Ask Dr. Z

With the new myelogram codes it states that you are still supposed to use the old CPT codes when two different physicians are performing the services. How does this affect the hospital billing? Should we follow suit and bill separately to be in line with the physician billing, or should we bill the new code by itself?

Would you use unlisted code 19499 for tomosynthesis-guided breast biopsy?

Our interventionist cardiologist has requested to clarify if he consults a patient in the hospital and does a procedure (i.e., cath/stent/PCI) in the same day can he bill for both?

What is the difference between 35556 fem-pop bypass, which includes procurement of the SVG, and 35583 in-situ vein bypass, fem-pop?

We are having difficulty determining whether we should code both C9604-LD for the drug-eluting stent and 92928-LD for the bare metal stent. Can you help? Report follows: "Saphenous vein graft to diagonal was selectively engaged with the left coronary artery bypass graft catheter. A 0.014 filter wire was advanced through mid body lesion of the graft. There is a 90% lesion with what almost looks like a dual tract. After crossing the lesion, a 3 x 12 mm stent was advanced and deployed at high pressure. There is an 80% to 90% lesion in the diagonal below the graft as well. At this point, filter wire was retrieved, and a 0.014 All Star wire was used to cross the diagonal lesions. A 2 x 23 mm Vision mini stent was deployed with no residual stenosis. The patient tolerated the procedure well, and there were no immediate complications. IMPRESSION: Successful drug-eluting stent deployment to mid body of saphenous vein graft and also a bare-metal stent deployment to diagonal downstream."

I am hoping you can lend your expertise on whether or not you consider this to be an adverse event/surgical complication/misadventure. The account is being audited, and third party believes it should have been coded with complication code 996.1 and manufacturer notified of defective coil. "While the coil was being introduced into the aneurysm, a snap was felt. At this point the coil was attempted to be removed, but it was clear it was broken and detached. At this point a 2 mm snare was brought up over the microcatheter after the microcatheter was cut, and the distal hub was removed. The coil was then ensnared and removed along with the microcatheter. There was a total of 4 coils placed into the aneurysm, and post coil emobolization after final coil demonstrated good position of the coiling with no herniation into the parent vessel and no associated thrombus or embolus. There's a small neck remnant remaining in close proximity to the PCOM measuring 1.1x1.1 mm, but the PCOM filled appropriately and control angio showed no filling of aneurysm neck."

Bilateral carotid (36222-50) with abdominal aortogram (75625) was charged. The billing department informed us that a surgical code should be added to charges (in this case 36200). They said to add with modifier -59. As code 36200 is non-selective, and 36222 is selective, why is 36200 needed? The billing department stated they are receiving an edit and cannot bill. I was under the impression that code 36222 includes 36221, and that code 36200 is bundled into 36221. Are we not billing 36200 twice in this scenario? I am in disagreement with coding. Please clarify.

When performing these tests and they are deemed normal findings, and the reason for testing was "leg pain when walking", what would you use for diagnosis 729.5 or 440.21? I say 729.5, but could you possibly use 443.9 if dictation states "leg pain when walking"?

Patient with right MCA occlusion with stroke. CT with contrast demonstrates evidence of RT MCA occlusion with a large area penumbra on the perfusion imaging. Now for attempted thrombectomy and revascularization of the right middle cerebral artery. Selective right ICA and cerebral angiogram, catheter advanced up to the edge of the clot and aspirated for 60 seconds, after removing catheter there was no evidence of clot within the tube. Following mechanical thrombectomy with direct aspiration technique and stent retriever x2,we were unable to obtain revascularization(37184), most likely due to the high-grade stenosis from an atherosclerotic plaque of the distal M1 segment. There appeared to be a very firm lesion at the distal MCA consistent with possible atheroma, and at this point we advanced a balloon across the stenosis and performed transluminal balloon angioplasty (61630). This resulted in partial revascularization. Can we report both codes since thrombectomy attempted but results were not to his satisfaction then he proceeded to angioplasty of stenosis?

Can you tell me if code 51600 is charged when you perform a cystogram through an indwelling Foley catheter? I thought you would only report code 74430 if the catheter was already in place.

I could use your input on the following scenario: The patient has a non-functional AV bovine graft in the left forearm, which our physician ligated and removed to prevent steal phenomenon in a new upper arm fistula, which he created in this same operative session. Normally, I would code for the ligation of the AV graft (37607) and the creation of the new upper arm direct type fistula (36821). Is there another code that could be used for the ligation and removal of the old forearm graft, which was not infected? The ligation was successful, but our physician was concerned that once he created the new AV upper arm fistula the patient would develop a steal phenomenon without removing the old forearm graft.

A 4-vessel cerebral arteriogram was performed on a patient with two aneurysms on two different vessels. 3D spin with reconstruction was performed on each vessel with the aneurysms. Can we bill 76377 for each spin that was done?

POSTOPERATIVE DX: Enlarging symptomatic thoracoabdominal aneurysm. PROCEDURE: 1. Left iliac artery to superior mesenteric artery bypass. 2. Left iliac artery to hepatic artery bypass. 3. Endovascular repair of thoracoabdominal aneurysm using Medtronic Valiant thoracic stents x2. IMPLANTS: 1. 12 x 6 bifurcated knitted Dacron graft. 2. Thoracic stent Valiant Medtronic 44 x 44 x 150, proximal main. 3. Valiant thoracic stent 46 x 46 x 100, distal main.

Could you please assist me with this scenario? Physician has placed drug-eluting stents in the posterior descending artery as well as the left ventricular branch. For coding purposes, is the left ventricular branch considered an additional branch off the right coronary artery? If so, are we allowed to code for stent placement in this vessel?

Which CPT code would we use to bill for the Allen test?

How would I code this open procedure to remove foreign body? "A median sternotomy incision was made, and she was placed on cardiopulmonary bypass. Cardio plegia given into the aortic root until good diastolic arrest was achieved. I placed tapes around the superior and inferior vena cava. Once these were shared I opened the right atrium. I could see with retraction the stent adherent to the tricuspid valve chart. We also did a transesophageal echocardiogram at the beginning of procedure. She was found to have moderate tricuspid insufficiency on TEE preoperatively. I removed the stent; it came out very easily. The tricuspid valve did appear to be intact but not in great shape. I felt there would be some leakage; however, at her age I did not want to replace her tricuspid valve if at all possible. I removed the foreign body and closed the atrium with 2 layer with running 4-0 prolene suture. The aortic cross-clamp was removed, and the patient rewarmed and weaned from cardiopulmonary bypass. Stable back to ICU. TEE performed."

We have recently started a CTO program. Here's the scenario: Heart cath performed by Physician 1. Physician 1 comes to the conclusion that the lesion present is a CTO. Physician 1 consults Physican 2 about the CTO case. Viability study done. Heart muscle viable. Physician 2 looks at films from recent (within the allowed period of time) heart cath. (Patient has not had a change in status.) Finds that the images don't show the collateral circulation well enough. Physician 2 decides to bring the patient back to re-study the coronary anatomy to fully assess the collateral circulation as staging for future CTO case. What can/do I charge for this encounter?

"Incision made in anastomosis; hyperplasia found with plaque. Extended incision down into vessel and removed stenosis then patch placed." I have always coded this with 36832 as an outpatient procedure due to being a minor, approximately 30-minute procedure. If documented that it is extensive, or incision taken further than basic, I then would code it as an endarterectomy. The physician states he would not consider this as extensive of what he would call a normal endarterectomy. What are your thoughts?

If the anesthesiologist actually places the TEE probe, can the cardiologist still charge the intra-op TEE code (93355) during procedures such as mitral valve repair, TAVR, etc.?

Should the following be reported with code 35102 only? Or with codes 35081 and 35131? "Diagnosis: AAA. Right common iliac aneurysm. OP: AAA repair (Hemashield 24 mm straight graft). RCIA aneurysm repair (Hemashield 12 mm graft from aorta to RCIA)...There is a large pulsatile infrarenal AAA...There is a large saccular aneurysm arising from the RCIA...The infrarenal aorta was clamped…Aneurysm sac opened...Aneurysm tapered at the level of the renals. A 24 x 12 bifurcated graft was transected above the bifurcation to create a straight graft and anastomosed to the aorta at renal level...Distally anastomosed to the aorta at bifurcation...Aneurysm originating off the RCIA was excised and couldn't be repaired primarily/inflow not good through the RCI orifice. We placed second graft using 12 mm limb of the bifurcation graft and anastomosed this to CFA at aneurysm level, end-to-side. The proximal end of the graft was then anastomosed to the previously placed Hemashield graft in end-to-side fashion."

We have a patient with an injury to the spleen; the radiologist is doing a diagnostic angio and embolization. I'm not sure how to code these additional catheter placements and angiograms. Can you please assist me? He did a selective celiac and angio (75726-26), selective splenic and angio (36246, 75726-26), and then three additional superselective 4th order splenic artery branch vessels with angiograms (36248 x 3, 75774-26 x 3??). He then performed an embolization for the bleeding (37244). Ultrasound guidance was used for femoral puncture with image stored (76937-26).

For the following, are both codes 37241 and 37238 appropriate? "Fistulogram performed. Multiple enlarged escape veins arising from the proximal venous outflow as well as stenosis and pseudoaneurysm formation of the perianastomotic venous outflow. The remaining portions of the venous outflow and central veins are patent. The arterial anastomosis is patent. To treat the perianastomotic stenosis, pseudoaneurysm, and enlarged escape vein, the fistula was accessed in a retrograde fashion under direct sonographic guidance. Brachial artery was then catheterized. Arteriogram was performed, confirming findings. A 6 x 5 cm Viabahn stent was then positioned across the pseudoaneurysm and stenosis and was successfully deployed. The stent was posted with a 6 mm balloon. The escape vein was then selectively catheterized. An 8 mm Amplatzer plug was then positioned and deployed. Delayed 10-minute venogram shows persistent filling of the escape vein despite adequate sizing of the Amplatzer plug. Therefore the stent was extended. Follow-up venogram demonstrates successful exclusion of the escape vein."

"From a femoral approach, the physician selectively engages the right subclavian, a collateral off the right subclavian, right internal mammary, and the right vertebral. Images are taken in each vessel. The purpose of the exam is to check for collaterals supplying the lungs for cystic fibrosis related hemoptysis." There is no mention of imaging of the cerebral vasculature. How would this be coded? Selective imaging of the vertebral is causing me some confusion.

For physician billing, is 37215 the only billable code to use for the following procedure? "Pigtail was brought to the aortic arch, and an aortic arch angiogram was performed. This revealed a type I aortic arch. There is also some calcification observed in the ostium of the right common carotid. The pigtail was removed, and a Simmons 2 catheter was used to selectively engage the right common carotid. Angiograms were taken. Intracerebral angiograms were taken. Given the type I arch and 95% occlusion, with adequate landing zone for an embolic protection device, we felt it was reasonable to proceed with carotid stenting. Stenting of the right internal carotid artery with distal embolic protection was done. The patient had prior to this procedure, a CTA of the neck."

If my IR physicians are not doing the injecting, we cannot charge for code 38792, correct? The surgeon is doing the injecting, not my imaging physicians.

Could you please clarify CPT code 93463? In question #2610 you state that it cannot be coded for intra-coronary injection of nitroglycerin. In the CPT Codebook it states to use code 93463 in conjunction with codes 93451-93453, 93456-93461, 93563, 93564, 93580, and 93581. This code range includes diagnostic heart cath procedures. The CPT Codebook and the Coders' Desk Reference do not explicitly state that it cannot be used for intra-arterial coronary injection. In the scenario I am questioning, the performing physicians are hand-injecting intra-coronary nitroglycerin to evaluate a stenosis in a vessel and then re-imaging that vessel after injection during a diagnostic heart cath without intervention. Is it appropriate to report code 93463 in this scenario?

The patient had supraventricular tachycardia. Electrophysiology was done, as well as ablations. At the end of the procedure, additional final venogram was done, which showed the coronary anatomy to be the same as when the procedure was started. Do you code separately for a venogram of the coronary sinus anatomy after EP and ablation?

"A patient has a left internal jugular vein to left common carotid artery fistula. A stent was placed in the left jugular vein, spanning the insertion of the fistula into the vein (via a left common femoral vein access). Coil embolization was placed in the distal aspect of the fistula at the jugular communication via the left common carotid artery (by right common femoral access)." Will I be able to report codes 61624 (36223, 75894, and 75898) and 37238 (36011) for the above procedure?

We have patients who are first taken to the radiology department to have a breast localization device percutaneously placed by a radiologist for lesion identification. The patient is then transferred to the operating room for an excisional biopsy of the lesion. We feel these two procedures should be reported with codes 19125 and 19281-59 because these procedures are performed by two separate physicians in two different locations. Is this correct coding, or is code 19281 bundled into 19125?

For the following, do you agree with codes G0269, 36217, 36218, 75726, 75774, 37242, and 37244? "Right CFA was accessed using a micropuncture needle. The right bronchial artery was catheterized, and angiogram was obtained. Subselective cath of a bronchial artery branch was then performed, and angiogram was obtained. The decision was made to perform embolization. The right bronchial artery was embolized until hemostasis was achieved. Post embolization angiogram right bronchial artery showed satisfactory hemostasis. Next right intercostal artery was catheterized, and angiogram was obtained. Subselective catheterization of a right intercostal artery branch was performed, and angiogram was obtained. The decision was made to perform embolization. The right intercostal artery was embolized. Post embolization angiogram of the right intercostal artery showed satisfactory hemostasis. The brachiocephalic artery was catheterized, and angiogram was performed. The angiogram demonstrated normal opacification of the brachiocephalic, right subclavian, and right common carotid arteries. Hemostasis was achieved with an Angioseal closure device."

When a duplex scan (93976) is performed on the patient, as well as color flow Doppler and spectral Doppler, is there anything additional to report? My understanding is that if something separate and distinct is happening, a modifier may be applicable. However, in this case, all patients seen in the facility for the duplex are also undergoing a pelvic ultrasound (non-OB), so none of the cases seen are encountering anything separate and distinct, as it has been adopted as a policy it seems. Just looking for clarification, as this is the feedback we received from some auditors: "Color flow Doppler done without spectral Doppler has always been a non-billable charge, as color Doppler alone is inclusive to the US procedure. However if a true duplex evaluation, including both color and spectral Doppler, is performed, there is most definitely an additional service to report (93975/93976)."

How do we code for cardiomens insertion with right heart cath? Do we report codes 93451 and 93568? Or do we only report code C9741?

What is the appropriate code for the creation of pericardial window with biopsy?

A radiology tech and I are having a disagreement on which fluoroscopy code is correct for a vertebral body bone biopsy. He says it should be 77003, but I think it should be 77002. I think code 77003 is for injections/aspirations, while code 77002 is for biopsies. Can you help settle this for us?

For patient with dialysis access, the following findings are noted and treated: "An 80% stenosis was observed in the arterial anastomosis. A 70% stenosis was observed in the axillary vein. A 70% stenosis was observed in the subclavian vein. The arterial anastomosis stenosis was treated with angioplasty using a standard balloon, size 8 x 4. The post intervention stenosis was 50%. The residual stenosis was treated with a nitinol stent, size 8 x 40. The subclavian vein stenosis was treated with angioplasty using a standard balloon, size 10 x 4. The post intervention stenosis was 40%. The residual stenosis was treated with a stent using a nitinol, size 12 x 40." We reported code 37236 for AA stent and 37239 for subclavian stent, but since 37239 is an add-on to 37238 the claim was denied for not having identifying code. Are we to submit code 37236 for arterial stent and 37238 for the venous stent since both are billable?

"Aortogram performed (75625) and LLE angiography performed (75710). Patient has iliofemoral venous bypass graft. Stenosis found at distal margin of venous bypass at junction of superficial femoral artery. This was angioplastied. Thrombus was found at blind ending portion at the anastomosis between the iliac limb and bypass vein graft and was treated with AngioJet." How would you code the angioplasty and thrombectomy? Would this be considered arterial or venous?

What documentation is required to submit code 71555? Would you feel comfortable reporting code 71555 according to the documentation that follows? "Technique: TWIST MRA and contrast-enhanced MRA of aorta performed after administration of a total of 16 mL Gadavist contrast. Delayed gadolinium enhancement imaging was obtained. MRA: The size of the right ventricular outflow tract, main pulmonary artery, and main branch left and right pulmonary arteries are normal without any evidence of stenosis or aneurysm. Thoracic aorta appears normal in size without any evidence of coarctation or aneurysm. LATE GADOLINIUM ENHANCEMENT: There is no definitive evidence of focal abnormal late gadolinium enhancement to suggest fibrous changes/scarring in the left ventricle. IMPRESSION: 1. Normal LV and RV size and function. LVEF=75%. RVEF=60%. 2. No evidence of pulmonic stenosis, including subvalvular or supravalvular stenosis. Normal caliber right ventricular outflow tract, main pulmonary artery, and branch pulmonary artery vessels."

The doctor would like to bill codes 36217, 37218, and 75710-26 for the following: "Right femoral artery cannulated in retrograde fashion. Catheter into origin of the innominate. Then catheter passed selectively into the origin of the common carotid artery. Then catheter passed selectively out into the subclavian and selective angiography performed, confirming subclavian to be widely patent. Balloon dilation was performed and did not get a good result. Stent placed over ostial and proximal portion of innominate artery." Any help on this is greatly appreciated.

The cardiologist performed a LHC, and an interventional cardiologist performed stent in the LD and RD. In the recovery the patient developed chest pain, which brought him to the cath lab. The interventional cardiologist performed a coronary angiogram and found the RC stent to be patent, but found thrombus on the newly placed LAD stent, which was successfully treated with PTCA. Can we charge for the repeat coronary angiogram for the different physician for change in medical necessity as new chest pain?

I had another attempted VSD closure that was aborted for technical reasons. Much effort went into closing it, but it was unsuccessful. In this situation, are we billing it as VSD closure with a modifier, or as 93531 and add the angios?

We are confused on what CPT and ICD-9 codes should be used for placement of a midline catheter. We were using code 36000, but our auditor recommends code 36569-74 (local anesthesia is used) based on CPT Assistant September 2014. The intent is to place a midline, not a PICC, so there is some confusion as to why code 36000 isn't appropriate. Also, wouldn't we change 38.97 to 38.99 as well, since these are not in the central circulation? Here is an example of our dictations: "An appropriate arm vein for line access in the upper arm was widely patent, and a hardcopy ultrasound image was recorded. 1% lidocaine was used for local anesthesia. Using ultrasound guidance, real-time visualization of midline needle entry was used to gain access to the patent right basilic vein above the antecubital fossa. The midline was deployed and was flushed with saline and fixed to the skin. Tip of the midline catheter lies in the peripheral venous circulation distal to the axillary vein. IMPRESSION: Successful right 18-gauge midline placement with use of real-time ultrasound."

What is the appropriate CPT code for a midline catheter placement?

What is the appropriate code for non-coronary stent replacement performed on a dialysis patient?

Our physician performed a biventricular pacemaker generator change. He also inserted a new right ventricular lead and capped the old one. I reported codes 33229 and 33216; however, code 33216 is being denied. Maybe I am not seeing what is a simple answer. Could you please assist?

We could use help on coding for the removal of the previous placed occluded graft. "Procedure: The common femoral, the superficial femoral, and profunda femoris arteries were dissected first on the right and then on the left. The femoral-femoral crossover bypass was dissected. The bypass was found occluded. The patient had an excellent pulse on the right side, but no palpable pulse on the left side. We cross-clamped first on the right side the distal external iliac artery, the profunda femoris, and the superficial femoral artery. We transected the femoral-femoral bypass that was occluded, and excised as much graft tissue as possible so that we had a good inflow through a wide opening in the right common femoral artery. On the left side, an identical procedure was performed of the occluded superficial femoral and profunda femoris artery. We transected the femoral-femoral crossover bypass. We almost completely excised the old graft that was well incorporated. It had no evidence of infection."

I'm still pretty new in coding cath and want to make sure I'm on the right path. One of my providers performed a coronary artery fistula closure with a congenital cath plus coronary angiogram and supravavular aortography. This is what I'm coming up with so far: 37242, 93531, 93567, and 93563.

Please help me code the following: 1) Coronary angiogram. 2) Angioplasty of distal RCA in-stent restenosis. 3) Angioplasty and stenting of mid RCA. 4) Angioplasty of proximal RCA. Report states this was a complex intervention due to multiple stents in place and a moderate tortuosity of the mid RCA, where the stent had been previously placed. Can modifier -22 be used when the MD has documented the difficulty of the case, such as complex intervention, challenging case with multiple attempts?

Is this additional work codeable? If so, what codes? "Implantation of dual chamber pacemaker was performed. The wound was then closed. During the closure, postoperative check revealed that there was increased impedance in the atrial channel. The wound was then reopened without the patient leaving the room. The lead was then removed from the header and reinserted with resolution of normal function. This may be secondary to air in the header. Set screw was in place. After this adjustment, the device is functioning normally. The patient was taken out of the room in satisfactory condition. The pocket was also irrigated with bacitracin solution for a second time."

Can you charge all attempts for a central venous cath? There were multiple sites tried and all failed. I know I can only charge guidance once, but I am not 100% on charging all attempts.

How would you code diagnostic pulmonary vein angiography and catheter placement for following pulmonary vein procedures if no heart cath was performed? 1. Left lingula pulmonary vein dilation (35476/75978). 2. Left upper pulmonary vein dilation and stent placement (37238). 3. Right upper pulmonary vein dilation (35476/75978).