Ask Dr. Z

Have there been any updates to not being allowed to code albumin infusions (96365) with a paracentesis (49083)?

In coding clinic 1st quarter 2024, there was a question and answer for angina with MI. "Assign code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, as the principal diagnosis. Assign code I25.10, Atherosclerotic heart disease of native coronary artery without angina pectoris, for the multi-vessel native CAD, as an additional diagnosis. It would be inappropriate to assign a code for angina in the setting of an MI." Can you explain why we would not code angina with a MI? This seems like new guidance. In the Coding Guidelines 1.C.9 Atherosclerotic Coronary Artery Disease and Angina it mentions "If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease." but does not mention anything about angina with the CAD in this statement. What are your thoughts on angina with MI?

Patient with thymic tumor. Successful particle embolization of the right superior thyroid artery feeding the thymic tumor. Would you report code 37243 since the tumor is in the thymus or 61626 because the feeding artery is in the neck?

A patient undergoes coronary IVUS in the cath lab. The physician states in his report, “IVUS was used for stent sizing.” No additional information is provided (other than identification of the specific artery evaluated). Is this sufficient documentation to support coding the IVUS?

If a patient in the cath lab is undergoing FFR and has an allergic reaction to the adenosine, prompting the procedure to be terminated, would it be appropriate for the hospital to report 93571-52?

Can 93623 be coded based on the following? 

"The completeness of the lines were verified both with a Lasso catheter as well as well as exit block from inside the isolated areas before and after adenosine infusion. No arrhythmias were induced with burst pacing from the cs catheter."

My question is assuming a CT chest, abdomen, and pelvis is performed with contrast (for professional billing). Provider documented: "3D multi-planar volumetric acquisition is obtained of the chest, abdomen and pelvis. Spinal reformatted imaging IS performed for the thoracic and lumbar spine." How would this be coded? In the same situation, if spinal reformatted imaging is NOT performed, how would this be coded?

I am hoping you can help us with Dyna CT 76380 being performed after a 61645 thrombectomy, n. I have been taught that if done after the intervention it is a follow up and it would bundle with the intervention. There is a edit with 61645 and 76380. Our neurosurgeon's feel it should be charged where it is not a required part of the procedure, and they are looking for intercranial hemorrhage after the thrombectomy . I am not seeing any old questions from DR Z Website addressing this and I am hoping you could give us your thoughts and opinion on this. I told the neurosurgeon I would reach out to you on this. Would the Dyna CT be separately reportable if performed after the intervention when the physician is looking for an intercranial hemorrhage after completing this procedure? I appreciate all your help on this question. Thank you DR Z I appreciate any help on this.

"With the patient prone the back was prepped and draped sterilely. Local anesthesia with lidocaine. 17-18-gauge coaxial biopsy system advanced to the margin of the inferior vena cava from retroperitoneal posterior approach. When needle was seen to be in satisfactory position three core specimens were obtained. Impression: Percutaneous CT-guided biopsy of intravascular inferior vena cava mass." 

77012 for the guidance and what is the appropriate CPT code for the biopsy?

Are PB coders able to use the embedded/included (not separate) procedure log to identify cath placements etc when 1) the physician includes the detailed procedure log in the final report, 2) Signs: Procedure Log and Final Result signed by John Doe, MD on 12/xx/24 at 1622 CST with corresponding Certification: I certify that I was present for catheter insertion, catheter manipulation, angiography, and angiographic interpretation of this patient, 3) and also notes: The procedure log was documented by Sally Smith listed and verified by John Doe, MD. The final report has all other required headers, signatures and procedure elements..OR..Does the physician need to add and dictate a special "Access" and "Technique" section in the same note to restate the access/technique details that are already stated in the embedded/included procedure log with supporting signatures as noted above? This qx was emailed to the ACC who supported the use of px log as noted above concluding: "in this location it is potentially all one connected flowing document."

Patient is brought in for a left heart catheterization with coronary angiography. Procedure is performed to completion with the exception of measurement and documentation of the LVEDP. The left ventricle was entered; however, equipment malfunction prevented the physician from obtaining the LVEDP. Can this be coded with 93458? Or am I allowed to code only for the coronary angiography, 93454? If 93458 is appropriate, what, if any, modifier would be appended? -52 says without anesthesia.

We are coding 92972 with the C9600-C9608 series when drug eluted stenting takes place for the facility side. We are getting denied indicating C9600-C9608 is not a primary base code. Should we switch these to 92920-92944 series?

I have a case that a NICU baby has had bipolar epicardial left ventricular lead and an epicardial generator Micra placed in anterior abdominal quadrant. Is this still 33274 / 33225??

"3 cm left anterior thoracotomy was performed, a bipolar ventricular lead was adhered to the left ventricle, tested with appropriate thresholds. We selected the Micra generator to avoid the previous infected sites. Generator was connected and final testing was completed without issue."

I'm really not sure if the Micra even has the ability to have a lead connected. Any direction on this is greatly appreciated.

When a Bentall is performed, does this include an aortic root replacement?

 "The tear originated in the arch and extended between innominate and left carotid artery. The tear was completely resected, and a hemiarch was performed using a 23 mm x On-X valve conduit. Distal anastomosis was sewn using 4-0 prolene using double layers of felt pledgets. The root was reconstructed using interrupted 2-0 ethibond sutures, and coronary reimplantation was performed using 6-0 prolene sutures." 

Would this just be reported with code 33863, or would we also code an aortic graft?

Our physician did a distal right coronary artery intravascular lithotripsy and InStent restenosis of the proximal right coronary artery. How many times should I report code 92972?

"Incision was placed in the left groin and taken down through subcutaneous tissue. We then carefully dissected the common femoral, the superficial femoral, and profunda femoris. The lateral circumflex femoral vein was doubly ligated and divided. I then dissected distally on the profunda, and two large terminal branches were circumferentially controlled. The patient was given full heparinization. At this point, we performed an arteriotomy in the common femoral. This was extended to the profunda all the way to the distal terminal branches. We then performed an endarterectomy on the common femoral and profunda and extensive eversion endarterectomy of the superficial femoral. I had to make a counterincision to get the plaque out of the proximal superficial femoral artery. After this was done, the shards of intima and media were circumferentially removed. A bovine pericardial patch was then placed on the common femoral to the distal profunda. This was sutured with 6-0 Prolene."

Does the counter incision mean that both codes 35371 and 35302 are billable?

Per the CPT Codebook, Code 33572 (coronary endarterectomy) can only be used for LAD, circumflex, or RCA. The provider stated, "The PDA and PL1 are the only major branches of the RCA, and so these qualify as part of the RCA, and the diagonal is the major branch of the LAD and is part of the LAD distribution. As such, endarterectomy of this vessel qualifies as part of  the LAD". Endarterectomy of other coronary arteries is not reported separately per Encoder. Please advise.

"Excision of the infected axillary Dacron graft. The axillary artery was exposed proximally and distally to the graft anastomosis. Once branch was ligated using silk ties and clips. Infected axillary Dacron graft. We decided to use a bovine pericardial patch for axillary artery repair. IV heparin weight-based was administered and ACT was allowed to come above 250. The axillary artery was clamped proximally and distally using clamps. Sidebranches were clamped using Vesseloops. 11 blade was used to transect the graft off of the axillary artery right at the suture line. The graft was sent to microbiology. We then debrided the vessel wall back to healthy tissues. Inflow and outflow was confirmed. We then washed the wound with 3 L of normal saline via cystoscopy tubing. A bovine pericardial patch was then trimmed to shape and length and sewn onto the axillary artery using a running 6-0 Prolene suture. Prior to completion flush was done." 

35905 & 35572 or only 35905?

If a bilateral pulmonary angiogram is performed from the MAIN pulmonary artery, then advanced selectively into the left and right segmental/subsegmental arteries with additional imaging, would that be coded as 75743 without additional imaging codes 75774?

Can we report code 64479 for the cervical selective nerve root injection when the injection was onto the nerve root sleeve? Should the epidural space drug distribution be documented?

"The needle was advanced into the inferior posterior aspect of the C6/7 neural foramen. 0.5 cc of Omnipaque dye was then injected, and spread of dye was demonstrated to be along the nerve root sleeve. 2 cc 0.25% bupivacaine was injected onto to nerve root sleeve."

Aided by CARTO 3 mapping system & ICE wide area circumferential ablation was performed around antrum of both LT &RT PVs(WACAs) Lesions were delivered @ 45W for F' goal 400-450 & 500-550 on posterior & anterior walls, respectively. LT vein isolation was achieved on first pass. Breakthrough were noted in RT PVs, which required reinforcement lesions along WACA & lesions in RT carina area, forming a carinal line. post-ablation voltage map also confirmed presence of ablation related scar along wide area antral lesion set without any evidence of residual viable myocardial tissue. Adenosine showed no evidence of inducible reconnection Burst pacing from CS resulted in induction of an SVT that quickly degenerated into AFIB, which later self-terminated Given abnormal PW voltage & inducible AF, posterior wall isolation was pursued. Ablation lesions were incorpoated in posterior box with roof line & floor line connecting posterior aspects of LT & RT WACA lesions around pulmonary veins.Additional lesions were applied in posterior box @site epicardial breakthroug

Physician requested 37799 and 36831 for thrombectomy of AVG that was ultimately excised.

"1 month s/p a left AV graft that initially had a good thrill but in post op visit was noted to thrombus"

"I made a transverse incision along the course of the graft. I placed a 3, 4, and 6 Fogarty through the outflow of the graft. I was able to get excellent back bleeding. I then attempted to pass a fogarty through the arterial anastomosis into the brachial artery. I was able to get some forward bleeding but was not significant enough to support a graft.

I thus decided that the graft was not salvageable and resected the exposed portion.

The wound was irrigated and closed in layers. . The patient tolerated the procedure well and went to recovery room in stable condition for later discharge home the same day.

Would both codes be appropriate? or would this just be an unlisted code for excision of graft without infection?

I know that we can bill two different ablation codes when performed on two separate/distinct lesions within the liver, but what about when they perform 2 different ablation types on the SAME lesion in the liver? Can we code both the alcohol and the microwave ablation or just the microwave?

IMPRESSION:

1) Successful ethanol ablation of the hepatic segment 4A metastatic mass using CT fluoroscopic guidance as described above.

2) Successful microwave ablation of the hepatic segment 4A metastatic mass using CT fluoroscopic guidance as described above.

The provider is doing thrombectomy and stent placement with emboshield in the left common carotid artery to the cervical internal carotid artery for occlusion as patient had a stroke. There is no mention of stenosis at all. I am thinking 37184 and 37799 but greatly need you help to know what would be correct. I believe cath placement would be included in 37799, if that is correct (it was femoral approach). Thank you!!!

For diagnostic angiograms (that meet requirements to code with interventions) we use XU on the diagnostic angiograms. For cases when it's diagnostic angiograms only, we use XS on the additional of the same code (75726, 75726-XS) for separate vascular family.

If both of these uses apply to a case, would coding 75726-XU, 75726-XU-XS be appropriate?

I have search everything I can find but have only found CPT code 33852 which seems to be partially correct or should I use the misc code 33999 CPT code for the following procedure. Please help. Sternotomy was performed; Aortic valve & root were inspected via TEE; Eccentric jet of mild AI noncoronary & right coronary leaflets; Aortic root was wrapped down to a 3cm size this reduced the AI down & all leaflets were moving well; chest tube & blake drains were placed. There is no mention of clamping or cardiopulmonary bypass. Thank you for your assistance

Convergent cannula was placed.VATS camera was then inserted. ablation of the posterior left atrial wall. convergent epi-sense system was then placed adjacent to the right superior pulmonary vein and suction was applied to the posterior left atrial wall. right inferior portion of the atrial wall and each ablation line was completed and carried laterally to the left-sided pulmonary veins. A total of 15 ablations to the left atrial wall were completed. a small pericardiotomy was created posterior to the phrenic nerve.The ligament of Marshall was then transected using the harmonic scalpel. The base of the left atrial appendage was approximately 40 mm. 40 mm clip was then placed over the appendage and positioned at the base and closed. TEE guidance, this confirmed full closure of the appendage. The clip was then released and the delivery device was removed.

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.

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?