Ask Dr. Z

Coding for this PX has never been addressed by you, so could you please enlighten us? On 6/14 patient has an abdominal CTA that identifies a mass of the RT kidney consistent with renal cell carcinoma. On 7/10 a referral is placed to our hospital for selective “renal angiography with oil/ETOH embolization to enhance the ablation”, and CT guided cryoablation. Consent for those procedures was signed on the morning of 7/24, and both were performed on that date. Angiography is performed with cath placements in the upper segmental and the lower segmental branches of the superior renal artery branch. Both branches are injected, first with contrast, then alcohol, then Lipiodol, then a small amount of Gelfoam. Four hours later, a CT guided needle core biopsy of the tumor is performed (not the basis for the intervention), followed by two freeze cycles of cryoablation. My codes are: 36247, 36248, 50593, 77013 because I believe the first procedure was tumor marking, and the angiography was not diagnostic. Cath lab staff coded this as 37243, 36253, 50593, 77013.

Can codes 93580 and 93662 be billed with 36215 and 75710 for the subclavian angiogram done during the PFO closure procedure?

What do you think is the appropriate code for this procedure?

"Procedure name: Foam sclerotherapy right varicose veins. Description: The foam agent was created using 1% Sotradecol and 4.5 cc of air agitated through a three-way stopcock. Under ultrasound guidance, a 21 gauge needle was passed into the symptomatic vein under ultrasound guidance in the posterior thigh, gentle aspiration was placed on the needle, and then the foam sclerotherapy was injected again under ultrasound guidance. The procedure was repeated two more times."

Hopefully you can give us some kind of directions when it comes to assigning ICD-10 CM codes for fluid collections.

Most of the times our doctors place drainage tubes and they document abdominal fluid collection, pelvic fluid collection or peri-renal, peri-splenic fluid collections, also they often times sent the collection for lab analysis.

We are not sure what ICD-10 CM to assign, our auditor is asking us to request for clarification from doctors to identify the fluid if its either seroma, abscess, ascites or hematoma. We wanted to find out what's your recommendation and what ICD-10 CM codes would you recommend to use for abdominal and pelvic fluid collections? Thanks so much!

Would you code 0600T (guidance included), 0600T-59, 20206, 20206-59 x2 for CT-guided biopsy and PEF ablation of metastases in the right mid gluteus medius muscle, proximal left vastus lateralis muscle, and the distal left vastus intermedius muscle? Each lesion has a 15 gauge trocar placed that the biopsy and PEF ablation were performed through.

I have a recurring scenario that I am not sure what to do with:

Happening in both POS 21 and 22. IR performs lumbar puncture and extracts CSF. Chemotherapy drug is administered by MED HEM/ONC provider. IR is billing 96450. MED HEM/ONC wants to be paid for their portion of the service.

Is there any way to make everyone happy? I have had one suggestion to have both divisions bill 96450 with -52 modifier for partial services, but this doesn't ring true in my brain (since administration for chemo is not permitted in POS 21/22, I don't feel like this is the right answer). I am having trouble finding any information on how to best handle this from a compliance/billing standpoint.

Would you add code Z76.82 (awaiting organ transplant) for a patient awaiting a stem cell transplant or bone marrow transplant? If not, what is the most appropriate code?

We are starting to see reports come over where 4D imaging is being used instead of 3D imaging. Is there a specific CPT code associated with 4D imaging? How is it to be coded?

Physician tried multiple wires but was unable to cross the stenosis. Since it was staged, can we charge for the heart catheterization or just the catheter insertion?

Would code 76942 be used for the US guidance with 27000 if a blade was used to complete the tenotomy rather than a needle? Excerpt from the procedure documentation: "Percutaneous tenotomy of the tendon at its insertion site using ultrasound guidance to cut and remove the patient's pathological tissue, tendon and fascia. A 11# blade was used to incise through the skin wheal about 1.5cm distal to the site of maximum tenderness. The blade continued through the subcutaneous tissue and incised the tendon/fascia."

You had said previously that if the physician documented a reason for the repeat diagnostic angiogram that it was billable with an intervention. I am wondering if you would include this reason. The patient had CTA & or an angiogram prior to the day of embolization. Both were diagnostic and confirmed an aneurysm. On the day of the embolization the physician documented that despite the fact they had previous angiograms these were "necessary to plan and carry out treatment" of the aneurysm. Sometimes this is stated for stent sizing reasons etc... In my opinion, those reasons equate to imaging required to do the procedure, which is bundled. In many cases there are ordering doctor notes and consults that describe the intervention as planned as well. So, would you agree not only do they have to document a reason but the reason must be for diagnostic purposes, correct?

What is the proper diagnosis to use after aortic stenosis? Our providers frequently submit an assessment and plan similar to this:

AS/ Status post TAVR

Or after a Watchman for Afib:

What diagnosis to use after Watchman:

Persistent Afib Status post Watchman

We have a provider who performed 3 baby grams at 8:45am, 8:57am, and 10:02am, ruling out tension pneumothorax. There are 3 individual orders. The same radiologist interpreted all three together on one report instead of three separate reports. The provider states "findings for all three are described in this dictation". Should there be three separate identifiable interpretations for each exam/x-ray, or is it appropriate to combine into one report/interpretation? This is not an isolated scenario, and for audit purposes would this be acceptable? Would there be any documentation to provide our radiologists?

"Localizing supine CT scans were obtained through the right chest wall mass and a suitable entry site selected. The overlying skin was prepped using ChloraPrep and then allowed to dry before sterile draping was applied in the usual sterile fashion. 1% lidocaine was administered, and stab incision wasmade with a #11 blade. A 17 gauge guide needle was advanced into the mass, appropriate position documented with CT scan. Four sequential 18 gauge core biopsy samples were obtained, submitted to cytotechnologist, present for the procedure."

Would this be reported with code 20206?

I've read the other posts about this issue but I still have a question please. The portion of the NCCI guidance where it states that both codes can be reported during the same session IF it is two separate and distinct technical studies, but the latter is uncommon. What actually constitutes a separate and distinct study? I've had some providers where they provide two separate reports; one for MRI and one for the MRA, however, they were done during the same session for a stroke protocol. Just confused as to when the angio can be reported separately. Any help appreciated!

“Thoracic T4-5 and T5-6 bilateral facet paravertebral medial nerve branch thermal radiofrequency ablation under fluoroscopic image guidance and trigger point injections were completed in the belly of four muscle groups today.”

Since fluoroscopy is included in some pain procedures and not in others, are we allowed to bill additionally for a procedure(s) fluoroscopy charge when it is performed in the same setting as another procedure that includes fluoroscopy?

Is there a way to charge for using a filter wire during a coronary artery stenting? Specifically stenting of the SVG to the OM? Or is that part of the 92941?

During CABG, ascending aorta was large, at 4.2 cm in size, but not thin walled, and was quite calcified. Aortic cannulation site was affected by the calcification and multiple pledgeted sutures were oversewn for hemostasis. Due to patient's age and stability of aneurysm, replacement was not warranted. Provider dropped CPT code 33881, which does not fit what was documented. Via research, could not find CPT code to describe this scenario. Would CPT 33999 for unlisted cardiac procedure be appropriate if this service is billable? Patient also had CABG with LIMA to LAD, RSVGs to OM1 & RPDA, and endarterectomy of RPDA.

How do we count the levels during an ABI? 

By definition, CPT codes are based "ankle/brachial indices at distal posterior tibial AND anterior tibial/dorsalis pedis arteries "ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries".

Does that mean measurements of the PT and AT or PT and DP are one "level"?

Documentation of triphasic arterial Dopplers waveforms, pressures and index have been taken.

What is the CPT code for bilateral measurements of the posterior tibial, dorsalis pedis and big toes?

What is the CPT code for bilateral measurements of the posterior tibial, anterior tibial and dorsalis pedis?

Which CPT code (37243 or 37242) is reported for embolization of arteries that are feeding hemorrhoids?

I have a follow-up question regarding question ID 20159. You suggest 36245, 36245-59 x 2 for catheter selection of three genicular arteries when the access is from the dorsalis pedis. Can you explain your rational for this selection? To me it looks like the dorsalis pedis is 36140, the popliteal/SFA would be 36245, and then the genicular arteries would be 36246, 36248 x 2. I'm just trying to understand why.

Would you assign 93653 + others or 93656?

"An Abbot Grid mapping catheter was then placed in the left atrium. Utilizing the Ensite X electroanatomic mapping system, a left atrial shell and voltage map was constructed. The LIPV had recurrent conduction, and the right PVs and LSPV were isolated distally but their antra were active. The Grid mapping catheter was then exchanged for the Medtronic PulseSelect PFA catheter, advanced over an Amplatz Super Stiff guidewire, initially positioned in the LSPV. Pulsed field ablation of the four pulmonary veins was then performed. Each vein was treated with four 90-degree offset lesions distally and 7-10 proximally. Additionally, lesions were applied in the LA dome. Repeat voltage mapping with the Grid catheter showed all PVs to be electrically silent. However, the LA dome was not isolated with activation coming through the LA roof and collision of wavefronts at the inferior LA dome, indicating intact inferior dome line from PFA."

IR hospital based physician request answer. Can you bill Y90 - C2616 multiple times if inserted in separate segments of liver at same session? ex: segment 8 x1, segment 5/6 x1. total 2 units. There is an MUE of 1 and MAI of 3. However physician feels it should be billable. Or can you perform 1 insertion and bring patient back later in day and insert 2nd site? Appreciate your quick response. Thanks.

Would ablation of a lymphatic malformation be considered an embolization or occlusion? Would it be reported with code 37241 or an unlisted CPT code?

"Under fluoroscopic visualization, the ablation probe was advanced into the target tissue in the right submandibular region. Positioning was confirmed with cone beam CT. The probe was activated per protocol and then retracted several millimeters, and a second alation was performed adjacent. The probe was removed. Uneventful percutaneous ablation of a microcystic lymphatic malformation of the right submandibular region."

An MRI of the brain was performed without contrast (70551) with positive findings. The recommendation was MRI brain with and without contrast. The second scan was done later on the same day but read by a different provider. Would both be billed?

We are working on a policy for cancelled procedures/attempted procedures. We are looking for guidance on what we can charge for the following scenario: Patient present to US for a biopsy, and they are unable to complete the procedure under US guidance, so they move the patient to CT. Under CT guidance the biopsy is able to be performed.

On the coding side, I didn't think we could use the -73/-74 modifier if there was a procedure that was successfully completed. Is there a CMS rule that states we use only the successful guidance or highest level of guidance (CT in this case)? Is the US department able to bill for the biopsy with modifier -73 to cover the expenses and then CT bill for the same biopsy CPT without a modifier?

When removing an IVC filter and an additional access has to be obtained, and the physician works through both in order to remove the filter, are the catheter placements into the IVC from the second access able to be coded? Or does 37193 include all accesses/catheter placements?

My provider reported a duplex scan with endovenous ablation. The endovenous ablation treated the right greater saphenous vein, and the duplex evaluated the right common femoral, popliteal, posterior tibial, and gastrocnemius veins. The CPT Codebook parenthetical does state, "(Do not report 36475, 36476 in conjunction with 36000, 36002, 36005, 36410, 36425, 36478, 36479, 36482, 36483, 37241-37244, 75894, 76000, 76937, 76942, 76998, 77022, 93970, 93971, in the same surgical field)." Would the surgical field only apply to the vessel treated, or would it apply to the entire right lower extremity?

As of July 1, 2024, C1761 extra payment for the facility is now sunset status. Do we still need to report the C2 shockwave supply with C1761 as the code causes many denials for experimental, not covered with the DES facility set of "C" codes, etc. Can we just charge C1725 for a regular balloon?

Is CMS going to up changing or creating different codes for shockwave intervention?

GRAFT THROMBECTOMY WITH BILATERL FEMORAL EXPOSURE bilateral groins, catheter directed thrombectomy bilateral graft limbs, arteriotomy right graft limb Fogarty passed several times distally down SFA fresh thrombus removed good Attention turned to left groin arteriotomy left graft limb. fresh thrombus removed good back bleeding arteriotomies partially closed retrograde angiograms on both sides there appeared to be stenosis at the proximal anastomosis. Antegrade angiogram was performed. significant stenosis at the proximal anastomosis .wires placed bilaterally, marked the level of the renal arteries placed bilateral 7x79mm VBX stents from level of the renal arteries into the graft limbs Repeat angiogram showed vastly improved flow

For the hospital, is it recommended that the order be changed from paracentesis to US abdomen for canceled para after US imaging reveals no/low fluid (essentially to match what was done/charged)?

Can you report code 32550 in this context with the following procedures, or would this be inclusive following CPT 32551 instructions in the NCCI Policy Manual?

Operation Performed:

1. Robotic assisted, left thoracoscopy

2. Pericardial window

3. Left pleural nodule excision

4. Placement of pleurX catheter

"Left upper catheter evaluated. Tube nephrostogram was performed. The catheter was partially dislodged with sideholes positioned in the abdominal wall. Significant leaking was noted. The catheter was removed over a guidewire. A new 8 French, 25 cm nephrostomy catheter was than placed. Left lower catheter was then accessed. Nephroureteral stent was in good position. New catheter was then placed without difficulty with the distal pigtail in the urinary bladder and proximal pigtail in the renal pelvis. Right upper catheter was accessed. Nephroureteral stent was in good position. New catheter was then placed without difficulty with the distal pigtail in the urinary bladder and proximal pigtail in the renal pelvis.  Right lower catheter was accessed. Nephroureteral stent was in good position. New catheter was then placed without difficulty with the distal pigtail in the urinary bladder and proximal pigtail in the renal pelvis."  

Should this be reported with codes 50387-50, 50435-59?

Do we also code 36500 with the stent 37238, IVUS 37252, and venogram 75820?

"Ultrasound was used to identify the left common femoral vein. I gained percutaneous access integrate with a micro access kit and upside to a 8 French sheath. 5000 units of heparin was given. I shot a venogram which showed some stagnation of contrast in the common iliac vein. I was able to negotiate across the stenosis with a lumps catheter and a glidewire. I shot a venogram to ensure I am in the venous system. I then upset to a 9 french sheath. I used IVUS to interrogate the left common iliac vein which demonstrated compression of the min common iliac vein of 50%. The area of stenosis measured approximately 10 mm versus proximal and distally measure approximately 16-18 mm This confirmed that there is May-Thurner pathology. Therefore we predicated the area of stenosis with a 18 mm Atlas balloon. Completion IVUS demonstrated minimal residual stenosis."

Hi there! One of our surgeons is performing pre-op vessel mapping for hemodialysis access; however, they are only taking vessel measurements and noting anatomy (vessel diameter, high bifurcation, etc.) without performing spectral or color flow Doppler. Per previous coding recommendations on ask Dr. Z, CPT 76882 should be coded if vessel mapping without spectral and color flow Doppler is performed for anything other than pre-op assessment for hemodialysis access. Would CPT 76882 still be appropriate in this case (with or without a 52 modifier), unlisted CPT 93998, or CPT 93985-93986 with a 52 modifier? One of the providers assisting with this is concerned that CPT 76882 is a misrepresentation of what is being performed since we are only imaging vascular structures and are not imaging the joint space, peri-articular tendons, muscles, nerves, or soft tissue masses per the code description. Thank you in advance for any recommendations!

The patient had a 70% lesion in the LAD, and 50% ostial disease in the first diagonal. The LAD was treated with ballooning, shockwave lithotripsy, and stenting. "A 2.0 mm by 12mm NC balloon was used to dilate the ostium of the first diagonal to ensure it remains open." Is angioplasty of the first diagonal (92921) supported by this documentation? Was the angioplasty done to treat the 50% stenosis, or was it done more as a prophylactic measure? If it was done prophylactically, is it correct to think that it would not be coded?

Can we report code 93657 for PWI done empirically? Patient has AFIB came in for PVI and the provider also did PWI done empirically.

Can we charge 64999 and 64493 for this procedure. June 10, 2022, answers this question, but we want to make sure we can charge both if same level.

The patient was placed in prone position on the CT table and localization of the target level and side was made and the low back was prepped and draped in usual sterile fashion. Ropivacaine 0.5% was infused in superficial and deep soft tissues. A 3.5-inch, 18-gauge Chiba needle was advanced into the posterior left L3-4 facet joint under CT guidance. Intra-articular needle placement was confirmed with instillation of a small amount of Isovue-M 200 contrast. Subsequently, Isovue-M 200 was then rapidly injected into the facet joint overcoming the resistance of pressure. Confirmation of the cyst rupture was performed with additional imaging. Subsequently, a mixture containing 1 mL of Depo-Medrol 80 and 1 cc 0.5% preservative ropivacaine was then injected into the joint. The needle was removed, and the skin was cleansed and bandage.

This is what we see on EP procedures and see catheter placement in the log. No note other than findings. Does this tell you whether Left Atrium pacing/recording was performed. Is this typical of EP documentation?

Baseline EP Study The presenting rhythm was sinus rhythm.

The baseline intervals in sinus rhythm were:

QRS duration: 62 ms

QT interval: 348 ms

AH interval: 94 ms

HV interval: 40 ms

An invasive electrophysiology study was then performed.

Retrograde Properties:

VA WB interval: 360 ms

VA ERP: 190 ms at a drive train cycle length of 600 ms

VA conduction was concentric and decremental. There was no evidence of accessory pathway.

Antegrade Properties:

AV node WB interval: 320 ms

AVNERP: 340 ms at a drive train cycle length of 600 ms

There was no evidence of dual AV node physiology.

Echo beats were not noted.

Arrythmia Induction and Characteristics Induction:

No arrhythmias were induced despite pacing maneuvers.

• No evidence of a slow or accessory pathway with no inducible tachycardia on and off of isuprel.

• Normal EP study.

We billed code 36830 for axillo-axillary AV graft (Artegraft), but code was denied stating: "There is a more appropriate CPT code that should be used to bill for the service." This was a nonautogenous graft from the axillary vein to the axillary artery. What other code would we use? What other code would be appropriate?

Hello. Coding for enterocutaneous fistula studies - we use 20500 / 76080 for any kind of therapeutic injection into the fistula, but struggle with a drain placement into the fistula. Would we use an abscess drain placement 49406, or 10030 ? Thanks!

HISTORY: Status post cholecystostomy tube for cholecystitis, assess patency of biliary system

TECHNIQUE: Approximately 15 mL of water soluble contrast was injected under sterile technique through the patient's cholecystostomy tube under fluoroscopic guidance.

FINDINGS: Contrast flows into the gallbladder, intrahepatic biliary ducts, cystic duct, biliary duct and duodenum without delay. There is no dilatation or obstruction.

IMPRESSION:

Patent biliary system. the tube was left in situ and patient was directed to follow up

Radiation dose: 292uGy/m2

Fluoroscopy time: 0.5 minutes

Earlier in the day, the patient was in the OR for "EGD CONVERTED TO EMERGENCY ERCP WITH SUBMUCOSAL INJECTION OF EPINEPHRINE, APPLICATION OF GOLD PROBE AND STENT EXCHANGE"

Patient now in the IR suite with the below indication.

"HISTORY/INDICATION:

Post sphincterotomy hemorrhage with attempts to control endoscopically. Patient continues to bleed. Angiography and embolization are requested."

The following selective angiograms were performed:

Celiac artery (1st order)

Common hepatic artery (2nd order)

Gastroduodenal artery (3rd order)

Superior pancreaticoduodenal artery (3rd order)

The gastroduodenal artery and superior pancreaticoduodenal artery were successfully embolized using a series of detachable Boston Scientific En-Bold coils.

Question - We know there is a continued bleed going into the IR suite but seems like they aren't sure of the location. Since there isn't a prior CTA/MRA/Catheter-based angiogram are we able to pick up the diagnostic angiography for this case?

If the provider placed an impella 5.5 with conduit during an Aortic Valve Replacement (90 day global), and brings to the OR a few days later to remove the impella can the removal reported within the 90 day global of the AVR? There were no documented complications or additional diagnosis listed for the removal of impella other than the Aortic valve disease and presence of the impella.

Coding software does not recognize modifiers: 58, 78, 79 for CPT 33992. Per CMS global surgery MLN907166, all miscellaneous services required during the post-op period are included in surgical package (excluding complications that require return to OR). Does this apply when impella is placed for support during major surgery and removed on a different date of service? Or we can code 33992 for removal?

What would be the recommended coding for a single AVM of the face treated with YAG laser followed by injection of doxycycline (direct stick)?

Patient had previous PVI 2021, mapping was documented that the pulmonary veins were isolated at baseline but there was reconnection at the posterior wall.

There's too much in the report to post in it's entirety so hoping this is enough:

Targeted Arrhythmias

Arrhythmia: Atrial Fibrillation

Lesion Sets:

Left atrial roof line

Left carinal ablation

Left atrial posterior wall line

Right antral pulmonary vein isolation

Endpoints Achieved:

Left pulmonary vein isolation

Right pulmonary vein isolation

Posterior wall isolation

Transseptal performed.

If our provider only images the peroneal artery, can we still report code 75710? Or are we only allowed to bill that for a complete examination of the extremity?

When coding for the facility, what else is reported at the same time as C9797? We understand that code C9797 is used instead of 37243 for embolization performed with the TriNav catheter.

We are seeing this TriNav catheter being used to deliver the Y90 for liver embolization cases.

Can 79445 still be reported?

Can diagnostic imaging still be reported (like 75726, 75774)?

Can selective catheter placements still be reported (like 36247, 36248)?

Can 76937 and G0269 still be reported?

Is there a CPT code for endovascular treatment of abdominal aortic aneurysm with a Nectero EAST delivery catheter and medication infusion with PGG or pentgalloylglucose?

Below is an excerpt from the cath report. Is code 37242 correct to use for closure of the Potts shunt? 

"Prior to proceeding with device closure, the left femoral vein sheath was exchanged for a 7 French Mullins sheath to accommodate the device delivery system. Initially a 16 mm AVP II was attempted to be delivered, but it was found to be too large. PA angiography was performed to check the device position. A 12 mm AVP II was then selected and delivered inside the Potts shunt. Brief hand angiography was performed in the MPA through a long sheath. The device was released. Final ascending aortography was performed using a 4 French Pigtail catheter."