Ask Dr. Z

A cardiothoracic surgeon is requesting digital waveforms and pressures when also performing bilateral radial artery mappings prior to CABG. The assessment of the RA is for possible use as a conduit for CABG vs. saphenous vein or other grafts.

The digit-brachial index (DBI) is the upper extremity equivalent of the lower extremity ankle-brachial index. Is it appropriate then to report both 93930 (duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study) -and- an ABI (93922 limited -or- 93923 complete) when pressure measurements and waveforms are obtained of the digits when measured and documented both with and without radial artery compression maneuvers?

In a brachial artery to jugular vein AVG, would angioplasty documented as venous outflow be considered central or peripheral for coding purposes?

One of our vascular surgeons sent us a recommendation from Boston Scientific to report codes 37211 and 37252 when using EKOS in an artery.

Per the recommendation:

“Ultrasonic fragmentation using EKOS” can be used in the dictation for clarity.

The specialist further clarified that 37252 can also be used together with 37211.

Is this appropriate, as the 37211 descriptor states "any method", and isn't the EKOS catheter usage just another method ? Or is the use of "ultrasonic fragmentation using EKOS" sufficient to allow for the 37252 billing?

We have had a scenario come up a couple times where an interventionalist and a cardiothoracic surgeon perform a TAVR, but need a vascular surgeon to come in and perform the access portion of the procedure for an open approach. We have been using unlisted code 37799 for this work by the vascular surgeon, since we're already billing the TAVR as a co-surgery for the interventional cardiologist and the CT surgeon. Would you agree with this?

Are we to code C1761 per vessel treated, or is this coded based on the number of Shockwave IVL catheters used during the case? 

Patient had 45-day post Watchman TEE, which revealed persistent 5.5 mm LAA. Physician opted for secondary closure with a vascular plug. Do we report unlisted code 33999 and compare to 33340 for pricing? I reviewed previous threads and think this would be correct.

One of our vascular surgeons performed an I&D of the antecubital region with debridement and resection of the antecubital vein. The coder reported unlisted code 37799. I see a response back in 2011 that supports that, but has anything changed to avoid the unlisted code?

The patient is status post PDA coil occlusion with no other congenital heart defect. Do we still report congenital codes when the patient returns for an echo?

"A patient was admitted for sepsis, and a request was made for bilateral nephrostomy. Using ultrasound guidance, a 22 guage Chiba was used to access the collecting system. Unfortunately, the was no hydronephrosis, and after a few attempts, the case was canceled."  In a discussion with a fellow coder, that coder wanted to report code 50432-52, and I said it should be coded 50430-52 because 50432 needs a catheter and no catheter is documented in the report. The coder came back with no contrast was injected. which is part of 50430. How should this case be coded?

We have an encounter in which the provider performed percutaneous coronary thrombectomy using an ASPIRATION EXPORT AP 6FRX140CM, CATH. Per an older ZHealth Publishing "Ask Dr. Z" Q&A, he states, "We do not recommend any code for aspiration thrombectomy of a coronary artery or branch." We do not recommend an unlisted code at this time." Does this still stand that we should not bill any code for aspiration coronary thrombectomy? 

How do we charge this for an abdominal aortogram? How do we charge CO2 contrast itself? I think procedure is the same CPT code (75625), but we used CO2.

For the following, are codes 35371, 37221, and 37223 correct?

"Evaluation of CFA showed complete occlusion w/ thrombus. I first passed the #5 fogarty embolectomy catheter into the EIA until there were no more clots. there was minimal flow into the CFA. The Freer elevator was then used to remove the CFA plaque. We went ahead and sewed the bovine pericardial patch in rifampin and sewed this with a 5-0 Prolene sutures. I then punctured the middle of patch with a 16-gauge needle and passed the storq wire into the aorta. confirmed this with fluoro. A 7 French sheath was advanced into the common femoral. An omni catheter was advanced into distal aorta. An aortogram with bilateral iliofemoral angiogram was obtained. This demonstrated occlusion of the EIA at the origin. The IIA was open but stenotic at the origin. There was stenosis of about 30% at the distal left CIA. I marked the area of occlusion and predilated with 7x80mm balloon. I placed 8mmx5cm stent from the top of the CFA patch into left EIA. I placed 8x59 omnilink to overlap that into the distal iliac to preserve the hypogastric."

On the hospital billing side, can we charge for fluoroscopy during coronary angiography or cardiac catheterization? If yes, what is the correct documentation for fluoroscopy?

Glad to see that CMS has updated its list of codes that are appropriate for use with C1761. However, we recently had a case where lithotripsy was performed and the vessel was then able to be opened with angioplasty (no stent, no atherectomy, and not a CTO). What do you suggest we report in this instance?

Patient has DC ICD for upgrade to biventricular ICD. His lead was implanted and connected to the CS/LV port of the device. Physician was unable to place LV lead due to small vessel, and multiple guidewires were unable to be advanced. Would I report codes 33264 and 33216 for the His lead?

As of 01/01/2022, code 93656 now includes 93613 (3D mapping) and 93662 (intracardiac echo). Does that mean if the provider performed 2D mapping (93609) during the same session as 3D mapping (93613) the provider can charge the 93609? Our providers often state that they perform both 2D and 3D mapping.

Should we use 33477 or 93799 because of the hybrid transapical approach? Any other recommendations?

"Patient with a history of pulmonary stenosis, prior balloon valvuloplasty x2, and failed transcatheter valve placement. PROCEDURES: 1) RHC. 2) Angiography: RVOT and branch pulmonary arteries. 3) Hybrid, transapical, transcatheter pulmonary valve replacement. Subxiphoid midline incision was performed, exposing the RV apex, and pursestring suture was placed. 18 gauge needle advanced through the suture and through the RV free wall into the RV cavity. Guidewire positioned in the ventricle and needle exchanged for a short sheath. Positioned a guidewire in the distal LPA. Transaortic Edwards delivery sheath positioned in mid RV. Sizing balloon used and then an S3 valve advanced over the guidewire and through the sheath and across the RVOT. Valve deployed. The guidewire and sheath were removed and the pursestring suture tightened, repairing the RV free wall access site. A mediastinal drain was placed." 

When is the middle meningeal artery considered extracranial in an embolization procedure? These hemorrhages are outside the brain. Shouldn't this be coded 61626 instead of 61624?

Cardiac surgeon does a graft conduit of axillary for Impella placement, then a week later removes it. I went with unlisted code 33999 for implant of conduit, but I am not sure on the removal. I am thinking 13160 or 33999. thoughts?

If the patient meets the criteria for the watchman device and the surgery is scheduled and performed, not as an inpatient procedure but only stays overnight, it would appear that on a physician claim (1500) the cpt code of 33340 should be billed. I am only seeing the 02L73DK code being used and no 33340. Appreciate the assistance with understanding the difference in when to use which code.

Do we code/charge 36573-52? The order and intent is for PICC placement.

"Multiple chest radiograph were obtained. However, the PICC line tip would not advanced beyond the axilla. Both lumens of the PICC line flushed and aspirated easily. Thus, the PICC line was left in the left axillary vein. Impression: Status post left-sided dual-lumen PICC line with distal tip in the left axillary vein."

"Patient brought to ASC cath lab, prepped, draped and local anesthesia was administered. The left axillary vein was cannulated using fluoroscopic landmarks. 2 guidewires were inserted through the needle to establish IV access. A micropuncture needle was used & the micro sheath was advanced into the vessel and used for electrode placement. The left infraclavicular pocket was opened with an incision over the previous one. The pocket appeared normal. Patient developed progressive SOB after being placed on the table for the procedure with 02 saturation dropping to low 90's despite 02 supplement. Then the patient was noted to be in acute respiratory distress and the procedure was aborted. The left subclavian wires were removed. The pocket was irrigated with sterile H2O solution, hemostasis was obtained with electrocautery and the pocket was closed with 2-0 and 4-0 vicryl."

Do I code the planned procedure (33349 & 33225) with a -53 modifier or what would I be able to code since nothing was completed with either the leads or the generator?

Can you bill a separate code for carotid shortening during an endarterectomy? The common carotid is being excised for the purposes of ICA straightening. My provider seems to think that you can bill code 35201 (repair blood vessel, direct: neck) along with the 35301.

Questioning procedures done outside the portal and hepatic veins during a TIPS revision - going with the same logic here when doing a thrombectomy in addition to revision - can we code cath placements along with angioplasties (or stent placements) if done in the splenic vein/SMV/IMV?

Indication: Post TAVR "with subsequent left femoral pseudoaneurysm which was repaired earlier in the operating room today. While in recovery room, unfortunately, his blood pressure spiked to over 200 and he had episodes of violent coughing. Afterwards nursing staff noted progressive swelling of left groin. Ultrasound performed on my request urgently showed recurrent pseudoaneurysm. I decided to take him urgently back to the operating room for surgical repair........." The physician billed 35141-78 for the return visit. There is an MUE of 1 and an MAI of 2 meaning there are no appeal rights. Is there a code to better capture the additional work or do we bundle it with the original procedure? We considered adding -22 to the original procedure, but are unsure if it is applicable since the work wasn't performed in the same session. Please advise.

Our hospital interventional radiology and interventional cardiology departments have a question about the definition of an "independent trained observer" when it comes to charging for codes 99151, 99152, and 99153 for moderate sedation.

What documentation is required by the facility and/or by the physician to support the presence of an independent trained observer? Can moderate sedation be charged if the RN providing the sedation and monitoring is also the circulator? Does the independent trained observer need to remain with the patient for the entire procedure, or can they perform other tasks within the room or nearby? Does this independent trained observer need to be the RN who administered the meds, or can it be a monitor tech or other staff member? We are trying to determine when it is and when it is not appropriate to charge for moderate sedation based on the staffing for the procedure and who is providing the sedation and monitoring.

Should this be 93451 (right heart cath) or 93453 (left and right heart cath)?

Patient with CM. Consult report indicates: Severe reduction in LV systolic function & CAD. Considering LVAD while pt waits for heart tx.

Arterial & venous access. Patient given Nipride.

Final diagnosis HFrEF w/severe elevation left heart pressures w/mild elevation right heart filling pressures. Severe elevation Pulmonary arterial pressures with mild elevation PVR. Compensated right heart function (RAP: PAWP 0.27, PAPi 4.7). Improvement in cardiac output and decrease in filling pressures and pulmonary arterial pressures with afterload/preload reduction.

Left heart filling pressures were severely elevated (PAWP 33 with V wave to 57 and pre-A wave 24); the elevation in pre-A/diastolic PAWP pressures in the absence of mitral stenosis is consistent with marked elevation in LV diastolic pressures. Pulmonary arterial pressures were severely elevated (PA 71/29/46) while femoral arterial pressures were 115/65/81, thus 62% systemic. Cardiac output was low (CI 1.8 L/min/m2) by measured Fick. Pulmonary vascular resistance was mildly elevated (PVR 3.6 WU).

What scenario would left veterbral artery be considered first order?

The ZHealth variant arch anatomy anatomical chart shows it as first order. All of their other anatomical charts with left vertebral artery, show it as a second order.

In the following scenario can both creation of pericardial window with repair of cardiac perforation be coded together, or is cardiac perforation repair included in creation of pericardial window? If not what code is used for cardiac repair?

"DX Pericardial tamponade following complex Impella supported PCI with Cardiogenic/Hemorrhagic shock.

Incision made over Xiphoid. Xiphoid dissected/excised. Internal Mammary retractor used to elevate the inferior aspect of sternum blunt/sharp dissection performed. Pt's body habitus such that exposure was excellent and I could see a fair distance up onto the anterior pericardial surface. Pericardium incised, moderate amount of free blood in pericardium. Evaluation of what I could see of the heart from this exposure revealed that there appeared to be 2 bleeding sites,probably from previous percutaneous pericardial drain placement (by another specialty group). Pledgeted 2-0 prolenes used to perform suture repair of these 2 areas at the acute margin Topical Evarrest hemostatic agent patches were placed over the repair sites."

Would code 35013 be the correct code for ligation of right arm ruptured pseudoaneurysm and partial graft excision, hemorrhaging right arm ruptured pseudoaneurysm?

"The right arm was prepared. An incision was preformed proximally to obtain flood flow control. Proximal and distal control obtained through the proximal incision. Damage control ligation of the proximal graft/pedicle of pseudoaneurysm and distal graft with 3-0 Prolene. Graft sent for culture/pathology. Soft tissue hemostasis was ensured with electrocautery. The soft tissue was approximated with interrupted 2-0 Vicryl. The skin was closed with staples."

Would this be coded as a revision with 36832, or can I code 37607 and 36901? "Under sterile and controlled conditions, the patient was prepped and draped in the usual sterile fashion. Micropuncture needle was then placed after lidocaine was infiltrated in the proximal part of the fistula. Fistulogram was obtained. It was noticed the patient had a patent arterial inflow and venous outflow with a large branch in the arm. The branch was localized. Small incision made over the branch. The branch was ligated with silk suture. Completion of fistulogram now showed a widely patent AV fistula with no flow in the accessory branch. The sheath was removed. Pressure was applied. Wounds were closed in a double layered fashion with skin reapproximated in a subcuticular fashion. Dermabond was applied, and patient left the operating room to be monitored in PACU."

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

"Under real-time ultrasound guidance, a 25 gauge needle was used to inject 5 cc of 1% lidocaine for local infiltration anesthesia. Subsequently, a 22 gauge spinal needle was advanced into the right L5 transverse process, around the area of pseudoarthrosis, and 5 cc mixture of 1% lidocaine and 40 mg of Kenalog was injected intra-articularly."

I understand that in order to bill for angioplasty in a dialysis circuit the percentage of stenosis must be greater than 50%. The physician I code for uses the word "narrowing" instead of "stenosis." For example: "There is focal narrowing in the mid fistula where the lumen is compromised by 85%." It is my understanding that the word "narrowing" may not always equate to "stenosis", but maybe I am wrong. If I am not, can you send me any information that would help me make my case?

Our patient had an existing biventricular defibrillator and was experiencing toning in her existing RV lead, which led the provider to believe it was fractured. My provider performed a revision of a CRT-D system by disconnecting and capping the existing RV pace/sense lead and connecting a capped RV ICD pacing lead to the active circuit (that had been placed previously).

The provider tried to bill it as a pocket relocation simply because he revised the pocket medially to eliminate encroachment across the left deltopectoral groove. I disagree with that strategy. The existing generator was placed back in the pocket, and we reused a lead that had already been placed and had been capped, so no new hardware was implanted. Would this be covered under a lead reposition 33215, or would there be something more appropriate, or should we use an unlisted code?

When a physician changes out just the generator on an SICD, do you use code 33270 or 33262? There don't seem to be clear guidelines in the CPT book.

Would this be coded as 36904 or 36905 or something else? From what we understand, "do not report removal of arterial plus during declot/thrombectomy as an angioplasty (36905) it's included in 36904, which includes balloon maceration. 1. u/s guided access LT thigh AVG directed towards venous outflow 2. inj. TPA into venous 1/2 of AVG 3. Balloon maceration & angioplasty of venous & AVG w/PTA balloon 4. 2nd U/S guided access of LT thigh AVG directed toward the arterial inflow. 5. Balloon sweep of arterial anastomosis of AVG w/Python balloon (to pull platelet plug of the AVG) 6. angioplasty of arterial end of AVG 7. completion venography w/cath parked in LT SFA FINDINGS: Initial AVG venogram = numerous filling defects along venous end of AVG consistent w/thrombus. 9mm graft aneurysm beyond apex of graft towards venous, fills upon inj. IMPRESSION: 1. Successful declot w/restoration of flow. entirety of graft angioplastied w/PTA balloon. 2. Viabahn stent-graft at venous anastomosis of AVG widely patent on completion image. Thank you.

We have recently started using an Amulet left atrial appendage closure device. I am not able to find any information related to this procedure. We tried billing 33340, but the insurance companies are denying asking for the Watchman device. What is your advice?

Can we bill 36012 during ICD implant? "After infiltration with local anesthesia, a percutaneous stick was performed to obtain vascular access medial to the deltopectoral groove using the second rib technique. Three accesses were obtained. An incision was made incorporating the wires and carried down to the level of the pectoral fascia using blunt dissection and electrocautery to obtain hemostasis. A subcutaneous pocket was constructed. The provider implanted ICD with LV lead." Can we bill 36012 with 33225 and 33249 for this case?

I wanted to get your opinion on the new 2022 EP ablation bundles coming in regards to 2D mapping (93609). I know prior to these updates if both 3D mapping and 2D mapping were supported, we could not report both and typically the 3D would be reported. With the new updates, CPT still allows the 2D mapping with the SVT and PVI ablations, but has bundled the 3D mapping with these services. If there is documentation by a provider that clearly shows both 2D mapping was performed and also 3D mapping, what are you thoughts on reporting the 2D mapping now that they have bundled the 3D in with the primary ablation?

Should a biopsy with a Rotex needle be billed with the biopsy code and 76942 (e.g., thyroid biopsy 60100 and 76942) or 10005 (fine needle aspiration)? The literature that we have found on the Rotex says that material is excised instead of aspirated, so it gets complete cell clusters instead of single cells. Please advise.

"The fourth intercostal space was entered with the lung deflated. There were adhesions from prior radiation that were carefully dissected A longitudinal pericariotomy was performed anterior to the phrenic nerve. A dlp vent was placed through 2 pursestrings in the ascending aorta and a flexible crossclamp applied. Cardioplegia was given antegrade and every 45 to 60 min or when electrical activity occurred(dekl nido0. a left atriotomy was performed to visualize the mitral valve. An atrial retractor was placed for optimal exposure.

The mitral valve was found to be with some restriction of the posterior leaflets and clefts. The clefts were repair with 4-0 and 5-0 prolene sutures and a 28-physio ring was placed with 2-0 Ethibond pledgeted sutures and corknot. The repair looked nice under pressure. Static testing of the valve showed it to be competent. The left atrial appendage was left intact."  

Not sure how to report this approach-33418 & 33426/7 do not seem to fit. Which T code or should this be unlisted-33999?

Question 11045 was answered in 2018, and I'm wondering if the direction is still the same. We found code S2205 but previously you've recommended using the "normal" CABG codes if done minimally invasive or with robotics. S2205 is not accepted by Medicare, but would commercial payers accept it? We would need to price the code. Would we compare it to the normal CABG codes for pricing purposes?

PROCEDURE:

1. Minimally invasive MICS CABG (minimally invasive off pump coronary artery bypass grafting).

2. Left internal mammary artery to left anterior descending artery with vein interposition.

3. Left greater saphenous vein harvest via open incision.

CPT codes 76376 and 76377 require concurrent physician supervision. I haven’t seen anything clearly defining the term beyond American College of Radiology 2012 FAQs which note that “concurrent means active participation in and monitoring of the reconstruction process that includes: design of the anatomic region that is to be reconstructed; determination of the tissue types and actual structures to be displayed (eg, bone, organs, and vessels); determination of the images or cine loops that are to be archived; and monitoring and adjustment of the 3D work product.” Moreover, the ACR’s Q&A notes that concurrent physician supervision “defines a temporal relationship to creating the 3D image”.

Are you aware of any more recent guidance or clarification of the necessary level of supervision required by these CPT codes given advances in technology that make 3D reconstruction mainly a computer-driven process?

The patient was brought in for a scheduled PCI of the RCA after a recent a diagnostic angiogram showed a 90% stenosis. However, the provider documented they were only able to probe the lesion a couple times with a guidewire and did not have adequate resources to continue. The end result is an unsuccessful crossing of the RCA lesion with plans for another PCI attempt in the future at a different facility. The patient had a coronary angiogram done during this procedure, so the question is: do we code for the coronary angiogram only even though the patient had a prior catheterization? Or do we code for an attempted intervention with a -74 modifier? I was thinking if we can't bill for this second coronary angiogram, we would only code a catheter placement into the aorta.

This is a hypothetical situation with the hope to better understand when an attempt could be coded for scheduled PCIs. There is, of course, grey area when it comes to what the provider might document for such a scenario.

I know your newsletter in August talked about this, but it is being interpreted in different ways by various staff so I'm hoping you can give us an answer that can clarify. Patient has a CTA that shows an aneurysm in the right anterior communicating artery. Patient is brought to the cath lab where bilateral intracranial arteries and bilateral vertebral arteries are selected and imaged. Coils are placed into the right ACA, and follow-up imaging is performed. Dictation states, "A full four-vessel diagnostic angiogram is performed due to inadequate visualization of the anatomy and pathology on prior CTA." Findings are presented. This is the physician's standard workflow for all embolization cases. I would code 36224-50, 36226-50, 61624, 75894, 75774. My colleague disagrees with the diagnostic imaging because the CTA diagnosed the aneurysm and the physician has no grounds for repeat diagnostics: no change in status, no surprise findings. How would you code it?

I have a doctor who feels that he does not need to use the word emergent for when he performs a PCI during an acute MI (92941). Do you know of any documentation per CMS that provides that clarification that I can reference for him to see that understanding? Any references would be greatly appreciated or documentation or articles that I can use to help him understand this reference.

Is it appropriate to report code 92960 at any time when a patient is coming in for an EPS ablation? The description of 92960 states "elective". In reviewing other questions on here this would need a consent form signed by the patient. There seems to be confusion in that we can code 92960 before any catheters have been placed at the beginning of the case. Will you please advise?

Had a patient for a cath with grafts and was going to discuss the case with other cardiologist and cardiothoracic surgeons to determine re-do CABG or do multi-vessel PCI. The patient was brought back the next day and all wanted a better image of the LIMA graft. What do you suggest I charge for this? I know there is a LIMA charge in interventional radiology, but I believe it's not to a graft. I didn't know if there was anything I could charge for this. 

During an EVAR procedure an open femoral cutdown was done and then an 18 French sheath was placed. Can add-on code 34812 for the femoral cutdown and add-on code 34713 for the closure of the femoral artery both be reported? Code 34713 states "percutaneous access and closure of femoral artery for delivery of endograft through a large sheath..." I am unsure if this would still be considered a percutaneous access when a cutdown was performed.

Would the following procedure note be enough to report code 25065 for this forearm biopsy, or would it still be 20206 since the biopsies were done via needle?

"The skin was marked at the point of needle entry site. 1% xylocaine solution was used as local anesthesia. The skin was incised, and through it a 14 gauge biopsy needle was placed under US guidance. Adequate core tissue samples were obtained."

I'm not sure because of the incision, or is that even relevant since the biopsy was through the 14 gauge biopsy needle? I also do not see closure.