Ask Dr. Z

How would you code percutaneous image-guided occlusion of left cheek malformation using 6 units of bleomycin?

"Patient was brought back to lab the following day after bilateral extremity angio and attempted PTA of contralateral SFA, which was unsuccessful. The following day, an attempt was made to access the posterior tibial artery. Ultrasound guidance was used, but access was unsuccessful. Ultrasound image was obtained. No angio images were obtained."

Patient was charged for attempted PTA the day before with modifier (37224-74). I'm not sure what to charge for the next day's visit and re-attempt at PTA - but no access.

For the following report, would we report code 36573 since the insertion is in the basilic vein, or should we report code 36558 since there is documentation of a tunnel? 

"Primary ultrasound evaluation demonstrates wide patency of the basilic vein, and a permanent image was saved for the record. Using ultrasound guidance, the basilic vein was percutaneously accessed. The needle was exchanged over a guidewire for a peel-away sheath. Using blunt dissection, a short subcutaneous tunnel was created. A 5 French double lumen power injectable PICC, which was cut to 40 cm, was passed through the tunnel and into the peel-away sheath. Using fluoroscopic guidance, the tip of the catheter was positioned in the SVC/RA. The catheter was fixed in place, and a sterile dressing was applied. The catheter was assessed for function. Catheter was flushed and aspirated easily. A final fluoroscopic chest x-ray was obtained."

Our cardiologist performed drug-coated balloon angioplasty to an in-stent restenosis lesion of the proximal LAD. Next he treated a lesion in the proximal segment of the first diagonal with routine balloon angioplasty. Code 0913T with 92921 is not passing our claim editing software. Is this the correct coding?

Can you bill an angioplasty in both the TB trunk and peroneal when those are the only two tibial areas billed? It does not make sense to me that you can't bill the peroneal when you can the AT because it branches off as well and you can bill a 2nd/3rd order cath placement for it when not tx is performed.

For physician billing, how is radiopharmaceutical A9699 - Tc-99m sestamibi (non-HEU) reported when doing a MPI/nuclear stress test? It is a non - compounded radiopharmaceutical. Our practice is using 2 units and still the claim is denied. The claims are submitted with the invoice since the radiopharmaceutical is a NOC.

CPT: 78451/78452

A9699 x 2

Please review.

What is the correct angiogram code for deep circumflex artery? The indication for procedure was retroperitoneal hemorrhage. Previous Q&A states 75710, 75774 for a case with selection of epigastric then circumflex iliac. Is 75710 the code to use? It didn't seem right to submit for extremity angio with the indication. Am I on the right track? Please help!

Now that the CPT codebook has updated guidance for code 64488 to include abdominal fascial plane block, is it appropriate to report QL blocks with code 64488, or should it continue to be reported with an unlisted code?

For a dorsal ramus diagnostic block, would we bill for a medial branch block 64493 or 64451? We have been billing the MBB, but we are questioning the 64451.

Patient had mapping for Y-90 radioembolization in future date. First selective hepatic arteriography with catheter placement in segment 6 and segment 7, cone beam CT, and MAA injection were done in IR room. Contrast use was documented. One IR report was created and findings for selective hepatic arteriography and cone beam CT were documented in one finding. Then patient was sent to NM and had SPECT with CT on the same day. SPECT CT with MAA and findings were documented in one NM report. 

 Are these coded with 75726 for selective hepatic arteriography, 36247 and 36248 for contrast injection, 76380 for cone beam CT, and 78803 SPECT CT? MAA and contrast HCPCS II codes were also added. This is for facility coding.

CPT Assistant, October 2023, page 18 Q & A regarding billing 93609 even when 93613 is done with 93653 and 93656 ablations. I am currently going back and forth if this would be billable with my coding department. I spoke to my EP physician, and he states that intra-atrial mapping of tachycardia is not the same as a 3D mapping. And also, the CPT Assistant article states that the 93609 can be billed even with the 3D mapping 93613 being done too. Should I be coding the 93609? If not, why?

A patient presents to the cath lab for a planned intervention for in-stent restenosis of the RCA. The physician performs lithotripsy followed by brachytherapy and then uses a drug-coated balloon to further dilate the stenosis. How we would code for the brachytherapy and the lithotripsy when using the drug-coated balloon since CPT codes 92972 and 92974 are add-on codes and 0913T is not designated as primary code?

We need guidance on how to report iFR in an ASC. We do understand for professional we would bill 93571-52, and for facility it should be billed as the unlisted 93799 until AMA has published the update verbiage in 2026. But how should we report in an ASC? Medicare is denying the facility charge 93799 with M6 reason code (No payment made; paid under another fee schedule) IOM- 100-04 Chapter 14 section 60.3 M6

Would this be 50436 or 50688/75984? Or unlisted or a combination of one or more?

"Contrast was injected through the right nephrostomy tube, performing a nephrostogram. This demonstrates satisfactory positioning and functioning of the indwelling nephrostomy tube. Contrast does traverse the distal ureter into the ileal conduit. The nephrostomy tube was removed over a guidewire and a 6 French sheath was placed. A second guidewire was advanced down the ureter and into the ileal conduit. Dr. from urology then used one of the wires as an access site to perform an antegrade ureteroscopy. After the antegrade ureteroscopy was performed one of the Glidewire was removed. Over the other Glidewire, an 8 French nephrostomy tube was replaced."

This is a question in reference to the same question asked in 2018. According to Optum Encoder, code 34808 cannot be used with code 34705 and 34706. In 2018, it was stated that this was a miss, they were aware, and it would be fixed with an erratum sometime in the future. Do you know if an erratum is still in the works or will it be left as is? 

What would you code for this - 32557-52, 76000, an E&M?

"Ultrasound chest to evaluate position of indwelling chest tube and pleural effusions. Skin of chest prepped/draped. Under Fluoro guidance, indwelling chest tube was cut/clamped, and an amplatz wire was advanced with fluoro guidance and coiled in the pleural space. The existing tube was then removed. A new 12 Fr Resolve catheter advanced over wire and coiled in the pleural space. Wire removed and flush performed with immediate reflux of fluid along tract of catheter. Addt'l. imaging showed no evidence residual cavity from prior pleural drainage.. Discussion....decision made to remove catheter and place vaseline-impregnated gauze. FINDINGS: Fluoro image shows indwelling drainage catheter with adjacent consolidation and pleural thickening. Subsequent replacement of catheter resulted in no additional drainage from chest cavity. CATHETER REMOVED."

Can you bill for angioplasty to provide occlusive hemostasis during a vascular surgical procedure?

Presenting rhythm was atypical atrial flutter, patient does have a hx of A-fib, MD wants to bill 93656 & 93657. He documented that the patient had atypical AF originating from LA. So he performed ablation for a-fib (93656) in the same setting as well as posterior wall isolation for add'l lines (93657). He did not do cavotricuspid isthmus ablation which is performed for typical atrial flutter originating in the right atrium.

"PFA Catheter catheter was delivered to the LA, and the PVs were sequentially isolated to an endpoint of vein potential eradication and exit block. Posterior wall isolation was performed. Atypical flutter terminated upon ablation at the roof of the LUPV ostium.

Final dx: Symptomatic Recurrent Drug Refractory Persistent Atypical Atrial Flutter s/p Pulsed Field Ablation PVI."

No mention of A-fib just PVI. Is it still correct to bill PVI 93656 & 93657?

0644T vs 37187

"The sheath was removed over wire and a 16 French dry seal sheath was advanced over the wire and positioned within the superior inferior vena cava.

Next, a 16 French aspiration catheter was advanced over the wire as well as a 6 French angled catheter. The aspiration catheter was positioned into the superior vena cava under fluoroscopic and TEE guidance. The inner wire and catheter were removed. Next, under fluoroscopic and TEE guidance the aspiration catheter was used to engage the thrombus and aspiration was engaged. Clot was externalized with extirpation of matter.

TEE demonstrated moderate amount of residual thrombus that did appear to be adherent to the wall. The 16 French aspiration catheter was then used to engage the remaining amount of this thrombus.

FINDINGS: Successful aspiration thrombectomy of clot in transit within the SVC/right atrium. Clot externalized with extirpation of matter.I MPRESSION: Successful aspiration embolectomy of clot in transit identified to be within the superior vena cava and right atrium after cardiac lead extraction.

Patient had an open thrombectomy performed earlier that day and was brought back for hemorrhaging. Would the AVF wound exploration be reported with code 35860-78?

ACCESS:

Side: Left

Site: Upper

Type: Radial Cephalic Fistula

Anatomy: Tortuous and Ectatic AV fistula wound exploration.

Patient was laid in the supine position and placed under general anesthesia. Left arm was extended prepped and draped sterile on armboard.

Staples removed from open thrombectomy incision. No surgical bleeding noted from venous suture line. Pt found to be coagulopathic. TXA given by anesthesia. Bovie electric coagulation and was used to provide hemostasis.

Lateral soft tissue flaps were created to allow tension-free closure which was achieved in 2 layers with stratafix suture. Skin was reinforced with skin clips.

Codes 36901-36908 describe procedures performed through a direct percutaneous access or a puncture of the dialysis circuit. These codes include all accesses; catheter movements within the circuit; contrast injections; imaging for diagnosis, guidance, and follow-up S&I of the circuit; and access closure. Conscious sedation (99151-99153, 99155-99157) and ultrasound guidance for vascular access (76937) are separately billable (however, code 76937 is only reported when the AV graft or fistula is documented as either immature or failing). If the provider states in the OR report pre/post of diagnosis of dysfunctional AV fistula; is that enough to support it is failing? All other doc requirements for 76937 have been met (selected vessel patency/permanent image on file).

How would this be coded? Do I just code for the use of fluoroscopy only?

"Excisional debridement right chest one cm squared of skin and subcutaneous tissue. Fluoroscopy of chest to evaluate port. The right chest was prepped and draped, and the port incision was inspected. There was a scab on the medial aspect of the incision. The scab was excised sharply, and there was granulation tissue under it. The port was not visible. There was no drainage. Antibiotic irrigation was applied and the small opening pulled together with Steri strips. A fluoroscopic image was obtained and showed the port to be in good position and intact. Prior to giving prophylactic antibiotics, a blood culture was drawn through the port."

BASELINE EKG Afib converted to sinus once under anesthesia.

ABLATION Q Dot DF ablation catheter inserted to the RA under mapping guidance. Upon completion of the CTI line and gaining transseptal access, the Farawave ablation catheter was inserted.

DETAILS Q dot DF catheter was positioned along the isthmus. Lesions were placed from the TV annulus until the IVC. Upon completion of the CTI line bidirectional block was noted with timing of 165 msec. The Farawave catheter was positioned in the left atrium at the os of the superior and inferior left and right pulmonary veins. Appropriate lesions were placed in the basket and flower position. Since there is a left common os lesions were placed in the left pulmonary vein in the olive position (small basket) Upon completion of the PFA isolation was confirmed. Upon completion of the ablation the catheter was placed in the right atrium and bidirectional block was confirmed at 165 msec

RESULTS Successful RF Ablation of typical AFlutter. Successful PFA of PV.

Would you code 93656, 93655 or 93653, 93655?

Is freeing enough to overcome unbundling? 34713 Neuroplasty, major peripheral nerve, arm or leg, open; brachial plexus with 21615 Excision first and/or cervical rib. A supraclavicular incision Platysma divided. Anterior scalene fat pad mobilized laterally & superiorly. Omohyoid divided. Phrenic nerve carefully preserved & a 2-3 cm segment of anterior scalene was resected. The brachial plexus was scarred and this was freed of its investing scar tissue. Bony structure that was most likely the cervical rib was identified. Was circumferentially cleared & divided with rongeur cephalad. PT had only the tendinous attachment and this was cut with sutures. This was removed & sent to pathology. The first rib was more lateral and larger than normal. This was freed circumferentially as well. An infraclavicular incision was carried out and the first rib was also circumferentially cleared at this location. Rongeur was used to divide the rib both posteriorly & superiorly & ultimately an 11 cm segment of rib was removed. The pleura appeared intact. Hemostasis ensured.

You answered a question ID# 20868 - I am confused as to why this upgrade would not be a replacement with using 33229 (multi-lead) as this how the can is functioning when the case is closed. The RV, RA (existing) and HIS bundle lead (new insertion). this for helping with clarification.

I just received a denial from Medicare for a TAMBE with code 37799. They stated a more appropriate code should be used. A colleague of one of our surgeons is using 34848. Any advice?

Patient was brought in for a CVA port removal but found to be at a risk for no future access due to age and other health factors. Fluoroscopy image with time of 0.1 minutes obtained and no removal was performed at the time of exam. Would this be captured with 76000, or would a low E/M be more appropriate?

What CPT code should be reported for a cardiac ICU physician who is credentialed to administer deep sedation? Some of the procedures that our physicians are performing and using deep sedation are ECMO decannulation, chest closures, and line placements/adjustments. We were looking at CPT codes 00100-01999 since our providers are credentialed to perform deep sedation. We are pro fee. 

Two discrete lesions in the LAD. Proximal lesion treated with atherectomy and PTA only. Distal lesion no atherectomy, but drug-eluting stent. Is it reported with code C9602 for all the work in the vessel or C9600?

My EP provider implanted, connected, and tested the azygous lead, then removed it after a failed DFT and then removed this lead, regained new access to implant a new separate lead in the MCV. Is there anything we can code for the azygous lead? Both leads were for RV pacing.

Congenital TTE codes 93303 and 93304 are described as echocardiograms for "congenital cardiac anomalies". We know BAV and PFO are "simple" and exempt from these TTE codes.

Would a bovine arch, which is coded to Q25.49, be considered a cardiac anomaly? The best I can find is "variation" of the aorta, but it does have a congenital Q code. Would you consider 93303 or non-congenital TTE coding?

How would the following be reported for thoracic surgery performed EGD with max distention of the stomach?

"We (acute surgeon) was asked to come in, Apposition of the stomach to the abdominal wall was confirmed with one-to-ton movement to palpation and transilumination. The location on the abdominal wall corresponding to the area around the PEG tube bumper was identified and the skin was infiltrated with local anesthetic. Six T-fasteners were inserted through the abdominal wall into the stomach around the PDF tube bumper under direct endoscopic visualization. The suture of the T-fasteners were pulled taut and secured with the associated locking button. The stomach was then desufflated and the PEG tube was evaluated to be snug but not under excessive tension."

Would you accept the following documentation to support billing 93458? The LVEDP was measured, but no documentation by the provider of actually entering the left heart to do this. My understanding is that the LVEDP can also be measured indirectly via PCWP measurement from pulmonary artery (I don't think that's what's occurring here, but think it's worthy of a query to clarify catheter placement). Please let me know thoughts.

"...Access was obtained in the right radial artery and 5/6F slender sheath was placed. Left ventricular end diastolic pressure was measured using a 5F Tiger 4.0 catheter. Coronary angiography was performed using 5F Tiger 4.0 catheters and multiple cineangiographic views were obtained. Coronary angiography showed severe 90% mid LAD stenosis, which was the culprit lesion. A 6 French EBU 3.5 guide catheter was used to engage the left main coronary artery....

When billing for the 77092 in addition to 77080, some of my radiology reports have N/A as the TBS Score. Is this billable if the report states N/A and there is not a numerical score of the TBS documented?

How would this procedure be coded for the hospital? Since there is no aortic aneurysm, would this be reported with only code 34705? Or would this be reported with code 34718? Or both 34705 and 34717?

"Patient with left common iliac artery aneurysm only. Gore iliac branch endograft was deployed with limb just above iliac bifurcation. A Gore limb was then deployed with maximal overlap on the iliac branch endograft into the internal iliac artery. This extended down with a VBX to the iliac bifurcation. The external iliac limb was then deployed. The main body was advanced up the right side. Landed just below the left renal artery. A bridging limb was deployed from the contralateral limb into the iliac branch endograft with maximum overlap on both sides. The remainder of the main body down the right limb was deployed. We extended the right side down with a distal bell bottom."

When coding for a pain clinic, we are given a final diagnosis of lumbar radiculopathy and low back pain with sciatica. When researching these two conditions, it is stated that sciatica is a specific type of radiculopathy and that radiculopathy is a general term. When both of these diagnoses are given, what would be your recommendation for coding? I am thinking to only code lumbago with sciatica since it is described as being a more specific type of radiculopathy.

If a single lesion is treated with a drug-coated balloon in a bypass graft, should we report code 0913T or 92937? Where does DCB fall in hierarchy when you could also use one of the codes that includes everything performed (like CTO, AMI, and bypass graft)? 

The doctor did a 93460 and a renal abdominal angiogram, which I’m going to use a 75625 cpt code. The patient only had hypertension; the renal arteries were fine. I’m having trouble getting this paid with the hypertension. Should I still bill the 75625?

I am new to PAE coding and need some clarity around an additional coil embolization to preserve function and prevent harm. The provider documented the following: "Angiography performed to confirm extraprostatic enhancement. Decision was made to proximally embolize this vessel to avoid nontarget embolization. Pushable Nestor coil was deployed in the rectal artery collateral branch of the right prostate artery. Post embolization angiography was performed and demonstrated successful occlusion of the vessel."

Would this support a separate surgical field to code 37242 in addition to 37243?

I remember reading a long time ago that if the provider documented the measurements for the aorta that this was the only area where measurement's could be used to support billing a complete echocardiogram-I am unable to find anything in writing now and this question has come up-

The provider didn't make mention of the aorta in his findings to which this is one of the required areas for billing-Because we can see that it was done by the raw data listed below would we bill a complete vs a limited study since they all basically same the same thing from what I am seeing under that heading- See snip below-

Aorta

The aorta is normal in size in the visualized segments.

Aorta

----------------------------------------------------------------------

Name Value Normal

----------------------------------------------------------------------

Ascending Aorta

----------------------------------------------------------------------

Ao Root Diameter (MM) 3.9 cm

Ao Root Diam Index (MM) 1.5 cm/m2

Definity (Q9957) comes in a single dose vial with 1.3 mL. When billed to Medicare (Palmetto GBA is MAC) in POS 11, it is being paid but for Q9957, I see a status indicator of N1. Does JW/JZ modifier policy not apply even when being billed in POS 11 since it is a single-use drug? A billing unit is per 1 mL. The entire 1.3 mL vial is drawn by the nurse and diluted with saline for a total of 10 mL. When billing Q9957, if you have 1.3 mL, shouldn’t 2 units be billed with no waste? There is confusion with the clinic. Once the full 1.3 mL is diluted with saline, they do an initial push of 2 mL to the patient. They will continue to push more if contrast wears off. They calculate 0.13 mL of Definity in every 1 mL of the diluted syringe. The provider will order 1.3 mL of Definity for a patient, but they may document that 0.26 mL was given if only 2 mL administered. This is being billed as 1 unit only of Definity and I am confused if this is correct. I don’t believe we bill only 1 unit for 0.26 mL of diluted Definity when the entire 1.3 mL vial is withdrawn.

"Initially a SMA branch vessel was isolated and controlled with Silastic loops. Thromboendarterectomy was performed at this location, while there was backbleeding, was unable to pass embolectomy catheter. Vessel was closed SMA was identified distally at a branch point and proximally the vessel was dissected free for several centimeters. Transverse arteriotomy was performed with an 11 blade and extended with Potts scissors. There was no bleeding at this site. There was notable fresh clot at the arteriotomy. This was picked free with DeBakey pickups. Proximally a #4 Fogarty balloon catheter was advanced 4 times revealing fresh clot. Two clot free passes were performed and pulsatile inflow restored. A #3 Fogarty was passed down the main SMA distally with ease for around 15 cm. This was passed several times until 2 passes without clot were revealed. A large clot burden was initially extracted."

Would you code both or just the thrombectomy since that was the intent?

Can you code a left ileofemoral endarterectomy (35355) with an endovascular stent placement in the left external lilac (37221)?

Coil embolization was previously performed for a left posterior communicating artery aneurysm. The patient returns six months later for follow-up angiography and is found to have a recurrence of the aneurysm due to coil compaction. Would this be coded as a complication?

I need clarification regarding code 36818 vs. 36821. My auditor is stating that 36818 is used only for transposition where the vein is transposed in location via a tunnel, and that 36821 is the correct code. Per the op report I believe the correct code is 36818. 

"Next a 10 blade was then used to make an incision over this previously marked area through the epidermis, dermis, and subcutaneous fat. Bovie electrocautery was used for hemostasis. The brachial artery and the cephalic vein were dissected out, and 5000 units of heparin were administered. Cephalic vein branches were tied off. The cephalic vein and it was flushed out with heparinized saline. The end of the cephalic vein was spatulated, and end-to-side arterio-venous anastomosis was made with 6-0 prolene sutures after brachial artery arteriotomy. The brachial artery had great forward and back bleeding, and the fistula was flushed before closure. Soft tissue flaps were raised bilaterally, and the deep layer was closed with interrupted 2-0 vicryl sutures." 

Does this sound like code 36818 or 36821? Please help!

I know that pocket revision verses relocation gets a lot of discussion. I have a physican who is giving a bit of push back about recommendation of repair codes. He states this is not a wound that is being repaired. Case summary. I would like to provide documentation that answers his direct question. 

"Ms. X is a 75-year-old female who reports that her pacemaker site is uncomfortable and impacts her quality of life and her sleep. Once the generator was removed from the pocket, I did not disconnect the right atrial, right ventricular, and left ventricular endocardial leads from this device. Instead, I performed dissection down to the pectoralis fascia and muscle more medially. There was adequate hemostasis, and antibiotic solution was utilized to irrigate the pocket. Device was placed back in the pocket, and a stitch with Ethibond was applied to keep the generator in place. It was moved more medial, deeper and more caudal. The pocket was then closed with 2-0 Vicryl, 3-0 Monocryl and Silverlon dressing. A TYRX pouch was placed."

There seems to be a discrepancy in answers to question IDs 12365 and 15039.

If percutaneously placed Impella is removed via open procedure and embolectomy with patch graft performed due to thrombus thrombus noted at the tip of the Impella as well as in the common femoral artery, then would coding for 35226 and 33992 be correct?

Patient is status post TAVR with a bovine prosthetic valve in the aortic position. The prosthetic valve manufacturer is 25 mm Carpentier-Edwards Magna. There is aortic regurgitation increased from pervious mild to moderate. Additionally, there is moderate mitral and tricuspid regurgitation. In regards to diagnosis coding, would a T82.- code be used to describe the leakage of the heart valve along with I08.3, or would I08.1 be more appropriate as the aortic insufficiency is accounted for by T82.-? 

We are holding a bill for the answer to this question if we could get an answer soon please. Per previous guidance, when both a stent and DEB of a lesion in the coronary artery are performed, the recommendation is to report the stenting procedure, not the DEB. Does this mean the hierarchy of coronary interventional procedures prevails and if an atherectomy of the lesion is performed along with DEB, we report the 92924?

Is this reported with codes 37241 and 10160?

"Under ultrasound guidance, a 5 French needle was advanced into the largest collection in the malformation. An Amplatz wire was advanced through the catheter and coiled in the collection. The needle was removed, and an 8 French pigtail drain was advanced over the wire and coiled in the collection. 50 cc of fluid were aspirated and sent for cytology. Contrast injection confirmed position. At this point, 6 cc of STS were instilled in the collection allowed to dwell for 15 minutes. The STS was drained, then 40 cc of doxycycline mixed with 5 cc of MRI contrast were instilled in the collection and allowed to dwell for 15 minutes. The collection was maximally aspirated at the end of this time period, and the drain was removed."