Wiki Need help please with coding/denial problem

[jodeleon1]

I posted this before, over 70 views, but no responses ....PLEASE... any advice you can give would be greatly appreciated!!!!!

Major problem when coding 36147 with 35475/35476-some claims are paid others are not and I cannot identify the oattern-is it incorrect modifier??? Incorrect coding?? Sample op report below.


PROCEDURES PERFORMED:
1. Right forearm fistulogram.
2. Right peripheral venous angioplasty.
3. Right radial artery balloon angioplasty with catheter introduction x2.
INDICATIONS FOR THE PROCEDURE: This 83-year-old male is well known to me. I have been managing his access for many years. We were notified that his fistula had become thrombotic; however, on examination, there seemed to be areas of stenoses within the fistula and some reduced inflows, but there was no evidence of thrombus.
PROCEDURE IN DETAIL: The patient was taken to the XXX and sterilely prepped and draped in standard fashion. After infiltration with 1% lidocaine, a needle, a wire, and a short 6-French sheath were inserted in the direction of the antecubital fossa. Aliquots of diluted Visipaque were utilized to visualize the fistula, and there seemed to be a 95% stenosis approximately measuring 3 cm medial to the antecubital fossa. A 6 mm balloon was passed across this lesion, and upon insufflating the lesion, a reflux study was done which showed arterial narrowing across the initial arterial segment of 85% to 90%. Following insufflation in the venous end, a second sheath was passed in the direction of the wrist. A 5 mm balloon was passed across this lesion, and serial insufflations were performed here as well. The completion study showed markedly improved flow. Catheters and wires and sheaths were removed. Pressure was held to the exit site until hemostasis was achieved. The patient tolerated the procedure well. He seemed to have a good quality thrill and bruit in the recovery area. All counts were verified.

Physician coded this as follows:
36147
36148
35475-59
35476-59
75962-59
75978-59

all codes were paid except 35475 & 35476, which seems to be a pattern with a lot of our claims---help please!!! Thank you!!!

 

[Rhurst1]

After reading the report I would code as follows:

36147
36148- this access might be questionable, the physician does not clearly state his second access.
35475
75962

All the angioplasty procedures were performed in the peripheral segment of the fistula, you can only charge one intervention per segment. In this case the arterial angioplasty, arterial PTA is coded when a venous and arterial are done in the same segment, per Dr Z and CSI. If the physician had moved into the central segment for an intervention, that would be separately billable.

There should not be a need for -59 modifier on any of these codes.

 

[jodeleon1]

Should I use a modifier on the 35475? This is the one they always deny, when I use a 59 they still deny. Was told perhaps a rt or lt will work. I will check with Dr Z. Thank you so much for your input. It is greatly appreciated!!!!

 

[dpeoples]

After reading the report I would code as follows:

36147
36148- this access might be questionable, the physician does not clearly state his second access.
35475
75962

All the angioplasty procedures were performed in the peripheral segment of the fistula, you can only charge one intervention per segment. In this case the arterial angioplasty, arterial PTA is coded when a venous and arterial are done in the same segment, per Dr Z and CSI. If the physician had moved into the central segment for an intervention, that would be separately billable.

There should not be a need for -59 modifier on any of these codes.

I agree with Rene's code choices, and you should not need a modifier. Perhaps the reason 35475/75962 and 35476/75978 are being denied is because they are both being billed. If you only bill one of these, you should get reimbursed.

HTH