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coding question??

Posted By Michael C. Kleinmann, Wednesday, May 11, 2016

I am looking for some guidance on a coding issue.  This doesn't seem to be specifically addressed in the coding manual.    This particular case began with a pateint with falling access flows a fistulagram was ordered and revealed an outflow occlusion in the primary outflow brachial vein.  The access was kept open via a communicator to the brachial vein.  

 

 

 

 


 

 

 

 

       

 

     

 

I was able to get across the the occlusion ultimately, and we were able to re-cannulate the access.  

This case required multiple wires adn guiding catheters to cross the occlusion and multiple balloons, and finally a stent and anticoagulation the re-cannulte the access.  Clearly there are more resources, time and risk involved than fistulagram.

 

Does anyone have experience with the most appropriate codes to use? Is this best coded as a thrombectomy, thrombectomy-in-situ, or just a PTA?

 

 

Thank you,

Craig Kleinmann

Tags:  Coding 

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Comments on this post...

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John D. Reed says...
Posted Wednesday, May 11, 2016
I think if you don't have clot you can't charge a thrombectomy so if it was a "clean' occlusion I think no. There are I believe modifiers (-22?) that you can use for more involved cases. Obviously documention has to support and payment likely highly dependent on local carrier.

JD Reed
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Suresh K. Margassery says...
Posted Thursday, May 12, 2016
This procedure does not support a thrombectomy code. Unfortunately, you have put in lot of effort, time and used many handy resources to fix the problem. A modifier code can be used for billing, which requires a comprehensive documentation of all the steps taken to achieve the successful outcome. At the end, there is no remuneration guaranty for your extensive work; which is highly depended on the patient's insurance carrier.
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Marc Webb says...
Posted Monday, August 15, 2016
Sorry - I don't see a clot, nor any effort to disrupt, dissolve, or extract a clot. This is a venoplasty and stenting pure and simple, and you won't get paid for the venoplasty. If the occlusion were in the subclavian, perhaps you could claim a "catheter to SVC" when passing the occlusion, but here, no.
And as for submitting your claim with a 22 modifier, I am completing a internal study of such charges submitted for 50 ridiculous 4, 5 or six hour complex revisions, and the net result so far is that of the few cases we have been paid for, the gain has been less than $100 - not worth time time required to document the extra effort - and in truth, in the majority of cases WE HAVE NOT BEEN PAID AT ALL, even after six months and several rounds of submitting and re-submitting supporting documentation. They will not tell you how they evaluate the 22 modifier claims, or what qualifies. The 22 modifier process seems to be a sham. Unless you are willing to make it a quest, I discourage it
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Marc Webb says...
Posted Monday, August 15, 2016
I am interested in the comments of anyone with a better understanding and a better experience with the 22 modifier than I have had (drwebb@drmarcwebb.com, or mgwebb101@aol.com)
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Jeffrey Packer says...
Posted Monday, August 15, 2016
Over many years have used the -22 only a few times with very limited success. The case submitted is a veno and a PTA. The philosophy of the intermediaries and CMS is that some cases are tough and some not so tough but they all "average out." When reimbursement is set up (RVU's and so on) they are based on the type of case that is the "50%-er" and so this is just above average effort on the part of the operator. BTW, using a -22 modifier pretty much will always lead to a review, delay adjudicating the claim, and you will rarely get higher reimbursement. YMMV.
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Bharat S. Sachdeva says...
Posted Monday, August 15, 2016
Angiogram and stent is all we can bill for this, with use of selective cannulation of first degree vein (36011), dropping 36147 then and using angio only code (75791)

Have to agree with the comments above
First 3 years in practice I used 22 a few times and every time the payment was NIL. All of those were Medicare

Are the private payers different?
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