Ask Dr. Z

Can an ambulatory cath lab bill the lithotripsy C-codes when the surgeon charges still have to reflect 37220, 37224, 37228?

"Patient presents after cardiac catheterization done month prior to have staged atherectomy of RCA. Wires were attempted but the physician was not able to cross the lesion. Report reads as " Right radial artery access was obtained with a 6 French sheath without ultrasound guidance. Selective left coronary artery angiography was performed with 6 French fl-3.5. Selective right coronary angiography was performed with 6 French FR-4. Left ventriculography was performed with a 6 French FR-4. Intervention was performed with an interventional guide. The radial artery was made hemostatic with a radial band. No complications were experienced. Intervention of RCA. Multiple guidewires were attempted. We even attempted an aggressive tip wire. We were not able even to cross the first lesion. Wire out shot was performed. There was no residual stenosis."

What would be the appropriate way to code this? 93458 or 92920-74

Can you charge for both axillary mass biopsy (20206) and clip placement (10035) during same session and same site? Guidance included with 10035 only.

Ongoing discussion with physicians. They use the word "severe" (on occasion "moderate") to describe lesions and they argue that is adequate for coding. We accept the word occluded is 100%. But the other words - every physician has a different percentage for those words. Are there are any specific guidelines or resources you could suggest that support the use of percentage of stenosis vs severity?? Thank you very much.

Physician advanced ablation catheter and did mapping in the RV and LV outflow tracks and into the LV all revealing no early activation points. He went into the CS where he found highly fractionated electrograms. He also did a coronary study which revealed that the catheters were overlying a large circumflex coronary artery. Given these findings no ablation was performed.

Would you code:

1. 93618 and 93612-59

2. 93620

3. 93654 with reduced modifier

4. something else

"A preliminary ultrasound evaluation of the right common femoral artery was taken and saved. A needle was used to access the vessel with direct ultrasound. A reverse curve catheter was advanced over a wire into the aorta. This was used to select the inferior mesenteric artery. A microcatheter was manipulated over a wire through the base catheter into a greater than third-order arcade vessel of the mid-descending colon."

Would codes 75625 and 75710 be included in the code for 36247 and 36248?

We are unsure how to code this situation, we think it maybe 50387 but they used drain catheters and that will not match the device dependent list. Can you advise?

Bilateral retrograde nephroureteral catheter exchange

Obstructed right retrograde nephroureteral catheter.

The patient was placed supine on the IR table. Contrast injection into the left retrograde nephroureteral catheter demonstrates pigtail formed within the renal pelvis. This catheter was exchanged over a Glidewire advantage for a new Cook 10.2 French x45 cm pigtail catheter with pigtail formed within the renal pelvis and contrast injection confirmed appropriate position.

The right retrograde nephroureteral catheter was occluded. This was removed over a Glidewire advantage and replaced with a new resolve 10 French x40 cm pigtail catheter with pigtail formed within the renal pelvis and contrast injection confirmed proper position.

Catheter ends outside the urostomy.

IMPRESSION: Successful exchange of bilateral retrograde nephroureteral catheters.

"ICD generator was removed, and high voltage wire was separated from ICD device. Cultures were obtained from deep inside the pocket. Pocket was irrigated. Necrotic tissue was removed. Two-inch iodoform gauze was used to pack the wound after copious irrigation with antibiotic-containing fluid. Wound was left open with gauze partially exposed. Bulky dressing applied on top with air permeability. Successful removal of ICD generator and debridement of pocket with irrigation. Unable to easily remove high-voltage lead therefore it was left secured inside pocket with packing. Lead was folded over and secured to itself and tip was capped to preserve access for wire in the future when lead extraction undertaken." 

I am coding 33241, but do not know what debridement code to use here. Can I capture this, and which one is best to use for this situation?

"Under ICE guidance, the left atrium was entered by a single transseptal approach using a Baylis needle advanced through a Vizigo sheath. A Biosense Pentaray and Thermocool SmartTouch 3.5mm irrigated ablation catheter were used for LA mapping and RF ablation. 3D geometry was created using CARTO 3D. There were 2 left and 2 right veins, with no PVPs in the veins., suggestive of durable PV isolation from prior ablation. Mapping in Afib did not identify any target areas for ablation. Isuprel up to 20mcg/min was administered, with frequent PACs noted from the posterior wall, and also some PACS arising from the RA near the CS os. AFib was triggered spontaneously on 20mcg/min, beginning with PACs progressing to PAT to Afib. Isolation of the posterior wall was performed, with a posterior line followed by a roof line. There was some PAT that was mapped to the CS os, as well as the floor of the CTI. CTI line was consequently performed, with extension of the line to the floor of the CS."  

93656 with 93657 x 2 and 93623, or 93656 and 93655 with 93623? Thank you.

We are having a coding dilemma for the following case. Should this be reported as a creation (36830) with reduced/aborted modifier or as a repair (35206)? This was an initial graft placement. "Summary: Brachial artery too small for AVG, so AVG was connected to axillary artery and vein. Loss of pulse after AVG placement due to dissection of artery. Artery very friable and required repair with multiple tacking sutures and patch angioplasty anteriorly with bovine patch. Decision was made to remove graft after perfusion was restored to the hand because the risk of proceeding with reconnecting the AVG after arterial repair was felt to outweigh the potential benefit."

What would you think about the coding for placement of a new left arm prosthetic dialysis graft, excision of old prosthetic graft (different incision) and ligation of old left arm AV fistula with wound vac? Note said high potential that it was contaminated and possibly infected? I will query provider about that. But without, could you code 36830 LT, 37799, 37607, and 97605?

A patient is admitted to the hospital for HF. Due to medical management reasons, his/her TAVR procedure will be a planned readmission within the next 2-3 weeks. Documentation would support this. Is there a value code, d/c status code, etc., that would need to be appended to the claim(s) to reflect this? Any other pertinent information either for the hospital or the physician. Kind Regards.

I wanted to verify the use of 36215 for catheter placements and 75705-26 for imaging when coding T1-T12 (without vertebral imaging). Recently, a provider mentioned he didn't think we could bill T1-T5 because the supreme intercostal arteries supply the T-1-T5 levels. The report mentions each of the arteries were selectively catheterized and imaged along with the findings, so now I'm a bit confused.

What CPT code would be used for a sternoclavicular joint aspiration under ultrasound?

Regarding "1 biopsy code per surgical site" - I see several references in your Q&A indicating qty 1 for a liver bx 47000 (MUE of 3), with mod 22 for physician coding if more that one lesion is biopsied . But then I see reference to coding more than one bx code 50200 (MUE of 1) for multiple kidney biopsies performed on separate and distinct lesions in ONE kidney (question ID #17685, 8/24/22). This seems contradictory. Can you explain the rational behind this ? Thank you!

Code for right femoral arteriography? Is it 36245 and 76937?

"Right femoral arteriography sono imaging LT groin demonstrated patency left common femoral artery. After local anesthetic administration, left common femoral artery was cannulated and retrograde fashion using real time US IMG guidance an 18-gauge access needle. Hardcopy US image documenting needle entry into artery was placed in patient's medical record. Using exchange technique, a 6 French sheath placed. A 5 French diagnostic catheter was then advanced over a floppy guidewire to the level of the distal abdominal aorta. The catheter was used to selectively catheterize the contralateral common iliac artery. The catheter was advanced over guidewire to the level of the right common femoral artery under fluoroscopic. With the catheter in this position multi planar MR angiography of the RT common femoral artery, right profunda femoris and RT superficial femoral artery was performed. Images reviewed. Catheter and sheath were removed and manual compression achieved hemostasis."

Can we use a regular inj arthrogram code for this? 

"Next, under radiographic guidance, about 2-3 mL of 1% lidocaine was injected utilizing a 25-gauge needle along the expected trajectory of the procedural needle. The same needle was advanced to the knee joint. 2 cc of joint fluid was aspirated to confirm needle positioning, and needle position was also confirmed with direct CT visualization.Next, about 40 mL of air was then injected into the joint. After this, the needle was removed and a dressing was placed. The patient was then repositioned in prone position and the right right knee was flexed a few times to improve air dissemination into the knee joint. Thin axial slices CT was performed. IMPRESSION: Technically successful intra-articular injection of air into the knee joint to perform right knee arthrogram."

My EP doctor performed an atrial fibrillation procedure, and during the procedure a few different additional ablations/lines were performed. Atrial tachycardia was induced and ablated along with a posterior wall ablation and a CTI ablation. Can we bill for all of these? He thinks we can bill 93656 and 93657 x 2. Is that correct?

The provider's intention was to do an AV graft, but the artery is extremely small (2 mm), so she decides to abort the procedure halfway. Can I bill 35702 or attempted AV graft?

Our docs perform endovenous ablation therapy, CPT 36475, on our patients in the short stay/daybeds area. Prior to the procedure they perform a preliminary ultrasound to prescreen the patient. The preliminary ultrasound consists of:

1. The vascular techs perform a 2D vascular ultrasound on the extremity.

2. The U/ S involves a minimum of four images.

3. The sonographer conducts marking.

4. The sonographer also conducts limited dopplers.

5. No report is generated by the sonographers.

After obtaining the imaging the cardiologist reviews to determine if they are proceeding with the venous ablation. If not, we would like to charge for the preliminary ultrasound instead of just canceling the procedure. What CPT do you recommend? Would unlisted be appropriate? 93970/93971 does not seem appropriate here.

After further review, would the Tisseel injection, as documented in this example, fit the definition of a “therapeutic” injection to report code 62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) for this procedure?

During a CABG the doctor obtained a biopsy. I am wondering if this is something that can be billed (what CPT code?), or if it would be part of the surgery?

"Sodium heparin 3 mg/kg was administered systemically to achieve total anticoagulation. The patient was then cannulated for cardiopulmonary bypass by inserting an arterial cannula in the arch of the aorta and a venous cannula in the right atrium and securing it with a #2-0 Ti-Cron purse-string tourniquet suture. When creating the incision in the right lateral atrial wall, a button of wall was excised within the pursestring suture and sent for permanent sectioning. Cardiopulmonary bypass was then begun. A small shave type biopsy was made in the inferior right ventricular free wall with adequate piece of myocardium obtained. This was sent for permanent sectioning."

Is there a code we can use for anastomosing a Hemashield tube graft to a common carotid artery for establishment of cardiopulmonary bypass, or would we need to use unlisted code 37799?

Recently one of our providers did an aortic septotomy before performing a FEVAR. My understanding is that it is done to optimize the landing zone, which would lead me to think it is not something that is separately coded. Is my understanding correct?

Does a provider need to state urgent or emergent for acute MI to use 92941 for acute MI?

If a bifurcated graft was used to treat an aortic aneurysm, would it be appropriate to use a -50 modifier on 35102, or can you give me an example of when a -50 modifier would be used with this CPT code? It was my understanding that 35102 includes bypasses to the iliacs.

Is hydrodissection included with the ablation or is there a CPT or do I use unlisted? Please see procedure summary below and the hydrodissection portion of exam:

PROCEDURE SUMMARY:

- Ablation, one or more renal tumor(s), percutaneous, unilateral, cryoablation

- CT-guidance for, and monitoring of, parenchymal tissue ablation

- CT guidance for, and monitoring of, protective hydrodissection

Hydrodissection:

Under CT guidance, a 20-gauge Chiba needle was advanced along the medial aspect of the right kidney. The tip was positioned near the superior medial cryoablation probe which was adjacent to the ureter. Hydrodissection was performed with diluted contrast.

This demonstrated anterior migration of the ureter. Next, under CT guidance, a 21-gauge spinal needle was advanced through the inferior aspect of the right renal mass. The tip was positioned in between the descending colon and the kidney.

Hydrodissection was performed with diluted contrast. This demonstrated anterior migration of the colon.

Thank you!

Our physician did a bilateral adrenal and bilateral renal venous sampling, also with high and low IVC sampling. Would this be coded with 36500 x 4, 75893 x 4? The reason for exam is hyperaldosteronism.

Can the AV node ablation (93650) be billed with 93600, 93602, and 93603 when the recordings are documented? I know these cannot be billed with 93656, 93654, and 93656, but I am having a hard time finding any documentation on whether or not these recordings can be billed with 93650.

Patient was placed in supine position. Skin left lateral chest wall cleaned and draped in usual sterile fashion. 1% lidocaine used as local anesthesia.

Using CT guidance, the tip of a 20-gauge spinal needle was placed along the inferior margins of the left seventh and eighth rib at the level of the fractures (involving lateral aspect). Next, 10 cc Exparel was injected at each fracture. Patient tolerated procedure well with no immediate complications.

The reason for the injection was painful traumatic fractures. Exparel would be coded as HCPCS code C9290. Can the administration of injection of Exparel be coded? Would it be coded as 62321 or 64480? If not, please advise on how to code this procedure and state the reasoning. Does a query need to be sent to radiologist?

Are we able to code a percutaneous coronary lithotripsy (0715T) when performed in conjunction with an intracoronary stent placement (92928 for the pro fee) in a facility setting (C9600)? If not, how can we code for the lithotripsy for the facility?

Main body was a 26 mm ALTO graft. Positioned and deployed just below the renal arteries with the covered portion of the graft. It was then per instructions filled with palmar. We then used a 3.0 x 140 mm with maximal overlap into the main body graft on the left side, we placed a 22 x 140 mm Ovation iliac extension limb, which was landed just proximal to the hypogastric excellent positioning and then mimicking the procedure on the right side with oblique imaging and iliac retrograde injection. We had trouble identifying the hypogastric takeoff, so I used an SOS Omni catheter to selectively cannulate the hypogastric perform injection and pelvic selective angiogram, and locate the position of the hypogastric. We then used a 3.0 x 140 mm with maximal overlap of the main body, positioned and landed just proximal to the hypogastric. We per instructions used 14 mm balloon to lock in iliac limb into the gate of the main body, we used a compliant balloon to iron out the proximal extent and overlap portions of the graft into the iliac vessels. 34705 with 34709 x 2?

Please see the case below and advise. I'm not sure if 33223 is capturing this case best since the description states subcutaneous tissue and they performed at inframuscular level. Should we use an unlisted code and compare it to 33223? EP provider had a CTS provider assist with this case. 

"An incision was made more interior and medial to prior incision. The generator was removed, and the lead was freed. A new pocket was created at an inframuscular level, and the lead was positioned behind the device to avoid erosions through the skin. We tested the generator and leads in the pocket with fluoroscopy, and we inserted antibiotics into the TYRX pouch in pocket. Pocket was closed in two layers using 2-0 vicryl."

Transected the basilic vein and ligated proximally & distally with 5-0 proline stitch the basilic vein was respected with no thrombus seen inside the basilic vein proximally or distally which CPT would be appropriate would unlisted code 37799 or exploration code 35860 be more appropriate

Would a thrombin injection into an AV graft pseudoaneurysm be billed with the primary CPT 36901/36902 and 36909-? (access via the fistula) Just clarifying, as there are many ways to embolize (coils, spheres, etc.) Thank you!

If the provider performs a thrombectomy and then does CT scan brain non-contrast is the CT scan included in CPT 64615 coding for thrombectomy, or can they bill it separately? Is it separately payable after any procedure? They do perform the CT and read the scan.

Please provide your advice on coding for a lumbar puncture first attempted at L3-L4, multiple attempts, when the needle was removed it was evident that the catheter had been sheared. Another lumbar puncture was then performed and completed at L4-L5. There was then a consult with spine surgeon and decision to remove the retained catheter.

How would you recommend to report the CABG procedure when it's performed by the primary surgeon, assisted by assistant surgeon, and PA harvested the EVH? Example, if these are the billing codes 33533, 33517, and 33508. Would you bill out the following: Primary surgeon - 33533, 33517, and 33508; Assistant surgeon - 33533-80, 33517-80; PA - 33508-AS or nothing to the PA since add-on is by itself and assign it to the assistant surgeon instead? Not sure what's the most appropriate way to bill this. Thank you for your help!

We do WB MRI studies. My question is when we do an MSK study; e.g. for CRMO. Technique states Whole Body, but the Head is not mentioned in the report. I feel that the report should document "Axial Skeleton" at the very least, if there are no aberrant findings in the head. Mostly they document: Bones, Joints, Muscle, other soft tissues, then Other Findings - large field of view images show no bulky lymphadenopathy, pericardial or pleural effusions, ascites or other fluid in the abdomen. Do you consider this a whole body MRI, or does the Head have to be documented in Body of report...I'm thinking that if they documented the Axial Skeleton, this would suffice. Would love to have your opinion on this.

Does code 36002 include the thrombin medication, or is the medication billed separately? If billable separately, what is the J code?

"Aortotomy was made and leaflets identified. The patient had two perforations bridged by flimsy aortic valve tissues. Resected that bridge portion and made common opening. The rest of leaflets were adequate. Then harvested autologous pericardium which was stapled to stiff card to fashion it. Then cut pericardium size of perforation. Placed stay sutures at four aspects of defect. The patch was adequate sized. Leaflet not distorted. Aortotomy was closed in two layers. "

How should this be coded? I'm thinking 33391? Would harvest of the autologous pericardium be included?

Physician performed percutaneous approach removal of bilateral internal ureteral stents via snare. He then exchanged them with internal/external ureteral stents bilaterally. Should we just charge for remove and replace of internal stents - 50382-50, even though he replaced with int/external?

"Successful three-piece endovascular aortic aneurysm repair with main body via right femoral 23 mm proximal 14.5 mm distal 12 cm in length Gore excluder with extender on the right side 16 mm proximal 14.5 mm distal 10 cm in length and with contralateral limb via the left femoral 16 mm proximal 14.5 mm distal by 14 cm in length with excellent results hemostasis obtained in the hybrid room utilizing the preclosed technique. No immediate complications."

Would this be reported with codes 34705 and 34709?

Can codes 61645 and 36140 be billed together, or is code 36140 (arterial catheterization) included with 61645 (thrombectomy)?

What is the appropriate CPT code for supraclavicular nerve block?

Patient came in for decreased abscess drain output. The abscess drain was flushed with saline and redressed. Drain was functional after the flush. No fluoroscopy was used, so I don't think 49424 would be appropriate. Could this go to an unlisted code? Or is this just included in the facility E&M charge? 

What documentation is required in order to bill for arthrography codes? What would be coded for the scenario below If the body of the report only states :

"Procedure: The patient's right shoulder was prepped and draped in the usual fashion. The skin and subcutaneous tissues were anesthetized with 1% lidocaine. Next, under real-time fluoroscopic guidance, a 20-gauge needle was advanced into the glenohumeral joint from an anterior approach through the rotator interval. Small amount of Isovue contrast was administered to confirm intra-articular location. Next, 15 mL of diluted Dotarem was injected without complications. 

Findings: Fluoroscopic images demonstrate dispersal of contrast in the glenohumeral joint. Complications: None. 

Impression: Fluoroscopically guided intra-articular administration of contrast in the right glenohumeral joint for MR arthrography."

Can strain imaging be billed on both physician and facility claims for the same service date even though there is not a -26/-TC modifier?

Patient has a single generator with one lead in RV. The RV lead has malfunctioned, therefore the lead was replaced, and the single lead pacemaker was upgraded to a dual pacemaker with RA lead added. How would you code this scenario? 

Can you provide some guidance on a scenario? What is the proper coding to describe treatment of a patient with ventricular tachycardia who has non-ischemic cardiomyopathy?

In this example a physician performs a needle insertion and multiple catheter insertions, via a femoral access, into the heart under fluoroscopic guidance. After 3D mapping and recording, the physician identifies the appropriate targets and then ablates specific target areas causing ventricular tachycardia. (93654)

Additionally, the same physician uses an epicardial approach to ablate targets on the outside of the heart. The physician inserts a catheter via a subxiphoid percutaneous epicardial insertion into the pericardium, then through a sheath, inserts mapping and ablation catheters to identify and ultimately ablate targets on the outside of the heart, for a patient with non-ischemic cardiomyopathy. Once the targets are identified, the physician ablates those targets on the outside of the heart.

What codes best capture the above scenario?