Ask Dr. Z

If a patient has high blood pressure controlled by medication. Can you still use I10 ICD10 code as the diagnosis since while on the medication technically it’s no longer “high” blood pressure.

In regards to question #17280:

When a provider places an AtriClip during a CABG, does he need to document that the patient has/had atrial fibrillation, or can he/she report 33268 to prevent Afib?

Do you have any insight on this? I have a provider who places clips to the LAA for prevention of afib or during a Bentall for exclusion secondary to a desire to not anti-coagulate the patient who has undergone an aortic root replacement if they develop postoperative atrial fibrillation.

Would you code 33268 in these cases, does it meet medical necessity?

I have a physician who is performing embolization of the genicular artery - however he is coming from a pedal access: **Vascular access - left dorsalis pedis - advanced to the left SFA, advanced to the left descending genicular artery branch, advanced to the left inferior medial genicular artery branch, advanced to the left superior medial genicular artery branch. Left superior medial artery genicular artery branch was embolized. Are we able to report 36245-36247 from this approach or 36140 until he reaches the aorta. Thanks!

How would you code this? Thank you!

Staples from a thrombectomy one month prior were removed. Sharp dissection was performed to identify an atretic brachial artery and two old bypasses in this scarred operative field. The cadaveric vein was opened however it was chronically occluded and thus unable to pass a Fogarty. Adjacent to a brachial vein, a small brachial artery was identified. Heparin was given. A transverse arteriotomy was made with an #11 blade. By passing a #2 fogarty, both inflow and outflow was established however no thrombus was noted. This was closed with interrupted 6-0 prolene sutures. Despite a multiphasic doppler signal on this vessel, its size remained diminutive and thus not adequate to perfuse his hand.

On the medial forearm another bypass was noted with mixed echogenicity contents. A separate incision was made. A vein bypass was noted. This too was occluded with subacute to chronic contents and neither Inflow nor outflow was established.

catheter was used to subselect the origin of the inferior mesenteric artery. Next, with the help of a true form wire, a 2.9 merit microcatheter was now advanced into the inferior mesenteric artery used to subselect the left colic artery and further into the sigmoid artery. A sigmoid artery angiogram was now performed which demonstrates multiple superior rectal branches that extend towards the anal rectal region specifically supplying the hemorrhoids.

At this point, the 2.9 merit microcatheter is used to subselect a single left-sided and 3 right-sided superior rectal arteries where a total of six 3 mm coils are deposited. On the right side, a decision is made to embolize with particles. A standard 700 to 900 µm Embosphere particle mixture is made with 10 cc of contrast. A total of 2 cc is used to embolize the right superior rectal arteries at the very distal aspect of the superior rectal arteries in order to allow for distal embolization

do we use cpt 37242 for this & what cpt is simoid angio? Pls help

"The patient underwent common femoral endarterectomy and left SFA to posterior tibial artery bypass graft earlier in the day. Patient now presents back in the OR later that day for lower extremity revascularization due to an acutely thrombosed bypass graft. LLE angiogram was performed. The left groin, thigh, and calf incisions were reopened and explored. Hematoma was evacuated from all three. Hemorrhage from the suture line of the proximal SFA anastomosis was controlled with Prolene suture. As it appeared there was adequate inflow in the superficial femoral artery and adequate outflow in the native posterior tibial artery. It was concluded based on imaging that the issue with the bypass was of conduit quality, and therefore a decision was made to revise the bypass by replacing the conduit."

The provider wants to report code 35860 in addition to the bypass graft revision code (for the exploration and evacuation of hematomas). Would this be considered bundled with the revision code? Or is it separately reportable with a -78 modifier?

New to Cardio coding. Please advise which modifier to use...

EKG done 12/4/23 then repeated on 12/8/23 by the same doctor. Would it be 93010 for DOS 12/4/23 then 93010- 77 - 1 DOS 12/8/23???

I understand that if repeated on same day then bill first line as 93010 - 1 then second line would be 93010-76 - 1 but I'm not sure about billing for the different DOS.... Please help... Thank you.

During diagnostic angiography of the coronary arteries and grafts for indication of angina, the IMA graft to the 2nd Diagonal branch is injected and visualized. A stenotic lesion is noted at the anastomosis of the IMA to the D2. Would this lesion be coded as atherosclerosis of the graft I25.729, or as native atherosclerosis I25.119?

"5 French angled glide catheter was advanced over this wire into the distal radial artery. Fistulogram with radiological supervision and interpretation was then performed. This revealed near occlusive stenosis at the arteriovenous anastomosis and proximal outflow. 4 mm x 40 mm Mustang balloon was brought to the arteriovenous anastomosis, and balloon angioplasty was performed of the segment. The 4 mm x 40 mm balloon was also used to perform balloon angioplasty of the proximal outflow. Fistulogram was performed, which revealed significant improvement of the severe arteriovenous anastomotic stenosis. The 6 mm x 40 mm balloon was then brought into the proximal venous outflow, and balloon angioplasty was performed." 

Would you report codes 36215, 75710, and 36902 since the catheter was advanced to the distal radial artery? I reported code 36902 only. Can you give more explanation to what is considered arterial inflow in the dialysis circuit? Isn't this beyond perianastomotic segment for 36215 and 75710 to be used?

I'm new to carotid angiogram and wondering which CPT code (36222 or 36223) is correct for this case. 

"Catheter advanced to the ascending aorta to right brachiocephalic then right common carotid artery engaged. Multiple views of right carotid system then catheter pulled back to brachiocephalic. A brachiocephalic angiogram performed. The catheter pulled back and engage left subclavian. The catheter used to engage the left common carotid artery with multiple views. Finding state left carotid artery is normal and bifurcates into the internal and external carotid artery. External carotid normal and internal reveals 90% focal stenosis."

Patient has atrial fibrillation referred for ablation. per report left atrium was mapped and the pulmonary veins were isolated from previous ablation. Only the posterior left atrial wall was ablated. Normally, posterior wall isolation is an adjunct after PVI isolation with atrial fibrillation. Reading the guidelines as recommended by CPT to use 93653 for non-PVI isolation. Is this correct? My dilemma is whether to use 93653 or 93656 since this is atrial fibrillation and not atrial flutter. Appreciate your feedback Dr. Z. Thankyou.

If a wire and sheath are placed into the the IVC with venogram from a jugular access, is that reported with 36010 or 36005? Can a sheath be considered a cath and coded as selective?

We have been getting errors when coding 93799 with modifiers LC, LD, & RC. I am finding conflicting information as of the proper coding. As of January 1, 2024 were the rules around this code with modifier changed? Do we now code 93799 without modifier or continue the use of modifier when only one IFR used? Thank you

Our hospital is using a new device called the Reflow Temporary Spur stent. After performing an angioplasty, they insert the Temporary Spur Stent and inflate it which causes the drug-coated spurs to create channels in the vessel lining and the physician leaves it in place for a period of time to allow the drug to be deposited into the vessel lining to prevent recoiling after angioplasty.

Please note we code for pro-fee and facility. Would this procedure be coded as an angioplasty procedure with use of the reflow system included? Would this be an unlisted code? For pro-fee, if we can code the angioplasty code, would we also assign a -22 modifier for the extra work? 

If my provider is performing a left to right femoral-femoral PTFE bypass, what is the correct modifier to use with 35661? Do you consider this to be a bilateral procedure needing a modifier 50 or a unilateral procedure needing RT or LT modifier? Please advise.

Can you provide any updates regarding guidance for code 76937 "Ultrasound-guided vascular entry" being reported separately with cardiac cath, EP ablation, or pacer/defib procedures? One of your responses to a previous question regarding 76937 was that it cannot be coded with cardiac cath, EP ablation, or pacer/defib procedures.

Can we code an additional 35700 (with 35666) because the patient had a femoral endarterectomy a couple of years ago (same vessel), and the patient did not have bypasses in the past?

According to AAPC guidelines, 35700 is used when the provider re-operates on an arterial bypass graft more than a month after the initial procedure.

According to ZHealth Vascular Book – “Report add-on code 35700 for reoperation of extremity bypasses greater than one month after original surgery”.

Am I understanding correctly that we can code the +35700 only if the provider does the “reoperation of extremity bypasses”? Our provider wants to code 35700 because the patient had an endarterectomy in the same vessel three years ago. On Question (ID : 18040) you answered that we can. I am confused. Please clarify.

Our physician did a PVI ablation for persistent atrial fibrillation. He then documents non-PVI foci ablations of the LA roof line and the LA anterior wall. Would this be considered one unit of 93657? Or two?

Here is an excerpt from the report:

"The four PVs were sequentially ablated with loss of PV potentials in all four veins and exit block. RF ablation line was created across the LA roof from RSPV to LSPV. RF ablation line was then connected from this RF line to the anterior MV annulus. At the conclusion of the ablation lesions in the left atrium, the catheter/sheath was removed as a unit from the left atrium."

I have a patient that had a pacemaker placement in early January with a diagnosis of sick sinus syndrome.

In the doctor's operative report it is stated "Arrange Tikosyn admission in 4 weeks after pacemaker for rhythm control".

The patient is now an inpatient and the doctors are submitting charges for atrial flutter.

I am going back and forth as to whether these can be billed with a 24 modifier or if they are part of the global and should not be charged.

I feel like it's part of the global, but I'm not absolutely positive, and I don't want to take charges away, so I am looking for some guidance with this scenario.

Thank you!

Our physicians are performing this procedure more often to elevate a fistula. "Preoperative ultrasound was used to interrogate the AV access which identified significant depth between the dermis and cannulation zone with depth of 15 mm. Standard wetting solution consisting of saline lidocaine and epinephrine mixture was infiltrated into the subcutaneous tissue space using tumescent technique immediately surrounding and superficial to the AV access. Suction lipectomy was performed in the subcutaneous tissue layer directly superficial to the AV access for the entire cannulation zone under direct visualization of ultrasound to achieve desired tissue depth for appropriate future cannulation. Final depth visualized by US was 3 mm. Post suction lipectomy access angiogram demonstrated no injuries." I reviewed Question ID 4005 from 2012 and wondered if your recommendation is still the same. Physician would like to report 36832 only for this service. Thanks in advance - you all are the best!

Pt w/radiocephalic fistula. A large collateral vein was cannulated with micropunture set. Dilator advanced in a retrograde toward the arteriovenous anastomosis. Arteriogram showed a severe stenosis of the proximal cephalic vein distal to the anastomosis. PTA of the stenosis was performed. In order to treat the thrombus within the access TPA was instilled within the access. The thrombus was also macerated percutaneously. Prior to the completion of the procedure a 2-1 Vicryl suture was inserted through the skin & subcutaneous tissue surrounding the collateral vein. The suture was tied so that the flow through the vein was disrupted. Findings: A critical stenosis of the proximal cephalic vein was dilated with 5mm balloon with improvement in caliber. A small volume of thrombus within the fistula at the level of the antecubital fossa was treated with TPA as well as maceration of the clot. The large competing collateral vein was ligated using 2-1 Vicryl. Would the codes be 36000 (access), 36905 (Fistula TPA & PTA) and 36909 (vein ligated)?

I was told that code 32652 address both the decortication and pleural effusion) The incision was placed along the intercostal space. VATS scope inserted. A large amt of fluid was found and a thick cortex surrounded the left upper lobe and anterior chest wall, a gelatineous pleural effusion was drained & debrided; lung was separated from the thoracic wall, fluid was drained, the lung was successfully decorticated & the major fissure was able to be opened. Thank you

If a patient had a history of EVAR several years earlier and now presents with enlarging aortic aneurysm, are we able to report 34830/34831/34832? The surgeon believes that these codes are only use if EVAR is attempted and failed on the same day and open repair is ultimately performed. If that's true, would we just use the open aneurysm repair code? I don't believe we would be able to code for the EVAR explant, since it was not infected? Can you please weigh in? 

Physician performed an aortic to inferior pancreaticoduodenal artery bypass. Since the IPDA is a branch of the mesenteric artery, would we be able to report code 35631, or would this have to be unlisted code 37799?

Co-surgery Interventional and Cardiac performed TAVR CPT 33361, towards the end, complication occurred, they both tried to retrieve the prosthetic valve but failed. This resulted to SAVR. How do we code this, 33361 (62,53) then 33405 (59)?

Creation of AICD pocket only by cardiothoracic surgeon. Placement of the leads and generator by cardiologist. Per the cardiologist's documentation: "The cardiothoracic surgeon then came in and performed creation of his left subpectoral muscle pocket." Per the cardiothoracic surgeon's note: "After informed consent was obtained, the patient was brought to the EP lab for device and lead placements that were performed by the cardiologist." If both providers cannot bill 33249 with modifier -62, how would you recommend this be billed?

"History: Left supraclavicular lymph node.

Interpretation: After obtaining informed consent, the patient was placed supine on the examination table, and the neck was prepped and draped in a sterile fashion. A timeout was performed confirming the correct patient, procedure, and site. Local anesthesia was achieved with lidocaine 1%. With ultrasound guidance, a 25 gauge needle was used to obtain a fine needle aspiration biopsy of the left supraclavicular, 4.3 x 2.3 x 4.0 cm lymph node. Three samples were obtained. Cytology was present and determined that the specimen was adequate for evaluation. Next, two 18 gauge samples were removed and placed directly in formalin. The patient tolerated the procedure well without complication.

Impression: Uncomplicated fine needle aspiration and core biopsy of an enlarged left supraclavicular lymph node."

Would this be coded with codes 38505 and 76942 or codes 38505, 76942, and 10005?

Hi Dr. Z I need your advise on this article from CMS A52850 it says that sedation is included in cardiac catheterization and coronary angiography and should not be separately billed to Medicare. This revision that went into effect 10/01/2023.

Can you please provide me the CPT code for a craniotomy? Basically a surgical procedure to open the brain and place a clip on the aneurysm. 

cpt 33233, 33234, 33235 was billed together, but cpt 33234 was ad mutually inclusive to cpt 33235.

We have just recently started using this technology. In 2019 a Q&A said the MD has to document 3D FFR. However our physicians will state the technology in a variety of ways. What is sufficient for coding 0523T?

1) LAD FFR by cathworks is 0.87

2) Diffuse mid LAD 40% stenosis. TIMI 3 flow. CathWorks FFR: 0.83.

Some have a section of their report where it is documented like this by staff:

3) Flow wire: FFR.

FFR measurement is 0.86. Measurements were obtained in the middle right coronary artery. CathWorks system.

(Because the title says Flow wire they are documenting Cath Works at the end. (When it is a flow wire the wire supply is listed in the statement.) We are working on removing the words Flow Wire from generated text.)

And to clarify - if 3D angio and FFR is done in the same setting - only report one code. Report 93571 or 0523T?

Thank you very much!

When coding a diagnostic study such as an Echo or EKG, if the findings state trace or trivial, should that be coded as a diagnosis? I did review question ID 18799 but the answer is that minimal should be coded. What about trace or trivial?

A chief tech at our hospital stated that vessel selection codes in intracranial embolization cases are now included in the embolization CPT 61624. I am unable to find supporting material for this statement. Can you confirm this?

In your Interventional Cardiology 2023 reference book pg 580 in order to bill for the code 0408T- Optimizer CCM system it would have to be a complete system (generator and leads). A complete system consists of a generator and 3 leads (2 RV and 1 RA leads). If the patient only receives two RV leads placed with the generator, would this still be considered "complete"? If it's not considered complete with just the two RV leads, how you we code this for facility? Thank you.

Clinical indication is: Ischemic Cardiomyopathy (functional class III), her EF 40% and does not meet criteria for CRT therapy.

Would this be unlisted? No catheterization due to extensive atherosclerotic disease. Agent: Packet of Gelfoam mixed with 5000 units of recombinant thrombin. fluid portion of the hematoma was accessed with a 5 French Yueh catheter directly. Under ultrasound guidance, Gelfoam slurry mixed with the recombinant thrombin was administered into the retroperitoneal hematoma. Via the 5 French Yueh catheter, other parts of the hematoma was also injected with Gelfoam slurry mixed with recombinant thrombin. A total of 50 mL of Gelfoam slurry mixed with recombinant thrombin (5000 units) was administered directly into the liquid portion of the hematoma. Catheter was removed.

Impression: Ultrasound-guided percutaneous administration of Gelfoam slurry mixed with the common and thrombin into the left retroperitoneal hematoma.

Any help would be appreciated!

Would this be 10035 or C9728/77012? We also charge for both facility and IR radiologists.

Excerpts from report:

PROCEDURE: CT-guided targe marker placement

Pre-procedure diagnosis: T8 metastatic lesion causing cord compression

Post-procedure diagnosis: Same

Indication: Presurgical planning for T8 laminectomy

Additional clinical history: None

IMPRESSION:

Technically successful CT-guided marker placement with the tip of the Kopans needle projecting adjacent to the tip of T8 the spinous process.

Imaging prior to biopsy

The patient was positioned prone. Initial imaging was performed using noncontrast CT.

Sagittal and axial images were obtained. The tip of T8 spinous process was identified.

Marker placement

Local anesthesia was administered. Under CT guidance, a Kopans needle was advanced to the target and deployed.

Imaging following biopsy

Immediate post-biopsy imaging was performed using noncontrast CT.

Post-biopsy imaging findings: No evidence of acute complications. Appropriate positioning of the tip of the Kopans needle

Thank you.

"The INARI thrombectomy catheter was inserted and advanced to the IVC/RA junction just below the mobile echo density. 4 ASPIRATIONS WERE performed with retrieval of significant harvest and TEE confirmed removal of large masses from the SVC/RA junction." Successful mechanical thrombectomy of right atrial mass in transit with removal of significant harvest using fluoroscopy and TEE guidance. - Would this be coded as 0644T or 33999?

Dr. Z, I am unable to locate a CPT for this procedure (unless is it unlisted). Is an unlisted code most appropriate? Thank you.

Sacral region was prepped and draped in usual sterile fashion. 1% lidocaine was used locally.

Under CT guidance 4 separate 20-gauge spinal needles were advanced through the sacrum disease 2 on the right and 2 on the left.

On the left at the needles were advanced through a large infiltrating tumor and positioned more towards the anterior aspect of the sacrum. On the right at the more superior needle was advanced through the sacrum and into the anterior presacral space. The inferior needle was positioned along the right lateral margin of tumor extending across midline.

A total of 30 mL of 0.5% bupivacaine and 80 mg of triamcinolone were instilled through the for needles.

The needles were removed.

IMPRESSION:

CT-GUIDED THE PRESACRAL NERVE PLEXUS BLOCK

Please let us know - What is the CPT Code for Robotic Assisted Resection of an Intercostal Neurofibroma?

Thank you,

How do you code for this procedure described below:

Completion of bilateral common femoral endarterectomies were done. Next a rt percutaneous transmural arterial bypass. Rt post tibial vein was accessed and a mirco-puncture kit was upsized to 6Fr sheath. A venogram was performed which demonstrated adequate caliber vein and bifurcated femoral venous system. A 8Fr sheath was used up/over the bifurcation using a support wire and Endo cross device was advanced into the SFA >than 3 cm beyond the origin of the profunda femoris. A snare was advanced up the femoral vein to the site of venous entry. The crossing device was deployed and wire advanced slowly retracting the needle with wire snared once within the venous lumen. Crossing device was advanced after ballooning the proximal anastomosis with 4 mm balloon. A rt LE angiogram was done to allow superposition of popliteal reconstitution and crossing catheter which was used to deploy needle and wire advanced to intra-arterial access. Lumen placement of wire and device were removed.

Please explain why physicians cannot bill 36598, 36593 in hospital setting when physician administers tPA to port following the port study. Status indicator T implies that 36598 is not payable only when other services that are payable are submitted by same provider on same DOS. If 36593 is not payable due to POS then 36598 would be payable to physician in this setting. We are reimbursed for the 36598 we are never reimbursed for 36593.

We exchanged a right femoral vein TDC under fluoroscopic guidance and then placed a new tunneled line with new access in the left femoral vein also under fluoroscopic guidance. Would we report code 77001 x 2, or would a single code cover both procedures?

I coded: 35081, 35371-50. I feel like I am not accurately coding for the femoral graft procedures. Open aortic exposure performed w/vessel control. Aortotomy made w/removal of thrombus and plague. Dissection carried down to the aortic bifurcation and RT & LT CIA arteries. Blunt dissection used from femoral incision up to retroperitoneum. Dacron graft applied end graft to end aortic anastomosis. Left femoral arteriotomy made & extended in CFA down to SFA, 1-2 cm. Endarterectomy performed. Left limb of graft approximate to arteriotomy. Right femoral arteriotomy performed, extended 2-3 cm into SFA. Endarterectomy performed. Graft applied end to side. Fogarty embolectomy performed, 5 passes, due to no backbleed from SFA. Anastomosis completed, flow reestablished to femoral vessels. Fascia closed. Femoral incisions closed. Am I missing a code or is there a more appropriate code?

Question ID # 4680 states that is a resection of part of the ICA took place its included within the 35301. It was answered in 2013 and we are wondering if there have been changes?

Facial veins are crossed carotid sheath was ligated and divided. CCA dissected free at the level of the omohyoid. The dissection was then carried out in a cephalad direction until the origin of the ECA and superior thyroid arteries were identified and dissected free. ICA dissected free up to the point where it passed below the posterior belly of the digastric muscle. It was noted to be somewhat redundant in this area, but it was dissected free past the area of stenosis. ECA/ICA and CCA’s were clamped. Arteriotomy in the CCA extended through the carotid bulb onto the ICA beyond the area of stenosis. All loose plaque and debris were removed. About a centimeter and a half of ICA was then resected just distal to the carotid bifurcation. The ICA spatulated suture the ICA was sewn to CCA reforming the back wall. The ECA & CCA were opened. After several heartbeats the ICA open.

Would 36901 and 36002/76942-26 be the correct codes for this procedure?

"LT ARM AV FISTULA ACCESSED FISTULOGRAM PERFORMED REVEALED NO PSEUDOANEURYSM OFF GRAFT ULTRASOUND USED TO INTERROGATE ARM SHOWING LARGE ANEURYSM W/FLOW AWAY FROM MAIN BRACHIAL ARTERY LIKELY SUGGESTIVE OF A BRANCH OFF THE BRACHIAL ARTERY.ULTRASOUND USED 18-GAUAGE SPINAL NEEDLE ACCESS ACTIVE ANEURYSM SAC INJECTED THROMBIN REPEAT INSPECTION SHOW LOSS OF FLOW IN SAC PATIENT HAD NICE PALPABLE RADIAL ARTERY AND GOOD FLOW INTO AV GRAFT.

PATENT AV GRAFT W/NO EVIDENCE OF ANEURYSM COMING OFF GRAFT ULTRSOUND ELVALUTION SHOWING ANEURYSM SAC MEDIAL TO AV GRAFT BUT FAR AWAY FROM MAIN BRACHIAL ARTERY THERE IS ACTIVE FLOW AFTER THROMBIN INJECTION THERE IS PULSATILITY AND NO FLOW IN ANEUYSM SAC."

I know you're swamped with 76937 questions with the new NCCI directive. I appreciate your consistency and diligence in helping us all understand this new directive!

Since 76937 is now bundled with any RS&I codes, does the requirement for permanent stored images essentially transfer to the RS&I code? I.e.: Embolization for hemorrhage is performed; vessel access with ultrasound guidance, but there's no documentation of stored images. Does this represent a reduced service on the embolization, now? Or insufficient documentation?

Thanks in advance!

For codes 93286 and 93287, the description states '"in person". We have documentation that does not state the service was provided in person. My question is, does the documentation have to specify that the service was performed in person?

I believe this guidance to be incorrect. Can you please clarify if 75625 should be reported? The celiac “trunk” is a small portion of artery that arises off the aorta. If the IR physician has accessed the right common femoral artery, taken the catheter to the aorta, aortogram done, then selected the celiac trunk only and released dye, the code assigned is 36245, as this is the first branch off of the aorta (75726 S&I). Notice that the coder does not assign a code for the catheter in the aorta (36200), even though the IR MD may have stopped and done an aortogram in the area. This is because a “selective” catherization always includes the “non-selective” catheterization before it. However, 75625 would be assigned for the S&I for aortogram.

Our Vascular providers whenever they do abdominal aortic aneurysm repair with 34705 and coil embolization of internal iliac artery they also place an extension graft to the external iliac artery to cover internal iliac artery origin in that side. Do we bill 34709 for this extension into external iliac artery to cover internal iliac origin along with 34705, 37242, and catheter placement?

This might be a completely stupid question, but I have been asked this question and don't quite know how to answer it. In your 2024 Interventional Radiology Coding Reference on page 158, can you explain why the superficial femoral on the left side (non-selective side) of the picture is a 1st order, while on the right side of the picture it is a 3rd order? I can't explain why the orders change.