Ask Dr. Z

How would you code for a LIMA to LAD graft and two SVG to OM1 and OM2 BUT before closing checked flow in the grafts and realized the LIMA is not a good conduit? Surgeon then creates SVG to LAD. Would you code 33512 for the three SVG, OR would you code for the LIMA 33533 and two or three SVG ( 33518 or33519)?

How would mitral valve in ring and mitral valve in MAC be coded?

Does I&D and removal of infected thrombosed vein left have to be coded to unlisted, or is there a more appropriate code?

I know from previous Q&As you state when a LBB lead is placed it is coded to the location of the placement, typically in the RV septum. I'm starting to see providers state they are placing the LBB lead to the LV endocardium. Would this support reporting with 33225?

"A permanent pacing lead was advanced to the RV septum and positioned in the LV endocardium for direct left bundle branch capture where a stable position with satisfactory sensing and pacing characteristics were obtained. Successful upgrade of St Jude dual chamber pacemaker to a Bi-V PM (CRT-P) with addition of LV endocardial lead for direct left bundle capture."

Would you code this as: 33233, 33207 OR 33229, 33225? Patient does have existing RA/RV leads from previous system implant.

I have a question I hope you can help me with. Cardiologist is seeing a patient who is getting an MRI (outpatient). The pacemaker was deactivated before the MRI. Physician stayed at patient's bedside to watch for any possible problems for the duration of the MRI, and then changed the programming back to how it started (and made sure there were no changes to the pacemaker because of the MRI).

Physician's question is, in addition to billing for the pacemaker check, how can I bill for the hour spent (outside of the pacemaker check)? Patient not in ED or inpatient (this is an outpatient procedure).

Seem like no extra charge for the time spent "monitoring" this patient.

The patient was positioned supine. Initial imaging was performed w/ CT. Local anesthesia was administered. A wire was placed thru the indwelling drainage catheter and the catheter was removed. The new catheter was advanced and position within the fluid collection was confirmed. How would this be coded? Can we code 49423 with 76380?

I'm new to EP coding and not sure how to code ablation of the left atrial roof line and partial left atrial posterior wall after redo PVI in this case. Any recommendation is greatly appreciated.

"After PVI was achieved for all veins with entrance and exit block, isup was then titrated and numerous PACs were noted from the posterior wall. A sinus rhythm scar map was created of the posterior wall showing dense patchy scar. A left atrial roofline was applied connecting the superior veins with bidirectional block achieved. Next an inferior posterior wall RF line was delivered from the bottom of the left inferior vein to the bottom of the right inferior vein. Further ablation was then applied to areas of the posterior wall. Despite targeting all early signals and reinforcing the radiofrequency ablation lines full isolation could not be achieved. Partial isolation was achieved of the right aspect of the posterior wall."

How would we code occlusion of a Mustard baffle leak?

Procedure performed was 0600T, but has been giving us issues with billing and the claims being denied since this is an experimental code. It was advised to use S9990 instead. The question would be for facility because health plan authorized the use of S9990 for PC.

I am new to cardiology coding, and this one has me perplexed. I appreciate any direction.

"1. Severe native three-vessel disease involving the left main, LAD, intermedius ramus, LCx, and RCA.

2. Successful IVUS guided PCI of the intermedius ramus with Abbott Xience sky point 2.5 x 28 mm DES postdilated using a 2.75 NC balloon in T stenting fashion to LCx.

3. Successful IVUS guided PCI of the LCx into left main and LAD into left main using DK crush technique with placement of a Abbott Xience sky point 3.0 x 23 mm DES in the LCx followed by Abbott Xience sky point 3.0 mm x 28 DES in the mid LAD and Abbott Xience sky point 3.5 x 38 mm DES in overlapping fashion extending from the proximal LAD to ostial left main. The mid to proximal LAD stents were postdilated using a 3.5 mm NC balloon while the left main stents were postdilated using a 4.5 and 5.0 mm NC balloons. Lithotripsy was performed using a 3.0 mm shockwave balloon extending from the distal left main through the ostial, proximal, and mid LAD.

4. Right femoral artery access with Perclose closure."

Add-on code 0439T (myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability) may be used with codes 93306, 93307, 93308, 93350, and 93351. What documentation would be necessary in the report in order to capture 0439T?

Can you please offer guidance on this case?

The Pulmonary Veins were engaged with the Octaray and the pre-op CT scan along with ICE registered images were all used to merge with the Biosense mapping data obtained from the Octaray. The initial map demonstrated activity in all 4 veins as well as significant area of fractionation in the mid posterior wall.

Exit and Entry block were created and demonstrated in all of the major Pulmonary Veins (PVs) after the completion of the wide area circumferential ablation lesion sets.

At this point, after having isolated the veins are continued to be repetitive salvos of a left atrial tachycardia which mapped to a fractionated areas on the posterior wall and for this reason we isolated the posterior wall with a standard box lesion set. We then demonstrated block in the posterior wall and saw no more salvos of left atrial ectopy.

Would this be 93656 and 93657 or 93655 for the box set?

Thank you!

Would this be 27884 or 13160 or other recommendation? I’m thinking 27884. 

"After prepping and draping, the previous VAC dressing was removed and the wound was felt to be stable and healthy-appearing there is no purulence material or necrotic areas and no significant areas of focal bleeding. The deep soleus muscle was debrided to allow debulking of the muscular layer and the gastrocnemius was mobilized to allow my releases to the tibia. Two drill holes were placed in the anterior tibial crest and a FiberWire suture was then used to go through the tibial bone tunnels to capture the fascia and tendon of the gastrocnemius to pull it up anteriorly after extensive irrigation of the muscle bellies and wound. He my recess was able to be closed without significant tension. Once this was closed the fascial layers were then closed using a 2. Strata fix suture followed by 0 strata fix and subcutaneous layer and 2 0 nylon in the skin. A sterile Prevena VAC dressing was then placed across the closed wound."

Not sure of catheter placement codes and which embolization code to use for this report.

"Endovascular revascularization of the RT lower extremity requiring embolization of multiple vein branches of the right femoropopliteal vein graft to include a direct arteriovenous fistula. The Left common femoral artery was cannulation in retrograde fashion. The catheter was advanced into the proximal aorta for imaging. The catheter was advanced into the contralateral right common femoral artery for right selective angiography. The catheter was advanced into the fem-pop bypass graft for super selective imaging. Decision was made to embolize venous branches from the mid to lower fem-pop vein graft to optimize perfusion into the widely patent trifurcation vessels below the popliteal artery. A microcatheter was advanced into 4 vein branches from the mid to distal fem-pop vein graft and coil embolization was performed. One branch vessel from the vein graft directly communicates with the femoral artery representing a direct arteriovenous fistula."

What if a doctor performs an ultrasound guided biopsy of one breast lesion (CPT 19083) and via the same incision an adjacent breast cyst was aspirated via ultrasound guidance (CPT 19000 - guidance would not be charged as same guidance was used for the breast lesion biopsy)? May each be separately billed for? If it were incidental (not planned) to the primary procedure we would not bill separately; however, if it was planned, may we bill for both, as the lesion and the cyst are two separate and identifiable issues?

This appears to suggest that same group practice providers can bill under one provider. Is this accurate and would it apply to stress test 93016? Doc A orders/interprets-Doc B supervises. Can we bill 93015 under doc A? POS11

20.3.1 – A/B MAC (B) Payment Rules

(Rev. 1931, Issued: 03-12-10, Effective: 06-14-10, Implementation: 06-14-10)

If a diagnostic test (other than a clinical diagnostic laboratory test) is personally performed or is supervised by a physician, such physician may bill under the normal physician fee schedule rules. This includes situations in which the test is performed or supervised by another physician with whom the billing physician shares a practice (see Pub. 100-04, chapter 1, §30.2.9). Section 80, chapter 15, of Pub. 100-02, Medicare Benefit Policy, sets forth the various levels of physician supervision required for diagnostic tests. The supervision requirement for physician billing is not met when the test is administered by supplier personnel regardless of whether the test is performed at the physician's office or at another location.

Hope you can help since we cant figure out what codes to use. Patient has abdominal aneurysm and iliac aneurysms. Vascular surgeon performed aorto-bi-femoral Dacron graft, bilateral common femoral and profunda endareterectomies and 6 mm Goretex common femoral to profunda jump graft and ligation of bilateral iliac arteries.

Should we go with 35102 for the Dacron graft? I am assuming that endarterectomies are not reported. Qhat about the jump graft? What code can we use and ligation of bilateral iliac arteries? Thanks!

I have an unusual case and need your help. Patient presented with NSTEMI in the middle of the night. He was responsive to nitro, and it was decided to defer consult until the morning. Throughout the night the pain waxed and waned, and he was responsive to increased nitro each time. When the cardiologist consulted in the morning, the patient stated he was having difficulty breathing.

"Impression: NSTEMI: Patient is having post-infarction angina and is developing heart failure. Emergent heart catherization recommended."

Stent was placed in the circumflex with resolution of symptoms. I'm having difficulty deciding whether to bill 92941 vs. 92928. It is documented the patient had an acute MI of the circumflex; however, with the initial deferral and the mention of POST- infarction angina, does the emergent status still allow for the stent to be reported using 92941?

Patient presents for RHC (93451-26) & EMB (93505-26) s/p heart transplant w/possible re-intervention on pulmonary veins. Both right/left PA wedge angiography performed to eval pulmonary venous return on levophase. Hand injection done with catheters placed in left lower branch of LPA, main LPA to evaluate the LLPV, RLPV, RMPV, Left lingular pulmonary vein. Findings: right sided pressures were reasonable, PA wedge angiography showed mild-moderate stenosis in left lower and right lower pulmonary veins on levophase with PCWP being 16-17 mmHg. Stenosis appeared to be stable compared to post-angioplasty angiography at the last cath. Therefore, we decided to leave those alone.

I don't feel that billing 93568/93569 is appropriate since not looking at the pulmonary arteries. Can we bill for selective placement 36014 for placement in LPA and 75746 for the S&I to look at the veins? Thank you.

A patient had a CTA. The finding showed subarachnoid hemorrhage. Patient brought to IR where the provider performed a diagnostic angiography prior to embolization. Provider indicates gold standard for a subarachnoid hemorrhage is not a CTA or MRA but rather an angiography. The angiogram is needed to confirm diagnosis and to confirm the suitable nature of the disease for treatment. He agreed in cases where they are just intervening that the diagnostic angiogram cannot be coded. However, a CTA or MRA is not adequate to diagnose the source of the subarachnoid hemorrhage and the catheter angiogram is needed.

Do you agree, in cases of hemorrhage, we can code for a diagnostic angiogram even though a CTA or MRA was performed? What about this same scenario for a non-ruptured aneurysm?

I am billing unlisted code 37799 for vena cava resection and reconstruction. What code(s) do you recommend comparing this to in order to send description to carrier and to help calculate the fee?

"We began to resect the medial aspect of the IVC using a combination of Potts and Metzenbaum scissors. The tumor did extend cephalad and encroached upon the Rummel tourniquet and thus we replaced the cephalad Rummel tourniquet with a Satinsky clamp. We completed the caval resection with the assistance of our urologic colleagues, and when we are both in agreement that all gross tumor was resected we evaluated our options regarding primary caval closure versus patch venoplasty. Given the amount of medial caval wall that was resected, we elected to pursue patch venoplasty with a bovine pericardial patch. We performed a patch venoplasty in a running fashion using 4-0 Prolene."

Is a coiling embolization for middle meningeal artery intracranial or extracranial?

Can you recommend any helpful illustrations that tell you which arteries are intracranial and extracranial?

I code OP accounts for hospital cath labs, and we have a couple of doctors who want to use acute CVA code I63.9 as the only indication for placement an implantable loop recorder, like LINQ 33285. I keep saying that this primary DX is not acceptable because the acute CVA occurred several weeks prior to the OP LINQ placement visit, and in most cases the patient has fully recovered. I find no other DX in the patient record that can be used, such as those suggested in your cardiology desk reference (syncope, arrhythmia, anti-arrhythmic drug monitoring, dizziness). But, when I use Z86.73 history of CVA as a primary diagnosis, I get an error from the encoder saying, "The current primary DX is listed by CMS as and unacceptable primary diagnosis." I believe the doctors want to use the LINQ to look for a latent arrhythmia, but these patients have no documented evidence of any arrhythmia or history of syncope. What can I use as an acceptable primary diagnosis?

How would you code repositioning of a GJ tube? I saw your answer to a previous question where you recommended 49465 because the catheter was only pulled back slightly and "nothing like trying to advance a catheter from the stomach into the jejunum". In my case, they had to advance the catheter into the distal duodenum.

"The retention balloon on the existing catheter was deflated, with a total of 2.5 mL of water removed from the balloon. The existing GJ tube was then advanced through the stoma and the retention balloon was injected with 4 mL of water without resistance. 10 mL of contrast was then injected through the gastrostomy port and lateral fluoroscopic image was obtained, which showed retention balloon within the stomach and no leakage of contrast outside of the stomach. 5 mL of contrast was then injected through the jejunostomy port to confirm appropriate catheter position. Both the jejunostomy and gastrostomy ports were then flushed with water. The patient tolerated the procedure well and there were no immediate complications."

Indication: Polyclonal gammopathy, thrombocytopenia, and macrocytosis. Clinical concern for bone marrow disorder.

During fluoroscopic and cone beam CT guidance, right posterior iliac crest bone marrow aspiration and core biopsy was performed. "Cone beam CT was performed throughout this procedure and 3D advanced post-processing was performed using an independent workstation with active physician participation and supervision."

Is 76377 separately billable during CT-guided biopsy?

What is the appropriate code for lateral epicondyle injection? Diagnosis documented lateral epicondylitis, tennis elbow. Can we code 20550/20551 or 20605/20606?

"Patient has failed AVG in the forearm and presents for new AVF. The cephalic vein was identified, which had been part of the previous graft. The graft was dissected, and the segment connected to the cephalic vein was excised. The lateral branch of the cephalic vein through which the graft was connected was remodeled and oversewn with stitches. Brachial artery and cephalic vein were used to create the new AVF. Only the cephalic end of the AVG was removed."

Would this be considered a revision or removal with modifier -52 and new AVF code? (Brachial artery not used in the original AVG)

If the procedure being done is a left to right fem-fem bypass graft, would we use the RT modifier?

Summary

1. The left ventricular systolic function is normal, LVEF is visually estimated at 60-65%.

2. The left atrium is dilated in size.

3. The right ventricle is normal in size, with normal systolic function.

4. There is a small, circumferential pericardial effusion.

5. The pericardial effusion is smaller compared to study of 7/31/23.

IVC/SVC

IVC Diameter (Insp 2D) 0.5 cm

IVC Diameter (Exp 2D) 1.3 cm <=2.1

IVC Diameter Percent Change

(2D) 57 % >=50

LV Dimensions 2D/MM

LVID Diastole (2D) 4.4 cm 3.8-5.2

LVID Systole (2D) 2.7 cm 2.2-3.5

Pericardium 2D/MM

Pericardial Effusion

Diastole (2D) 0.5 cm

Assessment states "calcification of coronary artery". Does this support I25.10 with I25.84 as secondary?

Patient with grade 2-3 aortic injury at the level of the left subclavian, consistent with dissection.

PROCEDURE: Thoracic endovascular aortic repair with thoracic branch

endoprosthesis 37 x 15 Gore Tag with left subclavian branch of 12 x 6 via bilateral common femoral artery and left brachial accesses.

Would this be billed using unlisted CPT code?

What should be documented to support the use of 93615, 93616? What does the numbers for the recording of atrial electrograms should look like on the documentation. Can you provide an example?

Patient with aneurysmal dialysis access:

After evaluating, I decided to repair with a stent graft, and I deployed a 9 x 60 mm Covera stent graft.

Following the stent graft deployment, it was dilated with a 9 mm balloon, and the pseudoaneurysm had no further pulsations after deployment of the stent graft. At this point, I decided to repair the aneurysm sac, and I performed a transverse incision over the aneurysmatic sac, dissected the sac from the subcutaneous tissues and excised the excess of sac. Then I closed with interrupted 4-0 PDS suture. Skin was approximated with interrupted 3-0 Prolene suture and skin staples.

Would you code with 36903, or 36832?

Physician evacuated a hemothorax following a stab wound using VATS. He placed a Tachosil hemostatic topical coverage on to the parietal plural exit site from the track of the knife. There was 1200ML of liquified hematoma evacuated. There was slight dark oozing from the site but no active red bleeding. I think this should be coded as 32653. But I was not sure if the placement of the patch should be coded separately. Is there a separate code for that or would it be included with the 32653?

"Patient with hepatocellular carcinoma in for Y90 mapping. Microcatheter was advanced into right hepatic artery, arteriogram performed demonstrated a hyperenhancing mass in the inferior right hepatic lobe. A Dyna CT was then performed demonstrating a small branch of the right hepatic artery supplying the mass in addition to a major branch of the right hepatic artery supplying the majority of the mass. Microcatheter was used to select the small right hepatic artery branch and particle embolization using 100 to 300 um Embospheres was performed to near stasis. Post embolization arteriography demonstrated markedly decreased flow into the target. At this point, the microcatheter was retracted and a total of 2 mL of MAA were slowly injected into the right hepatic artery."

Is 37242 appropriate for the embolization since this was prior to Y90, or is 37243 more appropriate since he states this was a feeding vessel? I'm confused if this is to be interpreted as prophylactic embolization.

Provider orders a CTA of the cardiac structure to evaluate the pulmonary vein anatomy/LAA for a planned ablation. When the CTA is read, the reading physician documents findings of the coronary arteries. Would you code this as 75572 based off of the indication for the exam and the order, or would you code as 75574 since it includes coronary angiography?

"Redo coronary artery bypass grafting times 3 with reverse autologous saphenous vein graft to the LAD, reverse autologous saphenous vein graft from the aorta to obtuse marginal coronary artery, reverse autologous saphenous vein graft from the aorta to LC.

There were extensive adhesions between all surfaces. Extensive lysis of adhesions was required. A saphenous vein graft was harvested using an endoscopic vein harvest. Patient heparinize. pericardial sac retracted. The patient cannulated, and cardiopulmonary bypass was begun. The aorta crossclamped and pt. received cardioplegia and systemic cooling.

Distal anastomoses were done with 7-0 Prolene in a running technique, Proximal anastomoses were done with 5-0 Prolene. The aortic cross-clamp was removed and the patient underwent complete de-airing of all grafts. The patient was weaned from cardiopulmonary bypass."

Would you use 33512 only? If not what CPT code(s) would you use for this re-do procedure?

Upgrade of left-sided dual chamber PPM to dual chamber biventricular ICD, US-guided vascular access, left upper extremity and coronary sinus venography, implantation of LV lead, pocket revision. Mixed cardiomyopathy EF 30-35%, NYHA class III heart failure, AVN ablation with DC PPM in-situ. Per the op report- the RA lead was re-used. The old RV was capped and a new RV lead placed in addition to the LV. 

Would this be coded as 33233, 33249, and 33225? Or 33231 and 33233?

During EP studies, our provider documents "Hemostatic introducer sheaths were placed percutaneously in the left and right femoral veins using the modified Seldinger technique. Multipolar recording electrodes were advanced from the femoral veins to the right heart and into the coronary sinus for comprehensive study. Once the comprehensive study was done, atrial flutter and atrial fibrillation were induced with low-risk findings." Should pacing and recording in the RA, RV, and bundle of His be specified or is "right heart" sufficient documentation to support billing 93620 and 93621? Placement in RA, RV, and bundle of His are documented in the cath lab event log but this information is entered and signed by nursing staff.

Patient presents for planned embolization of splenic arteries. Goal is to treat splenomegaly, as it is causing thrombocytopenia, which is complicating treatment for metastatic rectal cancer. Facility wants to charge celiac and splenic angios, as there is no documentation of previous catheter-based angio or CT. However, the decision to embolize a specific organ for a known pathology was made prior to the procedure, so my thinking is that any angiography performed during the embolization is necessary to perform the procedure and thus should not be considered as diagnostic. Any guidance provided is very much appreciated.

Please explain when you would use 35876 over 35656. I have a provider that tunneled in a new graft PTFE into the old graft and did partial thrombectomy of distal old graft to make sure there is outflow. He did remove part of the old thrombosed PTFE graft also. Would this be 35656 since whole new PTFE tunneled graft inserted?

Patient with nephroureteral stent and clamped nephrostomy tube came and had conversion from nephroureteral stent to nephrostomy tube. How should this be coded? what is the difference between nephroureteral stent and nephroureteral catheter?

Please assist with suggestion for CPT code(s) :

ACCESS ANEURYSM RESECTION

Pre/Post-Operative Dx: Infected thrombosed aneurysmal AVF- Complete resection all infected tissue

Indications for surgery:

Longstanding right AVF, aneurysmal. Now thrombosed with infected open wound. Catheter in place.

Procedure:

The procedure had been discussed with patient (and family when present) all questions answered. The patientconsented to the procedure including intraoperative decision-making and alteration of plan as needed. After site marking thepatient was brought to the OR and sedation and block were administered by the anesthesia team. The right arm was preppedand draped per routine and a time out verified correct patient procedure and side.

We fashioned two incisions to resect all compromised skin and infection. The aneurysm was entered and subtotally resected,removing all abnormal tissue.

The wound was irrigated and closed using 2-0 Nylon mattress sutures and the arm wrapped. Sponge needle and instrument counts were correct.

The left anterior chest wall was prepped and draped. Both venous and arterial ports of the catheter were de-heparinized with a 5cc syringe. Venous and arterial ports were aspirated, and small amounts of clots extracted from the catheter lumen. A central venogram view was performed identifying good flow into the right atrium. No clots or abnormalities noted. F/U completion venography noted widely patent central venous system with catheter tip position near the Cavo atrial junction. Excellent aspiration from the arterial port and venous port was noted. Both ports were flushed with normal saline. Findings: Preliminary scout film of the chest demonstrates an indwelling tunneled right IJ hemodialysis catheter with the tip positioned in the right atrium.

I am not sure how-to code for the clot aspiration along with the central venogram.

Right heart catheterization was performed thereafter. A 7-French Swan-Ganz catheter was then advanced under direct fluoroscopic guidance into the distal pulmonary artery. Right atrial, right ventricular, pulmonary arterial and pulmonary capillary pressure tracings were obtained. Measurements were obtained for calculation of a FICK cardiac output. Thermodilution was performed. The Swan was then pulled by to RA and advanced into hepatic vein. Pressure checked there. Swan balloon was inflated and portal vein pressure (confirmed by contrast) was checked. Swan was removed after that.

93541 & 36011

Patient has a dual chamber PM for 3rd degree AVB at end of life. The physician noted that the atrial lead has become dislodged and is tested and not found to be sensing. The ventricular lead is functioning without issue. The physician and patient discussed and agreed to leave the dislodged lead in place, and it is attached to the new dual chamber generator along with the ventricular lead. Would this encounter be reported with 33228 since both leads are connected to the PM or 33227 since only one lead is actually functioning?

If a patient comes in for a abscess drain check and/or exchange and the diagnosis for the visit is one of the T codes that receive the 7th character A,D,S, would it still be considered active treatment "A" on each return visit until the drain is removed? Or would the return visits be coded with "D" for subsequent for all the drain check/exchange visits following initial placement? If they are still treating/managing the abscess with checking, evaluating, and sometimes replacing the drain, wouldn't this be considered "active" treatment on the return visits?

I am one of the professional coders for Interventional Radiology. I am trying to get clarification on best practices for when to use a modifier (52/53) to reflect a discontinued procedure vs coding for what actually took place. The below scenario comes up quite frequently:

An order is placed for a CT-guided percutaneous drain placement; however, preliminary CT showed resolutions of the right lower quadrant fluid collection. Therefore no drain was placed, and only imaging took place. The acute side reports 49406-74 (I understand they are bound to report whatever was ordered), but on the professional side we feel it is most appropriate to report 74174-26, since that is all that took place. Is that correct thinking? Or should we be reporting 49406-53? Do the professional and the acute side HAVE to match?

I have a patient who had:

Explant of CRT-pacemaker, laser lead extraction of RVlead, placement of RV ICD lead, placement of CRT-D and threshold testing. I believe I should use 33233 for the removal of CRT-P, 33231 for insert of CRT-D, 33234 for the RV lead removal by laser extraction and 93641 for the threshold testing. However, what would I use for the new RV lead insertion to the CRT-P?

Am I correct that we do not bill for the contrast that is administered for localization such as the injection of omnipaque prior to performing a joint injection being done under fluoroscopic guidance?