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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."

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?

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?

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.”

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."

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.

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.

ICD-10 question

Does the following documentation satisfy requirements to report ICD-10 code I50.22, or would we need to ask the provider to state chronic systolic heart failure as the indication? "INDICATIONS: Severe non-ischemic cardiomyopathy with LVEF 30% on optimal medical therapy; class III congestive heart failure, complete heart block with pacing induced left bundle-branch block, heart failure duration exceeding 3 months, primary prevention."

External EKG coding

I am not finding all of the new CPT codes 93241-93248 on the CMS fee schedule. Do you have any information on why the codes were not included? Will Medicare be paying for these services?

EVAR for aorto iliac embolic disease with limb ischemia and thrombus

Recently our physicians have been placing a bifurcated endograft through a 12 French or greater sheath for aorto iliac embolic disease with limb ischemia and thrombus. Does this fall under aortic pathology for EVAR, or should we use an unlisted CPT? Question ID 4621 advised an unlisted CPT code but it is dated. What do you advise today?

S-ICD generator exchange

What CPT code do we use to report a replacement of an S-ICD generator due to end of life (no lead replacement)? (New implant: Boston Scientific EMBLEM MRI S-ICD)

Patient death during closing of grafting for ruptured AAA

Is modifier -53 appropriate to use in this case since the graft was completed and the patient decompensated upon closing.

"The midline fascia was then closed using a running PDS suture as the bowel was returned to the abdominal cavity. Marked distention was noted, but we were able to get the abdomen almost closed when the patient dropped her pressure again into the 60s and 50s. The abdomen was reopened and noted to be filled with blood. At this point, manual pressure was held on the aorta above the graft, and the aortic clamp was reapplied to the infrarenal aorta just proximal to the anastomosis. The distal clamp was also placed. At this point, the patient was noted to be in electromechanical dissociation, and despite numerous rounds of drugs administered by the anesthesia service, the patient did not return with a pulse."

Color/Spectral Doppler

Is the verbiage "color flow/spectral Doppler" required in the documentation to code and bill for a complete vs. limited scan?

Ductus Venosus Doppler

Can you clarify the Society of Maternal Fetal Medicine's recommendation for what procedure code to use to report a ductus venosus Doppler study?

Open Removal of axillary vein stent by open venotomy

(Patient with MRSA/Bacteremia) "Axillary stent - suspected as source of infection but not confirmed. The patient was taken to the operating room and placed in the supine position. After adequate regional block anesthesia he was prepped and draped in the usual fashion. An incision in the proximal upper arm near the axilla and this was carried down through the subcutaneous tissues. The fascia was incised. Care was taken not to disturb any nerves. The axillary vein was identified and proximal to the stent (mid arm) it was occluded and rubbery. The stent could be seen. I gently dissected the vein and then made a venotomy with an 11 blade and separated the plane between the stent and vein. The stent was grasped with a hemostat and gently retracted while continuing to separate the plane. Eventually I was able to completely remove the stent."

I am thinking 35206, or venous thrombectomy code 34490 because there was thrombus found inside of the stent incidentally, which was cultured and sent for path exam. Any assistance with this case would be appreciated.

Additional Coding for CPET 94621

"Patient brought to the cath lab, placement of a right pulmonary artery cath and a left radial artery cath, due to borderline biventricular pressures, cath left in place, patient transported to the exercise lab for cardiopulmonary exercise testing via bicycle ergometry with right heart cath and radial cath in place to evaluate hemodynamic response. Continuous oxygen saturation, ECG, expired gas, arterial pressure, right atrial pressure, and pulmonary arterial pressure monitoring were performed continuously throughout the test. Arterial and mixed venous blood gasses were collected every minute. Pulmonary capillary wedge pressure was measured every minute, etc… After the procedure was completed the catheters and sheaths were removed."  In addition to 94621 (CPET), would the correct additional codes to report be 93451, 93464, 36620?

Cervical Carotid Angioplasty with protection device but without stenting

Patient had very severe ICA stenosis and M2 occlusion initially. Planned for thrombectomy, but after primary angioplasty the thrombus was noted to have cleared. Further carotid angioplasty and stenosis was deferred, as well as intracranial exploration, because the patient was VERY sensitive to angioplasty, becoming asystolic instantly, requiring atropine resuscitation. Only cervical carotid angioplasty WITH protection device, but WITHOUT stenting was performed. Provider is asking if we can still bill 37236 on this one? Or should it now just be 37215-52? Please advise.

RV Lead Fracture and replacement

Could you please help with coding for the following OP note? Patient has an ICD implant. "Patient came in with RV lead fracture. I opened up his pocket and removed his existing pulse generator and disconnected it from the leads. I then took vascular access and implanted a new RV ICD lead. I then relocated the skin pocket superiorly since the lead implant was in a different location than the existing leads. I then capped the existing fractured RV lead. This is a single lead; however, it is a DF-1, which means that it has three electrodes and not just one. I capped all three electrodes. I then took the existing pulse generator and reconnected it to the existing RA and LV leads and also connected it to the new RV lead." When they remove and replace the same generator, I'm not sure if it would still be considered a "replacement" according to CPT language. Not sure if this should be coded as 33223 and 33216, or as 33241 and 33249?

FNA billed with core biopsy, same lesion, same image guidance

Per AMA we can bill both core biopsy and FNA aspiration same lesion for 2021. If liver core biopsy done with ultrasound guidance and FNA aspiration same lesion under ultrasound guidance done also (same image guidance), can we bill 47000 and 10005-59, no 76942?

Femoral Nerve Stimulation, Ultrasound Guided

"The femoral nerve was identified under the US, which lies lateral to femoral artery. The full electrode tip is inserted entirely to the fascia lata. The nerve electrode was introduced into the top of femoral nerve, and the transducer was removed. After the needle removal, the lead was again connected to the stimulator to confirm the lead dislodgment didn't occur during needle withdrawal. A connector block was attached to the lead approximately 2 cm from the skin entry point, the excess lead was removed, and the lead site was covered with a sterile dressing. The device was connected and set up." Can you advise what CPT code to use for this pain management procedure?

Attempted CardioMEM implant

"Our interventional cardiologist brought the patient to the cath lab for a RHC and CardioMEMS implant. The RHC was performed followed by a pulmonary angiogram via RFV access to identify a suitable vessel. The LPA was found to be an appropriate site for the device. The CardioMEMS device was advanced to the PA segment; however, they could not obtain reliable device waveforms. After multiple attempts and repositioning it was felt the patient's anatomy and BMI were preventing adequate device/controller signal. Device was removed and not implanted." Should we report the attempted CardioMEMS procedure (33289) or consider reporting the work that was done RHC with PA (93451, 93568)? Should we consider a modifier -53 here?

EPS followed by PPM insertion and AV node ablation

Would it be appropriate to charge for the following limited EP study followed by a PPM implant and then AV node ablation? What code(s) would be appropriate? 

"Using the modified Seldinger technique, a 7 French sheath was placed in the right femoral vein. Through this sheath, a duo decapolar catheter was placed to the right atrium, sitting anterior to the crista terminalis, with the distal poles in the coronary sinus. Activation mapping was performed. The right atrium had a chevron appearance of activation. Entrainment was performed from the CTI, which was found to be out of the circuit, with a long PPI minus TCL. The CS was found to be within the circuit. The tachycardia was consistent with mitral annular flutter." 

The PPM insertion and AV node ablation that followed were appropriately documented and were all performed in the same session.

Subclavian Artery Angiogram/Intervention

"Access site left CFA. Catheter was advanced over the wire to the ostium of the left subclavian, and selective angiogram was performed. This demonstrated a subtotally occluded left subclavian artery. Using digital subtraction angiography, the distal vessel did fill, suggesting some hibernating arterial supply for micro-channels. Balloon was advanced over the wire into the left axillary artery, and selective angiogram was performed. This demonstrated excellent flow to the arm. The balloon was then pulled back into the left subclavian artery, and selective angiogram was performed. This demonstrated no significant flow into the vertebral. The IVUS catheter was then inserted, and a pullback was performed. This demonstrated an axillary artery size of 7 mm. The left subclavian measured 6.5 x 7.3 mm with a 100% stenosis. Subclavian artery was then ballooned. It was inflated to 14 ATM for 20 seconds. Following this the lesion was then stented using a 6 x 40 mm Omnilink stent. It was deployed at 18 ATM for 30 seconds." Do I report codes 36225-LT, 37236, and 37252? Or do I report codes 75710-LT, 37236, and 37252?

Intracranial treatment of vasopasm plus diagnostic imaging vertebrals

If the provider performs prolonged administration of verapamil into one of the vertebrals (61650), and does diagnostic imaging and provides separate findings for the contralateral vertebral, are we able to code for both 61650 and diagnostic imaging for the contralateral side? Or does the 61650 bundle everything done in that territory (vertebro-basilar)?

Lumbar injection for RT planning

I'm questioning code for lumbar puncture done in IR for RT planning. Should I report codes 62284 / 77003?

"CLINICAL INDICATION: Rad Onc simulation. History of liposarcoma mets to spine s/p surgery. PROCEDURE: Following explanation...... consent for a a fluoro-guided lumbar puncture and CT myelogram were obtained from patient. Under fluoro guidance, L4 space selected, 20 gauge spinal needle advanced into subarachnoid space. Return of clear CSF confirmed. 10 mL of Omnipaque-240 injected slowly into subarachnoid space. Needle removed. Contrast confirmed in upper thoracic and lumbar levels. Patient was then sent to rad onc. IMPRESSION: Successful fluoro-guided lumbar puncture and intrathecal injection of contrast throughout the t- and l-spine levels for rad onc simulation."

51 modifier and 59/X modifiers

Can we use a -51 modifier with -59 or -X modifiers? Example: 36224, 36226-51, 36225-51-XS.

PRE-PROCEDURE ANTIBIOTICS

Are antibiotics typically given 30-60 minutes prior to a procedure billable to the patient? For example, I was told that when placing a neph tube the antibiotic is not billable, but if we are changing a neph tube it is billable. Basically if we don't always use antibiotics before something like a neph tube change then I was to bill for it. I see some doctors ordering it and some do not. Also was told that our OR does not bill for antibiotics given before, but if given after may be billable. I need clear information if I am to challenge the person who trained me.

Do images need to be stored in order to bill 93990?

If our provider performs a brief ultrasound in the office two weeks following PAVF to assess maturation, do we need to store the images in order to bill 93990? Is 93990 bundled with the E&M?

What are the documentation requirements for an LVAD Interrogation - 93750?

Per CPT description - the below listed parameters/device functions must be documented in the LVAD Interrogation report.

93750 reports a diagnostic procedure that is performed in person and includes a face-to-face assessment of all device functions. Components that must be evaluated include device parameters (alarms, drivelines, and power surges) and a review of the device function (flow/volume status, septum status, and recovery). This code includes physician or other qualified health care professional analysis, review, and report. It also includes device programming, if performed.

Based on information from provider Septum Status/Recovery can't be determined by an LVAD interrogation alone without performing a RAMP study.

Please elaborate on the required documentation in relation to Septum Status and Recovery for an LVAD Interrogation - 93750 - when a RAMP study is not being performed - only an LVAD Interrogation?

Cath placement to the aorta from the SMA access by abdominal incision

We are wanting to know if a catheter placement into the aorta from the SMA that was accessed with an arteriotomy by an abdominal incision is separately billable. The op note states in part: "An upper midline laparotomy incision is performed in the usual fashion… A small transverse arteriotomy was made on the anterior surface of the SMA. Next the micropuncture wire is inserted directly into the arteriotomy site followed by a micropuncture sheath… The SMA lesion was crossed retrograde. The sheath was upsized to a short 7 French sheath. Given the poor distal outflow is difficult to opacify the runoff however the heavily calcified ostial lesion is easily visible in a steep oblique angle. A flush catheter was placed into the aortic to confirm reentry into the true lumen. The SMA lesion was pre-dilated with a 5 x 40 mm angioplasty balloon over the stiff Glidewire. Next a 7 by 27mm VBX is deployed at the SMA origin with excellent angiographic result." Would the cath placement be billed with 36200 or be considered part of the primary procedure?

impella sheath removal

My physicians have been removing the Impella on the floor in the ICU but leaving in the 14 French sheath and then bringing the them down to the cath lab the next day to do a tamponade closure using an Armada balloon. Would there be a charge for Impella sheath removal with balloon tamponade (closure of the sheath removal site)?

Thoracotomy Pacemaker Gen Change

How should this be coded? 33237-52 along with 33213 for insertion? "PROCEDURE: The patient was brought to the operating room, put in a supine position on the OR table, and was endotracheally intubated for induction of general anesthesia. We prepped and draped the left chest in standard fashion. We then used some Marcaine in the skin. We placed a small incision in the left chest over the previous incision, went in between the ribs, and entered the left chest and pleura. We identified the pacemaker box, which was full floating freely within the pleura, and we were able to pull it in and exchanged it out without any problem. There were two leads, one ventricular and one atrial, that were reconnected to the new pacemaker generator. We used the antibiotic and pocket placed around the device, and then we placed it back into the chest cavity. We closed the incision in multiple layers. We placed a small 24 French Blake drain, and then the patient was then awakened and brought to the cardiac recovery room in stable condition."

Aggrastat or Angiomax 92977

Does administration of either Aggrastat or Angiomax during heart cath/stenting qualify to report CPT 92977 for physician side or facility side? If not, what would meet the criteria? "A repeat injection demonstrated 0% residual stenosis but there was only TIMI-1 flow with some slow flow noted which I treated with a bolus of Aggrastat, which 5 minutes later demonstrated TIMI-3 flow. Just as a precaution, I elected to give another bolus of Aggrastat."

RV lead replacement with DFT

Should the following be reported as 33216 and 93642? Or 33216 and 93641? "Usual prep and drape was done in sterile fashion. Anesthesia used was 1% xylocaine. Following satisfactory anesthesia, the generator of the ICD was explanted using sharp and blunt dissection. Following this, the lead was disconnected from the device. A new right ventricular lead was then placed using sheath placement with Seldinger technique in the subclavian vein on the left. This was advanced into the apex of the right ventricle, and satisfactory pacing and sensing thresholds were obtained. This was then attached to the existing generator and the excess lead and generator placed in the pocket. The pocket was flushed with antibiotic solution and was closed using running 3-0 Dexon suture for the subcutaneous tissue and subcuticular running suture of same for the skin. Following this, the patient was placed in ventricular fibrillation with a T shock, and the device successfully cardioverted the patient back to a sinus mechanism with 10 joules."

MR myelogram injection code 62284

My provider performs contrast injection for MR myelograms. I believe 62284 is correct. Please advise.

"Fluoroscopically-guided lumbar puncture for opening pressure measurement and CSF collection. Subsequent intrathecal injection of MR contrast for pending total MR myelogram and MR cisternogram. Using biplane fluoroscopic guidance, a 3 1/2 inch in length 25 gauge Whitacre needle was advanced through a 1.5 inch in length 19 gauge hypodermic needle placed in the posterior low back skin and subcutaneous soft tissues. The Whitacre needle was advanced into the subarachnoid lumbar space at the superior L3 level. AP and lateral images of the lumbar spine were acquired. Opening pressure was measured. 2 mL of clear CSF were removed and sent to the laboratory. 0.6 mL of Gadavist mixed in 8 mL of preservative-free normal saline were then injected through the Whitacre needle into the lumbar subarachnoid space. Stylette was replaced in the Whitacre needle."

EP code 93657

How many times can code 93657 can be billed per session?

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