Ask Dr. Z

In the left anterior descending (LAD), is the left posterior descending artery (LPDA) considered an additional branch in coding? Or are only the diagonals of the LAD considered additional branches?

I came across ICD-10 code B210110, Fluoroscopy of single coronary artery using low osmolar contrast, laser, intraoperative. In which scenario is laser used for angiogram? If it is for atherectomy or thrombectomy, I would think it should be an additional code instead of angiogram with laser.

In the facility setting, can we capture code 76937 for the ultrasound guidance used when a nurse places a PICC (stored paper image)? I was under the impression "no" because of the patency documentation (which requires a report), and they can't generate ultrasound reports.

I'm not sure what code would be appropriate for cystoscopy with insertion of an occlusion balloon catheter(52005 vs. 53899). "The urologist performs this prior to the patient going to IR for percutaneous nephrostomy tract dilation. The interventionalist manipulates the ureteral balloon cath, positioning it near the UPF, and the balloon is inflated. Contrast and air are injected, and the collecting system is opacified and distended. Tract is dilated (50395-59), and case goes back to urologist where he does the percutaneous endoscopic nephrolithotripsy and nephrolithotomy (50080, 50081). Then the interventionalist places a double-J ureteral stent and a nephrostomy tube (50393-59, 50392-59). The following day a percutaneous nephrostogram is done to evaluate integrity of right collecting system and ureteral stent function. No obstruction was noted, so removal of the neph tube was done (50394??, 50389)." The 70000 codes are picked up by the chargemaster.

I have a case in which the catheter was placed in the right brachiocephalic artery and documented as below. "Right brachiocephalic artery: Cervical view: The catheter was advanced into the right brachiocephalic artery, and angiography was performed over the cervical region. The cervical view of the right brachiocephalic artery shows tortuous origin of the right common carotid artery and tortuous origin of the right subclavian artery. The origin of the right vertebral artery is not well visualized. There is no significant steno-occlusive disease noted." If the left subclavian was also selected and the left vertebral was viewed and documented, would I only report code 36225 (unilateral)? Or would I also be able to report code 36221 for the right side? 

How would we bill for Definity administered as contrast during a non-stress echo? Code 93352 is defined as used during a stress echo, but they did not perform the stress portion and they used Definity instead of doing a bubble study. Would 93352 still be the correct code in addition to 93306?

Can code 76380 be added to the interventional coding for the following? "IVCgram with complex retrieval of IVC filter requiring dissection. Post retrieval cavagram and cone CT without contrast demonstrate a single fractured filter leg as seen on cone CT and with fluoroscopy."

The patient had breast cancer with multiple vertebral lesions. The physician biopsied the L1 and L2 vertebral bodies using two different access sites. Would you report code 20225 twice? One of the coders is saying that we should only code one biopsy since it is a contiguous site and it was probably done just to ensure a proper specimen. We would like your opinion.

If aortic pressure is documented, but not the ventricular pressure, can you still bill code 93458? We need to understand exactly what documentation is required to bill left heart catheterization code 93458.

We have a patient who presented with an existing dual chamber ICD for an upgrade to a biventricular ICD. The LV lead was inserted, but after the insertion this lead was accidentally damaged with the slitter catheter. This new LV lead was then removed, and a new LV lead was inserted. Do we code for a lead removal in this case or just stick with the code for the addition of the LV lead (33225) since it was all the same operative episode?

I am finding little reference for the use of this code. Would you use V45.82 if the provider documents history of stent or PCI? Can it only be reported if the exact word "angioplasty" is dictated and at no other time?

Recently our practice started placing MidLine catheters using US guidance for antibiotic use. The catheter lengths range between 14cm and 22cm. Can I code these as a CVC with a -52 modifier as it does not reach the central system?

A patient had thrombin mixed with gel foam slurry injected into subcutaneous tunnel tract site from left chest wall permacath to control tract bleeding. The tunneled permacath was removed the day prior and patient later developed unconrollable bleeding. What would you code for the thrombin injection in this case? Here is script from report: "The left chest wall was prepped and draped at the site of permacath exit. 100 international units of thrombin was mixed with gel foam slurry and injected through the micropuncture sheath which was introduced into the tract. Pressure was then held over the site."

For the following example, which is the correct code to report? 37241 or 37242? "Patient has in place a right common femoral artery to below-knee tibioperoneal trunk insitu great saphenous vein bypass, which appears patent. Several areas of enlarged tributary veins emerge from within the proximal, mid, and distal thigh, providing rapid flow of contrast into the venous system. These appear to be filling antegrade from the bypass. The anterior tibial artery, beyond the anastamosis, was in need of revascularization; however, it could not be accessed. A prograde catheter was advanced down into the bypass and selective access into a tributary vein branch off the insitu conduit was obtained. Coil embolization x three coils was performed using 2 x 20, 2 x 40, and 2 x 40 coils into different vein branches. These coils are under arterial pressure and were accessed through the arterial system, but as an insitu vein, it is connected to the venous system."

Laser catheter SFA, popliteal, tibioperoneal trunk. Angioplasty of the left popliteal artery. Aspiration thrombectomy of the left popliteal and left peronal/left tibioperoneal trunk arteries was then performed using a Pronto LP aspiration catheter. Is it okay to code the thrombectomy with atherectomy?

"Patient admitted due to multiple shock from defibrillator and deterioration of the insulation and exposed part of the RV conduction wire. After testing, the decision was made to implant a new RV lead and repair the old lead with silicone. A new RV lead was advanced to the right atrium transvenous and then positioned under fluoroscopic guidance with the tip in the mid right ventricular septum. Attention was then turned to repairing the exposed portion of the right ventricular lead. First all 3 pins were capped with silicone caps, which were tied in place. The exposed part of the lead was then covered with a silicone tube, the medical adhesive silicone was placed inside the tube, and the tube was closed with 2-0 silk ties at approximately 3 cm intervals. The right atrial lead was repaired in a similar fashion. The old atrial lead and the new RV lead were reattached to the old defibrillator. The leads were then checked through the device. The device with the capped RV lead was placed in the pocket and the wound was closed." Would you report codes 33216 and 33218?

Would you use code 35587 (in-situ vein bypass, popliteal-tibial, peroneal) or an unlisted code (37799) for popliteal-plantar artery bypass?

We are planning to use IschemaView software in our stroke protocol for cerebral perfusion studies. Code 0042T is status indicator N and not covered by Medicare/Noridian. Is code 0042T appropriate? What are the appropriate codes for CT cerebral perfusion study?

"Open exposure of the right axillary and later left femoral artery. A glide wire and catheter were used through the axillary artery and a pigtail placed in the mid aortic arch for aortogram. The wire was advanced down the true lumen of the dissection and followed carefully with IVUS to make sure we remained in the true lumen. The air into the true lumen was essentially completely obliterated. We followed the contrast into the infrarenal aorta and confirmed location with angiography and IVUS, then continued down into the left femoral artery, where we cutdown and grabbed the artery. We passed a long sheath retrograde back up into the non-dissected portion of the arch and a wire, which was opened pressed up against the aortic valve, and used a 22 dry seal sheath from the left groin. The TEVAR device was delivered. Completion images confirmed landing zone; guidewires and catheters were removed." I was thinking of reporting codes 33881, 75957, 34812, 36200x2, 37250, and 75945. Any coding advice on axillary exposure and conduit is appreciated.

"The right hepatic artery was selected. A single branch of the right hepatic artery was feeding the mass. The branch was totally embolized. The catheter was pulled back with the other branches of the right hepatic artery evaluated and none appeared to feed the mass. The catheter and sheath were removed from the celiac axis. A Simmons catheter over a glidewire; the SMA was selected. Contrast was injected with no evidence for feeding artery from the SMA to the hepatic mass. The catheter and sheath were removed." I was using 37243, 37247, and 75726. Should code 75726 be removed from this case? I was using it since the SMA was selected and imaged after the chemoembolization.

I see the charging staff reporting 36225 when there is a shot in the innominate artery as the catheter is on its way up to the common carotids for selectivity there. I would consider this a "drive by" and only report the 36222 or 36223 depending on the cerebral angiography documentation. If the physician selects the common carotids first, then stops at the innominate on the way out, I would not code the 36225 then either. The confusion is also fueled with the description of the code 36225. It states '"selective catheter placement, subclavian, or innominate" etc. To me, this description reads that the subclavian and innominate are the same when using 36225. Can you help us understand the proper reporting of code 36225 and if the innominate artery can be reported with 36225 when shot in conjunction with a common carotid, etc.?

"Patient with aortic stent graft in to evaluate for endoleak. From right CFA, catheter was advanced over a wire into proximal abdominal aorta cephalad to patient’s graft. Carbon dioxide aortogram performed. Catheter was withdrawn into the graft and aortograms performed in different projections. Selective right internal iliac arteriogram was then performed. Left CFA was accessed and catheter advanced into the left internal iliac artery for selective arteriogram. These demonstrated small endoleak at base of aneurysm below the graft bifurcation." Codes 36245-50, 75736, 75736-XS, and 75625 were assigned. As patient already has a known aneurysm treated with stent graft, would the aortogram be reported with code 75625 or 75630?

I am very confused about the Impella devices used during heart catheterization. I was comfortable using code 92970 since it was explained that code 33990 is for heart transplant patients and a long-term situation versus 92970 short-term (6-8 hours). However, the hospital is stating they are using code 33990. What is one key fact I can look at that would positively identify the proper code one way or the other?

How many times can you use code 76377 in a cerebral case? For the following example, would we submit codes 76377 and 76377-59? "There are multiple large aneurysms of the distal basilar artery. The exact characterization of these aneurysms is not possible on standard projection AP lateral imaging and would require a 3D angio, which was performed from the right vertebral artery. 3D performed on right vertebral, then right internal carotid artery injection shows multiple aneurysm of the infraclinoid and supraclinoid ICA. The exact measurements of these aneurysms are not clear on standard projection AP lateral imaging. 3D rotational angiogram was indicated."

I’m not sure if I can bill the numerous endarterectomies and thrombectomies since there is only one large incision. What are your thoughts? "Incision was made in the right groin. Right proximal CFA exposed and dissected. The SFA was dissected sharply and mobilized to about 10 cm along with the profunda artery. All vessels encircled with vesseloop. No pulse in the right SFA and the distal CFA. SFA entered. This was extended all the way to the mid CFA. Large burden of plaque including the proximal SFA and distal CFA. Extensive endarterectomies done at the SFA to at least the proximal 6 cm of the SFA and distal 2 cm of the CFA. All tissue was cleaned and debrided; the distal flap in the SFA was tacked. Bovine patch used to close. Of note before this step I forgot to mention I used balloon to thrombectomize the right SFA, popliteal, and tibial arteries because there was sluggish backflow from the SFA. First pass there was a very long fresh clot, about 30 plus cm in length. Second pass was about 20 cm long, fresh thrombus. But after three passes the entire length of 80 cm had no more thrombus."

"Patient was scheduled for MRI elbow arthrogram with contrast. Radiologist injected contrast in elbow with fluoroscopic guidance. A single radiograph in the lateral projection with the elbow flexed was obtained. Patient went to MRI." Procedure was canceled per nursing note: "Attempted, Unsuccessful, Claustrophobic." I appended codes for the contrast injection portion of the procedure (24220/77002), but I get an incidental services edit. Should I also code the MRI with a -52 modifier? Please let me know what you think.

According to the CPT Assistant March 2015, when both bone marrow aspiration and bone marrow biopsy of the same site are performed we can report both codes 38221 and 38220. Since there is an NCCI edit, can we use a -59 modifier to override this? Please clarify.

I code for a vascular surgeon who co-surgeons with an interventional radiologist from another practice performing AAA repairs. These are performed at the local hospital. My question is, what codes can I bill for the vascular surgeon as a co-surgeon? The vascular surgeon performs the exposure for AAA cases for the interventional radiologist. He is present throughout the entire procedure and both doctors note that both physicians were present for the entire duration of the procedure and performed all critical portions of the procedure together. The vascular surgeon confers after the takedown (34812), as the IR wants his opinion throughout. Can I code for the prosthesis (i.e., 34802-348083) as well as 34825 and 34826, if done, with a -62 modifier appended to each? The vascular surgeon concedes that he does the takedown only, but is present throughout the procedure to offer advice. If any complications arise at the time of surgery or postoperatively, the patient is still the vascular surgeon’s.

For the following, would you code both an arthrogram and an injection? "The left hip was prepped and draped in the usual sterile fashion. Fluoroscopic guidance used to mark a site overlying the left femoral neck. Local anesthesia was applied to the skin and subcutaneous tissues. 25 gauge needle was then placed in the left hip joint, and 3 cc Optiray was injected to confirm position. This was followed by injection of 7 cc 1% lidocaine and 40 mg of Kenalog. The needle was removed and patient transferred to the holding area. Impression: Fluoroscopic-guided left hip lidocaine and steroid injection."

Should the following be coded as 75726 or 75887? "A Simmons I catheter was formed in the aortic arch, and the superior mesenteric artery was selectively catheterized. A conventional angiogram was obtained and carried into the portal venous phase. Findings: Superior mesenteric artery is patent. This was carried out in the main portal vein, and the main portal vein and its branches appeared patent."

I have read the guidance for use of code 10160 when there is not site a specific code for aspiration of abscess, but with our Medicare carrier (NGS) they do not allow for coverage for the dx's that I usually receive for percutaneous aspiration of the gallbladder. I have therefore been using the unlisted biliary tract CPT code. What would you recommend for this scenario? Usually the dx is acute cholecystitis and the providers usually state that no catheter was to be placed.

"A 6 French EBU 3.5 guiding catheter was used to cannulate the LMCA without difficulty. UFH was used for anticoagulation and ACT was verified to be therapeutic. Target lesion for iFR is the proximal LAD. Before the pressure wire was guided into the distal LAD, air embolism was noted in the LAD system. Oxygen was set at 100% immediately and a BMW wire was delivered to the distal LAD immediately. Multiple runs of aspiration were done. Patient remained bradycardic and ST elevation was noted. Repeat aspiration runs were done. Dopamine was started and atropine was given. Epinephrine was also given ×1. A balloon pump was placed via right common femoral artery access. CPR was done for 30 seconds. He never completely lost consciousness. He did not require intubation. Flow was then restored, and hemodynamically he improved. We then proceeded with a pressure wire measurements, which didn't show a hemodynamically significant lesion in the proximal LAD." The above was done in addition to a left heart catheterization. What CPT codes would be appropriate to bill?

It is our understanding that we can report code 77002 (all anatomic areas except spine) or 77003 (spinal anatomy) for fluoroscopic guidance with codes 20600, 20605, and 20610. Is this applicable to all insurance carriers, including Medicare? Or would Medicare be excluded from this guidance?

In reviewing charges for a procedure, I came across a case coded 75625, 75716, 37228. The operative report states selective right leg angio and PTA to anterior tibial. Procedure portion states, "LCFA accessed and wire into aorta with use of Omniflush catheter to access left iliac. Omiflush catheter exchanged for 65 cm sheath. Selective angiogram with multiple views performed. PTA to anterior tibial performed." The physician's report is finalized with an impression, which dictates findings of an abdominal aortagram and findings of only the right side extremity and angioplasty. Due to the difference in charges and report I viewed the x-ray films. These show Omniflush catheter just below renals and abdominal aortagram imaging; next I see bilateral lower extremity imaging from bifurcation to toes. The selective right angio and PTA imaging. I queried physician to verify clarify op report and filming. I suggested including catheter position in their report to assist in proper coding. Physician says will not dictate maneuvers not performed. How can this be coded 75710, 37228?

"Injury to popliteal artery post knee arthroplasty surgery. Patient returned to operating room for femoral-tibioperoneal trunk bypass (beyond the take-off of the anterior tibial). At completion of the bypass, through the medial incision, a fasciotomy was completed of the medial compartment down to the level of the ankle; wounds are closed in layers." I’m thinking of reporting code 35666 since below the take-off of the anterior tibial, as well as 27601 for the fasciotomy. I'm not finding anything specific to just medial compartment. Thoughts?

Our cath lab is going to start placing RVADs with an Impella RPs. The vendor's description of the procedure matches the lay description for 33990 very closely; the main difference is right versus left. I want to validate with you that code 33990 would be appropriate, or if we should use unlisted code 33999 for these procedures. What are your thoughts?

I'm unsure whether to report unlisted cardiology procedure code 33999, skin tissue procedure code 17999, or pocket revision (as the doc is calling it) code 33222. He did remove the generator, place an antibiotic sleeve on it, and place it back into the pocket. "Procedure: Patient came into the pacemaker clinic with some drainage from her previously placed ICD site. After local anesthesia, the pocket was opened. The pocket was lavaged. There was no active bleeding. There was no obvious purulence. Cultures have been obtained in the clinic and were not done during this setting. The pacemaker was placed into an antibiotic sleeve and placed back into the pocket which was closed in layers. Sterile dressing was applied. Conclusions: ICD pocket revision for draining hematoma."

I need some guidance on how many times can I use 75898 for embolization of intracranial (CNS). Is it still as often as necesary to complete procedure? Six coils were placed with multiple angiographic views to ensure occlusion basilar tip aneurysm. Then two coils were placed posterior inferior cerebellar aneurysm with multiple angiographic views to ensure occlusion. Would this be 75898 x 8? For non-CNS/head and neck, SIR recommends coding only one follow-up angiography per embolization surgical site. Clarification on how to bill for CNS and Non-CNS would be helpful.

If a central line is placed (including a central venogram because of concerns that the left brachiocephalic might be occluded) and able to be placed "with its tip located in the mid superior vena cava even when the catheter was fully inserted. This high location and visualization of a kink in the neck suggested that this access would be problematic. It was felt that another puncture into the left internal jugular vein could be performed from a slightly lower location and using a different angle that would likely be less prone to create a kink in a catheter." So another access in the left jugular was used to replace the central line. Can the first access and venogram be placed in this situation in this situation in addition to the CVL placement or not?

My physicians would like me to explain why they can't use 75726 and 75774 during a Y90 or Sir Sphere injection, when they have done the mapping the day before and the diagnostic angiogram was done then?

Would we report codes 20500 and 76080-26 for the following example? "Int/ext drain recently removed, patient continues to leak previous contents from the previous catheter exit site. RT flank prepped , 5 French kumpe cath is advanced along the tract and contrast is injected, delineating the tract and the peripheral biliary ducts, The cath is then associated to the central of the tract and 8, 5mm coils were deployed wthin the tract centrally. small amount of contrast is then injected again and continue to flow through the coil pack. Because of this, approx. 0.5 ml of onyx 34 was slowly injected into the tract, with careful monitoring to make sure it was retained within the coil pack. contrast injection at the conclusion of this failed to demonstrate any ongoing communication with the biliary system. skin site was approximated with dermabond."

What CPT code should we be using for iFR done in the coronaries versus FFR?

I am about to take the CIRCC exam, and I hope you can clear up a discrepancy between your Interventional Radiology Coding Reference, 2015 edition, and the ZHealth anatomical charts. On page 142 of the reference book, #12 states "AMA appendix L considers the entire left brachial artery as second order selective (36216), with the ulnar, radial, and interosseus as third order vessels." This information conflicts with the upper extremity chart on page 671, and also with your 'exam ready' chart, that shows the left brachial as a third order artery (36217). So, I need to know if the left brachial should be coded as second or third order. Also, both charts show an unnamed short section of second order artery in the region of the subscapular and circumflex humeral arteries. If that short section is truly the only second order portion of the left arm, could you please tell me the name of it so that I can recognize it when coding from reports?

Is modifier 25 required to be appended to an E/M code in POS11 (office)? Code 93000 has an XXX global and is a diagnostic procedure, not therapeutic. Medicare requires that modifier 25 always be appended to the emergency department E&M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). Per NCCI: "With most “XXX” procedures, the physician may perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure is correct coding."

"The left popliteal vein was accessed. An advantage Glidewire was advanced through the catheter and directed into the femoral vein. A venogram demonstrated patency of the left popliteal and superficial femoral veins and left common, external, and common iliac veins. A 5 French straight flush catheter was advanced over the Glidewire into the left common iliac vein. A venogram demonstrated occlusion of the inferior vena cava in the mid abdomen. Prominent intrahepatic collaterals were noted providing drainage into the right atrium via a left hepatic vein. A C1 catheter was then used to select the right common iliac vein. A venogram demonstrating somewhat diminutive, but patent left common iliac, external iliac, and common femoral veins. A 2.8 French program microcatheter was advanced through the C1 catheter into the left superficial femoral vein. A venogram demonstrated tiny venous collaterals throughout the left thigh." Codes used were 88.66 and 88.51 with 36012 (left SFA) and 36011-XSRT (right common iliac vein), and 75822 (bilateral extremity), and 75825 (inferior vena cava).

We routinely perform pre-procedure embolization and roadmapping prior to the SIRTeX procedure. The GDA is embolized using CPT 37242. Can we bill the pre-procedure roadmapping for the SIRTeX at the same time as the GDA embolization? From report: "IMPRESSION: Arterial mapping and coil embolization as described above for preprocedure SIRTeX SIR-Spheres selective internal radiation therapy (SIRT)."

If embolization was performed on the right and left uterine arteries, only one embolization can be billed, correct?

"Right saphenous vein harvested for use in both legs. Right: The popliteal space was opened below the knee. I could see the area of obvious contusion at the proximal aspect of the popliteal below the knee. The thigh incision above the knee was then deepened into the popliteal space. Popliteal artery was identified. A tunnel was bluntly created between these two. Vein was brought onto the field reversed and marked oriented. It was spatulated and anastomosed end-to-end to the popliteal artery. Vein was then passed back into popliteal space. The vein was trimmed at the proper length and an end-to-side anastomosis was created. Left: The incision was made below the knee. I was able to identify the tibial/peroneal trunk. A longitudinal incision was made above the knee overlying the popliteal space. Vein was then anastomosed end-to-side to tibial/peroneal trunk and then run subcutaneous around knee to popliteal space. Anastomosed end-to-side to popliteal artery above knee." I'm not sure how to code: unlisted, fem-pop bypass, or popliteal-distal vessel bypass?

If my understanding is correct, for abdominal drainage, when a catheter is not placed for continuous drainage, we are to use code 10160 instead of 49406. My question is, if the previous sentence is correct, why can we not use code 49083 instead? Does it depend on what is being drained? Peritoneal abscess drainage would be reported with code 10160, but peritoneal fluid would be reported with code 49083 if catheter was not left in for continuous drainage? If so, if a patient has a fluid collection that requires continuous drainage, but the fluid is NOT specified to be an abscess, hematoma, seroma, lymphocele, or cyst, do we still use code 49406?

Dr. A performed device pocket creation, tunneling of LV epicardial lead to surgical pocket, vascular access. Dr. B performed positioning of RA and RV leads and DFT. The operative note states that Dr. A secured both leads to deep muscular plane of the pocket.

Dr. B wants to report codes 33249-62 and 93641-26. Dr. A wants to report code 33249-62 as well, along with 33225.  Please advise.