Ask Dr. Z

A question similar to this one was answered in 2012, and we wanted to see if there were any updates. The physician does a renal diagnostic angiogram from the main renal artery (36251). He then moves into two branches off the main renal artery for embolization of areas of extravasation (37244). Although the diagnostic angiogram was from the main artery, should we use code 36253 instead since the catheter was moved superselectively to do the embolization?

Does the report excerpt below support coding 93463 for the metabolic cart testing? Measurements obtained include right heart pressures, direct & indirect FICK and thermodilution measurements, and additional stats below after aforementioned measurements. Would the metabolic cart oxygen testing = 93463? (Unable to paste entire Hemodynamics due to character limit)

"A Swan-Ganz catheter was advanced to the pulmonary artery under fluoroscopic guidance and routine hemodynamic measurements were obtained (see below). A metabolic cart was used to measure oxygen consumption, which then allowed us to determine the exact cardiac output and index, rather than just using the estimate provided by the assumed fick (which uses a constant x body surface area to estimate the oxygen consumption) or the thermodilution (which can often times underestimate cardiac output in advanced heart failure, right heart failure, tricuspid regurgitation) methods.

PA Sat: 67 %

Systemic Sat: 98 %

Hgb: 12.5

Oxygen consumption: 335 ml/min

Inotropes: None"

1. RT brachial artery open exposure. 2. RUE angiogram. 3. RT subclavian artery pseudoaneurysm repair with a covered Viabahn stent. Incision made on medial aspect of RT arm. RT brachial artery dissected out and encircled with vessel loops. Direct needle access gained into the RT brachial artery with placement of a sheath. Kumpe catheter was advanced to the level of the RT subclavian artery where angiogram was performed and confirmed CT findings of RT subclavian artery pseudoaneurysm. There appeared to be a 3-4 cm segment proximal to the pseudoaneurysm as well as a landing zone proximal to the RT vertebral artery. I passed a 11 x 5 cm Viabahn covered stent and deployed this just distal to the origin of the RT common carotid within the RT subclavian artery. Angioplasty was performed and imaging demonstrated no endoleak. 

Is this considered an open procedure and coded with 37799 (with comparable code 35011 since there is no CPT code for open subclavian artery aneurysm repair via brachial incision) OR an endovascular procedure with 37236 and 36140? Thank you!

Can you please tell me what code(s) this would be, as I am leaning toward an unlisted code 22899?

Dx is lower back pain

TECHNIQUE:

After obtaining informed consent and performing an appropriate timeout, the area overlying the lower back was prepped and draped in usual sterile fashion. The skin overlying the interspinous processes of L3-L4 and L4-L5 were anesthetized. Using a 22-gauge needle interspinous access was gained in both levels. An injectate which consisted of 80 mg of Kenalog, 2 mL of 0.5% bupivacaine, was injected into both spaces. The patient tolerated the procedure well and left the angiography suite in stable condition.

FINDINGS: Hypertrophy of the posterior spinous processes

IMPRESSION: Successful L3-L4 and L4-L5 interspinous blocks.

I have a question about billing CPT code 51600. Our provider documented “pre-existing suprapubic Foley catheter, approximately 250 cc of Cystografin was instilled by gravity drip into the urinary bladder”. In a follow-up email, the provider also stated they evaluated the anatomy post administration. Is this enough to code 51600, even if a -52 modifier is needed for us not placing the catheter? I have seen in earlier Q&As that “gravity technique is a common method of contrast instillation into the bladder”.

My facility is working on building a charge for C9780 from the Surfacer System. It appears that for the Inside-Out approach, they are recommending a combination of 36010, 75825, 75827, and 76937 to capture the entire procedure portion of the service for non-medicare payors. Our concern is that the charge amount of C9780 vs. the other four will result in overcharging our commercial payors. Can you please advise if those four codes would be the equivalent of C9780?

https://wellspan.file.force.co...

Would this stellate ganglion cryoablation be reported with 0442T for cryoablation nerve plexus or other truncal nerve or unlisted 64999?

"STELLATE GANGLION ABLATION: The patient was positioned supine with head tilted to the left. Initial CT/US imaging was performed to identify and localize the region of the left stellate ganglion. Under continuous ultrasound guidance, the region of the left stellate ganglion was approached with a 17G IceSphere Cryoablation probe by traversing the region between the right jugular and carotid artery and the right vertebral artery. Location was confirmed with CT. A single 8 minute freeze cycle was performed, with CT images obtained at 7 minutes, followed by passive thaw. The probe was removed, and post-ablation CT images were obtained."

Physician performs a limited TEE CPT 93308-26 with 93325. On same day at different session physician performs a complete TEE with Doppler and color flow (93306-26). How should 93308-26 with 93325 be coded? I can use modifier -59/-XE on 93308-26, but what about 93325? Since it is an add-on code, guidelines state no modifier usage on add-on codes. How should this be coded?

Please clarify if documented as axillary tail mass the biopsy code would be 20206 and would be 38505 if axillary tail lymph node, or should axillary tail mass be coded as a breast biopsy ex 19083?

Would you clarify the documentation required for CPT 93880 - duplex extracranial complete bilateral study? Is documenting the common carotids, internal carotids and veterbrals enough or do we also need the externals. Since the CPT description states "complete bilateral study", would that not mean that all the extracranials should be documented and not just a few? We have conflicting guidance and would appreciate your input.

"Under CT fluoroscopy, the stomach had transited and now entirely draped in nodule and there was no longer a window. At this point we decided to abort the procedure."

Sedation time was only 7 minutes so unbillable.

We billed the CT guidance only. A coding auditing program is advising that we also bill 49180-74. Since the conscious sedation was unbillable, would this be correct?

The initial intention was to place a ND/NJ tube. However, the tube wasn't able to be manipulated into the duodenum, only to the stomach. In this case, I know we shouldn't code the 44500, 74340 due to the tube not reaching the duodenum/jejunum but would instead go with 43752. The issue is, it's an APRN-CNP placing the tube, and the description of 43752 is strict and clear about it needing to be placed by a PHYSICIAN. How would you recommend coding this? 44500-52, 74340-52 crossed my mind, but wasn't sure.

"Indication: Traumatic subdural hematoma.

Under fluoro and roadmap guidance, Prowler Select microcath advanced over Synchro Select 0.014 microwire into parietal branch of the RT MMA, distal to foramen spinosum, images obtained in biplane projections. Angiogram shows normal antegrade flow w/ no evidence of intracranial anastomosis and no opacification of RT ophthalmic artery or RT retinal blush. Tortuosity in proximal frontal branch of the RT MMA, cath not attempted due to concern for inadvertent embolization of central retinal artery. Under blank roadmap 100-300 micron Embospheres, mixed w/ contrast, injected w/ progressive occlusion of parietal branch of RT MMA. Under blank fluoro & roadmap, microcath slowly flushed w/ heparinized saline. Under fluoro guidance coils deployed into main trunk of RT MMA w/ progressive occlusion."

61626 vs. 61624? I say 61626 due to dura encasing CNS by definition and not CNS from coding description for 61626 also MMA is part of extracranial branches, so non-CNS. Do you agree?

I'm not a vascular coder so I need some help. Doc intended to do a coronary PCI but pre-op angio demonstrated extensive femoral disease and cath was not able to be advanced, so doc did diagnostic angio in the femorals. He accessed the right femoral and shot vessels, then accessed the left femoral and shot the vessels. For some reason I'm thinking 75716 would be used if the dye was shot above the aortic bifurcation. So, since doc assessed the right and left separately, we should use 75710 x2. Yes? No?

Is there anything to charge for the attempt?

EXAMINATION: Right elbow arthrogram.

FINDINGS: After explanation of the procedure and potential complications of infection and bleeding, the patient was given the opportunity to ask questions. Signed informed consent was then obtained from the patient. Patient verification and time out was performed.

The right elbow was prepped and draped in the usual sterile fashion. Buffered one percent lidocaine was used for local anesthesia. Under fluoroscopic guidance, a 25-gauge needle was used to attempt to get into the radiocapitellar joint space. We were not successful at cannulating the joint space. There were no immediate complications. The patient was instructed to observe for signs or symptoms of infection.

IMPRESSION: The elbow joint was not successfully cannulated.

The innominate artery was selected, followed by the right common carotid artery. Biplane cervical and intracranial angiograms were performed from the right common carotid artery before stenting. Measurements were made from magnified oblique projections and an 8 mm x 2.5 cm GORE Viabahn covered stent was selected. This was prepped in the usual fashion with an Aristotle 18 microguidewire. The stent was attempted to advance through the Cerebase, but the sizes were not compatible.The Cerebase was fully removed from the body. Next, a 90cm BMX96 was advanced over the 130cm Berenstein selection catheter and Terumo Glidewire to the level of the aortic arch and the right common carotid artery was selected.  The 8 mm x 2.5 cm GORE Viabahn covered stent was then advanced over the Aristotle 18 microguidewire to the distal right common carotid artery. Next, the stent system was removed and we proceeded with balloon angioplasty to ensure good wall apposition. Would this qualify as 37215, EPD not specified?

We have a physician documenting IVUS in the lower extremity like this: "We then performed intravascular ultrasound. This was necessary as the angiogram did not adequately demonstrate location of wire as well as morphology of plaque. The findings are as follows: Please note, we performed individual intravascular ultrasound, which was distinct from the pullback. In the peroneal artery, there was no significant stenosis appreciated. The tibioperoneal trunk

had no significant stenosis. We were indeed in the true lumen. The popliteal artery had 100% occlusion. There was soft plaque and what appeared to be chronic thrombus. The superficial femoral artery had mild stenosis measuring

20%-25% diffusely. The common femoral artery had no significant stenosis." Would you count each individual vessel as a separate 37253? We have still been only giving credit for 1 vessel as it still seems to be a pullback even though they are documenting it isn't.

"Limited incision was made thru subcutaneous tissue with cautery. The femoral sheath was sharply incised. A severely diseased artery was identified that was circumferentially severely calcified. Dissection extended under the inguinal ligament where the external iliac artery was controlled. Heparin was administered. Longitudinal arteriotomy was made with a #11 scalpel and then extended with a Potts scissors. Severe calcific and mixed plaque in the common femoral artery was identified. Endarterectomy was extended up into the distal external iliac artery. Separate endarterectomy profunda femoris artery was necessary due to the extent of the plaque. Good backbleeding was obtained. The SFA was endarterectomized as the saphenofemoral junction was noted to be relatively low. Primary closure of the endarterectomized vessels was undertaken with running 6-0 Prolene suture."

Would you code this as 35355 and 35372-- is "arteriotomy was extended" to bill both?

During a port a cath placement, the provider stated the guidewire was inserted through needle and confirmed to travel to the IVC via x-ray imaging intraop. Later in the note he says x-ray was utilized to confirm location of the catheter at the atriocaval junction. I was advised by the audit team to query because fluoroscopy was not mentioned and we felt the 77001 was not supported. The provider responded that "x-ray is fluoroscopic guidance". Would this be enough documentation to support 77001? There is nothing else in the note, procedure list, or findings that mentions the fluoro guidance. Would you recommend an addendum as well?

We have a physician who is performing transperineal MRI-ultrasound fusion prostate biopsies. As a preparatory step of the procedure, MRI segmentation and contouring of the prostate is required. This step is usually performed by the radiologist, but they use a different system at this site and the urologist is performing this step. He was told by a vendor this step is billable with code 76377 and that the contouring/segmenting needs to be done on a day other than the day of the biopsy. Would you agree that codes 76377 and 72197 could be billed by the urologist if the documentation supports billing the two codes?

Redo sternotomy; Cutdown of Femoral for cannulation for cardiopulmonary bypass; Extensive adhesiolysis; Inferior approach to the mitral valve with radical mitral valve debridement and preservation of the posterior mitral annulus; Mitral valve replacement (TRANSCATHETER SAPIENT 3 ULTRA 26MM

I'm confused because the surgeon describes performing a sternotomy (not a mini-thoracotomy) w/extensive lysis of adhesions. He also excises anterior leaflet and resects posterior leaflet partially. He uses a 26 Sapien balloon inflated w/saline to assess the size. He goes on to talk about using a balloon to size the annulus and selects the Sapien 3 ultra valve. Under direct vision the crimped valve was advanced antegrade through the mitral annulus. Then the balloon was deflated and deployed uneventfully. Would the 0484T, 33368 be reported? Or 33430 with 33530? Maybe the confusion is the procedure performed states TMVR Sapien, but in actuality this was open. I would appreciate any help?

According to the Shockwave IVL reimbursement guide (included link below) CPT add-on code 0715T is appropriate for physician billing only. The HCPCS Coding Clinic 2nd Q 2023 states that 0715T can be reported with codes C9600-C9608 or 92928 along with the device code C1761. However, this Coding Clinic does not differentiate the encounter type (physician billing vs. hospital outpatient APC billing). Please clarify if it's appropriate to report CPT 0715T on Hospital Outpatient/ASC claims. 

https://shockwavemedical.com/r...

I had heard in an IR webinar that for ultrasound guidance 76937 permanent recording of images didn't have to be stated if the ultrasound machine used uploaded the images to the patient chart automatically, since now most equipment used in hospitals now have that capability. Are you in agreement with this statement or do you feel they should still state the permanent recording (of course it's best to state it) but wanted to know your thoughts on this and/or if you had seen this documented anywhere?

I have a question regarding your response to Question #19449. You advised that since the physician documents "Successful ablation for slow pathway for treatment of typical AVNRT" to code 93653 even though the patient was not inducible for Atrial tachycardia or Atrial Fibrillation during the EP study and it was an "empiric" ablation? I thought we are not to code empiric ablations. Please clarify. Thank you in advance.

Patient came in for a right ventricle to pulmonary conduit replacement due to severe conduit dysfunction with stenosis and regurgitation. Patient had tetralogy of Fallot with pulmonary atresia with repair ten years ago, so would you report code 33920 for the replacement since patient did originally have pulmonary atresia, or would you report code 33608 since the pulmonary atresia was corrected ten years ago?

I am having an hard time choosing a code for this interspinous bursa injection that was done for interspinous bursa with pain. Would this be considered being coded with the arthrocentesis/injection codes? Intermediate or major joint? Please help on this one. Below is the report:

FOLLOWING THE INFILTRATION OF LOCAL LIDOCAINE AND USING FLUOROSCOPIC GUIDANCE, A 22 GAUGE SPINAL NEEDLE WAS INSERTED INTO INTERSPINOUS BURSA AT THE L3-L4 LEVEL. CONTRAST INJECTION DEMONSTRATES THE NEEDLE TO BE WITHIN THE BURSA. A TOTAL OF 120 MG OF DEPO MEDROL AND 4 CC`S OF 0.25% SENSORCAINE FOR A TOTAL VOLUME OF 7 CC WAS INJECTED INTO THE BURSA. THE NEEDLE WAS REMOVED AND HEMOSTASIS WAS ACHIEVED. THERE WERE NO COMPLICATIONS. A TOTAL OF 2.2 MINUTES OF FLUOROSCOPY WAS USED.

93297, 93298: As per CPT guidelines, to bill CPT 93297 and 93298 requires a minimum of 10 days of monitoring. Suppose the provider receives the report on the 10th day with 9 days of remote monitoring data and signs the report on 10th day. The provider has not received and signed any other reports between day 10 and day 31. Is the charges billable?

93294 and 93295: As per CPT guidelines, to bill CPT 93294 and 93295 requires a minimum of 30 days of monitoring. Suppose the provider receives the report on the 30th day with 29 days of remote monitoring data and signs the report on 30th day. The provider has not received and signed any other reports between day 30 and day 91. Is the charges billable?

Confused on documentation for the two codes, if injection by the radiologist do we code 62370 or does the report need to say the physician skill was needed and we should code 62369 if not mentioned?

Can we bill transthoracic echo limited with color flow and pulsed wave codes 93308-26, 93321-26, and 93325-26 on the same date of service as the TAVR code 33361? The TAVR IS PERFORMED by one cardiologist and the TTE is preformed by a DIFFERENT cardiologist. I know we can bill the TEE 93355 when a TAVR is preformed when a different cardiologist performs the TEE. Our cardiologist are now starting to do the TTE with the TAVRs. I had read on one of your post if they preformed a TTE the diagnosis would need to be different from the reason we preformed the TAVR. Could you please give clarification on if we can bill a limited echo 93308-26, 93321-26, 9325-26 with a TAVR with two different providers, one preforming the TAVR and the other preforming the transthoracic limited echo when the same diagnosis is being applied?

Diagnosis - Pseudoaneurysm, left femoral artery /Dehiscence of the pericardial patch from femoral artery.

Dictation: I made a left flank incision to obtain retroperitoneal control of the left limb of an aortobifemoral graft. I dissected out the left limb of an aortobifemoral graft and was able to put a spring clamp on the left limb of the aortofemoral graft. I then proceeded to remove sutures from a left groin wound. I evacuated all the clots and there was a hemorrhage. On exploration, it appeared that about 25% the pericardial patch had dehisced from the left common femoral artery. I then proceeded to re-suture it with a 5-0 Prolene and ran several sutures along that anastomosis at the site where it had dehisced several interrupted sutures. After I placed the sutures and removed the clamps, it appeared that the bleeding was controlled.

Would this procedure be coded to revision of graft 35883 or would 35141 be more appropriate. Thanks for your help.

Need correct code for procedure.....

Patient catheterized via umbilical cath channel by Urology...and needle inserted into bladder. Bladder lumen opacified. ...Then IR.....Skin of Abdomen prepped and draped and Ropivicaine infused at Venous insertion site. Urine obtained, rosen wire inserted into bladder and coiled. Tract dilated with stiff micropouncture set and secured within bladder. Care then transferred. to Urology for stone extraction. 

Is it 51702? Urology billed 51102 in addition to code for stone extraction

Our vascular surgeons have started perform the Detour percutaneous femoral-popliteal bypass graft. There is not much information regarding the billing of this procedure. What would this procedure be comparable to? What CPT code(s) would be a comparable “crosswalk”? Additionally, I understand this is a carrier priced; however, what would be the best practice as far as post op visits? Should visits after fall within a global package like they do with an open bypass?

"The graft was accessed under ultrasound guidance. Contrast was injected, confirming a focal stenosis at the level of mid humerus. A 6 French sheath was placed and a Kumpe catheter advanced into the proximal graft where contrast was injected. This demonstrates a second more proximal stenosis near the graft/venous anastomosis. Angioplasty was performed of these stenoses. Contrast was then injected more centrally where prominent collaterals are present. These seem to be related to a recurrent stenosis in the subclavian vein. Angioplasty was performed with a 12 mm balloon. The balloon ruptured and would not fit in the 7 French sheath. Unable to remove the balloon through the sheath, access was achieved in the right common femoral vein and a 10 French sheath placed. A snare was used to capture the proximal end of the balloon."

Are codes 36902, 36907 and 37197 correct? Can we also code the catheter placement from the groin?

We have an order in a hospital setting for a CT-guided abscess drainage (49406). After the patient is prepared, the radiologist is unable to drain any fluid. How should that be coded?

During EPS study, at the end of the procedure note it was mentioned as “Drug study with arrhythmia induction, Adenosine was infused and repeat arrhythmia induction was performed with no inducible sustained arrhythmias”. Is the physician trying to check the adequacy of the procedure performed? If yes, should we deny CPT 93623 based on NCCI Policy Guidelines? Or the physician is performing a diagnostic study in order to see if there is any arrhythmogenic foci left over to ablate and therefore CPT 93623 should be billed separately?

Procedure: Intracranial embolization of chronic subdural hematoma through middle meningeal artery.

Please provide confirmation, that although a CTA/MRA was performed, a catheter-directed diagnostic angiogram is reportable if the provider documents medical necessity; and, second, when a diagnostic angiogram is not reported (intervention only), that it is proper to report the catheter placement codes during intracranial embolization (referring to CPT code 61624). Have I misunderstood something? Having this guidance from you, in 2023, will resolve issues on this matter. If any changes have occurred please kindly inform. Your help is greatly appreciated.

Patient had a tonsillectomy and adenoidectomy with intraoperative course complicated by oropharyngeal bleeding. IR did cerebral angiography of internal carotid (36224), external carotid and facial artery (36227). Coil embolization was then done of the left inferior pharyngeal artery and again in the left ascending palatine artery.

Your previous guidance, question ID 18819, states to code to the highest level performed when it is a bleeding tumor, but would the same guidance apply for intracranial or extracranial arteries? Would this be 61626 (75894, 75898) or 37244?

After angiogram done -I pass an intravascular ultrasound through the right common femoral artery, superficial femoral, popliteal, tibial peroneal trunk, posterior tibial arteries. This demonstrated patent right common femoral artery, occluded right superficial femoral artery stent, 60% stenosis of the right popliteal in the P1 plus P2 segments but patent P3 segment, patent tibioperoneal trunk and posterior tibial arteries without stenosis. I see 37252 and 37253 x2 . My coworker thinks it is pull back and only gives 37252. but there are 3 separate pathologies (with tibio being patent) also if you could clarify if SFA and CFA are the same or separate vessels for IVUS imaging.

A right femoral PTFE graft was punctured, fistulagram and central angioplasty were performed due to a pseudoaneurysm along the right arterial limb and common iliac stenosis. A direct needle injection of thrombin under US guidance into the pseudoaneurysm sac was performed. Can this be coded as 36909 or 36002/76942 with modifiers? 

When a patient comes in for a G-tube placement and has dysphagia secondary to ALS or in other instances dysphagia due to throat cancer what would be the proper diagnosis coding/sequencing? Is dysphagia considered inherent to ALS and not coded at all? In patients with throat cancer would the dysphagia be coded first since that is why they are getting the G-tube? Or would dysphagia be considered a sign/symptom of the cancer and not coded? If both dysphagia and cancer should be coded, what would be the proper sequencing?

We have a procedure that took place similar to question ID 5119, since this is an older question we wanted to see if the guidance has changed. Our physician completed a new bypass where a PTFE was placed between the CFA/SFA. It did take place on the same leg (left). There was no previous bypass. Would we treat this as a FEM-FEM bypass 35661 even though that specifies right to left. Or would we go with the unlisted CPT?

Can I bill 36558 and 36821 during the same operative session? I am getting a denial as not separately payable.

Left radial cephalic AV fistula. 2. Right internal jugular tunneled hemodialysis catheter placement. 3. Removal of right femoral temporary dialysis catheter.

I did not bill for the temp cath removal, as there is no code I could find for that.

43-year-old female on peritoneal dialysis admitted with fluid overload, shortness of breath, cardiac tamponade who was not tolerating peritoneal dialysis and recommendation to convert to hemodialysis.

Is code 37243 appropriate for the following procedure?

"A 4 French Cobra catheter was advanced over the aortic bifurcation and the left internal iliac artery was selected. Angiography was performed-microcatheter was advanced into the left uterine artery. A small vessel travelling inferiorly, likely a vaginal artery, was identified and the microcatheter advanced beyond this point. Embolization was performed with 500-700 micrometer beads until there was sluggish flow. After some difficulty attempting to cannulate the ipsilateral, right internal iliac artery with a SOS catheter, Omni flush catheter was used to access the artery and then exchanged for angled glide catheter over the wire. Angiography was performed which showed a smaller right uterine artery which was quite tortuous. Numerous attempts to advance the microcatheter distally were unsuccessful. This site was abandoned. The catheters were removed and an angiogram of the right external iliac artery and common femoral artery was performed showing normal caliber and anatomy."

Patient presented for biventricular pacemaker. RV lead was placed in the RV apex. Multiple attempts made to place a lead in the CS, but continued to dislodge. A left bundle lead was placed in the RV septum and leads connected to the pacemaker generator. Would you code this as 33207 or 33207 and 33225-74?

Can you please advise if there are any billable CPT codes for CMD studies performed in the cath lab at the same time as coronary angiograms and FFR, with codes 93454 and 93571. Our provider is performing these and is asking for additional billable codes for the CMD studies.

Procedures performed: Right/Left coronary angiography. CMD Study Values. Pressure flow reserve measurement.

6F FR4 catheter was placed. Selective right coronary angiography. Contrast was injected. Images were obtained using multiple projections. Selective left coronary angiography. A 6F JL4 catheter was introduced. Contrast was injected. Images were obtained using multiple projections. Successful CMD Study Values for the LAD Mid was performed. A CMD study was performed and data was obtained. The study was Positive and the results were: RFR = 0.92, CFR = 1.3, IMR = 81, AND FFR = 0.99. Pressure derived flow reserve measurement for the mid LAD. Flow reserve was measured using a 175 CM PRESSURE WIRE X pressure-monitoring guide-wire. The flow reserve was calculated to be 0.92.

What would be the appropriate codes for this scenario? 36556, 77001, 36589?

"Procedure performed: Over the wire exchange right tunnel dialysis catheter to non-tunneled temporary catheter.

Fluoroscopic guidance: Existing catheter and skin was prepped and draped in usual sterile fashion. Lidocaine was infiltrated around exit site of the catheter. The catheter was mobilized and pulled back and an over the wire exchange was performed for a 24 cm non-tunneled temporary dialysis catheter. Catheter was positioned with the tip in the right atrium."

Transjugular liver biopsy was scheduled for the patient. Physician was unable to access the hepatic vein, so the decision to abort the procedure was made. The physician performed a percutaneous liver biopsy instead. Can I code the transjugular biopsy? I feel like I cannot because the percutaneous biopsy was completed instead.

This is a 21-day-old patient with a complex intrahepatic arterioportal fistula. The report says to apply modifier -63, which I have never used before but seems to apply. They are embolizing two arterial feeders to this AVM via an umbilical venous approach. Sounds like they went through the ductus venosus and selected both arterial feeders separately (which appear to stem from bilateral inferior phrenic arteries). My question on the catheterization is would this be two second order venous catheterizations 36012 x 2, or does it switch to arterial? If we code arterial, what order of selectivity? They're trying to assign 36247 and 36248. Also, would this be coded 37241 for venous embolization or 37242 for arterial? What would be the correct cod, and should I use a -63 modifier? 

What CPT would be best to use since the provider only replaced the valve on the pleural catheter?

Patient was positioned in the semiright lateral decubitus position and the left chest and pre-existing catheter were prepped and draped in usual sterile fashion. Preliminary fluoroscopic images demonstrate satisfactory positioning of the catheter. Ultrasound of the left chest demonstrated a large left pleural effusion. A syringe was attached to the catheter valve and aspirations were attempted. No pleural fluid was aspirated. Given these findings, the pre-existing valve was removed after which copious amounts of pleural fluid was noted to be draining through the catheter. As a result, the valve was replaced and aspiration yielded pleural fluid via the new valve. Approximately 1200 mL of yellow fluid was then removed successfully without incident.

What code would you recommend for the G-tube repair described below?

"Procedure: The existing jejunostomy tube was injected and images obtained. The tube was then removed and a new custom length 14 F EnFit jejunostomy tube was placed with its tip in the distal ileum. Attempted retraction and shortening, however, patient could not tolerate additional manipulation. Post placement injection was performed. The balloon was inflated with 4 mL of saline. Attention was turned to the leaking Kangeroo-type gastrostomy tube. The gastric port was noted to be gastric contents. A new MIC-type dual port a doctor was applied and the like he was controlled. The gastrostomy tube was injected with contrast material. 

Findings: Initial injection shows existing jejunostomy tube terminating in the cecum. After exchange, jejunostomy tube terminates in the distal ileum. Patient could not tolerate additional manipulation and thus the case was terminated. Gastrostomy tube in good position. 

IMPRESSION:

1. Jejunostomy tube exchange.

2. Gastrostomy tube repair."