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33745

Can you use 33745 for stent placement in a vein for treatment of severe SVC stenosis in pediatric patient?

IVUS in lower extremity procedures

I have a lot of physicians using IVUS during their lower extremity procedures. My question is when they use IVUS in the SFA, anterior tibial artery, and posterior tibial artery, do I report code 37252 for the SFA and 37253 x 2 for the AT and PT vessels?

2 Encounters Same DOS. 37184, 37185, 37184XE? Same LLE family.

Are 37184 and 37185 per encounter or per DOS for same vascular family? For this case I have two encounters same DOS.

1st Encounter- Thrombus in SFA and Popliteal. 90% stenosis and thrombus in peroneal. Thrombolysis cath placed in peroneal. Prime MTD of SFA and popliteal. Dx angios and sel cath placement w/balloon angioplasty of 90% stenosis in peroneal. Result 70% stenosis of peroneal. Relook and stenting of peroneal later in day. 1). 37184,37185, 36247, 75710-XU 99152. I assume since stenting of peroneal at follow up we don’t code plasty for the perineal we bundle into 2nd encounter? And code cath placement for first? 2nd Encounter- Relook and rem of lytic cath, Prime thrombectomy of peroneal and angioplasty w/stenting of 70% per stenosis . Result -0% stenosis and no residual thrombus of peroneal. Encounter 2- 37230, 37184-XE, 37212-XU. 99152-XE. Can 37184,37185 be coded at follow up for same fam diff vessels or are they per dos? Can 37228 37230 be unbundled over 2 encounters? If not is cath placement good for 1st encounter?

Suprapubic Cath Insert and Imaging

Would the correct codes for this case be 51102, 76942, and 77002? "PROCEDURE: With the patient placed supine on the angiography table, ultrasound was utilized to identify the urinary bladder. This scan in the immediate suprapubic region was anesthetized with 1% lidocaine. Deeper anesthesia with a spinal needle was utilized. Using ultrasound guidance, a 5 French Yueh catheter was introduced into the urinary bladder, and a 0.035 Amplatz guidewire was advanced. Several dilators were then utilized, followed by placement of a 14 French pigtail multipurpose catheter, which was formed within the urinary bladder. Small amount of contrast was injected, confirming location of the pigtail catheter within the urinary bladder. Catheter was secured to the skin using 2-0 Prolene suture. Patient tolerated the procedure well without immediate complications. Conscious sedation using intravenous Versed and fentanyl was provided under direct physician supervision for 30 minutes. Total fluoroscopy time 0.9 minutes." 

C9764-C9767

Would C9764-C9767 be coded as 3722X on the professional fee side?

TC Atrial Shunt Creation 33745/33746

If the patient already has an ASD, and the pulmonary vein stent protrudes into the atrium at the veno-atrial junction, can we report code 33745? Are all pulmonary vein stent placements reported with 33745/33746? Also, does a PDA stent qualify as an intracardiac shunt creation (33745)?

Right Ventricular Cardiac Resynchronization Therapy

"For this patient, a dual chamber ICD generator was replaced with a CRT-ICD generator. Original RA and RV leads were kept, and a third lead was added, placed on the anterolateral RV free wall, and plugged into the LV port of the generator. Lead placement in the coronary sinus/LV was not attempted."  How should this be coded? I’m guessing 33241 and 33249, since no lead was placed in the cardiac venous system, but I would appreciate your input.

Lyphaticovenous Bypass with SPY Indocyanine Green imaging

What is the CPT code for Lyphaticovenous Bypass with SPY Indocyanine Green imaging? Injected ICG into each webspace in the wrist and forearm. SPY technology used to image the lymphatics. The hand and distal wrist demonstrated a prominent dorsal hand lymphatic vessel. In her forearm there were several areas of congested lymphatics with marked reticular pattern, but there wasn't any prominent vessel that could be bypassed. I injected isosulfan blue in the dermal layer just distal to the proposed incision in the hand. After exhaustive dissection a prominent lymphatic vessel identified this was dissected circumferentially. I made a small venotomy after placing microvascular clamps. The distal end of the lymphatic vessel was sutured to the vein in an end to end manner. This was performed with 11-0 nylon under maximal zoom under operating microscope. After anastomosis was complete clamps were removed and the tourniquet was taken down. There was egress of lymphatic fluid in the vein from the lymphatic vessel. After this wound was irrigated and hemostasis obtained.

33508

I am having issues with code 33508 when billed 33517-33521 for the vein graft. Code 33508 is denying due to 33533 being billed for the artery. For 2021 should 33508 be billed with a modifier, and if so which one? Please provide some guidance.

right aorto-uni-iliac bypass with full limb extesnion left leg

I really need some help with an EVAR. Was a main aorto uniliac on the right with a complete leg extension to the internal iliac on the left. Making it an aorto-bi-iliac in my opinion. But I can find no supportive documentation either way. Would this make this a 34705 or 34703 and 34709.

Multiple Vessel PE Mechanical Thrombectomy

Physician did a multiple-vessel (R & L) PE thrombectomy for a patient with commercial insurance. Can the physician code separately for the two distinct vascular families? 37184 in the RPA, 37185 in the right upper lobe, 37185 in the right lower lobe. Then code 37184 on a separate lesion in the LPA, 37185 on the left upper lobe and 37185 on the left lower lobe. Is it appropriate to code 36015 for selective cath placement in each of the segmental pulmonary branches, 75743 for each selective diagnostic CTA, and 99152 for moderate sedation?

Sternal clavicular joint 2 view CPT

What is the appropriate CPT code for a sternal clavicular joint exam that is two views only (oblique and PA)? We are currently reporting 71130; however, that code is for a minimum of three views. Code 71120 is for the sternum (not the joints).

2021 E&M

For 2021 E&M, should the providers document the risk in their office note now?

Multiple cysts same kidney

Using US guidance 10 cysts were drained from the left kidney yeilding 3000cc's of fluid. 20 gauge needle used for some of the cysts, 19 gauge for deeper cysts. Is it appropriate to code 50390 10 times with one US code ?

Stent in the LVAD graft with unlisted 33999

In 2018 you answered that you would report a stent in the LVAD graft with unlisted code 33999. So for reimbursement purposes, what CPT would you compare that to? I need to submit, so that we can create a .dot code to the 33999, and I am unsure what this needs to be based off. 

Mitral valve repair with annuloplasty band and neochords

"There was redundancy of P2 with ruptured cords. Ruptured cords were excised. The mitral valve was repaired as follows 2 sets of Gore-Tex neo-cords were placed to the P2 segment and the posterior prolapse was reduced and the valve was tested and was competent. There was a small leak between P1 and P2 which was closed with a 4-0 Cardionyl suture in a mattress fashion. Then we placed a 36 mm Cosgrove annuloplasty ring with 2-0 interrupted Tycron sutures and the Cor -knot device. The valve was then tested and it was competent and the cortex Neo-Chord for type II proper left. A folding plasty of the P2 segment was then performed using a 4-0 Cardionyl suture to reduce the height of the posterior leaflet." Would this be coded as 33427 or 0543T? Does 0543T include the ring if used? Or, does the "radical reconstruction" cover the artificial chordae placement?

Selective Bil common , internal carotid with left subclavian, vertebral

Our IR cardiologist are performing more specific catheterizations and I am having difficulty w/ carotid and subclavian; I think we need more specific documentation; see below; Physician is charging 36215 and 36222; and I am getting 36215; 36216; 36217; I am not sure how he got 36222; and input on what additional documentation is needed would be appreciated re: carotids and further.

PROCEDURE: Coronary Angiogram, LHC, Ventriculogram, Bilateral carotid angiogram, left subclavian.

ACCESS: Right femoral artery. CATHETERS: 6 French JR4, JR6 CONTRAST USED: Isovue 350 cc.

3. Bilateral Selective Carotids: Right common carotid is angiographically normal. Right Internal carotid artery has 60-70% disease. Left common carotid has anomalous takeoff from right brachiocephalic trunk. Left common carotid artery is normal. Left internal carotid has 20 to 30% disease.

4. Left subclavian: Left subclavian is normal, Left vertebral artery is normal.

37236, and 37237 vs new codes 33745, and 33746

In the past we have used code 37236 for a stent placement in the pulmonary artery for congenital cardiac treatments. Would 33745 be the appropriate code to use now?

Venovenous Reconstruction

Patient came in for calf mass excision, and vascular surgeon was called in to assist. Vascular surgeon harvested saphenous vein graft, then the vein was non-reversed in order to keep proper orientation for the venous reconstruction. An end-to-end venous anastomosis was created using a running 6-0 Prolente suture distally. The vein was then pressurized by releasing the distal control. MD then replaced and bulldog clamp on the saphenous vein segment. Then MD sewed end-to-end venovenous anastomosis with a running 6-0 Prolene suture. Following this, the proximal and distal clamps were removed. The right greater saphenous vein harvest site was irrigated with warm saline solution."

Should we go with unlisted because we can't find another code that would describe such procedure?

Types of endoleak

I have a diagnosis question. In your case of the month for October 31, 2018, type II endoleak is coded to other specified complication of vascular graft. However, in 3rd Quarter Coding Clinic 2020, pages 3-5, type II endoleak is coded to I97.89 (other postprocedural complications of circulatory system). Can you explain which is the correct coding for type II endoleak?

RHC with shunt run/shunt study

What is a shunt run/shunt study when it's done with a RHC? Can we code anything extra for that?

Doppler vs Spectral during echo

This is the only documentation for Doppler during a stress echo:

Doppler Measurements & Calculations

MV Peak E Wave: 0.6 m/s

MV Peak A Wave: 0.44 m/s

MV Peak Gradient 1.46 mmHg

TR Velocity: 2.34 m/s

MV Deceleration Time: 220.8 msec

TR Gradient: 21.93 mmHg

Is this enough to indicate spectral and color flow velocity were done?

Stereotactic mammography biopsy w post mammography imaging

If a report documents the abnormality was approached from the craniocaudal aspect using an upright digital tomographic mammography unit, and a biopsy needle was placed adjacent to the abnormality under computer guidance, and confirmatory stereotactic mammography images were obtained to document needle placement, would the post mammography imaging still be billable? Would the tomographic mammography be considered the same as stereotactic mammography biopsy?

Coding for guidance with Intrathecal pain pump refill

If a physician performs the reprogramming and refill of an implanted pump (62370) under ultrasound or fluoroscopy guidance (used to locate the reservoir fill port on the implantable pump), are we able to separately report the guidance? If the guidance can be separately reported, which code would be appropriate for ultrasound guidance (76942)? Or for fluoroscopy guidance (77002)?

Gastrostomy tube insetion without fluorscopy

We know that a gastrostomy tube insertion without the use of fluoroscopy should be coded with an unlisted CPT. Would it be more appropriate to use code 49999, Unlisted procedure, abdomen, peritoneum and omentum, or code 43999, Unlisted procedure, stomach? The CPT code book classifies a percutaneous G-tube insertion within the Abdomen, Peritoneum, and Omentum section.

Celiac artery and LMAL cosurgery

Hi, have cosurgery dictated as laproscopic median arcuate ligament release and exploration and lysis celiac artery. The celiac artery was dissected. The median arcuate ligament was identified. thick white band causing severe compression of the celiac artery. The band was transected in layers until the celiac artery takeoff was reached. Dissection was carried further proximally to celiac-aortic junction. The surrounding fibers of ligaments were transected with electrocautery. On releasing some of the fibers there was a pulsatile bleeding encountered from anterior surface of the celiac artery. It appeared to be small branch. This was clipped under direct visualization with good hemostasis I was satisfied that the celiac artery was freed as much as it can be safely handed over the case to Dr.. I think the mal release is unlisted 49329? so not sure if can bill also for the vascular portion or what that should be coded as. Thank you

64680 with 64530?

We have a patient who has pancreatic cancer. Patient is here for CT-guided celiac nerve block followed by celiac neurolysis with alcohol. Can we code both 64680 and 64530? Previous advice from 2016 said to only code 64680. Is this advice still correct for 2021?

Can i code both 33016 and 33017?

"Patient was brought to the cath lab. He was draped and prepped in sterile fashion. A micropuncture needle was advanced from the subcostal approach. Pericardial cavity was reached. Straw-colored fluid was drained through the micropuncture needle, then a micropuncture wire was advanced and a micropuncture sheath was introduced into the pericardial cavity. A J-wire was advanced through the micropuncture sheath, and a pericardial drainage catheter was placed in the pericardial cavity. Around 450 cc of fluid was drained from the pericardial cavity. Afterwards, the drain was left in place and sutured." In this case can I report code 33016 (pericardiocentesis with image guidance) along with 33017 since the physician left the drain in place? Or does 33017 include the work for 33016?

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.

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