Ask Dr. Z

One of my providers went to a conference where he was told he could perform an atherectomy and secondary thrombectomy using the Auryon catheter and code for both. My understanding is if it is the same device in a distal vessel, you can't code both. They also said if it was a documented pre-existing thrombus you could code both. What is your opinion?

"Some Auryon (to include adjacent thrombus aspiration when treating stenoses in native & stented infrainguinal arteries) users have reported being paid for both thrombectomy & atherectomy when performed in the same vessel & clinical session. As with many emerging technologies, some payers may not pay for both when performed in the same treatment session. We encourage you to check with your particular payer for any coding, reimbursement, or billing questions that may arise. Current Medicare NCCI guidance says that secondary thrombectomy is inherent in the work of atherectomy and should not be separately reported. Some payers may defer to NCCI guidance, while others do not consider it in payment decisions."

Patient had a CT-guided kidney biopsy (50200/77012). Patient then had two CT-guided drain placements into "perinephric and paranephric fluid collections" (49406 x 2). Can I keep 77012 for the biopsy even though imaging is bundled with the adjacent drain placements?

If the stent placement was just part of the thrombectomy procedure to revascularize only, then 61645 would be most appropriate, but if the reason for stent placement was for atherosclerosis disease then 61635 would be more appropriate. Is that correct?

My understanding is that the reason for stent placement will determine which code to report - column one code 61635 or column 2 code 61645. Or should we still report column 2 code 61645 always when both procedures are performed within the same vascular family?

Patient had previous tube graft repair of AAA, now presents with infrarenal AAA and iliac aneurysm. Can this be coded as 34705, 34713-50, or 34710/34711?

"Subsequently a universal flush catheter with guidewire guidance was passed up from the left femoral access and bolus angiography was performed visualizing the level of the renal arteries the infrarenal aorta as well as the aortic bifurcation and iliac anatomy. With these landmarks identified a stiff wire was passed up from the right femoral access. The 11 French sheath on this I was now exchanged out with a 16 French sheath. This was passed up into the aorta. Through this sheath and over the stiff wire a Gore-Tex bifurcated IBE endograft was passed. This was specifically a 23 x 14 x 100 device. This was now deployed extending up into the previously placed aortic tube graft. The bifurcation of this device was placed just above the native aortic bifurcation and the right limb of the graft extended down into the distal right common iliac artery just prior to the origin of the internal iliac artery."

We have a patient (transferred from a different facility) with a broken J-wire lodged in the anterior leaflet/chordae tendineae complex of the tricuspid valve. Our MD is going to do a percutaneous retrieval. We are coming up with an unlisted code instead of 37197. Do you agree with the unlisted in this instance?

I am questioning if 10160 or 49083 is the appropriate code. The doctor dictates: "The fluid collection was accessed using an access needle. Position within the fluid collection was confirmed, and fluid aspiration was performed. All instruments were then removed. Thick-rimmed fluid collection in lateral aspect of the left lower abdomen/upper pelvis. The patient is having fluid due to a bilateral tubo-ovarian abscess and had prior catheters placed for drainage per CT report." What code would you recommend please?

Per Medicare one of the requirements for ICD coverage is that LVEF must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac MRI, or catheter angiography prior to implant. Can you advise on the timeframe requirement/limit for the EF measurement? We have combed through Medicare's coverage database and cannot find a definitive answer. The MD has an echo on file from March 2022 and wants to know if that is sufficient enough for the upcoming implant scheduled in March 2023 or if he has to have another EF measurement performed. The NCD/LCD is very specific about having to be on med therapy for three months, must not have had an MI within 40 days of the date of implant, more than 90 days post PCI/CABG, etc., but not on the timeframe of EF measurement. Any guidance or insight is greatly appreciated!

If the mass is biopsied in the lung but states it is "pleural based" but extending into lung is that a 32400 or 32405?

Can we bill separately for the carotid cutdown/exposure (37799) to selectively catheterize the carotid artery when attempts to access the cerebral artery failed via percutaneous approach? Would this be 61645-22 instead or nothing at all?

"Instead, the left neck was prepped and cutdown in a sterile fashion employing a longitudinal incision to expose the carotid bifurcation.divided and dissection was carried down the medial border of the sternocleidomastoid. The internal jugular vein and vagus nerves were identified. The carotid complex, including the carotid bifurcation was exposed. Circumferential dissection was carried out around the common carotid artery. A vessel loop was placed around the CCA for proximal control. A U-stitch was made around the entry point of the catheter using a 6-0 Prolene. The vessel was accessed with a 5 Fr micropuncture kit and a 6 Fr Prelude 4 cm sheath under fluoroscopic guidance and secured appropriately. Craniocervical digital biplane angiography of the left internal carotid artery was then performed."

How should we code an AVG angiogram, balloon maceration with 8 x 40mm Conquest balloon, angioplasty of venous outflow anastomotic stent with 8 x 40 mm Conquest, Fogarty, angioplasty of inflow artery, arterial anastomosis and juxta-anastomotic segment with 6 x 40 mm Charger, 6 x 60 mm Lutonix balloon, and angioplasty of the intra-graft stenosis 6 x 40 mm Conquest balloon. The doctor reported codes 36905, 37246, 75710, and 36215. Is this correct coding?

If they access the jugular vein, select the right hepatic vein, don't do anything, and further select a portal vein collateral and do a venogram, do we report codes 36011, 36481, and 75887? Or is code 36011 bundled?

Can 61645 be reported together with 37215?

"The patient presented to the EP lab in fasting state. She was prepped and draped in the sterile fashion. Propofol sedation started. Analysis of 12-lead EKG showed no PVCs. Isuprel infusion up to 20 mcg per minute resulted in HR increase from 70 yo 170 bpm. No PVCs seen with infusion or washing period, with and without propofol. The procedure concluded. A/P: negative for PVCs."

Please advise on how to code this case. I used unlisted code 93799; however, the physician wants to bill 93463. This was done prior to a possible RF ablation. No catheters were placed. No RF done.

Which is the best way to identify on the cath report if it is a right or left cath or both? I do know that if they enter through the artery or vein, but which is the best way to educate someone else on how to identify for coding purpose? I ask this question because the documentation is not the greatest.

22-year-old male comes in for LHC/ RHC/COR 93460 for anomalous pulmonary venous return of the right PVs with a significant 2.5 Qp/Qs shunt fraction. per Echo. No prior hx of congenital heart disease. Would you use 93460 or congenital codes 93597, 93598, 93563?

"VATS with mini thoracotomy was completed. The chest was entered, and a soft tissue wound retractor was placed as well as a minimally invasive rib spreader. The lung was then retracted anteriorly, identifying the posterior mediastinal mass. Biopsy forceps were then used to perform multiple excisional biopsies. The specimen is sent for pathology." 

What CPT code should be reported for mediastinal mass biopsy by mini thoracotomy?

"Access into the endograft was established. Occlusion of the left graft limb within the aortic bifurcation. An aortogram was performed, demonstrating widely patent right side occluded left. Intravascular ultrasound was then undertaken to evaluate the CIA and EIA on the left side and aorta. This demonstrated compression of the graft with adjunctive presence of thrombus. Decision to proceed with intervention was made. Penumbra CATx catheter was used to undertake mechanical thrombectomy of the graft within the aorta and in the iliac artery. This significant amount of thrombus was removed. Revision of the endograft repair here was undertaken with VBX stent with deployment from the aortic bifurcation and reaching just close to the end of the graft. The contralateral limb was protected with a 10 mm balloon inflated opposing leg."

Provider wants to bill codes 37220, 34710, 37184, and 37185. Could you advise on correct coding for this scenario? I'm not sure about 37220 and 34710 together.

Would you recommend billing a pectoralis minor Botox injection(s) as a trigger point injection (20552-20553)? These are being done at the same time as scalene Botox injections for TOS (64616). Is it appropriate to add a -59 modifier to the trigger point injection?

"This patient is a 35-year-old male with right upper extremity thoracic outlet syndrome. The skin over the right anterior scalene was prepared and draped using sterile technique. Under ultrasound guidance, a 1.5 inch 25 gauge needle was advanced into the right anterior scalene muscle belly under ultrasound guidance. The right scalene muscle was then injected with 50 U of Botox. The skin over the right pectoralis minor muscle was prepared and draped using sterile technique. Under ultrasound guidance, a 1.5 inch 25 gauge needle was advanced into the right pec minor muscle belly under ultrasound guidance. The right pec minor muscle was then injected with 50 U of Botox."

Patient with sepsis underwent explantation (complicated by extensive scar tissue) of two old, failed AV dialysis grafts from the RFA: one infected (source of sepsis) and one occluded. All anastomoses taken down. The two arteriotomies were repaired with harvested left saphenous vein patch grafts. Venotomies were repaired with sutures. May 35903 be used for the AV graft explantations? How are the patch grafts represented? 

Reference Question ID 16596 - If the physician dictates that the cholangiography is done with ICG cholangiogram, is this still coded as 47563? Or should it be 47562. There is no mention of of contrast injection with the ICG injection. I code only for physicians that perform the procedures as inpatients or observation patients.

"I made an initial port incision in the midaxillary line in approximately the 8th intercostal space. The chest was entered, and a port was placed, as well as a thoracoscopic camera, which was a 30 degree camera. Using this, we placed two more port incisions, one in the anterior axillary line and one in the posterior axillary line. The lung was nicely deflated. We retracted the lung anteriorly with an endoscopic grasper and dissected out the vagus nerve inferior to the recurrent laryngeal nerve. We dissected it out and encircled it with hook electrocautery. We then divided the vagus nerve with electrocautery. The ports were closed, and a chest tube placed." 

Should I report unlisted code 32999 (lung procedure since VATS was used) or 64999 (unlisted nerve procedure)?

If a patient is having a PICC or non-tunneled CVC inserted for the sole purpose of having a line before an upcoming surgery, and there is no other information provided, would it be appropriate to use diagnosis code Z01.818? Or is there a better Z code to choose in this situation?

I am really in need of help on this case. I was thinking of coding 35081 and 35646, but another coder said to just report 35102. Please let me know what you think is best in this case. 

"Patient has Ao aneurysm with Ao and iliac dx with rest pain of rt leg. There is atherosclerosis bil CFA. "We opened and controlled the bil CFA, then open abdomen and worked on the RT IIA as planned for anastomosis. Controlled the Lt CIA and then entered AO aneurysm infrarenal and bifurcation region. Repaired infrarenal aortic aneurysm with graft. This bifurcated graft was then anastomosis to the Lt CFA and Rt IIA. Due to Rt EXT iliac artery chronic occlusion a jump graft from the right limb of the Ao graft to the Rt CFA was completed with Dacron graft. " From the op report he states the bilateral CFA anasomosis where tunneled retroperitoneal. After completing we evaluated for signals in Bil CFA and they were excellent."

I have a radiologist who would like to schedule a patient for T4 chemical/alcohol ablation. Then, two weeks later,  possible kyphoplasty. Is there a CPT code for the ablation, or would we need to use unlisted code 22899?

We have a patient who presented for a right ventricular outflow ablation. Prior to any access being obtained in the EP lab, Isuprel was infused and the patient observed for one hour with only four PVCs. At that point the procedure was aborted. Do you recommend reporting unlisted code 93799 for the Isuprel infusion?

Is this coded with an unlisted for FAD or 62290/72295 for discography each level or both? 

Provocative discogram of L2-3, L3-4, L4-5, L5-S1. (4 separate levels). Technique: The patient was prepped and draped in usual sterile fashion. Local anesthesia was achieved with 1% lidocaine. The L2-3 disc space was accessed with a 22g Chiba needle introduced coaxially through a 18g spinal needle from the left. The L3-4, L4-5, and L5-S1 levels were similarly accessed. Injection of contrast was performed at each level, blinded to the patient. Findings are listed for each level similar to this: Level L2-L3: Opening Pressure: 30 psi CC's of contrast: 1 End Pressure: 100 psi Pain Severity: moderate Pain Classification: Concordant Moderate concordant pain elicited at L2-3, L3-4, and L5-S1. No pain elicited at L4-5. Endpoint for each level is as follows: 1) 3cc total contrast volume, or 2) pain level of "severe" or 3) pressure of 100 PSI in a normal disc or 4) pressure of 50 PSI over the opening pressure if there is grade 3 degeneration or higher.

Provider makes a decision for talc pleurodesis to be instilled via an existing chest tube. Under the Risk column on the Table of Risk, would this procedure be considered low risk or moderate risk?

What CPT code is used for embolization of left occipital?

Can code 20610 be used for sacroiliac joint injections, or must you use 27096?

Are we able to code for Impella device placement for a patient coming in with STEMI? Coronary angiography and PCI were done.

"A 4 French angled glide catheter in concert with a Glidewire was advanced into the main portal vein. The Glidewire was removed, and venography was performed, demonstrating a large left gastric varix and posterior gastric varix. The large left gastric varix was cannulated with the 4 French angled glide catheter and embolized to stasis using a combination of coils, Gelfoam, Sotradecol foam, and n-BCA glue. A 4 French Cobra glide catheter was used to cannulate the posterior gastric varix. A 2.8 Progreat and 0.016 Fathom microwire were used to further cannulate the posterior gastric varix. The posterior gastric varix was embolized. Cobra glide catheter was positioned within the splenic vein. The Cobra catheter was exchanged for a 5 French flush pigtail catheter. Venography was performed." 

I'm thinking 36481, 36011-XS, 36011-XS, 75887-XU, 37241, 75891-XU. Is this correct? 

Can you please help me with the following case? Provider performed a 'lend a hand" external bypass from the left common femoral to the right superficial artery. Documentation states the following: Successful placement of an external bypass from left common femoral artery to right superficial femoral artery via 5 French antegrade sheath. Technique:I decided to perform an external bypass from the left common femoral artery to the right superficial femoral artery via an antegrade sheath in the right SFA. A 7 French sheath was placed in the left common femoral artery under real-time ultrasound guidance and micropuncture technique after administering local anesthesia. Similarly, a 5 French sheath was placed in the right superficial femoral artery. Subsequently the 2 sheaths were connected using a male-to-male connector after adequate de-airing. 

I am leaning more to an unlisted code, but would appreciate your expertise on this. 

Would hydrodilatation for a frozen shoulder be coded with 20610 and 77002? 

"Under fluoroscopy contrast was injected from a syringe containing 3cc of Omnipaque 300. The contrast was seen to be distributed within the joint. A total of 60mg Kenalog, 10cc of .25% Bupivacaine, 9cc of Omnipaque and 12 CC of sterile saline was injected. The needle was withdrawn. Successful non-complicated therapeutic steroid injection of the left glenohumeral joint with Hydrodilation under fluoroscopic guidance."

We know that a right heart cath is included in the biopsy. However, if the provider does a right/left heart cath with a biopsy, is the right/left heart cath appropriate to bill?

Can you assist whether 37229 would be appropriate for this procedure?

"The patient was systemically anticoagulated. A 018 wire and catheter were used to recanalize the total occlusion of the anterior tibial artery with re-entry at the dpa in the foot. A 014 wire was then exchanged for the 018 wire in preparation for atherectomy. IVUS was used over the wire for vessel sizing in the vessel. This was used in the anterior tibial artery, superficial femoral artery, and popliteal artery. SFA and popliteal artery had minimal disease. The ATA was occluded with a native vessel size of 2.5 - 3 mm. The segment was treated with CSI atherectomy throughout. Angioplasty with a 3x0 x 220 mm balloon was performed. There was recoil of the vessel with incomplete revascularization. The patient had a labile blood pressure during the CSI, likely secondary to the low dose vasodilator. This returned to normal with additional IV fluids. At this point, the case was completed. The wire and catheter were removed."

"Radiology report: Gray-scale and color Doppler ultrasound of portions of the liver was performed for ultrasound-guided biopsy. Please note that a radiologist was not present for the intra-operative acquisition of these images. No immediate complication. No large perihepatic or parenchymal hemorrhage is detected."

We are not reporting the biopsy; however, it is appropriate to report the 76942-26.

If a dual chamber ICD is upgraded to a biventricular ICD, CS lead inserted, and an old capped RV lead removed, how would this be reported? The patient has a functioning RV lead and RA lead (which were left in), and a capped RV lead that was removed. Our coding software does not offer a choice for lead removal without lead replacement. This assumes leads were replaced, which is not the case, and leads us to replacement codes. CPT instruction states 33244 can be used with 33264. Which coding group is correct in this case: 33249, 33225, 33241, and 33244? Or 33264, 33225, and 33244?

We have an embolization involving the posterior inferior cerebellar artery. It was originally coded with 61626; however, the provider and I feel it should be 61624 since it is intracranial. The coder is citing the definition of intracranial as the vessel needs to branch from internals or directly from spine. I am somewhat new to this and would like clarification.

We have a scenario where the physician was trying to pass a wire to get the CS catheter through, and it was discovered that the patient has a total occlusion of the left subclavian vein. Physician performed venoplasty and said intervention allowed for easy passage of the CS guide catheter. Physician does document venous stenosis of the subclavian vein and the occlusion.

We stumbled upon an October 2022 CPT Assistant that is making it seem like we can report for the venoplasty. The CPT Assistant mentions a stenosis found during a "transcatheter electrophysiology procedure". Would our scenario qualify for reporting the venoplasty with the upgrade to a CRT-pacemaker? Thoughts?

Indication: Right lower extremity DVT. FINDINGS: Patient's placed in prone position on the fluoroscopic table. The right popliteal fossa region was scanned using the linear probe. A permanent copy of the ultrasounds placed the patient's records. Popliteal vein appears patent. The scheduled thrombolysis was not performed since the patient's clinical condition has significantly improved and no longer has pain in the right lower extremity and swelling has significantly improved. Recommend continued conservative management with anticoagulation. 

Previously the recommendations were to use 76881/76882 per ACR in Question IDs 8142, 8366 and 10687. Since 76881/76882 are for non-vascular structures, is this still the current recommendation or can we use 93971-52? Please advise what the best CPT to use in this case is.

I have a physician wanting to do CTA A/P venogram with contrast, but I'm having trouble locating a CPT code. The test is being done for DVT and varicose veins.

What documentation is needed to bill code 93662? Is a separate report with permanent imaging in the patient's chart needed? My provider is saying they do not document a separate report and all information is documented in the operative report.

In the process of a diagnostic congenital cardiac cath, a catheter is placed in the right ventricle, and indirect pulmonary angiography is performed (93568). Additionally, the catheter is advanced and placed in the LUPA where angiography is also performed. Is it appropriate to bill both codes 93568 and 93569?

If a patient has a shockwave lithotripsy and stent to the external iliac and then also has angioplasty and stent of the common iliac, should this be coded with C9765 plus 37223? I am getting an edit that 37223 cannot be billed without the base code, but 37223 seems the most appropriate.

I want to verify that IABP removal (33968) should not be reported with insertion (33967) when removed at the same session. Is that correct? For example, IABP is placed for use during the procedure and removed at the conclusion of the case, or IABP is placed and used for the case but removed and exchanged for Impella at the conclusion of the case. 

"Left/right common femoral SFA and profunda were isolated and dissected. Retroperitoneal tunnels created LT/RT a 14 x 7 step graft limbs. Clamp on the aorta below renal arteries. Arteriotomy within the aorta and extended. Significant clot in the aorta removed. Graft was tailored to fit. LT common SFA and profunda are placed on vessel loop. Made arteriotomy within the common femoral and extended. The graft was tailored to fit. SFA and profunda placed under traction on the right. Significant atherosclerotic disease within the common arteriotomy extended to the proximal SFA. Endarterectomy common femoral and the proximal SFA. Plaque in the proximal SFA had eaten through wall of the vessel. Bovine pericardial patch was tailored to fit. Still some bleeding from the repair of the wall of the SFA common region. This was reinforced with a piece of felt. Aortobifemoral limb on the right was tailored to fit."

Would this be 36246 only? Or 34832 due to an open procedure? The indication does not specify AAA.

Our provider was implanting a Watchman device. During the procedure, before the Watchman was placed, the provider stated the following:

"Due to the thickness of the septum, the dilator would not advance into the left atrium. The VersaCross sheath was then placed across the septum, and the pigtail RF wire was exchanged for a 0.035 Amplatz wire,which was placed in the left superior pulmonary vein. Then, an Armada 6 x 40 mm balloon was placed across the interatrial septum, and two inflations were made up to nominal pressure. Once the venoplasty was completed, the Watchman access sheath was then placed into the left atrium."

Is there a code that we can bill in addition to the Watchman for balloon septoplasty for left atrial transseptal access?

The physician implanted a dual PPM a few days before, and both the RA and RV lead became dislodged. Patient was brought back, and the physician completely removed both leads. He then implanted a new RV lead and re-used one of the leads he removed from the RV and implanted it back into the RA. For the hospital, we billed 33235, 33216, and 33215-XU. Do you agree with this coding? Do these codes cover the work performed adequately? Our issue was making sure the CPT codes aligned with the work performed as well as supplies billed.

Incision in midline sternum-pubis we dissected the infrarenal aorta. Blunt dissection at infrarenal aorta completely freed of the surrounding tissue.  Please note that inferior mesenteric vein was ligated during the process. Retroperitoneum opened. Iliac arteries and aorta was clamped. Aorta was opened in the middle. Identified 3 lumbar arteries which were controlled with the help of 2-0 silk ties. Our cryo artery was brought into the field, soaked graft with rifampin.  The side branches were tested on the back field and all but 1 was tied off. The proximal aorta was cut in a beveled fashion. Graft was cut to the length we need. Brought to RT retroperitoneum where we had exposed the RT EIA the hypogastric artery anastomosis was made again in an end-to-end fashion.LT side anastomosis was made at the level of the iliac bifurcation. Next the IMA was dissected further and in the it was anastomosed to the main graft with the reimplantation of the renal arteries. Tongue of omentum created & brought to the wall of the retroperitoneum. 35638, 35697 x’s 2 & 49905?

The patient comes in for right ischiofemoral impingement. Doctor localizes the ischiofemoral space (skin prepped with anesthesia/lidocaine), and under CT guidance 12 mg of Celestone and 2 cc of Marcaine 0.75% were mixed and injected into ischiofemoral space. What CPT code do we use for injection?