".

Is there a open CPT code for a resection of pleural-based schwannoma

For the following documentation, would code 39220 be correct? "I began by making a standard left posterolateral thoracotomy skin incision over the eighth intercostal space. The subcutaneous tissue and latissimus muscle were divided with electrocautery, sparing the serratus anterior muscle. The eighth intercostal space was identified in the intercostal muscle over the top of the ninth rib and was incised anteriorly as far as possible and posteriorly to the spinal ligament. The intercostal nerve bundle was dissected off of the inferior aspect of the ninth rib, and then ligated with silk suture and clips. The ninth rib was divided posteriorly with shears, and a static pilling retractor was placed. The retractor was gradually opened throughout the case to provide adequate exposure and avoid inadvertent fracture to the ribs. The opening in the intercostal space was positioned directly over the intrathoracic portion of the schwannoma. On initial survey of the left pleural space, there was the expectant large pleural-based schwannoma adherent to the posterior chest wall, overlying the foramen at T9-T10."

Coding 93650 with 93613

Please help me understand why an electrophysiologist cannot bill 93650 with 93613. It is impossible to locate the His deflection without either fluoroscopy or 3D mapping. 3D mapping allows for a more precise localization of the His prior to an AV node ablation. Arrhythmia induction is not necessarily required to report code 93613, as our electrophysiologist will bill 93613 with atrial fibrillation ablation without having to actually induce atrial fibrillation if the patient arrives in normal rhythm. 3D mapping helps to localize exactly where ablation should be performed. It's seems logical to report code 93613 with 93650.

GP denervation

How would the following scenario be coded? "After denervation, SVC was ablated. The baseline HR prior to GP denervation was 60. Denervation was performed at standard anatomic locations for GPs. The LSGP, LIGP, RIGP were initially targeted with subsequent sympathetic and parasympathetic responses. Attention was then directed to the right anterior aspect of the left atrium the RAGP was targeted with specific focus on fractionated potentials. The basal sinus heart rate at this time was noted to be 80-90 bpm. The Agilis and ablation catheter were then withdrawn into the right atrium. The anterior aspect of the RAGP was reinforced with additional lesions. The SVC was subsequently ablated with a transient sympathetic response causing the sinus rate to increase to 105 bpm. Finally attention was directed at the floor of the CS."

Complex clipping of anterior circulation aneurysm, MCA aneurysm

Hi Dr. Z,

When performing complex clipping (61697), the surgeon also is documenting use of intraoperative flow measurement, microsurgical technique and microscope for dissection and use of ICG. Are these elements separately billable? For example, 69990 for the microscope and unlisted code 37799 for the flow measurement and the ICG (indocyanine green angiography).

Thank you

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