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Tag Archives: help

MCR Denied 36901 as medically unlikely-Please help

Posted on by
I am new to this IVR coding world and Medicare has denied this OP not coded as 36901 as medically unlikely….any help is greatly appreciated. This was coded by a previous coder and I’m battling with the correct CPT code.

Coding assigned: 36901 and 36907 ICD-10 T82.858A T82.868A N18.6 and Z99.2

Summary
Access type: Right Brachial A-Basilic V arm non-transposed AVF
Right unilateral upper extremity fistulogram
Subclavian vein: angioplasty
Contrast type: Omnigpague 18cc (LOCM 300-399mg/ml iodine, 1ml)
Closure type-sutured

Technique:
The patient as brought to the endovascular suite, placed in a supine position and draped in routine sterile fashion. All aspects of the time-out verification were satisfactorily completed prior to the beginning of the procedure. The right upper extremity was prepped using Chloraprep. Moderate sedation/analgesic(conscious sedation) administered with critical care nurse to monito the level of consciousness and physiological status for the total of 30 min(s) using 100 mcg Fentanyl and 1 mg versed. The lower basilic vein was accessed in an antegrade fashion using an 18 gauge needle. A guide wire was introduced through the needle. The needle was removed and a 4-FR sheath was advanced. The sheath was flushed and fistulogram was performed. After carefully reviewing the diagnostic fistulogram, it was decided to proceed with intervention. The 4-Fr sheath was removed and upsized for 7-Fr sheath.

Intervention:
A catheter was placed over the wire in the subclavian vein. A 12 mm x40mm balloon angioplasty was performed on the vessel

Hemostasis:
All wires, catheters and sheaths were removed. The puncture site was sutured.

Findings:
Subclavian vein: occluded

Post Intervention Findings:
The residual stenosis is 40% in subclavian vein

Conclusions:
Successful, uncomplicating recanalization and treatment of outflow central venous occlusion at right subclavian vein with high pressure 12 mm balloon angioplasty as described above

This access is ready for use as needed. Given the high likelihood of recurrent stenosis/occlusion, it is recommended that this patient be clinically evaluated for possible repeat intervention in 3 months. From our standpoint, this access is useable. There is a superficial segment near the arterial anastomosis in the antecubital fossa involving the median cubital vein/ lower basilic vein that courses over the medial epicondyle that is easily palpable and of sufficient caliber before plunging far too deep in the upper arm basilic vein component. We recommend that using this portion should be attempted now. To facilitate cannulation the desired cannulation zones were marked on the skin with a magic marker. Depending on how this goes, a decision to revisit superficialization/transportation surgery can be reconsidered. If access continues to give difficulty and is never going to be transposed/superficialized, then access ligation at the arterial anastomosis is recommended to lessen likelihood/severity of recurrent symptomatic right subclavian vein occlusion.

Medical Billing and Coding Forum

coding help PLEASE

Posted on by
How would you code this op ?

I am feeling like it should be
61512-22

due to the fact that 61512 cannot be reported w 50 mod

Do you agree?

OPERATION: Bilateral frontal craniotomy and resection of bifrontal parasagittal meningioma,
Stealth frameless stereotactic computer guided navigation for intradural tumor resection, microscopic
dissection.

DETAILS OF THE OPERATION: After induction of general endotracheal anesthesia, the patient was
placed in a Mayfield headholder and positioned with his head was kept neutral and his head of bed
elevated. The patient’s head was secured to the operative table. The
Stealth navigation was registered, the incision was planned using Stealth. The entire area
was prepped and draped in the usual sterile fashion. The patient received IV antibiotics,
IV mannitol, IV Decadron and IV Keppra, preoperatively and prophylactically. A bicoronal incision
was made posterior to the parasagittal meningiomas. Scalp clips were applied. The scalp was
reflected anteriorly.
The old crainiotomy sites were identified. Some of the cranial plates were removed. Right and left
craniotomies were performed encompassing the old craniotomy. Right frontal and left frontal burr
holes were made with the acorn bit on the midas rex drill. Right and left craniotomies were made
with the B1 foot plate on the midas rex drill. The right and left crainiotomies were then connected
by using the midas rex drill with a B1 foot plate to cross the sagittal sinus. The bone flaps were
elevated. The MRI was reviewed with Dr. Dougherty and we determined that the sagittal sinus was
evaded by the tumor and was occluded. There was essentially no dura covering of the brain, the
skull was inspected and any soft tissue attachments of the skull were drilled off with an acorn bit on
the Midas Rex drill. The bilateral meningiomas were identified and cottonoids were placed around
the right parasagittal meningioma which was then debulked using CUSA, bipolar cautery and suction.
Bleeding was controlled. The brain was protected. The occluded sagittal sinus was divided using
weck clips and suture and the left portion of the parasagittal meningioma was identified. Stealth
frameless stereotactic navigation was used for intradural navigation and tumor resection to minimize
brain retraction. Microscopic dissection techniques were used for tumor dissection from the cortex.
The falx was cut beneath the tumor utilizing an approach from both the right and the left
craniotomies and the tumor was elevated and then removed en bloc with the occluded sagittal sinus.
Exposed brain was covered with Surgicel. Hemostasis was achieved with bipolar cautery and
thrombin gel mix. The initial plan was to do a right parasagittal tumor debulking however, the
bleeding vessels were coming from the falx and this necessitated resection of that region of the
tumor which included the falx on the left parasagittal tumor. The entire area was irrigated with saline
solution. Hemostasiswas confirmed. The dural defect was covered with DuraGen. Gelfoam was
placed over the DuraGen. The craniotomy flaps were reconstructed with cranial plates and secured
into position with cranial plates. A 7 mm flat JP drain was tunneled subcutaneously and connected to
bulb suction. The scalp was closed in layers. The incision was covered with a dry sterile dressing.
The patient was taken out of
Mayfield head holder, awakened, and taken to the PACU in stable condition. Patricia Vieth,
P.A. assisted with skin incision, right and left craniotomies, resection of meningiomas, brain

Medical Billing and Coding Forum

Neuropsychological Testing by Tech HELP!! :)

Posted on by
Need some help!

When billing for CPT codes 96138 and 96139 Neuropsychological testing by Technician, (1st 30 min and each additional 30) Who is the billing provider?

there is a post doctorate fellow performing as the technician, and the supervising PhD will be completing the reports, etc. I assume it is billed under the supervising? I have never used these codes and this is a new service we will be thinking of doing.

anyone have experience with this?

Thanks!

Medical Billing and Coding Forum

Colectomy-44145 and 44139- New at Colectomies,Please help!

Posted on by
Would you code as 44145 and 44139? thank you

FINDINGS: Rectosigmoid inflammatory mass (cannot exclude neoplasm) associated with perforation and and an ascending right retroperitoneal infection. Normal-appearing stomach duodenum and small bowel. Normal liver except for a 1.5 cm hemangioma of the left hepatic lobe. Normal gallbladder.
*
PROCEDURE: Exploratory laparotomy. Rectosigmoid resection. Mobilization of the right colon, hepatic and splenic flexures. Debridement of right retroperitoneal space.

*DESCRIPTION OF PROCEDURE: General anesthesia was induced. A nasogastric tube had previously been placed. A Foley catheter was inserted. Thromboguards were applied. The anesthesia department placed an arterial line and central line perioperatively. The abdomen was prepped and draped in standard sterile fashion.
*
A standard midline incision was performed. Prior to entering the peritoneal cavity, there was a purulent infection noted coming from the right lower quadrant and right mid abdominal retroperitoneal space. Upon entering the abdominal cavity, there was murky peritoneal fluid but no obvious succus entericus identified. The omentum was matted and fixed to a pelvic inflammatory/neoplastic mass. The omentum was mobilized by dividing it between Kelly clamps and tying off with 0 silk suture. Loops of the terminal ileum or fixed to the mass as well but not incorporated by it. The inflammatory adhesions were taken down freeing the small intestine from the pelvic mass.
*
Once it was decided that the the pelvic mass was the probable source of perforation and sepsis and resection was eminent, the right hemiabdomen was explored by mobilizing the right colon. There was evidence of a previous appendectomy. The right ureter was identified. There was a foul-smelling diffuse infectious process involving the soft tissues of the right retroperitoneum, incorporating the renal space. The hepatic flexure was mobilized and the duodenum exposed. There is no bile staining in the sub-hepatic space and the duodenum appeared intact and without inflammation as did the stomach and gallbladder. The NG tube was palpated. The liver appeared normal. There is a small hemangioma in the left hepatic lobe. The necrotic tissue of the right retroperitoneal space was excised.
*
The small bowel was run from the ligament of Treitz to the ileocecal valve and there is no evidence of perforation or malignancy. The transverse colon was palpated and normal. The left colon–sigmoid colon junction was then divided with a TA stapler. Mesentery was scored medially and the left colon/sigmoid avascular line was incised to fully mobilize the left colon and sigmoid. The sigmoid colon mesentery was divided between Kelly clamps and tied off with 0 silk suture. Left ureter was identified and protected. The inflammatory–possibly neoplastic mass was then mobilized from the pelvic sidewall. Upon dividing the dense tissue surrounding the mass, a small colotomy was created. The posterior rectal space was entered allowing for isolation of the lateral stalks that were divided under direct vision using sharp dissection and cautery. The inflamed anterior space was entered as well allowing for the contour stapler to encompass the superior rectum for excision of the rectosigmoid. 0 Prolene sutures were placed on the lateral aspect of the superior rectum for future identification. The left colon was viable and mobilized to the splenic flexure.
*
Anesthesia department reported difficulty maintaining the patient’s blood pressure despite maximum fluids and pressor agents. Therefore the decision was made to irrigate the abdomen with several liters of warm saline and to place an AB Thera device for closure and to take the patient back for a second look in 24-48 hours. There was diffuse oozing from the right retroperitoneal space. Upon mobilizing the liver by dividing the ligamentum teres, there was a small tear made in the left lobe that was cauterized and a small piece of Surgicel placed for hemostasis. Otherwise there is no significant bleeding. Sponge needle count was correct. The abdomen Ab Thera was placed to vacuum suction with a good seal. The patient was then taken to the intensive care unit intubated and stable but in critical condition.
*

Medical Billing and Coding Forum

***please help with peripheral coding***

Posted on by
Coronary Angiogram and Intervention Report
Date of procedure: 12/20/18

Pre- op Ox: CAD, CCS II chest pain, Abnormal stress test
Post-op Ox: Coronary artery disease

Procedures:
1. Selective left coronary angiography
2. Laser arthrectomy of the proximal and mid left anterior descending artery for 70-80% in-stent restenosis.
Pre procedure 70-80% in-stent restenosis with TIMI 3 flow. Post procedure less th an 50% in-stent restenosis with TIMI 3 flow.
3. Stenting of the proximal left anterior descending
artery for 80% disease with a 3.0 x 12 mm drug-eluting stent Onyx; pre procedure and 80% diseaseTIMI-3 flow.
Post procedure 0% disease with TIMl-3 flow
4. Angioplasty of the mid 70% occluded left anterior descending artery with a 2.25 x 12 mm balloon; pre procedure 70% disease TIMI- 3 flo w. Post procedure less than 50% disease TIMl-3 flow

Anesthesia: Lidocaine 2%

Access Site: Right femoral artery 6 French

Findings:
LMCA · mild disease
LCX · 60· 70 % m id left circumflex artery OMl · mild to moderate disease
LAD • 80% proximal disease prior to stent; 70-80% in-stent restenosis of the proximal-mid left anterior descending artery stent; 70% disease post stent
Dl – moderate disease

Procedure in detail :
The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed.
Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.

Right groin was anesthetized with lidocaine and a 6-French sheath was put into place percutaneously via guide-wire exchanger using ultrasound guidance and a micro puncture access kit. All catheters were passed using a Hipped guide* wire. Left system coronary angiography performed using a 6-French EBU3.5 catheter.

Intervention:
A 6 French EBU 3-1/2 guide was used to engage the left system. Once engaged, a run- through wire was placed distally down the left anterior descending artery. The laser catheter was then placed over the run-through wire and attempted to place inside the in-stent restenosis. Multiple attempts were made and the catheter was unable to enter the stent. The wire was pulled back and re-placed inside the stent as there was a concern that the wire may have gone behind the stent. The laser catheter was still unable to be advanced into the stent. A smaller laser catheter was exchanged and still unsuccessful in going inside the stent. After multiple attempts, the laser catheter was finally able to enter the stent and multiple runs were made. Post arthrectomy with laser, an angiogram was done showing less than 50% disease inside the stent. The laser catheter was removed and a 3.0 x 12 mm balloon was used to dilate the in-stent restenosis. Multiple different balloons were used without much improvement.
Given the inability to use the larger laser catheter, the
decision was made to leave the in-stent restenosis as it
is given TIMI -3 flow and less than 50% disease. The laser catheter was removed and an angiogram was done showing no perforations or dissections TIMI 3 flow. A 2.25 x 12 balloon was placed distally to the stent where there was 70%>
stenosis and that area was angioplastied. Post
Angioplasty, there appear to be less than 50% disease and no perforations or dissections TIMI 3 flow. The proximal portion prior to the stent in the LAD appeared to be significantly diseased and a 3.0 x 12 mm drug -eluting stent Onyx was placed. Post stenting, an angiogram was done showing no perforations or dissections and TIMI-3 flow. Heparin given during the entire procedure.

Closure Device: None

EBL: Less than 20 ml Complications: None Lines: None

Specimens: None Condition: Stable

Finding s:
Status post arthrectomy of the proximal to mid left anterior descending artery in-stent restenosis
Angioplasty of the mid left anterior descending artery after the stent
Stenting of the proximal left anterior descending artery with a
3.0 x 12 mm drug-eluting stent Onyx

Recommendation:
Continue with aspirin, Plavix, Lipitor therapy
Consider stage PC! for patients left circumflex artery as an outpatient

Medical Billing and Coding Forum

Coronary Angiogram and Intervention Report ***HELP PLEASE***

Posted on by
Coronary Angiogram and Intervention Report
Date of procedure: 12/20/18

Pre- op Ox: CAD, CCS II chest pain, Abnormal stress test
Post-op Ox: Coronary artery disease

Procedures:
1. Selective left coronary angiography
2. Laser arthrectomy of the proximal and mid left anterior descending artery for 70-80% in-stent restenosis.
Pre procedure 70-80% in-stent restenosis with TIMI 3 flow. Post procedure less th an 50% in-stent restenosis with TIMI 3 flow.
3. Stenting of the proximal left anterior descending
artery for 80% disease with a 3.0 x 12 mm drug-eluting stent Onyx; pre procedure and 80% diseaseTIMI-3 flow.
Post procedure 0% disease with TIMl-3 flow
4. Angioplasty of the mid 70% occluded left anterior descending artery with a 2.25 x 12 mm balloon; pre procedure 70% disease TIMI- 3 flo w. Post procedure less than 50% disease TIMl-3 flow

Anesthesia: Lidocaine 2%

Access Site: Right femoral artery 6 French

Findings:
LMCA · mild disease
LCX · 60· 70 % m id left circumflex artery OMl · mild to moderate disease
LAD • 80% proximal disease prior to stent; 70-80% in-stent restenosis of the proximal-mid left anterior descending artery stent; 70% disease post stent
Dl – moderate disease

Procedure in detail :
The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed.
Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.

Right groin was anesthetized with lidocaine and a 6-French sheath was put into place percutaneously via guide-wire exchanger using ultrasound guidance and a micro puncture access kit. All catheters were passed using a Hipped guide* wire. Left system coronary angiography performed using a 6-French EBU3.5 catheter.

Intervention:
A 6 French EBU 3-1/2 guide was used to engage the left system. Once engaged, a run- through wire was placed distally down the left anterior descending artery. The laser catheter was then placed over the run-through wire and attempted to place inside the in-stent restenosis. Multiple attempts were made and the catheter was unable to enter the stent. The wire was pulled back and re-placed inside the stent as there was a concern that the wire may have gone behind the stent. The laser catheter was still unable to be advanced into the stent. A smaller laser catheter was exchanged and still unsuccessful in going inside the stent. After multiple attempts, the laser catheter was finally able to enter the stent and multiple runs were made. Post arthrectomy with laser, an angiogram was done showing less than 50% disease inside the stent. The laser catheter was removed and a 3.0 x 12 mm balloon was used to dilate the in-stent restenosis. Multiple different balloons were used without much improvement.
Given the inability to use the larger laser catheter, the
decision was made to leave the in-stent restenosis as it
is given TIMI -3 flow and less than 50% disease. The laser catheter was removed and an angiogram was done showing no perforations or dissections TIMI 3 flow. A 2.25 x 12 balloon was placed distally to the stent where there was 70%>
stenosis and that area was angioplastied. Post
Angioplasty, there appear to be less than 50% disease and no perforations or dissections TIMI 3 flow. The proximal portion prior to the stent in the LAD appeared to be significantly diseased and a 3.0 x 12 mm drug -eluting stent Onyx was placed. Post stenting, an angiogram was done showing no perforations or dissections and TIMI-3 flow. Heparin given during the entire procedure.

Closure Device: None

EBL: Less than 20 ml Complications: None Lines: None

Specimens: None Condition: Stable

Finding s:
Status post arthrectomy of the proximal to mid left anterior descending artery in-stent restenosis
Angioplasty of the mid left anterior descending artery after the stent
Stenting of the proximal left anterior descending artery with a
3.0 x 12 mm drug-eluting stent Onyx

Recommendation:
Continue with aspirin, Plavix, Lipitor therapy
Consider stage PC! for patients left circumflex artery as an outpatient :eek::eek::confused::confused:

Medical Billing and Coding Forum

Still confused on some of these… Please help Peripheral Coding

Posted on by
Coronary Angiogram and Intervention Report
Date of procedure: 12/20/18

Pre- op Ox: CAD, CCS II chest pain, Abnormal stress test
Post-op Ox: Coronary artery disease

Procedures:
1. Selective left coronary angiography
2. Laser arthrectomy of the proximal and mid left anterior descending artery for 70-80% in-stent restenosis.
Pre procedure 70-80% in-stent restenosis with TIMI 3 flow. Post procedure less th an 50% in-stent restenosis with TIMI 3 flow.
3. Stenting of the proximal left anterior descending
artery for 80% disease with a 3.0 x 12 mm drug-eluting stent Onyx; pre procedure and 80% diseaseTIMI-3 flow.
Post procedure 0% disease with TIMl-3 flow
4. Angioplasty of the mid 70% occluded left anterior descending artery with a 2.25 x 12 mm balloon; pre procedure 70% disease TIMI- 3 flo w. Post procedure less than 50% disease TIMl-3 flow

Anesthesia: Lidocaine 2%

Access Site: Right femoral artery 6 French

Findings:
LMCA · mild disease
LCX · 60· 70 % m id left circumflex artery OMl · mild to moderate disease
LAD • 80% proximal disease prior to stent; 70-80% in-stent restenosis of the proximal-mid left anterior descending artery stent; 70% disease post stent
Dl – moderate disease

Procedure in detail :
The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed.
Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.

Right groin was anesthetized with lidocaine and a 6-French sheath was put into place percutaneously via guide-wire exchanger using ultrasound guidance and a micro puncture access kit. All catheters were passed using a Hipped guide* wire. Left system coronary angiography performed using a 6-French EBU3.5 catheter.

Intervention:
A 6 French EBU 3-1/2 guide was used to engage the left system. Once engaged, a run- through wire was placed distally down the left anterior descending artery. The laser catheter was then placed over the run-through wire and attempted to place inside the in-stent restenosis. Multiple attempts were made and the catheter was unable to enter the stent. The wire was pulled back and re-placed inside the stent as there was a concern that the wire may have gone behind the stent. The laser catheter was still unable to be advanced into the stent. A smaller laser catheter was exchanged and still unsuccessful in going inside the stent. After multiple attempts, the laser catheter was finally able to enter the stent and multiple runs were made. Post arthrectomy with laser, an angiogram was done showing less than 50% disease inside the stent. The laser catheter was removed and a 3.0 x 12 mm balloon was used to dilate the in-stent restenosis. Multiple different balloons were used without much improvement.
Given the inability to use the larger laser catheter, the
decision was made to leave the in-stent restenosis as it
is given TIMI -3 flow and less than 50% disease. The laser catheter was removed and an angiogram was done showing no perforations or dissections TIMI 3 flow. A 2.25 x 12 balloon was placed distally to the stent where there was 70%>
stenosis and that area was angioplastied. Post
Angioplasty, there appear to be less than 50% disease and no perforations or dissections TIMI 3 flow. The proximal portion prior to the stent in the LAD appeared to be significantly diseased and a 3.0 x 12 mm drug -eluting stent Onyx was placed. Post stenting, an angiogram was done showing no perforations or dissections and TIMI-3 flow. Heparin given during the entire procedure.

Closure Device: None

EBL: Less than 20 ml Complications: None Lines: None

Specimens: None Condition: Stable

Finding s:
Status post arthrectomy of the proximal to mid left anterior descending artery in-stent restenosis
Angioplasty of the mid left anterior descending artery after the stent
Stenting of the proximal left anterior descending artery with a
3.0 x 12 mm drug-eluting stent Onyx

Recommendation:
Continue with aspirin, Plavix, Lipitor therapy
Consider stage PC! for patients left circumflex artery as an outpatient

Medical Billing and Coding Forum

HELP !!!! THR with draining seroma

Posted on by
1-15-19: Pt. underwent right total hip replacement.
2-21-19: Taken back to OR with "draining seroma." Dr. exchanged right total hip femoral ball and polyethylene liner and performed extensive lavage of wound with insertion of antibiotic beads.

Do I bill 27030 or 26990 ? Would DX be M96.840, Z96.641 ??

I’ve spent all day on this and have even entertained 27134 – 78, 52

Can anyone help? I feel ridiculously stupid !!!!!

THANKS!!!!!

Medical Billing and Coding Forum