# 36005 denied as bundled to 33249



## coders_rock! (May 10, 2011)

Hello everyone,

CPT codes billed are 33249, 33225[53], 36005, 75820[26], & 71090[26].

everthing was paid except 36005. Per CCI says bundled to 33249 but a modifier is allowed.

I can really use your help. Does anyone have any suggestions?


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## OliviaPrice (May 10, 2011)

Why were you billing the 36005 & 75820?  If the Inj was completely unrelated to the implant then you can bill using the modifier, if it was not separate then you should not bill either of the above codes.


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## coders_rock! (May 10, 2011)

Thank you for responding, I did not code this op-report. It was sent to me to determine is 36005 should be paid. I know the op report is a bit much, but I need help. Your guidance is greatly appreciated.

Procedure: Given prior ICD placement, a left upper extremity venogram was performed to confirm left subclavian patency and to delineate the course of the axillary and subclavian veins. 5cc of IV contrast x 3 was injected via the left antecubital vein; the cephalic, axillary and subclavian veins were patent.
The left infraclavicular area was prepped and draped. After adequate local anesthesia, the skin was incised and the subcutaneous tissue was dissected. After establishing hemostasis, venous access was obtained by left cephalic vein cut-down. Under fluoroscopic guidance, the ventricular lead was positioned at the RV septum. A satisfactory distance was achieved between the new defibrillator lead and the chronic defibrillator lead. I confirmed that lead position was stable, and that sensing and pacing thresholds were adequate after stylet removal, with no diaphragmatic stimulation at 10 volts output. The stability of the lead position was established fluoroscopically. The lead was stabilized by suturing to the tissue at the venous access site. 
A second sheath was then placed in the left subclavian vein using a retained guidewire. A guiding sheath was advanced to the right atrium. The sub-Eustachian space was markedly enlarged. Multiple sheaths (EH, EH-wide, MPH, with & without inner catheter) were used in an attempt to engage the CS. The CS os could be identified with contrast injection and the MPH with an IC-90 successfully engaged the CS os. Despite this, the CS could not be cannulated with the sheath or a wire. Contrast injection at the os failed to opacify the CS, consistent with a valve occluding the CS or an acutely angled take-off. A 6 French steerable EP catheter was used in an attempt to cannulate the CS. The catheter again failed to advance beyond the CS os. Ultimately, the CS lead was aborted due to inability to cannulate the CS after a prolonged attempt. The sheath was removed. 
The subcutaneous tissue was dissected to the previous ICD pocket. The ICD pulse generator and the electrode terminals were exposed. After establishing hemostasis, the electrode terminals were detached from the pulse generator, which was removed. The Fidelis lead was capped and replaced in the pocket. The new ICD lead was connected to a new CRTD generator. A CRTD generator was chosen in anticipation of repeat attempt at ICD upgrade; the atrial, LV and SVC ports were plugged. The CRTD generator was replaced in the prior ICD pocket and hemostasis was confirmed. I confirmed that pacemaker function was satisfactory. All of the sponges were removed and the wound was irrigated. The wound was closed in three layers. A sterile bandage was applied.


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## Jim Pawloski (May 11, 2011)

tmontgomery767@yahoo.com said:


> Hello everyone,
> 
> CPT codes billed are 33249, 33225[53], 36005, 75820[26], & 71090[26].
> 
> ...



Per Dr. Z, the venogram is bundled into the 71090 when used for access to the vein.
HTH,
Jim Pawloski, CIRCC


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## OliviaPrice (May 11, 2011)

tmontgomery767@yahoo.com said:


> Thank you for responding, I did not code this op-report. It was sent to me to determine is 36005 should be paid. I know the op report is a bit much, but I need help. Your guidance is greatly appreciated.
> 
> Procedure: Given prior ICD placement, a left upper extremity venogram was performed to confirm left subclavian patency and to delineate the course of the axillary and subclavian veins. 5cc of IV contrast x 3 was injected via the left antecubital vein; the cephalic, axillary and subclavian veins were patent.
> The left infraclavicular area was prepped and draped. After adequate local anesthesia, the skin was incised and the subcutaneous tissue was dissected. After establishing hemostasis, venous access was obtained by left cephalic vein cut-down. Under fluoroscopic guidance, the ventricular lead was positioned at the RV septum. A satisfactory distance was achieved between the new defibrillator lead and the chronic defibrillator lead. I confirmed that lead position was stable, and that sensing and pacing thresholds were adequate after stylet removal, with no diaphragmatic stimulation at 10 volts output. The stability of the lead position was established fluoroscopically. The lead was stabilized by suturing to the tissue at the venous access site.
> ...




Procedures 36005 & 75820 should not be reported separately since the venogram was done to assess the subclavian for the lead placement.  This is bundled into the procedure.


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## coders_rock! (May 13, 2011)

Thanks Olivia & Jim, have a great weekend!


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