Ask Dr. Z

During EP with ablation of Afib by pulmonary vein isolation, the physician performs the ablation around Watchman device. "Ablator was positioning on the head. There was a ridge; no flow noted. No thrombus. Ablation was performed and around this tissue. Approximately 15-20 lesions were applied." Would it be report with unlisted code 33999? If yes, what would be a comparable code?

From one of our physicians: Just did a case for a patient with occluded SFA stents. A few of these stents were stent grafts, so I used the Jetstream device to perform thrombectomy. The rest of the SFA had bare metal stents, for which I did atherectomy with Jetstream. In addition to the atherectomy code, would I use 37184 or 37186?

Will you please clarify which code should be used for percutaneous ethanol sclerotherapy of a vascular malformation of the face? There is some confusion between appropriate usage of 61626 (which specifies head/neck) and 37241. No catheter was placed, just an injection of ethanol from a small needle.

Is 37242 correct for geniculate artery embolization for OA tibial plateau?

"Under ultrasound guidance the left common femoral artery was accessed with 21-guage needle. A 4 French exchange dilator and Bentson wire was placed into abdominal aorta. A 5 French SOS-2 catheter was then utilized to select the contralateral, right common and external iliac arteries. Bentson wire advanced into the right superficial femoral artery. Indwelling 5 French sheath was exchanged for 6 French Balkan sheath, and advanced to the level of mid external iliac artery. A 5 French Bentson catheter was inserted over wire into distal right superficial femoral artery. A TrueSelect microcatheter and shapable tip Fathom microwire used to manipulate into a branch arising from the popliteal artery which was the superior lateral geniculate artery The superior lateral geniculate artery was embolized with a temporary embolic agent, Primaxin, to a point of near arterial stasis."

Physician did debulking of the tricuspid valve using Inari FlowTriever using TEE manipulation. Seventeen passes of FlowTriever aspiration. Would I get a catheter placement with 37184, or would this be 93799?

For the following, would codes 36252 and 36245 be correct? "Procedure: selective and non-selective renal artery angiogram and direct stent to ostial proximal segment of the right renal artery. Description: A 4 French sheath was placed in right common femoral artery. A 4 French JR4 diagnostic catheter was used to perform selective and non-selective renal artery angiography. With following findings, the abdominal aorta showed no evidence of abdominal aortic aneurysm. Left renal artery had proximal 30% stenosis, large 4.5 to 5 mm vessel. Right renal artery had an ostial proximal 90% stenosis. A 6 French sheath was exchanged for a 4 French sheath. 70 units/kg of heparin given. ACT was 271. A 55cm JL4 guide and 0.01 Prowater guidewire place distal right renal artery. 5.0 x 14 mm EV3 Paramount mini GPS stent placed ostial proximal segment of right radial artery with approx 2 mm of the proximal edge located inside the abdominal aorta. Stent was deployed, and stenosis went from 90% to 0% with TIMI-3 flow." 

Since there are two different levels, is it okay to report codes 64999 and 64483 together in the following situation?

CT-guided rupture of right L-3-4 synovial cyst (64999) and CT-guided L4-5 nerve block (64483)

Which code would you use for incision and debridement of the infected port pocket? "The port pocket incision and neck dermatotomy site were reopened. Using manual pressure, purulent contents were expressed from the incisions. The pocket was copiously irrigated and anterior antegrade and retrograde fashion using normal saline. The port pocket was debrided. The incisions were packed and were then left open and packed with iodoform gauze." If unlisted, which unlisted code would you suggest and what will be the comparable code for it?

The cardiologist performed a TEE, and his documentation states that he performed color flow, but there's no mention of spectral Doppler. Would you bill 93312-26 and 93325-26, or would you include 93321-26 for the documentation of the regurgitation and wall motion? Study details state: "A complete echo was performed using complete 2D and color flow Doppler. During the study the esophageal view was captured. The probe was inserted by the cardiologist. There was no probe insertion difficulty. Anesthesia performed sedation. Irregularly irregular rhythm was present during the study. The study was limited due to hypoxemia. LV is with normal systolic and diastolic function. The RV has normal size and function. Normal wall motion. LA has normal atrial appendage and no thrombus. Mitral valve is structurally normal, with normal leaf mobility and trace mitral valve regurgitation."

With the new PICC codes, the notes state when catheter tip confirmation is not documented to report code 36573 with a -52 modifier. If we placed a bedside central venous catheter with no documentation of catheter tip confirmation, would you also code 36556 with a -52 modifier? 

New HCPCS code C9780 goes into effect October 1, 2021. Do we assign a regular non-tunneled central line CPT code for physician billing or an unlisted code?

"Doctor removed infusaport, inserted AI pacemaker, angioplasty superior vena cava due to scar tissue. This was cut from the port body. Subsequently a Glidewire was advanced down through the port channel through the right atrium and into the inferior vena cava. Over the Supra core wire a 4.0 x 100 mm angioplasty balloon was used to perform angioplasty of the fibrotic scar bands which restricted passage of the sheath. Stenosis in the superior vena cava in this region of sheath was in excess of 90% though the majority of the superior vena cava likely remained patent."

Is 36590 the correct code for infusaport removal? Is this plus 37248 appropriate to be billed with PM insert?

Are you aware of any bundling issues between 34710 and 34718? Patient had prior aorto-bi-iliac EVAR now with leak and new iliac aneurysm. Physician extends the graft proximally in the aorta and distally in the right iliac, then places an iliac branch device in the left iliac. We have coded as 34710, 34711, 34718. Guidelines say, "Do not report 34718 in conjunction with 34710, 34711 on the same side," so we believe we should be able to bill both if done on different sides. However we get an edit that only 34710 is billable and no modifier is allowed. Do you agree with coding?

How would you code this case? 36221, 36902, 0237T?

"Pre/post op diagnosis: left AV fistula inflow stenosis. Description: The right common femoral artery was accessed using a micropuncture needle. This was exchanged for 5 French sheath using Seldinger technique. A pigtail catheter was advanced into the ascending aorta and arch angiogram was performed. Please see above findings for details. Next the left subclavian artery was selectively catheterized and a left upper extremity angiogram and left upper extremity fistulogram was performed. 5 French short sheath was exchanged for 5 French 90 cm sheath positioned in the left brachial artery. The proximal left brachial artery was subsequently balloon anigoplastied using a 4 x 60 drug coated ranger balloon. Completion angiogram and fistulogram revealed widely patent left radial artery without residual stenosis. Findings: high grade proximal left radial artery stenosis successfully treated with atherectomy and balloon angioplasty."

We understand that 71045 is for a single view, 71046 is for two views, etc., and that it is inappropriate to report 71045 multiple times when another CPT code offers multiple views. However, what about multiple single-view radiology examinations NOT done at the same radiographic session? For example, an inpatient with pneumonia may have multiple chest x-rays on the same day but not at the same session, one at 8:00 am, 12:00 pm, 4:00 pm, and 10:00 pm. If all four studies are interpreted by the same physician, what are the correct codes for billing?

I coded 50389 for the catheter removal. Not sure if 50684 and 74425 are correct for the contrast injection into the double-J stent (ureterogram)?

"Right tube nephrostogram was performed. Then a right ureterogram was performed to determine if the double-J ureteral stent is patent. Following identification of contrast flowing into the urinary bladder via the indwelling double-J ureteral stent, the right nephrostomy tube was removed under direct fluoroscopic visualization to prevent inadvertent retraction of the indwelling ureteral stent. Finding: An antegrade tube nephrostogram demonstrates mild dilatation of the right collecting system with contrast flowing through the double-J stent into the urinary bladder."

Is it appropriate to report 37221-50 when bilateral common iliac kissing stents are placed for 100% occlusion of left side and 30% occlusion of the right? Is there a guideline for treating peripheral arteries based on percentage of stenosis, as there is for dialysis circuits and coronary arteries?

What is the difference between using CPT code 33340 and 93580?

"I advanced a JR4 catheter over a J-wire into the lower portion of the inferior systemic venous baffle and advanced a pigtail catheter retrograde into the body of the left ventricle and left the guidewire in it to act as an additional landmark to guide the direction of the transbaffle. I proceeded with closure of the atrial septal defect to eliminate the possibility of a paradoxical embolus given his transvenous pacer leads and atrial shunt. The Agilis sheath was still across the defect, and based on the size, I chose a 5 mm Amplatzer Septal Occluder. This was carefully prepared and de-aired and advanced through the Agilis sheath. The wire and dilator were removed and the sheath carefully flushed. I advanced the septal occluder through the delivery sheath and using intracardiac echo and fluoroscopic guidance, deployed the distal disk in the pulmonary venous side of the baffle, pulled everything back until there was good tension and then deployed the remainder of the device on the systemic venous side."

Are we still able to charge for the diagnostic procedure, in the event that we find disease that we need to fix? So can we charge 93458 and C9600 when we do them in the same day, or does C9600 include the diagnostic procedure in the code with the angioplasty?

Patient comes in ER with complete heart block, and provider places a temporary transvenous pacemaker that was advanced into the right ventricle using fluoroscopic guidance (33210). The following day, the same provider had to do an implantation of an active fixation temporary pacemaker lead to facilitate ambulation over the weekend, because the primary provider that would perform the permeant pacemaker procedure is not available until the following week. Would I report code 33211 for the dual chamber temporary pacemaker?

From H&P: "Woman with PMHx s/f PAH, pulmonary emboli (PAH thought to be out of proportion, Eliquis) here for PA angiogram." PMH lists CTEPH (chronic thromboembolic pulmonary hypertension) and pulmonary embolism. Cath report states: "Pulmonary artery angioplasty. Right heart catheterization. 60-year-old female with PMH of CTEPH referred for BPA #1. RHC performed with findings (93451). Sheath into right pulmonary artery. Selective angiography (93568). CTEPH treatment: Right lung A9 web lesion and A10 subtotal occlusion. Lesions in A9 subsegmental branch and A10 segmental branch were serially dilated with balloons, restoring flow distally with improved pulmonary venous drainage." How should this be coded: as a pulmonary angioplasty with 92997/92998 (LCD Article A56365 states I27.24 CTEPH is a covered diagnosis) or as thrombectomy with 37184? If patient's have CTEPH, would we code angioplasty because they have stenoses/narrowing of their pulmonary arteries as webs, bands, occlusions form, or would we code as maceration of clot/organized thrombus? (Patient not covered by Medicare.)

If I remember correctly from a seminar it was indicated that if a patient is brought to IR for an embolization for hemorrhage that we are not able to bill for a diagnostic angiogram. Is this correct? Example would be a GI bleed. Patient has had CT angio or endoscopy for diagnosis. Patient is referred to IR for possible embolization. The angiography was performed in multiple arteries to locate the site of hemorrhage with subsequent embolization. Are there any instances that it would be appropriate to charge for both imaging and embolization at the same episode?

I have been told to append a -KX modifier to pacemaker insertions and pacemaker removal/replacements (33206, 33207, 33208, 33227, 33228, 33229) for Medicare patients. In one of your 2021 webinars  you stated that removal/replacements for EOL should have an -SC modifier instead of -KX. I have tried to do this, but now I'm being questioned about it. Can you verify that I should actually be using the -SC modifier for these? Or should I drop it and do as I'm told?

During a venogram of the lower extremity, the catheter placement went as far as the common femoral vein. This was an ipsilateral approach. Is the appropriate catheter placement code 36011 (first order) or 36005 (non-selective)?

For the following would you recommend code 32557 or unlisted code 32999? "Successful fluoroscopically-guided exchange and upsize of left pleural catheters (x2) with the lateral chest tube repositioned into the LEFT lung apex."

For kyphoplasties, do PACS images of balloon usage support 22514, or is this something that should be queried and downgraded if no additional documentation other than cement placement?

The patient comes in with a dual pacemaker at end of life. The decision is made to replace a biventricular pacemaker and add an extra lead. I'm a little confused about how this is coded. Should we use the initial pacemaker insertion/ replacement for these procedures (33206-33208), and is it appropriate to also code the removal of the old pacemaker? We are looking at code 33208 with 33225 vs. 33228/33229. Codes 33228 and 33229 seem like they should be used when a dual or biventricular pacemaker is changed for the same unit.

A provider performed atherectomy in the SFA occlusion using a Jetstream device. He then also performed thrombectomy in the same segment using the same device. The atherectomy and thrombectomy were done almost simultaneously. In this case, can we code separately for the thrombectomy, and if so, would it be coded as primary or secondary?

The IR physician can only code for the catheter placements and angiogram. The infusion of the drug is not billable because it is not treating anything. The neurologist will bill for the WADA testing with code 95958; is that correct? Or if the interventional radiologist injects the anesthetic but does not perform all the testing, should the radiologist report 95958-52?

"Same day return to OR after ax-bi-fem bypass. We reopened the left groin incision first and noted there was no obvious pulse in the graft. We then opened the right groin incision and noted that there was a great deal of redundancy to the graft here. When we opened the incision we were actually able to see that there was a pulse within the graft at this point, and now there was a pulse in the left groin as well. We became concerned that this was possibly a technical issue with the right groin with the redundancy of the graft. We then accessed the left limb and obtained an angiogram, which showed no technical issue within the graft. We then also imaged the inflow, which appeared to be without any issue and brisk flow through the graft, which was patent in its entirety without any evidence of any thrombus. We then turned our attention to revising the right groin redundancy. The graft was transected and spatulated. A portion of it was resected and was re-anastomosed, removing some of the redundancy from the graft."

What's appropriate to code here? 35879, 35883, or 35860?

My question is regarding how to code correctly for Wada testing when done during an embolization procedure for an arteriovenous malformation. Listed under operation performed is "superselective neurophysiological provocative testing (Wada test) and neurophysiological monitoring with EEG and SSEP recordings". The documentation within the report states, "Injected 5 mg of methohexital through the microcatheter over 5 minutes. There were no neurophysiological monitoring changes. This was considered a negative provocative test, and we felt that we were in a safe position for embolization." Does this qualify for billing 95958?

Due old laminectomy changes at L5-S1 there is no posterior epidural space available for injection from an intralaminar approach. Therefore left L5-S1 transforaminal ESI as well as a sacral hiatus approach performed with separate needles and contrast injection followed by injection of dexamethasone with Marcaine.

Can we code 64483/64484? Or only 64483? Please advise.

We have a provider that is performing CT-guided injections of the pars interarticularis defect trigger points. The needle is placed via CT guidance into the posterior aspect of the pars interarticularis defect trigger points. Is this coded as a facet injection or as a TPI?

Can you tell me whether or not the great saphenous vein has to be imaged and documented in order to bill a complete study?

"Removal of infected fem-pop bypass. Creation of ilio-profunda bypass w/cryo-preserved fem artery.Multiple stents were removed from pop artery w/no blood return from above-knee pop to suggest adequate revascularization.Tunnel was created w/end-to-side anastomosis with the segment of cryo-preserved fem artery to the profunda bypass.Graft was tunneled w/end-to-side anastomosis b/w the cryo-preserved fem artery and the above-the knee pop. GSV in upper thigh was harvested for 20cm. End-to-side anastomosis b/w cryo-preserved fem artery and reverse GS. Below knee pop was exposed. Then the vein was tunneled deep in the pop space w/end to side anastomosis b/w below knee pop and reverse GSV." 

Would this be considered a sequential composite graft (ilio-pop with vein) and add-on bypass graft, composite, prosthetic to vein (unlisted 37799, 35681), or would we look to multiple bypass codes? It reads like like multiple bypass grafts "jumping" off from one another.

Would the Impella be coded if RFA sheath was exchanged for Impella CP?

Patient's surgery included aortic valve replacement (mechanical) and left coronary sinus aortic root annuloplasty.

"During the aortic annulus debridement, it was noted that there was gross amount of purulence that was cultured and negative for any bacteria. It was felt that the best course of action would be to patch this left coronary sinus to help strengthen as a result of the chronic inflammatory nature of the native valve, which had been slightly weakened. Therefore a small patch of autologous pericardium was sewn in place as a patch to the left coronary sinus directly below the left coronary ostia to help strengthen the annulus for eventual valve sutures in this area. The valve annulus was then sized with valve specific sizers."

Is there a specific CPT code I should use for the aortic root annuloplasty, or would this be included with code 33405?

Do we append a -25 modifier to an office visit when they do an EKG same day? I am getting conflicting answers on this.

We are a cardiology group. Can you explain the rule on how many diagnosis codes payers want on a claim? I see articles about one of the most common billing errors is too many diagnosis codes being used, then I see articles about making sure we have the complete picture of the patient's health; using acute and chronic diagnosis codes. 

Would you code this with 35141, 35142, or 35226? "Pre- and post-operative diagnosis: Pseudoaneurysm of right femoral bypass graft. Patient with history of of right femoral to tibial bypass graft with cryovein that was done four weeks ago. Patient presented today with acute bleeding episode. CTA confirmed arterial extravasation from the proximal aspect of the bypass graft. Previous groin incision was opened with a scalpel. The subcutaneous tissue was divided with electrocautery. The inguinal ligament was identified. Sharp dissection was used to clear the femoral artery. The bypass graft was palpable and clamped. Pressure was held proximally for control. There was a large defect in the anterior surface of the graft hood with active bleeding. It took several clamps to gain control. The defect was repaired with a running prolene suture. Clamps were removed. Pressure raised, and there was no active bleeding. Wound was irrigated. Tissues were re-approximated in layers. Skin was re-approximated with nylon. A closed suction dressing was placed."

If a patient is brought to IR for pre-op mapping for a liver tumor embolization and they embolize the gastric artery for treatment protection of the stomach, would this be code 37242? The patient has the Y90 embolization of the hepatic arteries five days later.

My docs are doing 3D echos and TEEs. I understand that code 93356 should be reported with 93306 and 93312, but I am confused with the reasons for doing the 3D as opposed to doing the standard tests. I have checked the Medicare website, and it sounds like doing 3D is for pre-op for a procedure such as TAVR, MVR, valve repairs, biopsies, etc.

Would 36902 and 36907 be appropriate to code in this case?

"Patient brought back to the hybrid room and placed in supine position on the table. Right arm prepped and draped in sterile fashion. I accessed the AV fistula. A micropuncture needle and sheath were placed. A fistulogram was performed with retrograde filling into the artery. There was a severe stenosis in the right innominate vein into the SVC associated with the TDC. A stiff angled Glidewire was then brought in, and we brought in a 7 French sheath. The patient was systemically heparinized. I then used a Mustang 12 x 60 millimeter balloon angioplasty, which was performed multiple times. After the angioplasty, a repeat fistulogram showed good flow. At this point in time wires were removed. I used a pursestring 4-0 Monocryl stitch and more pressure. Occlusive dressings were placed. The patient tolerated the procedure well and was transferred to the recovery room."

Does the recommendation remain to bill 93307 if a TTE is performed with only spectral or only color flow and not both?

Our radiologist did an ultrasound breast localization (19285), but the post-images showed the wire wasn't positioned correctly. He then redid the localization, but this time with mammo guidance (19281). Are we able to charge for both?

Patient had PEG tube replaced in the ER (43762). Patient was then sent to Radiology to have PEG tube checked for position or extravasation of air or contrast in the peritoneum. Radiology department is charging code 74190 for this tube confirmation. Should code 49400 be charged as well? We are not sure if the coder should charge code 49400 in addition to code 43762 on the claim. Please advise.

Facility setting, patient presents because G-tube fell out to the ED. IR provider comes to the ED and places new tube bedside with no imaging guidance and orders X-ray to be performed to confirm positioning. Should this be included in the facility E/M or be reported with 43762?

I understand that we would report the implant of a new CRT-D system with 33249 and 33225 after removal of the initial system due to infection on a prior date. Would we still apply the -QO modifier?

My provider is saying I can report code 93452 with this note. I see no edits for billing 93452 and 92928.

However, the coronary arteries were also imaged, therefore I would code 93458, which is bundled with the intervention. There are no indications to support the LV was assessed for monitoring purposes. Should I code the 93452? 

"A diagnostic cath was performed five days prior to this procedure confirming disease. Patient has no new symptoms. Diagnostic images were completed with a JR4 and JL3.5 diagnostic catheter. The JR4 was used to assess the LV, the right coronary artery was not re-imaged given that it was a known chronic total occlusion. Instead of a JL3.5, we actually chose an EBU 3.5 guiding catheter, which gave good imaging although dual ostium were present between the LAD and circumflex. This identified known two-vessel coronary artery disease and a known chronic total occlusion to the right coronary artery with collateralization. Intervention: Stents were placed in the LC and LD."

What would you code for this? 19081 or 19499?

"The calcifications in a segmental distribution at 3:00 axis are visualized on scout image and subsequently targeted using tomography. Through a small dermatotomy, the rotating automated vacuum-assisted biopsy device was advanced to the appropriate coordinates and positioning was confirmed using tomography guidance."

Ultrasound guidance was then used to deploy the biopsy clip. Would this be 76999?