Ask Dr. Z

The distal ascending aorta was opened. There was a fragile clot in the distal arch, which was able to be removed with minimal force. There was a small ruptured plaque underlying it. The arch was irrigated and suctioned to remove any residual debris. We elected at this point to cover the ruptured plaque with an endograft. A 26 x 26 x 100 mm Medtronic Valiant endograft was brought onto the field. The Lunderquist wire was passed through the delivery system which was delivered into the visualized aortic lumen and deployed such that it landed in zone 3, just distal to the left common carotid artery. The delivery system was withdrawn. An ophthalmic cautery was used to fenestrate the graft directly opposite the left subclavian artery ostium. Once this was completed, the leading edge of the endograft on the inner curve of the aorta was secured using a 4-0 Prolene pledgeted suture. He would like to bill this as a 33880 and 75956-26 but we wondered if an unlisted code is more appropriate since he was treating thrombus and not an aneurysm?

The right common femoral artery had pulsatile bleeding following deployment of both Perclose devices. A third Perclose device was deployed, however, the patient continued to have pulsatile bleeding from the access site. The 16 French sheath was then replaced into the common femoral artery for hemostasis. A 10 blade was then used to make a incision overlying the sheath access. Electrocautery was used to dissect through the subcutaneous tissue and the proximal common femoral and distal common femoral artery to the access site were dissected out and encircled in Vesseloops. The sheath was then removed and the Vesseloops were used for hemostasis. The arteriotomy was freshened with Potts scissors. Using multiple interrupted 5-0 Prolene suture the arteriotomy was then closed. A microcatheter was then placed through the Kumpe catheter into the primary trunk of the right internal iliac artery. 20 mm x 60 mm framing coils were then deployed into the trunk of the right internal iliac artery. This was then followed by four 8 mm x 60 mm filling coils.

How would you bill the following procedure, 93603, 93612 or can you use additional add-on codes? "An EP catheter was advanced to the RV apex via the SRO a DecaNav catheter was advanced to the right ventricle. The Catheter was withdrawn to the AV groove and placed out the CS. A 3D activation and EP map of the CS wa created using the cardio system. The maximal extent that the CS could be instrumented was to about the 1 o'clock position at which point the local ventricular signal in the CS was largely eqiuvalent to the QRS onset of hte PVC and pace mapping was 85%. Despite extensive efforts, the catheter could not be advanced further. In an effort to get to an earlier point for ablation, the DecaNav catheter was exchanged for an ablation catheter and further mapping points were taken in the area of interest. Despite the bidirectionally of the catheter, the ablation catheter could not be successfully advanced to the primary area of focus. As a result, further attempts at reaching the epicardial PVC focus were abandoned and the procedure was terminated."

We have times that we perform an echocardiogram pre- or intra-procedural for line placement, ECMO placement, device closures, etc. Would we still bill CPT codes 93303/93308/ 93320/93321/93325

If the provider performs a congenital RHC and injects IVC and SVC, do we bill 93584 or 78525 and 78527? What would be considered appropriate documentation for anomalous persistent SCV when it exists as a second contralateral SVC- does that mean if the patient has two SCV and the second one is on the opposite side?

Can you please tell me if this qualifies as CT guidance (77012) or should we be using flouro guidance (77002)? "Patient was positioned prone in the angiography suite. Preliminary CT Images were obtained using the angiography suite identifying an appropriate site for bone marrow biopsy as well as appropriate site for skin access. Under real time fluoroscopic guidance an on control device was advanced to the left ischium." (It goes on to talk about the samples obtained). The last line of the report states "Successful uncomplicated fluoroscopic guided bone marrow biopsy". 

I have an appeal denial from UHC stating that cpt code 37233-59-LT (1 Unit) remains not supported. As per the Society of Interventional Radiology Coding Manual, if an angioplasty or atherectomy of an occlusion is unsuccessful because the lesion cannot be crossed, then the appropriate access and/or selection only should be coded. As such, the request for CPT code 37233 is denied as "Not Documented."

I don't understand this - our provider documented atherectomy/PTA in left AT, and a partially successful atherectomy and PTA of the left PT (residual stenosis). Are we not able to bill for code 37233 for the second vessel because it was partially successful?

Prior to a Mako robotic knee replacement, a CT is required preoperatively. The CT is used to generate a 3D virtual model of the patient's anatomy. The virtual model is loaded into the Mako System software and used by the surgeon to create a personalized operative plan. Do we bill for CT of the lower extremity? We are starting to see pre-auth denials, so our radiology department is asking if we should use 77011 instead.

When assigning the unlisted procedure code 93799 for iFR studies, do we need to add the coronary modifier? Physician performed iFR studies in the LD and RC (93799-LD, 93799-RC).

Hello, Will you revise previous advice regarding 47562 vs 47563, for example in question ID 18535, based on Coding Clinic for HCPCS 2nd qtr. 2023? Clarification/correction of the advice in CC 1st qtr 2022 was provided. From my understanding of the advice, imaging with ICG (IVC) is not the same as IOC. Therefore, 47563 would not be appropriate for intravenous ICG cholangiogram, as it requires placing a catheter into the cystic duct to inject contrast. Than you,

What is compliant to code on selective angios w/o narrative dictated, i.e. "selective" indicates the vessel catheterized?

Dict:

Procedures Performed - Aortic arch angiogram. Selective brachiocephalic and subclavian angiogram

RCFA access

Findings: Heavily calcified aortic arch with severe atherosclerosis and a 30% aortic narrowing

Heavily calcified occlusion of the left subclavian artery with retrograde filling via the vertebral to the axillary artery

Moderate heavily calcified ostial brachiocephalic stenosis

Patent left carotid artery

36225, 75710-LT, 36215-XS?

If the clinical indication on a report is lumbar radiculopathy, and findings state spondylosis of L2-L3, L5-S1, can we use the combination code for both levels with M47.26/M47.27 or does the provider have to link which is causing radiculopathy?

Also, is it acceptable to code osteophyte of the vertebra when coding other conditions such as stenosis, spondylosis, etc.?

What is a CPT code that is comparable to unlisted code for reduction aortoplasty?

"A section of the enlarged ascending aorta was resected along the greater curvature. The resected margins of the ascending aorta were approximated between two felt bolsters with a double running 4-0 Prolene suture, thus reducing the dilated section of the ascending aorta to a much more normal diameter."

We have echos where we check the placement of lines, ECMO placement, device closures, etc. Would we still bill the normal echo codes either congenital or non congenital? 93303/93308, 93321/93320/93325?

Code 92972 has replaced 0715T in 2024 for percutaneous transluminal coronary lithotripsy. If atherectomy and/or angioplasty with stent is performed as well, should the C9600-C9608 series be coded or in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975?

If a patient received an IVL procedure in the iliac (just the IVL, e.g., C9764), and an atherectomy in fem-pop, how would this be coded by both the physician and the facility (hospital outpatient)?

I am coding for a new group, and we are using the following dictation to bill code 76377. The powers that be are stating the standard procedure in the department is that the radiologist is directly involved in the creation of the images. Is this enough dictation in the report to consider concurrent supervision and bill appropriately? "3D post-processing of the images was performed on an independent workstation, and the post-processed images were used in interpretation." I want to make sure we are compliant when using this code in our IR cases.

If there's more than one laceration repaired for two diaphragmatic injury, can code 39501 be reported twice? Example: repair of right-sided diaphragmatic injury with closure of mediastinal and left-sided peritoneal layer tear overlying left diaphragm, LEFT and RIGHT side repaired.

In regards to question # 18403: If one APP assists with the harvest and CABG and a second CT surgeon assists with the MAZE procedure, how does the CT surgeon get to code 33259-80 without also coding the parent code 33533? How should this be broken down? APP get 33533AS 33518AS 33508AS -xu--How do you code for the 2nd CT surgeon helping out with MAZE? you cant code 33259 w/o a parent code...which would be 33533, but he didn't assist with that..........

On question 13390, it was advised that mod 59 was not required when one physician of a group practice performed the diagnostic cath and another physician provided the intervention because they are "billed as if they are one physician." Even when one physician performs both the cath and the stenting, the cath must have modifier 59 (or appropriate X modifier), or the cath will deny because it bundles with the intervention. Can you please clarify the previous response of question 13390 that no modifier 59 is required? Thank you.

When an angioplasty is performed only in a coronary SVG, do we report code 92920 or 92937? Code 92937 says a "combination of", so I'm not sure if it would be appropriate to report 92937. Please advise.

I know the sternotomy and exploration are inclusive, but need guidance on the perforation repair. I have 33300 and 33268. Perforation occurred during a Watchman placement.

Emergency Sternotomy

Emergency mediastinal exploration

Repair right atrial appendage perforation

Excision left atrial appendage

Perforation on the medial aspect of the right atrial appendage was noted and grasped and controlled with DeBakey clamps. Vas clamp placed last across the site. Patient received 10,000 units of heparin intravenous.

Main portion of pericardium/mediastinum was evaluated. No obvious additional perforations. The right atrial appendage perforation was then oversewn with pledgeted 4-0 Prolene sutures. Hemostasis was achieved. The perforation appeared to be adjacent to the aorta slightly cephalad from the noncoronary cusp. The adventitia appeared to be slightly irritated; however, there was no perforation.

Left atrial appendage was ligated with a GIA stapling device.

For reporting CT CTA / MRI MRA on the same date of service. For stroke rule outs and different techniques used between the CT and the CTA. Is this a scenario in which both are chargeable and not just the CTA?

If the indication on the operative note for ICD implantation only states primary prevention of cardiac arrest, would it be appropriate to code I46.9?

Provider billed 33225, 33229, 78520, and 36005 LT-59. Insurance denied stating codes 36005 and 78520 are bundled. Per Encoder Pro both codes can be paid separately and a modifier is allowed. We appended a -59 modifier, but the claim was still denied.

Left upper extremity fistulogram. The stenosis in the graft venous anastomosis was crossed with the wire. Angioplasty of the stenosis in the graft venous anastomosis was performed using 8x40 mm Balloon; then sheath was redirected towards the arterial inflow. Balloon angioplasty of the arterial anastomosis with a 6x40 mm balloon. (Same Access) do I bill both 36902 and 36907?

What if the physician uses a second access to access arterial anastomosis, any other access code to bill for second access? 

"Procedure: Ultrasound-guided percutaneous core biopsy of left auricular lymph node. Clinical History: left auricular lymphadenopathy. Technique: Ultrasound of the left auricular region  was performed. The lesion was identified and multiple images were stored. The skin was prepped using ChloraPrep, and allowed to dry before sterile draping applied in the usual sterile fashion. Using lidocaine for local anesthesia as well as direct ultrasound guidance, using an 18 gauge Biopince needle, a total of four percutaneous core needle biopsies were made. Ultrasound images of needle entry were saved and sent to PACS. A sterile dressing was applied. The patient remained stable during and immediately after the procedure. Impression: Ultrasound-guided percutaneous core biopsy of left auricular lymph node."

Would this be reported with code 38505?

I have a physician who performed an upgrade of a single chamber ICD into a CRT_D. He is billing 33264, 33217, 33225, 33244. My question is can you bill the 33264 and 33217 together? I am seeing conflicting information.

Two AT ablations

The tachycardia was most consistent with a microreentrant right atrial tachycardia at the high right atrial septum. A TactiCath 3.5 mm irrigated tip ablation catheter was used to deliver radiofrequency lesions to the SVC to IVC septum line ablation performed. The AT was altered with ablation.

A second AT was identified. The tachycardia was most consistent with a microreentrant left atrial tachycardia at the endocardial mitral annulus. A TactiCath 3.5 mm irrigated tip ablation catheter was used to deliver radiofrequency lesions to theendocardial mitral annulus. The AT terminated to sinus rhythm with ablation.

Can I code 93653 & 93655?

Pt came into holding room area and tunneled picc line was removed. Can 36589 be charged for a tunneled picc?

Does HydorMark clip placed after the biopsy support CPT 10035 + 38505 ?

The procedure was explained to the patient including benefits and risks.

Consent was obtained. The procedure was done with the Hologic Sertera core

biopsy unit in the supine position under ultrasound guidance. Initial images

were made. Skin of right axilla was prepped in the usual sterile manner. Local

anesthesia was made with the 1% xylocaine, sodium chloride and epinephrine

solutions. A small skin incision was made. A 14-gauge needle was used. The

needle was placed under ultrasound guidance, and the tip was passed through the

lesion. Seven cores were collected and placed in a formalin solution. All

specimens were sent to pathology at the XTS for histopathologic diagnosis. A

HydroMARK clip was placed in the area of the biopsy cavity, and a MLO view was

taken. The patient tolerated the procedure well. No immediate complications were

noted.

We understand that traditional Miller banding on a dialysis fistula is considered an open revision and coded with 36832. Is the more minimally invasive “modified Miller banding” also considered open and coded with 36832? Or would it be considered percutaneous?

"Basilic vein was marked on the skin using duplex and local anesthetic applied. A small 15 blade was used to make a skin incision and the basilic vein was identified. Basilic then encircled with a Prolene and a stiff glidewire was placed on top of the basilic vein and a modified miller banding was then performed. Incision site was then irrigated and closed with interrupted 3-0 Vicryl buried deep dermal followed by 4-0 Monocryl and skin glue."

I have read the Retinoblastoma arterial chemo administration question examples ID:11790/ID:11838/ID:2490. Is there a medical reason for using CPT 61650 - prolonged administration which is an Inpatient only procedure instead of using CPT 96420 or 96422 Chemotherapy administration intra-arterial which is not an Inpatient only procedure. Are there clinical factors that make CPT 61650 the best coding for the procedure performed?

"The patient has acute bilateral iliac DVTs with IVC thrombus. The Excel mechanical thrombectomy catheter was advanced, and a single pass was performed through the left external iliac vein. Attention was then turned to the right common iliac, and using the Bold mechanical thrombectomy catheter and appropriate tension over the confluence. Subacute to chronic appearing thrombus was removed."

Can this be coded as 37187-50 since it was done on both sides, in two different vascular families? Or should it be coded as one 37187? And if they also did a mechanical thrombectomy of the IVC at the same session as the bilateral thrombectomies, can this also be picked up with 37187?

Do you know what manufacturer application an actual device was approved that led to the creation of HCPCS C1604-Graft, transmural transvenous arterial bypass (implantable), with all delivery system components? I have read through the HCPCS Summary and decision documents where that info is usually found but have been unable to locate it.

Which code would you use for the Augmentation of the left acetabulum with cement??

Vertebroplasty

Target level: Left anterolateral aspect of the L4 vertebral body lesion

Pedicle access: Unipedicular

Access trocar size (gauge): 11

Manufacturer: Stryker/Carefusion

Cement type: Polymethyl methacrylate (PMMA)

Clinically significant cement leak occurrence: Small volume leakage in the adjacent disc space

Augmentation of the left acetabulum with cement

Target level(s): Left acetabulum

Access trocar(s) gauge: 11 gauge

Cement type: PMMA.

Manufacturer: Stryker/Carefusion

Clinically significant cement leak occurrence: No

Thanks in advance for your assistance.

"A patient with radial artery thrombosis underwent thrombectomy by surgical cutdown (34111). After removal of a significant amount of acute thrombus both proximally and distally, there was good distal radial artery backbleeding but no good inflow. Thrombectomy of the inflow was attempted by filling the Fogarty catheter with saline (initially it had been filled with air), but this did not result in any significant improvement. The surgeon then inserted an angiocatheter into the radial artery and performed an angiogram, which revealed significant residual chronic thrombus in the proximal radial artery. Additional thrombectomy was then performed with good result." Would it be appropriate to report code 75710 for the angiogram performed in this case? If so, would we also report code 36140 for the catheterization?

Do you use the location modifiers (-LD, -RC, ect.) on code 92972?

Is 21603 still reportable with 32480 when chest wall tumor is removed en-bloc with left lobe?

"Procedure: Thoracotomy was performed. The left upper lobe was found to be infiltrating a portion of the chest wall involving segments of ribs 3, 4, and 5. Therefore, this portion of the chest wall was resected en-bloc with the left upper lobe. The left 3, 4, and 5 ribs were transected anteriorly and posteriorly. The second intercostal space was cut along the upper border of the third rib to complete the resection of the chest wall. The left pulmonary vein was dissected free and transected with a stapler load. Finally, the left upper lobe bronchus was also dissected free and transected with load stapler. Then mediastinal lymphadenectomy was performed. The specimen was removed en-bloc from the operative field. Goretex patch, dual layer (20cm x 30cm) was used for plastic reconstruction of large chest wall defect."

I am really at a loss here. This is more than a straightforward Foley removal to charge as an E&M. Would this go to an unlisted and 77002?

"Ultrasound confirmed the presence of the Foley balloon in place within a contracted urinary bladder. Through the lumen of the Foley catheter, an 8 French dilator was advanced, and contrast was administered opacifying the contracted urinary bladder. Balloon was clearly identified as well. Under fluoroscopic guidance, the Foley catheter was advanced forward. An area in the suprapubic region was then infiltrated with 1% lidocaine. Under direct fluoroscopic and sonographic guidance, a 20-gauge needle was advanced into the region of the balloon and the balloon was punctured successfully. The balloon was deflated. Foley catheter was then removed intact. Patient tolerated the procedure well without immediate complications.”

Is the coil embolization separately billed or included as part of 35151 for the popliteal aneurysm repair?

1. Right proximal popliteal artery to distal popliteal into the tibioperoneal trunk artery bypass with greater saphenous vein

2. Open thrombectomy of the right posterior tibial artery with fogarty balloon

3. Open thrombectomy of the right anterior tibial artery with fogarty balloon

4. Ligation of the right popliteal artery aneurysm

5. Right lower extremity arteriogram with supervision and interpretation

6. Embolization of two separate right popliteal genicular arteries using terumo azur 035 coils.

7. Selective catheterization of two separate genicular arteries

"We then used a navicross and glide wire advantage and selectively catheterized the popliteal artery genicular branch. Two terumo coils 5x11mm were then deployed. We then selectively catheterized a second genicular popliteal artery branch and coil embolized with a 6x17mm genicular branch"

Is it correct to charge 76380 CT limited for a intraoperative 3D CT C-arm study when used during a neuro spine case or orthopedic implant case? Can the 3D code 76376 also be charged?

Procedure was “Hepatic radioembolization preparatory angiogram and Tc99m-MAA administration.” Can we code 36247 catheter placement for MAA administration? CPT Assistant, February 2012 says, “The administration of a radiopharmaceutical is inherent to nuclear medicine studies.” Is catheter placement included in nuclear medicine studies? Selective angiography was done with catheterization at left hepatic artery trunk. Radioisotope: Technetium-99m MAA administration was done from catheter position: Segment 4 branch off the left hepatic artery trunk. Contrast was also used, but it was not mentioned when or how it was given. 78202 and 78830 were done.

Can we code 36247 with 78202 and 78830 without 75726? Or should this be 75726, 36247, 78830, and 78202?

Would this documentation support CPT codes: 93656, 936557 and 93623?

PVI was achieved for all veins with entrance and exit block. High dose isuprel induced 2 separate triggers from the posterior roof near the left-sided veins. A detailed sinus rhythm scar map was created showing patchy scar in this region. Scar modification was performed after which no further PACs were noted. Atrial pacing induced brief typical appearing flutter. Pulmonary vein isolation continued through a 30-minute waiting period.

Please advise.

What CPT code(s) would be billed for the following.

The right tunneled PICC tip was shown to be in the internal jugular vein.

Aggressive saline flush was performed, which was successful in

repositioning the PICC tip to the SVC/RA junction.

Fluoro was used but no contrast

Thanks

The left main coronary has normal takeoff from the left coronary cusp, has mild disease. The LAD is totally occluded. Left circumflex artery has a 70% very distal stenosis. The 2 obtuse marginal branches have 90% stenosis as well, and actually one of them is more like a left PDA. The RCA is a small nondominant vessel and has a 90% proximal stenosis. The left internal angiography demonstrated patent LIMA to LAD. Saphenous vein graft angiography demonstrated patent graft to the first obtuse marginal branch, and graft angiography demonstrated patent graft to the left PDA. Left ventriculography was performed with ejection fraction of 60%. Pullback from the left ventricle to the aorta did not reveal any severe stenosis.

My concernt is there is no mention of placement of catheter in bypass grafts.

Is catheter placement reported with shockwave llithotripsy in the lower extremities? For example, would 36247 be reported with C9764? In the other lower extremity revascularization CPT codes, it is bundled and there is an NCCI edit. But there is no edit for these.

Preliminary Ultrasound of Left breast demonstrates slightly thickened wall, few internal debris within cystic lesion. Ultrasound -guided FNA of the above complex cystic lesion at 5 o'clock position of Left Breast was performed using 18-gauge needle attached to 10 cc syringe. Less than 1 cc of blood-tinged was aspirated followed by insertion of biopsy clip. Specimen was sent to the department of Cytology. Unilateral left mammogram confirmed that the clip is in satisfactory position.

Should we use 19000 or 10005?

Can 19285 & 77065 be coded separately?

The patient comes in for TCPVR procedure with elective right heart/left heart cath and angiograms. Would you code the RHC/LHC and angiograms with 33477?

We are trying to figure out what code we would use for repositioning of lumbar drain with fluoroscopic guidance. The drain was manipulated and slightly withdrawn from the spinal canal. Location confirmed by fluoroscopy. What would you recommend coding? Thanks!