Ask Dr. Z

According to AHA Coding Clinic 2nd Q, 2014 - Breast Codes: Biopsy and localization devices, under the Q&A section, the answer to Q #3 states both 19301 and 19283 (in my case 19281) can be coded together if performed on the same breast. What if the marker is placed in the lumpectomy cavity, not if a different location on the same breast. Would it still be appropriate to code both procedures? There is a CCI edit and modifier is allowed, but I am thinking that that is if the lumpectomy and marker placement was done in different locations on the same breast.

Would this be 35226 or 37799, or would it be something else entirely since technically its repair of a previously placed right common iliac to right external iliac bypass graft?

Approximately 3 mm x 4 mm defect in the proximal 3rd of the bypass graft in the posterior lateral aspect. After debriding the friable portion of the artery, there was too large of a defect for immediate primary closure and so after mobilization of the bypass graft and trimming of the edges of the artery for more sustainable tissue, we performed a end-to-end anastomosis of the existing bypass graft in a primary fashion.

“I did not feel comfortable repairing this without additional exposure and mobilization, so then I transected the artery to obtain a circumferential evaluation of the artery, CryoArtery. After additional debridement I felt comfortable reattaching each end in end-to-end fashion with 5-0 Prolene suture in simple interrupted fashion in its entirety.”

Physician billing - Pt had a LHC w/ stent for anteroseptal MI and later in the same day, patient develops a high degree AV block so returns to the cath lab requiring a temporary wire placed same day, same provider but separate encounter. There is a 0-edit between the cath and the temporary pacer so the -59 modifier cannot override the edit. Does that mean that even in a situation such as this, the pacer is not billable?

Would you report code 10030 or an unlisted chest code for this report?

"CLINICAL INDICATION: Subcarinal cystic structure. Under CT guidance, a 17 gauge coaxial introducer needle was placed into the subcarinal cystic structure via right posterior approach. A 0.038 guidewire was inserted through the cannula, and the cannula was removed. The tract was serially dilated, and a 10 French pigtail drainage catheter was ultimately placed into the cystic structure. Fluid was manually aspirated through the catheter, and the catheter was attached to a drainage bag. The catheter was secured to the skin with a Percu-Stay device. Fluid was sent off for cell count, cultures, and cytology. IMPRESSION: Uncomplicated CT-guided drainage with catheter placement of mediastinal cystic structure."

Our radiologist is performing needle placement only via fluoroscopy for a cervical spine injection. The pain management provider is actually giving the injection. Can the radiologist bill anything for the fluoroscopic needle placement only?

Can you please clarify whether the Penumbra (Indigo) is still considered aspiration thrombectomy or is it now considered mechanical thrombectomy. Previous responses stated it is aspiration, but our Cath Lab disagrees. The Mechanical Thrombectomy E-Learning Module states the only device that is appropriate for use with 92973 are the AngioJet devices. There are many MTD devices shown in the module, are none of them other than Angiojet coded with 92973? Of note, the Optum Guide to IR has an example that codes a Penumbra thrombectomy as mechanical.

My provider is documenting that he placed a stent in common iliac vein, and placed a stent in external iliac vein. however he is only using 1 stent. Would this fall into "a single therapy"? Do I only bill 37238 since he used 1 stent? Or do I bill 37238,37239 since 2 different vessels were treated? 

Code G2066 was billed with 93298 for remote loop recorder device interrogation; however, code G2066 is now deleted. What code is replacing G2066?

The cardiologist I code for have and in-office cath lab and perform LE resvascularization and a few other procedures there. My question is with meds given, are they allowed to code also 96374?

Common meds are

Versed

Fentanyl

Protamine

Zofran

Benadryl

Flumazenil

From right side femoral access,  catheter was placed in infrarenal aorta above bifurcation and performed angiogram, and catheter was placed in left external iliac for left leg runoff. Findings state aorta patent with iliacs and complete left leg findings. Can we report code 75625 in this case? Not sure whether significant portion of aorta was imaged since he said catheter was placed above bifurcation.

How would you code the axillary cutdown when the Impella is removed? Is this billable?

This is another persistent afib patient returning for repeat ablation.

" A voltage map revealed pulmonary vein isolation from prior ablation procedure. In this context we decided to extend the line of isolation. Radiofrequency applications with 25 to 45 watts were delivered around the left and right pulmonary veins to achieve wide antral circumferential isolation. Entrance and exit block was confirmed bilaterally. High esophageal temperatures were noted while ablating the posterior aspect of the RPVs. Applications were interrupted once the temperature reached 38.5 C in the esophagus. After pulmonary vein isolation was achieved, pace capture at 10 mA x 2 ms was performed along both lesion sets. Additional radiofrequency energy was applied at the areas of capture."

If the pulmonary veins were identified as isolated from a prior ablation is the extension of the line of isolation in the presence of persistent afib still reported as 93656?

Is it appropriate to report 36569 when an RN, employed by the hospital (Vascular Access Team), places an PICC? There is no physician involvement, other than the reading of a post procedure chest x-ray.

They are using ultrasound and had wanted to report 36573, but, don't believe that to be appropriate due to lack of physician supervision and interpretation. Do you agree?

If a renal duplex scan is done plus the mesenteric artery, do I bill code 93976 only, or do I also add 93976?

In a case where the patient was scheduled for an upgrade from dual PM to BiVi PM, the doctor was not able to implant the LV lead. I’m coding 33225-74 because it is specific to why patient was on the table, because additional supplies and time was used, and because the doctor states “concern for complications” and aborted the procedure. The doctor then added a new RV lead and exchanged the dual PM so I’m also coding 33207 and 33233. Do you agree with my codes? Also, if the patient is for a brand new BiVi PM and doctor cannot place the LV lead and just places the dual PM, should I be coding 33225-74 as well? I have been just coding for a dual PM insertion. I’m interested in your thoughts. Thanks!

Cardiac Surgery came in and opened the right carotid artery. Cardiologist then performed the Aortic Valve Replacement using the Carotid Artery for Delivery of the Valve. Is this still an unlisted procedure code 33999?

Physician placed an AFX 2 with a Proximal extension Vela 25-75. Is the correct CPT coding for this a 34703 and 34709 for the proximal extension?

What should be coded for the following?

A four-quadrant sector transducer scan reveals that there is only some a small amount of ascites fluid in the right perihepatic space, no fluid seen in the left upper and left lower quadrants of the abdomen and also in the right lower quadrant and hypogastric region respectively. Therefore we elected not to perform a repeat paracentesis at this time. Instead we elected to perform closure of the prior peritoneal cavity tract which had resulted from the prior ultrasound guided paracentesis performed a few days ago. Therefore we embarked on performing a circ lage suture to pucker the tract followed by skin to skin apposition with adhesive skin glue. Using sterile technique and 1% local regional anesthesia with buffered lidocaine for total of 10 cc. This resulted in complete cessation of fluid coming out. We then performed a dry dressing.

Impression :successful management of a peritoneal ascites leak coming from the prior site of peritoneal fluid drainage

Need Dr. Z's opinion with this op report :) Thank you in advance!

An arteriotomy was made mid common femoral artery extended across the femoral bifurcation to the origin of the superficial femoral artery which was widely patent. Occlusive highly exophytic plaque was at the femoral bifurcation. An endarterectomy plane was identified, taking care to preserve the abrupt termination of the plaque at the origin of the profundofemoral artery. We endarterectomized from the proximal superficial femoral artery retrograde to the level of the inquinal ligament w/a penfield elevator. At the origin of the profundofemoral artery I divided the plaque with Potts scissors, resulting in preservation of a nice ostium. I tacked down the plaque at the origin of the profundofemoral artery w/7.0 prolene sutures and passed the plaque off as a specimen. The 8 mm graft was spatulated to match and end to side anastomosis completed with 5-0 prolene sutures.

Then the op goes on to discuss completion of the axillary to bifemoral bypass.

Would the profunda reimplantation to the graft be part of establishing inflow/outflow in code 35141 or would this be separately billable with a 22 mod or unlisted 37799?

"Patient has right CFA aneurysm with complete occlusion of right SFA and profunda femoris. We dissected the CFA proximal to the aneurysmal area. The vessel was encircled with a vessel loop and controlled. We repeated the same process for the SFA and profunda. The aneurysm was then entered anterior arteriotomy with a 11 blade. The arteriotomy was extended proximal and distal with scissors. We completely transected the proximal and distal ends of the affected artery in order to proceed with reconstruction. An 8 mm Dacron graft was sewn to the CFA in an end to end fashion. The same process was repeated for the distal anastomosis to the SFA. Next, the profunda was transected and ligated. The distal portion was mobilized in order to anastomose to the Dacron graft. End to side anastomosis with 5-0 Prolene was performed. All the arteries were flushed prior to completing the anastomosis."

Just confirming -

If TIPS procedure is performed, and ICE (Intra-Cardiac Echo) is used - does it fall under the "all associated imaging guidance" or can Intra cardiac echo be charge separately with 93662?

Patient has pre-existing brachiocephalic av fistula which now has aneurysms. Physician resects the cephalic vein from where it was anastomosed to the brachial artery. A subcutaneous tunnel was then made distal to the antecubital fossa

with the distal cephalic vein brought in juxtaposition to the previous brachial artery anastomosis. The anastomotic segment was cleared to allow for end-to-side anastomosis to be completed from the brachial artery to the cephalic vein. This was then completed.

due to lack of significant palpable thrill, in order to better provide outflow from this retrograde system, incision was made overlying the basilic vein in the forearm. Subcutaneous tunnel was made and the distended basilic vein was passed through. Distal basilic vein was transposed and juxtaposed to the cephalic vein. A venotomy was made within the cephalic vein and the basilic vein spatulated to accommodate an end-to-side anastomosis.

Since original anastomotic site used, is this revision (36832) or new creation (36819)?

Since code 27096 now includes fluoro, does G0260 follow the same rules and include Fluoro? Because in the lay description it says The physician injects the sacroiliac joint for the purpose of arthrography, which is taking radiographic pictures of the joint internally to visualize the cartilage and ligaments. The contrast material, or gas, is drawn into a syringe and the target structure is localized. Through a posterior approach, the needle is inserted and advanced into the sacroiliac joint, the articulation between the sacrum and ilium in the pelvis, and the contrast injection is visualized under the aid of separately reportable computerized tomography (CT) or fluoroscopic guidance.

In facility do we report G0260 and 77002?

Please advise thank you

I have a vascular surgeon who wants to bill CPT 64905 for the TMR a newer technique that he states is allowed with Nerve Pedicle Transfers. He did a below knee amputation. After that the op note reads:

"The Tibial Nerve was identified and isolated. The Soleus muscle was meticulously dissected until the motor nerve plexus was identified. A coaptation was created between the nerve and the motor nerve plexus using 6-0 prolene, and the vascularized muscle was closed around the nerve."

We have exhausted our appeals and are unsure if this is going to work or if a Unlisted code should be used?

Can you please clarify if we should use 19285 or an unlisted code for an ultrasound guided needle localization of right axillary lymph node? CLINICAL HISTORY: Patient is seen for an ultrasound guided Pintuition Seed localization of a malignancy and tissue marker in right axilla. FINDINGS: The patient was positioned on ultrasound table and the right axilla was prepped and draped in the usual sterile manner. High resolution real time ultrasound imaging was performed. The malignancy and tissue marker to be localized was identified in the axilla. Ten (10) cc of 1% lidocaine was utilized for local anesthesia. The localizing needle was inserted and the needle tip was advanced through the lesion using real time ultrasound guidance. A Pintuition Seed was then deployed through the needle and the localizing needle was removed. A post localization mammogram was performed confirming accurate localization of the lesion. CONCLUSION: Successful ultrasound guided Pintuition Seed localization of a malignancy and tissue marker in the right axilla.

Does this support a dual chamber insertion?

"Using fluoroscopic guidance a lead was inserted into the area of the left bundle via guide sheath. Pacing and sensing parameters were appropriate with LV activation time of 71 ms. The guide was slit. The lead was anchored in position using sutures around the anchoring sleeve. Next, another sheath was used to place an atrial lead in the area of the right atrial appendage. The lead was anchored in position using sutures around the anchoring sleeve. The leads were then connected to generator and the pocket was irrigated with saline.

The device and leads were placed in the pocket and the pocket was closed with a combination of subcutaneous absorbable sutures and Steristrips. Pacing and sensing parameters were checked through the device and were appropriate, there was no phrenic stimulation with high outpatient pacing from both atrial and ventricular leads."

Can you advise me as to what the correct CPT charging would be for 4D CT angiography? I understand the charging for 3DCT angiography for S&I is 76376 and 76377 as to whether this was reviewed on an independent workstation. I cannot find any information concerning 4D CT charging.

What code should be used for white smatter small vessel ischemic changes? Some coders use R90.82; some use I67.82. Is there a definitive code that should be used?

In the cases where US is done prior to thoracentesis if not enough fluid, we report the limited chest US only. However, if US is done on both RT and LT side but only LT side has enough fluid and thoracentesis is done, are we still able to report the limited US done for the RT with not enough fluid?

Is this considered a revision or a ligation of the AV fistula?

"Intraoperative ultrasound was used to visualize the arterial anastomosis. An oblique incision was made with a scalpel, and the incision was deepened with electrocautery and metzenbaum scissors until the brachial artery and fistula were both identified. The artery and fistula were both confirmed to be as such with Doppler. A 6 mm Dacron tube graft was brought onto the field, opened with metzenbaum scissors so that it was formed into a patch instead of a tube, and wrapped around the proximal fistula for sizing. This was then sutured into place sizing the fistula to the graft with interrupted 5-0 prolene suture. A palpable thrill was still noted over the fistula. Hemostasis was obtained with electrocautery. The wound was closed with 3-0 vicryl, 4-0 monocryl, and skin glue. A radial pulse was palpable on completion."

For iliac artery stent procedures, we understand the coding is first based on pathology and then based on the type of endograft used to treat the pathology. For an iliac artery dissection (not stated for occlusive disease), should we use code 37236 or 34707 when a Cook Zilver 8 mm x 60 mm stent is used? Would this type of stent qualify for the ilio-iliac tube endograft code 34707, or would this be considered a “regular" stent code 37236? If the dissection was caused during a lower extremity revascularization procedure, is the iliac artery dissection stenting still codeable?

Based on the following, would CPTs 78315 and 78832 both be reported?

Order- NM Bone Scan 3 phase w/SPECT CT

Tech Info- Pt injected w/ 24mCi. Blood flow imaging of pelvis performed. Blood pool imaging of pelvis and knees (4images) performed. Whole body anterior & posterior & 10 spot views of skeleton obtained 2hrs later. Subsequently, 2 SPECT-CT acquisitions, one of the pelvis and another of the knees.

Findings- Blood flow of pelvis shows subtle hyperemia regional to R hip prosthesis. Blood pool imaging shows periprostatic uptake outlining the entirety of the prosthetic, though the greatest laterally at the hip and lateral R knee. Delayed images of pelvis, there is increased tracer uptake R acetabulum... at the level of the knee there is tracer accumulation w/i the patella. SPECT-CT of the pelvis shows increased uptake R greater trochanter & L femoral head. SPECT-CT of knees shows increased tracer uptake R patella. Remaining whole body images show flare metaphysis at the L knee, compatible w/ marrow expansion in setting of SCD & splenic autoinfarction.

At our hospital facility we do a number of abdominal wall fat pad biopsies for amyloidosis. Are there any updates for what CPT code should be used for these? I've read unlisted code 17999, Unlisted procedure, skin, mucous membrane and subcutaneous tissue, from a 2019 Dr. Z. response. 

Patient had PA, PWCP, AO, and LV pressures. I think 93458 for the LV and AO pressures and then one of these add-on codes for the pulmonary piece: 93568, 93569, 93573, or 93574? Thoughts?

"Coronary angiography was performed. We then did the right heart catheterization and performed cardiac output in triplicate by thermodilution method. We then also did left ventricular end-diastolic pressure along with pulmonary capillary wedge pressure to calculate the mitral valve area and a 6-French Angio-Seal was deployed at the right femoral artery and D-stat pad was used to do the closure in the femoral vein. The right coronary artery shortly after its origin has diffuse disease to the mid-vessel stenosis maximum of about 40% proximal, and about 20% mid. The ascending root is mildly dilated, aortic valve area 1.1cm2 capillary wedge pressure was approximately 18 to 20 mmHg, pulmonary artery pressure 48/26. Initial left ventricular pressure 183/21 mmHg. Left ventricular end-diastolic pressure 26. 40 mm, peak to peak gradient across the aortic valve max gradient 50 mmHg."

What codes are supported for billing the endovascular procedure and why?

"Ultrasound-guided cannulation right common femoral artery- Selective left leg angiogram- Left anterior tibial lithotripsy with 3 mm x 40 mm Shockwave lithotripsy balloon- Angioplasty distal left anterior tibial artery with 2 mm x 100 mm ultra verse balloon-

Operative findings:

#1. The left posterior tibial artery still patent with minor areas of disease proximally and distally. The posterior tibial goes into the foot but does not appear to supply much of any blood flow to the digits on the left foot.

#2. The anterior tibial was able to cannulated with 0.018 wire and 0.014 wire. The wires could not be advanced all the way into the foot. After treatment of the anterior tibial with 3 x 40 mm lithotripsy shockwave balloon, it was quite obvious that the lithotripsy balloon could not be advanced all the way into the foot. This was replaced with 2 mm x 100 mm balloon which once again could not be advanced across the heavily calcified and diseased distal anterior tibial artery into dorsalis pedis. The procedure was then terminated."

Would you code this as 20206/76942 or go with unlisted 20999?

Pre-procedure diagnosis: Right thyroid bed vs. paratracheal nodule

Post-procedure diagnosis: Same

Device: Temno Evolution

Size: 18 Gauge

Passes: 5

Specimen: Surgical pathology

Successful US-guided right thyroid bed / paratracheal nodule biopsy.

What is the correct CPT coding for the initial insertion of a gastrostomy tube (Moss) with extension into the proximal duodenum? This was performed percutaneously and under fluoroscopic guidance.

I could use your expertise. A left heart cardiac cath was performed. The procedure report goes into detail about entering all major arteries and branches but does not describe how the catheter entered the left ventricular. There are, however, pressures recorded for the left ventricular reading. Are we to code from these pressure readings assuming the left ventricular was done?

The 2023 CPT book now directs us to bill the repair code when an Impella device is removed from an open exposure. If an embolectomy or endarterectomy is also required, would that still be considered a repair or would you bill those procedure codes instead? Is the repair code appropriate for open exposure and closure with just suture for the removal?

We have a debate amongst our team as to if you can charge an initial vertebroplasty and initial kyphoplasty in the same operative session. The patient had a T5 and T7 kyphoplasty and T12 and L1 vertebroplasty. Can we charge 22511 and 22512 for the vertebroplasty and 22513 and 22515 for the kyphoplasty?

Patient placed in a supine position. Skin left lateral abdominal wall cleaned and draped in usual sterile fashion. 1% lidocaine used as a local anesthesia. Patient monitored by radiology nurse using automated blood pressure cuff, EKG, and pulse oximetry. No sedation related complications.

Using CT for guidance. the tip of a 20-gauge Quincke spinal needle was placed immediately adjacent to the foreign body in the left side of the peritoneal cavity. Next, a mixture of 2 cc of endoscopic tatoo ink and a half a cc of Ominipaque 240 was injected through the needle. Patient tolerated the procedure well with no immediate complications. Patient was sent to recovery in stable condition. Radiologist performed this procedure.

How would this be coded? Would it be coded as 49411 or 10035?

The patient undergoes a procedure, can be various types of procedures for different reasons. The cardiologist performs a TEE pre, and post operative on the same day. Are both of these TEE procedures billable on the same day? Are they billable if they perform them on different days? They are performing these as a post operative check for the procedure. We are struggling with the medical necessity rationale other than a routine post operative check.

If the provider performs an endarterectomy of the external iliac artery to common femoral artery and places a stent in the common iliac artery, can we bill both codes 35355 and 37221? If so, does the documentation need to support two separate lesions to bill both, or can it be a contiguous lesion?

We have a patient who is returning multiple times for sclerotherapy of a lymphocele. However, after a few visits they are now sending the patient home with instructions as to wait 1 hour and then drain the doxycycline. "...The catheter was reconnected to a closed suction drainage bag. A sterile dressing was applied. The patient was instructed to reopen the stopcock after allowing the doxycycline to dwell for at least one hour. The patient was discharged."

There are mixed reviews as if it would it be appropriate to bill this out as 49185 or 49185-52 with the reduced services modifier for these cases. Can you please advise?

Report only has documentation for catheterization of the left internal carotid artery, but the findings section has imaging results for both the left and right internal carotid arteries. Can I code this as 36224-50?

How does Profee code for a left bundle branch pacing lead insertion? Please see example below. Patient had a dual pacemaker insertion (atrial and ventricular leads in addition to an LBB pacing lead. "LB pacing lead guiding catheter and .035 wire advanced, 3830 lead advanced and positioned in left bundle branch area. LB pacing lead position stable and lead sutured in place." Is this included in the insertion pacemaker/ICD codes? I'm not sure 33224/33225 would be correct in this situation either. Please advise.

We have a patient that received a DES for an acute MI originating in the LAD. In the cath report after IVUS and stenting they state "Following this super saturated oxygen therapy was started with ZOll system for 1 hour. Following this the system was disconnected, sheath was removed and Angio-Seal closure device used." I cannot find any guidance about a CPT for this type of procedure. Is this oxygen therapy included in the MI stenting procedure or should I look at an unlisted code?

May i ask you if we can still bill 77046-77048 if our radiology tech perform an abbreviated MRI with the following sequences :• · Sequences (all axial, no sagittal sequences)

o o Ax T2 FS

o o Ax FS Multiphase

 § 1 Pre contrast

 § 2 post contrast. Standard 10 mL gadavist 20 sec delay

o o MIP early phase

Thank you very much.

When a patient is having a pacemaker implanted and has second degree heart block causing symptomatic bradycardia, would both diagnoses be coded? I'm trying to determine if the bradycardia would be considered a sign or symptom and not coded, or if it can be added since it may or may not be present with a heart block and further explains the patient's condition?

Please help. We have a patient w/a multi-focal venous malformation. Physician did sclerotherapies at the shoulder, upper arm, and forearm. Separate draping was required for each one. These malformations are not at all connected. Can we bill for three units of 37241 for three separate Op sites?