Ask Dr. Z

Which CPT code would you assign for a procedure documented as "Botox trigger point injections in the puborectalis, pubococcygeus, iliococcygeus, coccygeus, and obturator internus muscles"? Some coders recommended 20553 for trigger point injection [three or more muscle(s)]. Other coders suggested 64646 [chemodenervation of trunk muscle(s); 1-5 muscle(s)]. A third group prefers to assign 64999 (unlisted procedure, nervous system).

I would like to know your opinion on which code to use. My other question is, are these muscles that were injected classified under trunk muscles, as the pelvis anatomically is the lower part of the trunk?

What is the proper coding for when bilateral ovarian vein venography, embolization, and left renal vein venography are performed? I have seen this is a grey area, and many publications all have different ways to report these together. The procedure is:

"The left renal vein was selectively catheterized, and venography was performed. The left and right ovarian veins were selectively catheterized. Venography and embolization were performed."

Your book states to use 75833 for bilateral ovarian venography and 75831 for unilateral renal venography. Can you report these two codes together?

I have seen where others say to use 76496 for the bilateral ovarian venography. So what is the proper way to code this?

For complex arterial/venous interventions, sometimes we will floss the patient and externalize the wire through two access sites. For example, body flossing from the right internal jugular vein access to the right common femoral vein access for SVC stent placement. How do you code for the added effort to floss a patient? I've heard some physicians code for foreign body retrieval, but I'm not sure if that's allowable. They are treating the wire as the "foreign body" that's snared from one access through the other.

"TV USG microwave ablation of C-section ectopic pregnancy. Transvaginal ultrasound shows ectopic pregnancy located gestational sac located in the lower uterine segment of  the uterus. Needle seen traversing ectopic pregnancy. Under real-time ultrasound, the ablation was seen to encompass the entire ectopic. An initial burn was performed at 48 sec @ 100 watts. This was followed by a second burn with the needle pulled slightly back for 24 sec @ 100 watts. The needle was withdrawn, and a post ablation ultrasound was performed. Post ablation ultrasound shows small amount of expected bleeding and gas within the endometrial cavity." How would you code this procedure? We are considering CPT code 59899.

The CPT code description for 93623 includes ankle/brachial indices distal posterior tibial and anterior tibial/dorsalis pedis arteries. Do toe pressures count?

Is a cooled radiofrequency neurotomy of three genicular nerves reported with unlisted code 64999, or can I use the new RFA code 64624 for this procedure? "Fluoroscopy was used to identify appropriate entry sites for radiofrequency genicular neurotomy of the superolateral, inferomedial, and the superomedial nerves. Once radiofrequency introducers position was confirmed, motor and sensory stimulation testing was completed. Each nerve was tested first with a radiofrequency probe in place; motor testing was complete @ 2Hx with a range of .1V to 2.5V. Sensory testing @ 50 Hz with maximum of 1.5V was then completed. The radiofrequency probes were placed into the superolateral, inferomedial, and the superomedial nerves, and treatment was initiated at each site with 90 seconds of radiofrequency lesioning completed at 85 C degrees. After lesioning, 40 mg Depo-Medrol was injected through the introducers at each site."

Bilateral common iliac artery was selected, and angiogram was performed during spinal angiogram procedure. The findings were: "This demonstrates no evidence of spinal arterial venous fistula or other vascular malformation. There is appropriate filling through the level of the bifurcation without significant stenosis or luminal irregularities. No significant arteriosclerosis."

Would you report code 75716 for bilateral iliac artery angiogram or 75705, as the intent was to check spinal fistula?

Can you bill code G2170 with ultrasound guidance code 76937?

Is it medically necessary to code an abdominal aortogram (75625) or non-selective iliac and/or femoral angiogram (G0278) at the time of a heart cath to assess for possible hemodynamic support?

If a radiologist starts an IV for another service (not for a with contrast exam), is it billable by the radiologist? Example: A patient needs IV access for chemo. We understand the IV is included in the service of chemo administration for the provider billing for the chemo, but is it also included if the radiologist is consulted to place the IV and not the provider performing the other service the IV is included in?

"The abdomen was prepped and draped in the usual sterile fashion. The skin was anesthetized with lidocaine anticipation of removal of the Pleurx catheter. Pre-procedure imaging demonstrated large loculated collection extending from the abdomen into the hernia sac with the Pleurx catheter coursing through it. We then connected the Pleurx catheter to the Vacutainer bottle, and there was removal of fluid. I then placed pressure over both the hernia sac and adjacent abdomen was able to evacuate 200 mL of ascites. Repeat ultrasound demonstrated complete collapse of the hernia sac and no residual significant fluid within the hernia sac or adjacent abdomen. We also performed ultrasound of all 4 quadrants demonstrated no other additional pockets of fluid. The catheter was retracted, and the patient was transferred to the recovery area." What code would you recommend (49083-52)?

Patient has excessive uterine bleeding, anemia, and pulmonary embolism. She has two left uterine arteries. She had successful embolization of one left uterine artery along with diagnostic angiography during first procedure, and then the procedure was terminated due to radiation dose limits. She came back two days later and had the other left uterine artery, as well as the right uterine artery, embolized. On both days the physician states "successful embolization". My question is, should I only bill the diagnostic angiography for day one and one embolization on day two since this involves one surgical field? I've never had a case where embolization of one surgical field was done over multiple days. Any guidance would be appreciated. 

Can IVUS (37252, 37253) be billed when both the central and peripheral segments are accessed, or is only one code allowed per dialysis circuit?

Can you tell me if I can bill code 33477 (pulmonary valve implant) with 33745 (shunt creation by stent placement for congenital cardiac anomalies)?

"We performed a diagnostic cerebral angiogram showing an 8 mm aneurysm of the left A2/3 junction, which was coiled. The follow-up imaging showed acute thrombus in the left middle cerebral artery. Thrombectomy was performed."  

The physician wants to charge 61645. I'm thinking we can charge 61624 for the embolization and 61645 for the thrombectomy. Would you agree? If we can charge both, what about the selective catheterizations (36223-RT, 36224-LT, 36226-RT) and imaging (75894, 75898)? They selected the right common, left internal carotid, and the right vertebral.

I know with 61624 we charge separately, but with 61645 all is bundled. Would modifiers be appropriate in this situation?

Can you report codes 33745 and 33477 together?

"Transection of radial artery due to traumatic glass window injury. Decision made to perform an interposition bypass. A small incision was made in the proximal forearm; branch of the cephalic vein dissected free and harvested. The radial artery was spatulated, the cephalic vein was spatulated, and end-to-end anastomosis performed using 6-0 Prolene. The clamp was then moved onto the bypass. The distal radial artery was interrogated with a 2 Fogarty to ensure no thrombus, spatulated, and an end-to-end anastomosis was performed from the cephalic vein to the radial artery with 6-0 Prolene. Clamps released, suture was tied down, and hemostasis was achieved. A palpable radial pulse was present, and a Doppler signal was present in the superficial and deep palmar arches."  There is no code for radial-radial BPG. Would you use code 35523?

"The capsule was incised and the generator removed from the pocket.  The leads were visually inspected and found to be free of any  obvious defects. The pace/sense characteristics of the leads  were found to be functioning normally. The generator pocket was  relocated with extension deeper towards the pectoralis fascia and  more superiorly due to the superficial nature of the original  generator pocket and risk for skin erosion. The pocket was  flushed with Gentamicin irrigation solution. The generator was  connected to the leads and implanted in the pocket. The  connections were tested and found to be functioning  satisfactorily. The pocket was closed in layers using 2-0, 3-0, and 4-0 absorbable suture." I would only code for this replacement of pulse generator. Should pacemaker pocket relocation be also coded since deeper toward the pectoralis fascia and there was a risk of skin erosion? Or there needs to be active erosion and deeper toward subpectoralis instead of pectoralis in order to code relocation?

Should you report 0439T if contrast is only to enhance imaging and not for assessment of viability?

Based on appendix E in the CPT book, 36573 is NOT exempt from modifier -51. But based on Supercoder and Medassets you can't use -51 on 36573. Can you please clarify if it can or can not be used for 2021?

I need some guidance on coding this case. My understanding was it is part of 20550/20551. I am being directed to use 27299 for the needling part.

"Under ultrasound guidance, a 20 gauge spinal needle was advanced into the left gluteus minimus tendon. Needling/tenotomy of the tendon was performed with simultaneous administration of 1% lidocaine solution. Subsequently a solution containing 1 mL (40mg/mL) Depo-Medrol and 4 mL 1% preservative-free lidocaine was injected into the greater trochanteric bursa. The needle was removed and hemostasis achieved."

Would you agree with 37242 for this procedure? "Patient has a post-traumatic right forehead pseudoanurysm. With direct ultrasound guidance, a 23 gauge needle was passed into the pseudoaneurysm, and 0.5 mL of thrombin was then injected. There was immediate, complete thrombosis of the pseudoaneurysm. Successful percutaneous thrombin injection for treatment of an enlarging right superficial temporal artery pseudoaneurysm."

We were wondering from a coding aspect if you would treat LBB leads for left bundle branch pacing any differently than Bundle of His leads? Our facility is leaning towards following the AHA HCPCS guidance from 2019 and using the unlisted codes for the BOH, but since that guidance does not specifically address the LBB leads they are wanting to code them differently:

We have a patient who received a PM insertion with three leads: an RA, an RV, and a BOH lead. They are wanting us to utilize 33999 to encompass the entire procedure (both 33208 + 33225).

However if the same patient receives a PM insertion with three leads: an RA, an RV, and a LBB lead, they are wanting us to bill 33208 and 33999 and map the 33999 back to the 33225 code only.

On the professional side, we have concerns with coding them differently, as we are not seeing a difference in their purpose: both the BOH and LBB leads are replacing the use of the a traditional LV lead. We already have concerns with denials, as we know that MA Products are not going to pay for unlisted codes. What are your recommendations?

I have a case where the patient previously had a Watchman device placed but now has a peri-device leak and they are going in with an Amplatzer vascular plug for closure of the leak. Per reading in your 2020 Diagnostic & Interventional CV coding book on pages 197-198 it looks like the direction is to code 33340 again unless it's the LARIAT II and you state to use 33999-GZ. Am I reading this correctly? Should we be using 33340 for the plug via transseptal approach?

For the following, would 36832 and 36833-XU be correct? "Suffering from Steel syndrome. Incision made and band removed from the AV fistula. There was a thrombus between the arterial anastomosis and the start of banding. Cephalic vein was transected. The stump toward the brachial artery was oversewn. Alpha vein which was the cephalic was treated with thrombectomy by balloon. Clamp placed on cephalic vein. Incision made in the right axilla. Dissection allowed the axillary artery to be mobilized and vessel loops placed for proximal and distal control. Plan was to create proximalization of arterial inflow so inflow would come off the axillary artery. PTFE graft was tunneled along the medial aspect of the arm. Anastomosis was created between the axillary artery and the PTFE graft. At the antecubital fossa the detached cephalic vein was sutured in an end-to-end anastomosis with a portion of the graft. There was strong palpable thrill and audible bruit."  

We had a patient who had right carotid bifurcation stenting with DEP (37215-RT) and then went on to have an anterior communicating aneurysm coiled. Since the stent catheter placement is bundled, can we capture a catheter placement for the embolization? (It appears that there was not a separate access site.)

The provider does bilateral ilio femoral angiogram with catheter placement in distal aorta from left femoral access and then selects right femoral for complete right lower extremity angiogram. Is it 75710-RT? How do we bill for left ilio femoral angiogram? Provider has findings for bilateral ilio femoral arteries and right tibial, peroneal arteries.

New to coding this and trying to understand angiography 36222-36228. Understanding is that we code as far as the cath tip goes. Is there enough info to code 36224 per this per the findings vs. the proc section?

"CEREBRAL ANGIOGRAM: Injection of the left common carotid artery with imaging centered over the head. PROCEDURE: Right common femoral artery was accessed. Catheter was advanced over the angled Glidewire and used to selectively catheterize and inject the left common carotid artery artery. Two-dimensional digital subtraction angiograms of the head were obtained in multiple projections. FINDINGS: Device is in excellent position extending from cavernous to supraclinoid left internal carotid artery left internal carotid is widely patent. The left anterior cerebral artery and the left middle cerebral artery are widely patent. The left external carotid is patent with persistent opacification of a right parasagittal tumor stain via the enlarge left middle meningeal artery."

Our facility radiologist in 2020 performed... "CT fluoroscopic guidance, a 17 gauge trocar needle was advanced from the percutaneous entry site through the lung and was positioned just superficial to the nodule. In a coaxial fashion, 4 x 18g core specimens were obtained. The specimen were placed in formalin and transported to the pathology department for evaluation. Samples was also submitted for flow cytometry. Through the introducer trocar, a fiducial marker was placed along the posterior aspect of the mass. The needles were removed, and a sterile Vaseline gauze dressing was applied."  IR wants to use 77012 (CT/fluoro guidance biopsy), but I'm looking at 77014 (CT guidance fiducial). Can one or both be used?

Can you use 33745 for stent placement in a vein for treatment of severe SVC stenosis in pediatric patient?

I have a lot of physicians using IVUS during their lower extremity procedures. My question is when they use IVUS in the SFA, anterior tibial artery, and posterior tibial artery, do I report code 37252 for the SFA and 37253 x 2 for the AT and PT vessels?

Would the correct codes for this case be 51102, 76942, and 77002? "PROCEDURE: With the patient placed supine on the angiography table, ultrasound was utilized to identify the urinary bladder. This scan in the immediate suprapubic region was anesthetized with 1% lidocaine. Deeper anesthesia with a spinal needle was utilized. Using ultrasound guidance, a 5 French Yueh catheter was introduced into the urinary bladder, and a 0.035 Amplatz guidewire was advanced. Several dilators were then utilized, followed by placement of a 14 French pigtail multipurpose catheter, which was formed within the urinary bladder. Small amount of contrast was injected, confirming location of the pigtail catheter within the urinary bladder. Catheter was secured to the skin using 2-0 Prolene suture. Patient tolerated the procedure well without immediate complications. Conscious sedation using intravenous Versed and fentanyl was provided under direct physician supervision for 30 minutes. Total fluoroscopy time 0.9 minutes." 

Would C9764-C9767 be coded as 3722X on the professional fee side?

If the patient already has an ASD, and the pulmonary vein stent protrudes into the atrium at the veno-atrial junction, can we report code 33745? Are all pulmonary vein stent placements reported with 33745/33746? Also, does a PDA stent qualify as an intracardiac shunt creation (33745)?

"For this patient, a dual chamber ICD generator was replaced with a CRT-ICD generator. Original RA and RV leads were kept, and a third lead was added, placed on the anterolateral RV free wall, and plugged into the LV port of the generator. Lead placement in the coronary sinus/LV was not attempted."  How should this be coded? I’m guessing 33241 and 33249, since no lead was placed in the cardiac venous system, but I would appreciate your input.

I am having issues with code 33508 when billed 33517-33521 for the vein graft. Code 33508 is denying due to 33533 being billed for the artery. For 2021 should 33508 be billed with a modifier, and if so which one? Please provide some guidance.

Physician did a multiple-vessel (R & L) PE thrombectomy for a patient with commercial insurance. Can the physician code separately for the two distinct vascular families? 37184 in the RPA, 37185 in the right upper lobe, 37185 in the right lower lobe. Then code 37184 on a separate lesion in the LPA, 37185 on the left upper lobe and 37185 on the left lower lobe. Is it appropriate to code 36015 for selective cath placement in each of the segmental pulmonary branches, 75743 for each selective diagnostic CTA, and 99152 for moderate sedation?

What is the appropriate CPT code for a sternal clavicular joint exam that is two views only (oblique and PA)? We are currently reporting 71130; however, that code is for a minimum of three views. Code 71120 is for the sternum (not the joints).

For 2021 E&M, should the providers document the risk in their office note now?

In 2018 you answered that you would report a stent in the LVAD graft with unlisted code 33999. So for reimbursement purposes, what CPT would you compare that to? I need to submit, so that we can create a .dot code to the 33999, and I am unsure what this needs to be based off. 

"There was redundancy of P2 with ruptured cords. Ruptured cords were excised. The mitral valve was repaired as follows 2 sets of Gore-Tex neo-cords were placed to the P2 segment and the posterior prolapse was reduced and the valve was tested and was competent. There was a small leak between P1 and P2 which was closed with a 4-0 Cardionyl suture in a mattress fashion. Then we placed a 36 mm Cosgrove annuloplasty ring with 2-0 interrupted Tycron sutures and the Cor -knot device. The valve was then tested and it was competent and the cortex Neo-Chord for type II proper left. A folding plasty of the P2 segment was then performed using a 4-0 Cardionyl suture to reduce the height of the posterior leaflet." Would this be coded as 33427 or 0543T? Does 0543T include the ring if used? Or, does the "radical reconstruction" cover the artificial chordae placement?

In the past we have used code 37236 for a stent placement in the pulmonary artery for congenital cardiac treatments. Would 33745 be the appropriate code to use now?

Patient came in for calf mass excision, and vascular surgeon was called in to assist. Vascular surgeon harvested saphenous vein graft, then the vein was non-reversed in order to keep proper orientation for the venous reconstruction. An end-to-end venous anastomosis was created using a running 6-0 Prolente suture distally. The vein was then pressurized by releasing the distal control. MD then replaced and bulldog clamp on the saphenous vein segment. Then MD sewed end-to-end venovenous anastomosis with a running 6-0 Prolene suture. Following this, the proximal and distal clamps were removed. The right greater saphenous vein harvest site was irrigated with warm saline solution."

Should we go with unlisted because we can't find another code that would describe such procedure?

I have a diagnosis question. In your case of the month for October 31, 2018, type II endoleak is coded to other specified complication of vascular graft. However, in 3rd Quarter Coding Clinic 2020, pages 3-5, type II endoleak is coded to I97.89 (other postprocedural complications of circulatory system). Can you explain which is the correct coding for type II endoleak?

This is the only documentation for Doppler during a stress echo:

Doppler Measurements & Calculations

MV Peak E Wave: 0.6 m/s

MV Peak A Wave: 0.44 m/s

MV Peak Gradient 1.46 mmHg

TR Velocity: 2.34 m/s

MV Deceleration Time: 220.8 msec

TR Gradient: 21.93 mmHg

Is this enough to indicate spectral and color flow velocity were done?

If a report documents the abnormality was approached from the craniocaudal aspect using an upright digital tomographic mammography unit, and a biopsy needle was placed adjacent to the abnormality under computer guidance, and confirmatory stereotactic mammography images were obtained to document needle placement, would the post mammography imaging still be billable? Would the tomographic mammography be considered the same as stereotactic mammography biopsy?

If a physician performs the reprogramming and refill of an implanted pump (62370) under ultrasound or fluoroscopy guidance (used to locate the reservoir fill port on the implantable pump), are we able to separately report the guidance? If the guidance can be separately reported, which code would be appropriate for ultrasound guidance (76942)? Or for fluoroscopy guidance (77002)?

We know that a gastrostomy tube insertion without the use of fluoroscopy should be coded with an unlisted CPT. Would it be more appropriate to use code 49999, Unlisted procedure, abdomen, peritoneum and omentum, or code 43999, Unlisted procedure, stomach? The CPT code book classifies a percutaneous G-tube insertion within the Abdomen, Peritoneum, and Omentum section.

We have a patient who has pancreatic cancer. Patient is here for CT-guided celiac nerve block followed by celiac neurolysis with alcohol. Can we code both 64680 and 64530? Previous advice from 2016 said to only code 64680. Is this advice still correct for 2021?

"Patient was brought to the cath lab. He was draped and prepped in sterile fashion. A micropuncture needle was advanced from the subcostal approach. Pericardial cavity was reached. Straw-colored fluid was drained through the micropuncture needle, then a micropuncture wire was advanced and a micropuncture sheath was introduced into the pericardial cavity. A J-wire was advanced through the micropuncture sheath, and a pericardial drainage catheter was placed in the pericardial cavity. Around 450 cc of fluid was drained from the pericardial cavity. Afterwards, the drain was left in place and sutured." In this case can I report code 33016 (pericardiocentesis with image guidance) along with 33017 since the physician left the drain in place? Or does 33017 include the work for 33016?