Ask Dr. Z

My providers have begun to use only Rutherford score as indication for lower extremity revascularization. Would this be acceptable from a coding perspective? Rutherford score 6 was documented, and it looks like that could fall under ulcer or gangrene. What are your recommendations?

"Through incision & under US guidance visualization of needle penetration of the bladder Yueh needle placed in bladder. Needle removed & urine drained. Dilating the tract was difficult despite using surgilube & serial dilators incl 6, 7, 8, 9, 10, & 12 French. This required us to resort to balloon dilation of the tract from skin to the bladder. Inflation performed 4mm balloon. Calcium within wall of bladder & thick wall of bladder a 10 French catheter was successfully placed. It was placed to facilitate upsizing & cystoscopy being performed by urology this week."

In addition to 51102 and 76942, could I report 50436 or 50437?

Please help! Should this be coded with 64479 or 62321? "1% lidocaine was used for local anesthesia. Under CT guidance, a 22-gauge needle was advanced to lie with its tip adjacent to the verve root. Appropriate needle position was confirmed with CT imaging and injection of myelographic contrast. A mixture containing 0.5 mL of 0.25% bupivacaine, and 10 mg of dexamethasone was then administered in and around the nerve root. the needle was then withdrawn. Pre-procedure pain score; 7. Post procedure pain score: 2. Successful CT-guided right C5 selective nerve root injection." The indication is for Foraminal stenosis of C-spine, radicular pain of RT upper extremity. Pt is S/P C-spine fusion (order does not specify the level of fusion). The facility is reporting 64479. The coder wants this changed to 62321 because there is no documentation of transforaminal. Do codes 64479-64484 require documentation of transforaminal? How should this be reported? Thank you!

We are wondering how to code this procedure. There is the question of the PA and PCWP. Would this be a right and left heart cath? And would there be additional reporting for the thermodilution and PCWP?

"The patient was brought emergently to the Cath Lab in cardiac arrest. The right femoral artery was engaged and selective angiographic images were obtained in multiple views. 6F and JL4 were used and the Left coronary artery was selectively engaged angiographic images were obtained.

We then obtained femoral venous access and a 6F sheath was placed in the same fashion as above. I then advanced a 5F Swan into the RH and the RA, RV, PA, and wedge pressures were recorded. PA sat was drawn. Thermodilution cardiac output was performed. Swan was removed. The patient tolerated the procedure well."

the procedure was to remove an existing leadess pacemaker from RV and insert a new leadless pacemaker in the RV. Our provider is dropping CPT 33274 for insertion and 33233 for the removal. Would that be the correct codes for this?

Is it permissible to bill 0715T with C9600?

My surgeon was called emergently to the OR during another procedure due to a rupture of the paravisceral aorta. He ultimately placed an Endurant II aortic extension cuff in the distal thoracic aorta to the paravisceral aorta to cover the celiac artery down to proximal to the SMA. Since this is the abdominal aorta I would like to use code 34702. However, the description states "repair of infrarenal aorta". What would you code in this situation?

Code 33745 would be billed if we were placing a stent in the pulmonary vein for congenital stenosis per page 414 (e book #19 & page 431#40) & page 647 in Chapter 10 (e -book #74) shows to report 33745 for stent placement for pulmonary vein stenosis in patients with congenital heart disease. What would be the appropriate way to report venoplasty of an existing pulmonary vein stent for congenital disease? Would we bill 37248 for venoplasty of existing pulmonary vein stent for congenital disease or do you recommend 33745-52 (#74 page 647 e-book) or is that for only the RVOT or 33999 (pg 648 #80 e book) since it is an existing intracardiac shunt?

Our IR dept reported 36223-50 and 36225, and insurance denied based on incorrect modifier. Should an add-on CPT code be reported? 

Left PCA aneurysm, SP coil embolization.

"Fluoro identified right femoral head introduced a 5 x 10 sheath into the right femoral artery using US, micropuncture and Seldinger technique. Angiography demonstrated adequate placement. Then introduced a 5-French catheter over an 0.035 Glidewire. Patient had very tortuous origins of her great vessels. I selectively catheterized the right brachiocephalic artery after attempting to catheterize the right common carotid artery. I evaluated the brachiocephalic artery for visualization of the vertebral artery and carotid artery. I then selectively catheterized the left common carotid artery and left subclavian artery to image the left vertebral artery. Each vessel was evaluated using multiple projections including the angiogram. I removed the catheter and sealed the arteriotomy."

Is this enough documentation to bill 93986 performed during the same session as the creation of the AV fistula?

"Ultrasound was used to map out the superficial femoral artery, femoral vein, and great saphenous vein in the right groin. The site in which they were closely related was marked on the skin."

Is the note "with direct ultrasound visualization" enough documentation to use CPT code 76932 for ultrasound guidance of endomyocardial biopsy? Example: "With direct visualization the right internal jugular vein was cannulated via modified Seldinger technique with a micropuncture system. A J-tipped wire was advanced and a 7Fx23cm sheath was placed. A 7 French bioptome was then used for the endomyocardial biopsy using fluoroscopic guidance."

Also does the provider's documentation have to state endomyocardial biopsy using/or under ultrasound guidance?

Would it be appropriate to report code 75820 in addition to 21615 when performed to demonstrate that no bypass or patch be needed? The provider also passed the vein outside of the treatment zone.

Would you code the repair of a gunshot wound in the thoracic aorta as a TEVAR 33881, 75957 or 37236, 36200?

In Question 17097, you recommend reporting 33999 for Lampoon procedure of the mitral valve at the time of other percutaneous mitral valve procedures. Can you clarify if you would report the other mitral valve procedure separately along with the 33999, or do you recommend reporting just 33999 for the entire surgical procedure ?

In my case the Lampoon procedure was performed in conjunction with a transcatheter mitral valve in valve replacement for which I would normally code 0483T. Do you recommend 0483T and 33999 in this case ? Thank you

Could you please resolve a coding issue btw coders. Is the below procedure CPT 62321 or 64479. And the reason for the code selection. Thank you! History of previous cervical spine injury. Exam consistent with an element of right C6 & C7 nerve root irritation. MRI documented pathology with foraminal compromise. A sterile prep of the cervical/thoracic spine. A local wheal was raised over the T2-3 interspace. Utilizing the LOR technique, a 15 gauge, epidural needle was advanced into the epidural space toward the ipsilateral side of the patient's pain. Negative aspiration for heme and CSF observed. A soft navigable epidural catheter was threaded under fluoroscopic guidance to each appropriate level/nerve root exit site. (right C6 & C&) and a total of 3mg of dexamethasone and lidocaine was gently and slowly injected toward the foraminal opening of each respective nerve root exit after a small of contrast confirmed proper placement in the epidural space along the ipsilateral side of the patients pain as well as at the level of suspected pathology.

What is the CPT for administration intraventricular thrombolytics through an existing EVD?

A patient has a diagnostic cath, which showed 75% stenosis in the LCX, and a stent insertion is planned. A month later he comes in for the stent, but angiography done at that time shows only 60% stenosis and no stent is placed. What procedure codes should I use for the second encounter?

What is the appropriate CPT code when TCAR is aborted and carotid arteriogram is performed via open exposure?

"Planned TCAR for internal carotid artery stenosis with associated occlusion of the external carotid artery. The common carotid artery was exposed and microsheath and arteriogram documented occlusion of the distal internal carotid artery at the level of the carotid bulb. The internal carotid artery was not visualized in the neck. The external carotid artery was occluded. It was decided to conclude the procedure based on these findings."

Our docs say we should be using 76492 with cath codes and interventions procedures (92920, 92928 and 37224, 37220). I have never billed this code with these procedures before. Please clear this matter up for our coders.

How would the following be reported during a mitral valve replacement (aortic valve exploration no repair or foreign body/mass or thrombus removal)? 

"There was questionable thickening of the aortic valve involving the noncoronary cusp. Due to the questionable nature the decision was made to explore the aortic valve. An aortotomy was then created above the right coronary artery. The aortic valve was then inspected this demonstrated small lumen like sac lesions along the left coronary cusp and there was some calcification on the ventricular side of the noncoronary cusp however there were no obvious vegetations. The aortotomy was then closed with a running 4-0 Prolene suture."

Would this also be reported, and with unlisted code 33999?

A SVC cavogram was performed through the catheter which showed a fibrin sheath in SVC. A 12 mm angioplasty balloon was advanced over the guide wire. The balloon was inflated in three different segments of SVC. A follow up cavogram showed widely patent SVC without any fibrin sheath. Subsequently a new tunnelled dialysis catheter was advanced over the guide wire. The 13.5F dialysis catheter wa tunneled under skin over right upper chest and then introduced over the guide wire with the tips positioned in right atrium under fluoroscopy guidance. The catheter was flushed with heparinized saline and sutured to skin with 2.0 Silk. IMPRESSION: 1.Successful replacement of a right jugular tunneled dialysis catheter. 2. Successful removal/disruption of fibrin sheath with angioplasty balloon. Is it appropriate to bill: 36581, 77001, 36595-52? Thank you.

DX : Severe SMA stenosis/abdominal pain. I was able to navigate into the SMA and placed a catheter in the distal portions performing an angiogram demonstrating the distal portions of the SMA. Placed a Rosen wire down and performed a 6x60 balloon angioplasty first, followed by a 7x60 shockwave (IVL) to the proximal and mid portions of the artery. Selected a 7x37 stent, landing this into the aorta itself and in a portion of the artery that appeared free from disease. How would this be coded and are there codes for shockwave in the SMA?

Patient has a tunneled central venous dialysis catheter in the left internal jugular as well as a functioning straight radio-brachial AVG in the left forearm. The physician removes the LIJ CVC and does central venography through the same access, and findings are documented as severe (50%) recurrent left innominate vein stenosis. Patient also has venous hypertension diagnosis and difficulty with accessing the AVG. He then angioplasties the innominate vein stenosis through the same access and does not replace the tunneled catheter. Would this be coded as 37248, 36589, and 77001?

a 0.014 wire was passed into the peroneal artery, which was single vessel runoff and intravascular us was performed of the peroneal artery, tib trunk, popliteal artery, and the sfa. the pt has 72% stenosis in the peroneal, 67% stenosis in the tib trunk, 70% stenosis in the popliteal artery & 73% stenosis in the sfa.

a laser atherectomy was performed across the sfa, pop, tib trunk & peroneal artery followed by balloon angioplasty using 2.5 mm balloon in the peroneal artery and tib trunk & a 5mm balloon in the pop artery and sfa.

findings: pt's aorta and iliac vessels appear widely patent. the pt has a stent in the rt sfa with intrastent stenosis. also evidence of popliteal stenosis & single vessel runoff via ant tibial artery. left sfa stenosis including intrastent pop, tib trunk, & peroneal artery stenosis which was single -vessel runoff.

we billed 37229 lt, 37225 lt, 37252, 37253 but uhc isnt paying 37229 based on this doc. does anything look like 37229 should NOT be paid

We have an IR Dr. that placed a chest tube and then used a wire to break up loculations. The Dr. would like to get credit for breaking up the loculations because of time and effort involved with using a wire. Is there a code you would suggest using in addition to the chest tube code? 32560/32561 does not fit the description.

Would you recommend billing C7519 when IFR is performed with Heart Cath in the ASC?

Would there ever be a scenario where 75774 would apply when performing a diagnostic angiogram retrograde whether or not there is intervention? Typically our provider will access the DP and stay within the same extremity advancing to ipsilateral iliac and feels because he is advancing through each vessel on the way up he should get 75774 for those vessels. I have explained this is all non selective when staying in the ipsilateral extremity going retrograde but he feels this is not correct. Please advise, I would greatly appreciate any feedback on this.

What are the appropriate CPTs for this procedure performed? Left common femoral artery access. Catheter and wire were advanced to distal abdominal aorta where aortoiliac angiogram was performed. Catheter was pulled down to the aortailiac bifurcation and advanced over the wire to the contralateral common femoral artery and a right extremity runoff was performed. FINDINGS: patent distal abdominal aorta, bilateral common, external and internal iliac arteries. Right common, SFA and profunda arteries with mild plague, patent tibial peroneal trunk, patient peroneal with 100% stenosis anterior tibial and posterior tibial arteries.

Is there an update on the documentation requirements for myocardial strain 93356?

When a patient presents to the outpatient IR dept for a scheduled paracentesis for chronic ascites associated with liver cirrhosis, is the proper sequencing to report the ascites as the reason for visit and first listed diagnosis, followed by the cirrhosis? Or should the ascites be reported as a secondary code after the cirrhosis? The only Coding Clinic advice I can find is related to the sequencing of malignant ascites.

I am seeing different instruction on G0269. When is it appropriate to code separately for closure device placement for hospital coding? Can it be reported with most interventional radiology procedures such as embolizations but NOT with cerebral angiograms and lower extremity revascularizations? Does CMS have a current list of allowed procedures? 

If the RIMA and LIMA are embolized at the time of a congenital L&R heart catheterization, just confirming we would code both the heart catheterization (93597) along with the cath codes for the RIMA & LIMA (36216 and 36217) from a femoral approach? If there are three additional right chest wall collaterals embolized, we code for catheterization of these collaterals as well?

Is there a CPT code to use to bill a vasodilator test with a right heart cath procedure for the professional side?

In the code description for 34705 it states all angioplasty and stenting performed from the level of the renal arteries to the iliac bifurcation is included. When is it appropriate to bill for renal artery stents?

Outpatient had a left heart cath and found blockage in LAD. We place 2 stents. I charge for 93458 & C9600. Billing is telling me that we cannot charge for the 93458 since we did the C9600 in same day and we would charge for the highest level of care. Please advise. We must do the heart cath to even see if there is anything to fix. Then they do not want to use 59 modifiers in these cases.

This is an unusual case for the mapping being performed on same encounter as the tumor embolization. Embolization for tumor & mapping performed on same encounter. I understand that if the mapping 37242 and tumor embolization is performed on the same encounter that only use CPT for the tumor embolization 37243. I believe that I can use CPT 75726 & 75774 for the arteriogram procedure that was performed on the mapping procedure? On the selective catheterization "posterior segmental branch" for both the mapping and the embolization, can 36247 be coded twice for each procedure performed 36247, 36247-59? Or would only 36247 be used once for the tumor embolization procedure 36247?

I have a report that was documented as retrograde pyelography. Patient had post-operative diversion ureteral catheter, which was inserted via urethra. Contrast injection was performed into ureteral catheter and renal pelvis; collecting system and ureter findings are documented. How do you code for this procedure?

Can retrieval of previously implanted pulmonary flow restrictors (microvascular plugs) be coded as 37197?

We have a case where a HeartMate 3 (33979) was placed via sternotomy in the same session as an Impella RP Flex via right IJ (33995?). Codes 33979 and 33995 have a 0 edit and cannot be billed together. How does this get billed to capture all the work if you cannot bill them together? Is 33995 the correct code for the Impella RP Flex via IJ?

Can we code for both 37243 and 47382 done during the same encounter? I was thinking embolization only and that the ablation would be inclusive, but there is no edit and physician is questioning.

Hi Dr Z,

My question is in regards to your answer regarding question # 17202..

I was always under the impression that 34716 was for when the AXILLARY OR SUBCLAVIAN artery was exposed with a creation of of conduit for delivery of an endovascular prosthesis OR establishing CPBP with a conduit using the axillary or subclavian. Please explain WHY it would be correct to use when the innominate is the vessel??

In this example it would be a Bentall procedure with Right innominate artery cannulation and placement of 10 mm Hemashield graft for the initiation of CPBP.

Thank you.

We have a scenario where the provider performed a non-selective study of the bilateral extracranial carotid circulation (36221). However, they then selected the right common carotid and did further imaging of the right side intracranial carotid artery (36223-RT). Can we report anything for the images of the left extracranial carotid?

INJECTIONS:

LEFT vertebral artery

RIGHT vertebral artery

RIGHT internal carotid artery

RIGHT external carotid artery

RIGHT external iliac artery

INTERVENTION:

Selective verapamil infusions into both vertebral arteries and both internal carotid arteries. Each vertebral artery infusion exceeded 10 minutes in duration. Each internal carotid artery infusion was less than 10 minutes in duration.

How would we code this? We were thinking 61650 and 61651.

I have a question that our team has been discussing with regard to CEU coding. If the lesions are on two different organs (liver and spleen), it would be 76978 x2? What about for the paired organs? Say a lesion on the left and right ovaries? 76978 & 76979? The add on code of 76979 states each additional lesion with separate injection…, the additional lesion meant “ with different features, having distinctive character” then the initial lesion. When multiple lesions found on liver with same sonographic feature would we only code 76979?

We are unsure if lesions on left and right ovaries count as 76978 & 76979?

An omniflush catheter and Advantage glidewire were used to select the inferior mesenteric artery and angiogram confirmed access of this vessel. A MVP was then introduced through the catheter into the origin of the IMA and deployed right at that location. Completion angiogram showed ideal placement of the plug and successful embolization.

Findings:

There was no type 1a or 1b leak seen at completion of the operation. The patient's groins were hemostatic and the bilateral arterial pulses in the feet were unchanged at completion of the operation.

Hi, the above embolization plug was performed prior to graft placement, however, no documentation on the dictated report as to why. After reviewing the findings, I believe it was done to prevent an endoleak? If so, would 37242 and 36245 be appropriate to code along with the 34705? Thank you!

What is the access code for endomyocardial biopsy when RHC and LHC are not reported? Can we report 36010 here? Or is it included in 93505?

Our echocardiogram technologists are performing strain imaging as needed, with or without an order. Currently, our facility is not charging for the strain without an order on the hospital side, but the professional side is.

Does there need to be an order to be able to bill for the strain when performed, or does it just need to be documented in the report that it was performed?

A VATS left upper lobe wedge resection was performed using an endoGIA stapler because of her history of potential interstitial lung disease. Final pathology report shows “interstitial pneumonia”. Should this be coded with 32607 or 32608?

Provider placed a temporary pacemaker on day one. On day two after a dressing change it was noted that IJ sheath was completely out of the patient's neck. Provider removed that and the temporary pacemaker. Then she placed a new temporary pacemaker. I can't find any information on reporting 33210 two days in a row. Please advise.

There is an NCCI edit between 37200/75970 and 75889. If performed during the same session, with the biopsy being performed on the liver, do you feel the criteria is met for adding modifier -59 or an -X modifier to suppress the edit? I am having trouble with this, as it is the same anatomical structure, same incision, same encounter. It seems 75889 meets the incidental edit that CMS has assigned, for this code combination.