Ask Dr. Z

For the LimFlow procedure, would unlisted code 37799 be the appropriate code to use? I have searched and have not found anything on this procedure.   

Is he correct?

The MD did a redo of Atrial fibrillation ablation. Since the veins were silent I told him we were advised to bill as SVT 93653 not Afib ablation 93656.

His response was this is not exclusively PVI. At redo AF ablation one can do other ablation such as CFAE ablation and posterior wall isolation which is what we did.

Summary:

1. Symptomatic persistent atrial fibrillation

2. Symptomatic roof dependent atrial flutter, termination to sinus rhythm with roof line

3. All pulmonary veins were isolated from prior ablation

4. CFAE ablation targeting posterior wall non-PV triggers

5. Left atrium ablation with floor line creation and posterior wall isolation targeting posterior wall non-PV triggers

"Percutaneous access was achieved in the left common femoral artery. A micro access sheath was placed. This was upsized to a 4 French sheath over a 0.035 wire. A UF catheter over a Glidewire was advanced over the iliac bifurcation and then exchanged for a 4 French endo catheter. An angiogram down the right leg was obtained."

There is no documentation that the catheter went into right leg, so should catheter placement be coded as 36140 or 36200?

Are you able to code an Ileofemoral endarterectomy (35355) and a profunda embolectomy (34201) with repair of CFA aneurysm with external iliac artery to profunda bypass (35141)? I'm not sure if a modifier would be appropriate.

Would 62323 and 78630 be the correct codes, or would 62323 and 78650 be correct? I'm having a hard time distinguishing the difference between 78630 and 78650.

"PROCEDURE: Lumbar puncture with radiotracer and iodinated contrast injection for cisternography using pledgets, NM cisternography imaging, CT of head. Patient was placed in the prone position and L3-4 level was localized. Using a maximum sterile barrier local anesthetic, single puncture was made into the thecal sac at L3-4. There was prompt return of clear CSF. Injection of radiotracer is performed followed by 11 mL of Omnipaque 300 the needle was subsequently removed. The patient was placed in the headdown position and the contrast migrated cranially under fluoroscopic guidance. Subsequently, the patient was rolled into the supine position and nasal pledgets placed 2 in each nostril.

IMPRESSION: Successful lumbar puncture with contrast injection into the thecal sac and radiotracer injection for cisternography. Pledgets placed. CT and nuclear medicine studies pending."

We are being tasked to find out if we can bill for multiple EKG reads CPT 93010 during inherited stress testing for Brugada syndrome.

Current state, when our cardiologist are performing the stress test for Brugada syndrome they are dropping charges for three the EKGs, but we are being asked should EKG #2 and #3 (not normal 12 leads because they use different lead positions) be billed, or are they bundled with the stress test?

Based on my understanding, EKG #2 and 3 would be bundled into the stress test based on "continuous electrocardiographic monitoring", but I want to make sure my understanding is correct that these two EKGs would not be billable (but EKG #1 is billable).

Are catheter placement codes bundled if utilizing a radial approach for lower extremity intervention?

What is correct billing for TriNav infusion system when embolization (37243 or 37242) in hospital outpatient IR setting? The TriNav rep has instructed physicians to add C9797 in dictation as procedure code and C1982 as device code because CMS is tracking this?? Do we still bill the 37243 along with C9797 and C1982? The physicians really want to make sure this is coded correctly and would appreciate your response. Thanks.

HCPCS code C9797 is new for hospitals this year. Code C9797 includes S&I, roadmapping, and imaging per the description. Would catheter placements be separately billable?

Do you have any guidance on how to bill 4D ICE imaging performed during Watchman procedure? The patient also had 93656 and 93655 performed, but there was no mention of 4D ICE used during that portion of the procedure. I copied portions of the Watchman that mention the 4D ICE below.

“The 4D ICE was then placed in the LA with fluoro. Catheter was advanced through the Watchman sheath. Catheter was maneuvered into the left atrial appendage, and contrast injections were performed for positioning of the Watchman sheath. 4D ICE images were reviewed along with contrast injections. The device and passed the anchor or tug-test under ICE and fluoroscopic visualization. When measured in multiple 4D ICE views, compression was measured at 20%.”

It was noted in question ID 10960 say "Codes 93350 and 93016/93018 are used for physician billing when two different physicians are involved – one performs the cardiovascular stress test (93016/93018) and one performs the echocardiogram (93350)"

The question outstanding is can we report 93350 if there was one supervising physician for echo and stress (ECG monitoring) and 93018 for a different provider to interpret? or do we report 93351 and loose the interpret? If we choose 93350, does there need to be two different documents for each provider?

Please advise correct coding. Successful particles embolization of bilateral sphenopalatine arteries. Dx-nosebleed (refractory epistaxis. Would this be consider 61626 x 1 as there is only one nose or would it be 61624 x 2 due to location of embolization?

A patient underwent PVC ablation. Following the ablation, PVCs were suppressed for a while, but then a lower burden of PVCs with a slightly different morphology resurfaced. The decision was made to not ablate at the new site of arrhythmia. Isoproterenol was infused, and the burden of the new PVCs did not increase, although several other polymorphic PVCs occurred. HIM assigned CPT code 93623 to the case, based on this documentation. However, the EP physician is questioning the use of the code: "Can I add [code 93623] if we administered the isoproterenol only to see if PVC burden increases, but I did not stimulate the heart during isoproterenol infusion?"

I would appreciate ZHealth's advice on this.

"A site was selected just above the bifurcation of two joining basilic veins just a few cm above the elbow. The left basilic vein was identified during sharp dissection and mobilized circumferentially. The lateral most vein branch was divided with silk ties so that a tensionless anastomosis could be created. The vein was transected a few cm below the elbow for sufficient length. Sharp dissection with Bovie was used to circumferentially dissect the brachial artery and adjacent branchial veins. The left brachial artery was controlled with vessel loops and vascular clamps. The artery was opened with an 11 blade, and the arteriotomy was extended with Potts. The vein was spatulated and sewn in a 4 quadrant heel-to-toe anastomosis with Prolene in end-to-side fashion. The fistula was patent, but a sclerotic area was noted proximal. A Fogarty was passed, and this was ballooned several times until thrill and color flow duplex improved." 

Would this be reported with code 36821 or 36819? Would there be an additional code for the balloon?

Other imaging guidance codes (76942, 77002, 77003, 77012, and 77021) are only allowed to be reported once per encounter/treatment session. May code 75894 be reported for each intracranial vascular territory embolization at the same encounter/treatment session when 61624 is performed/reported more than once? 

Stents were placed in common and external iliac arteries to reline the iliac system after open thrombectomy of iliac arteries and femoral endarterectomy via same arteriotomy. Can we report code 35371 along with 37221 and 37223 in this case, or is it just billed with code 35355?

Patient with angina and CAD comes in for left heart cath/coronary angiograms. The physician states in his findings left main eccentric 60% distal with MLA 7.1 mm2 and normal iFR 0.95 in mid LAD. LM MLA was 6-7 mm2. How is MLA (minimum lumen area) calculated? Is this done via IVUS? And if so can we code IVUS, 92978, based off this documentation? We would, of course, also code the heart cath and iFR.

Physician was performing a TAVR, and on the way out there was a "valve delivery dissection in the right common iliac". A Viabhan stent was inserted, then a balloon was placed across the stent with a maximum inflation of 10 atm. I am reviewing iatrogenic laceration in Chp 5 of NCCI as my resource for not coding a repair for an injury caused by a surgeon.

Is the dissection repair with a stent a codeable procedure?

Can code 61650 be used for the radiologist's portion of the WADA test?

"Bilateral common carotid arteries.

Bilateral internal carotid arteries.

With the diagnostic catheter in the left internal carotid artery we proceed to administer 4 mg of Brevital over 3 seconds, the patient is seen to turn left-sided hemiplegic and is assess for language and memory. Once she regains strength additional 2 mg of Brevital administered intra-arterially and new memory items are shown to the patient. After the patient fully recovers from both injections the catheter is placed in the right internal carotid artery. 4 mg of Brevital over 3 seconds are administered into the left ICA and once the patient becomes right-sided hemiplegia we assess for language and memory. Additional 1 mg of Brevital was administer interest E really and new memory attention to the patient. The patient recovers fully from the injection and the catheter is removed without complication. The sheath is removed and a 6 French Angio-Seal is used as closure device."

Is radiofrequency for nerve localization a billable procedure? Or would it be included in the nerve block with imaging guidance procedure? If billable, would this be unlisted code 64999, comparable to a pulsed RFA procedure?

"Indications: The patient's history and physical findings include pain consistent with ilioinguinal neuralgia. The patient is here for left ilioinguinal nerve block with radiofrequency neurostimulation.

A 22 gauge 54 mm curved sharp RF cannula was inserted percutaneously and advanced under ultrasound guidance using linear probe with medial to lateral approach to the target nerve. No paresthesias occurred, and aspiration was negative. Radiofrequency neurostimulation was used to assist with nerve localization. The nerve(s) were then stimulated at 42 degrees C at 20 msec pulse width and 2 Hz for 6 minutes, then a nerve block was performed by injection of Dexamethasone (10mg/mL) 5 mg and Bupivacaine (0.5%) 8 mL."

Can you charge 64520 more than once? In our Vitaware it has a MUE of 1. I am getting referrals to add 64520 two more times.

"Left Lumbar Sympatathetic Block

Once the needle(s) was past the transverse process L2, lateral fluoroscopic views were then used to advance the needle tip(s) to the anterior margin of the vertebral body. After negative aspiration was confirmed, 1 ml of contrast medium was injected at each level, showing good spread along the distribution of the lumbar sympathetic chain on both lateral and AP fluoroscopy. Then, after reconfirming negative aspiration, 10 ml of 0.25% bupivacaine was injected at each level. The needles were then removed and a bandage was placed over the needle insertion sites.

The same procedure was repeated at the L3 and L4 levels."

"Right biliary system: The indwelling biliary drain was exchanged over a wire for a sheath through which contrast injection was performed. A guidewire was passed through the bile ducts and into the small bowel, and a biliary stent was deployed. An external biliary drain was placed, and final contrast injection was performed. Initial cholangiogram findings: Severe segmental distal CBD stenosis causing intra and extrahepatic biliary dilation. Stent(s) placed: 6 x 80 mm. Stent type: Uncovered. Stent position: Common bile duct. Balloon dilation of stent (mm): 8. Following this, repeat cholangiogram was performed through the sheath. This demonstrated mild delay of contrast passage into the duodenum distal to the inferior terminus of the newly placed CBD stent. The distal CBD inferior to the stent was then subsequently treated with cholangioplasty using an 8 x 40 mm balloon. Completion sheath cholangiogram demonstrated widely patent common bile duct stent with passage of bile into the duodenum. Subsequently a safety external biliary drain was placed." Should we add code 47542?

The P. wall showed fractionated activity. There was a narrow area of the P. wall which was active with lot of fractionated activity. I decided to proceed with P. wall isolation.

RF energy was delivered connecting the previously done wide area circumferential ablation line the left infer. PV to right infer. PV. Two sets of RF were delivered. This was followed by evaluation of the P. wall. Activity was still noted. This was followed by few more RF applications. P. wall was isolated. Roof line was evaluated. No activity noted towards the roof line however event pacing at high output capture was noted. Decided to place few more RF along the roof. This was followed by re-evaluation which showed no activity. Pacing was performed at high output along the roof and did not show any capture.

PV’s previously isolated and now isolating the posterior wall and it takes 2 sets of RF. to isolate, come up with 93656, after two sets activity still noted and more RF applied 93657. Do not believe 93657 would apply for ablation along roof for high output capture.

“We dissected out the distal external iliac artery as well as the CFA, SFA, tertiary & quaternary branches of the profunda femoris artery which is severely diseased. Arteriotomy created in common femoral artery & extended down the profunda femoris into that large lateral branch as described above. I endarterectomized the CFA into the distal external iliac artery & down into the profunda femoris lateral branch as described above…. Nice flow through the femoral artery into profunda femoris artery. Bovine pericardial patch angioplasty performed.“

Then performed a bypass. “Performed arteriotomy in the patched portion of the CFA-passed through the tunnel…arteriotomy in the posterior tibial artery for side anastomosis.”

“It should be noted that this femoral endarterectomy was an attempt to reestablish the best flow possible into the deep femoral system for long-term limb salvage. This endarterectomy is not strictly done to provide inflow for the bypass. These are separate procedures designed to accomplish limb salvage by revascularization different vascular beds.

I'm hoping you can shed some light on how to handle situations where the left innominate vein is selectively catheterized and imaged for evaluation of veno-venous collaterals, but none are found. It seems that codes 36011 and 75820 would be appropriate in this case, but we're uncertain because this yields more RVUs than if collaterals were found and selected for additional imaging (remove 36011, add 93587). Are codes 93587 and 93588 meant for use when selective venous imaging is done to evaluate for collaterals (whether found or not), or are they only used when collateral vessels themselves are selectively entered and imaged? And if the latter, how do I explain to my doctors why they receive fewer RVUs for performing a higher order level of venous selectivity and imaging?

R-arm Peripheral IV was used to perform a venogram of the r subclavian vein under fluoro with 10 cc dye injection in r arm PIV. Is it ok to bill 36005 & 75820 via existing IV or just bill 36005?

Which HCPCS C code do you recommend for a Swan/thermoperfustion catheter - for the supply?

I am not sure what codes I should be using to code this. I am thinking would it be 36222-RT and 36227-RT. Is this correct?

"We advanced a 5 French Simmons 2 diagnostic catheter over a Glidewire up the subclavian artery into the aortic arch. We selectively catheterized the right common carotid artery, and under fluoroscopic roadmap guidance, we subsequently catheterized the right lingual artery. We then obtained AP and lateral angiographic views centered over the head and neck region. Diagnostic catheter was then carefully removed."

Our providers perform a colectomy and uses ICG to check the blood flow to both ends of the bowel prior to completion of the procedure. Would it be appropriate to report 15860 with the colectomy?

Does the wording "Doppler interrogation" satisfy definition for 96976, 76870? Or does spectral analysis and color Doppler need to be documented in the report to charge 96976 and 76870?

Hello, can we please have CPT guidance on the following exam:

We are doing planar imaging for the ventilation AND perfusion and doing an ADDITIONAL SPECT/CT.

We are using 2 tracers, and 3 imaging sets, Vent planar, Perfusion planar and Perfusion SPECT/CT.

- Should we be reporting the lung vent and perfusion (78582) separate with the SPECT/CT (78830) in this scenario?

My codes:

93458 Left Heart Cath

75710 LT XU and 36215 XU Subclavian Angio and Cath placement

75716 XU and 36246 XU LE bilateral Angio and Cath placement

I am really unsure about the cath codes and coding 75710 and 75716 together. The subclavian angiogram is for suspected occlusion and not bypass suitability. LE angiogram of the entire RT/LT legs claudication.

If a collateral emerges from the RIMA and we occlude the RIMA (37242), do we use the selective catheterization code 36217, or do we use the code for MAPCA 93575?

R CFV accessed w/ ease & 8F sheath inserted followed by single Preclose suture. Series of dilators used to insert 24F Inari sheath. Angled pigtail catheter used to access the pulmonary artery. RT pulmonary artery accessed & MPA catheter used to access subsegmental branch. J-wire was exchanged for Amplatz wire. T24 inserted w/ ease, multiple rounds of thrombectomy performed w/ successful retrieval of thrombus. Angiography confirmed excellent result. Small thrombi in peripheral/subsegmental branches, too distal to retrieve. T24 was withdrawn to the main PA. Angiography was performed. Curved T20 introduced. Thrombectomy performed, but there wasn't return of blood. Both catheters placed under suction & T20 was removed. Thrombus was retrieved. Angiography performed again & confirmed an excellent result on the LT side. Realizing there was clot in transit resting inside the RV 2 rounds of thrombectomy were performed as the catheter was withdrawn. Significant thrombus was removed from the right ventricle.

Is there a code for the right ventricle thrombus?

An ICD generator and lead were removed due to a pocket infection and a wound vac was placed. The patient was brought back in 5 days. Local anesthetic was infiltrated, and moderate conscious sedation was administered. The wound vac sponge removed. The ICD was pocket irrigated with antibiotics solution and residual hematoma removed. The wound was inspected without signs of infection. The pocket was closed with sutures. The report calls this a successful CIED pocket/wound debridement, wound vac removal. Is the closure coded 12020 or 13160 or the hematoma removal 10140, no incision is mentioned? Is the wound vac removal included in the placement?

Please suggest. Indication: Esophageal varices bleeding. Paracentesis performed. left common iliac vein access , iliac venogram , IVUS performed to determine If the patient is a candidate for DIPS placement in future. US guided to puncture to get splenic access. After venogarm selection of gastric vein , gastric venogram, selection of 5 different branches supplying varices , embolization of them. I know procedure is 37244. Please suggest codes for this catheter placement? Can we report IVUS? cath placement for that? Thank you

Scenario: Patient came in for scheduled dual chamber permanent pacemaker implant. While in recovery, patient was continuously moving and had runs of V Tach with intermittent loss of capture of the RV lead. Patient was brought back urgently to the EP lab. The old RV lead was completely extracted from the body and a new RV lead was inserted.

We are receiving an edit for 33208 & 33216.

How should we proceed for hospital billing

How should this be coded it was done with a CABG? 

"Prior to any manipulation of the heart the decision was made to perform a transaortic, ventriculoscope assisted left apical thrombectomy. A transverse aortotomy was then performed about 0.5 cm above the sinotubular junction. The aortic valve leaflets were then carefully identified. A smooth S shaped retractor was then used to retract the right coronary leaflet out of the way. A 30 degree angled 5 mm scope was then introduced into the left ventricle. The thrombus was then identified. The thrombus was identified as a globular appearing mass at the apex (ventriculoscopy pictures in patient's chart). The decision was then made to remove the thrombus with forceps. Once the thrombus was encountered and a few pieces were removed with the forceps it was quite obvious the thrombus was friable and the forceps will be inadequate for removal. The decision was then made to remove thrombus using a sucker tip. A sucker was introduced and removed friable thrombus."

How do you code the injection in right L5 transverse process injection?

Patient was diagnosed with discitis/osteomyelitis. IVR doctor placed drain under CT guidance into left paraspinal soft tissue. CT confirmed drain was placed adjacent to an area of discitis and osteomyelitis with gas in psoas musculature. Also, deep conscious sedation was provided by anesthesiologist. We are not sure what to code, 10030 or 64999. If it's unspecified, what code do you think we can compare it to?

Would cardiologist report code 75756 when only IMA angio performed, no cath?

Physician Charges

Percutaneous abdominal fat pad biopsy. CPT 22999 or 17999?

Organ targeted: Soft Tissue, abdominal wall

Biopsy side: Left

Fine needle aspiration: No

Core biopsy:

1. Biopince 16 gauge 13 - 23 mm, 5 samples

Has the AMA published an explanation as to why a central venous catheter or device termination location must be documented? How must the catheter/device tip location be identified/documented? For example, confirmation by CT scan the next day.

We have a new vendor that is taking our MRI images of the heart and using their software to do a detailed review for cardiotoxicity. The study is Myostrain and asking us to bill 75557. The study does not require function studies. Do you have to perform function studies to code/bill 75557?

If the injection of Tc99 is given for a liver tumor, are we billing 79445 with 37243 or just the 79445?

Axillary bi-fem bypass was performed for infected aortitis Then through separate incisions an open lap was performed with excision of the infected aorta/iliac arteries. Would the excision of the infected aorta/iliacs be included in with the bypass procedure, or is it separately billable? If billable, how would you code this?

"Once we completed the axillary bifemoral bypass, we decided to resect the distal infrarenal aorta, aortic bifurcation, entire right common iliac artery, and proximal left common iliac artery. The tissue was sent for culture and pathology. We then performed further debridement along the left iliac vein and distal vena cava, confirming that all infected retroperitoneal peritoneal tissue was removed. We oversewed the right and left common iliac cuffs with a Blalock stitch, using 3-0 Prolene suture. The aortic cuff was oversewed in a similar fashion. We confirmed hemostasis. We then thoroughly irrigated the retroperitoneum with both saline and Betadine solution."

Just checking to see if the guidance remains the same: Does CPT code 33244 still cover removal of RA, RV, and LV lead(s)? Encoder is showing an MUE of 2, so I was wondering if one 33244 is for the RA/RV leads, and one 33244 is for the LV lead. Thanks!

Per your response for question ID #11629, if embolization via spinal arteries is done for a vertebral body met, this should be coded as 37243. However, we are getting some pushback from one of our providers stating they feel 61624 is more appropriate when the vertebral body metastasis is compression and/or invading the spinal cord since now it's affecting cord, which is CNS. Could you provide some insight?

CPT Assistant (November 2020) states that a patient does NOT have to be in Afib if patient has persistent or paroxysmal Afib in order to code 93657 (additional Afib ablation), although the code still reads Afib should be remaining. So if PVI is complete and a linear carina line is required, can we code for the 93657 when the patient is not still in Afib after PVI is complete? Also, if the carina line is performed for "right PVs were difficult and required carina line for isolation", could that be reported with 93657 or not since it sounds like they are still isolating the PVs?

"Patient upgraded from dual ICD to biventricular ICD. Surgeon was unable to access the coronary sinus for the LV lead. The CS sheath was withdrawn to the right atrium, and wires were advanced to the heart. Over remaining wire the pacing sheet was advanced to the right atrium. Then, the wire and sheath were advanced to the right ventricle, and the sheath was positioned into the high basal RV septum approximately 2 cm distal to the aortic valve. Lead was tested, which demonstrated a septal paced morphology with a wide QRS. The lead was then screwed deep into the septum."

We have 33264 for the upgrade, but since the surgeon is attempting LV lead (and that is the intent) but has to come into the septum, would you report code 33225 or 33999?