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Broader coverage comes as great news for those with profound hearing loss. Cochlear implants were first covered for adult Medicare beneficiaries in October 1986 with coverage for children following in 1992. Since then, devices have been improved and there have been gradual changes in the degree of hearing loss for which the Food and Drug […]
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Does anyone have any experience with how to bill for bone marrow harvesting for transplantation with Medical Mutual of Ohio? Our podiatrists have been submitting code 38232, however these claims are coming back denied as service not payable for rendering provider specialty. I’ve called MMO and I’ve been advised that neither 38232 or 38220 are payable to this specialty. If anyone knows how to get our providers paid for this service your help would be greatly appreciated.
93660, 26
36620
33282
Our coding team has a problem billing for 36620 however our Provider seems to think that we can. Any advice would be appreciated:)
PROCEDURES PERFORMED:
1. Head-up tilt test with intra-arterial hemodynamic monitoring with and
without isoproterenol provocation.
2. Implantation of an implantable loop recorder.
INDICATION: Syncope.
POSTOPERATIVE DIAGNOSES:
1. No evidence of neurocardiogenic syncope except as exemplified by a lack
of vasodepressor and cardioinhibitory response to passive head-up tilt
test as well as with isoproterenol provocation.
2. No evidence of carotid sinus hypersensitivity.
3. Successful implantation of an implantable loop recorder.
PROCEDURE IN DETAIL: The patient was brought to electrophysiology laboratory
in a fasting postabsorptive state. Informed and written consent was obtained.
After performing the appropriate time-out, the patient was placed on a head-up
tilt table. Baseline recordings were obtained. An intra-arterial hemodynamic
catheter was placed in the left radial artery for invasive hemodynamic
monitoring.
FINDINGS: Baseline recordings: Blood pressure is 147/81 with a heart rate of
72, oxygen saturation was 96%. The patient was in a normal sinus rhythm.
After approximately 20 minutes passive lying in supine position, the patient
was raised to 70 degree head-up tilt, where continued monitoring was
performed. After 45 minutes of passive head-up tilt test, there was no
evidence of vasodepressor or cardioinhibitory response noted.
Isoproterenol provocation: Following a 45-minute passive head-up tilt,
isoproterenol was subsequently infused to 1 mcg/minute. Continued monitoring
was continued. Heart rate increased to approximately 121 beats per minute.
Again, there was no evidence of vasodepressor or cardioinhibitory response
noted after 20 minutes of isoproterenol provocation. The patient subsequently
was returned back to supine position and isoproterenol was discontinued.
Response to carotid sinus pressure: After the patient returned back to normal
hemodynamics, carotid sinus pressure was performed bilaterally, which
demonstrated no evidence of carotid sinus hypersensitivity.
Implantation of implantable loop recorder: After prepping and draping in the
usual sterile fashion, 1% bupivacaine was infiltrated into the 4th intercostal
space, left parasternal border. Utilizing an insertion tool, a Medtronic LINQ
implantable loop recorder was subsequently inserted into the subcutaneous
location. Adequate sensing was noted from the device. Steri-Strips and
pressure dressing were applied.
The patient tolerated the procedure without any complications.
IMPRESSION:
1. No evidence of neurocardiogenic syncope as exemplified by lack of
vasodepressor and cardioinhibitory response both in the baseline state as
well as with isoproterenol.
2. No evidence of carotid sinus hypersensitivity.
3. Successful implantation of implantable loop recorder.
Many thanks,
Jane;)
PREOPERATIVE DIAGNOSIS 1. Morton’s neuroma, 3rd interspace, left foot, causing chronic discomfort.
2. Morton’s neuroma, 3rd interspace, right foot, causing chronic discomfort.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: 1. Excision of Morton’s neuroma, 3rd interspace, left foot, under loupe magnification.
2. Nerve implantation, left foot.
3. Excision of Morton’s neuroma, 3rd interspace, right foot.
4. Nerve implantation, right foot.
ANESTHESIA: Local with intravenous sedation per Dr. Scott Himelstein.
FLUIDS: Crystalloid.
ESTIMATED BLOOD LOSS: 20 mL.
TOURNIQUET: Bilateral ankle pneumatic tourniquets to 250 mmHg.
COMPLICATIONS: None.
INDICATIONS: This 49-year-old female has been followed in my outpatient clinics over the past year with multiple foot complaints. Her main issue has been Morton’s neuromas that have been treated conservatively with cortisone injections, orthotic management, NSAIDs, and attempt at sclerosing agent injections. She did obtain relief for short periods of time with the injections — making the diagnosis definitive, but unfortunately, the injections did not ameliorate her symptoms. She is requesting operative intervention in an attempt to address her underlying structural/functional foot deformities in an attempt to ameliorate her symptoms.
PHYSICAL EXAMINATION: Neurovascular status was grossly intact of the bilateral extremities. Pedal pulses are +2. There is pain with palpation of the 3rd intermetatarsal space with distal and proximal paresthesias, positive Mulder’s. There is no pain at the 2nd or 4th interspace area. No pain at the lesser metatarsophalangeal joint areas bilateral.
CONSENT: The above diagnosis was established and the procedures recommended. The procedure, postoperative care, and possible complications, including but not exclusive to risks of infection, delayed or nonhealing, continued pain at the area, possibility of numbness and/or nerve entrapment and chronic pain syndrome/RSD/CRPS, and stump neuroma formation. Heather relates she accepts the above stated risks and complications and requests the above operative intervention. No medical contraindications were identified to preclude the above surgery.
Prior to the patient being brought into the Operating Room, she was administered 2 grams Ancef for general orthopedic prophylaxis.
OPERATIVE SUMMARY: The patient was brought to the Operating Room and placed on the table in the supine position. Intravenous sedation was administered per Dr. Himelstein. At that point in time, Dr. Miller performed a local field block consisting of 0.5% Marcaine with dexamethasone phosphate in a 9:1 ratio over the proximal surgical sites of the both feet. Both feet and legs were prepped and draped in the usual aseptic manner. Pneumatic ankle tourniquets were placed, and after elevation to 60 degrees for 3 minutes, inflated to 250 mmHg.
1. Excision of Morton’s neuroma, 3rd interspace, left foot, under loupe magnification. Attention was directed to the 3rd intermetatarsal space where approximately 3 cm incision was made and under loupe magnification the procedure was performed. The incision was deepened, vital structures identified and retraced, bleeding vessels cauterized per electrocautery. Both sharp and blunt dissection was carried down to the deep transverse intermetatarsal ligament where it was identified and transected to reveal a large neuromatous mass. The neuromatous mass was identified and traced out distally to its bifurcations to the 3rd and 4th toe where it was transected and the neuromatous mass was then brought back proximal-proximal to the deep transverse intermetatarsal ligament where it was transected while utilizing gentle traction on the nerve. It was transected with a 15-blade without incident. The wound was irrigated with copious amounts of sterile saline and bacitracin solution. The skin was reapproximated with 4-0 nylon in simple horizontal fashion. This completed the excision of Morton neuroma, 3rd interspace.
2. Excision of Morton’s neuroma, 3rd interspace, right foot, under loupe magnification. Attention was directed to the 3rd intermetatarsal space where approximately 3 cm incision was made and under loupe magnification the procedure was performed. The incision was deepened, vital structures identified and retraced, bleeding vessels cauterized per electrocautery. Both sharp and blunt dissection was carried down to the deep transverse intermetatarsal ligament where it was identified and transected to reveal a large neuromatous mass. The neuromatous mass was identified and traced out distally to its bifurcations to the 3rd and 4th toe where it was transected and the neuromatous mass was then brought back proximal-proximal to the deep transverse intermetatarsal ligament where it was transected while utilizing gentle traction on the nerve. It was transected with a 15-blade without incident. The wound was irrigated with copious amounts of sterile saline and bacitracin solution. The skin was reapproximated with 4-0 nylon in simple horizontal fashion. This completed the excision of Morton neuroma, 3rd interspace.
3. Implantation of nerve, left lower extremity. Attention was directed to the 3rd interspace area where an approximately 3 cm incision was made coursing back out to the previous incisional area. The incision was deepened, vital structures identified and retracted, and bleeding vessels cauterized with electrocautery. The procedure was performed under loupe magnification and dissection was carried down to the transected nerve where it was identified and then the nerve was placed within the intrinsic muscular area of the 3rd interspace and sutured with a perineurial technique utilizing 3-0 Vicryl suture to secure the nerve into the implanted area. The wound was irrigated with copious amounts of sterile saline and bacitracin solution. The skin was reapproximated with 4-0 nylon in simple horizontal fashion.
4. Implantation of nerve, right lower extremity. Attention was directed to the 3rd interspace area where an approximately 3 cm incision was made coursing back out to the previous incisional area. The incision was deepened, vital structures identified and retracted, and bleeding vessels cauterized with electrocautery. The procedure was performed under loupe magnification and dissection was carried down to the transected nerve where it was identified and then the nerve was placed within the intrinsic muscular area of the 3rd interspace and sutured with a perineurial technique utilizing 3-0 Vicryl suture to secure the nerve into the implanted area. The wound was irrigated with copious amounts of sterile saline and bacitracin solution. The skin was reapproximated with 4-0 nylon in simple horizontal fashion.
The tourniquet was released and blood flow was reestablished to digits 1, 2, 3, 4, and 5 of both feet and, in particular, all four quadrants of digits 1, 2, 3, 4 and 5 and the surrounding incisional areas. A sterile dressing was applied with surgical shoes. The patient tolerated the procedures and anesthesia well, and was discharged to PAR in stable condition.
HERE IS THS ISSUE IM HAVING………
Due to specific CPT 2018 instructions: "For Morton neurectomy, use 28080"
Excision of Morton’s Neuroma, each, (RT Foot; Lt Foot): 64782×2 should be 28080×2
Due to CPT 2018 instructions for the add-on codes: "Use 64787 in conjunction with 64774-64786"; this does not allow use with 28080.
Implantation of nerve end into bone or muscle for each nerve: 64787×2 should MAYBE be an unlisted code 64999??
I believe Documentation supports the 64787 codes…..
I can’t find definitive instructions about the use of 28080 and 64787 codes that would allow reporting the implantation part of the surgery with the Morton’s neurectomy.
Any help is greatly appreciated.
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:)
PREOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.
POSTOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.
PROCEDURE:
1. Closure of vesicostomy
2. Left ureteral reimplantation.
INDICATIONS:
Patient is a 13-year-old boy with low level myelomeningocele with resulting bowel and bladder dysfunction. He has been managed with vesicostomy due to his unwillingness to perform intermittent catheterization. He is now performing intermittent cath and would like closure of the vesicostomy. There is also grade 4 left reflux which persists despite previous Deflux injection.
FINDINGS:
Vesicostomy with evidence of chronic bladder inflammation. Deflux injection sites noted around left orifice with significant fibrosis.
DESCRIPTION OF PROCEDURE:
After adequate general anesthesia was obtained, the patient was placed in a supine position and the external genitalia and lower abdomen were prepped and draped in usual sterile fashion. A 12-French Foley catheter was inserted in the vesicostomy site and the balloon inflated. A transverse incision was then made encompassing the vesicostomy site and carried down to the rectus fascia. This was opened transversely and elevated in the fashion of a Pfannenstiel incision. The vesicostomy site was secured with 2 sutures of 3-0 silk and dissected free from the rectus muscles. The bladder was then opened in the midline. The mucosa was noted to be mildly inflamed throughout. The Bookwalter retractor was then brought onto the field and placed in such a manner as to allow adequate visualization of the bladder interior. Despite this, however, there was exceptional difficulty seeing the area of the trigone due to superior location of the vesicostomy incision. For this reason the rectus fascia was then divided in the midline inferiorly to allow further separation of the muscle and better visualization of the base of the bladder. The left ureteral orifice was identified and cannulated with a 5-French feeding tube without difficulty. The right ureteral orifice was also identified. Dissection was then performed to free the left ureter from the surrounding detrusor. There was exceptional fibrotic reaction, however, and this intravesical dissection was unsuccessful. The ureter was entered during the dissection and I made the decision to perform extravesical dissection. The Bookwalter was rearranged to allow visualization of the left perivesical space. Dissection was commenced and it was noted that there was a very large amount of hard stool throughout the colon. This filled the pelvis and made dissection more difficult. The left vas deferens was identified and protected. Because of the difficulty in dissection I asked Dr. Chandler, pediatric surgeon, to come in and assist. We were then able to free the ureter from the surrounding detrusor muscle up to the pelvic brim. During this dissection the Deflux mounds were encountered and removed. Adequate length was then gained for ureteral reimplantation. The ureter was brought in through the posterior aspect of the bladder and a submucosal tunnel created in a Politano-Leadbetter fashion. The ureter was secured in its new location with interrupted 4-0 Vicryl suture. The defect where the left ureter was originally located was significant due to the degree of fibrosis. This was closed with running 2-0 Vicryl suture. The bladder was then closed with 2 layers, the first layer of 2-0 Vicryl followed by a second layer of 3-0 Vicryl. Prior to this, clear efflux was seen from both the right and left ureteral orifices. An 18-French Foley catheter was then brought out through the right side of the abdomen and secured with 3-0 nylon suture. The rectus fascia was closed with running 2-0 Vicryl. The wound then closed in layers with 3-0 and 5-0 Vicryl. A 12-French Foley catheter was inserted per urethra with return of light pink urine. Irrigation of suprapubic catheter showed no significant bladder leak prior to closure of the fascia. The wound was infiltrated with 0.25% Sensorcaine and sterile dressing applied. The patient was awakened and transferred to the recovery room.
Thanks in advance for you help!