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Novitas Solutions issued a reminder March 10 about billing for temporary implantable female urological prostheses, reported with CPT® codes 0596T and 0597T. If your claims for these services are being denied, it’s no wonder, what with all the policy changes in recent years. The service coding isn’t the problem; it’s the device coding. Coding Insertion […]
The post Coding InFlow Device? Check Date of Service appeared first on AAPC Knowledge Center.
Diagnosis: Status post Charcot reconstruction with external fixation, Wound of right foot
Procedure performed: Right foot: #1 removal of external fixation #2 debridement of wound 2×3 (same foot) consisting of excisional debridement of skin, subtenons tissues portion of the fascia. #3) application of a well-padded short leg splint
The external fixator was removed in total. 2 half pins were removed as well as a trans-calcaneal pin and multiple smooth wires.
Extremity was then prepped, draped, and usual aseptic sterile manner. Patient has edema and venous insufficiency noted to the leg with verrucous hyperplasia nonhealing wound noted at approximate 2 x 3 cm. This was debrided consisted of excisional debridement of skin subtenons tissues portion of the fascia. Remenant of retained suture was removed. Then further debrided utilizing a curette. No purulence no clinical signs of infection were noted. At this time we pulse lavaged the wound out with 3 L normal saline. Please Xeroform over the wound followed by dry dressings and placed the patient in a well-padded posterior splint
Any help would be great! 
Any thoughts or suggestions are much appreciated!
Cardiomyopathy, ischemic [I25.5 (ICD-10-CM)]
Coronary artery disease involving native coronary artery of native heart with unstable angina pectoris (CMS-HCC) [I25.110 (ICD-10-CM)]
Abnormal cardiac function test [R94.30 (ICD-10-CM)]
Conclusion
This patient with a known history of ischemic heart disease distant history of inferior posterior lateral ST segment elevation myocardial infarction with RCA stenting and left ventricular systolic dysfunction subsequently had recently developed increasing dyspnea and deteriorating LV function, ejection fraction 30% or less and stress ischemic assessment revealed now in addition to inferior wall scar, apical ischemia LAD territory ischemia.
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Coronary angiography revealed patency of the stented RCA small circumflex and severe progressive disease in the proximal LAD. Given the patient’s severely reduced LV systolic function and proximal LAD intervention, high risk PCI is recommended but with support with Impella device.
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After obtaining informed consent from the patient, he was brought to the catheterization laboratory. A 6 French sheath was placed into the right common femoral artery under fluoroscopic guidance and a long sheath 6 x 25 was advanced into the lower abdominal aorta pre-bifurcation. Under direct roadmap visualization technique the left common femoral artery was entered and a 6 French sheath was placed. Patient was given 7000 units of heparin, ACT was documented to be greater than 250, and left arterial access was then dilated with 8 and then 10 French dilator and placement of an Impella 2.5 device sheath, 13 French. Over a standard guidewire a 5 French pigtail catheter was then advanced across the aortic bifurcation and positioned into the left ventricle. The guidewire was removed and a 0.018 long stiff support wire was then advanced into the left ventricle and the pigtail was removed and the Impella 2.5 device was then inserted across the aortic valve without difficulty and positioned. Impella flow was then initiated, after removal of the rapid exchange support wire.
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Utilizing the right common femoral access an EBU 3.75 guide was advanced to the left main coronary artery, left coronary angiography was performed, a wire was advanced into the distal LAD and angioplasty of the proximal LAD stenosis was performed with a 2.5 mm balloon followed by placement of a single Boston Scientific Promus drug-eluting stent 3.0 x 16 mm, and the entire stented segment was finally postdilated with a 3.5 mm balloon. After withdrawal of the balloon angiographic result was excellent, wire and guiding catheter was then removed. Iliofemoral angiography through the right common femoral sheath revealed the sheath in the right common femoral artery and closure on the right was then obtained with an Angio-Seal closure device.
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The patient’s Impella flow was then weaned, device was removed to the descending aorta flow dropped to P0 and the device was removed through the sheath. For hemostasis, this initial sheath was then exchanged out for a 14 French by 13 cm sheath which was then sutured into place with hemodynamic monitoring applied. Patient was transferred to the recovery area with palpable left DP pulse, and stable condition hemodynamically.
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Following resolution of elevated ACT, the left common femoral access sheath will be removed and manual compression utilized for hemostasis.
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Hemodynamics:
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Central aortic pressure 110/70 left ventricular pressure 110/16-18, no transaortic valvular gradient mildly elevated left ventricular end-diastolic pressure.
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Coronary angiography:
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Left main was patent left circumflex was small nondominant noncritical disease LAD was a large vessel which was quite dominant with proximal stenosis of 90%.
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PCI:
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Proximal LAD stenosis was treated with a single large drug-eluting stent dilated to 3.5 mm, excellent angiographic result.
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Summary and conclusion:
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Severe de novo proximal LAD stenosis, treated with successful supported PCI.
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Ischemic cardia myopathy ejection fraction 2530%, stable post PCI with Impella assist device.
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Recommendation:
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Left common femoral access sheath removal once ACT below 180-200 seconds, manual compression plan, continue dual antiplatelet therapy aspirin and Brilinta, patient to be admitted for hemodynamic monitoring and his severe ischemic cardiomyopathy post PCI of proximal LAD high risk PCI.
Radiation Tracking
Implants
SYSTEM CORONARY STENT 3MM 16MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE – SGTIN08714729844730 – LOG342634
Inventory item: SYSTEM CORONARY STENT 3MM 16MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE Serial no.: GTIN08714729844730 Model/Cat no.: H7493952816300
Implant name: SYSTEM CORONARY STENT 3MM 16MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE – SGTIN08714729844730 – LOG342634 Laterality: N/A Area: Coronary
Manufacturer: Boston Scientific Corp Action: Implanted Number used: 1
thank you in advance for your time and support
should I code 33990, c9600 his left heart cath was on a week prior and the patient was brought back for impella device implant and was removed same day I am hospital coder and this is our first impella case which is already denied per insurance so wanted to clarify the codes
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REASON FOR PROCEDURE: Paroxysmal atrial fibrillation, hematuria on
anticoagulation.
PROCEDURES:
1. Transesophageal echocardiogram with 2D echo, M-mode Doppler, and color
flow mapping.
2. Watchman left atrial appendage occlusion device implantation.
3. Arterial catheter placement.
4. Venous catheter placement.
HARDWARE:
1. Boston Scientific Watchman access system sheath, double curve, 14-French,
lot #21482043.
2. Boston Scientific watchman 24 mm device, lot #21485158.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient,
signed, and placed on the chart. He seemed to understand the risks, benefits,
and alternatives and agreed to proceed. The patient was brought to the
cardiac electrophysiology lab in a fasting state and placed supine on the
fluoroscopy table. General endotracheal anesthesia was administered and
supervised by the Anesthesiology staff. The right groin was prepped with
ChloraPrep and draped in the usual sterile fashion. A bite block was placed,
and this was also draped in sterile fashion. The TEE probe was inserted
through a sterile sleeve, and then inserted into the esophagus without
difficulty.
The transesophageal echocardiography was performed. In the 0, 45, 90, and 135
degrees angles, the appendage ostial width was 15.5 mm, 13 mm, 15 mm, and 17.0
mm, and the length was 25 mm, 18 mm, 17 mm, and 16 mm.
The skin of the right groin was anesthetized with 1% lidocaine local, followed
by the deeper structures. Using the modified Seldinger technique, an 8-French
25 cm sheath, an 8.5-French SL1 sheath were placed in the right common femoral
vein, and a 4-French 11 cm sheath was placed in the right common femoral
artery. All sheaths were aspirated and flushed. Pressure tubing was
connected to the arterial sheath and was handed to the anesthesiologist for
invasive hemodynamic monitoring.
Heparin was given with an additional dose of 15000 units, with repeated bolus
was given to maintain an ACT of greater than 300 seconds.
Under fluoroscopic guidance, the wire in the SL1 sheath was advanced to the
superior vena cava, and the sheath and dilator were advanced over the wire.
The wire was removed, the dilator was flushed, and a flushed Baylis needle was
advanced through the dilator. The dilator, needle, and sheath were withdrawn
under fluoroscopic guidance to the fossa ovalis. Tenting was visualized on
transesophageal echocardiography. The fossa ovalis was small. Once a
suitable location was found, radiofrequency energy was applied and a
transseptal puncture was performed. The needle was flushed, and micro bubbles
were seen in the left atrium as expected. A left atrial pressure waveform was
noted, and the mean left atrial pressure was 17 mmHg.
The dilator was advanced over the needle, and the sheath was advanced over the
dilator. The dilator and needle were slowly withdrawn, and bright red blood
was aspirated from the sheath. The sheath was carefully flushed. An Amplatz
Super Stiff wire was then advanced through the sheath into the left superior
pulmonary vein, and the sheath was exchanged over the wire for a double curve
14-French Watchman access system sheath and dilator.
Once the dilator was in the left atrium, the sheath was advanced over the
dilator and wire, and then the dilator and wire were withdrawn. The sheath
was carefully aspirated and flushed. A flushed 5-French straight pigtail
catheter was advanced through the sheath into the left atrium. The pigtail
catheter was aspirated and flushed. It was inserted into the anterior lobe of
the left atrial appendage, and angiogram of the appendage was recorded using
hand injection of contrast.
The sheath was advanced over the pigtail catheter up to the 24 mm depth
marker. The Watchman 24 mm device was carefully prepared and flushed. The
pigtail catheter was withdrawn, and the Watchman delivery catheter was
inserted through the sheath until the distal markers aligned. The sheath was
then withdrawn to expose the end of the catheter. During apnea, the sheath
was withdrawn to deploy the device in the left atrial appendage ostium.
A tug test was performed, and the device was in stable position. Followup
measurements using TEE were recorded, with measurements at 0, 45, 90, and 135
degrees of 18.6 mm, 17.5 mm, 16.6 mm, and 18.6 mm. This yielded compressions
of 22% to 31%. Color-flow Doppler and injection of contrast through the
sheath showed no residual leak surround the device.
The threaded rod was unscrewed to release the device. IV protamine was given.
The sheath and dilator were removed under fluoroscopy to avoid dislodging
leads. A suture was tied around the insertion site in the groin using #2
Vicryl. Transesophageal echocardiography was performed to rule out
postprocedure pericardial effusion.
After protamine was given, the sheaths were removed, and hemostasis was
obtained with manual compression with tightening the suture. The patient was
successfully extubated and transferred to the PACU.
CPT CODES: 33340 Q0
ICD 10: I48.0, Z00.6
Clincial trial number etc.
As far as the interoperative Tee is concerned, according to the Boston Scientific Guide Point Reimbursement Resources, this can only be charged by a separate individual who is not performing the interventional procedure with CPT 93355.
Our Provider would also like to charge for Arterial Catheter Placement and Venous Catheter Placement; CPT 93503? and 36010? I’m not sure about these codes but I thought they were included in.
Any help will do for information I can provide my provider as to why certain codes cannot be charged while doing a Watchman.
Many thanks,
Jane:)
An important update has been made to the Medicare National Coverage Determinations (NCD) Manual regarding coverage of magnetic resonance imaging (MRI) for patients with certain implantable cardiac devices. In a National Coverage Analysis (NCA), the Centers for Medicare & Medicaid Services (CMS) determined there is sufficient evidence to conclude MRI for patients with certain implantable […]
The post MRI for Patients with Cardiac Device, Covered appeared first on AAPC Knowledge Center.
E0666 – NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG
E0669 – SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG
E0673 – SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEG
E0676 – Intermittent limb compression device (includes all accessories), not otherwise specified
Thank you very much indeed!