David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: When performing a duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access (93985/93986), if you were to perform a duplex scan on the entire radial and ulnar artery as well as the palmar arch, would you be able to bill for the additional studies (e.g. 93930/93931)? I know code 93930 is a column 2 code for 93985, but you may use a CCI-associated modifier to override the edit under appropriate circumstances, so just wanted to check whether the use of

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: "11 Stab phlebectomies were performed over varicose veins of her abdomen,” Since 37765-37766 are for extremities, would this be unlisted? 37799? Answer: There is no code for treatment of varicose veins by stab phlebectomy anywhere but the lower extremities. We agree with recommendation to report unlisted code 37799 for this treatment.   Complete IR and Cardiovascular Coding Detailed information on a broad range of IR and Cardiovascular procedures and the guidelines for proper coding. Includes 25 individual self-study medical coding elearning modules. Each module is CIRCC certified! Learn more

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: What is the correct code to bill for the embolization of middle meningeal artery (MMA)? Is it CPT code 61624 or 61626 since the MMA is part of the external carotid artery (ECA)? For this procedure, selective catheter placements and angiograms were done on the bilateral common carotid arteries (intracranial), bilateral ECAs and bilateral MMAs, along with the embolization. I am coding 36222-50, 36227-50, 75894, and 75898, just unsure whether to assign the 61626 or the 61624. Our coder says it should be 61624 but the provider thinks it

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: How would you recommend the facility coding for coronary intravascular lithotripsy (Shockwave) with a drug-eluting stent? We would bill C9600 for the stent, but how can we capture the intravascular lithotripsy (IL)? We are being told to add modifier 22 to C9600, but I thought this modifier was for professional use only. Answer: There is no code for IVL in the coronary arteries at this time. The procedure was just FDA approved and, hopefully, they are working on new codes for us. We are not recommending any change in

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: 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. Answer: Note code Z45.2 Encounter for adjustment and management of vascular access device is an after care code. Based on the Official Guidelines for Coding and Reporting, Section I.C.21.c.7, report the acute condition requiring the initiation of a vascular access, rather

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Access site left CFA. Catheter was advanced over the wire to the ostium of the left subclavian, selective angiogram was performed. This demonstrated a subtotally occluded left subclavian artery. Using digital subtraction angiography, the distal vessel did fill suggesting some hibernating arterial supply for micro-channels. Balloon was advanced over the wire into the left axillary artery, selective angiogram was performed. This demonstrated excellent flow to the arm. The balloon was then pulled back into the left subclavian artery, selective angiogram was performed. This demonstrated no significant flow into the

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: If more than one abscess drain is placed within a large, loculated abscess, can you code 49406 and 49406-XS or can you just code for one abscess drainage? Answer: We would recommend one. Loculations can be broken up with catheters or wires. Large abscesses sometimes need two catheters to sufficiently drain the infection and sometimes for irrigation. We recommend one code for one abscess regardless of loculations. The use of fibrinolytics can break up loculations (fibrin).   Now Available from ZHealth! 2021 Updates for Interventional Radiology, Cardiology, and Vascular

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: The patient was placed on the CT scanner in the supine position. Initial CT images of the upper abdomen were obtained. Automated exposure control was utilized. The skin overlying the liver was prepped and draped in the standard sterile fashion. Under CT guidance 3 IRE ablation probes were advanced to the lesion in the caudate lobe. Once the 3 probes were positioned appropriately, sagittal reconstructions were performed and ablation parameters were calculated. Ablation was performed using standard protocol and reverse polarity. Probes were removed. 2 IRE probes were then

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Which CPT code would best describe a VSD closure that is not for a congenital VSD, but post MI? Answer: We recommend reporting unlisted code 93799 for ventricular septal defect (VSD) closure of a NON-congenital (post-infarct) VSD.   November 30-December 4: ZHealth IR/CV Medical Coding Seminar Virtual or In-person.  Coding seminar focused exclusively on the coding of interventional radiology, cardiology, and electrophysiology procedures. Earn up to 37 AAPC CEUs (all of which are CIRCC-approved by the AAPC), 31.5 ASRT CEUs, 38 AHIMA CEUs, and/or 27.5 RCCB CEUs. Learn more

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Report: Vessel catheterized: Segment 2 hepatic artery Gives rise to a subsegmental vessel that is the minor supply to large tumor spanning segments 2 and 3. Vessel catheterized: Subsegmental branch of the segment 2 hepatic artery would the codes be 36247 and 36248? Answer: No. A subsegment of a segment off the right hepatic off the common hepatic off the celiac is a single catheter placement 36247. 36248 would be used if another segment (like segment 3) or another subsegment off segment 2 was additionally selected.   IR/CV Anatomy

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Angiogram (DSA) of the entire left lower extremity and iliac arteries using a 4-French x 45 cm long Rim catheter advanced from the right common femoral artery up and over and down into the left SFA. Selective angiogram of the left Posterior Tibialis, peroneal, and Anterior Tibial using a 4 Fr x 150 cm long Navicross catheter advanced from the right common femoral artery -up and over the left lower extremity. Please confirm use of the correct codes. 36247, 36248, 76937-26, 75710-26. Answer: IF the catheter was actually advanced

National Government Services (NGS), the Medicare Administrative Contractor for Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin, just posted guidelines for billing for the intrathecal injection of Spinraza. NGS requires CPT code 96450 for the injection procedure and HCPCS code J2326 for the nusinersen. HCPCS code J2326 is reported per 0.1 mg administered. From the NGS website: SPINRAZA (NUSINERSEN) BILLING Spinraza (nusinersen) is a medication that was approved in December 2016 by the U.S. FDA for the treatment of all forms of SMA. HCPCS code J2326 - Inj, nusinersen, 0.1mg should be used to

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Can you please let me know if I coded this correctly? The doctor says I should be able to code the cath placement into the collateral vein and the venogram. I thought it was included in the fistulogram and embolization. US guided access into left forearm AV fistula (all documentation is there) 76937-26 fistulogram of left radiocephalic AV fistula and Central Venogram - PTA peripheral dialysis circuit in the outflow vein. 36902 Selective catheterization of lateral collateral vein arising from the peripheral juxta anastomotic outflow vein (included in embolization

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Does the 2020 code 64451 (nerves innervating the sacroiliac joint) replace the 27096 when the injection states "into the SI joint," or is the code used in place of billing the S1, S2, S3 as peripheral (64450)? Answer: No, it does not replace CPT code 27096 when an SI joint injection is performed. Code 64451 is reported for the injections of the nerves that innervate the SI Joint, such as the S1, S2, S3 injections you mention.   Complete IR and Cardiovascular Coding Get detailed information on a broad

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: How would you code the following ablation procedure? 1. Pulmonary vein antral ablation was performed to isolate PV antral regions with bilateral PV isolation (PVI) confirmed on HDX mapping electrogram. 2. Additional linear ablation was performed at the left atrial (LA) roof to achieve bidirectional LA roof conduction block. 3. Additional linear ablation was performed at the left atrial (LA) lateral wall from the mitral annulus to the LPV anterior carine to achieve bidirectional LA anterior block. 93656 for the PVI then 93655 x 2 or 93655 & 93657?

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Patient is status post pipeline embolization. Patient clinically, CTA (CT Angiography) and TCD's (Transcranial Doppler) are consistent with vasospasm. Right vertebral angiogram showed vasospasm. Vasospasm was treated with 10mg of intra-arterial verapamil over a 10 minute infusion. Left internal carotid angiogram showed vasospasm and filling of the left ophthalmic aneurysm. The vasopasm was treated with 10 mg of intra-arterial verapamil over a ten minute infusion. Given persistent filling of the aneurysm, an additional Pipeline embolization was performed. A 4 x 12 pipeline was successfully deployed. Two follow up angiograms

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Can we use CPT code 49185 if imaging guidance wasn't performed and contrast wasn't administered? Can we also use CPT code 49185 when sclerosants aren't used? Per documentation, provider Injected 30 mL of desiccated ethanol into the abdominal wall seroma via previously placed drain. Patient was turned every 15 minutes to allow the alcohol to bathe all sides of the seroma cavity. The alcohol was then aspirated completely with 30 mL removed. Patient tolerated procedure well. Answer: Yes, CPT code 49185 would be used here. Usually an ablation of

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC If a diagnostic abdominal angiogram and bilateral runoff is performed (2 cath positions) (36200, 75716) and then the physician decides to do an intervention in the contralateral leg, do we need to drop CPT code 36200 (catheter placement for the diagnostic exam) or do we still bill code 36200, adding a -59 modifier? Answer: Since the aorta is on the way to the contralateral leg, and the contralateral leg intervention includes catheter placement, you would not report 36200 at the same session. IF there are two access sites, one for