Ask Dr. Z

Is it correct to report codes 36247, 36247-XS for bilateral selective catheterization of prostatic/uterine arteries? As the arterial system is a whole vascular family, we felt that modifier -50 would not be appropriate. Please advise.

During aortic valve replacement (33405), a questionable fistula was repaired. Physician notes the significant aorta to the pulmonary artery defect was repaired by direct technique (suture repair). Would this be reported, and what CPT code would be used? Code 33500 does not seem correct since it was noted as questionable and appears to be an incidental finding. Also, aortic root abscess was noted, and debridement of the aortic valve and root abscess was completed with closure. Would this be included in code 33405 since it was necessary to complete the valve replacement?

The code 75889 falls under the venography CPT rules. I have the below documentation from an IR physician. The actual portion of the pressure measurements within the report, doesn't state the necessity. Doesn't he have to give me more than the below to support?

Pre-procedure diagnosis: Cirrhosis

Post-procedure diagnosis: Same

Indication: Suspected portal hypertension

Additional clinical history: None

Complications: No immediate complications. 

IMPRESSION: Transjugular liver biopsy with 3 x 19-gauge core biopsy samples obtained. The corrected sinusoidal pressure (wedged hepatic vein pressure minus free hepatic vein pressure) is 9 mmHg.

Venography

Vein catheterized: Right hepatic vein

Indication for venography: Document catheter position

Findings: Patent right hepatic vein.  

Pressure measurements

Pressure measurements were obtained via balloon occlusion catheter.

Mean right atrial pressure (mmHg): 7

Mean free hepatic vein pressure (mmHg): 9

Mean wedged hepatic vein pressure (mmHg): 18

Thank you

Is it appropriate to bill for cryoablation of intercostal nerve(s) for the same surgeon that is performing a VATS procedure (or sometimes open thoracotomy procedure)? Per CPT Assistant (November 2019), code 64620 should not be billed because the procedure is to control pain, which is inherent to the global surgical package. Is this correct?

If a procedure started as a VATS but was converted to a mini thoracotomy, this would be coded as the thoracotomy, correct?

What would be the most appropriate CPT code for a CT scan of the salivary gland?

Femoral vein central venous line placement: Under ultrasound guidance, right femoral vein identified as being patent. Right groin prepped in sterile surgical fashion. Cannulated right femoral vein. Using a Seldinger technique, central venous line catheter was advanced. The cath was matured, dressing placed. Physician was queried for location of catheter tip and replied "No clinical reason to identify positioning of a femoral catheter. This is not standard of care." The CPT guideline, in part, states: "To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium.” This guideline also states that central insertion sites are “jugular, subclavian, femoral vein or inferior vena cava catheter entry site.” Is it necessary for the physician/HCP to also document where the catheter terminates when it is inserted via a central vein such as femoral, jugular, subclavian? Thank-you.

For facility coding, the patient had removal of a PCN under fluoroscopic guidance (50389) and in post op experienced leakage of urine from the nephrostomy site. Decision was made to replace. Same DOS, four hours later,  a nephroureteral tube was placed. Would this be coded 50389, 50433, or 50434?

If a synovial cyst is injected with meds, is this still considered an unlisted procedure code, or would this be considered a facet joint injection?

"The needle was then withdrawn into the extraspinal component of the synovial cyst located lateral to the left L4-5 facet joint. The cyst was aspirated and lavaged with preservative-free sterile saline, and then 1 mL dexamethasone was injected into the synovial cyst. The needle was then removed."

If a patient has bilateral PVD and then has a right lower extremity angiogram with a diagnosis of atherosclerosis in the right leg, can I73.9 still be coded in addition to the atherosclerosis code for the PVD in the opposite leg that was not imaged? There is an "Excludes 1" note, but would this be an "unrelated" exception where both codes can be used since there is PVD in one leg and confirmed atherosclerosis in the other?

What is the correct CPT code for a carina ablation?  We have EP providers that perform additional RF lesions after the initial first pass in the region of the posterior right carina, right roof, and anterior carina in close proximity to the course of the phrenic nerve. This is performed before PVI is completed. 

Due to the carina anatomical location we are wondering if the carina ablation qualifies for the use of code 93657. Does the patient still need to be in A-fib in order to charge 93657 for the additional carina ablation? Does the carina ablation need to be in a different location or is it included in the initial PVI ablation code 93656?

"A 4 cm incision was made around the prior incision carried down to the device pocket with device extracted. The capsule was carefully dissected. We then disconnected the single-coil, bipolar, defibrillation lead. The capture threshold was 1.0 V at 0.4 ms. The R wave measured 14.6 mV. The impedance was 456 ohms. The bipolar atrial lead was also tested. Pocket flushed with vancomycin solution. Cardiac synchronization defibrillator was re-attached to the leads and implanted in the preformed pocket. Correct needle, instrument, and sponge counts were reported. The wound was closed in two layers with absorbable sutures. The skin was approximated with staples." 

Is it appropriate to only charge 12032?

Hello!

This is regarding Pro-Fee coding only for which we code services for all doctors involved: Physician inserted a new Trans-venous trans-pulmonary pacemaker with lead at the epicardial left atrium via a trans-artery approach for which I came up with 33206. Problem is that 33206 does not allow for assistants (mod 80) but our physician actually had TWO, only one is documented as being an actual assistant though.

All three physicians are part of the Pediatric Cardiology department.

Dr. A is the primary and gets the 33206.

Dr. B is the documented assistant to the procedure and is also credited specifically with helping with the intracardiac echo.

Dr. C is not listed as an assistant but did come in and "assist" by performing a biplane angiogram with pigtail cath in the left pulmonary artery.

Assuming 33206 is the correct code, is there anything we can code for physicians B and C?

Can you confirm if provider treats the AASV in two separate segments/accesses - should it be 36465 or 36466?

I have a case where the patient has two abscess drains. One is left flank into abdomen. The other is left transgluteal into pelvis. Separate abscess collections. For the left flank drain, they do an absessogram and then an exchange (49423, 75984). The left transgluteal drain, they do an abscessogram and then, based on that, decide to remove the drain (49424, 76080). Normally, it's the same drain and abscess and we code 49423/75984 only, due to the separate procedure rule. However, in this case, do you think it's an exception to the rule and we should code these four CPTs together due to separate procedures, drainage catheters and fluid collections? Thanks for your expertise.

The patient had a CABG, and 14 days after the patient has a subxiphoid pericardial window for symptomatic pericardial effusion with respirophasic variation. Is this still code 33025-78?

Hospice patient with malignant melanoma of RT thigh and inguinal lymph node that has eroded thru skin causing acute blood loss anemia. Taken to the OR for debridement, epinephrine injection, and compression packing. Patient wants intervention if indicated for bleed, but does not want any further oncologic treatments. Two days later, due to continued bleed, transferred to our hospital for angiography and IR intervention. Two feeding branches arising from the RT SFA are selected and embolized with microspheres. We are on the fence with this one, as it is the first time we have encountered a severely bleeding tumor. Should the embolization be coded as 37243 because a tumor is treated; or 37244 because the stated indication is bleeding?

Sudden onset of pulsatile bleeding from rt groin pressure applied rt groin immediately. CT angiogram showed pseudoaneurysm & large hematoma in rt groin. external iliac artery stents. Iliac arteriogram revealed large common femoral patch & patent proximal anastomosis of bypass graft w/o evidence of active extravasation. A stiff Glidewire in aorta & brought over 7 mm balloon into external iliac artery and stent graft portion. Incision was made in the rt groin after staples removed. Immediately a hematoma was evacuated. Opened incision, to femoral artery. This is actually a large dacryon or interposition graft. We followed the graft distally until identified bovine pericardial patch on proximal anastomosis of the bypass graft. Immediately there was pulsatile bleeding from the patch. Proximal & distal control by inflating the balloon to 7 mm & clamping distal bypass graft with a straight PV clamp. This provided adequate control for repair. Two 5-0 Prolene sutures were used to repair bleeding from the patch using figure-of-eight sutures. 

Repair 35860 or 35142?

On 1/1/23, CPT guidelines state, "Do not report 50081/50080 in conjunction with 50433/5434 (when performed on same side)." If the nephrostomy is performed by IVR prior to and on same date of service as PCNL 50081/50080 (performed by urologist in OR), would an unlisted procedure be appropriate to report? (Trying to capture the resources and complexity performed in the Interventional Radiology deparment.) This is for facility coding.

Would you code this with 35355 even though there's no mention of endarterectomy? I am thinking this is more of a repair of CFA with thrombectomy open of EIA. I appreciate your expertise!

"Patient had recent TEVAR and now has thrombus in EIA. Arteriotomy over CFA with control of vessels. Fogarty for thrombectomy retrieved clot in the left EIA. With back bleed we noticed intimal injury on posterior wall of CFA, which we thought was the culprit for thrombosis. This may have been secondary to sheath placement for TEVAR. A bovine patch was brought into the field and placed in standard fashion/ anastomosis. Duplex should injury was not flow liming after patching. The one arteriotomy was closed." 

I have a provider that performed an embolectomy of popliteal/tibia vessels with a vein patch (34203). Would you bill for the vein patch with a 35256 on top of the embolectomy 34203?

"We therefore elected to make an incision down in the distal calf overlying the posterior tibial artery after the gastroc muscle thinned out, identified the posterior tibial artery. It was soft. It was disease free, but was firm and hard with thrombus. Because of the size, we made a longitudinal arteriotomy with an 11 blade and a micro Potts scissors. We then passed a 2 Fogarty embolectomy catheter all the way down into the forefoot and were able to pull out a large amount of fresh and old thrombus. We then passed it proximally up to the popliteal artery and pulled it out and we were able to get good pulsatile flow now. Two more passes yielded no more thrombus. We were pleased with the result. We ossicles on the posterior tibial artery and then we splayed open the small vein that we had used and used that as a patch with 7-0 Prolene suture."

What is the CPT code for selective catheterization of thoracic aortic aneurysm sac via laser atherectomy generated transgraft tract?

"52-year-old female presented with multiple myeloma not having achieved remission.

PROCEDURE DETAILS: The area was marked, prepped, and draped. Local anesthesia was administered.  A 14-gauge radiofrequency ablation probe was advanced into the lesion in the right glenoid.  The lesion was  ablated for 4 minutes.  Subsequently, 8 mL of Omnipaque 240 were administered into the lesion via a 10-gauge Bonopty introducer needle.  4 mL of cement were then administered into the lesion via the introducer. All needles were removed. Images were stored.

DEVICES USED: Ablation Needle - 14 gauge Amica. Access Needle - 10 gauge Bonopty.

ESTIMATED BLOOD LOSS: Minimal.

NUMBER AND TYPE OF REMOVED SPECIMENS: None.

RESULTS: Successful CT-guided right glenoid lesion radiofrequency ablation and cementoplasty."

We are suggesting codes 20982 and 23929 for cementoplasty of the glenoid. Is the cementoplasty included with the RFA or reported separately?

After stent placement from the pulmonary side for treatment of a PDA, the physician elected to place a second stent within the aortic side. Would code selection be 33902 with 33904 or 33902 with 37236 for the aortic portion, or possibly only 33902 since this is a single intervention?

Provider inspected level 5 and level 6 but only removed one node from level 5 as a sample. Is this sufficient enough to report 32674-52? STS and AMA coding book state mediastinal AND regional lymphadenectomy, which would lead us to more than one would be typically removed, but he did inspect the area and deemed it was not necessary.

"A level 5 lymph node was isolated and dissected free using the Ligasure. Level 6 was inspected but no nodes noted. The chest was irrigated and suctioned. The area of surgery was inspected for hemostasis, which was adequate."

Question: Is it appropriate to charge venogram 75827 along with 36581?

"Attention was focused to the malfunctioning dialysis catheter initially, which was partially removed with blunt dissection under local anesthetic over a guide wire. An SVC cavogram was performed through the catheter, which showed only a small fibrin sheath in upper SVC unlikely to cause any issues with flow of catheter during dialysis. Subsequently a new tunneled dialysis catheter was advanced over the guide wire. The 13.5 French dialysis catheter was tunneled under skin over right upper chest and then introduced over the guide wire with the tips positioned in right atrium under fluoroscopy guidance."

Can we report codes 36410 and 76937 for midlines and IVs placed using US guidance by our trained vascular access team on inpatients? Also, can we report 36573 for PICC lines placed by the same team of RNs on inpatients?

Can you please give us a source for not coding the biopsy at the time of an ablation procedure such as renal? It has been mentioned at seminars not to code for the biopsy if the ablation procedure is planned, but there is no edit and clients are questioning.

Would the following be coded as 64640 or 64999? The procedure was performed for severe debilitating pain.

"Two 22 gauge Chiba needles were advanced anterior to the vertebral body at the L2-3 level lateral to the aorta under CT guidance. A total of 10 mL dilute contrast material was then injected and repeat imaging obtained. Next, a total of 10 cc of alcohol were injected in each Chiba needle for a total of 20 cc for a lumbar sympathectomy. The needles were flushed and then removed. Follow-up CT was obtained to identify any complications. Successful needle placement anterior to the L2-3 vertebral body level at the lumbar sympathetic nerve complexes with contrast seen in the region of the nerve complexes crossing the midline. Successful alcohol injection for a lumbar sympathectomy."

Should findings described as "trace", "trivial", or "minimal" be coded from diagnostic imaging reports? Are they clinically significant? Why or why not?

I need your expertise on this case. Our provider performed transesophageal echocardiogram, color flow Doppler, pulse Doppler limited. Our department submitted 93312, 93321, and 93325; however, our second level reviewer recommends 93312,93319, 93321 because 3D was mentioned in the body of the report. I checked the images saved on file and it shows both color flow velocity mapping 93325 and 3D echocardiography imaging 93319 was performed. Per CCI edit 93325 is bundling with 93319 because 93325 is in column 2. However, per parenthetical instruction in CPT manual for 93319 it says "Do not report 93319 in conjunction with 76376, 76377, 93325, 93355." I'm confused on what to report in this case. Should I report 93319 or 93325. Please advise. 

Patient had a PCN in place, which was removed over a guidewire. Then a catheter was advance over the wire, down into the ureter, and out the urostomy. A UDC cath was then placed retrograde over the wire with a pigtail loop formed in the collecting system, and the wire was removed. I want to code 50688/75984 here, but I am wondering if we can also code 50389 for the removal of the PCN?

Looking into possible same day discharges for Watchman patient. Can the patient be discharged same day while still being an inpatient admission? More and more facilities are discharging same day. Please advise if this would affect payment.

What code is used for a barium esophagram performed during a cardiac ablation? 74220?

Provider states that the pre-interventional distal flow is decreased(TIMI 1). Interventional guide catheter was used to successfully engage the vessel. A straight tip pilot 50 was used to cross the lesion. A guidingguidezilla II 7FR guide liner catheter used for additional support. Angioplasty was don with sapphire ballon 1.0x8. multiple infations were performed. maxumum pressure: 20 atm. inflation time: 11 sec. The pos-interventional distal flow is decreased(TIMI 1). He then states that the RCA is 100% stenosed CTO. and was unable to cross the proximal RCA. He did a LHC and coronary angiogram. My question i coded it with 92943-RC and 93458-26-59.My clinic staff are wanting me to amend it with 53 for the professional and 74 for the hospital. My understanding is because he crossed the lesion with the wire it does not need the 53/74.

On balloon assisted embolization of the cerebral AVM would the Scepter Mini balloon be separately coded, provider requested 95999. Left Occipital AVM S-M grade 2, main arterial feeder distal left PCA, aneurysm

Scepter mini balloon was prepped and introduced into the intermediate guide catheter over microwire and placed distal left PCA over microwire. Super selective run from distal left PCA demonstrated good position of the scepter mini, with good visualization of the AVM as well as intravenous gadolinium verses distal arterial aneurysm .3mg Brevital was give, no change in neural monitoring. The balloon was inflated gently underlive fluoroscopic guidance. Next, balloon catheter was prepped with DMSO and subsequently ONYX 18 was injected in under live fluoroscopy guidance to embolize the AVM and the aneurysm, The balloon was deflated and subsequently removed.

With embolization procedures 61624,  would these also be coded with unlisted 95999, comparison code?

Could you please share feedback on billing of IVUS and diagnostic venogram when findings are patent/0% stenosis for the vessel? Should we be billing for both? I have some providers that bill for both with normal findings.

I am coding for a hospital, and we are being told that 0715T is for use for physicians only and not valid for facility billing. Can you confirm whether or not 0715T should be coded for facility when performed in conjunction with the codes listed in the CPT book 92920, 92924, 92928,92933,92937, 92941, 92943, 92975?

I am having trouble coding valve-in valve TAVRs, etc. I was trying to paste the report but too many letters. Procedure: Valve-in-valve transcatheter aortic valve replacement with a #26 Sapien 3 Resilia valve. Is there a good way to get better coding these cases? Does your cardiothoracic book help? My office usually uses CPT 33999, but I do not know why. I tried to post the report but it wasn't letting me.

Real-time visualization of the common femoral artery and vein were identified as the artery was accessed. At this time the Neurosurgery team expose the T10 screw and transected the upper segment of the rod and prepared the screw for removal. Under the protection of a Kumpe catheter a Lunderquist wire was placed into the aortic arch. We upsized to a 16 Fr DrySeal sheath via the left groin. A 28 x 33 mm Gore cuff was advanced to the area where the screw was. Under fluoroscopic visualization the screw was slowly backed out and the stent graft was deployed over the area where was located. The screw was then ultimately removed with no signs of bleeding. We exchanged for a flush catheter and two views demonstrated patent stent graft with no extravasation. Perclose devices were tightened over a stiff wire after the sheath was removed with good pedal pulses. Protamine was given. The remainder of the spine closure was performed by Neurosurgery. 

Would you consider this 37236 or 33881 for the stent graft?

How would you code an LVAD outflow tract occlusion using a combination of embolization coils and vascular plug?

Which code, if any, should we report when a covered stent was used due to uncontrolled bleeding at the access site during TAVR (for pro fee)?

A stent was placed in the severe calcified lesion in the RC. Then another stent was placed in the RC acute marginal branch and was stented across in order to save the main RC and was occluded and the end procedure end. What should be the code if any for the stent placed to occlude the marginal branch? 

The TAVR delivery went smoothly except our cardiologist also did... "The origin of the left main was then cannulated with a moderate degree of difficulty given the cephalad course of the left main and a low coronary height. A BMW guidewire was then advanced to the LAD and a 4 mm stent was advanced to the left main and into the mid LAD. A GuideLiner device was left in place to facilitate stent delivery of a stent in the left main in the event of left main occlusion related to valve deployment." Unfortunately the patient has significant disruption of the femoral artery and needed open repair, which was not done by our cardiologist. Can you please advise if the portion that our cardiologist perform would be considered complex? I know that we cannot bill for the stent, and I am not sure we can bill with the -22 modifier.

We are pretty clear on moderate sedation documentation requirements, but we are a teaching hospital and our attendings are not in the room the entire time. Can a time the resident is there face to face with patient be counted since the resident/fellow is the one performing the procedure under supervision of attending?

Twiddler issue, extracted RA, RV and LV removed and re-implanted the existing CRTD with a new RV lead.

I am thinking 33224 for the LV lead extraction and 33225 for the RV and RA extraction, but I am not finding a code for the removal and re-implanting of the PG and new RV lead?

Is it appropriate to report a -52 modifier when the chest is left open following a heart procedure?

Please clarify if it is acceptable to bill a post-biopsy mammogram 77065 or 77066 unless it is a mammography-guided biopsy as noted in the NCCI Manual. The AHA 1st Qtr 2022 lists an example to illustrate the NCCI guidance, which I think is incorrect but others disagree.

Per AHA answer to Question 1: "It is not appropriate to assign CPT code 77065 following placement of a breast localization device represented by CPT code 19085." "In this case, since the confirming mammogram is not a diagnostic exam, it is not appropriate to additionally assign CPT code 77065."

In regards to repeated imaging studies, the 2023 NCCI Policy Manual (Chapter IX, page 5, C-1) states, “However, if additional films are necessary due to a change in the patient’s condition, separate reporting may be appropriate.” What constitutes a “change in condition”? Can it be any or all of the following: reduction of a fracture, tube reposition, cast placement? 

I'm sure you've answered this question, but unfortunately it seems the information I've shared from your Q&A database doesn't satisfy the provider.

A known thrombus in the SFA is treated with Jetstream catheter, then atherectomy and stent are placed. This is coded with 37227 and 37184.

Meanwhile, secondary thrombus is found in the tibials, and a separate Penumbra catheter is used to treat those vessels to remove thrombus. Provider also wants to code 37186.

CPT guidelines direct coder to NOT report 37184 and 37186 together. The provider disagrees stating that the Penumbra catheter is very expensive to use and should be able to report for the extra work involved.

How would you handle this?