Ask Dr. Z

Can we bill CPT code 37252 in the cases where the Pioneer Re-entry Device is used for guidance? Example of case below:

"Multiple wires were used to try to traverse from the false lumen into the true lumen at the level of the distal SFA which were unsuccessful thus the decision was made to proceed with Pioneer re-entry device. A 0.014 grand slam was advanced & doubled over into the false lumen at the level of the distal SFA. Then the Pioneer re-entry device which utilized intravascular ultrasound guidance (IVUS) was advanced to the level of the distal SFA. Utilizing intravascular ultrasound imaging the Pioneer catheter was used to target the true lumen from the false lumen. After successful recanalization & re-entry into the true lumen of the distal SFA with the Pioneer device, popliteal angiogram was performed to confirm positioning within the true lumen."

What CPT code can be used for percutaneous paravalvular leak repair of a pulmonary/Melody valve?

What would you code for a TIPS stent removal? Would this be reported with unlisted code 37799 or revision code 37183?

"Technically successful removal of TIPS stents (thought to be 2 Viatorrs and 1 VBX), which had fistulized to bowel, using a loop snare technique with a wire passing through the uncovered portions and going around the covered portions."

The patient has a diagnosis of menorrhagia and heavy uterine bleeding. Patient has had extensive work-up done with no cause found for the heavy bleeding. Patient was not interested in a hysterectomy, so the IR physician proceeded with uterine artery embolization. What is the correct embolization CPT code for this case when the cause of the bleeding is unknown?

When billing for the removal of a nephrostomy catheter and a nephrostogram, done by the same provider, what are the correct CPT codes? Can you also bill for the injection?

Left ventricular pseudoaneurysm non-congenital. Would you code this as 93799 for both HB and ProFee?

"The catheter was advanced into the left ventricle pressures were recorded.A LT ventriculogram was then performed.An 8 French guide liner was then advanced over this wire to the ostium of the pseudoaneurysm.A 2.0 mm x 15 mm coronary balloon was then advanced over this wire to the ostium of the pseudoaneurysm.Using the wire and the balloon at the support the telescope was advanced into the sac of the pseudoaneurysm without any difficulty.Angiographically and under TEE its position was confirmed.A 6 mm Amplatz to vascular plug was prepared and introduced into the guide catheter and eventually into the 8 French guide liner into the sac.It was deployed using standard technique with the distal disc and the body and the track and the proximal disc just at the ostium of the defect.TEE and angiography the device was released and found to be in a stable position. Prompt in situ thrombosis of the aneurysm sac was noted."

Our question is how to correctly code the approximately two-hour aborted procedure done on 5/21/25?

93619 or 93653-74/53 or?

92960, +93662 procedures actually done and reportable?

Pt was brought back to the lab 5/27/25 and had a successful ablation.

Procedures done:

-External cardioversion

-CARTO/SOUND Intracardiac 3 dimensional mapping

-Intracardiac echocardiogram

-Ultrasound-guided venous access

-4 Perclose device closures for venous hemostasis

Conclusions

1. SVT procedure aborted because of patient having incessant atrial fibrillation and flutter

What does a physician report for this study? Do we report 0042T?  Is anything reported for rapid LVO?

"Exam type: CT perfusion analysis.

Technique: Dynamic contrast enhanced CT perfusion study of the brain was performed. RAPID software was used for postprocessing. CT angiogram was post processed using RAPID LVA detection to include quantitative measurements of cerebral blood flow and automated results in location to be stroke and/or neural interventional team.

FINDINGS:

1. CBF < 30% volume: 0 mL
2. Perfusion (Tmax >6 seconds) volume: 16 mL
3. Perfusion (Tmax >10 seconds) volume: 0 mL
4. Mismatch volume: 16 mL
5. Mismatch ratio: n/a

INFARCT LOCATION: None identified.

IMPRESSION: These findings indicate no evidence of cortical infarction or significantly decreased blood flow."

Are there specific documentation requirements for coding a CTP?

If the angiograms necessary to complete the intervention are bundled, would their selective catheter codes be as well? For example, prior conventional angiograms done, and day of intervention they repeat to rule out which vessels to embolize or not to embolize. Would the angiogram selective catheter codes bundle (since their angiogram codes bundle) and then you only report the selective codes that apply to where an intervention was done? Like doing a six-vessel head (36224-50, 36226-50, 36227-50 repeated) to embolize a known aneurysm. Would you just code one 36217 for the interventional selective, or would you also code all the selective codes for the repeat bundled angiograms?

PB Billing.

"Patient placed on table with right arm abducted. Limited US of right arm and upper chest to choose site for venous access and confirm integrity and thrombosis of right subclavian vein. Brachial vein chosen and vein punctured... wire to axillary vein. Sheath and catheter passed beyond subclavian vein to atrium. Right subclavian venography/findings...then intervention. Chemical thrombolysis and aspiration via AngioJet cath to subclavian... tPA injected by power pulse, 15 min. dwell, then aspiration for few cycles. Venography.....still thrombus...procedure repeated. Venography done... still stenotic subclavian vein... venoplasty of subclavian vein done. Successful mechanical chemical thrombolysis and aspiration of right subclavian vein and venoplasty. Catheter removed."

Are codes 37187, 37248, 36010, and 75820 correct?

For professional coding, what is the correct CPT charge for this area stated where biopsy was performed?

"TECHNIQUE: Informed consent was obtained. Patient placed on the CT scanner in the left side down decubitus position. 3 mm axial images were obtained through the lower chest/upper abdomen without oral or IV contrast. Using CT guidance, preferred skin entry site was marked, prepped, and draped in sterile fashion. Generous local anesthetic was administered. Using CT guidance, 19 gauge trocar needle advanced into paramedian nodule left diaphragmatic crus. Multiple core specimens were obtained with a 20 gauge spring biopsy needle. Both needles removed. Post biopsy scanning show no acute hematoma or pneumothorax. Patient tolerated the procedure well without immediate complication."

Are codes 36247, 36140, 75625, and 75716 all reportable?

"Procedures performed: aortoiliac angiography with bilateral runoff and selective bilateral lower extremity angiography.

Description: Abdominal aortogram with bilateral iliac runoff was performed via injection into a flush catheter. The catheter was withdrawn to the distal abdomen aorta where a bilateral iliac runoff was performed. Injection of the site was also utilized to perform left lower extremity angiogram, which was suboptimal below the mid tibial segment. Right lower extremity angiogram was performed via injection into the right common femoral artery. Procedure was completed, and all catheters were removed."

In 2026 AMA will update the FFR language to include non-pharmaceutical induced stress; however, in the interim would the use of contrast to induce stress meet the requirements to report the FFR? Clinically it's believed that contrast is a drug and would meet the coding requirement.

If previously implanted flow restrictors were retrieved from left and right pulmonary arteries by snare technique, can we report code 37197-50 along with the catheter placement? 

Can provider report codes 93016, 93018, 78452-26, A9502, and J2785 if cardiac stress test with myocardial perfusion testing is performed in the hospital setting, or can only codes 93016, 93018, and 78452 be billed by provider?

Would you consider the RPAV a recognized branch in the RCA? It's not listed in CPT Assistant as a recognized branch so we wanted to get your opinion.

Am I able to bill 93454 or 93458 with 0913T or 0914T?I find conflicting information on this, so looking for some clarity.

Is Rotarex atherectomy performed of occluded iliac stents (0238T) billable, or this only billable when performed on the native vessel?

"At this point we turned our attention to the left groin and accessed the CFA with micropuncture kit and ultrasound, placed a PerClose, and then placed an 8 French sheath into the left external iliac artery. Heparin was given. Using a Bernstein catheter and stiff 035 wire, we were able to cross both occluded iliac arteries. We used IVUS to size vessels (common and external iliacs, bilateral) and confirm that we remained inside each common iliac stent. Next, after upsizing both sheaths to longer 8 French sheaths, over an 018 wire, we performed rotorex atheterectomy of the occluded left iliac stent followed by the right. We then performed 8 mm POBA followed by placement of new kissing 8 x 79 mm VBX stents in bilateral common iliac arteries, extending each 15 mm cephalad and 5mm caudad from prior stents."

I have an EP provider who wants to report code 37248 when they perform Dotter dilation during a pacemaker or ICD lead insertion. Here is an example of the documentation: "I was able to visualize a fair caliber right internal jugular vein. Using Seldinger technique, I was able to access this vein and place a 0.038 guidewire. The guidewire would not fully advance down into the SVC. I exchanged this for a catheter, and right internal jugular venogram did demonstrate a high-grade stenotic occlusion. Using the 501J catheter and a 0.038 guidewire, I was able to manipulate across this high-grade stenosis. Using Dotter dilation, I was able to advance up to a long #10 French introducer sheath to achieve access to the right heart. Through the #10 French sheath, I then placed the right ventricular lead." My understanding is that the Dotter dilation creates a small channel for the lead, and this would not be coded separately. The provider disagrees and wants this coded as a venoplasty with 37248.

"Subsequently, a Glidewire was passed through the 8 French MP sheath to the left vertebral vein. This was confirmed with contrast injection. A 7 French multipurpose catheter was advanced over the wire, which was removed and exchanged for a 6 French Inquiry decapolar catheter. Sedation was then delivered with dexmedetomidine to minimize discomfort. Stimulation was delivered to the left vertebral vein at 20 Hz for 10 minutes. One PVC was elicited during stimulation but was greatly obscured by noise from the stimulus and was unsuitable for mapping." 

Do we bill for catheterization of vertebral vein during the PVC ablation? If yes, is code 36012 billable?

Does code 0644T require intraoperative reinfusion of aspirated blood to be performed to capture the complete code? And would modifier -52/-53 be required with aborted procedure in this context?

37184 + 0664T? With or with out modifiers?

Example: 

"Over an amplatz wire, Triever24 was advanced into the interlobar right pulmonary artery, and mechanical aspiration was performed. The Triever24 was then pulled back to the right main pulmonary artery and additional aspiration performed. Trevogram was obtained to assess clot burden. The Mariner catheter and Glide Advantage wire were used to select the TA and aspiration thrombectomy performed.

The Mariner cath and glide wire were used to access the LT main pulmonary artery. The wire was exchanged for Amplatz wire and Triever24 was advanced into the LT main pulmonary artery. During the procedure, patient oxygen slowly drifted down requiring additional oxygen and mask support. At this point the surgery was aborted."

NCCI requires a modifier on 76705. Would it be appropriate? Reason: R74.8, Z94.4

Pancreas: Not well visualized.

Liver: Heterogeneous coarse parenchymal echotexture with mild surface nodularity. Within the left hepatic lobe is an echogenic observation measuring 2.5 x 0.9 x 0.9 cm not seen on prior imaging. This finding appears to be adjacent to fat within the fissure.

Biliary: No biliary dilation. Common duct at the porta hepatis measures 0.6 cm.

Gallbladder: Cholecystectomy

Vascular: Color Doppler and spectral analysis were performed. The following vessels are patent with antegrade flow: main, right and left portal veins; left, middle and right hepatic veins; inferior vena cava; proper hepatic artery. Hepatic arterial resistive indices measure 0.57-0.58.

Spleen: 21.3 cm (previously 22.5 cm). Resolving known splenic infarct measuring 7.4 x 6.4 x 10.3 cm.

Other findings: Adjacent to the left hepatic lobe, there are small fluid collections, measuring 4.6 x 1.1 x 2.6 cm and 1.3 x 0.3 cm

I have researched your response on this. Our doctor doesn't agree with the RVU attachment with comparable code 37226-22. I have done other research and was given the advice to add 36247+75710+37236+76937 together for the RVUs. What are your thoughts?

What is the correct CPT code for MRI stereotactic guidance in preparation for surgery?

If provider documents drug-eluting balloon in the left main and also in the left anterior descending, do we report codes 0913T-LM and 0913T-LD?

With the concomitant LAAO + Afib ablation, does the same physician have to do both procedures to qualify for DRG 317, or does it just have to be done together? How do the RVUs work if done by two different physicians? Do they still get 33340 = 14 and 93656 = 17? We are looking into having our EP physician do the Afib ablation part and then having our structural physician do the LAAO.

Would the following be reported with code 50387, or should we report codes 50389 and 53899?

"Patient is status post cystectomy and ileal conduit and had antegrade NUC catheter placed a month ago. They now present for conversion of this to a retrograde trans-stomal NUC. Patient was placed in right lateral decubitus position with the left side up. A scout image was obtained, and contrast was injected through the existing catheter showing adequate position of the LEFT NUC pigtails in the renal pelvis and conduit. The catheter was cut to release the pigtail. Glidewire was inserted through the existing nephroureteral catheter and positioned in the bladder under fluoroscopic guidance. The tube was then removed over the wire, and a sheath was placed. A LEFT antegrade nephrostogram was performed. The Glidewire was then advanced out of the stoma in his right lower quadrant. A new nephroureteral catheter was advanced over the wire retrograde via the stoma under fluoroscopic guidance. The pigtail was coiled in the renal pelvis, and the proximal hub exited the stoma into the ostomy bag."

The images ran consecutively from 0921 – 0934, renal arterial and venous flow, followed by 0935 – 1015 for mesenteric arterial flow. They consistently report 93975 X two units. As the mesenteric study does not include and venous outflow information, should we report this as one unit 93975 for the renal study and one unit of 93976 for the mesenteric study? Or since the imaging is back-to-back organs of the abdomen, is it one unit 93976 because there are no mesenteric venous outflow results?

We sometimes receive a referral for an ultrasound where the referral reason does not substantiate medical necessity (i.e., "pain" and nothing else). Is the ultrasound technologist allowed to clarify with the patient why they are here for this test, and to put that information onto the preliminary report in a way that we can use for more precise diagnosis coding? In other words, can they ask the patient why they are receiving this exam or where the pain is, in this example, and document that on the preliminary report so that this could be used for diagnosis coding if nothing if found? One of the ultrasound techs stated it "is fraud" for them to document the patient reason for exam. The ASRT scope of practice guidelines do not back this up. I think she is concerned with somehow changing the referral reason? 

How would an ultrasound-guided biopsy of a reconstructed breast be coded? Is this considered breast tissue, or would we use codes 20206 and 76942?

INDICATION: HISTORY OF BILATERAL MASTECTOMIES FOR LEFT BREAST CANCER IN 2022. NOW WITH REGION OF PALPABLE CONCERN IN THE RECONSTRUCTED LEFT BREAST. THE BREAST WAS STERILELY PREPPED AND DRAPED AND LOCAL ANESTHESIA WAS PRODUCED WITH 7 ML 1% BUFFERED LIDOCAINE. UNDER ULTRASOUND GUIDANCE, A 13 GAUGE TROCHAR WAS ADVANCED TO THE LESION AND A 14 GAUGE SPRING-LOADED BIOPSY NEEDLE WAS USED TO OBTAIN 4 CORE SAMPLES THROUGH THE LARGER OF THE HYPOECHOIC OVAL MASSES LOCATED AT 10:00, 3 CM FROM THE NIPPLE IN THE LEFT BREAST. TISSUE CORES WERE PLACED IN FORMALIN AND SENT TO PATHOLOGY.

IMPRESSION: SUCCESSFUL ULTRASOUND-GUIDED CORE BIOPSY OF LEFT BREAST MASS.

Our physician performed a port check 36598 includes contrast injection and fluoroscopy, then decided to removed it 36590, and place a new port via new access 36561, 76937, 77001. Our edit is saying 36598 conflict with 77001 and modifier not allowed. Can we bill for the port removal 36598?

I need your expertise on this case. Patient went in for TEE and stress echo; the procedure was performed on separate encounter. Can the facility report C8930, C8929 if contrast was used? Or if only the stress used contrast and the TEE did not, can we report C8930 and 93306? Per NCCI, modifier is allowed on TEE 93306 or C8929 when supported reported with stress echo. Some payer is denying for the reason CO 97 -Pmt included in allowance for another svc/px. What is your input on this?

Pt presented to ED for dizziness, CT Scan with contrast performed. at same visit Pt received IV push of Zofran what would be the correct X modifier to use for 96374?

It has been ACR and your recommendation to use unlisted 76498 for MRI WB citing AMA Clinical Examples in Radiology Spring 2009. In a recent AMA CER Winter 2024 Q&A on the appropriate code to report a whole-body CT or MRI, the CPT codes for the relevant body parts of interest should be reported. When appropriate to report, modifier 52, Reduced Services, could be applied to designate a limited degree of anatomical overlap of the imaging range with the advice to check with local payers on the use of mod-52. What is your guidance on this?

Code 0338T is listed as a base code for IVUS code 37252, but 0339T is not listed as a base code. Do you recommend coding IVUS if performed with 0339T?

I have a cardiologist who is asking to charge 93312 and 93355 for his part in a Watchman procedure. He performed a baseline TEE and TEE for guidance, per his report. I see in CPT codebook that these cannot be billed together.

Since an interventional cardiologist performed the Watchman (33340) procedure, should code 93355 or 93312 be reported for the non-interventionalist?

Please help! I am just learning ASC coding. Our provider was "intending" to perform an angioplasty of the SFA in the ASC setting. However, the provider was never able to get the catheter past the contralateral external iliac and down into the SFA to attempt to cross or work on the SFA lesion. Per the provider documentation, all that can be reported is code 36246 for the catheter placement in the contralateral external iliac artery. Are we able to report code 37224-74 for the ASC (the patient did have anesthesia)? Is it okay that the provider's and ASC's CPT code would not match in this particular case? I have researched but cannot find a definitive guidance on this issue. 

Are the posterior segment VIII branch of the right hepatic artery and the medial segment VIII branch of the right hepatic artery hepatic artery two different artery branches?

If an IVUS catheter is placed in a renal artery for measurements to determine what size Paradise ultrasound catheter to use for therapy, can the IVUS be charged/coded? There is no NCCI edit that CPT 37252 and 37253 cannot be coded with 0338T or 0339T. Re Cor said this is a grey area and could not advise whether to charge or not to charge for an IVUS. What is your recommendation?

Would you please provide some clarity as to when it is appropriate to use code 55706? CPT Assistant, November 2010, Volume 20, Issue 11, page 5 states that it must be performed under general anesthesia, 35-60 samples are obtained, and a previous negative standard prostate biopsy was performed. I have a provider insisting that these guidelines are outdated and per clinical standards she should be able to use this code when moderate sedation is used, 20 cores are obtained, and no previous standard prostate biopsy needs to be performed. She states it is the technique, not the type of anesthesia or number of cores that defines this. All the other guidelines are met, including the use of a template and a transperineal approach.

In 2021 you advised using unlisted code 64999 for renal hilar blocks. Has that advise changed since 2021? Can we code these with CPT 64415 or any other category I code?

If we place a drug-eluting stent in the native LC (C9600) and a drug-eluting stent in SVG to OM2 (C9604), how would we code angioplasty to SVG to OM3? Code 92938 is add-on to 92937, but would that still apply in this case, or should I just code as 92921?

Our urologist and radiation oncologist work together on brachytherapy cases, and we’ve been coming documentation within the Radiation Oncologist reports that supports “transrectal ultrasound probe is inserted into the rectum to visualize and measure the volume of the prostate using planimetry “does this meet documentation and medical justification to report CPT code 76872? We should also take in consideration that he (Radiation Oncologist) is also reporting the transrectal guidance (CPT code 76965) for these cases which bundled with 76872, based on CCI edit.

What is the correct way to report this procedure?

"INDICATION: Hydronephrosis. Acute kidney injury.

TECHNIQUE: The pre-existing retrograde biliary drains used as ureteral stents were prepped and draped. The catheters were then cut and catheters removed under fluoroscopic guidance.

FINDINGS: Bilateral retrograde ureteral stents were removed and completely intact. The stents were externally accessible via the urostomy.

IMPRESSION: Successful removal of bilateral retrograde ureteral stents."

Should I report code 37218 for the following?

"A Seldinger needle was used to gain access to the carotid artery with placement of a wire directed into the descending aorta. A 6 French dilator was used to upsize the channel and facilitate placement of an 8 French sheath. Angiography was performed, showing evidence of a greater than 90% stenosis at the origin of the innominate artery. The patient had previously been anticoagulated. Subsequently, a 7.0 x 20 mm balloon was advanced to the area of high-grade stenosis, and angioplasty was performed. Angiography was performed, and ideal stent location was determined. Secondary to the near bovine anatomy ability to not cover the origin of the left common carotid artery was limited and obtained good results into the innominate artery. An 8.0 x 19 mm Omnilink stent was positioned to cover the area of atheroma and stenosis and deployed at 10 atm. This resulted in good apposition."

If a lesion is treated in the right coronary artery with a stent (C9600-RC), and the RPDA is treated with a drug-coated balloon, would the PDA be 0914T or 0913T?

If both were treated with DCB would it just be 0913T alone?

If the left hepatic and middle hepatic arteries are both selected, would the coding be 36247 and 36248, or would it be only 36247 for the middle hepatic being the farthest artery selected?

Is both color flow and spectral analysis documentation required to report code 76820 as it is for duplex CPT codes?

What is the appropriate CPT code for CT-guided bilateral T9, T10, and T11 intercostal nerve cryoneurolysis? Would it be 0442T or 64999? I saw a previous post that suggested 0442T, but I also saw some other guidance that possibly unlisted code 64999 may be assigned.