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Stent question

"After routine prep & drape. An 8F sheath laced in common femoral artery, balloon guide cath with VTk select cath used for selection. left CCA was selected with cath inside walrus balloon guide cath. Balloon guide cath advanced into L CCA. advanced into position into distal CCA. Under balloon guide pfa we advanced 018 wire over which a 6mm 2.5 viabahn stent was then advanced into left ica. Under flow arrest the sent deployed. Second stent of same size was also deployed into Cervical ica. at this pint we used apex balloon. performed angioplasty . Supranominal pressures and angioplasty was performed. balloon pulled back and a run performed showing no evidence of stenosis, showed improved transit w/ no evidence of distal embolization. Final delayed cervical and intracranial run showed no evidence of in-stent thrombosis." 

Would this be 31727 or 61635?

POS codes for 93452

At what place of service can a 93452 be performed and billed?

Left Bundle Pacing When the CS Access Is Not Available

If the provider decides to implant a left bundle delivery system because he was unable to access the coronary sinus and place the left ventricular lead, can the provider separately bill for that? If so, please advise which CPT code to use, because all of the current information indicates that 33225 is not acceptable in this scenario.

CPT CODE FOR MONITORING IMPELLA

Recently our physicians said the Impella rep stated there is a seperate code for monitoring of an Impella balloon, and I thought that would just be bundled with insertion, etc. I believe the scenario would be monitoring on a separate visit and not upon insertion, possibly instead of repositioning. If not a separate code for monitoring, what would be the correct charge if they brought the patient to the lab and did just that with no explant, repositioning?

Paraspinal aspiration with vertebral body biopsy

Is the paraspinal aspiration (62267) bundled with the biopsy (20225) or is the biopsy (20225) bundled with the aspiration (62267)? Our coders state the former, but our providers state the latter.

TECHNIQUE AND FINDINGS: A pre-procedure time-out was performed per the current Universal Protocol guidelines. The patient was prepped and draped with the standard sterile barrier technique followed: Cap, mask, sterile gown, sterile gloves, sterile sheet, proper hand hygiene, and 2% chlorhexidine for cutaneous antisepsis. Following local anesthesia with lidocaine, using a paravertebral approach, aspiration was obtained of the L2-L3 disc space. Additionally, using left transpedicular approach, 11-gauge needle was advanced into the L2 vertebral body and core biopsy was obtained. Samples were sent to laboratory for analysis. There were no apparent immediate complications.

IMPRESSION: Technically successful fluoroscopically guided aspiration of L2-L3 disc space as well as bone biopsy of L2 vertebral body. No apparent immediate complications.

50382 vs. 50435

We were denied 50435 and were advised to report code 50382. We exchanged a nephroureteral stent for a nephrostomy catheter. We cut the catheter and exchanged over a wire. Catheter was left to external drainage. What would you code?

Selective Interlobar with Subsegmental Pulmonary Catherizations

Regarding previous Question ID: 17660

If selective catheterization of the right interlobar artery is performed with thrombectomy, then catheter advanced into the right upper and lower lobes with thrombectomy, is the selective catheterization of the interlobar also coded, i.e., 36015 x3 or because this is a 'pass through' vessel would only the upper and lower lobe catheterizations be coded i.e., 36015 x2?

Abdominal PPM gen change question

There was a complication during this procedure where a surgeon scrubbed in and repaired the disruption in the parietal peritoneum in the pocket that was densely encapsulated with fibrotic tissue (the disruption occurred with electrocautery cutting through the tissue.

My question is would I just append a -22 modifier (33228-22) to the case, or is there a more appropriate charge??

Transplanted renal artery

Should we report code 36251 for an angiogram of a transplanted renal artery?

Posterior Wall Isolation Ablation

Please clear up the posterior wall roof and floor line ablations for us. Following a pulse field ablation for pulmonary vein isolation for atrial fibrillation (93656), we performed an ablation of the posterior wall LA roof line and an ablation of the posterior wall of LA floor line, both for atrial fibrillation. Is the posterior wall roof and floor line a boxed set ablation coded with 93657 x1, or would it be coded with 93657 for the roof line and 93657 for the floor line?

75571

Can 75571 be reported with 78431? When can code 75571 be reported separately with other radiology codes?

Valve Replacement W/ Tear repaired by patch graft

"The Aortic Valve was replaced with a resilia tissue valve & Mitral valve repaired with annuloplasty band. During the replacement of the aortic valve there is documentation of extensive calcification eroding into the muscle of the pulmonary outflow tract, mitral annulus, and anterior leaflet along critical stenosis. "Once the valve was seated and during the removal aortic cross-clamp noted bleeding near the pulmonary arterial portion of the aortotomy very close to the post of Inspiris valve. I placed a single pledgeted 4-0 suture to repair this and it appeared to be successful several minutes later with the heart beating the bleeding recurred. I reclamped the aorta and excised a small portion of the aorta that had torn and sutured a pericardial patch."

Would the aortic repair with the patch be billable in this case with 33999? Or would we treat this as a -22 modifier if documentation supports it?

Emergent Cardioversion during Cardiac Cath

"During the coronary angiography patient developed cardiac arrested and provider treated with cardioversion.

Coronary Angiography: Right coronary artery was cannulated, and selective angiography was performed using a diagnostic catheter. Catheter was inserted into the left main, and left coronary artery selective angiography was performed using a diagnostic left catheter.

Cardiac arrest during the procedure was treated with defibrillation x2, additional dose of amio given, amio drip continued."

Do we report code 92960 for the cardioversion?

VALVE-IN-RING PROCEDURES

Should 0483T-62 (cardiologist and interventional cardiologist) be used for ViR procedures, or should it be coded as unlisted 33999-62? CPT states TMVI/R percutaneous approach without specifying if the valve is being implanted/replaced in a native valve, a MV replacement or a ring. Thank you.

Jejunostomy tube removal

Will you please advise if there is a code for JJ tube removal with fluoro? Our provider performed the removal. Thank you

PROCEDURE: The patient is prepped and draped in the usual fashion. Under fluoroscopic control, access was obtained into the indwelling jejunostomy tube with wire placed. Tube was able to be removed without complication. The site was then dressed appropriately at the conclusion.

FINDINGS: Complete removal of jejunostomy tube.

Fluoroscopy time: 0.2 minutes with DAP 980 CG Y

IMPRESSION: Successful removal of jejunostomy tube performed under fluoroscopic control."

CPT C7557

Could you please explain code C7557 in greater detail? I am having difficulty finding information on this CPT code. Is this code for hospital billing and payable by Medicare for OPPS? If so can you report it with 93458 and when you use Cathworks FFR instead of using 0523T?

Conscious sedation

Does the physician have to be face-to-face for exams such as MRI brain or MRI hip when the patient requires conscious sedation, or do they just have to be close by?

IVC venogram with pulmonary thrombectomy

Our provider performs IVC venogram from femoral venous sheath to confirm no significant thrombus every time during pulmonary thrombectomy procedures. Do we report code 75825 for these routine IVC venograms?

36589/36590

May code 77001 be reported with 36589/90 when a tunneled catheter is removed under fluoroscopy?

Percutaneous TAVR w/ Endarterectomy

Patient had TAVR via percutaneous femoral approach (we report 33361 for this). Patient then required femoral artery cutdown due to occlusion and had endarterectomy with patch angioplasty. The cath lab wants to assign OR charges for the endarterectomy/patch part of the procedure and CPT for the TAVR. Can we do this?

CTA Chest/Abdomen & Pelvis without contrast

Because of abnormal renal functions, I am seeing a lot of CTAs of chest/abdomen & pelvis being done without the use of contrast at our facilities. Should CTA codes 71275 and 74174 still be used for these procedures since contrast was not given?

temp pacer w/valvuloplasty

Should a temporary pacemaker (3321) be billed with an aortic valvuloplasty (92986)? The most recent response I found was from 2018.

PVI Technique for Afib ablation 93656?

"Pulmonary vein Isolation technique for A-Fib"

Do the doctors have to place the ablation catheter inside the pulmonary veins in order for it to be considered

Pulmonary vein Isolation technique? or can they just ablate the outside around the PVI's--would that also be considered Afib ablation by PVI?

Example#1 Three dimensional electro-anatomic mapping of the left atrium and pulmonary veins was performed using Carto 3D Mapping system guidance with OctaRay Catheter (Circumferential). There was no electrical activity in any pulmonary vein so an empiric PVI was performed. We isolated all pulmonary veins, using wide area circumferential ablation.we isolated all pulmonary veins, using wide area circumferential ablation.

Final Dx-Symptomatic atrial fibrillation status post successful PVI & Vein of Marshall ablation.

Example #2 --With use of a 28 mm Arctic Front Balloon , ostial and antrum ablation was performed in all 4 pulmonary veins and postablation complete, bidirectional pulmonary vein isolation was documented.

bone density

May a bone density peripheral and axial be charged on the same date of service? May the edit be overriden, or are there guidelines? (77081/77080)

EMBOLIZATION SURGICAL FIELD

Would embolization of the right epigastric artery and right distal mammary artery be considered one or two surgical fields? Indication for the procedure was right rectus sheath hematoma with active bleeding.

93922 93923 Upper Extremity With WBI

When doing physiologic non-invasive studies on the upper extremities, is it acceptable to use WBI instead of ABI? In referencing a prior question regarding utilizing DBI, it was stated that was not acceptable. However, that question was answered in January 2022 (ID# 16476). Have there been any updates since?

T1 Mapping with ECV during a Cardiac MRI

Is there a CPT code we can report for the extra work involved with pre and post contrast T1 mapping performed during a cardiac MRI, or is this bundled into 75561? Documentation supports that our physicians are measuring the native T1 pre contrast and calculating the extracellular volume (ECV) post contrast.

Tomosynthesis guided breast biopsy, asking again

We have been coding 19499 for tomosynthesis guided breast biopsy per your recommendation(Question ID : 11697). Patient had tomosynthesis and mammographic guided breast biopsy when queried MD, the response was that tomosynthesis is mammography, that we both use stereotactic guidance and tomosynthesis. Can you please clarify for us? Should we still continue billing 19499 for tomosynthesis guided breast biopsy or what do you recommend, 19081? But 19081 is stereotactic. Much appreciated!

20610, 77002 vs 27096

A referring physician ordered injection into hip for pain management. I am being informed by our denial recovery team that based on this report the CPT code they feel should have been billed is 27096 only. What was billed was 20610 and 77002. What are your thoughts?

"History: Right hip pain. Procedure: An area was infiltrated with lidocaine; thereafter, a 22 gauge spinal needle was advanced into the joint space of the hip. Intra-articular position was confirmed with the administration of contrast. Once intra-articular position was confirmed, 80 mg of Depomedrol were injected intra articularly. 2 mL of 1% lidocaine were also injected intra-articularly. Impression: Successful steroid injection into the right hip as previously described. Fluro time 0.1 min - 3 fluro images obtained."

Endarterectomy of profunda with Fem-Pop bypass

Please see a previous question to Ask Dr Z #20448. I ran out of room to be clear of my question.

There is an endarterectomy of the CFA into the profunda femoris artery. Then surgeon created a bypass from the CFA (thorough the patch) into the posterior tibial artery.

The question: Is the endarterectomy of the profunda (into CFA) bundled into the bypass code?

It is providing a completely separate flow into the deep femoral system. Different vascular bed from the bypass.

Sacral augmentation plus biopsy at separate bone and site, or not?

Patient presents for planned sacral augmentation procedure for pathological fractures of the sacral alas due to secondary neoplasm of bone. The bilateral sacral alas are injected with cement (no cavity creation). This was coded 22511 with no modifier. Next, a needle core bone marrow biopsy of the LT iliac crest is obtained with CT guidance. Aspiration is also attempted via the same access as the needle core, but no aspirate is obtained. Are we allowed to code 38222 for the core biopsy under these circumstances? Or, is the iliac crest considered part of the same bone or surgical site and bundled? Would we need to add a modifier to 38222?

IVUS vessel vs. territory coding

Dr. Z,

Per question 15112 IVUS should be coded per vessel not by territories, however, we get numerous denials from payers using the territories to code this. Using CPT guidance, the external iliac-common femoral is one vessel, and the superficial femoral-popliteal is another vessel. The payers are saying to code the external iliac as one vessel, and the entire fem-pop as one vessel. So, when we IVUS a stenosis in the common femoral artery, and then IVUS a separate stenosis in the popliteal, we code this as two vessels per CPT. Payers want us to consider this one vessel per the territory system. Given that all the documentation for IVUS is done correctly, what are your thoughts on this? Thank you.

VT Ablation with separate circuit VT ablated after primary

I know to code the 93655 it must be a discrete mechanism of arrhythmia that is different from the primary. In a VT ablation and they do an ablation on a second distinct circuit of VT that is seen, in a separate area from where the Primary VT was ablated would this also qualify to code for the 93655 additional ablations? where still VT but it is a different circuit of VT? or must it be a different morphology and arrhythmia?

eries

pt has had an endoleak with enlargement of his aortic sac with a hx of EVAR with type 1a endoleak

we deployed the extension cuff extended to the SMA it did not hold the curve for a prox seal so a conformable cuff extension was deployed so it had maximum coverage all the way to the SMA. I then positioned and deployed bilateral renal stents; the proximal portion of the stent extended just above the prox portion of the cuff

I think the codes would be access (brachial cutdown) 34834 and 34710 with 37236-50?? I can't find a FEVAR code that works for extensions so am needing some guidance please.

2ND Request - ECA selection for SDH Embolization-other imaging done

Hi Dr. Z Diagnostic bilateral ICA and LT vertebral artery angiograms performed. Then RT external carotid artery was catheterized for middle meningeal artery embolization for subdural hematoma. I know 61624, 75894, 75898 (as appropriate), 36224-50, and 36226-LT; but what do I code for the RT external carotid catheter placement, if anything? I have only ever seen this with the external carotid angio also performed. Thank you for all your help, your expertise is greatly appreciated!

Laparoscopic placement of gallbladder drainage tube

"A diagnostic laparoscopy was performed first, and then a laparoscopic cholecystectomy was attempted. The cholecystectomy was abandoned due to the duodenum adherent to the gallbladder. A cholecystostomy tube was placed through the trocar site for aspiration and drainage." Would the correct CPT code be 47490, or 47579 for an unlisted laparoscopic code?

EP fluoroscopy and venography

What code(s) should be reported for the following procedure?

"An IV was placed. Patient was taken to the EP lab where a venogram was performed, demonstrating patent axillary/subclavian vein was noted. Patient was then brought to PACU, where the IV was removed and patient was discharged home without incident."

Modifier 74 outpatient facility

In your newsletter regarding modifiers it states that modifier 74 can be used for partially reduced outpatient facility procedures per CMS. Do you still agree with the answer to question #19698? Or, can we still code modifier 74 for remote accesses? I know you stated this does not effect payment, but I am also trying to figure out how to apply the 74 to other similar situations. Can you explain the difference between the Coding Clinic and CMS reference?

Corematrix Patch

If a provider places a CorMatrix patch over the left hilum due to continued bleeding after pneumonectomy completed during same session, can this be reported separately? For example, the report states: "There continued to be some bleeding from this region, and at this point we opted to suture a CorMatrix patch over the hilum. This would act as a buttress to the bronchial stump and also to tamponade any residual bleeding. The CorMatrix patch was sewn using a running 4-0 Prolene suture around the mediastinum, periaortic tissue, pericardium." Would this be reported with unlisted code 33999 or is it included in the pneumonectomy? Or would this be included in 32440?

What is the CPT Code for Talc Pleurodesis via Atomizer?

Please let us know if we can use code 32560 for talcpPleurodesis via Atomizer, or will this be unlisted?

"An incision was made in the mid axillary line in the eight intercostal space corresponding to the area where the basilar pneumothorax existed. The pleural space was directly entered , 4 g of talc was insufflated into the space followed by placement of an angled 28 French chest tube into the basilar pneumothorax."

Is this new LIMFLOW procedure

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.   

92972 MUE usage

Physician performed IVL (Intravascular lithotripsy) on the LM, LAD, and LCX coronary arteries which was coded with 92972 x3. There is a MUE edit stating it should only be coded once. Can 92972 be coded more than once and add coronary artery modifiers?

Advised by MD, At PVI redo is ok to bill Afib ablation 93656?

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

Cath not documented beyond iliac bifurcation

"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?

Iliac and profunda bypass with endarterectomy and embolectomy

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.

CSF injection/cisternography

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."

93306 vs. 93308

If a physician orders a follow-up or limited echocardiogram, but the technician views all required elements for a complete echocardiogram and all elements are all documented in the physician's interpretation and report, should the physician report code 93308 based on the fact that the original intent and order for the exam was to be a limited or follow-up? Or should we report code 93306 since all required elements were viewed, documented, and interpreted?

Ultrasound of Radial artery for CAGB surgery.

Would it be appropriate to report code 76882 for an ultrasound of the radial artery as pre-op for CABG surgery? AP measurements of the radial artery are being taken; duplex is not being used.

Billing for multiple EKG's during inherited stress testing

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).

Radial Access with LE peripheral intervention

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

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