Ask Dr. Z

Does the following documentation satisfy requirements to report ICD-10 code I50.22, or would we need to ask the provider to state chronic systolic heart failure as the indication? "INDICATIONS: Severe non-ischemic cardiomyopathy with LVEF 30% on optimal medical therapy; class III congestive heart failure, complete heart block with pacing induced left bundle-branch block, heart failure duration exceeding 3 months, primary prevention."

I am not finding all of the new CPT codes 93241-93248 on the CMS fee schedule. Do you have any information on why the codes were not included? Will Medicare be paying for these services?

What CPT code do we use to report a replacement of an S-ICD generator due to end of life (no lead replacement)? (New implant: Boston Scientific EMBLEM MRI S-ICD)

Is the verbiage "color flow/spectral Doppler" required in the documentation to code and bill for a complete vs. limited scan?

Can you clarify the Society of Maternal Fetal Medicine's recommendation for what procedure code to use to report a ductus venosus Doppler study?

(Patient with MRSA/Bacteremia) "Axillary stent - suspected as source of infection but not confirmed. The patient was taken to the operating room and placed in the supine position. After adequate regional block anesthesia he was prepped and draped in the usual fashion. An incision in the proximal upper arm near the axilla and this was carried down through the subcutaneous tissues. The fascia was incised. Care was taken not to disturb any nerves. The axillary vein was identified and proximal to the stent (mid arm) it was occluded and rubbery. The stent could be seen. I gently dissected the vein and then made a venotomy with an 11 blade and separated the plane between the stent and vein. The stent was grasped with a hemostat and gently retracted while continuing to separate the plane. Eventually I was able to completely remove the stent."

I am thinking 35206, or venous thrombectomy code 34490 because there was thrombus found inside of the stent incidentally, which was cultured and sent for path exam. Any assistance with this case would be appreciated.

"Patient brought to the cath lab, placement of a right pulmonary artery cath and a left radial artery cath, due to borderline biventricular pressures, cath left in place, patient transported to the exercise lab for cardiopulmonary exercise testing via bicycle ergometry with right heart cath and radial cath in place to evaluate hemodynamic response. Continuous oxygen saturation, ECG, expired gas, arterial pressure, right atrial pressure, and pulmonary arterial pressure monitoring were performed continuously throughout the test. Arterial and mixed venous blood gasses were collected every minute. Pulmonary capillary wedge pressure was measured every minute, etc… After the procedure was completed the catheters and sheaths were removed."  In addition to 94621 (CPET), would the correct additional codes to report be 93451, 93464, 36620?

Patient had very severe ICA stenosis and M2 occlusion initially. Planned for thrombectomy, but after primary angioplasty the thrombus was noted to have cleared. Further carotid angioplasty and stenosis was deferred, as well as intracranial exploration, because the patient was VERY sensitive to angioplasty, becoming asystolic instantly, requiring atropine resuscitation. Only cervical carotid angioplasty WITH protection device, but WITHOUT stenting was performed. Provider is asking if we can still bill 37236 on this one? Or should it now just be 37215-52? Please advise.

Could you please help with coding for the following OP note? Patient has an ICD implant. "Patient came in with RV lead fracture. I opened up his pocket and removed his existing pulse generator and disconnected it from the leads. I then took vascular access and implanted a new RV ICD lead. I then relocated the skin pocket superiorly since the lead implant was in a different location than the existing leads. I then capped the existing fractured RV lead. This is a single lead; however, it is a DF-1, which means that it has three electrodes and not just one. I capped all three electrodes. I then took the existing pulse generator and reconnected it to the existing RA and LV leads and also connected it to the new RV lead." When they remove and replace the same generator, I'm not sure if it would still be considered a "replacement" according to CPT language. Not sure if this should be coded as 33223 and 33216, or as 33241 and 33249?

Per AMA we can bill both core biopsy and FNA aspiration same lesion for 2021. If liver core biopsy done with ultrasound guidance and FNA aspiration same lesion under ultrasound guidance done also (same image guidance), can we bill 47000 and 10005-59, no 76942?

"The femoral nerve was identified under the US, which lies lateral to femoral artery. The full electrode tip is inserted entirely to the fascia lata. The nerve electrode was introduced into the top of femoral nerve, and the transducer was removed. After the needle removal, the lead was again connected to the stimulator to confirm the lead dislodgment didn't occur during needle withdrawal. A connector block was attached to the lead approximately 2 cm from the skin entry point, the excess lead was removed, and the lead site was covered with a sterile dressing. The device was connected and set up." Can you advise what CPT code to use for this pain management procedure?

"Our interventional cardiologist brought the patient to the cath lab for a RHC and CardioMEMS implant. The RHC was performed followed by a pulmonary angiogram via RFV access to identify a suitable vessel. The LPA was found to be an appropriate site for the device. The CardioMEMS device was advanced to the PA segment; however, they could not obtain reliable device waveforms. After multiple attempts and repositioning it was felt the patient's anatomy and BMI were preventing adequate device/controller signal. Device was removed and not implanted." Should we report the attempted CardioMEMS procedure (33289) or consider reporting the work that was done RHC with PA (93451, 93568)? Should we consider a modifier -53 here?

Would it be appropriate to charge for the following limited EP study followed by a PPM implant and then AV node ablation? What code(s) would be appropriate? 

"Using the modified Seldinger technique, a 7 French sheath was placed in the right femoral vein. Through this sheath, a duo decapolar catheter was placed to the right atrium, sitting anterior to the crista terminalis, with the distal poles in the coronary sinus. Activation mapping was performed. The right atrium had a chevron appearance of activation. Entrainment was performed from the CTI, which was found to be out of the circuit, with a long PPI minus TCL. The CS was found to be within the circuit. The tachycardia was consistent with mitral annular flutter." 

The PPM insertion and AV node ablation that followed were appropriately documented and were all performed in the same session.

"Access site left CFA. Catheter was advanced over the wire to the ostium of the left subclavian, and selective angiogram was performed. This demonstrated a subtotally occluded left subclavian artery. Using digital subtraction angiography, the distal vessel did fill, suggesting some hibernating arterial supply for micro-channels. Balloon was advanced over the wire into the left axillary artery, and selective angiogram was performed. This demonstrated excellent flow to the arm. The balloon was then pulled back into the left subclavian artery, and selective angiogram was performed. This demonstrated no significant flow into the vertebral. The IVUS catheter was then inserted, and a pullback was performed. This demonstrated an axillary artery size of 7 mm. The left subclavian measured 6.5 x 7.3 mm with a 100% stenosis. Subclavian artery was then ballooned. It was inflated to 14 ATM for 20 seconds. Following this the lesion was then stented using a 6 x 40 mm Omnilink stent. It was deployed at 18 ATM for 30 seconds." Do I report codes 36225-LT, 37236, and 37252? Or do I report codes 75710-LT, 37236, and 37252?

If the provider performs prolonged administration of verapamil into one of the vertebrals (61650), and does diagnostic imaging and provides separate findings for the contralateral vertebral, are we able to code for both 61650 and diagnostic imaging for the contralateral side? Or does the 61650 bundle everything done in that territory (vertebro-basilar)?

I'm questioning code for lumbar puncture done in IR for RT planning. Should I report codes 62284 / 77003?

"CLINICAL INDICATION: Rad Onc simulation. History of liposarcoma mets to spine s/p surgery. PROCEDURE: Following explanation...... consent for a a fluoro-guided lumbar puncture and CT myelogram were obtained from patient. Under fluoro guidance, L4 space selected, 20 gauge spinal needle advanced into subarachnoid space. Return of clear CSF confirmed. 10 mL of Omnipaque-240 injected slowly into subarachnoid space. Needle removed. Contrast confirmed in upper thoracic and lumbar levels. Patient was then sent to rad onc. IMPRESSION: Successful fluoro-guided lumbar puncture and intrathecal injection of contrast throughout the t- and l-spine levels for rad onc simulation."

Can we use a -51 modifier with -59 or -X modifiers? Example: 36224, 36226-51, 36225-51-XS.

Are antibiotics typically given 30-60 minutes prior to a procedure billable to the patient? For example, I was told that when placing a neph tube the antibiotic is not billable, but if we are changing a neph tube it is billable. Basically if we don't always use antibiotics before something like a neph tube change then I was to bill for it. I see some doctors ordering it and some do not. Also was told that our OR does not bill for antibiotics given before, but if given after may be billable. I need clear information if I am to challenge the person who trained me.

If our provider performs a brief ultrasound in the office two weeks following PAVF to assess maturation, do we need to store the images in order to bill 93990? Is 93990 bundled with the E&M?

Per CPT description - the below listed parameters/device functions must be documented in the LVAD Interrogation report.

93750 reports a diagnostic procedure that is performed in person and includes a face-to-face assessment of all device functions. Components that must be evaluated include device parameters (alarms, drivelines, and power surges) and a review of the device function (flow/volume status, septum status, and recovery). This code includes physician or other qualified health care professional analysis, review, and report. It also includes device programming, if performed.

Based on information from provider Septum Status/Recovery can't be determined by an LVAD interrogation alone without performing a RAMP study.

Please elaborate on the required documentation in relation to Septum Status and Recovery for an LVAD Interrogation - 93750 - when a RAMP study is not being performed - only an LVAD Interrogation?

We are wanting to know if a catheter placement into the aorta from the SMA that was accessed with an arteriotomy by an abdominal incision is separately billable. The op note states in part: "An upper midline laparotomy incision is performed in the usual fashion… A small transverse arteriotomy was made on the anterior surface of the SMA. Next the micropuncture wire is inserted directly into the arteriotomy site followed by a micropuncture sheath… The SMA lesion was crossed retrograde. The sheath was upsized to a short 7 French sheath. Given the poor distal outflow is difficult to opacify the runoff however the heavily calcified ostial lesion is easily visible in a steep oblique angle. A flush catheter was placed into the aortic to confirm reentry into the true lumen. The SMA lesion was pre-dilated with a 5 x 40 mm angioplasty balloon over the stiff Glidewire. Next a 7 by 27mm VBX is deployed at the SMA origin with excellent angiographic result." Would the cath placement be billed with 36200 or be considered part of the primary procedure?

My physicians have been removing the Impella on the floor in the ICU but leaving in the 14 French sheath and then bringing the them down to the cath lab the next day to do a tamponade closure using an Armada balloon. Would there be a charge for Impella sheath removal with balloon tamponade (closure of the sheath removal site)?

How should this be coded? 33237-52 along with 33213 for insertion? "PROCEDURE: The patient was brought to the operating room, put in a supine position on the OR table, and was endotracheally intubated for induction of general anesthesia. We prepped and draped the left chest in standard fashion. We then used some Marcaine in the skin. We placed a small incision in the left chest over the previous incision, went in between the ribs, and entered the left chest and pleura. We identified the pacemaker box, which was full floating freely within the pleura, and we were able to pull it in and exchanged it out without any problem. There were two leads, one ventricular and one atrial, that were reconnected to the new pacemaker generator. We used the antibiotic and pocket placed around the device, and then we placed it back into the chest cavity. We closed the incision in multiple layers. We placed a small 24 French Blake drain, and then the patient was then awakened and brought to the cardiac recovery room in stable condition."

Does administration of either Aggrastat or Angiomax during heart cath/stenting qualify to report CPT 92977 for physician side or facility side? If not, what would meet the criteria? "A repeat injection demonstrated 0% residual stenosis but there was only TIMI-1 flow with some slow flow noted which I treated with a bolus of Aggrastat, which 5 minutes later demonstrated TIMI-3 flow. Just as a precaution, I elected to give another bolus of Aggrastat."

Should the following be reported as 33216 and 93642? Or 33216 and 93641? "Usual prep and drape was done in sterile fashion. Anesthesia used was 1% xylocaine. Following satisfactory anesthesia, the generator of the ICD was explanted using sharp and blunt dissection. Following this, the lead was disconnected from the device. A new right ventricular lead was then placed using sheath placement with Seldinger technique in the subclavian vein on the left. This was advanced into the apex of the right ventricle, and satisfactory pacing and sensing thresholds were obtained. This was then attached to the existing generator and the excess lead and generator placed in the pocket. The pocket was flushed with antibiotic solution and was closed using running 3-0 Dexon suture for the subcutaneous tissue and subcuticular running suture of same for the skin. Following this, the patient was placed in ventricular fibrillation with a T shock, and the device successfully cardioverted the patient back to a sinus mechanism with 10 joules."

How many times can code 93657 can be billed per session?

Since the new 33741 code contains the description "for congenital cardiac anomalies" and the deleted codes (92992, 92993) it replaces did not have the "congenital" description, do you think that an unlisted code should be used for "non-congenital" conditions requiring the transvenous balloon or blade septostomy? If so, from which CPT section? Surgery (33999) or Medicine (93799)?

When using CPT code 76000, do you need to have a permanent image?

What would be the proper diagnosis code for a tortuous coronary graft? Would I77.1 be considered? "RIMA graft to 2nd marginal. Graft is angiographically normal, but the vessel has significant tortuosity."

During a minimally invasive mitral valve ring repair, the TEE probe could not be placed. Two providers tried and failed, so the cardiac surgeon called in his thoracic surgery partner to do a flexible esophagoscopy to evaluate why. Thoracic surgeon did not find a reason to prevent the TEE probe being placed. They tried again and TEE probe could not be placed, and surgery done with TTE. Is the thoracic surgeon's esophagoscopy separately billable? I think it is; please advise.

I have a case where the physician is performing a thrombectomy (37184) with a Penumbra catheter as well as an atherectomy/balloon angioplasty (37229) in the right anterior tibial artery. Anterior tibial stenosis is documented as well as an "occlusion" in the same artery. Is it okay to capture the thrombectomy even though he is only naming it an occlusion?

If a patient is in a skilled nursing facility, what codes get billed to the SNF vs. Medicare, 93295 and 93296?

It is my understanding that certain cardiac conditions, such as ASD and VSD, can technically be congenital or acquired. The ICD-10-CM classification assumes these conditions to be congenital (when not otherwise specified, of course). The CPT codebook does not include ASD and VSD in its list of diseases for which only the non-congenital cath codes may be assigned. When a patient with a known ASD or VSD undergoes a cardiac cath, and the physician has not indicated whether the disease is congenital or acquired, can we automatically code from the congenital family of cath CPTs? Do we need to query the physician? (All of our cath lab patients are adults.)

Is the following sufficient for 93656, 93657, 93655 x 2? "Indication: Persistent A-Fib. Procedures performed: Comprehensive EPS with attempted induction and PVI ablation of A-fib, isolation of anterior wall for A-Fib. Report: Ablation catheter advanced into the left atrium. Mapping showed isolation of left veins, but right veins reconnected. Lesions placed along the posterior wall right side veins. Additional lesions placed along the floor of the left atrium to achieve a floor line. Block across the floor line confirmed by pacing. Additional lesions placed along the roof of left atrium, along a roof line, until the posterior wall was isolated. He remained in a-flutter, so additional lesions were placed, creating an anterior line. All lines were confirmed by re-mapping. Mapping showed several fractionated electrograms that appeared to be reentrant triggers; these were also targeted. During the ablation he had five separate activation patterns. He then developed a sixth pattern after ablating the fractionated areas. He was cardioverted. His recorded and EPS done."

When a urologist places a nephrostomy tube (50432) prior to a percutaneous nephrostolithotomy (50080), can both codes be coded? If the tube is taken out at the end of the procedure, is it appropriate to append a -52 modifier?

Preop uterine myomectomy in OR, but had balloons placed in IR suite prior to procedure. Physician placed bilateral temporary uterine artery balloons. Balloons were removed after myomectomy. Is there a code for placement of temporary uterine artery balloon placement?

I had a patient who had a CRT-P downgraded to a single chamber pacemaker (His, RA leads capped, RV lead remains, old gen out/new gen in) and coded this to a 33227. The patient came in later that day for a CardioMEMS implant. This I coded to 33289. I am receiving NCCI edit that 33227 is component of 33289, not bypassable with mod. Should I attempt to send these two codes through and appeal, or do I really have to consider the pacemaker procedure a component of the CardioMEMS implant? This edit seems to make no sense to me, unless there is a clinical rationale why they should not be rendered on same DOS? What course of action would you take?

Can you advise of the percentage reduction in physician work given an iFR /DFR is less time/less intensive than FFR? Also how it is documented correctly?

Is this injection coded with 64400 x 2 or 64400 x 3? Do we code per branch or nerve? "The supraorbital, supratrochlear, and auriculo-temporal nerve regions were identified by manual palpation. The overlying skin was prepped with an alcohol pad. At this point, after negative aspiration, a total 1.5 mL volume of treatment injectate, consisting of 0.75 mL of 1% lidocaine and 0.75 mL of 0.25% Bupivacaine, was injected easily at each area. Needles were withdrawn, and the patient was monitored for 15 minutes with no ill effects."

Is an EKG with the reason "pre-op" and on the same day as a procedure always non-billable/bundled no matter what the IR procedure, or is it bundled with only certain procedures?

Patient presented to ER with CP @ 21:19PM; first troponins were negative. Patient left AMI before second troponin results came back. ER staff called patient to return to the hospital. Patient returned next morning at 7:53 with CP, jaw pain, sweating. EKG showed ST elevation V3 and aVF, ST depression V2 and aVL. Patient taken to cath lab emergently. Would 92941 be appropriate in this scenario?

The provider performed intravascular lithotripsy of left superficial femoral artery, left common femoral artery, and left external iliac artery. Do we code C9764 x 2?

I coded this with unlisted code 49999. I am having trouble finding a similar comparable procedure or code. Can you please help? "TECHNIQUE/FINDINGS: Imaging guidance for device/catheter insertion: Fluoroscopy with permanent image storage. Access device: 5 French dilator. Insertion technique: Around the previous existing catheter site for gastrostomy tube the abdomen was prepped and draped in usual sterile fashion. 1% lidocaine was used to anesthetize the soft tissue around the original gastrostomy site. A 10 French dilator was inserted through the tract and used to confirm placement within the stomach. A short Amplatz wire was then placed into the stomach. Next, the inner portion of the gastrostomy site tunnel was scored and aggravated with the 10 French dilator now scored. Pressure was held at the site to achieve hemostasis."

When performing a cemontoplasty, may I report the hydrodissection of nerves as a separate unlisted code, or is it considered part of the main procedure?

If the old implantable cardiac monitor is removed, and the insertion tool is used to form a new channel and insert the new monitor in a slightly different plane (but using the same incision), can codes 33285 and 33286 both be reported? I know previous guidance states if performed via same incision then we only report insertion, but I want to confirm about the "new channel" and "different plane".

"PROCEDURE: Infected cardiac pacemaker lead removal, pulmonary vein isolation, left atrial appendage exclusion. FINDINGS: Two leads fully removed via right atriotomy and opening of the innominate vein + SVC junction. Dr. T of Electrophysiology inspected all parts of the extracted leads. The innominate/SVC was then repaired, and right atrium was closed with suture. (CPT 33243???) // Bilateral pulmonary vein isolation with RFA AtriCure. Left atrial appendage excised and closed. Next, bilateral pulmonary vein isolation with RFA AtriCure was performed with three burns on each side until evidence of transmural lesions. The left atrial appendage was then clamped, resected, and oversewn with 4-0 prolene suture. A small residual appendage remained, however, was felt to be too close to the circumflex artery for further resection." Can PVI RFA and LAA reconstruction can be coded separately? Because EP was there, would this be 93656, or would 33256 be appropriate due to sternotomy? (The add-on codes are not applicable to 33243.) Or, is this bundled into 33243?

We have a new physician who is performing nerve blocks prior to performing an ablation and documents that the medication was injected "for procedural nerve block and postprocedural pain control". My understanding is that if it is for the procedure we CAN'T code it separately because it's considered bundled, but if it's for post-procedural pain we CAN code for it separately. But I usually see this procedure with moderate sedation or under GA, so this whole nerve block thing is throwing me. Do we, or do we not, code separately for the nerve block when performed in the same setting as a percutaneous radiofrequency ablation procedure?

Is 61645 used for both mechanical and aspiration thrombectomy? If not what code do we use for aspiration thrombectomy, unlisted?

On the second day of thrombolysis, the patient is transferred to the suite for a relook angiogram--CPT 37213. Six hours later on the same date of service, the patient is returned to the suite for another relook, without intervention performed. Is CPT 37213 allowed to be billed again?

The patient has peripheral artery stenosis with non-healing wound. May the non-healing wound be coded (ICD-10-CM) as an ulcer?