Ask Dr. Z

"Patient with hypoplastic left heart syndrome (mitral/aortic atresia). Patient underwent stage I palliation with Norwood, Sano conduit, PDA ligation and atrial septectomy as a neonate. He then underwent Sano takedown, creation of a right cavopulmonary anastomosis (bidirectional Glenn shunt) and intraoperative direct aortic balloon angioplasty. A 4 French was placed in the right femoral artery. Complete right heart and left heart catheterization via abnormal native connections was performed with oximetry, hemodynamics, and angiography in multiple planes." Would these cases be coded to 93597?

Would it be correct to use 38900 when the method of sentinel node identification during surgery is gamma probe, or is an injection required intraoperatively when using 38900? Op note states, "We then opened the clavipectoral fascia and used the gamma counter to identify a total of four lymph nodes with counts of 88, 129, 256, and 401 per second ex vivo. They were submitted as right axillary sentinel lymph nodes #1-4."

Radiofrequency ablation for atrial fibrillation (pulmonary vein isolation), additional radiofrequency ablation for atrial fibrillation (roof line), Additional radiofrequency ablation for atrial fibrillation (posterior line with isolation of posterior wall), additional radiofrequency ablation for supraventricular tachycardia (mitral annular line), additional radiofrequency ablation for supraventricular tachycardia (cavotricuspid isthmus line), additional radiofrequency ablation for atrial fibrillation (CFAE lesions along coronary sinus).

Would the correct coding of this procedure be 93656, 93657 x 2( box-roof line and posterior wall then CAFE lesion) and 93655 x 2 (mitral annular line and cavotricuspid). Does it matter that the mitral annular line was done prior to completion of the pulmonary vein isolation?

Has there been any update for 2022 on how to properly code an IFR? We have been using 93571 with -52/-74 modifier, but some staff are pushing back stating to use unlisted code 93799. We are unsure what is correct.

Leadless pacemaker was placed in right atrium and right ventricle. Would this be reported with codes 33274 and 33999? Or only 33999?

"The introducer was advanced through the long sheath into the right ventricle where it was positioned at the apical septum. Contrast was used to confirm location and proximity to the myocardium. Once appropriate position and contact was noted, the leadless pacemaker was exposed and screwed into the walls. Next the atrial lead was pursued. The introducer was advanced through the long sheath into the right ventricle where it was positioned initially at the base of RAA but didn't have good numbers and eventually positioned at lateral RA wall. Contrast was used to confirm location and proximity to the RA wall. Once appropriate position and contact was noted, the leadless pacemaker was exposed and screwed into the walls."

Can you code both an IVUS and an OCT in the same coronary artery? If not, what can you can code for two different procedures in the same coronary artery?

"Procedures: 1) Redo right femoral to anterior tibial artery bypass with 6 mm PTFE. 2) Cephalic vein patch angioplasty of anterior tibial artery. 3) Ligation left SFA. 4) Left common femoral artery thrombectomy/endarterectomy. 5) Left arm cephalic vein harvest.

Due to concerns about the thrombus in the SFA potentially washing out into the bypass or into the profundofemoral artery the SFA was then divided off of the common femoral artery at the level of the femoral bifurcation and ligated with a 3-0 Prolene suture. The arteriotomy on the common femoral artery was then debrided and shaped so that the bypass could lay very nicely with the heel of the graft just at the start of the profundofemoral artery coming off the femoral bifurcation."

I understand that the ligation is typically included in the bypass procedure. Would the ligation be billable in this instance?

"Retrograde coronary sinus venogram. Vascular US guide access to right femoral vein. Using direct US guide access obtained to right femoral in two separate locations. The long steerable sheath advances in the right atrium. A decapolar electrophysiology catheter advanced to the right atrium. Guided by fluoroscopy and intracardiac electrograms, the coronary sinus engaged successfully and the steerable sheath advanced over the decapolar EP catheter to the coronary sinus. IV contrast injected in the steerable sheath and coronary sinus venogram showed normal to large size coronary sinus two marginal branches of small to medium size. RAO to LAO images stored. Total contrast 30 cc."

Please advise on CPT codes to bill. 

For 2022 hospital billing, is there any additional guidance on territories for IVL above the knee? Are the iliac arteries and femoral arteries considered one territory or two? If IVL on left common iliac artery and IVL on left superficial femoral artery, would C9764 x 2 be correct?

If the radiologist accesses the right common carotid, right internal carotid, and right distal M2/proximal M3 and performs thrombectomy, then retracts the catheter and manipulates through the A-comm into the left ACA and performs thrombectomy, would that still be considered two vascular families even though he did not retract into the arch and go through the left common carotid to left internal carotid to the left ACA? Can we report codes 61645, 61645-59?

Our physician brought a patient in for atrial tachycardias and paroxysmal atrial fibrillation. He starts out with Afib ablation (93656), then states, "Following a period of observation, all pulmonary veins were remapped and were persistently electrically isolated." The patient was then given adenosine with no evidence of acute reconnection. The physician chose to look for SVT. Isuprel was given. The patient developed an artial tachycardia, which quickly transitioned to atrial fibrillation. Isuprel was stopped. Cardioversion was unsuccessful. A series of ablation were performed around the SVC. I chose 93657, but my co-worker is saying it would be 93655 because the rhythm started as SVT. What are your thoughts?

I’m not really sure how to code this. Would this still code to 37197 even though a cutdown was performed?

"Angio demonstrates a RFB extending from distal ext iliac into thrombosed pseudoaneurysm. 6 French sheath advanced over g-wire to left external iliac proximal to the RFB. Multiple attempts to snare the FB was unsuccessful as FB incorporated the vessel wall of the external iliac. Elected to remove via cutdown. Under u/s guidance RFB extended into the thrombosed left groin  pseudoaneurysm closest. Stab incision made using 11 blade. Grasped the foreign body and carefully remove it while applying pressure over the arteriotomy site. A flow-limiting dissection in the distal left external iliac at point of proximal attachment of the foreign body. There was little distal  flow to the dissection. 4 French catheter was advanced over g-wire, contrast confirm position of cath. G-wire was readvanced. Attempt to treat dissection with prolonged inflation and 8 mm balloon. Some improvement post prolonged inflation, but dissection flap persisted and hemodynamically compromising. Repair with 10 x 30 Protege stent."

Does the provider need to specify "angioplasty of the stent due to re-coarctation" to code 33897 for angioplasty of a previously placed coarctation stent? Would angioplasty of coarctation stent due to a patient growth or small stent size fall under coding as 33987?

Are codes 47382 and 47540 appropriate for the following? 

"Contrast was injected to fill the right-sided biliary system. Under fluoroscopic guidance, a 21 gauge needle was advanced in a peripheral right-sided biliary duct. A vascular sheath was then placed. Angled catheter and Glidewire were used to pass the stricture and gain access into the duodenum. Stiff wires were then placed. Endo biliary RFA was then performed from both the right and the left sides. A 7 x 80 and a 9 x 80 LifeStar uncovered stent were then deployed from the right and left sides. Post stent placement cholangiogram was performed. Two 10 French long biliary drains were then placed. The drains were secured in place. The patient tolerated the procedure well with no complications. FINDINGS: Cholangiogram from the left-sided access demonstrates severe stricturing at the biliary hilum consistent with the patient's history. Impression: Endo biliary radiofrequency ablation with bilateral biliary stents and bilateral biliary drain placement."

"Patient with a biventricular ICD has generator changed to a dual chamber ICD. New subcutaneous lead was tunneled, inserted, and connected with a Y connector to the RV socket. LV lead was capped." Would codes 33270 and 33241 be correct to report? Codes 33271 and 33263 cannot be reported for this because 33263 edits outs.

In 2021, code 33508 falls under NCCI Edit 1 and can be billed with modifier -59. We still get denials that it is an integral component of the procedure and therefore procurement of saphenous vein should not be reported separately with the venous graft codes. Is it appropriate to bill this and how do we fight it in an appeal? Any suggestions? We now have the same issue with the new code 33509.

How should complete non-invasive Doppler be coded with three or more levels studied for both upper and lower extremities during the same encounter? From what I've read it would be 92923 and 92923-59, but we've received a denial from Medicare, so I wanted to double check.

The procedure is a CABG x3 (33533; 33518), PV isolation with RF clamp ablation (33257), and LAA ligation.

The patient is a 74-year-old female who presents with atrial fibrillation and severe CAD on angio.

"PROCEDURE: Patient was systemically heparinized. Right and left pulmonary vein isolation was performed with atrcure system clamp ablation. Pt had bradycardia to 50 and conversion to NSR during right side PV isolation. LIMA was carefully anastomosed to the proximal LAD with 7-0 prolene. De-airing was performed. Sidebiting clamp was placed on the proximal ascending aorta and the proximal SVG was carefully anastomosed to the ascending aorta us 6-0 prolene in standard running technique. Ascending aorta and SVG were carefully de-aired and the sidebiting clamp was released. Heart was then lifted and the SVG was carefully anastomosed side-to-side to the D1, followed by end to side to the D2 using 7-0 prolene sutures. Careful deairing was performed and SPY angio imaging was used to visualize all grafts. Hemostasis was confirmed."

This question is for Pro Fee. Since LAA closure with a percutaneous approach (33340) is reported for patients with atrial fib, does the new add-on code LAA closure with an open approach at the time of other sternotomy (33268) follow the same medical necessity guidelines? My provider performed an ascending aorta graft, with cardiopulmonary bypass (33858) with an open LAA for diagnoses of aortic dissection and IVC thrombus. Can 33268 and 33858 be reported together?

How would you code the following?

"3 cm left chest incision was made and two LV epicardial pacemaker leads were placed. GBM 511 served as the primary new epicardial lead and GBM 5112 was placed as a back up. Both leads had excellent pacing and sensing thresholds. The left pacemaker incision was reopened and the DDD pacer was explanted. The two epicardial leads were tunneled into the pacer pocket and all leads were connected to a new St Jude Allure RF biventricular pacemaker model # PM..."

It's been quite some time since I've coded pacemakers, so I am unsure of the appropriate codes here. I was thinking 33202 for the epicardial lead placement via thoracotomy and 33228 for the removal and replacement of the pacemaker pulse generator. Am I close on this?

Would it be appropriate to report code 93287 with 93642?

Does the CPT coding of cardioneural ablation differ from the usual types of cardiac ablation? A patient presented with SVT and syncope. She underwent cardioneural ablation of vagal ganglionated plexi in both left and right atria. Would this procedure still be coded with 93653? If not, what should we report for this?

For biopsy of a lymph node in the axillary tail of the breast, should this be coded as a lymph node biopsy (38505) or a breast biopsy (19083, for example)?

"Fractional flow reserve (FFR) of the entire LAD artery lesion was performed. A 6F EBU3.5 LAUNCHER guiding catheter was used to engage the vessel. Once ACT came therapeutic, a Volcano Verrata 014x185cm wire was used and equalized at the guide catheter tip. Guide was engaged and Adenosine was given, the guide was disengaged  with measurements obtained. The iFR of the lesion was measured as 0.83. Baseline Pd/Pa was 0.85. Following administration of 100 mcg of intracoronary adenosine, the FFR was 0.62. Apical LAD wire position. Measurements recorded before nitroglycerin administered. Multiple pressure wire artifacts observed FFR: 0.62. The iFR of the lesion was measured as 0.88. Baseline Pd/Pa was 0.86. Following administration of 100 mcg of intracoronary adenosine, the FFR was 0.82. Apical LAD wire position. Measurement recorded after nitroglycerin 100 mcg IC bolus administered. Multiple pressure wire artifacts observed. FFR: 0.82."

Is this enough to support 93463, or only 93571 will be reported?

A patient was transferred from a smaller facility for STEMI. MD documented that the patient was delayed in our ER due to another case being performed in the cath lab and no other team available and that the patient was brought to the cath lab as soon as they were able. A LHC and angiography was performed and drug-eluting stent placed in the LCX (culprit lesion). Can we still code C9606 for the AMI intervention?

How would you code a RHC and LHC with only graft selections? The physician did not select the coronary arteries at all, only the grafts. Would you code 93461-74 or unlisted where selection of coronary arteries are part of the 93461 code?

What do you code if physician selectively engaged in right and left common carotids and said this: "The right common carotid artery injection demonstrates normal antegrade flow into the external and internal carotid arteries with normal filling of the external carotid artery branches. Course and caliber of the cervical portion of the right internal carotid artery is unremarkable." Then he also says he engaged in right and left internals, right and left subclavians, and right and left vertebrals. He engaged in all these selectively.

If a child has a cardiac congenital defect such as TOF repaired, should the follow up imaging be ordered/coded as non-congenital? Our practice routinely performs CT Heart post surgical repair that comes over ordered as 75573 (congenital) but our coders feel this should be 75574 (non-congenital).

"EXAMINATION: CT HRT W/3D IMAGE CONGEN.

CLINICAL HISTORY: 17-year-old with repaired Tetralogy of Fallot presents for evaluation of pulmonary arteries.

Technique: CT angiogram (CTA) of the heart with prospective gating and volumetric (wide axial) technique on a Canon AquilionOne CT scanner. Test bolus technique was used with 18 mL Optiray 320 intravenous contrast. 105 mL was used for the CTA. The total amount of Optiray 320 is 125 mL. Before contrast injection, the heart rate was 56 bpm. Heart rate during the study was 49 bpm regular. CTDI used during the CTA portion was 6.9 mGy. Total DLP 110.9 mGy-cm."

Should this be reported with 50431 x 2?

"TECHNIQUE: The 2 left nephrostomy tubes and surrounding skin were prepped and draped. Scout imaging was obtained. The more superior left nephrostomy tube was injected with dilute contrast and fluoroscopic images were obtained. The contrast was then aspirated out. The more inferior left nephrostomy tube was then injected with dilute contrast and fluoroscopic images were obtained. The contrast was then aspirated out. Both tubes were then reconnected to gravity drainage.

FINDINGS: The 2 existing left nephrostomy tubes appeared patent and in good position and so no intervention was performed on them. The patient is due for routine exchange of all 3 nephrostomy tubes on 07/19/2022. It should be noted that, in the past, one of the left nephrostomy tubes was felt to be a perinephric drain, but on further evaluation of prior imaging and the patient's medical record, it appears both left-sided tubes are nephrostomy tubes.

Impression: SUCCESSFUL LEFT NEPHROSTOMY TUBE EVALUATION X2 DEMONSTRATING THE TUBES TO BE PATENT AND IN GOOD POSITION."

I'm a charge analyst at a hospital. Our radiologists are using endoscopes occasionally with percutaneous procedures. We had a patient with a cholecystostomy tube where the radiologist used an endoscope with an attempt to cross the cystic duct.

"The Spyglass endoscope was introduced through an 11 French sheath. Visualization of the gallbladder demonstrates small gallstones. The origin of the cystic duct was visualized. The scope was advanced to the cystic duct. Multiple attempts were made to advance a wire through the cystic duct without success due to extreme tortuosity of the cystic duct. Given the difficulty decision was made to abandon attempts at internalizing the cholecystostomy tube. The endoscope was removed. A wire was advanced through the 11 French sheath. The sheath was removed over a wire. A new 12 French cholecystostomy tube was placed." 

Is it appropriate to report 47552 and 47536? I'm questioning 47552 since the code description states "diagnostic".

Our providers routinely perform a bilateral lower angiography (75716) when they are performing their pre-op TAVR left heart caths (93458). NCCI edits indicate the angiography as bundled with the cath; however, our providers believe the peripheral angiography warrants a -59 modifier since an angiography of the iliofemoral system is not a routine part of a left heart cath. Can we bill a lower extremity angiography with a -59 or -XU modifier at the same time as the left heart cath?

Question ID 9849 from 2017 indicates that for a synovial cyst rupture 64999 should be billed. If both a synovial cyst rupture and a facet are completed, are we able to bill for both 64999 and 64493?

I know the codes for the CABG are 33533, 33518, and 33508. I am unsure how to bill for the pericardium reconstruction.

"The pericardium was then reconstructed with the extracellular matrix proxy core. A 4-0 prolene suture was used to anastomose the extracellular matrix to the pericardium circumferentially. Once this was completed, the mediastinal chest tube and one left and one right pleural chest tube were placed and secured."

Would this be just one code 36832, or would a second or unlisted code be used for lipectomy? 

"1. Revision of right AV fistula by way of side branch ligation.

2. Subcutaneous fatty tissue excision overlying cephalic vein and forearm for vein superficialization.

PROCEDURE: After team timeout and performed sterile mapping with ultrasound of the fistula, found a large side branch coursing laterally marked this position. We also marked several positions along the forearm 4 counterincisions versus lipectomy of subcutaneous fat to bring the skin closer to the fistula. After team timeout, we performed a small incision overlying the side branch and ligated this with 3-0 silk sutures x2. We then turned our attention to the lipectomy with 2 transverse incision across and performed cylindrical removal of fatty tissue overlying the vein, we also lysed the vein fascia that was keeping it in place in the forearm, superficializing this and had a nasal groove of palpable cephalic vein afterwards. We had excellent hemostasis."

Would this IT band trigger point injection be coded 20552 or 20550 plus 77002? I don’t know if the IT band is a trigger point or a ligament?

"Fluoroscopy was used to guide a 25 gauge spinal needle to the appropriate location in the area of the IT band. Isovue 200 was injected to confirm positioning along the IT band and injection of 50% of the mixture of 40 Kenalog and 5cc of Bupivacaine was made in this band area. A second injection was made more at the inferior area of the band. Following two locations, the patient reported 100% relief of his pain in the leg and needles were removed. Findings: Right IT band inflammation responsive to trigger point injections. Impression: Successful injection of right IT band into locations."

"The patient had an MRI and was diagnosed with invasive lobular carcinoma of the right breast. A week later, the patient was seen in mammography for evaluation of an area of non-mass enhancement in the right breast as well as a mass in the left breast seen on recent outside MRI. In mammography, she had a bilateral diagnostic mammogram and a bilateral breast ultrasound. On the same day, the patient had an ultrasound-guided core biopsy of the right breast and an ultrasound-guided FNA with micromarker placement on the left breast." What CPT codes would be used for this patient?

"Upper limit vulnerability testing was successful at 20 joules." Does this meet the DFT testing code (93641) requirement?

Patient had EKOS placed at 9:00 pm, and the EKOS cath was subsequently removed 12 hours later (on the following day). Is it appropriate to report 37214 since the service spanned two days? What documentation do we need to support EKOS thrombolysis on the subsequent days of treatment? What documentation do we need for removal? Can patient have EKOS cath removed at bedside in ICU? Should there be a procedure note?

Could you help us understand when to code 35221 versus 34502. We have a case where patient presented for GSW to the abd. Provider documented: "We examined the IVC and it was noted that the injury was well under 50% and this could be repaired primarily. A 3-0 Prolene was brought onto the field and a whipstitch of the IVC was performed along the linear tear". Would 34502 be appropriate for this case?

We have searched your website for the answers, the latest question was from 2019.

In order to use the 93459 for the purposes of LHC with viewing potential grafts WITHOUT PREVIOUS BYPASS, does the catheter tip have to be SELECTIVE (cath tip in LIMA) or can it be NON-SELECTIVE (cath tip in subclavian)?

Physician performed the following: flexible bronchoscopy, esophagogastroduodenoscopy, right thoracotomy, incision and drainage of mediastinal abscess, drainage of effusion, intercostal muscle flap, wedge resection of the right lower lobe of the lung.

The wedge resection was done to repair an intraoperative lung tear. Dictation states: "We were able to elevate the lung and take the inferior pulmonary ligament. There was a small tear in the lung and we subsequently performed a small wedge resection around that tear, placing a nice solid staple line on the lower part of the right lower lobe." Physician wants me to report code 32505, which would be inappropriate since there were no nodules or masses. Would code 32110 (thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear) be okay to use in this scenario? Or, would this code strictly be used for a traumatic laceration? If so, which CPT code should be applied?

Patient has tachy-brady syndrome with complete heart block post AV node ablation. When the biventricular PPM was originally implanted in 2013 the atrial port was plugged. The biventricular PPM generator has reached end of service and was therefore replaced with a new generator; again only the RV and LV leads were attached to the new ST Jude CRT-P generator, model PM3222.

Seeing that CPT defines a multi-lead system as a pacemaker or implantable debrillator with pacing and sensing function in three or more chambers of the heart,  is it appropriate to bill the 33229 due to the LV lead and CRT-P generator model used, or is it more appropriate to bill the 33228 due to patient only having two leads?

If the patient has a dual chamber pacemaker, came in for a venogram where the dislodged atrial lead was removed and due to stenosis could not receive the planned CRT upgrade, does the patient now have a single or dual chamber pacemaker since they still have the same generator minus a lead? I ask because I am trying to code the following encounter where the patient returns for a bivent system, but documentation does not indicate the generator is removed, but states a dual chamber pacing system was placed. They used the existing ventricle lead and placed an atrial lead. The ventricle lead was repositioned. What CPT® codes are used?

Code 93319 can be submitted in addition to codes for TEE exams (93312, 93314, 93315, 93317) as well as congenital TTE procedures (93303, 93304). The TEE codes describe both non-congenital (93312-93314) and congenital imaging procedures (93315, 93317). We are a having a debate whether codes 93306 and 93308 can be billed with add-on code 93319, as there is no NCCI edit, but the CPT Codebook does not state that they can be billed with 93319. What is your thought this?

During an open heart procedure, patient is in need of a pacemaker upgrade to biventricular pacemaker. They removed old generator, removed RV lead, placed LV lead, placed new RV lead, and placed new biventricular generator. Am I right in thinking, 33235, 33202, 33221, 33225? Looks like 33233 bundles and modifier is not allowed. Or am I way off the beaten path? In question ID 13070 (from Dec 5, 2019) Dr. Dunn responded to a question saying that 33202 includes 33225. However, the CPT Codebook says under 33225 to code also placement of epicardial electrode when appropriate (33202-33203). Is this an appropriate time to code 33225 also?

Coding Clinic (4th quarter 2020, page 10) states to report 33206 for pacemaker insertion with atrial and His bundle lead insertions. I believe your advice has been to report His lead based on chamber in which it is placed. If the physician states the His lead is placed in the right ventricle, and a right atrial lead is placed along with pacemaker insertion, do you recommend reporting 33206 or 33208?

Which code should be used when a blood vessel is repaired during a tumor resection? For example, right thigh mass resection with right superficial femoral artery interposition graft using PTFE. Would this be 35661 or 35286?

What code do you recommend for core needle biopsies of the spleen? Code 49180 has been suggested, which we know the ACR recommends for the ovary, and Coding Clinics recommend for the adrenals.

How would you report angiography here? "Catheter was advanced to the suprarenal abdominal aorta and abdominal angiography performed. This demonstrated patent celiac trunk and SMA and its branches. Left renal artery was seen and appeared normal. Right renal artery was not seen. Catheter was placed in distal abdominal aorta and abdominal angiography pelvic angiography performed. Bilateral common femoral and iliac external iliac arteries were patent without significant obstructive disease. Selective right lower extremity angiography was performed, which demonstrated occlusion right SFA throughout its course occlusion of the right popliteal artery throughout its course with extensive collateral filling of the distal vessels and reconstitution of the right posterior tibial artery distally. Catheter was advanced over the bifurcation and left lower extremity angiography performed."

Upgrade of ICD to BiV was attempted - Physician was unable to advance the lead past mid portion of any target vessels so patient was brought back on a different day for "intraseptal pacing.” The lead was fixed in the mid septum. The new lead was then placed in the RV pace sense port and the RV electrode was paced in the LV port of the new device. (There is also an atrial lead that was not moved or changed. Would we still report 33264 with 33225 for the intraseptal pacing?