Ask Dr. Z | Medical Coding Resources (2024)

Knowledge Base

All 2024 2023 2022 2021

I hope you can give some insight into this procedure. Basically the physician performed open revision with thrombectomy (36832), then performed fistulogram (36147), followed by percutaneous venous angioplasy (35476and 75978-26), andthen decided to ligate the entire fistula (37607) and create a whole new graft (36830). Based on the below documentation, would you bill all those codes? Or should only the open procedure be coded as per NCCI Chapter 5, Section D, #9? Any assistance will be appreciated!

A linear incision was made in the fistula at the arterial anastomosis. I noted immediately that the thrombus was well organized and adherent to the fistula walls. It required mechanical removal. I carefully inspected the area of the arterial anastomosis, removing the fibrin plug. I passed a #3 Fogarty catheter distally in the brachial artery and retrieved no additional thrombus. I sounded the proximal brachial artery with the right angle, and there was no evidence of a stricture at the arterial anastomosis. I removed as much thrombus from the body of the fistula as allowed by the arterial cuff, which had been placed proximally. In order to control the arterial inflow and to avoid stricturing of the fistula, I acquired a bovine patch and partially closed the fistulotomy with the bovine patch and 6-0 Prolene suture. This allowed for application of an atraumatic clamp at the arterial anastomosis and removal of the proximal arterial tourniquet. I evacuated the clot from the remaining portion of the fistula body by vigorous manipulation beginning at the axilla. I removed a relatively small amount of clot. I did retrieve venous backbleeding. Heparinized saline was instilled, and an atraumatic clamp was placed on the body of the graft. The patch angioplasty was completed. There was a pulse within the graft with removal of the arterial tourniquet. This was not accompanied by a thrill though there was a continuous Doppler signal. I cannulated the patch with a 21 gauge micropuncture needle. I advanced the 0.018 guidewire under fluoroscopy. The needle was exchanged for a 5 French transitional dilator. I removed the inner stiffener and 0.018 guidewire, and through the transitional dilator, I performed a fistulogram. Although there was continuous flow in the fistula the fistula was noted to be quite sclerotic. This did not appear to be thrombus. A retrograde filling of the brachial artery revealed the arterial anastomosis to be widely patent. I attempted to pass a short 0.035 guidewire through the transitional dilator, but it would not negotiate the fistula. I acquired a 0.035 Glidewire, and with some manipulation the Glidewire traversed the fistula and was placed in the superior vena cava. I removed the 5 French dilator and advanced a 6 French short sheath. I advanced a 5 French Kumpe catheter over the Glidewire and exchanged the Glidewire for a 0.035 Rosen wire. I repeated the fistulogram documenting the fairly extensive sclerotic changes within the fistula. Again, these did not appear to be thrombus. I acquired a 5 French and subsequently a 6 French x 4 centimeter balloon catheter and proceeded to dilate the entire fistula from the end of the sheath to the basilic vein junction with the brachial vein. There was no evidence of a central stenosis. The balloons were inflated to pressures of 14 millimeters of mercury. Following the balloon angioplasty, I repeated the fistulogram. While there was some improvement in the luminal diameter of the fistula, it remained quite ratty and there was sluggish flow. I did not feel that further efforts at maintaining the fistula would be productive. I ligated the fistula just beyond the arterial anastomosis. I proceeded with an AV graft insertion. A short incision was made in the axilla, and I identified a 12 millimeter brachial vein. I carefully dissected between the nerve trunks and identified a 6-7 millimeter axillary artery. The artery lies medial and deep to the vein. A counterincision was made on the upper arm to allow for tunneling in a loop configuration. The patient was given an additional 1000 units of heparin. I carefully exposed the artery, placing no tension on the nerve trunks. An end-to-side arterial anastomosis was completed with 5-0 Prolene suture. Two of thethree large nerve trunks lie medial to the graft andone lies lateral. Upon completion of the anastomosis, there was no anastomotic bleeding. The bovine graft was then withdrawn through the subcutaneous tunnel intwo movements. It was allowed to lie in a gentle loop configuration. A partial occlusion clamp was placed on the axillobrachial vein, and an end-to-side anastomosis was completed between the bovine graft and the vein with a 5-0 Prolene suture. Whereas the arterial anastomosis is 5-6 millimeters in length, the venous anastomosis is 8-10 millimeters in length. Prior to completing the anastomosis, the vessels were vented and were flushed with heparinized saline. There was minimal anastomotic oozing. This was readily controlled with Fibrillar. Once hemostasis was confirmed, thethree operative wounds were closed withtwo layers of absorbable suture.

I have a case that thephysician accessed the right renal artery, and right renal arteriogram was performed, demonstrating filling of the adrenal artery with supply up in to the right lobe liver mass. The right adrenal artery was selective along with an adrenal arteriogram (the adrenal artery comes off the renal artery). Chemotherapy was then infused into the right adrenal artery slowly over 20 minutes. Embolization was then performed with a combination of 100-300 and 300-500 micron particles of biospheres. Because the renal code 36251 includes the renal arteriogram, how would I code for the adrenal artery that comes off the renal artery? Would you reportcodes 36246 and75731-26, or just code 36251?

I have a group of cardiologists who are inserting a permanent pacemaker lead and then attaching it to an external device. The patient is often returned to his room like that. Since some of these patients are in observation status, I am getting a device edit looking for the procedure. But I also know that I cannot charge for a temporary pacemaker insertion in most of these cases. Should I just continue removing the C-code from the lead on the claim to remove the edit?

I am being questioned about how the following report should be coded: "Using CT guidance a Jamshidi needle was placed in the left posterior iliac line. A 15 cc aspirate was obtained and handed to cytopathology technologist. A core was attempted to be obtained through the Jamshidi needle; however, despite multiple attempts all that was gained was clot.Core specimen was not obtained." Should this bereported with code38220 or 38221, with/without a modifier? Is there any difference between the physician and facility coding in a case like this? Also I am being asked in what cases would code 38220 be reported? He thought just an aspiration (38220) would never be performed. Thanks so much for your help!

I have a case where the patient hastwo renal arteries coming off the aorta on the right side and an angiography was done on each. Would I report code 36251 twice because you have to come back out to the aorta to select the second renal artery, or is it coded once because the description for code 36251 mentions accessory arteries also, but does that just mean arteries that branch off the main renal? And if it is coded twice with 36251 would the second have a -59 modifier?

Patient has a native fistulathat is clotted off. The fistula is accessed and imaging is performed, showing the venous end is thrombosed. Thrombectomy is performed, but there is residual clot. A 10 cm infusion catheter is placed, and overnight thrombolysis is started. Patient returns the next day for a follow-up angiogram. Can we report codes 36147, 37187, 37212, and 37214? Our coding staff is having a difficult time knowing when it is appropriate to code thrombolysis for AV fistulae. What is the anatomical landmark you would suggest?

I am having trouble coding one of our physician's dictation. He is trying to bill a left andright heart catheterization as well as left and right congenital heart catheterization. Is that possible? He wants to bill the following: 93460-26, 93531-26, 93463, 93464-26, 93567, 93568. Would this be appropriate?

CARDIAC CATHETERIZATION INDICATION FOR STUDY: Evaluation of hemodynamic significance of patent ductus arteriosus. FINAL IMPRESSION: 1. Angiographic confirmation of a 3.8 mm diameter patent ductus arteriosus with an associated QP:QS shunt fraction of 1.25. 2. Mild pulmonary hypertension. 3. Elevated left ventricular end-diastolic pressure. 4. Widened pulse pressures secondary to patent ductus arteriosus. 5. Normal pulmonary vascular resistance and pulmonary vascular resistance index and transpulmonary gradient. 6. Normal coronary anatomy. DISCUSSION: The hemodynamic significance of the patient's patent ductus arteriosus is likely a modest contributor to the patient's exercise intolerance and recent heart failure admission. Her QP:QS is likely underestimated as a definitive sample distal to pulmonary flow was difficult to ascertain, but was confirmed as best as possible via angiographic method using a JR4 catheter. Her other contributors to exercise intolerance include obstructive lung disease, the etiology of which is yet to be elucidated, particularly given her abcense of smoking history. Alpha 1-Anti trypsin serology is pending. Formal pulmonology consultation has been undertaken and her high resolution CT scan today evidences air trapping of unclear etiology. Consideration may be given to coiling of her patent ductus arteriosus or the usage of an Amplatz occluder. Formal consultation with pediatric cardiology at XX Hospital may be considered. PROCEDURE: Risks and benefits were explained to the patient. The patient was brought to the catheterization lab in a resting fasting state. The right femoral artery and vein were chosen for vascular access. JL4 JR4 catheters were used for selective angiography. Pigtail catheter was used for aortic angiography. A JR4 catheter was used for pulmonary arterial angiography. At the conclusion of the procedure, a StarClose device was deployed for hemostasis. No immediate complications were noted. CARDIAC CATHETERIZATION DATA: 1. Weight 56.7 kg. 2. Body surface area 1.56. 3. Blood pressure 109/41 with a mean of 60. 4. Oxygen consumption directly measured outside the catheterization lab was 208 mL per minute. 5. Respiratory quotient 0.78. 6. RA pressure, 8/60 (4). 7. RV 36/1, 7. 8. PA 26/ 3 (15). 9. With exercise, mean PA pressure was 20/8 with mean of 13. 10. Wedge pressure was 10/9 (7). 11. Aortic pressure 118/50, mean of 76. 12. LV pressure process 125/4, 19. 13. Saturations in the aorta were 96%. 14. PA saturation was 76%. 15. Pulmonary capillary wedge saturation was 92%. 16. Right ventricular saturation was 73%. 17. Right atrial saturation 64%. 18. Superior vena cava saturation 69%. 19. Inferior vena cava saturation 74%. 20. Attempts to cannulate patent ductus arteriosus, either from the pulmonary or arterial circuit were unsuccessful using a JR4 and IMA catheter. Wires including a BMW wire and Versa Core wire. Selective angiography of the pulmonary arterial tree did not evidence a communication with the aorta likely secondary to increased aortic pressures relative to pulmonary artery pressure; however, communication was identified from the arterial circuit to the main pulmonary artery in the LAO 60 degree position. 21. Hemoglobin 10.5. 22. Heart rate 65. 23 QP:QS 1.25. 24. Cardiac output and index by the Fick method were 6.12 and 3.92 respectively. 25. AVO2 difference 3.4. 26. Transpulmonary gradient 8. 27. Pulmonary vascular resistance 1.3. 28. Pulmonary vascular resistance index 2.04. 29. Right ventricular stroke work index 663. 30. Aortic root angiography demonstrated a 3.8 mm ostial diameter of a patent ductus arteriosus. The maximal luminal diameter of the ascending aorta was 34.9 mm. 31. Pulmonary artery angiography did not evidence a communication to the aortic circuit. CORONARY ANATOMY: Left main arose from the left coronary cusp, bifurcated into the left anterior descending and left circumflex coronary arteries, and left circumflex was dominant. The right coronary was nondominant and arose from the right coronary cusp. COMPLICATIONS: None. FLUOROSCOPY TIME: 30.9 minutes. TOTAL CONTRAST ADMINISTERED: 180 mL.

We have a case where they placedthree needles for localization in the breast, each dictated in a separate report. They were placed at 12 o'clock posterior depth, 12 o'clock anterior depth, and 12 o'clock middle depth. In each impression it reads needle localization for the marker clip in the left breast at 12 o'clock middle depth, 12 o'clock anterior depth, and 12 o'clock posterior depth was successful. We asked the tech at the hospital if these werethree separate lesions, and she said no they werethree separate areas of the breast, not really a lesion. The patient did havethree biopsies of these areas with the clip placement. Would we report this with codes 19290 and 19291 x 2? Or just code 19290?

Patient comes into ER with back pain. Coders are trying to code a retro limited x2 because there is a report for the aorta for AAA and then a report for the renals, and there is an MUE of 2 allowed. In reading the info, renals and bladder were actuallydone, so retro complete should have been coded for renals, but they insist that there can still be a retro limited for the aorta also now. I am thinking if just renals and aorta, thenone limited... and if renals, bladder, and aorta then just one complete.

While performing uterine fibroid embolization, an accidental puncture of the uterine artery was made. This required an additional coil embolization. Is there any way to code this separately?

What is the correct code for reporting open angioplasty of AV graft, arterial side?

SFA is stuck and catheter goes antegrade to the anterior tibia...would the catheter placement be 36246 because it is same leg? Or ,would it only be code 36140? Same scenario, but in the veins SFV is stuck and catheter goes to (retrograde) anterior vein. Would this be reported with code 36011 or 36005? We have been having a long discussion in my office, and now I am confused.

Could you please assist with coding the following?

Indications and findings: ESRD patient noted swelling in the region of his LT chest/shoulder. MRI suggested a subcu mass superficial to the mid clavicle, suspicious for a complex loculated fluid collection, with angulation of the stent. The patient's stent graft in the axillary vein was known to be thrombosed. I&D of abscess was performed; however, after one month, the wound has not completely closed. Today, the patient was found to have a chronic draining sinus, which extended down below the clavicle. There was an infected stent graft within the axillary vein identified at this level. The vein wall appears to have necrosed, and purulence was identified associated with the graft. After establishing proximal and distal control, the stent graft was removed. (From body of note:) ...I then made a curvilinear incision around the base of the previous LT shoulder wound....this was deepened and extended toward the clavicle....we also began exploring the base of the wound...the center of the wound...could be probed down and there appeared to be a sinus tract going below the level of the clavicle. We continued our excision of the surrounding tissue in an elliptical fashion along this sinus tract. At the base of the wound, we identified an FB...we identified a stent graft, going along with the history of previous LT axillary stent graft placement...we extended our incision medially and laterally along the course of the clavicle. This gave us better exposure along the segment of the axillary vein.

This procedure does not fit codes 35903 nor 35905 [site is shoulder/chest, instead of extremity or thorax (within pleural space)]. Do we need to go with an unlisted procedure code?

What are the correct codes for replacement of dual chamber pacemaker with insertion of new LV lead? During the replacement of a dual chamber pacemaker generator, the LV lead is found to be nonfunctional, and a new LV lead is inserted. The old RA lead and the new LV lead are attached to the new dual chamber generator.

We are still confused about the new coding for arch angiograms. How would you code the following surgery? We came up with codes36221, 36217, 36218, 75710, and75774. Please help with explanation!

PREOPERATIVE DIAGNOSIS: Clinical steal syndrome, right upper extremity. POSTOPERATIVE DIAGNOSIS: Clinical steal syndrome, right upper extremity. OPERATION PERFORMED: 1. Arch angiogram. 2. Unilateral right upper extremity arteriogram. ANESTHESIA: Local with moderate sedation. INDICATIONS FOR OPERATION: The patient is a 31-year-old male with a history of end-stage renal disease. He has clinical steal syndrome, right upper extremity. Presents now for arteriogram. FINDINGS: 1. The patient had no branch stenosis of the supraaortic trunk; specifically, subclavian, right and left common, and right subclavian arteries were widely patent. 2. On the right upper extremity axillary and brachial artery were widely patent. The fistula anastomosis was visualized, and distal to the anastomosis clinical steal was occurring, as blood was flowing retrograde up the fistula from the more distal aspect of the brachial artery. Intrinsic arteries of the forearm, namely brachial, interosseous, and ulnar artery were otherwise widely patent. Palmar arch was predominant and from the ulnar artery distribution and with an intact palmar arch. DESCRIPTION OF OPERATION: After satisfactory monitoring lines were placed, the patient underwent moderate sedation. Single puncture access right common femoral artery with up size to a 5 French sheath over a Bentson wire. Pigtail catheter advanced into the ascending aorta where an arch angiogram was obtained. Selective catheterization then undertaken into the innominate artery and down the right subclavian artery. Sequential films were taken down the right upper extremity with advancement of a Mariner catheter. This included all the way down to the magnified view of the right hand. Catheter was then removed, and the sheath removed. A StarClose device was deployed uneventfully with satisfactory hemostasis achieved. The patient tolerated the procedure well with minimal blood loss. PLAN: Based upon the above angiographic findings, the patient will need to undergo a right upper extremity distal revascularization with interval ligation to improve flow to the right hand.

For the case that follows, I came up with the following: right subclavian 36225-RT, right vertebral 36226-RT(delete 36225), right thyrocervical 36217-RT/75774-RT, right costocervical 36217-59RT/75774-59RT, left subclavian 36225-LT, left vertebral 36226-59LT (delete 36225), left ascending cervical 36216-LT/75705, left thyrocervical 36216-59LT/75774-59LT, left costocervical 36216-59LT/75774-59, andright and left bronchial 36216-50/75705-50.

INDICATIONS/COMMENTS: Upper thoracic possible intradural/subarachnoid hemorrhage to rule out AVM. HISTORY: Acute onset of the upper thoracic spine pain and chest pain. Cardiac workup has been negative. Questionable findings on total spine MRI. Please evaluate for vascular malformation in the upper thoracic spine. PROCEDURE: The risks and benefits were discussed with and accepted by the patient. The right groin was prepared and draped using maximum barrier sterile technique. Dermal and subcutaneous local anesthesia was given with 1% lidocaine. Moderate sedation was administered under my direct observation using continuous oximetric and hemodynamic monitoring. The patient received small titrated doses of Versed and Fentanyl, remained hemodynamically stable, and maintained oxygen saturation levels comparable to preprocedure levels. Total time of conscious sedation was 120 minutes. Catheter tip was placed in the right subclavian artery, contrast injected and images obtained over the upper chest and neck. Catheter tip was subsequently placed in the right vertebral artery, right thyrocervical trunk, and right costocervical trunk. At these locations, contrast was injected and images obtained over the right shoulder, neck, and upper thoracic spine. The catheter was placed into the left subclavian artery. Contrast was injected and images obtained over the neck and upper chest and shoulder. The catheter was subsequently placed into the left vertebral artery, left acsending cervical artery which had a separate origin from the left subclavian artery, the left thyrocervical trunk, and the left costocervical trunk. Then we made numerous catheter exchanges and placed a catheter tip in left and right bronchial arteries and numerous intercostal arteries in the upper thoracic and middle thoracic aorta. Catheter tip was removed and hemostasis was obtained with an Angio-Seal. RESULT: The anterior spinal artery is well identified in the cervical spine and upper thoracic spine down to the T2 or T3 level. It is very small with no nidus or early venous filling identified. In the middle and lower thoracic spine, I believe we can identify radiculomedullary branches but we never identify the anterior spinal artery. The anterior spinal artery is a direct continuation of radicular medullary branches, so that vessel must be very small. No abnormal blush or enhancement is identified in the paravertebral regions. CONCLUSION: 1. No significant abnormality.

Patient was being treated for a GBM. After completion of cerebral angiogram, a guide catheter and a Terumo guidewire were used to selectively catheterize the distal LICA. A roadmap technique demonstrated best view of the feeding pedicle. Once this was achieved, a microcatheter and Precision Microwire were used to selectively catheterize the distal M2 segment. Superselective angiogram revealed a discrete tumor blush. Once this was achieved, 35 mg of mannitol, after being filtered, was slowly injected. This was followed by a total dose of 400 mg dosing selectively injected into the distal MCA. He does say that this is an off-label non-FDA approved and compassionate use procedure. The only codes I can see to use are either 37202 or 37211, but neither seems to fit. And would I assign code36228 for the superselective angio of the M2 segment even though done by roadmap technique?

Should a TEE be charged separately if done during a CT operating room procedure? Or, should it be included in the operating room Level Charge?

I have a hospital that charged for temporary pacing prior to cardiac intervention. Here is the documentation:

After written informed consent was obtained, right groin was anesthetized with 2% xylocaine. Using modified Seldinger technique, a 7 French sheath was inserted in the right femoral artery. A 7 French CLS-4 guiding catheter was used to cannulate the left coronary artery. Angiomax was given per protocol. A 6 French sheath was inserted in the right femoral vein, and a transvenous pacemaker was placed at the RV apex to prevent bradyarrhythmias. After which, a choice PT extra support wire was advanced distally to the OM. Over wire exchange was done for a Roto extra support wire. Rotational atherectomy was performed with a 1.5-mm burr. Thereafter, a 2.5x10 cutting balloon was placed and inflations were done with a cutting balloon. Thereafter, IVUS was performed. IVUS revealed heavily calcified vessel, diffusely diseased approximately 2.75 vessel distally and a 3.5 vessel proximally. A 2.75 x 30 Resolute drug-eluting stent was deployed. A second Resolute 3.5 x 12 was deployed proximally. Post-stent deployment, IVUS revealed good stent wall apposition. There is TIMI-1 flow into the second OM. The wire was then repositioned into the OM, and a 2.25 x 12 Sprinter balloon was inflated across the second OM. There was TIMI-3 flow, less than 10% residual stenosis. Wire was removed. Final images obtained. Femoral angiogram revealed access to be in the common femoral artery above the bifurcation. There was no severe atherosclerotic disease. Angio-seal closure device was deployed with good hemostasis. Patient tolerated the procedure well and left the cardiovascular lab in stable condition. The left main had mild disease, and bifurcates into the left anterior descending and circumflex arteries. The left anterior descending artery has widely patent stents in the mid segment. The circumflex artery has a heavily calcified 90-95% proximal stenosis followed by a 95% stenosis in OM1. Femoral angiogram revealed access to be in the common femoral artery, and Angio-Seal closure device deployed with good hemostasis. Patient tolerated the procedure well and left the cardiovascular lab in stable condition. (I think this last sentences is a repeat of what he said above?)

Department reported codes 92953, 92978, C9602, and 33210. I'm not sure that code33210 should be charged. Wouldn't it be considered part of the procedure? Please advise.

My question to you is regarding when the physician starts at the access site internal jugular vein (36012) and moves the catheter through the heart down towards the superior vena cava and places the catheter and also images the superior vena cava (36010, 75827), and also performs a congenital right and left heart catheterization (93531), and the exit site of the catheter is back through the internal jugular vein (the access site). Also, while using the access site as the same exit site, the physician decides to perform a selective injection and also image the internal jugular vein (36012, 75825) as he exits the body. I'm thinking that the codes that need to be selected would be the following: 93531, 75827, 75825, and 36012. I'm thinking that you would not report code 36010 because it's a major vessel that leads to and from the heart, but can also pick up the image code for the superior vena cava. Is this correct thinking for facility billing?

I think I have been misinterpreting the definition of ICD replacement codes 33262, 33263, and 33264. My understanding of these codes was that thenumber of chambers explanted had to match thenumber of chambers implanted. In the case of a dual chamber ICD generator only being explanted and a multi-chamber ICD being implanted with use of two existing leads and implantation of a left ventricular lead, we are being instructed to use code 33264. I thought it should be reported withcodes 33241, 33230, and 33225. However, I see that the CPT parenthetical notes under code33230 for implant generator only with existing dual leads instructs us to NOT report code33230 with 33241 for removal and replacement of the ICD pulse generator and to use codes 33262-33264 when pulse generator replacement is indicated. Code 33241 is for removal only not replacement. Is this a misprint in the parenthetical notes? If we are to use codes33262-33264 in this instance, am I understanding that it doesn't matter what we are explanting, we only code by what we are implanting?

What would be the appropriate code to report mechanochemical ablation of great saphenous vein? Can code37204 be used, or dowe have to use an unlisted code?

I'm looking at a case trying to help another coder out and now I'm confused. SMA/portal vein confluence. I'm leaning towards an unlisted code at this point...your thoughts?

PREOPERATIVE DIAGNOSIS: Pancreatic cancer, status post neoadjuvant therapy. POSTOPERATIVE DIAGNOSIS: Locally advanced pancreatic head adenocarcinoma with invasion of the superior mesenteric vein, status post neoadjuvant therapy.. OPERATION PERFORMED: End to End reconstruction of the superior mesenteric and portal vein confluence. INDICATIONS: Mr. xx is a 53-year-old gentleman, who was undergoing a Whipple procedure by Dr. xx and was found to have a locally invasive pancreatic head adenocarcinoma involving the superior mesenteric vein. I was consulted in the operating room for the superior mesenteric vein reconstruction as it appeared that a portion of the superior mesenteric vein at the level of the confluence of the splenic vein was attached on the right lateral aspect to the pancreatic head cancer and could not be separated. Please refer to Dr. xx operative report relating to the indications for the Whipple procedure. OPERATION: The patient was already in the supine position and Dr. xx had performed the major portion of the Whipple procedure, other than the section where the pancreatic head cancer was attached along the right lateral aspect of the superior mesenteric vein at the level of the confluence of the splenic vein and at the start of the portal vein origin. There appeared to be a slight aneurysmal dilatation on the anterior wall of the superior mesenteric vein at the point of entry of the splenic vein. The patient was given heparin intravenously by Anesthesia and approximately 5 to 10 minutes later, the superior mesenteric vein, the portal vein, and the splenic vein were each individually clamped with 3 separate pediatric Potts clamps. Dr. xx excised an oval shaped section of the right lateral aspect of the superior mesenteric vein just across from the point of entry of the splenic vein. The Whipple specimen was then handed out for pathology. At that point, the vein was flushed with hep-saline solution and I divided the superior mesenteric vein by extending to the left aspect to just below the point of entry of the splenic vein. I then approximated the 2 cut ends using 5-0 prolene on either side. An end-to-end anastomosis was performed using a continuous suture of 5-0 Prolene involving first the posterior wall and then the anterior wall. A growth factor of approximately 1 to 1-1/2 cm was placed and the total reconstruction took 17 minutes. The clamps were removed and the superior mesenteric vein expanded through the growth factor. There was a small area of bleeding on the right lateral aspect and this was controlled with a U-stitch of 5-0 Prolene. An intraoperative duplex was obtained, which showed slight turbulence in the area of the aneurysmal dilatation just above the anastomosis at the confluence of the splenic vein. There did not appear to be any area of stenosis and there was excellent flow without evidence of any thrill distal to the anastomosis. Dr. xx went on to complete the operation with the assistance of Dr. xx and Dr. xx. I was only present for the consultation relating to the revision/reconstruction of the superior mesenteric vein at the point of confluence with the splenic vein. I left the operating room and Dr. xx continued with completion of the Whipple procedure.

Can you tell me which drain code should be used for an inguinal fluid collection? Would this be code10160, 49021, or 49061?

Patient had AAA graft earlier in the day with bilateral cutdown. Patient started complaining of limb and back pain. Returned to OR. Re-opened bilateral cutdowns. Embolectomy of iliac artery and aorta. There was narrowing of the left limb of graft at level of aortic bifurcation. Decided to place kissing stents. Repair of femoral arteries. So, they placed kissing stents inside the AAA graft. Would this be billable with codes 34825/34826 or 37221- 50? Also, can we bill for code 34201 since it was the original treatment option with a decision to place stents?

If we went through the whole process of performing a lumbar puncture after anesthetizing the area and could not obtain any fluid, do I have to modify the procedure as attempted but failed?

Is the following coded as a fibrin sheath (36595-52), a PTA (35476), or both? "A pull-back SVC venogram was then performed, revealing a fibrin sheath and stenosis at the superior cava/right atrial junction. The existing catheter was exchanged for an 11 French vascular sheath. Balloon angioplasty was performed using a 12 mmballoon,followed by a 14 mm balloon for fibrin sheath disruption and stenosis dilation. Follow-up venogram demonstrated satisfactory results with disruption of the fibrin sheath and slight improvement in the SVC stenosis."

I'm wondering if you can share when you would use ICD-9 code 440.3x and when you would use ICD-9 code 996.74. Most of our occluded bypasses, whether vein or synthetic, are due to atherosclerosis; however, the description of code 996.74 mentions stenosis, occlusion, thrombus, etc. Thank you in advance for your help!

"Accessed the right greater saphenous vein, and a venogram was done. The catheter was then advanced into the right hypogastric vein, and venogram was done again. The catheter was then advanced into the left hypogastric vein, and a venogram was done. The catheter was then advanced into the left femoral vein, anda competent valve was encountered at the saphenofemoral junction. Contrast was injected. None was refluxed into the leg. Catheter was then pulled back, and a completion cavogram was done. The catheter then was advanced into the left renal vein, and a selective renal venogram was done. Several unsuccessful attempts to locate the gonadal vein, and it was not identified on the cavogram. The right renal vein was selected, and a venogram was done." The codes we came up with are 36012, 36011, 36011, 75833, 75825, and75822. I am questioning the catheter placements mostly. Can you clarify this?

We are performing SIR sphere embolization for hepatic cancer at our facility, and it is done in two encounters. The first time the patient is seen, extensive angiography is done of the celiac, common hepatic, right hepatic, etc. Sometimes the gastroduodenal artery is embolized with coils. MAA is administered. A few weeks later, the patient comes back for the SIR sphere embolization, and the physician does some angiography of the same vessels as in the previous encounter. Since the patient has already had diagnostic angiography during the first encounter, can we bill for angiography again for the second encounter since the embolization of the GDA may have altered the blood flow to the lesion?

Is there anything that can be coded for the physician in the following scenario? "Patient has a left femoral arterial line that is no longer needed for monitoring in the ICU. The patient is taken to the interventional suite, and angiography is performed for placement of an Angioseal plug. No other intervention is performed on this day. The patient had intracranial embolizationfive days earlier with Angioseal placement on the contralateral side (right side)." I don't see a way of coding anything, but Iwant to be sure I'm not missing anything.

I have not encountered this before. The patient came in for a left heart catheterization done by one cardiologist, and because of continuing parascapular pain, a second cardiologist repeated the left heart catheterization the same day, the same outpatient encounter. I bill for the hospital and understand that most procedures in the hospital have a one day global period. I am unsure if this would apply to the left heart catheterization (93458) and if this would be billed only once, which is how I believe it should be, or if it would be appropriate to bill twice with a -59 modifier because of the continued symptoms.

If one cardiologist does the diagnostic catheterization, and his partner does the intervention, do they have to apply a modifier?If so, which one (same day, same encounter with the patient)? I'm not sure if modifier -62 applies. I'm seeing more and more of this with physician groups. One reason is cheaper malpractice insurance.

A patient has a port-a-cath, and while in the hospital the catheter is noted to be in the subclavian artery instead of the internal jugular vein. The physician takes the patient to angio to remove the catheter. From the femoral artery he places a catheter in the subclavian and performs an angiogram of the extremity andremoves the port-a-cath. The physician then inflates a balloon for hemostasis. A coder is telling us we can report codes 35475, 36215, 36590, 75710-2659, and 75962-26. I do not agree with the arterial angioplasty codes, as there was no stenosis. Nor do I agree with code36590, as it was not in the venous system. I'm thinking this should be an unlisted code along with the diagnostic angio. Can you give me your thoughts?

What would be the appropriate code for a vertebral artery angioplasty? The angioplasty was performed months after placement of a vertebral artery stent and was performed to revascularize the in-stent stenosis.

I want to confirm when performing angioplasty with infusion if you should reportcodes 61640, 37202, and 75896... or, is code 75896 dropped since the catheter placement is included in code 61640?

I have a question about code 93657. The physician did a pulmonary vein isolation for atrial fibrillation. The veins were completely isolated. However, right atrial pacing medial and lateral to the cavotricuspid isthmus failed to demonstrate isthmus block. Therefore ablation was performed in the isthmus. I know code93656 is correct, but can I also report code 93657 for the ablation of the cavotricuspid isthmus?

There are physicians at our facilities who state in their documentation “X catheter was attached to heparinized saline with nitroglycerin for the prevention and treatment of catheter induced vasospasm”. There is no documentation that vasospasm has occurred. My understanding is that code 37202 is not to be used for preventative treatment, butthe IR coders state that this is an allowable charge. We all want to make sure that this is being done correctly. Please clarify.

We have cases where the patient is scheduled for an MRI-guided breast biopsy. The MRI guidance is performed, and a lesion could not be found, so the biopsy is canceled. Report example: "After discussion of potential risks, alternatives, and benefits of the procedure, the patient gave verbal and written informed consent for the procedure. She was placed prone on the table, and her breast was placed in the compression grid. Initial noncontrast fat suppressed T1 images were obtained. This demonstrates satisfactory positioning. Subsequently, three sets of postcontrast fat suppressed T1 images were obtained. These do not demonstrate the finding of interest seen on the initial mammogram. On today's exam, there is just scattered normal background parenchymal enhancement. It is felt that the initial finding represents part of this normal background parenchymal enhancement. Since the finding was not reproduced, no biopsy could be performed. The procedure was then terminated. Findings were discussed in detail with the patient at the time of interpretation. The recommendation is for six-month follow up breast MRI to evaluate stability. There are no suspicious areas of enhancement to biopsy on today's exam. Impression: Previously identified 8 mm enhancing mass left breast is not reproduced on the current exam. It is felt that this may represented background parenchymal enhancement. As it is not reproduced, no biopsy is performed."

Per Coding Clinic for HCPCS, 2nd quarter 2008, it has an example for a canceled stereotactic breast biopsy. "Q. A patient was scheduled for stereotactic breast biopsy of theleft breast. Stereotactic images were performed; however, the lesion to be biopsied was not visualized. Anesthesia was not administered and the biopsy was not performed. How should this encounter be reported? A. It would be appropriate to report the CPT codes 19102 with modifier -LT, and 77031 for stereotactic localization, for the procedures performed. Although the breast lesion was not visualized, the biopsy was planned; therefore, CPT code 19102 should be reported with modifier -73 only if taken to the treatment room."

Does a canceled MRI-guided breast biopsy follow the same rules as a canceled stereotactic biopsy? Should we only bill for a breast MRI (77058) on both the FAC and PRO side, or should we bill codes 19102-73 and 77031 on the FAC side and only 77031 on the PRO side? Also, is the guideline for the canceled stereotactic biopsy okay to follow, or has that changed? Since we bill for both FAC and PRO, please address both.

I noticed in your radiology and IR reference books that effective for 2013 mammography following image-guided wire or clip placement is not reported separately. Does this also include when the breast biopsy was done with ultrasound guidance?

In the hospital setting, if they use code 93351 they say it doesn't include any reimbursem*nt for the physician. However if you look at what 93351-26 pays, it appears to only cover code 93018 and 93350-26. Is code 93016 included in code 93351 for the hospital? I know it states there is no physician reimbursem*nt, but isn't reimbursem*nt for the APC figured by the cost report submitted by the hospital? If the hospital paid the physician, wouldn't that be in the cost report and thus be covered under code 93351? Just trying to make sure I understand it correctly.

I'm not sure whatI should bill for the following:

INDICATIONS: This lady had a stent-assisted coil embolization of left cervical ICA. This is a follow-up angiogram. Benefits and risks were discussed in detail with the patient, including bleeding, femoral artery injury, loss of blood supply to the leg, loss of the leg, dissection of the aorta, stroke, TIA, and dissection of the carotid and benefits. The patient consented procedure and was brought to the operative room. DESCRIPTION OF OPERATION/PROCEDURE: The patient was brought to the operative room by the Neuro Anesthesia team. Monitored aesthetic care was induced in supine position. All the pressure points were padded appropriately. The groin was prepped and draped in the usual sterile fashion. Lidocaine was injected along the right groin crease. Skin knife was used to make 2 mm skin incision. Eighteen gauge needle and single wall technique was used to access the right common femoral artery. 5 French sheath was placed over the guidewire provided. Using 5 French Berenstein diagnostic catheter and Terumo 038, multiple coils vessels were imaged. FINDINGS: Right common femoral artery selective injection: The right common femoral artery was selected. The catheter was advanced in it. AP view showed the internal iliac artery, right common femoral artery, right superficial, and profunda femoral arteries to have normal caliber and branching. The puncture site was appropriate for Angio-Seal device deployment. Common iliac selective injection: The right common iliac was selected. The catheter was advanced in it. AP view showed there was a possible dissection of the common iliac artery. Thoracic aortic injection. Thoracic aortic injection. The catheter was kept in the thoracic aortic area. An injection was noted that there is a dissection. At that time, the patient was complaining of chest pain and we consulted the Vascular Surgery and Cardiothoracic. The patient was then intubated and a TEE was performed to ensure there was no dissection of the ascending aorta or the arch. Following that, the patient was transferred to the CT for obtaining a CT of the chest and abdomen. Also, we sent for labs to make sure there is no troponin increase or worsening of the creatinine. I applied manual compression for 15 minutes.

If, following an a-fib ablation, the physician performsnine CFAE ablation sites in the left atrium, would code 93657 be reported once for the one site of operation (left atrium)? Or would it be reportednine times for each specific site in the left atrium? Thanks for your assistance.

Is there a difference in an MRI venogram and an MRA?

I would just to ask a follow-up question to question ID #4783. After the AV fistula aneurysm was excised, they didn't revise it anymore because the patient didn't need the dialysis access anymore. Do we still code that as revision even though the fistula wasn't revised? At the end of the case the fistula was nonfunctional or totally closed.

Would you please guide us through coding this case? What would be the correct diagnostic code for splenorenal shunt outflow venography? The report is included below:

SPLENORENAL SHUNTOGRAM AND GASTRIC VARIX EMBOLIZATION (BRTO) CLINICAL INDICATION: Portal hypertension with spontaneous splenorenal shunt and large gastric varix. The patient has developed refractory encephalopathy. Right common femoral vein accessed. Selective catheterizations of the left renal vein were performed with a 5 French multipurpose catheter, which was ultimately manipulated into the splenorenal shunt outflow vein (36012), and venography was performed (75887) OR (75810). A 16 mm x 4 cm Atlas balloon catheter was then positioned across the splenorenal outflow into the left renal vein. The balloon was inflated, and contrast was injected. Venography revealed opacification of a gastric varix with a couple of small veins extending toward the gastroesophageal junction. The splenorenal shunt was occluded with the inflated balloon.with the balloon inflated, embolization was performed with foam (37204, 75894). A total of approximately 25 mL of foam was delivered until complete opacification and stasis in the gastric varix was noted at fluoroscopy.The inflated balloon and introducer sheaths were then fixed in the right groin, and a sterile dressing was applied. The patient was transferred to the PACU in satisfactory condition with no complication. FINDINGS: Balloon occluded shuntogram reveals opacification of the large gastric varix projecting over the medial aspect of the gastric body. No collateral flow into the IVC nor portal vein is appreciated. IMPRESSION: 1. Large gastric varix emptying into a spontaneous splenorenal shunt to the left renal vein. 2. Successful gastric varix embolization 3. Followup venogram will be performed in 4-6 hours. Following routine sterile preparation and local infiltration with 1% lidocaine around the indwelling 9 French right transfemoral venous sheath, injection of the occluded balloon in the splenorenal shunt demonstrate stasis alongside the gastric varix cast (75898).The balloon catheter was then slowly deflated and withdrawn, with no evidence of washout from the gastric varix. The left renal vein remains patent with brisk antegrade emptying into the inferior vena cava. IMPRESSION: Successful occlusion of gastric varix and spontaneous splenorenal shunt following BRTO.

Can both angioplasty and stenting be coded if performed in the same vein?

I have a question regarding the use of the "branch" add-on codes for coronary interventions. If the patient has a stent placed into the RC and also has an angioplasty of the OM, would the OM be reported as a "branch", even though it is not a branch of the RC? Would this be reported with codes 92928-RC/92920 (OM), or would it be reported with codes 92928-RC/92921 (OM)? Thank you! You are our go-to guru!

Physician selectively catheterized the LCCA, left external carotid artery, and left occipital artery branch #1, #2, #3. Are codes 36223, 36227, and 36228 x 2 the appropriate ones to report? Please advise.

A left heart catheterization was performed with an LV-gram. There was a 99% thrombus burden found in the right coronary. A temporary pacemaker was placed, and AngioJet thrombectomy was performed in the right coronary with multiple runs. Bolus injections of Integrillin were given. One more AngioJet run was done, and the patient had a VT arrest and needed to be shocked. Post procedure films showed the 99% thrombus burden was reduced to about 85%, but there was TIMI 2.5 flow and a satisfactory result considering the thrombus burden. Via a 1.5 x 20 Clearway, 2.5 verapamil and 200 mcg of Nipride were given. Since code 92973 is an add-on code to a primary coronary intervention procedure, what can be billed?