Ask Dr. Z

Under CT guidance, cholecystostomy was placed. This was a 8 French locking drain. At the conclusion, the GB drain was at the GB margin. Sideholes were outside of the GB lumen. We were unsuccessful in repositioning in CT. Patient was taken to specials and under fluro the drain was removed. Yueh centesis catheter was placed over the guidewire and contrast injected into the gallbladder. Showed filling of the GB lumen showing irregular luminal features compatible w/gangrenous cholecystitis. There was filling of the cystic duct and partial opacification of the CHD. A new 8 French locking drain was placed over the guidewire and a more desirable position within the GB. The catheter was secured to the skin.

How would I code this? Do we charge 47490 with the exchange/replacement 47536?

If a cardioversion is performed at the start of an ablation prior to any ablation work, but we do not have separate consent/discussion for the potential cardioversion with the patient documented, is the cardioversion still separately billable?

If a patient has a stenosis in a lower extremity bypass, fem-pop for instance, and it is treated with stent or angioplasty would you code from 37236-37246 since it is not an 'artery' of the lower extremity? Or is the bypass now considered an artery of the appropriate territory and would be coded with 37224-37226? Thank you.

Dr Z in 2012 you answered this question can we code both biopsy and ablation on same lesion. Is your answer the same in 2023, if the results from the biopsy are used to make the decision to ablate then we can code both?

Hello! We have a case where a provider did two separate bypasses via 2 arteriotomies and 4 anastomoses off of one vessel (right external iliac). He begins the procedure with a midline abdominal incision, lysis several adhesions due to extensive scar tissue to locate the mesenteric artery. He creates an arteriotomy and a PTFE graft is sewn end-to-side fashion to the right EIA. The graft was tunneled to the level of the SMA and perform an end-to-end anastomosis to the common hepatic artery. An arteriotomy was made and placed a 2nd PTFE graft onto the EIA in the region of the pelvis creating an end-to-side anastomosis and this limb of the mesenteric bypass was then tunneled in this retroperitoneal tissue up to the level of the SMA where an end-to-side anastomosis was created. Provider is choosing codes 35632 for the ilio-hepatic bypass and 35633 for the ilio-SMA bypass. My question is - can two bypasses be reported off of one vessel? If so, are these the correct bypass codes? Also, are lysis of adhesions separately reportable?

"Midline sternotomy incision was made with removal of anterior mediastinal tissue starting from the diaphragm inferiorly, then dissected laterally as far as the phrenic neurovascular bundles , dissection continued over the innominate vein,, all venous attachments of the anterior mediastinal fat to the innominate vein were ligated, dissection then continued superiorly to the lateral horns of the thymic tissue. Of note the anterior mediastinal mass encroached upon the left phrenic neurovascular bundle as it crossed over the left pulmonary hilum. I did have to transect the thickened mediastinal fat at this point to preserve the phrenic nerve. Enlarged LN at stations 5 and 6 were removed."

We are thinking that this is a radical thymectomy and should be billed with 60522. But are unsure of how to code for the lymph node removal as this code is not a primary procedure for the add on code 38746.

Your 2023 Interventional Radiology Coding reference under Dialysis circuit intervention #10 advises “When imaging of the dialysis circuit is performed from a remote access (not via direct access of the circuit), use code 36901-52 (or -74 for hospital billing) as well as the remote arterial access catheter placement code (e.g., 36217 for right brachial artery injection of fistula when access is via the common femoral artery).” Based on recent advice in HCPCS Coding Clinic, they indicate modifier 74 should not be used if the intended px is performed. Your facility coding advice to use -74 doesn’t appear correct. However, uncertain if an unlisted code would be used or code i.e. 36901 with no modifier. What code would you assign if a cephalic vein fistula is accessed via the right internal jugular and fistulogram performed?

Our provider performed a balloon angioplasty on the superior mesenteric artery. CTA demonstrated a high-grade stenosis on a previously stent in the same SM artery. Our system is telling us that it requires a laterality modifier (which we have used in the past for upper extremity interventions). Being that in this case we have the balloon intervention in the superior mesenteric artery, we are seeking information on if possibly another CPT code is required or if a laterality modifier will be required.

I have a case where the provider attaches a Dacron graft to the carotid artery to use as a conduit to give me more length to deploy the two stents. Made an arteriotomy with an 11- blade scalpel in the carotid artery. I then shaped the end of the Dacron graft appropriately and did an end-to-side anastomosis using 5-0 Prolene. After the TCAR was performed and the flow reversal system was disconnected - the conduit was then controlled at the arterial anastomosis and transected the Dacron graft using 6-0 Prolene suture to oversew this graft. Would we use an unlisted code for the Dacron graft conduit or would this be considered bundled to the procedure? Thanks

We are getting conflicting information regarding pre vascular mapping prior to AV fistula. Pt presents to ASC for vascular mapping of bilateral extremities. IV access obtained in both hands, Arterial evaluation includes pulses, allen test and arterial size in radial, brachial and ulnar arteries. Vein mapping in Cephalic Vein, forearm, elbow, upper arm, Basilic vein, elbow and upper arms. Central Vein , SVC evaluated. Again this is documented bilaterally. Can we bill 93985, 93970, 36005, 36005-XS, 75822 and 75827. Thanks for your input

Dr. Z,

An SMA stenting was performed (documentation not included) then the attempted work in the celiac artery. 37236 for the SMA stent. We're considering 36245-74 but not certain that is the correct way to bill it. Please advise.

Thank you

1. Right common femoral artery percutaneous access

2. Stenting of SMA

3. Selective celiac artery catheterization

I proceeded with attempts at canalizing the existing celiac artery stent. Using several different catheters I was able to get the angled glidewire to engage the celiac artery. I was not able to get the catheter to advance more than 1 to 2 mm into the artery itself and there was a question of whether the guidewire was actually going through the interstices of the stent or through the end of the stent itself. The attempts at canalizing this were successful several times but I was never able to advance a catheter through the interstices and after 40 minutes of fluoro time had been used I ceased efforts at recanalizing the celiac artery. Therefore, the guidewire and catheters were removed.

We wanted to clarify. Patient came in for bilateral masses biopsy due to bilateral masses noted on diagnostic imaging recently. MD first performed targeted bilateral axilla ultrasound and findings are normal lymph nodes, no adenopathy, fluid collection or masses. Then bilateral breast biopsy under ultrasound guidance was performed followed by mammogram. Our questions are, can we bill 76882 -LT, RT for the bilateral axilla ultrasound. Also can we bill for mammogram as well? MD didn't specify what kind of imaging was performed prior to patient coming in for biopsy. Can we report 77066 for bilateral mammograms? Thanks!

Patient presents for PVI ablation for persistent A-fib. TEE is performed, and RT atrium is mapped. Next (before TS puncture or any ablations are done) "Left ventricuclar pacing and recording was performed via the coronary sinus... to augment hemodynamic stability as opposed to RV pacing and to provide catheter stability during atrial fibrillation." This sounds suspiciously like a supportive measure to me, rather than diagnostic. No findings from the LT ventricle recordings are documented in the report, and VT is not documented either, although the patient does have a history of NSVT. Do you believe that the text I have quoted supports reporting 93622?

"Localized prone CT scans were obtained through the left pelvic cystic mass in suitable left transgluteal entry site was selected, marked and prepped and draped in the usual sterile fashion. 1% lidocaine was administered and stab incision made with a #11 blade. Utilizing intermittent CT fluoroscopy, a 5 French centesis catheter was advanced into the mass with 20 cc of serous fluid aspirated, sent for cytology, as requested. There were no adverse incidence.

IMPRESSION: CT-guided aspiration of left cystic pelvic mass."

Would this be coded with 49180 or 10160? Diagnosis reported for biopsy would be the pre-procedure diagnosis or the post-procedure diagnosis per the pathology report?

We bill code 92921 often, and we always get denied because this is a status code B charge. We typically write off the charge when we get the denial, but is there a better work flow for this? How should we submit this charge on claim form 1500? Do we need to submit it with a zero dollar amount since we know we wont get paid any way?

Our physician does a pulmonary vein ablation followed by a bilateral carina ablation using "pulldown of the cryo balloon". Can we report code 93567? He does not indicate anything about the patient remaining in Afib. I am thinking we cannot charge.

Since there isn't a code for temporary PPM removal, how are we to code (or can we code) this since that is the only thing being done during the encounter (usually at bedside)? There seems to be some confusion among my providers because some are wanting to report code 33234, but I don't think we can do that since it's a "temporary" PPM lead. Any guidance to help with provider education would be most helpful.

Devices used - Bifurcated stent graft - Access sheaths (15F, 7F)- cutdown- Diagnosis is not aneurysm. Can we report w a non-aneurysm diagnosis? revascularizing the aorto-iliac bifurcation because of occlusive disease at the aorto-iliac bifurcation, using a single unibody device . There is no repair of the infrarenal aorta. 34705?

Are we allowed to perform carotid stenting by the new criteria after the decision memo was released 10/11/23? I cannot find an actual effective date change on the policy yet, so I wanted to make sure we were clear to stent by the new rules.

Question ID 5448 says report code 49406 for trans-gluteal approach. Code 10030 would be for a soft tissue drainage in the buttocks, not in front of the sacrum, which is in the pelvic cavity.

Question ID 8089 says The catheter must be indwelling for 49405, 49406, 49407, and 10030. Indwelling is not just a couple hours. It is intended as a long-term drainage (more than on a single DOS).

If 49405-49407 & 10030 must be indwelling and 10160 is for superficial / subQ drainage and 49083 is for ascites, and 50390 is for a cyst, what would be the appropriate code for when only a needle is used to drain a deep peritoneal fluid collection and no drain is left behind?

Example: US-guided and therapeutic aspiration of intra-peritoneal fluid collection around transplant kidney.

Local anesthesia was administered. .. ultrasound guidance .. 5 Fr Yueh advanced into the fluid collection with spontaneous return of fluid. A total of 65 cc of fluid was removed, a sample submitted for laboratory analysis. Hemostasis was achieved.

Thanks!

I have been asked this question many times, and there is always conflicting information. For remote and in office pacemaker, ICD, and LOOP recorders, which diagnosis codes do we use? I was taught to use the Z95 series codes; however, there are some sources that state to use the Z45 series codes. Can you clarify which is correct and the reasoning behind it please?

The patient has a Watchman fabric separation. Right thoracotomy, cardiac arrest, decision made to cover Watchman with bovine pericardium.--anastomosed around Watchman to cover completely. I can't find a code to describe this procedure, or a code close enough to use 33999.

When a patient comes in for a procedure related to a research study, say a biopsy or CVC placement, what diagnosis code should be first listed on the IR claim? Should it be Z00.6? Or should it be the diagnosis prompting the study?

Based on the description below, are the following codes correct: 93654, 93462, 93662)? 

"Right femoral venous access was obtained; catheter was advanced to the R atrium & ablation catheter was introduced into the R atrium to create geometry, then advanced to the SVC, transseptal access was obtained under ICE guidance; the PVC was mapped & localized to the anterior mitral annulus, lesions were successfully made."

The list of procedures performed indicates the doctor performed R & L ventricular pacing & recording, but when I read the report I can not find any reference to the ventricles. Any help you can give is appreciated.

Is partial anomalous pulmonary venous return or congenital pulmonary vein stenosis considered abnormal connections?

In spite of having all the correct wording to code 76937 and an understanding that lymph vessels generally code to venous, I do not feel that 76937 would be appropriate here for injection into the lymph node. Can you please clarify based on this documentation? They are injecting for lymphangiography.

"The vessel was sonographically evaluated and judged to be patent. Real time ultrasound was used to visualize needle entry into the vessel and a permanent image was stored. The lymphatic access was confirmed by slow infusion of lipiodol by hand. Intermittent fluoroscopic and spot images were obtained. Vessel accessed: Left inguinal lymph node."

I reported code 38790-50 for the bilateral injections performed.

Can we code separately for iatrogenic ASD closure when done in conjunction with MitraClip insertion (33418)? If so, do we use code 93580 or unlisted since it is an acquired defect?

"MitraClip device was prepped and advanced under the guide sheath into the LA. Proper adjustment was completed, and after several attempts the device was able to grasp both anterior and posterior leaflets of the mitral valve in a medial position. The device was closed and deployed successfully. The acquired ASD from the transseptal was felt to be large (19 mm) and noted to have significant L-R shunt. Decision was made to close the acquired ASD defect. A 37 mm Gore Cardioform ASD occluder was advanced and deployed under TEE and fluoro guidance with excellent result. No residual interatrial septal shunt."

Does this documentation qualify for 76937 since MD does not state "needle" or "real-time" but micropuncture catheter?

"Left radial artery was assessed and confirmed for patency, and accessed with a micropuncture catheter in a retrograde fashion with permanent recording of ultrasound images."

Some dictations state "kit" and I have the same question - kit or catheter suffices?

Do we need to add the -KX modifier for an attempted placement of a dual chamber pacemaker?

"Patient was given Ancef for antibiotic prophylaxis. Several angiograms were performed in the AP cranial AP views to visualize the axillary and subclavian veins. Ultrasound guidance was utilized to try to visualize the axillary vein. Despite multiple attempts access could not be obtained. The procedure was aborted, and family wishes to have the procedure done at the XX Clinic." 

Are we allowed to bill 33208-74 and append the -KX mod for an MCR patient? 

A provider would like to do two LEV on separate days. One to test for reflux, and the 2nd day US to check for DVT. Since the 93970 description is inclusive of all of those elements, would both DOS be billed as limited (93971) or only one DOS to be billed at 93970?

We have a physician who will occasionally deploy two Watchman devices in a large bi-lobed left atrial appendage. Would you recommend any charges for the deployment of the additional device?

Would you report code 37197 for the snare retrieval of the lead since the physician had to create a separate access for this?

"While upgrading a DC pacemaker to a CRT-P, our physician had to access the femoral artery and vein. From a right femoral approach using a 25 mm Amplatz gooseneck snare via the 7 French sheath, the chronic RA lead was snared and remained connected to anchor this lead in anticipation of extraction for the chronic RA and chronic LBBAP lead. This was done to anchor and retain access." 

I coded the following as 37238 and 37239 x 2. Was this correct?

"Indication/findings: Better visualized focal stenosis at the right transverse sigmoid sinus junction with long segment narrowing of the right transverse sinus and occipital superior sagittal sinus. Procedure: Stenting of the superior sagittal sinus was subsequently performed using a 6 x 40 mm PRECISE stent. Next, a 7 x 30 mm stent was placed across the torcula into the right proximal transverse sinus. Next, a 7 x 40 mm stent was placed into the right transverse sinus. Finally, a 8 x 40 mm stent was placed from the transverse to the sigmoid sinus."

Our vascular access team is looking into placing a PICC via superficial femoral vein (i.e., mid-thigh PICC). I'm thinking this is a central vein and would not be considered peripherally inserted. What CPT code would be reported for insertion of a venous catheter into the superficial femoral vein?

When plaque is excised from the common femoral artery walls using a scalpel before eversion endarterectomy, is it appropriate to report code 35371, or would I report unlisted code 37799?

Can you please help us understand which CPT code to use when they are performing a PET/CT brain with attenuation and correction for metabolic evaluation? Some references seem to direct us to 78608, but others seem to direct us to 78814 since it was performed with CT. What would you recommend using and why?

How would you code a right vrachiocephalic venogram?

"Access is on the right vasilic vein with catheterization of the right brachiocephalic vein. Findings: Patent RT BCV and SVC stent with no evidence of stenosis."

Would I code this as 36005-RT and 75820, or 75827?

A patient with recurrent A-fib undergoes PVI, as well as AVJ ablation to create complete heart block. There does not appear to be an NCCI edit between codes 93656 and 93650. May we report both of these? Or should we report code 93656 and 93655 instead?

For the CardioMEMS device 33289 I know the remote interrogation code is 93264. Our doctor performed reprogramming in person. Is the cpt code still 0417T? I can't locate any information.

In September 2022, CPT Assistant gave the guidance to use 75774 for selective add on venography after a main vessel venography. As per AMA's proposed code change summery in September 2023, AMA accepted and revised the change, but it is going to be effective from Jan 2025. Should we start using this guidance as per CPT Assistant or wait till Jan 2025? Please advise. Thank you!

Our provider is requesting the correct CPT code for "performing a limited assessment of the abdominal veins by utilizing spectral Doppler images overlaid on grayscale images to obtain hemodynamic information. This does not typically involve arteries except in the kidney to measure resistive index."

We are a little stuck on the description of limited code 93976 stating BOTH arterial inflow and venous outflow. Does the "limited" portion refer to the targeted organ or part of the organ? Or is venous evaluation only enough for an otherwise limited study? We would like to confirm that reporting limited study, 93976, is appropriate when either arterial or venous evaluation performed.

Sometimes when I am coding LINQ placements (hosp OP billing), the provider lists a CVA or TIA as the only indication, and I presume they are looking for a latent, previously undetected arrhythmia. Then when I look into the patient history, I see that the CVA actually occurred 4-6 weeks prior to the LINQ encounter, and usually the patient has made a full recovery. The cath lab supervisor wants me to code these as an acute CVA from I63. She says that a history code like Z86.73 can never be used as a first listed diagnosis, but I believe that is actually an IP coding rule. Does Z86.73 support medical necessity for an OP LINQ placement?

Does this support code 93459? I don't see the graft selectively engaged.

"Under direct US guidance, access was obtained to the right common femoral artery with a micropuncture needle and micropuncture wire, and then a micropuncture sheath was placed. After that, it was upgraded over a J-wire to a 5 French sheath, and initially a JL4 catheter was used. We were unable to engage the left main coronary artery ostium. That catheter was replaced with a JL5 catheter, which was then engaged into left main coronary artery ostium. Multiple angiograms of left coronary systems were done. That catheter was then removed. Right coronary angiogram was performed with a JR4 catheter. Saphenous vein graft angiogram x2 was performed with that catheter, and the same catheter was used to place the catheter in the left subclavian artery. Over an exchange length wire, that catheter was replaced with a LIMA 5 French catheter, and left internal mammary artery angiogram was performed. Then, I went in with a pigtail catheter, and left heart cardiac catheterization was done."

Do you still recommend using code 37246 for lower extremity PTA for treatment of a thrombus? The physician documents a thrombus causing an 80% stenosis of the popliteal artery.

"There was separate thrombus resulting in 80% stenosis of the native distal (P3) popliteal artery and the tibioperoneal trunk. An additional 3000 the lesions were administered corresponding to a total of 100 units/kg. The lesion was angioplastied with a 3 x 200 mm followed by a 4 x 150 mm and a 4 x 60 mm Armada balloons. The final angiogram showed good results with less than 20% residual stenosis and only a minute amount of residual thrombus. The heparin effect was reversed with protamine.

Conclusion: This is a patient with acute thrombus of the native distal (P3) popliteal artery and tibioperoneal trunk treated with balloon angioplasty."

What is pass-through code to go with C1761?

The IR physicians are wanting to bill code 96365 for the prophylactic antibiotics done prior to procedure for lung chemoembolization. The IR physician places the order, but the RN (hospital setting) performs the administration and the IR physician isn't present.

My understanding this isn't a billable service for the IR physician even though they place the order. Can you please clarify or confirm? Thank you

Is it ever appropriate to report 76942 at the same session as 76937? (hospital/facility coding)

Example case in IR: Port-A-cath placement for cancer at same session as thigh muscle US guided core biopsy for soft tissue mass.

All required elements are documented for reporting ultrasound guided access for the port placement. Would it be appropriate to report 36561, 76937, 77001-XS (NCCI edit with 20206) for the port along with 20206 and 76942-XS (NCCI edit with 36561, 76937, 77001) for the muscle biopsy? The -XS modifiers clear the NCCI edits, but there is still the 3M edit stating, "Do not report 76937 with 76942." My rationale is that I'm reporting them for completely separate procedures performed from different access sites and performed on different anatomy areas. Is that the correct thought process for this scenario, or is it just a never ever report 76937 and 76942 together no matter what?

Patient presented with both AAA and iliac aneurysm. The physician placed an iliac branch endovascular graft in the internal and external iliac artery followed by an iliac extender graft. After this was deployed the physician started the AAA repair with a Gore main body with bilateral limbs. Would you code for the AAA 34705, iliac 34707, and 34709 since this was a completely separate repair from the AAA? If this repair had been performed with just an extension graft would you only use 34079?

Procedures performed were 37187 and 37212 with cardiopulmonary bypass for capturing thrombus in the filter. Would the cardiopulmonary bypass be included in the mechanical thrombectomy procedure since it was used as a filter to capture thrombus?

We have a patient who presented for Watchman procedure. The device was inserted, but "PASS criteria unable to be met despite repeat TS and new device: clinical decision was made to remove device". Would the correct code be 33340-74? Or 33340 with removal of foreign body?